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NC50543 | Sexual abuse of 4 children under the age of 13 by their father over a number of years. Family U composed of mother, father, and the four siblings. The siblings were part of a larger sibling group who were living independently. In October 2015 Sibling 2, aged 11 years, who had very recently been placed in foster care by the local authority, made disclosures that she and three of her siblings had been seriously sexually abused by her father over several years. All four children were made subject to Care Orders. The father subsequently received a life sentence with a minimum tariff of 16 years for a number of sexual offences. The mother pleaded guilty to an offence of child maltreatment and was sentenced to 2 years imprisonment. An older sibling also pleaded guilty to a sexual offence with a child. Learning includes: understanding and mapping family history; difficulty in recognising or naming sexual abuse prior to 'disclosure'; implications of limited focus on relationship building, especially with adolescents; impact and causes of drift. Recommendations for the Local Safeguarding Children Board include: to continue developing a multi-agency approach to child sexual abuse so as to ensure it is not reliant on disclosure by victims, but on proactive and supported practitioners; review the support provided to front line staff regarding the impact of the emotional content of child safeguarding on frontline; to develop a shared approach by which partners report on, or seek information about, any significant changes to an agency's function, resources or practice which could impact on multi-agency safeguarding.
| Title: Serious case review: Family U. LSCB: Norfolk Safeguarding Children Board Author: Sian Griffiths Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. SERIOUS CASE REVIEW FAMILY U Independent Author: Sian Griffiths Date: July 2018. Case U SCR Final for NSCB 1 CONTENTS 1. Introduction: 1.1. The circumstances leading to this Serious Case Review Page 3 1.2. Family Composition Page 4 1.3. Methodology Page 4 1.4. Contribution of family members Page 8 2. Summary of the case and agencies involvement Page 8 Section 1: The Early Years: 2005-2011 Page 9 Section 2: The Primary period: January 2012 - October 2015 Page 10 Section 3: Post disclosure: October 2015 onwards Page 23 3. Family Contributions Page 24 3.1: The Mother Page 24 3.2: The maternal grandmother Page 26 3.3: The Older Sibling Page 27 3.4: Sibling 1 Page 28 3.5: Sibling 2 Page 31 4. Appraisal of Practice and Analysis Page 32 4.1: Introduction Page 32 4.2: Understanding what was happening in the family Page 33 4.3: Medical Diagnoses and managing behaviour Page 35 4.4: The adults in the family: The Mother Page 37 4.5: The adults in the family: The Maternal Grandmother Page 39 4.6: The adults in the family: The Father Page 39 4.7: The adults in the family: The Older Sibling Page 41 4.8: Understanding the children as individuals Page 42 4.9: Indicators of Sexual Abuse Page 42 4.10: Why was it so difficult to see what was happening Page 46 4.11: The Response to the Family’s needs as they were understood: the interventions Page 50 4.12: Drift Page 55 4.13: The response at the time and following disclosure. Page 57 5. Concluding Comments Page 60 6. Recommendations for the Boards Page 61 Case U SCR Final for NSCB 2 Appendix A: Single Agency Recommendations Page 63 Appendix B: NSCB Thematic Learning Framework Page 66 Bibliography Page 67 Case U SCR Final for NSCB 3 1. INTRODUCTION 1.1 The circumstances that led to undertaking this Review 1.1.1 In October 2015 an 11-year-old child, Sibling 2, who had very recently been placed in Foster Care by the Local Authority with parental agreement1, made disclosures that she and three of her siblings had been seriously sexually abused by her father. Her older sister, Sibling 1, was already in a foster placement. The two younger children, Sibling 3 and Sibling 4, were removed under powers of Police Protection and placed in foster care. Care Proceedings were initiated in relation to the four children all of whom were made subject to Care Orders in January 2016. 1.1.2 The parents were both arrested and charged with a number of offences. The father pleaded guilty to a large number of offences of rape and sexual assault of a child under 13 relating to 6 victims. He received a life sentence with a minimum tariff of 16 years. The mother pleaded guilty to an offence of child maltreatment under Section 1(1) of the Children and Young People’s Act 1933. The mother was sentenced to 2 years imprisonment. An older Sibling pleaded guilty to Sexual Activity with a Child Family Member and received a 2-year Suspended Sentence with a Supervision Order. 1.1.3 The case of Family U was referred to the Serious Case Review Sub Group of the Norfolk Safeguarding Children Board on 26th October 2015 by Norfolk Constabulary. At this point the SCR Sub Group concluded that it was not in a position to make a decision until the Criminal and Care Proceedings were concluded in early 2016. The SCR Sub Group met again in April 2016 and recommended that the case had met the criteria for a Serious Case Review as identified in Working Together to Safeguard Children 20152, in that there was information that: (a) abuse or neglect of a child is known or suspected; and (b) either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. The Independent Chair of Norfolk Safeguarding Children Board formally made a decision to undertake a Serious Case Review on 11th April 2016. The National Panel was notified the following week and the Independent Reviewer was also identified at that point. 1.1.4 Due to complex criminal investigations and proceedings involving 3 family members which were not completed until January 2018, the Review was unable to be completed until March 2018. 1 Section 20 of the Children Act: provision for a child in need to be accommodated by the Local Authority with the consent of the parents or others with parental responsibility. 2 Working Together: HM Govt 2015 Case U SCR Final for NSCB 4 1.2 Family Composition The family members referred to in this review are as follows: IDENTIFIER Relationship Born Children subject of the SCR Sibling 1 Child of mother and previous partner 2001 Sibling 2 Child of mother and father 2004 Sibling 3 Child of mother and father 2006 Sibling 4 Child of mother and father 2007 Mother Mother of the children under review Father Father of Siblings 2,3,4 Older Sibling Older Brother 1994 1.3 Methodology 1.3.1. Statutory guidance within Working Together requires Local Safeguarding Children Boards to have in place a framework for learning and improvement, which includes the completion of Serious Case Reviews. The guidance establishes the purpose as follows: Reviews are not ends in themselves. The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children. (Working Together, 2015:73) 1.3.2. The statutory guidance requires reviews to consider: “what happened in a case, and why, and what action will be taken”. In particular, case reviews should be conducted in a way which: recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and Case U SCR Final for NSCB 5 makes use of relevant research and case evidence to inform the findings. 3 1.3.3. The methodology used for this Review was underpinned by the principles outlined in Working Together 2015, including the need to use a systems approach. The author of this report is familiar with a systems based methodology. In particular this approach recognises the limitations inherent in simply identifying what may have gone wrong and who might be ‘to blame’. Instead it is intended to identify which factors in the wider work environment support good practice, and which create unsafe conditions in which poor safeguarding practice is more likely. A central purpose therefore is to move beyond the individual case to a greater understanding of safeguarding practice more widely. 1.3.4. The Review was led and authored by Sian Griffiths who is independent of all the agencies involved. Sian Griffiths has significant experience in undertaking Serious Case Reviews. A second Independent Reviewer, Bridget Griffin, was commissioned for a limited number of days to provide additional capacity including offering a quality assurance role, given the complexity of the case. 1.3.5. The Independent Reviewer worked with a core Review Team from relevant agencies in Norfolk. The Review Team was made up of Senior Safeguarding representatives from the following agencies: TITLE AGENCY Head of Quality and Effectiveness Norfolk County Council, Children’s Services Education Advisor Norfolk County Council, Children’s Services Named GP Great Yarmouth and Waveney Clinical Commissioning Group Police Inspector Norfolk Constabulary Named Nurse for Safeguarding Children Norfolk and Norwich University Hospital NHS Trust Norfolk Community Health and Care NHS Trust Safeguarding Lead Norfolk Community Health and Care NHS Trust Deputy Named Nurse Norwich City Council Head of Neighbourhood Housing Services Norfolk Suffolk NHS Foundation Trust Specialist Safeguarding Practitioner Cambridgeshire Community Services NHS Trust Designated Nurse -Safeguarding The Norfolk Safeguarding Children Board Manager was also a member of the Review team and the Board provided administrative support. 3 HM Govt, Working Together (2015:74) Case U SCR Final for NSCB 6 The Review Team met on 6 occasions. 1.3.6. The review process included the production of chronologies and succinct Agency Reports produced by the following key agencies: o Cambridgeshire Community Services NHS Trust (Health Visiting services) o Norfolk Community Health and Care (Health Visiting and Community Services) o Norfolk County Council Children’s Services o Norfolk County Council Education o Norfolk Constabulary o Norfolk and Norwich University Hospital Foundation Trust o Norfolk and Suffolk NHS Foundation Trust o Great Yarmouth and Waveney Clinical Commissioning Group (in relation to General Practice) A shorter chronology was also provided by CAFCASS. A full check was made across the voluntary and statutory sector and several organisations who were identified as having contact with the family in the time period under consideration were asked to check records and provide any information. Many of these agencies had limited information to contribute or had not retained information given the passage of time and change of roles or commissions. However, some further specific information was provided as a result. 1.3.7. A range of primary documentation was made available to the Review including: Specific extracts of records from Children’s Services Records from Norfolk Housing Families Unit Summary Psychological Assessment in relation to Care Proceedings. Legal department chronology CAF records 1.3.8. The Independent Lead Reviewer and members of the Review team undertook a wide range of meetings with individual professionals who had direct involvement with key members of the family. A total of 24 professionals, from across the key agencies took part in individual meetings, providing a significant amount of information regarding their involvement with the family. 1.3.9. Towards the end of the process a full day event took place involving the review team and the majority of the key professionals who had been seen individually. The purpose of this event was to maximise factual accuracy as well as for the professionals concerned to contribute to the analysis and future learning. 1.3.10. The timeframe under consideration for this Review was: January 2005 – October 2015 Case U SCR Final for NSCB 7 The four children subject to this review were part of a larger sibling group, most of whom at during the prime period under consideration were living independently. Information available to the Review suggested that some of the older siblings may also have experienced problems as children. Whilst it was considered disproportionate to consider the 10-year period in full detail, it was agreed that there should be some consideration of the family’s earlier years to identify if there might be learning which would not otherwise be identified. 1.3.11. It was therefore agreed to consider the time period in three parts: i. 2005 – 2011: The review of this period would entail an analysis of the chronology and identification of any significant learning that did not emerge within the primary period for consideration. ii. January 2012-October 2015: Primary period for consideration iii. October 2015 to April 2016: Consideration only to be given to any significant issues of multi-agency working, immediately post disclosure. 1.3.12. The Review was asked to take into account any learning gained recently from previous Serious Case Reviews. The focus would be to identify further learning, or the degree to which previously identified learning had been translated into practice. The Terms of Reference identified four particular issues for consideration by each agency within the Review, however these were not intended to limit any other learning that might emerge: 1. What does this review tell us about the effectiveness of the multi-agency safeguarding partnership, particularly when working under thresholds of statutory social care intervention? This will include challenge around thresholds for intervention and fora for discussion and information sharing. 2. How do professionals and agencies working with large families understand the needs of the individual children in the context of the whole family? 3. How do we work with children so that they feel safe to talk about or otherwise express their feelings in order to enable professionals to make sense of what they are seeing and hearing? 4. What does this case tell us about professionals’ and agencies’ level of confidence in identifying and working with different types of child abuse, including sexual abuse and neglect? The Serious Case Review was also asked to take into account the NSCB’s Thematic Learning Framework (see Appendix B). Case U SCR Final for NSCB 8 1.4 Contribution of family members 1.4.1. The involvement of key family members in a Review can provide particularly helpful insights into the experience of receiving or seeking services. Careful consideration was given to informing and involving key family members given the highly sensitive nature of this case, the long-term impact on the four children and their older siblings of what had taken place and the impact of the ongoing criminal proceedings. 1.4.2. The mother and father were informed by letter at the outset that the Review would be taking place. Following the completion of criminal proceedings, they were again contacted to see if they would be willing to meet with the Independent Reviewer to provide their views. The Independent Author and the NSCB Board Manager met separately with the mother and maternal grandmother. The father did not respond to the offer of a meeting. The children’s older siblings were also informed and later asked if they were willing to take part but did not respond to attempts to contact them. 1.4.3. Advice was taken from social work staff in relation to informing the four children subject to this Review that it was taking place and then asking if they would want to meet and contribute to the report. Sibling 1 and Sibling 2 both met with the Independent Reviewer and the Board Manager. Sibling 3 decided not to attend a meeting. Sibling 4’s Social Worker advised that Sibling 4 would not be able to undertake such a meeting at this stage. Nevertheless, she was informed that her siblings would be contributing to the Review. 1.4.4. Each of the family members contributions are summarised in Section 4 and as relevant are also included in the analysis at Section 5. 1.4.5. The author would like to thank all the family members who contributed to this Review. Particular thanks go to Sibling 1 and Sibling 2 for their strength of character and courage in being willing to talk about their experiences. Their contribution will best be repaid by agencies and professionals taking action to better help children in the future. 2 SUMMARY OF THE CASE AND AGENCIES’ INVOLVEMENT WITH THE FAMILY The following is a chronological summary of what is now known about the family and their involvement with agencies. The summary, as far as is possible, will identify what was, or was not, known to the relevant agencies at the time the events were taking place. It should be noted that although the summary has been significantly condensed from all the available information, it nevertheless remains quite lengthy, and reflects a complex family story. A conscious decision was made to include it in this way so as to effectively reflect the complexity of agency involvement as it would have been experienced both by the children and by professionals themselves. Case U SCR Final for NSCB 9 Section 1: Early years 2005 - 2011 i. This first section consists of a summary of the relevant information known about the family and the involvement of services with the family prior to 2012. ii. At the beginning of 2005 the family was composed of the mother and father, the older siblings, who were children of mother’s previous partners, and Sibling 2, the first child of the mother and father. It is not known whether all the older siblings were living in the household. Sibling 3 was subsequently born in 2006 and Sibling 4 in 2007. It is understood that the father did not have Parental Responsibility for the children. iii. The school age children were all in local schools, although there were problems regarding attendance and behavioural concerns particularly with Older Sibling. There were a range of problems and concerns regarding each of the children, including direct allegations and disclosures of sexual abuse. A number of services were involved with members of the family and had different levels of knowledge of these concerns. There was a pattern of the mother not attending appointments. iv. The father was being treated throughout this period for depression linked to his own experience of abuse by his father when he was a child. There were increasing references to his anger. Although he was referred to the Mental Health Trust, he was eventually discharged due to non-engagement. The father had a significant level of involvement with Health Services as a result of his depression. The mother also had significant physical health problems and had a high level of contact with Health Services as a result v. Between 2005 and 2011 there were at least 7 referrals made to the Police and Children’s Services regarding the children. These included referrals as a result of two of the older children going missing, as well as concerns about the conditions in the home. On one occasion in 2008 Children’s Services completed an Initial Assessment and a referral was then made to Homestart. One of the older siblings was referred for a mental health assessment following an overdose, and two had young pregnancies, with their children becoming subject to referrals and assessment by Children’s Services. vi. CAMHS were working with Older Sibling as a result of anger management, with particular concerns about his behaviour with his sister. He had been identified by a psychologist in 2006 as suffering from anger, anxiety, PTSD and ADHD. vii. On several occasions referrals both from professionals and neighbours related to allegations of either inappropriate sexual behaviour by adults towards children, or more directly that sexual abuse had taken place. This information came from the children themselves using explicit language and description. viii. On one occasion a relative of Older Sibling, who lived in a different family, told her teacher that she had been sexually assaulted by him. Strategy discussions and Police investigations were initiated but did not lead to further action being taken. The reasons for not taking action included the child not making a disclosure to the Police in interview and alternative explanations being provided Case U SCR Final for NSCB 10 by the mother. The allegation was not felt by the Police to be credible and her ‘limited intelligence’ was noted as a feature of the assessment. ix. On another occasion in 2006 there was an allegation both that 5-year-old Sibling 1 had been made to drink washing up liquid by the father, but also that she seemed to have been made to perform sexual acts. The father was required by Children’s Services to leave the house temporarily in order to resolve his mental health problems and was assessed by a mental health practitioner. After 6 months he returned home with no further assessment by Children’s Services. Separately, another police force sought and shared intelligence about the father ‘regarding sexual abuse issues’ relating to his birth family with Norfolk Police. x. The school noted continuing concerns about Sibling 1, who was frequently described as having a lot of worries about her family, including that her brother was physically abusive to her, also describing him as a pervert. The mother produced a log of her behaviour which she gave to the school. There were increasing references to Sibling 2’s ‘problematic behaviour’, including physical aggression and signs of emotional distress. This led to the GP referring Sibling 2 to the Mental Health team, who informed her she should refer to the Community Paediatrician instead for assessment. The Community Paediatrician had concerns about Sibling 2’s presentation and requested health visitor follow up with the possibility of clinical psychology involvement in the absence of any improvement. In October 2011, following a referral to the specialist ADHD nurse, the Consultant Paediatrician diagnosed Sibling 2 as having mixed neurodevelopmental problems and ADHD. xi. The three youngest children, Sibling 2, Sibling 3 and Sibling 4, all gave some cause for concern to health services from an early stage due to home conditions, and developmental delay. All three had speech and language difficulties involving the SALT service. There were also a small number of occasions when there were potentially concerning bruises or injuries to the children, although explanations were given for these and accepted. Each of the three girls was presented to the services by their parents as having worsening behavioural problems. In 2011 an Educational Psychologist recommended the school develop an Individual Education Plan for Sibling 4 and for a few months a CAF4 was put in place and led by the school. Section 2. The Primary period under analysis January 2012 – Oct 2015 I. 2012-Summer 2013: School Concerns and a CAF is put in place. i. At the beginning of 2012, Older Sibling was enrolled at college part time and had been re-referred to CAMHs by his GP for anger management problems, this service worked with him until the summer. Sibling 2 continued to be 4 The CAF is a shared assessment and planning framework that was used when it was assessed that child had additional needs, to identify those needs and co-ordinate services to meet the needs. This has been replaced in Norfolk by the Family Support Process. Case U SCR Final for NSCB 11 reviewed by the Community Paediatrics team. Her behaviour was described as deteriorating and aggressive by her mother and grandmother, who were keen for her to receive further medication. Sibling 4 had also been identified as having significant learning difficulties as well as social, emotional and behavioural difficulties. A statutory statement regarding her educational needs was requested and she and was also being seen by the SALT team (Speech and Language Therapy). There were ongoing concerns regarding Sibling 1’s school attendance. A referral was made to the School Attendance Service who worked with the family and it was subsequently agreed that no legal action would take place due to improved attendance. Mother and Father were separated but there continued to be contact between father and the children. ii. In February 2012, a girl at Older Sibling’s school told a pastoral support worker that he had sexually assaulted her. This was reported to the Police, but no further action taken as the girl and her mother did not want to make a formal complaint. The police referred this to Children’s Services, but there is no information as to whether any further action was taken. iii. In April 2012, the CAF which had been closed in October 2011 was reopened and the family was said to be working with the Families Unit, part of the Housing Department at Norwich City Council, in relation both to school attendance and home conditions. Sibling 2’s aggressive behaviour at home was of concern. iv. During May 2012, there were two issues of concern in relation to Sibling 1 who was 10 years old. Firstly, she was heard by a teacher talking about sex in a way which caused concern. A few days later she told a teacher that she had been raped by a 14-year-old boy some months previously. The school contacted the Police and made a referral to CSC. Sibling 1 subsequently told the Police that she had lied, and as a result no further action was taken by the Police other than forwarding a routine notification, known as a C39d, to Children’s Services. This was discussed at the CAF meeting and the GP was then asked to make a referral to CAMHS. The GP who saw Sibling 1 identified the concerns as a child protection issue and contacted Children’s Services. A duty team Social Worker visited the home and was told by the mother that the alleged rape could not have taken place. The mother agreed to a referral to the school nurse and Families Unit, although there is no evidence that the referral was received. An Initial Assessment was subsequently completed and concluded that no further action was required as the family was engaging with the CAF. v. From this time onwards these behavioural and presentational difficulties, as well as school attendance, continued to be a problem for all the children. The mother provided a range of explanations as to why she was unable to get the children into school, primarily that Sibling 2’s behaviour was the cause of the family’s difficulties. On one occasion, Sibling 4 was seen at school to have finger-tip bruising apparently caused by Sibling 2. This was again noted by school as a Record of Concern and referred to Children’s Services, who stated it was already an open case. Both the family and the professionals who were part of the CAF appeared to be unclear as to the role of Children’s Services at this time. The CAF notes stated again that a referral to the Families Unit would be made. Case U SCR Final for NSCB 12 vi. During the summer the mother was admitted to hospital with serious health problems. It was recorded at the CAF that the father and maternal grandmother were taking care of the children in her absence. There was other information around this time that the Mother had gone to visit her ‘boyfriend’, leaving the children with an older sibling and providing no means of contacting her. The mother’s health problems continue to be managed by the GP and are frequently referred to over the period covered by this Review. vii. Following the school summer holidays, the children’s problems continued as before and CAF meetings recommenced. A mixed picture was provided to professionals of the father’s involvement. On the one hand, he was said to settle Sibling 2 in bed at night before going back to his own home, on the other hand the mother told the GP that the father provided little help. The GP records note an intention to speak to the Social Worker involved, but there is no further information. As the mother was now very immobile, an arrangement was made for her to be provided with a hospital bed in the front room and for her to be provided with a wheelchair. viii. One of the concerns identified by the school was that Sibling 2 often made inappropriate personal comments to both teachers and other children. This was a feature of her behaviour which was noted on a number of occasions. Later in the year 11-year-old Sibling 1 was taken by her grandmother to see the GP as she was self-harming and talking about ending her life, this was said to be linked to bullying by her brother as well as others in school. The GP made a referral to CAMHS asking that Sibling 1 be assessed and also made a referral to Children’s Services. A CAMHS practitioner concluded that Sibling 1 did not have any mental illness. She was however offered counselling by Family Solutions, part of the CAMHS service, but did not want to take this up. ix. A further Initial Assessment was undertaken by Children’s Services in December 2012 after Sibling 1 was reported missing and then made allegations of being threatened and bullied by other children. Sibling 1 had also written in her diary about wanting to hurt herself and about ending her life. Again, she eventually said that she had invented the allegations of being bullied and threatened but could only explain that she would like more attention from her mother. The house was described as ‘dirty and in a state of chaos’. The assessment concluded that the family were working with the CAF and there was no role for Children’s Services. At the end of the year the school records state they made another referral to the Families Unit identifying the family’s biggest concerns as being Sibling 2’s extremely challenging behaviour and Sibling 1 being bullied. This was however the first referral that is known to have been received by the Families Unit. x. In the Autumn of 2012 the father had also referred himself back to the mental health wellbeing service for counselling and had his first appointment in December. He is recorded as being treated for depression and anxiety by his GP and seeing his three children during the week. xi. The Families Unit began working with the family in January 2013 and their primary role was to help the family maintain their tenancy. Two workers were allocated, and they worked consistently with the family until the case was closed Case U SCR Final for NSCB 13 in November 2013. The practitioners identified a wide range of needs and actions, from arranging for garden clearance, to helping with school attendance, to providing support to several of the family members, particularly Sibling 1, who was identified as having needs in relation to identity and emotional wellbeing. xii. The Families Unit Practitioners recorded that Sibling 1 behaved in an inappropriately sexualised way and that both Sibling 2 and Sibling 3 were overfamiliar with them. Older Sibling was also identified as having serious anger problems, including assaulting Sibling 1. The staff from the Families Unit visited on a very regular basis over the following months, spending time with all the siblings including Older Sibling, helping with morning routines, liaising closely with school and taking Sibling 1 to school. The parents had been given a place on a parenting course run by the school which had first been agreed over a year previously. However, neither parent actually attended. CAF meetings continued, and included the school, Families Unit, the mother, maternal grandmother and Older Sibling. xiii. A range of professionals continued to be involved with the family and other referrals were also made to organisations but were not taken up by the parents. This pattern continued throughout the time period under consideration. xiv. In early 2013 the mother was recorded by Children’s Services as planning to ‘trial alternate nights away from the family home for respite’ with other family members working collaboratively to provide care. It is not clear what Children’s Services’ involvement was at this time and how, or if, this arrangement was assessed. In March, the Ambulance Service informed the Police of a disturbance when Sibling 1 was said to have kicked her grandmother. This led to the Police informing Children’s Services but there is no information as to what action, if any, was taken by them as a result. Around the same time the Schools Attendance Service concluded that it should proceed to a prosecution in relation to Sibling 1 and the Mother in due course was prosecuted and fined. xv. Older Sibling was identified as struggling with depression and anger. One of the practitioners from the Families Unit took him to see his GP who arranged for another referral to the Mental Health Wellbeing team. xvi. Sibling 1 went missing from home on 2 further occasions in 2013 but was found and returned by the police who informed Children’s Services using the agreed C39d form. After one of these occasions a manager at the MASH referred it to the Duty Team for another Initial Assessment. A referral had also been made by the Families Unit a few weeks earlier, but the outcome of this had been that they were told the CAF was a satisfactory way of working with the family. xvii. The Initial Assessment was allocated 6 weeks after it was referred to the Duty Team and completed a further two months later in July 2013. By this point there were numerous continuing concerns being identified by the school and Families Unit, including: Renewed court action regarding Sibling 1’s school attendance Mother’s physical health and the impact on the children; The emotional health of both parents; Case U SCR Final for NSCB 14 Mother going away at weekends to visit her boyfriend some distance away, leaving the children with the father who was said to ‘struggle to cope’, including having been seen ‘pushing Sibling 2 against a wall’. Conditions in the home; The quality of parenting and lack of progress or improvements. Sibling 2 suffering from bedwetting, and a bruise on her cheek after ‘falling on her bed’ Police called by a neighbour who heard screaming and shouting – explained by mother as Sibling 2 having a tantrum. Sibling 4 withdrawn, very emotional and ‘often looks very sad.’ xviii. The Families Unit practitioner had also recorded concerns about the risks to Sibling 1 of sexual exploitation and spoken to the mother about it. During an individual session with this practitioner, Sibling 1 said that she had something she wanted to share but would not say any more. As a result of this the Families Unit practitioner spoke to her manager and made a further referral to Children’s Services. They had also made a referral to Adult Social Care for a community care assessment in relation to the mother, but she declined the support they offered. xix. The Families Unit also referred Older Sibling to Norfolk Carers Support, however the service was unable to engage with him and eventually closed their involvement. The Father had been offered contact with the Wellbeing Service including a place on a Stress Control group. However, he did not respond to their attempts to make contact, despite continuing to present at the GP with the same problems, and the Wellbeing Service closed the case. Sibling 2 was re-referred to the ADHD nurses by the Community Paediatrician following her mother raising further concerns about her aggression. II. July 2013 – March 2014 Child in Need Plan put in place i. The outcome of the Initial Assessment was that the children were transferred to the Child in Need team in July 2013 ii. Between late August and the end of 2013, the Police were called out on 6 occasions in relation to incidents involving Sibling 2. On the first occasion, they were called by a neighbour who described seeing the father responding badly to Sibling 2, who was distressed and trying to run away. The Police were told that the incident was triggered when the father came to collect two of the children to stay with him for the night. Other occasions involved Sibling 2 being said to be in violent rages, including times when her mother restrained her. The mother stated she had numerous injuries as a result of needing to restrain Sibling 2 and school staff also recorded the mother being assaulted by Sibling 2. On one occasion Sibling 1 called the Police, who also noted the house to be damp and smelly. All of these events were referred to Children’s Services. iii. At the beginning of October 2013, a Social Worker from the Child in Need (CIN) team was allocated to the family and the first CIN meeting took place. The focus was initially on neglect with Sibling 1, but soon included Sibling 2 who was also now refusing to go to school. The Social Worker at this point made referrals to Case U SCR Final for NSCB 15 the Children’s Services Targeted Support Team, Home Based Support5 and Starfish, the children’s Learning Disabilities service run by NCHC. The Housing Families Unit initially continued to visit 2 or 3 times a week but ended their work in November 2013 due to the recent involvement of CSC and the lack of progress. iv. In November, the Social Worker visited the father at his home. It is recorded that he had not been allowed to have weekend contact with the children following the earlier incident when the Police were called. He was however visiting the home twice a week. It is not clear who was responsible for this decision to place restrictions on the father’s involvement with his children. The result of the Social Worker’s visit was in any event that contact would continue to be supervised until the father had a ‘mental health assessment’. v. By late November 2013 Sibling 1’s school attendance was recorded as being less than 5%. It was agreed that she should attend for the afternoons as part of the School Inclusion Project, that Home Based Support would support her school attendance but also that the local Authority would commence legal proceedings for her non-school attendance. The involvement of Home Based Support lasted for just three weeks when it was concluded that it was insufficient for the family’s needs. A recommendation was also made in the Child in Need action plan that Sibling 1 be found a residential school placement from Monday to Friday. vi. Both the Social Worker and the Home-Based Support care worker were concerned about the apparent violence in the home from Sibling 2, in particular towards her mother. On one occasion in December the Police were called out, and requested a home visit by Children’s Services. The Police recorded “a real risk of further harm to the mother…..also a risk to the other children… the injuries she seems capable of causing are significant”. The mother told the Social Worker that Sibling 2 would not take her medication and the Social Worker contacted the Community Paediatrician, who made a further referral to the ADHD service. Children’s Services also noted the Community Paediatrician’s advice that if Sibling 2 took her medication it should be sufficient for other interventions to be successful. It was agreed by the Social Work Manager that extra resources would be provided to help with this. vii. In December 2013, the Social Worker and her manager concluded that if there was no improvement in the next few weeks Sibling 2 would need to be accommodated by the Local Authority. The Targeted Support Team visited for the first time on Christmas Eve and then visited weekly. A further service was commissioned by Children’s Services from a private organisation, CF Social Work. This was to provide a month of daily visits each lasting 4 hours but ended when a complaint was made about a worker and it was noted that there was in any event little improvement. viii. By January 2014 the Social Worker was visiting weekly and the Targeted Support team were visiting twice weekly. Over the next three months Targeted Support visited the family on over 40 occasions. During these sessions, a 5 Home Based Support and Targeted Support are Children’s Services resources available to Social Workers. Case U SCR Final for NSCB 16 variety of work was undertaken and a number of issues of concern were identified: Parenting capacity work undertaken with the mother Sibling 1 speaking to strangers on Facebook and mother’s lack of concern Suicide notes written by Sibling 1 a couple of years previously Sibling 2 making penis shapes out of PlayDoh ix. Over one weekend the Targeted Support Team worker became involved in arguments that were going on in both parents’ houses in front of the children and was abused and spat at. This worker expressed concern to the Social Worker about the safety of the children. It was agreed with the Social Worker that the mother would, for a trial period, spend alternate nights away from home, and other family members would step in to provide the care on those nights. Different agencies recorded different information as to the care arrangements for the children and whether the father was ‘supervised’ in his contact. x. At the end of January 2014 Sibling 2 and her parents met with the ADHD Community Psychology team for an assessment having been referred by the Community Paediatrician. The Psychologist liaised with the Social Worker, Targeted Support Team and the school and attended CIN meetings. One of the issues identified to the team by school and family was that Sibling 2 had difficulties leaving her mother. This assessment was completed in April 2014 and identified that Sibling 2 had some learning difficulties and would require additional support at school. It was also agreed that an assistant psychologist would undertake individual sessions with Sibling 2 to help her with her anxiety. A referral had also been made by the school to the Educational Psychology Service although at the first meeting Sibling 2 refused to see the Educational Psychologist alone and when seen with her mother Sibling 2 appeared reluctant to be assessed. The mother was described as not overly worried about Sibling 2’s learning and felt that her behavioural problems were at home not in school. xi. The mother during this period had been referred to the Hospital Outpatient department by the GP but failed to attend on a number of occasions and was subsequently discharged by the team. This identification of health problems by the both mother and father, followed by a failure to attend appointments was a repeating pattern. xii. In March 2014 the Social Worker had returned to monthly visits and the TST team to weekly visits. The rationale for this change was not recorded. Children’s Services records identified that Sibling 1 was not attending school and not being encouraged to do so. She was also said to be Skyping older boys ‘worldwide’ while she was in the bath and she was self-harming. It was further noted that her mother did not seem to be aware of where 12-year-old Sibling 1 was much of the time. Sibling 1 attended the Mental Health Access and Assessment team where she was seen to have superficial cuts to her wrists but was not diagnosed as having a mental illness. Case U SCR Final for NSCB 17 III. April 2014 – March 2015 Core Assessment completed and first consideration of foster placements. i. The Core Assessment initiated in November 2013, was completed in April 2014. It recommended that: Sibling 1 be placed in therapeutic foster care and referred for counselling and/or psychological assessment. Sibling 2’s psychological assessment be completed and to provide a time limited assessment in foster care. Sibling 3 and Sibling 4 to be provided with time limited assessments in foster care. The children to have regular contact with their parents and family. Consideration to family therapy on reunification. Mother and father to receive support in relation to their future parenting. Sibling 1’s birth father to be assessed as a carer for her. ii. The Social Work Team Manager noted that the parents were willing for Sibling 1 and Sibling 2 to be accommodated by the Local Authority, but not Sibling 3 and Sibling 4. Their grandmother was said to be willing for the two youngest to live with her if this was felt to be necessary. Legal Advice had been taken and it was agreed that the threshold for removal had been met for all four children. The plan was that ‘this would only be considered if alternative education or therapeutic provision can be found and intensive support within the home proves not to be successful. All four children were also referred to the Young Carers service. iii. In May 2014 Sibling 1, was with an older female friend when she was sexually assaulted by an adult male who was known to them. This was reported to the Police and the man concerned, who was known by Police to be a Schedule 1 offender6 was later charged and convicted. It was recorded by Children’s Services that Sibling 1 was spending time with a group of friends older than her and said to have a 19-year-old boyfriend. Advice was given to the mother about keeping Sibling 1 safe. Discussions with Sibling 1 in the following weeks suggested that she did not accept she was at risk. There was liaison between the Police and Children’s Services about Sibling 1’s vulnerability and what action would be taken if she was found out after 7.30pm. iv. A Children’s Services management review in relation to Sibling 1 took place and described the situation as fluctuating. The review records concern as to who Sibling 1 was associating with, the care in the home and the lack of parental attention being given to the younger children. There is no record of any discussion or decisions regarding the previous recommendation of accommodating Sibling 1 and her younger siblings in foster placements. The school contacted Children’s Services worried that there was no progress there no information about the response has been found. The school SENCO7 contacted the Educational Psychologist requesting a statutory assessment 6 Schedule 1 Offender: term previously used to describe a person who has been convicted of an offence against a child listed in Schedule One of the Children and Young Persons Act. 7 SENCO: Special Educational Needs co-ordinator. Case U SCR Final for NSCB 18 regarding her educational needs, but this was not agreed on the basis that it was felt to be a means to manage poor school attendance. v. In June of 2014 a professionals meeting took place chaired by the Children’s Services Team Manager. As well as the Social Worker and her manager 11 professionals from other agencies attended and three others gave apologies. The manager noted that given the numbers involved it must be difficult for the family. The plan for a Boarding School placement for Sibling 1 was confirmed, as well as referrals to the Rose Project8, a specialist activity holiday and Family Group Conferencing. The Psychological assessment, a CAMHS assessment and a TST assessment were noted as continuing. CAMHS later declined to offer a further service as there had been a previous assessment. A Boarding placement was also to be considered for Sibling 2. Sibling 4 was to move to a School for children with special needs at the start of the autumn term. vi. At the end of that month, the Child in Need Team Manager reviewed the case and recorded concern about the lack of progress. The Manager considered the current plan was achievable but concluded that a change of Social Worker was required. Agreement had just been granted by the CSC Admission to Care Panel (ATCP)9 for a Boarding School place to be found for Sibling 1 locally. The evidence available at this point was that all the previous concerns remained and some, for example Sibling 2’s school attendance, were becoming worse. A new Social Worker was allocated the case in mid-July. vii. During the Summer and Autumn of 2014 there were two further occasions when the Police were called, one a result of abusive behaviour towards Sibling 3 and Sibling 4 by other children, another due to a report that Sibling 2 had been aggressive in the home, although she was found to be calm when the police arrived. Both incidences were reported to Children’s Services. A Child in Need meeting took place but there is limited information about who attended or what was discussed. A mental health representative who attended advised the meeting that Sibling 1 did not have a mental health problem, but that the concerns were about poor parental boundaries and exposure to adult experiences. The mental health team discharged Sibling 1 from their service. viii. CSC records identify the following during this period: all 4 siblings ‘remain at home’ Fortnightly social worker visits to take place Sibling 2 not engaging with the psychologist Sibling 1 had been seen by the Bethel clinic and had stated she was thinking of killing herself on her 13th birthday. Sibling 1 absent from home overnight and mother not aware where or who she is with. Possibility that Sibling 1 is at risk of Child Sexual Exploitation Grandmother had admitted to hitting Sibling 2 on one occasion 8 Rose Project: a service provided to young people at risk of or experiencing Child Sexual Exploitation 9 ATCP: Children’s Services internal process for making decisions as to when an application for a child should be brought into the care system Case U SCR Final for NSCB 19 Mother has ‘adult’ conversations with both Sibling 1 and Sibling 2 and is ‘guarded’ about her current relationship Sibling 3 and Sibling 4 exhibiting fear at home believed to be in relation to their grandmother’s care style and are sent to their rooms when Social Workers visit. TST witness grandmother causing Sibling 2 to have an angry outburst. TST have not been able to effect change and cannot continue the intensive level of support long term. ix. A potential Boarding School placement had been identified for Sibling 1 and subsequently a place in the same school was also found for Sibling 2. Sibling 1 eventually took up this place in November, but Sibling 2 would not attend and remained at her local primary school. The Community Psychologist offered to provide some family therapy. The mother told Children’s Services that she would agree to them being accommodated by the Local Authority under S20, but would not accept the concerns about Sibling 3 and Sibling 4 and or agree to them being accommodated. Sibling 4 was given a place at a school for children with complex needs starting in September. There was repeating evidence of various appointments being cancelled or not attended by the family, as well as social work home visits during which the behaviour of family members was extremely difficult. x. In early September 2014 the CSC Divisional Manager requested that Sibling 2’s case be withdrawn from discussion regarding a foster placement. This was to allow further case discussion and further support to be provided to the family. In supervision with her manager in September the Social Worker identified a number of agreed actions in particular including: Request for Resource Form to be sent to panel for placement. Child Sexual Exploitation consultation with the CSE Decision Maker at the MASH. Meeting with Child Psychologist regarding possible additional commissioned resources. xi. The school specifically contacted the Social Worker stating their concerns about the family’s ability to make meaningful changes and stated they would be concerned if the foster placement plan was no longer being pursued. At around this time a Family Group Conferencing co-ordinator10 became involved. There were no signs of improvement and evidence of some things worsening, including Sibling 1’s self-harming. Sibling 2 now told the Social Worker that she wanted to go to a foster placement. The father was said to have disengaged from involvement with services. The Social Worker noted that Legal Advice 10 Family Group Conferences Family Group Conferences (FGC) are meetings which bring children and families and their wider support networks together to jointly find solutions to the difficulties the family are experiencing. This service was at the team commissioned by Break, a charity working with children. Case U SCR Final for NSCB 20 would be sought, with the expected outcome being that a letter would be sent to the family explaining the process before legal action could be taken. xii. In late October 2014 a Children’s Services Operational Manager who had reviewed the case with the team manager concluded that the Sibling 1 and Sibling 2’s situation was urgent and required a legal strategy meeting as to whether the threshold for care proceedings would be met. This manager also asked what plans were in place to meet Sibling 3 and Sibling 4’s needs but did not include them in the request for a legal meeting. In particular, there is reference to undertaking wishes and feelings work with the two younger siblings in relation to Older Sibling’s behaviour and not allowing Older Sibling to discipline or parent the children. The information provided does not explain why this was necessary. xiii. The legal meeting took place the following week and the family were advised to contact a solicitor. The Admissions to Care Panel (ATCP) agreed to a 6 week foster placement for Sibling 2, who continued to show interest in this despite her mother’s negative views about it. During one social work visit she said that her mother told her she did not have to answer any of the Social Worker’s questions if she did not want to, after which weekly visits were put in place outside the home to prepare her for the placement. At the end of November, the ATCP met again and agreed that Sibling 2 should be in a foster care placement while therapeutic work continued. In the following weeks Sibling 2 asked on several occasions about going into foster care again and whether she would go into care ‘if she was good’. At a Review Meeting with the Community Psychiatrist, the mother said that there was an improvement in Sibling 2’s behaviour and that the medication seemed to be working. xiv. There were continued concerns regarding Sibling 1’s self-harming and worrying relationships with boys, again with no apparent concern shown by her mother. Once again, her GP, asked for a CAMHS assessment, which took place and identified a risk management plan. In December 2014 Sibling 3 told the safeguarding lead at her school that she had ‘one big worry’ but she did not want to talk about it and that sharing it would mean she would get hurt. When asked more she went on to say that it was about family members who had died, including her mother’s boyfriend in Kent. Children’s Services had requested further intensive support from Home Based Support for the family in the form of 6 hours a day for 4 weeks. xv. In the first week of January 2015 the Police were called when Sibling 1 did not return to boarding school and then ran away from home. When she was found by the Police she said that she did not like school and was worried about her mother’s health and ability to cope. She showed the officer the scars from her self-harming and spoke of idolising rock bands, and particularly where individuals had taken their own lives. The officer was concerned about her mother’s response and made a referral to Children’s Services. The same day a ‘Letter Before Action’ Meeting11 (meeting with the authority’s legal advisors) 11 ‘Letter Before Action’ meeting: This is the term used at the time when referring to the Public Law Outline Pre-Proceedings meeting with social work staff and Local Authority legal department to consider whether care proceedings should be initiated. Case U SCR Final for NSCB 21 concluded that there should be a further period of testing for both Sibling 1 and Sibling 2 and a review in four weeks. The ATCP would not agree to a foster placement for Sibling 1 without an Interim Care Order in place. Another management discussion took place a couple of weeks later about the possibility of considering a Child Protection Plan, but it was felt this would not change anything for Sibling 1. xvi. Another ‘Letter Before Action’ meeting took place in early February. There had a few days previously been a further referral from a Police Community Support Officer who knew Sibling 1 from previous contact with the family and who she spoke to about her distress, loneliness and self-harm. At this meeting it was agreed that the Local Authority should initiate Care Proceedings for Sibling 1, in the meantime seeking a foster placement with parental agreement under S20. In relation to Sibling 2 it was decided to test out her progress after Sibling 1 had left the home. Work would continue with Sibling 3 and Sibling 4 who remained assessed as Child in Need. Neither Sibling 1 nor Sibling 2 were attending school at this point, but given the Local Authority’s decision, the School Attendance service decided not to pursue their legal case. A senior management review by Children’s Services noted concern about chronic neglect, the case drifting and the future risks to the two younger children. The Social Worker was required to provide a chronology for each child and a genogram. xvii. Over the following weeks there continued to be episodes of concern in relation to Sibling 1, including being missing for several days, spending time with an older friendship group of concern and her mental health. Sibling 1 was identified by Police as at risk of child sexual exploitation. A number of actions were taken including the issuing of a Child Abduction Warning notice to one of the adults of concern. The Police Community Support Officer who visited the house to explain that the Warning Notice was in place made a detailed record of the poor conditions in the home and evidence of neglect. IV March 2015 to October 2015 The children are placed in Foster Care and the first disclose of sexual abuse. i. In March 2015 Sibling 1 was placed in Foster Care with her mother’s agreement, under S20 of the Children Act. Concerns continued to be recorded about the three younger siblings, including deteriorating home conditions and increasingly distressed behaviour. It was again noted that there was ‘drift’. There were more discussions about a boarding school placement for Sibling 2, but no further decisions were made in relation to her at this time. Sibling 1 began to settle in her placement, although there were problems with her contact with her mother, who was not following the contact agreement, by for example allowing Sibling 1 to access social media. ii. In April 2015 there was a Family Court hearing at which the following were agreed: Psychological assessment of the family as a whole An educational assessment for Sibling 2 Sibling 1 to remain with her foster carers Case U SCR Final for NSCB 22 Viability assessment of any identified family members. iii. At the end of May 2015, the Father was admitted to hospital where he was found to have a condom in his small bowel which required an operation and a two week hospital stay. He could give no explanation as to why or how this had happened. Around the same time the children were found to have scabies. iv. The independent Educational Psychologist’s report, completed in relation to Sibling 2, identified that she was experiencing significant depression, anxiety, anger and disruptive behaviour and ‘emotionally based school refusal’. It concluded that she had moderate learning difficulties, but her needs could be met in a mainstream school rather than boarding school which Sibling 2 and her mother wanted. v. An independent Clinical Psychologist’s report which had been ordered by the Family Court was received by Children’s Services in July 2015. This report identified that Sibling 1 had experienced multiple traumas, including sexual assault and stated that she remained exceptionally vulnerable. It further identified significant concerns for all four children, who were said to need ‘above average parenting’ and concluded that the younger children could be expected to experience the same mental health problems as their older sisters in the future. vi. A Social Work Core Assessment was completed in July 2015 and the contents shared with the family. No decision had been reached as to whether there should be Care Proceedings regarding Sibling 3 and Sibling 4, although further Legal Advice was being sought. The mother’s view was that she would be able to care for the younger children if Sibling 2 was found boarding school and foster placements. On 6 occasions during July the Police were called after Sibling 2 was said to have assaulted family members and caused damage in the home. On one of these occasions it is recorded by the Police that Sibling 2 went to stay with her father but Children’s Services recorded that she went to her older sisters to calm down. On another occasion it was recorded by the Police that she was taken to her father’s address as he was able to control her. The day after Sibling 2 was taken to her father the Police were again called after she was said to have assaulted him. vii. Children’s Services records at this point identify that Sibling 1 and Sibling 2 had been significantly harmed by their parenting. The plan for Sibling 1 was to remain at her boarding placement and foster placement with therapeutic intervention. Sibling 2 was noted as requiring a stable foster placement and it was recorded that the Authority would seek a Care Order on her behalf. A Placement matching form for a foster care placement was completed. The form submitted had previously been completed and submitted in November 2014, and new information, including that within the Independent Psychological Assessment was not included. It was noted that there was a risk that the parents would undermine a placement. The plan for Sibling 3 and Sibling 4 was that mother would receive intensive support for 3 months, but that the contingency plan was to apply for care orders for the two younger siblings. viii. On 12th August 2015 an Admission to Care Panel confirmed there would be a Foster placement for Sibling 2; Sibling 1 would be referred to the Children’s Case U SCR Final for NSCB 23 Case Advisory Service and Sibling 3 and Sibling 4 would be returned to Panel in 6 weeks for further discussion. The Children’s Case Advisory Service would commission intensive daily support within the family home alongside a parenting assessment over a 12-week period. ix. At the beginning of September 2015, a foster placement was identified for Sibling 2 and she finally moved towards the end of the month. From the outset there was considerable concern about her behaviour. Within a very short space of time Sibling 2 described her younger sister as having initiated sexual activity with her and making her perform sexual activities. A Strategy Meeting took place and it was agreed that a S47 Core Assessment should be undertaken. x. Just a couple of days later, on a Sunday in early October 2015, Sibling 2 disclosed to her foster carers that she had been sexually abused by her father. Her foster carer contacted the Children’s Services Emergency Duty team that evening. The Emergency Duty team contacted the mother who confirmed that the other children were at home with her. Given that the father did not live in the home it was concluded that there was no necessity to take urgent safeguarding action that night, but that a full response would be required from the allocated Social Worker the following morning. xi. The following morning the Social Worker told the mother that an allegation had been made by Sibling 2, though no further details were given. The mother was told not to allow any contact between the father and the children until she was given further information. A strategy meeting was arranged between the Police and Children’s Services, but no record of that meeting has been identified. Both parents were arrested, and Sibling 3 and Sibling 4 were removed under police protection powers and placed with separate foster carers. Section 3: Post disclosure October 2015 onwards i. On the day that Sibling 2 made disclosures of having been sexually abused by her father, there was some disagreement between Children’s Social Care and the Police as to the approach that should be taken with the family. The Police position was that the children should be subject to immediate police protection, whereas initially the CSC manager considered that the children were safe to remain with their mother and wanted planned interviews and any removal to take place at school the following day. ii. Foster placements for Siblings 3 and 4 were already being considered within family court proceedings, these were accelerated during the day and the children were taken into police protection at 7.30 that evening. iii. Over the following weeks and months all 4 siblings made a number of disclosures of sexual abuse. These ultimately resulted in the prosecution and convictions outlined at the beginning of this report. Case U SCR Final for NSCB 24 3 FAMILY CONTRIBUTIONS TO THE REVIEW This section of the report documents the views and understanding of the family members about the services they received as they explained them. Those views and their perceptions of what was either helpful or unhelpful are presented in this section in their own right without comment or analysis. Where family members have referred to practice that would not be considered to meet acceptable standards, these will be considered in the analysis section. 3.1 Mother 3.1.1. The children’s mother prepared a written document for the meeting with the Independent Reviewer and Board Manager, outlining her reflections on the family and in relation to the involvement of services. This then formed the basis of a fuller discussion and the contents are summarised as follows. 3.1.2. The mother described her relationship with the father as initially fine but said that he began to become domineering in a subtle manipulative way over time. This was expressed by taking over domestic tasks when she began to have health problems which eventually wore her down mentally and emotionally. She described this behaviour as ‘suppression’. She also spoke about the difficulty of living with his mood swings and depression and said, ‘in the end he wore me down to such an extent I could hardly function’. The mother spoke about the help her own mother would give her. 3.1.3. The mother described having a very close bond with Sibling 2. She described Sibling 2 as having separation problems in relation to her father when she was younger, but that this shifted back to the mother when the couple separated. She described Sibling 2 as becoming distressed and physically violent at any separation from herself. Sibling 2 would constantly seek her attention and would cling to her mother when she was taken to school and refuse to go in. After the parents separated she said that Sibling 2 was happy to go to spend time with her father initially although she would sometimes say she did not want to go to see him. Sibling 2 would worry about her father being lonely and would often spend time with him in the holidays. 3.1.4. She spoke of Sibling 1 as a very bright child who needed a good education but had attendance issues and at her age she was not able to run after her. She described Sibling 1’s mental health as being fine until the point that she (mother) had to go into hospital with a serious health problem that could have killed her. It was Sibling 1 that had found her and rung for help and she felt that afterwards Sibling 1 was scared that her mother might have died and she became very anxious. She confirmed that Children’s Services tried to help Sibling 1 and that the GP referred her to CAMHS, but that they said she didn’t need any mental health help. Mother described Sibling 3 as having no issues and that Sibling 4 had issues around global development delay and hypermobility and that all her needs were met. Case U SCR Final for NSCB 25 3.1.5. The mother was adamant that she had never suspected sexual abuse and that the children had never said anything to her about it. This was something she had thought a lot about and she wondered whether she missed anything? She recognised that she sometimes switched off with Sibling 2 who was always on at her. She said ‘If I had had any inkling, I would have ripped his head off’. She felt that someone should have told her that there had been allegations of sexual abuse previously by a member of the father’s birth family years ago. The father had later asked for his records from Children’s Services in the county where he had lived at the time, but a lot of the information was redacted, so she had no way of knowing what it said. She thought that the Children’s Services in that County should have told someone in Norfolk Children’s Services. 3.1.6. The mother said she had some concerns about the services the family received. She had told the Social Worker (in 2013) that she thought the father’s contact with the children should be supervised because of his mood swings. A worker was identified who then supervised contact, but this ended because there was a problem with how the worker restrained Sibling 1 and they were never given another worker. The mother then supervised contact herself and later agreed that the father would have the children on alternate weeks and that he would have Sibling 2 on his own and Sibling 3 and Sibling 4 would go together. Her mother supervised until the children were in bed. Later she asked again for the father’s contact to be supervised, but the Social Worker told her it was her responsibility to ensure contact was maintained. 3.1.7. The mother valued the support provided by the Targeted Support Team and particularly appreciated one of the professionals from that team who she felt understood her, she felt she spoke to her like an equal and that she could relate to her. She felt that some of the Social Workers did not really understand how difficult it was with Sibling 2 and did not seem to believe her about how aggressive Sibling 2 could be until they saw it for themselves. She felt there was constant pressure and scrutiny on her and not on the father and that she was expected to protect the other children from Sibling 2’s attacks, even though you did not know when it was going to happen. 3.1.8. The mother was critical of Children’s Services for the way they managed finding a placement for Sibling 2. She said that it had been her idea for Sibling 2 and Sibling 1 to go into foster placements as she felt this would benefit them and the family as a whole. However, she thought it was badly planned particularly as the Social Worker told Sibling 2 about a placement which she, as her mother, could not agree to as it did not seem suitable and then Sibling 2had to be told it wasn’t happening. Sibling 2 then got it into her head that her mother did not want her, despite all her reassurances. “I spent almost 9 months with her telling me she wished that I had died when I was seriously ill, regularly violently attacking me and other people for no reason.” 3.1.9. She said that it was not all about Sibling 2, but it was Sibling 2 where the problems were. She felt that she needed more help earlier with Sibling 2 who started displaying aggressive behaviour when she was about two and a half. She described in detail how difficult it was getting Sibling 2 into school. Case U SCR Final for NSCB 26 Looking back, she thought this might be because Sibling 2 felt safer at home. Having the diagnosis of ADHD and mixed neuro development helped but she said that she was not given much information about the diagnosis or what support would go with it, which was important as different traits across the spectrum need different support. 3.2 Maternal Grandmother 3.2.1. The children’s maternal grandmother identified many of the same experiences as her daughter, including Sibling 2’s violence and the lack of supervision of the father’s time with the children. She felt particularly that Children’s Services seemed more concerned with monitoring her daughter than the children’s father. Her view was that the father was alright when he took his medications and could be a loving affectionate dad, but she was always vigilant when he was around because of his mood swings. She also felt that ‘the father had hoodwinked lots of people’. She confirmed that they had been given lots of support, ‘all for the right reasons’ and that the Family Unit had been very helpful. She had not always agreed with the approach some workers took, for example one of the Family Unit officers said they would give Sibling 1 an expensive ticket to a concert if her school attendance improved and questioned why they would reward her for something she should be doing. She described herself as stronger and she believed that you shouldn’t let children rule you. 3.2.2. Maternal grandmother was of the view that it was the sexual abuse of Sibling 2 by her father that had made her violent, which they did not know at the time. She spoke about Sibling 2 not being willing to take her medication and how they had tried for ages to get an educational statement for her. Professionals thought that her behaviour was down to bad parenting, but the doctor changed this attitude with the diagnosis. Grandmother questioned how the mother was supposed to know about the sexual abuse if the children did not tell her. 3.2.3. Maternal grandmother described having a lot of involvement with the children’s care, she would get there early to get the children to school, would do a lot of the housekeeping and decoration and if the mother’s legs were playing up she would do the shopping. The mother could not do heavy housework because of her health problems. Grandmother thought the CAF and Child in Need meetings worked well as they came up with plans, such as taking the younger children off their mother so she could have more time with Sibling 2. She also felt that the school had been very good. Grandmother and mother talked about all the decisions involving the children and were always in agreement. 3.2.4. Grandmother also described Sibling 1 as very bright and believes she was bored at school although with hindsight she wondered if her absence from school was a cry for help. She felt that the house fire which had happened when Older Sibling was about 9 years old had traumatised him and said that that was when he started having problems. She said he was placed in a special unit for a time. However, Grandmother was never worried about Older Case U SCR Final for NSCB 27 Sibling as he was never left alone with the children other than when he and the father were looking after them because their mother ‘was on respite’. 3.2.5. Grandmother was also critical of Children’s Services for the delay in finding Sibling 2 a foster placement and then leaving her in limbo for 9 months before another place was found. 3.3 Older Sibling 3.3.1. The children’s Older Sibling met with the Independent Reviewer and Safeguarding Children Board Manager accompanied by his Probation Officer. 3.3.2. Older Sibling began by saying that he felt that the various agencies could have done more to help his family, in particular that they should have recognised the problems with the father and the younger children earlier. He questioned why the information about allegations against the father when he was younger was not brought up. He spoke about the numbers of different people coming into the family ‘there were people coming in and out every day…..the family was passed from this group to that”. 3.3.3. He said that when the Social Workers first got involved with his family they were ok and helpful. However, his memory of the Social Worker who was involved in 2015 was not positive. He did not like her manner and said she would behave in a way that led Sibling 2 to ‘kick off’, but then blamed this on their mum. He felt that she had influenced Sibling 2 in making some of the allegations and that all she wanted was to take his younger sisters away. He also referred to an occasion when he believed another worker was present when the father had done something to Sibling 2 and yet this worker had not spotted it. 3.3.4. Older Sibling was very positive about one of the workers from the Family Support Team and said that if anyone could have helped it would have been her. He said that she was able to calm Sibling 2 down and helped his mother with her confidence. ‘she seemed like she actually cared and wanted to help’. He also remembered a PCSO who had been friendly and tried to help, chatting to him about his problems. Older Sibling’s experience of school was mixed in that he felt quite happy in school until year 8 (when he would have been 13 years old). At this time, he said he had become very scared for his mother because of the fire his own father had set in the house when he was younger and he became scared to leave her so stopped going to school. He did go back to school later and would attend the Excellence Centre which involved going in on different days and times and this worked for him. But he felt it had been very unfair that he had not been allowed to take his GCSEs, which he said he was told was because he had had a fight when he was in Year 9. 3.3.5. Older Sibling particularly thought that the services could have helped more with Sibling 2, who described as being confused ‘because of her complaints’. He believed that his younger sisters felt terrible pain at ‘being ripped from their Case U SCR Final for NSCB 28 family and each other’. He spoke positively about his mother and said that she loved him and all the children, that she did her best but couldn’t cope. 3.3.6. Older Sibling described getting ‘a little bit of help with his mental health issues’ from the Family Support Unit workers, but that he only had two appointments. He was not exactly sure who everyone was, but he talked about meeting with a ‘younger lad’ who he had connected with, but then an appointment being cancelled and not seeing him again. Another worker had not been helpful and he said that offers of help to get him into employment had been ‘empty promises’. What he felt he had needed would have been to be given help ‘getting my mindset right, sorting my mental health out, help becoming a man”. 3.3.7. He also explained that he had had counselling provide by CAMHS from the age of 10 up to the age of 17. He did not think this counselling was helpful because it was always about reliving the trauma of the house fire, he described having hypnotherapy, but he did not want to relive it, he wanted help to walk away from it. He described suffering from flashbacks and being very stressed when he came out of the hypnotherapy, but that the worker had done nothing to help him calm down afterwards. At the time he had not felt able to say that he didn’t think it was helping. Older Sibling felt that although they knew about the trauma he had experienced they didn’t really understand. He said that he later self referred to the mental health Wellbeing service, but was never given an appointment. 3.3.8. Overall Older Sibling felt that it would have been better if professionals had asked him more about what he wanted rather than deciding for themselves what would work for him. He believed this meant that he was often ‘set up to fail’. “People could have listened more….they worked around their ideas to a pre-set plan and my thoughts weren’t taken into account”. He felt that what families need is “someone to trust, someone to listen and help instead of having the mindset of ‘do it my way’”. 3.4 Sibling 1 3.4.1. Sibling 1 provided a powerful and rather dismal picture of her experience of social work during the time period of this report. She was not impressed that Social Workers behaved as if they knew her whole family even though they only saw them once every 6 weeks. Her overwhelming response was that she was irritated by being told what to do by people who barely knew her. In her words, “if I’m not going to do what my mum tells me, why do you think I’m going to listen to you when you have only met me for 5 minutes”. From Sibling 1’s point of view, these were complete strangers who did not understand or know her but still thought they could tell her what to do. She was particularly infuriated with one Social Worker who started telling her what to do the very first time she met her and would say, in what sounded like quite a bossy manner, that ‘this was the bottom line’. 3.4.2. Sibling 1 did feel that a couple of workers were better, although because of how she was feeling at the time, she still would not have been willing to talk to Case U SCR Final for NSCB 29 them. What made a difference was when people spoke to her more like an equal and had a conversation with her that didn’t feel she was being talked down to. She said that she knew she was a ‘bit of a bitch’ and wasn’t open to speaking to professionals. She had felt that everyone was ‘constantly on my case’ and that just had the effect of making her more rebellious than she already was. She knew in her head at the time that she was probably making the wrong decisions, but that was just what she was doing. 3.4.3. Although she was offered other services to go to for support she simply was not in the frame of mind for them. The offer of Young Carers she felt was particularly pointless. She did not see herself as a Carer, she was simply doing things like making her mum some toast or a cup of tea, things that anyone would do for their mum. Sibling 1 was also especially critical of her experience of CAMHS. She described going for a first meeting and actually beginning to talk quite openly about herself. She had been having suicidal thoughts and was still anxious about her mum. But she said that their report labelled her a ‘manipulative attention-seeker’ and she shut off completely. She said that experience stopped her wanting any counselling. Although she has more recently had some counselling she is clearly still a little distrustful of the process. She was also referred to the Rose Project because of the CSE but only went once as she couldn’t see the point. 3.4.4. Sibling 1 described being out of the house a lot of the time, mostly spending time in a park in the city where drug users were. She said that she only smoked weed but now realises that she was at quite a lot of risk. There were several things that were happening which meant she was in her words ‘rebelling’. Being the one who had to call for help when her mother had ended up in hospital evidently had a powerful effect on Sibling 1. As well as what was happening with the father, she said she was also being bullied at school. And of course, she was a teenager. 3.4.5. Sibling 1 was very critical of the way the Social Worker, and others, had viewed the father. When her mum was having respite, the Social Worker thought he was the better parent and wanted him to have more contact with the kids. He would come over to the house and look after them. He had fooled professionals. Whilst Sibling 1 knows that the Social Worker didn’t know what else was happening, and she didn’t mean to, but she put her and her sisters at more risk from the father. “You could see that with his mental health issues he wasn’t capable…just that, without anything else that was going on.” 3.4.6. The way that she was told about going into care had made her very cross. She said she was not asked what she thought or ever told in advance that it was a possibility. She should have been given a chance to say what she thought. When she first went to boarding school, she was there all week, just coming home at weekends. She had been out of school for most of the last 3 years and it was quite a change, quite fun. But after being at home for the Christmas break she didn’t want to go back. The Social Worker threatened her with going into Care then and said, ‘the bottom line is boarding school or no school …so of course I chose no school…’. After that she had spoken to her mum and then with her mum and the Social Worker and they said they Case U SCR Final for NSCB 30 were looking for foster placements. Sibling 1 said she ‘went mental’, she had never been told Care was a clear option. She was told it was because she was a high risk of CSE. At the same meeting she said that the Social Worker told her mum to look into her children’s eyes and tell them she had failed them. Sibling 1 thought that was a terrible thing to say. 3.4.7. Sibling 1 did not think that she would have been able to talk to anyone about what was happening with her father at the time. There were opportunities to say something, but he had threatened her. She was scared to tell anyone. But with the right person and right approach she might have talked about other things, like her mother nearly dying, and perhaps that might have led on to something else. The Social Workers at the time never saw her on her own, although one of them did try. Her sisters wouldn’t see them on their own either. 3.4.8. When she did go into a foster placement it initially worked well and she really liked the family. She started going to school again. But the placement broke down after Sibling 2 told people what had happened, and her mother was arrested. That was in her exam week and she was told at school and then was told she couldn’t see her mum. She wanted to see her family and friends and be distracted so she stayed at school for three weeks. The Social Worker thought this meant she should have a different foster placement so then she changed. Eventually Sibling 1 decided she also had to say something or the father would get a shorter sentence. The first person she told was her foster sister. 3.4.9. Sibling 1 also spoke about her life since her sister made the disclosure. In particular she found it really difficult that she was not allowed to see her mum and her sisters. ‘I didn’t have anyone at the time I needed my mum most’. She said that no-one had ever really explained why this was. She thought that once everything was over she would be told more but that hadn’t happened. She can see her mum now and her mum has told her, but she has never been told by anyone why she couldn’t see anyone at that time. It was very lonely. Sibling 1 also questioned why she was not allowed therapy before the trials. Again, she said that no-one had ever talked to her about this. 3.4.10. It had also been difficult for Sibling 1 to understand why she could not see Sibling 2. She said that she loved her little sister to pieces, but when they were younger she had been angry with her because of her behaviour with their mum. She now understood more that this was about Sibling 2’s special needs. She also wanted to know more about the father’s convictions, she knew there were other people who had been abused. She could guess who this might be, but no-one had told her. Sibling 1 accepted that there might be some difficult things to hear but said “I am 16. I can handle it. Everything’s sorted now, but I still have questions….it would help me move on.” 3.4.11. What Sibling 1 really wanted was someone who would just be there for her. Someone who would listen, not nag and tell her what she should do all the time. Just listen and be there for her. Case U SCR Final for NSCB 31 3.4.12. As a result of what Sibling 1 said about not knowing some important information about her family, the Independent Reviewer asked Children’s Services to ensure that all relevant information was shared with her. An arrangement was therefore made for Sibling 1’s Social Worker to specifically prepare Sibling 1 for the fact that there would be information and views in the Serious Case Review some of which might contradict her understanding of what had happened in the family. 3.5 Sibling 2 3.5.1. The Independent Reviewer and Board Manager met with Sibling 2 in the residential unit where she is currently living, supported by the House Manager. Sibling 2 had been nervous about the meeting but spoke quite openly given the circumstances. The House Manager confirmed that what Sibling 2 said reflected their understanding of her experience. Sibling 2 also said that the Independent Reviewer could speak to her Social Worker about how she felt. Sibling 2 was very positive about her current Social Worker. “she helps a lot, she is good at talking”. 3.5.2. Sibling 2 remembered various professionals, including teachers at school that she had liked and some that she did not. She said that she hated school because she was bullied and beaten up. Sibling 1 did not go to school and Sibling 2 thought that was clever. Sibling 1 told her not to go to school, so she did not go. Sibling 2 is now attending school every day and making very good progress. 3.5.3. Sibling 2 could not have been clearer about what the Social Workers could have done to help her “they could have got me out of the house sooner. They could have got me out when I was four”. Of those she remembered there was one Social Worker she really did not like and said that she talked a lot of junk and that the Social Workers tried to get her into school when she didn’t want to go. When she was not in school she would be at home watching television. 3.5.4. We talked about her understanding of the diagnoses she had been given. “they kept putting me on tablets. It was stupid. None of it made sense”. Sibling 2 is very pleased that she had been taken off most of the medication she previously had. She now only has medication to help her sleep and she is going to see the Community Psychiatrist soon to see if she can also stop this medication. She told us that her family always said she had special needs and that her father used to push tablets down her throat. She questioned whether this had been right. The Home Manager spoke about how much progress Sibling 2 had made, she had lost a lot of weight, she was going to school every day, had friends and was doing activities. Sibling 2 was obviously proud of what she had achieved and told us in particular about horse riding which she does regularly. 3.5.5. Sibling 2 talked a little about who she had told about what was happening to her. She said that she told her best friend and told her why she was always Case U SCR Final for NSCB 32 running away and ‘kicking off’. She thought about talking to her friend’s mum, but then she didn’t say anything, because ‘she had her own kids to worry about’. She felt that no-one was listening to her. She talked to one of her older sisters, but she lived a bit far away and she couldn’t speak to her about the abuse. Sibling 2 was very clear that she had told her Mother a few times and her Mother’s response had been “so shall we call the police?”. Her older sister said not to do this as they would end up in Care, which is what happened. Sibling 2 did not like going to CAMHS. “I didn’t like talking…. I was worried they might guess”. 3.5.6. Sibling 2 did not really understand why she was being taken into Care and taken away from her sisters. But when she got to her first foster placement, the foster carer listened to her and that is when she told. Sibling 2 said “dad told me not to tell anyone what happened. But I don’t keep secrets about that horrid stuff. They only secrets I keep are birthdays and Christmas”. Sibling 2 told us that she is doing life story work and the abuse is just Chapter 1. We asked Sibling 2 what would help other children like her in the future and she replied: “it would help if you make sure they’re safe. Put them in a safe place. If I wasn’t in care I probably wouldn’t have survived” 3.5.7. Meeting Sibling 2 allowed us to see a young person who has made incredible progress since she first disclosed what happened to her. She feels safe, she has ‘nice adults’ around her, she is making progress at school, she enjoys seeing her younger sisters, and she has reached a point where both she and the professionals around her are questioning whether any of the diagnoses that she previously had are in fact accurate. The Sibling 2 we met and who is now known to her Social Worker and other professionals, is a funny, quirky and endearing individual very different from the picture that might otherwise have emerged during this Review. We asked her what message she would want to give to professionals who had worked with her before and she replied: “I’m fine, thanks.” 4. APPRAISAL OF PRACTICE AND ANALYSIS 4.1 Introduction 4.1.1. This Section will appraise the key aspects of multi-agency practice that have been identified by this Review. It will consider what multi-agency learning there may be for future practice in respect of the Terms of Reference outlined by the Safeguarding Board and any other learning that might have emerged. This analysis will also take into consideration the NSCB’s Thematic Learning Framework. The analysis will be structured under two overarching headings: Understanding what was happening in the family The responses to the children’s needs. Case U SCR Final for NSCB 33 4.1.2. The analysis will consider the key features of the practice of those agencies involved, identify where practice standards may not have been met and seek to understand why this may have been the case. It will use examples to illustrate the most significant aspects of practice. Through this approach it will reach conclusions about the significant learning which has relevance to current and future working practice and processes. 4.1.3. Where individual agencies, or the multi-agency partnerships, have already established appropriate learning, and taken action within their agency, this will not result in further recommendations within this Review. Similarly, where practice has already been addressed, including as a result of previous Serious Case Reviews further recommendations will not be made. 4.2 Understanding what was happening in the family 4.2.1. At the core of these children’s experience was the difficulty professionals and agencies experienced in making sense of what was actually taking place within this family. Whilst this Review cannot assume to fully understand all the complexities of the children’s experience it is clear now that both neglect and sexual abuse were present. There is no doubt that different professionals and agencies identified neglect of the children as a cause of concern from as early as 2006, when Health Visitor assessments recorded concerns about the home environment, parental capacity to respond to the children’s needs, parental mental and physical health problems and the impact of all these on the children’s development. Whilst this was recognised by many of the agencies, the chronic nature of that neglect and its implications for the children were too slowly identified and responded to. 4.2.2. What is now also clear but was less so for much of the time under consideration, is the limited capacity of the parents to meet the children’s needs over time. While often presenting to agencies as cooperative, in reality the children’s carers repeatedly failed to make the positive changes that the children needed. This was without doubt recognised by some of the professionals involved, for example the Family Support team explicitly ended their involvement in an attempt to highlight the lack of progress. It was also the case that by 2014 problems with parental ability or willingness to make changes was also being recorded by Social Work managers and the outcome of these concerns will be considered further in this report. 4.2.3. However, it was not until Sibling 2 was removed from the home and made a direct disclosure to her foster carer that the reality of the sexual abuse which had been taking place within the family was finally understood. Again, with hindsight it is possible to identify that there was both direct evidence and symptomatic evidence that some of the children might be experiencing sexual abuse. There is no doubt there were concerns at the time about the children and, for some professionals, a sense that there was something else behind the children’s behaviour. However, for reasons which will be explored later in this analysis, this did not lead to an understanding of what was taking place Case U SCR Final for NSCB 34 4.2.4. The issue of neglect and the quality of the multi-agency response in Norfolk has been explicitly recognised as an area for improvement for the partnership and has been a priority area for the Safeguarding Children Board since 2014. A number of Serious Case Reviews and other multi-agency reviews have previously identified neglect as an area of concern, as did the 2015 Ofsted report. A Revised Neglect Strategy was adopted in June 2017. This both identifies neglect as a top priority for the board and recognises that further work is needed to ensure effective identification and response. Specific steps have been taken by the partnership including the introduction of the Graded Care Profile12 and the use of Signs of Safety13 which are subject to ongoing monitoring and outcome evaluation. The response to neglect in relation to this family reflects the wider concerns identified for the partnership at that time. Given the continuing level of recognition and response to neglect, this will therefore not be considered in further detail except if there is new learning as a result. 4.2.5. The history of Family U as seen and experienced by all of the agencies involved with them, was of multiple problems and needs. They were a family living in one of the most economically deprived parts of the county14, where many services were under significant pressures to meet the needs of families they worked with. This was a family, with a large number of siblings, the older of whom were living away and about whom there is limited information. Older Sibling seemed to be in the home more frequently, sometimes with a girlfriend. It was not always clear if and when he was actually living in the home, but it was known to some that he at times took on a parental role with the younger children. There was little recorded as to any relationship between Older Sibling and Sibling 1 and their own father. Whilst there was some information about family history, there is little evidence that this was well understood by any one agency or professional working with the 4 younger children. 4.2.6. Not only were there multiple problems apparent within the family, it is also clear that professionals working them could also be faced with situations of fairly high emotion. School staff referred to there being constant dramas and another professional referred at one point to a ‘hysterical atmosphere’ in the home during a visit. Professionals were not infrequently witness to or attempting to help deal with a variety of difficult situations: attempts to get the children out of the house and to school; Sibling 2 in highly visible distress including becoming violent; Sibling 1 walking out or running away. Professionals did not experience threatening behaviour themselves from the mother or grandmother, although there were some recorded incidents with the father. Overall this was a family where there was a significant amount of noise which it is evident had an impact on how professionals were able to respond. 12 The Graded Care Profile is an established, evidence based tool for assessing neglect. 13 Signs of Safety: An evidence based system for risk assessment and intervention in child protection 14 The area in which the family lived was ide identified in the latest Indicator of multiple deprivation as in the bottom 10% in the country. https://www.gov.uk/government/statistics/english-indices-of-deprivation-2015. Case U SCR Final for NSCB 35 4.3 Medical diagnoses and managing behaviour 4.3.1. What is particularly striking is the way in which the children were presented in terms of medical diagnoses. Children’s Services identified that when a new worker went into the house they would be told each child’s name and medical diagnosis. Other professionals described the mother as having her own medical and behavioural file on each of the children although the contents were not shown to professionals. Older Sibling had been identified as having a range of defined conditions, including ADHD and depression. Sibling 4 was diagnosed as having a learning disability and developmental delay and at one point the Mother is said to have pushed to obtain a diagnosis for Sibling 1 as having a bipolar disorder. Information available to the Review since the children’s removal into care raises questions about the various medical and developmental labels given to differing degrees to all the siblings. Rather it would appear, that all the children were showing symptoms of complex emotional damage, trauma and significant attachment difficulties. This was also powerfully reflected in the psychological report prepared for court proceedings in 2015. 4.3.2. It was however Sibling 2 who was most powerfully presented almost entirely in terms of her diagnoses. The mother has told this Review that Sibling 2’s symptoms began when she was only 2 years old. The first reference of any concern was regarding contact with the Speech and Language Team when she was 3 years old and also that she had an Individualised Educational Programme, an approach designed for children with learning needs. At 4 years old she was referred by her GP to CAMHs for behavioural difficulties, including aggressive behaviour and by 5 years old she had been referred to the Community Paediatrician for temper tantrums, developmental delay and eating problems. The Community Paediatrician, who was concerned about Sibling 2’s presentation, referred her to the Health Visitor for a follow up. 4.3.3. From the outset, the Community Paediatrician felt that Sibling 2 was likely to be in need of psychological help rather than the particular medical perspective of a Paediatrician. Despite her attempts to link Sibling 2 with Health Visiting and Psychological or other support, the family continued to bring her back for a Paediatric assessment. The Community Paediatrician ultimately did make a diagnosis of both ADHD and mixed neuro developmental disorder. She did still consider that Sibling 2 may well have had ADHD, but also always felt that there was something else that needed unpicking. She was under some pressure from the mother to provide a diagnosis and her experience was that if Sibling 2’s behaviour was better managed she would be more likely to be able to remain in school which would be in her interests. 4.3.4. The Community Paediatrician described the pressures on doctors to provide diagnoses of ADHD and was frustrated at the appeal that medication holds for many parents. The Paediatrician’s view was that the medical model and system, of which she clearly recognised she was a part, should be changed to focus on a more multi-agency approach with less focus on diagnosis and medication and more on what the cause of the presenting behaviour might be. A Community Paediatrician at that time would see a child on average for 20 Case U SCR Final for NSCB 36 minutes every 6 months and would have a case list of 600-700 children. It is therefore evident that in this context, making holistic assessments for children presenting with complex problems in the absence of a full assessment of the family functioning, would be extremely difficult. 4.3.5. The mother, in her contributions to the Review, spoke about how the diagnosis had helped as it had led to “more support and discussions about strategies for managing her behaviour”. What is not explained is how it helped Sibling 2 and indeed, given what is described throughout as Sibling 2’s increasing behavioural problems, it is evident that the diagnosis in itself did not lead to any significant improvements for Sibling 2. 4.3.6. The diagnoses that Sibling 2 had in 2009 however had a powerful impact on other professionals. Over time her diagnoses were routinely referred to by the family as the explanation for all her difficult behaviour and this does not appear to have been challenged by professionals. One of the GPs reflected that once a Paediatrician has made such a diagnosis, they would not consider challenging it. Similarly, school health assessments were focussed on what they understood to be the children’s existing medical conditions rather than taking a more holistic view of their health. The Police were called out to disturbances involving Sibling 2 on 9 occasions in just over a year (2013) but they too accepted the view that Sibling 2 was aggressive as a result of her ADHD. Although the local PCSO who attended the house on a number of occasions made several referrals, neither he nor those in the police dealing with these notifications considered questioning what was happening in the home or sought a response from Children’s Services. In effect Sibling 2’s diagnoses were viewed as even more defining by other professionals than it was by the diagnosing doctor. 4.3.7. Some professionals did consciously try to keep in mind Sibling 2’s symptoms and behaviour rather than just seeing the label of ADHD. The safeguarding lead at the school who had been told that Sibling 2 had various problems including Tourette’s, Autism and ADHD had doubts that there was evidence of any of these. However, the continual reinforcement of these labels obviously impacted on the way the professionals understood Sibling 2’s behaviour and had the effect of distracting from any other explanations. This was not only in relation to Sibling 2 herself, but also to other problems in the family for which she appeared to serve as a scapegoat. There is for example evidence of the Mother distracting family support workers from the other children’s problems by talking about Sibling 2 or by blaming Sibling 2’s behaviour. However, what is evident from the school is that the children were able to make progress when working with skilled professionals. Although this was recognised it did not lead to a fundamental rethinking of what this might say about the causes of the Sibling 2’s behaviour. 4.3.8. It was not only the professionals who were significantly influenced by Sibling 2’s diagnosis. Sibling 2 herself had clearly understood that she was seen to have something wrong with her, asking one professional (CAF): ‘will they be able to make me better?”. Case U SCR Final for NSCB 37 4.3.9. It must be acknowledged that undoubtedly Sibling 2’s behaviour did become very difficult and that she was witnessed being violent to her family causing bruising and other injuries. She was very rarely violent towards professionals and only then when they were attempting to help the mother or grandmother manage her behaviour. School staff spent a considerable amount of time attempting to coax her into class but on those occasions they succeeded she would settle quite quickly and was described as being fully accepted by the other children. 4.3.10. Whatever the underlying cause of Sibling 2 and her siblings’ behaviour, there is no doubt that the adults’ powerfully presented views of the children acted like a smokescreen, distracting professionals from other possible explanations. A very similar concern had also been identified in a previous Serious Case Review15, and a recommendation made about the impact of labelling a child with ADHD and the capacity of that label to distract from the quality of parental care. 4.3.11. In June 2017, Norfolk Community Health and Care NHS Trust put in place a new pathway for ADHD and Autism Spectrum disorders. This arose from the recognition that many of the referrals did not require assessment by a Paediatrician and that there needed to be a significant rethink about this approach in order to ensure a quality service to children and families. As a result, a new single Neurodevelopmental Service was created to provide a joint service for children in relation to ADHD and Autism Spectrum Disorders (ASD). This was developed in conjunction with other partners including GPs and schools and has included a revised approach to referral criteria. Children are assessed by a team of specialist nurses, therapists and psychologists and will be seen by a Paediatrician if assessed as necessary by this team. Further work is being developed in relation to a range of interventions subsequent to assessment. 4.4. The adults in the family: The Mother 4.4.1. The children’s mother was the central adult figure in the family and was seen frequently by a range of professionals. However, there appeared to be limited knowledge as to her own family background and what life experiences might have influenced her approach as a parent. Whilst there was some information about significant events in her background, there is no recorded evidence of any systematic attempt to understand her history. In the absence of this sort of information agencies were working without knowing fundamental aspects of what she was bringing to her parenting of the children. 4.4.2. Professionals were very aware of the mother’s own health problems, which were often cited as reasons why she could not undertake particular aspects of child care. The mother experienced some serious medical complaints, including one occasion when she was admitted, as an emergency, to hospital for 10 days. This particular event remained a defining feature of the family’s story. It was viewed and described by the mother and grandmother as a 15 SCR Family L October 2014: Sally Trench and Sian Griffiths Case U SCR Final for NSCB 38 significant explanation both for aspects of the mother’s parenting and for some of the children’s behaviour. As was the case with the children’s diagnoses, this was largely accepted by many of the professionals meaning that other possible explanations were not always considered. 4.4.3. Both Sibling 1 and Sibling 2’s school refusal was linked by the family to separation anxiety due to worries about their mother’s health. Sibling 1 told the Review that she now felt that one of her reasons for being absent so much from the house was linked with her anxiety about her mother dying. Similarly, Sibling 2’s school attendance was considered by the family to be an expression of her need to be with her mother. The underlying reasons for the problems with school attendance, which took up a great deal of professional time and energy, necessitated much greater challenge and exploration, but this did not happen. 4.4.4. It was 11-year-old Sibling 1 who called her grandmother for help when the mother had the very serious health episode that led to her being hospitalised. This would no doubt have had a significant impact on Sibling 1. In a calm, reassuring environment with good attachments between children and their carers, it should have been possible to contain and reduce any subsequent distress or separation anxiety. However, reassuring parenting or praise of children was largely absent from the parenting that the professionals observed. There is for example considerable evidence that all the children were exposed to inappropriate levels of adult information, some of which will have raised anxieties. This included frequent conversations about the mother’s ill health and as the mother described to the Review “they had never seen blood clots like it and I was lucky to survive. This scared Sibling 1 as she realised her mum might have died and she became very anxious’. 4.4.5. Whilst this Review does not doubt that the mother’s health was significant in family life, what is of concern is that this again seemed too easily to become an explanation of the family difficulties. That, for example, Sibling 2 could actually settle well in class once she was away from her mother might have suggested that her relationship with her family was more complicated than was being presented. Separation anxiety disorder is a recognised condition, but again this appeared largely to be a parental diagnosis, rather than a psychological or psychiatric diagnosis. What appeared to be taking place was that the mother’s ability to present her own perceptions in such an effective way resulted in Services being largely focussed on managing the extreme behaviour rather than understanding what the children, particularly Sibling 2, were expressing and trying to help them and their carers reduce the causes of the anxiety. Why it proved so difficult for professionals to take a step back from the concerns of the mother will be considered further in this section. 4.4.6. The mother’s relationships with other men was also of some concern to various professionals. She was open about using the internet to contact and initiate relationships with men. Despite her ill health preventing her from taking her children to school, she was nevertheless able to visit one of these men in Kent at weekends. Some of the professionals were uncomfortable about obvious indicators that the mother was very sexually active and that this was not kept away from the children but was in fact something she would openly talk about in front of them as well as to professionals. The mother considered that her Case U SCR Final for NSCB 39 relationship with Sibling 1 was like that of a friend, something which both she and the grandmother saw as a positive. One of the professionals, who was very worried about lack of a proper parenting relationship from the mother to Sibling 1, described never having heard the mother talking to Sibling 1 about anything other than who they fancied, which bands they liked and boyfriends. 4.4.7. There was also concern for some about the mother’s unwillingness or inability to act on advice or make changes to her parenting, the impact of which will be considered further in Section 5.6. Whilst some believed that the mother could make changes, there were also those who were frustrated that agreements to make those changes or to follow through on plans were short-lived. The conclusion of one of the workers who had significant contact with the family was that mother ‘had the ability to take on information but didn’t follow through. Her needs outweighed everything else.’ 4.5. The adults in the family: The Grandmother 4.5.1. What has emerged during this Review is that the children’s maternal grandmother played a much more significant role in the family than was always understood. Certainly, some of the professionals were very aware that the grandmother provided a high level of care and practical support in the home. She was a regular attender at meetings, would take the children to appointments and was known to be very supportive of her daughter. 4.5.2. Grandmother told the Review that she helped her daughter out daily as she was not able to do heavy housework because of her heart condition. Grandmother would arrive early in the morning, tidy the house, help get the children into school, do all the decorating and do the shopping when her daughter wasn’t well enough. Grandmother shared her daughters’ views of the family situation and said that they two of them discussed all the decisions. She confirmed the view that the mother only needed help with Sibling 2 because of her medical problems. 4.5.3. On occasion Grandmother’s parenting style clearly caused some professionals concern. From her own description to this Review she took a quite robust approach to parenting. A better understanding of how much of the practical parenting was being undertaken by the maternal grandmother, what influence she had on the approach to parenting and how the children experienced her in that parenting role, should have been a significant part of an assessment of this family. 4.6. The adults in the family: The Father 4.6.1. After the parents separated it appears that the father continued to have a significant level of involvement with the children. Records from the different agencies are not always clear about the level of involvement he had, and he was viewed by several of the agencies as very much on the periphery of the family. It is now apparent that he actually had significant contact with the children. The services that were offered to the father however, were Case U SCR Final for NSCB 40 predominantly for him as an individual rather than as a member of a family. As with the mother, there was no detailed assessment undertaken regarding his role as a parent and no chronology that would have led to a better understanding of his history 4.6.2. There was information that the father had experienced mental health problems and was regarded as vulnerable by mental health services. The father had intermittent periods of contact with his GP and mental health services prior to and throughout the children’s lives. In 2006 the mental health Trust (NSFT) assessed the father as having a moderate learning difficulty and recorded that he had a long history of depression and had himself experienced abuse as a child. He spoke of being anxious and scared about being a father due to the way his own father had treated him. He said that he was going to attend parenting classes and gave his permission for his information to be shared with his GP and Children’s Services. 4.6.3. The father had moved out of the home in 2006 following the incident when Sibling1 complained about having washing up liquid put in her mouth and also made what appeared to be allegations of sexual abuse by both the father (her stepfather) and her brother. The focus of the response by Children’s Services and the Police at this time appears wholly inadequate. Children’s Services records suggest that attention was only on the washing up liquid issue and on the father’s depression and mental health. It was said that he should not have any unsupervised contact until his ‘mental health issues had been addressed’. It appears from NSFT’s records, that he was in fact referred to and assessed by them, though there is no reference to this in Children’s Services Records. 4.6.4. The mental health practitioner subsequently contacted Children’s Services to inform them that the father was planning to return to the family home and to discuss his risk and treatment. The records then state that the Social Worker said the case was closed and that in any event she would not have been willing to discuss the father and would not accept any information from the mental health service about him. Eventually the father returned to the family without any record of an assessment or obvious involvement of Children’s Services. 4.6.5. Given the passage of time it has not been possible to reach any specific conclusions as to why Children’s Services responded in the way they did to these events. Both the absence of any serious follow up of the allegations of a sexual nature and also that the father simply returned to the home without any further assessment would have been considered very poor practice at that time, as it would be today. If an assessment took place but was not recorded, then this would have been equally unacceptable as it would have meant an important source of information was lost. 4.6.6. The Police investigation was equally poor. No interview was conducted with the father and no crime was recorded. Norfolk Police have described a significantly under resourced Child Abuse Investigation Team during this and poor data recording systems, which might provide some context to the lack of a robust police investigation. 4.6.7. It is not the case that there is direct causal connection between being the victim of abuse and becoming an abuser. However, the knowledge that the father Case U SCR Final for NSCB 41 himself had experienced childhood abuse, combined with his own stated anxiety about being a father, should have been recognised as a significant factor in the assessment of his parenting capacity, including any potential risks he might pose. That this information was not accepted by Children’s Services at that time was a fundamental error. 4.6.8. It is apparent that the father was felt to be someone who was vulnerable and who himself probably had learning difficulties, “he attended in physical form, but did not add much to the sessions.” There was a general sense for example in CAF and Child in Need meetings that he ‘appeared to do the right thing’ although there were also occasions when he would become very angry and on at least one occasion was threatening to a worker. 4.6.9. With the benefit of hindsight, we can now see that this picture of the father was at best very limited, at worst fundamentally mistaken. More than one of the professionals has since reflected that they were taken in by the father, that perhaps they were groomed by him. The siblings who spoke to the Review talked about professionals being taken in, ‘brainwashed’ by the Father. Sibling 1 particularly felt that even not knowing about the sexual abuse, it should have been obvious that given his mental health problems the father was not a good parent. And Sibling 2’s perception about her father’s apparent problems is humbling: “Dad’s ADHD was not an excuse to be a jerk. He would use anything as an excuse”. 4.7. The adults in the family: Older Sibling 4.7.1. Older Sibling was also a significant part of the family at this time. There was information available during the key period covered by this review that Older Sibling had a complex history and was a young person with a number of serious difficulties including anger management, and who had also been assessed as having ADHD. An allegation of rape had been made against him in the past and there were other indications of worrying behaviour. He was referred to CAMHS on more than one occasion and was understood to have been traumatised by a serious fire in the family home when he was younger. 4.7.2. What professionals saw was a complex and at times contradictory young person. One of the family support workers described Older Sibling as ‘charming, polite and articulate”, but also said that he often appeared as if he had the weight of the world on his shoulders. Others witnessed him being quite authoritarian, even intimidating with the younger children and assuming a ‘man of the family’ role after the father left. There is information about an at times very difficult relationship between Older Sibling and Sibling 1 with a lot of angry arguments. As was the case with the parents, what was missing was a joined up understanding of Older Sibling, his own experience of being parented, and what part he played in the way this family worked. Case U SCR Final for NSCB 42 4.8. Understanding the children as individuals 4.8.1. One result of the overwhelming emphasis on the family’s story on what was wrong with the children, was that it seems to have made it difficult for the agencies involved to gain a proper picture of the needs of all four children. Sibling 3 and Sibling 4’s views and voices are largely absent in records and they would frequently be sent upstairs when Social Workers or others visited. Whilst considerable support was brought in to help Sibling 1 and Sibling 2, the younger children were not identified as being a problem from the parental perspective and as a result of this they did not attract the same sort of professional attention. 4.8.2. Sibling 4 was identified as having special educational needs as a result of which she was eventually transferred to a specialist school. There had been a range of concerns about Sibling 4 as a young child, in particular including early failure to thrive. However, for much of the time the focus for professional intervention was predominantly on her educational needs and she was not subject to the intensive attention or support that was being provided for her older sisters. 4.8.3. Sibling 3 in particular remained largely unknown within the timescale of this review. She was described by school staff as quiet and compliant: “she was missed – she was so good she went under the radar. She was doing everything right.” 4.9. Indicators of Sexual Abuse 4.9.1. As is identified in the narrative section of this report, there was information about previous allegations of a sexual nature within this family that could, or should, have triggered much greater concern about the children’s safety. This included separate allegations made by two of the children in 2006. Although it is outside of our prime-time period for analysis, one of these allegations links to a concern which has also been raised specifically by the family. 4.9.2. The mother, Older Sibling and grandmother believe that statutory authorities in Norfolk should have been aware that there had been an allegation of non-recent sexual abuse against the father and another family member when they were in another area of the country. The mother told the Review that the father had asked for a copy of his records from a period when he was in the Care of another Local Authority. These notes were apparently heavily redacted, and the mother and Sibling 1 believe this must have been because of this allegation. As a result, they question why the originating authority did not share this information with Norfolk. In fact, at the time the allegation was made in 2000 the records show that the father was not living in Norfolk and was also not known to have any children. The authority who received the information did pass on their concerns in relation to the other family member who lived in another county about whom the allegation was made and who did have children. Case U SCR Final for NSCB 43 4.9.3. Intelligence about this allegation was also provided to Norfolk Police by another Police area in 2006 when they were investigating the allegation of possible sexual abuse previously referred to in Section 5.7. There is no evidence that the Police told Norfolk Children’s Services about this allegation which they undoubtedly should have done. It is particularly concerning in that the person who raised the allegation had gone to Children’s Services in the originating county specifically because she was aware that the father had children. There has been clear recognition by the Police that this was very relevant information that should have been considered. The only explanation that is available to us remains the limited resources in the police Child Abuse Investigation team at that time. 4.9.4. It is not clear if Norfolk Children’s Services were aware at the time that the father had been in care in another area, and there is no evidence that Norfolk was aware of the allegation made against him. Had it been known the father had been subject to Care this might have at least triggered a greater level of consideration of his role in the family. Had Children’s Services also been made aware of the allegation, then it would have been reasonable to expect that further enquiries would have been made. As this was an allegation which had not at that time led to a criminal conviction, it is not possible to judge what impact this would have had, but good practice would have been to undertake a risk assessment. Whatever that assessment concluded it might, if nothing else, have alerted professionals to the possibility of sexual abuse as an explanation for behaviour and difficulties within the family. 4.9.5. A detailed analysis of the chronology provided by agencies in relation to this family identifies time and again both specific references to incidences of sexual abuse and to signs and symptoms which should trigger consideration of child sexual abuse within the family. These included: Children talking about sex using adult language, or in a context inappropriate to their age and development. A pattern of children running away from home and relationships with older friends and boyfriends. Bedwetting Inappropriate comments or physical closeness to professionals Simulation of sexual behaviour Children wearing sexualised clothing Concerns raised by neighbours Self-harm and suicidal thoughts. 4.9.6. These and other signs, including the extreme behaviours already described, were present throughout the years under consideration and related to all four siblings as well as to at least one of the older siblings. An individual professional might only have been aware of some of these concerns and might not themselves have the experience or expertise to assess what such behaviour signifies. Nevertheless, there are some simple established tools that can be used to consider whether some of these signs, for example use of sexual language, are of concern given the child’s age.16 Unfortunately 16 Brook Sexual Behaviours Traffic Light Tool Case U SCR Final for NSCB 44 although many professionals were concerned about the behaviour, there is no clear evidence that agencies were talking openly about the possibility of sexual abuse in the family and therefore there was no consideration as to how to assess that behaviour. Practitioners from the Family Support Unit told the Review that sexual abuse was one of the issues they considered and one of the actions they took was to talk to the children about ‘safe adults’ who they could talk to. Nevertheless, no formal referrals were ever made by any of the agencies and there was no reference to sexual abuse of the children as a possible concern in any of the service records. 4.9.7. Many of the professionals were worried about the parental boundaries within the home. There was a widespread view that very poor boundaries were in place. All the children had access to the internet and their mother’s Facebook page as well as films which were inappropriate for their age. Sibling 2 said that when she was not at school she was at home watching the television, including programmes with a high content of violence and sex. The mother appeared to have no boundaries as to what she would discuss in front of the children, where the children slept and what sexual activity they might witness. Practitioners from CAMHS described Sibling 1 being ‘overwhelmed with issues about Mum’s health, financial problems and relationship issues – there did not seem to be any moderation of what was discussed with her.” 4.9.8. It is not that all professionals were unware or unconcerned about these signs, but where they did have concerns their attention became focussed on other explanations. In particular, there were quite significant concerns that Sibling 1 was at risk of Child Sexual Exploitation (CSE), given the time she spent away from home and some of the people she was known to be friends with. Assessments took place regarding her risk of CSE, assessments which perfectly reasonably concluded that she was at risk and which she herself now agrees with. Safety measures were also put in place, such as the Child Abduction Notice. The response to her risk of CSE was properly managed. However, unfortunately this did not lead to a re-examination of what might be happening within the family that was making her so vulnerable. 4.9.9. There is also evidence that the mother at times presented explanations in relation to allegations of sexually worrying behaviour and that these explanations appeared to be accepted. Examples included: When a CAMHS worker was told by Older Sibling that the father had ‘made a pass’ at one of his siblings. CSC records state that mother had discussed this with the father and he had denied it. The mother took the view that as his sibling did not want to go to the police that it was not true. When Older Sibling was alleged to have raped another child, the mother was considered to be acting protectively in assuring social workers that he would not be allowed to be alone with this child or with any of his siblings When the mother was asked in 2014 about one of the siblings simulating sexual behaviour, she ‘seemed unworried’ and provided various explanations including that the child must have seen the older brother and his girlfriend together or that maybe she had seen something on the internet. Case U SCR Final for NSCB 45 4.9.10. The Older Sibling told the Review that he believed one of the workers had been in the father’s home on one occasion and failed ‘to spot’ some abusive behaviour towards Sibling 2. No other information has been provided to the Review to confirm that this in fact took place. The information given to the Review was not of a specific nature. It was not being suggested that the worker was complicit. In the absence of any further information to support this suggestion the Review would not be justified in making any judgement about the worker concerned. 4.9.11. Disclosure: In their conversations with the Reviewer and Board Manager, both Sibling 1 and Sibling 2 said that they had not felt able to tell anyone outside the family about the sexual abuse. Sibling 1 talked very specifically about being threatened by the Father not to tell. She recognises that there were people who might have listened to her, but she did not feel able to say anything. Sibling 1’s experience of CAMHS and their apparently negative description of her was for her a reason why she would never talk openly to professionals. Given this context and the potential practice implications, further information was requested from the Norfolk and Suffolk NHS Foundation Trust responsible for the CAMHS service. 4.9.12. Sibling 1 was referred to CAMHS on 3 occasions, once in September 2013 and twice in 2014. The records for this period have been retrieved by the Trust. No records or letters have been identified that refer to Sibling 2 in the terms that she described, i.e. as a ‘manipulative attention seeker’. A 4 page letter outlining the assessment in December 2014 and referencing CAMHS previous contact with Sibling1 was sent to the GP. This letter provides a detailed and non-judgemental summary of Sibling 1’s assessment which she attended with her mother. The assessment concluded that she was not suffering from any mental health disorder, but that her difficulties related to her emotional and social situation. It included a detailed analysis of any risks relating to self-harm or suicidal thoughts concluding with Sibling 1’s agreement that she did not have active suicidal intentions. An opportunity to speak to the Mental Health Nurse on her own, was declined. This is not to say that Sibling 1’s response is not based on a genuine belief, but the assessment provided does not reflect the negative judgement that Sibling 1 remembers. 4.9.13. Sibling 2 told her friend what was happening to her and thought about telling other people outside the house, like an older sister or a friend’s mother, but never actually did. Sibling 2 told us quite clearly that she repeatedly told her mother but to no effect. What is powerfully apparent is that as soon as Sibling 2 felt safe and was out of the family, she not only found her voice but was heard. Sibling 2 wanted to tell and wanted to be removed. Sadly, although she was telling at the top of her voice by her behaviour, professionals, many of whom were very empathetic and worried about the children, some of whom were very knowledgeable about sexual abuse, could not understand what she was saying. It should be noted here that this Review has found no corroborative evidence to suggest that Sibling 1 was influenced in making disclosures by any of the professionals. Case U SCR Final for NSCB 46 4.9.14. Whilst the absence of disclosures can create real difficulties in pursuing criminal proceedings, child safeguarding systems should not be reliant on direct disclosure. Research has consistently shown how difficult it is for children to verbally disclose17 and further, how rare it is for them to disclose any form of abuse to professionals. Instead professionals need to be alert to the different ways in which children may be telling about their experiences. Cossar et al18 describe this as a “spectrum of disclosure” which has four aspects: hidden signs and symptoms prompted telling purposeful telling Prompted telling is likely to follow a sensitive response from a professional who has recognised signs and symptoms, or a gradual development of a trusting relationship with a professional over time. Purposeful telling requires the child to understand what is happening them and deliberately approach someone, which is likely to be particularly difficult especially when the abuse is taking place in a family setting, which creates particular barriers for children in disclosing. 4.9.15. There are indications throughout the story of each of these children that they were telling, but not being understood. It is widely recognised that this is a common experience for many children “the evidence….demonstrates that accessing help for child sexual abuse in the family environment, from both statutory and not-statutory services, is largely dependent on a disclosure”. 19 There is further evidence that the younger the child the more difficult it is for them to disclose. A key challenge to the multi-agency partners is therefore to shift that burden of disclosure away from children and develop a safeguarding system which is not reliant on children speaking, but has the ability and confidence to take that burden from them. Recommendation 1 The NSCB and its partners continue developing their multi-agency approach to CSA so as to ensure it is not reliant on disclosure by victims, but on proactive and supported practitioners confident in their knowledge, skills and organisational support. 4.10. Why was it so difficult to see what was happening? 4.10.1. It is one thing for a Serious Case Review to be able to analyse the complexities of this family with the advantage of all the information that is available to it, including the extent of the abuse now known. It was evidently much more 17 Allnock et al (2013:6). OCC (2015:7) 18 Cossar et al (2013:v) 19 OCC (2015:34) Case U SCR Final for NSCB 47 difficult for the professionals involved to confidently identify and name what was happening. Consideration as to why this was so difficult has been a major thread throughout this Review, including with those professionals involved at the time, many of whom have evidently struggled to make sense of why they could not see what we can see now. The conclusion of this Review is that there were a number of factors and distractions that were in play and that the response to this will need to be thoughtful and nuanced. 4.10.2. The very complexity of the family’s problems, the effectiveness of the way the children’s medical and behavioural problems were presented to professionals and the demands put on professionals to try to deal with these problems, undoubtedly had the impact of confusing and distracting from the reality of the sexual abuse, as well as the cumulative impact of the neglect. For several of the frontline staff the amount of work that was required to manage the presenting problems of school avoidance and difficult behaviour was extremely high, leaving little time or thinking space. The school safeguarding lead for example described the family as being ‘all day, every day’; of regularly spending an hour simply attempting to coax Sibling 2 into class; of having to prise her off the radiator. She felt very supported by her Head teacher and they spoke regularly about managing the situation. But with hindsight she could see that they had been focussed on managing the daily pressure, not taking a step back and reflecting on the whole situation. 4.10.3. What undoubtedly was primarily in the mind of all the professionals involved was the existence of neglect within the family. It was also ultimately neglect, specifically in relation to Sibling 1 and 2’s parenting and lack of school attendance, that was the focus of the threshold for Care Proceedings. The predominance of neglect in relation to the children however, seemed to get in the way of professionals considering whether they could be experiencing other forms of abuse. That child sexual abuse was not also considered reflects both a local and national picture in that it is significantly underreported and provides the reason for less than 5% of Child Protection Plans.20 Evidently child sexual abuse can be difficult to see and, when it is seen, it is often identified only after children come to the notice of statutory services for other reasons, including neglect. 4.10.4. Although there is no simplistic causal correlation between neglect and other forms of abuse, including sexual abuse, there is recognition that a significant number of children do experience more than one form of abuse. Specifically there is ‘enough evidence for us to be certain that neglect and IFCSA (intrafamilial child sexual abuse) do co-occur.”21 The evidence as to the degree of overlap and why this might be the case is at present limited. Nevertheless, the same research suggests that ‘potential explanations’ may be linked to the vulnerability of children who are experiencing neglect and the quality of parent-child relationships. The degree to which professionals are alive to the possibility of sexual abuse being hidden behind other forms of abuse is difficult to tell. However, the experience of this case, involving a very significant number of agencies and professionals over many years, would 20 Alcock (2016:7) 21 RIP (2016:8) Case U SCR Final for NSCB 48 suggest that this was not something that was a routine consideration either at an individual level or organisationally. 4.10.5. Another factor that has emerged, quite directly from some of the professionals involved, is a lack of confidence about working with sexual abuse. Whilst some agencies and staff felt more confident about this area, there was also a recognition that they had not ‘named it’ and this raised questions as to why. Some professionals felt that there was quite a widespread lack of confidence in talking both to children and to other professionals about sexual abuse. They identified that this was linked not only to professional knowledge and skill but also discomfort, personal experience and a wish not to make moral judgements. Several workers had ‘gut feelings’ that something else was wrong but appeared to have suppressed those feelings, or not said anything to colleagues as they felt they did not have evidence. 4.10.6. Several of the professionals and their agencies identified a lack of an adequate knowledge base across the agencies, including a lack of identified individuals with expertise who could provide advice and specialist support. This was contrasted with the recent development of the Harmful Sexual Behaviour22 Team who were felt to have had a significant impact on awareness and were also a trusted source of advice. Similarly, there was a perception that Child Sexual Exploitation awareness and practice had improved in recent years in Norfolk, again due in part to a more specialist approach. A number of professionals however felt that there was less awareness of familial child sexual abuse and that to some extent the recent focus on CSE had overshadowed abuse within the family. Whilst more recently Child Sexual Abuse has become a priority for the NSCB, this was not reflected in direct practice during the period relating to these children. 4.10.7. Recent research23 in relation to Social Workers’ confidence in working with child sexual abuse, whilst based on the social work profession, nevertheless provides some learning for all partners and chimes to a significant degree with the experience of this Review. The following were identified as some of the difficulties they were faced with: The rapidly changing nature of environment in which sexual abuse of children is taking place (CSE, internet, sexting etc) made it difficult for Social Workers to keep pace. Social Workers had very limited training on CSA during qualifying training and many felt unprepared for the work. Limited workplace-based training, which was predominantly focused on understanding sexual abuse, rather than direct work with families Lack of understanding of healthy sexual development in children. Social Workers who had no direct experience being allocated to work with cases involving sexual abuse. 22 Harmful Sexual Behaviour: Sexual behaviours expressed by children and young people under the age of 18 years old that are developmentally inappropriate, may be harmful towards self or others, or be abusive towards another child, young person or adult’. (Hackett 2014 Children and Young People with Harmful Sexual Behaviours). 23 Martin et Al (2014) Case U SCR Final for NSCB 49 Lack of adequate time for reflective supervision or peer support. The overall picture from this research was too often of those Social Workers operating without the support, time, knowledge and training required to help children experiencing sexual abuse in their families. Each of these aspects can be seen at times within different agencies in relation to this Review. 4.10.8. Working within the field of safeguarding and child abuse places very high demands of any professional, yet the resulting emotional and personal response is something to which less attention is often given. The work requires professionals to routinely deal not only with the family’s stresses and the children’s distress, but also their own emotional reactions. Further if they are to really understand what might be happening in a family they need to seek out information confident that “whatever they unearth, including their own feelings of horror, fear and despair will be managed.” 24(Reviewer’s emphasis). This was a household where the ‘emotional and sensory overload’25 that the professionals were required to deal with was at the highest level. This Review has been able to have some, however limited, insight into the way in which that context is likely to have impacted on professionals and their roles; their ability to engage in a more in-depth way with the children and better understand their experience; their capacity to think critically and to question their own hypotheses. 4.10.9. What is identified in Ferguson’s research is that Social Workers who seemed not to see or meaningfully engage with children in some situations, responded perfectly competently elsewhere, evidencing that there was something about the particular set of circumstances and pressures in which they were working which impacted on their ability to work to their best standards. How well professionals feel able to manage their work in these complex situations will be a result not only of their individual strengths personally and professionally, but also the support they receive to make sense of what they are seeing and the demands and expectations of their organisations – for example in relation to workloads, priorities and bureaucratic requirements. 4.10.10. Whilst there are some potential ‘quick fixes’ such as training or introduction of new assessment tools, unless there is a fundamental focus by services on the emotional content and the impact on critical thinking for those working in safeguarding, children’s needs in complex situations will continue to be misunderstood. If safe practice is to be more consistently ensured, practitioners need to be provided with ‘”an organisational culture in which they routinely receive opportunities to critically reflect on their experiences”26. Skilled reflective supervision is an obvious starting point for those professionals with significant safeguarding responsibilities. However, formal supervision is not the only means to support frontline staff. Other approaches whether that be providing specialist accessible support and advice, enabling joint working in complex cases, reviewing the range of work 24 Burton and Revell(2017) 25 Ferguson (2017) 26 Ferguson (2017:1021) Case U SCR Final for NSCB 50 being undertaken by individuals and what impact this has on their capacity to focus on safeguarding. Ultimately what is required is an organisational culture which views its frontline staff as its greatest resource for which it will provide maximum support. Recommendation 2 The NSCB and Partner agencies review the support provided to front line staff in the light of the learning within this Review regarding the impact of the emotional content of child safeguarding on frontline professionals’ capacity to maintain critical thinking in complex situations. 4.11 The Response to the Family’s needs as they were understood: the interventions 4.11.1. The professional view of the family was reflected in the interventions that were put into place. In practice the very existence of those interventions at times contributed to the difficulty in properly understanding the family and the children’s experience. Predominantly the actions taken reflected the view, although this was not shared by all, that this was a family struggling to get it right. The focus was, to a significant extent, on supporting the mother with the various parenting difficulties she faced. This was not that the children’s needs were ignored, but because they were so significantly understood through the mother’s lens, the impact was that their actual needs largely went unmet. 4.11.2. The responses to this family, although significantly affected by the way they were understood, also highlighted some fundamental problems within the safeguarding system during this period, particularly within the statutory role of Children’s Services. These systemic problems will be considered within this section. 4.11.3. The analysis of responses to this family prior to 2011 has not revealed significantly different learning than has been identified between 2012 and 2015. As a result, the examples of practice used in this section are predominantly drawn from the Review’s main period for consideration. 4.11.4. Some statutory assessments were undertaken by Children’s Services but until Sibling 2’s disclosure these remained focussed on the issues as identified in Section 5 of this Review. As described in the 2014 Core Assessment the purpose was: “to improve routines, home conditions, school attendance, boundaries and behaviours”. In the earlier years, including during the period when some of the older siblings lived at home, there was an absence of effective assessment. Any interventions that were identified generally proved ineffective in engaging the family in any meaningful way or in leading to change. Two Initial Assessments were completed in 2012 both in response to events relating to Sibling 1, the first following an allegation of rape by another young person, the second due to her suicidal thoughts and episodes of going missing. Neither of these resulted in any further action and the assessment is heavily reliant on the mother’s perspective. It was not until the Case U SCR Final for NSCB 51 Core Assessment completed in March 2014 that it was decided to initiate S17 Child in Need Planning. 4.11.5. Although the siblings and their family had a considerable level of contact and were subject to a high number of referrals from various agencies to Children’s Services, including from Police and schools, none of the children were subject to Child Protection Procedures prior to Sibling 2 making her disclosure in October 2015. Irrespective of the unrecognised sexual abuse, it is clear that Child Protection Planning should have taken place at a much earlier point given the level of neglect the children were experiencing and the visible distress that they were exhibiting. Several of the professionals specifically expressed their view that the children should be in Child Protection Proceedings, but felt they were not heard, to some extent because of their perceived lower status. For much of the period from 2011 onwards the children were instead subject of a CAF led by the school. Then from 2015 the children were subject to Child in Need27 planning led by Children’s Services. During both periods the focus of multi-agency activity was as, outlined in Section 5, largely on dealing with the children’s behaviour and school attendance. 4.11.6. What is immediately striking in relation to the response to this family is the extent of service involvement and the numbers of agencies who became involved. A large number of professionals were going into the home at various times, and numerous referrals were made for family members to other services. Often children or adults would be re-referred to services that they had been to before with little evidence of progress, or where it was evident that they had not previously engaged. Whilst the mother would agree to referrals her real commitment was often questionable. As she said about contact with one agency intended to help with Sibling 2’s problems she felt she was “being taught to suck eggs”. When there was a lack of engagement with one service, alternative services were offered. This was especially noticeable for Sibling 1, who was referred to one organisation for support after another, without any evident understanding as to why she was not engaging or what she might find helpful. As one professional said to the Review, they were “throwing everything at the situation, not really knowing what the underlying causes were, but let’s keep trying”. 4.11.7. Some services were never able to move from the assessment stage to the point of implementing planned work, often because of missed appointments and other difficulties in meeting with family members. For example, the Community Paediatrician had made a referral to the ADHD team for Sibling 2, who attended with her mother, father and occasionally maternal grandmother. The team clearly had significant concerns about Sibling 2, but also about the nature of the parenting she was receiving “Mother always said that she was trying really hard, but there was never any evidence of action taking place”. Sibling 2 would cling to her mother and attempts to see her alone were 27 Child in Need: A Child in Need Plan, or CIN, is a multi-agency plan put in place with the family under Section 17 of the children Act when a child is in need of extra support from different agencies, but is not assessed to be at risk of significant harm. Case U SCR Final for NSCB 52 unsuccessful. Ultimately the service, whose model is to work with the whole family, concluded that in the absence of parental willingness to make changes, continuing the service was not worthwhile. 4.11.8. The volume of services involved, in the absence of a strong lead professional, meant that there was no clear track to show what had been achieved, and in particular to what degree the parents were actively taking part or seeking to make change. At times records are contradictory as to whether the parents had engaged with a particular service and it is difficult to identify an audit trail. What seemed to be absent was a clear review process and reflection on what was or was not working. Equally there is limited evidence of strategic or long- term planning with most of the interventions being focussed on dealing with immediate behavioural problems or with the children’s medical diagnoses. 4.11.9. With regard to the CAF process, the experience of the professionals working with this family reflects inherent weaknesses that have previously been identified regarding the CAF, in that it lacked independent oversight or a clear framework for review. A previous SCR made a finding about similar problems for professionals working within a CAF during the same time period. The CAF system has now been replaced by the Family Support Process (FSP) in Norfolk. Ofsted’s inspection report in October 2015 and in 2017 found improvements in Early Help of which the FSP is an important part. Early help services, provided through a range of interventions, are increasingly reaching children when needs are first identified and result in effective support. When risks escalate, children’s cases are appropriately stepped up to children’s social care. However, the recording within the family support process is of inconsistent quality, and the processes to oversee how quickly children are seen and to measure impact are underdeveloped. The local authority recognises these weaknesses and has already commissioned a new electronic recording system to strengthen record-keeping28. In this context it would not be proportionate for this review to make recommendations regarding the FSP process. 4.11.10. Two of the organisations who responded to referrals, the Housing Unit’s, Family Support Team and the Local Authority’s Targeted Support Team, were involved in very intensive work with the family. Staff from both teams clearly worked very hard to support mother and the children, at times visiting the home daily as part of attempts to get Sibling 1 into school. Whilst it was evident from meeting some of the practitioners that they brought considerable personal skills to the work, in terms of their role, training requirements and status they were in a difficult position from which to challenge the approach being taken. Staff felt frustrated that were taking on a role that they felt should more appropriately be done by Social Workers and described a lack of clarity about what the work plan was. The Family Support Team concluded after a period of almost 6 months that they were not making progress and withdrew from their involvement specifically to 28 Ofsted (Oct 2017:9) Case U SCR Final for NSCB 53 indicate to Children’s Services that there needed to be a different approach. Similarly, the Targeted Support Team worker identified within 3 months that there was no meaningful change. 4.11.11. At the same time one of these practitioners, who worked with the family for nearly 9 months, felt that she was just beginning to get to know the mother and to have an understanding of what might be at the cause of the problems. She was particularly concerned about the adult sexual behaviour in the house and the mother’s approach to relationships. Her sense was that this family required a much longer working relationship in order to truly understand what was taking place. What is evident here is that the lack of a consistent primary worker who had a good knowledge of the family and could take decisive action when required, was a significant contributor to the indecision and delay that followed. 4.11.12. The lack of an effective means to engage both Sibling 1 and Sibling 2 with services that could have understood and responded to their level of emotional distress and trauma is of significant concern. Both children were displaying highly worrying, sometimes extreme behaviour, including violence, self-harm and suicidal thoughts yet there seemed to be no place where they could be enabled to feel safe enough to talk. Although both children, and two of the older siblings, were at various times referred to CAMHS, neither met the threshold for that service which at Tier 329 is based on a patient having a diagnosable mental illness. The assessments of the children’s needs given the existing threshold is not disputed. However, for children such as Sibling 1 and Sibling 2 with very high levels of emotional distress, the resulting lack of access to skilled psychological therapies created a significant gap. 4.11.13. The commissioning of mental health services for children and the narrow way in which thresholds are set, is a cause of significant concern at a national level. The current position being described as a crisis in a recent report by the Office of the Children’s Commissioner.30 4.11.14. Sibling 1, as she herself powerfully described, was reluctant to the point of hostility to talk to professionals. Taking into account what we know about the number of professionals who had been in and out of her life, the pressures within her family and the knowledge that she was carrying about her family, it becomes understandable as to why she might have felt this way. Her prime experience of professionals was that they always wanted to make her do things or tell her how she should behave. Her description of simply needing someone who was there for her, someone who would listen and give advice if asked is completely consistent with what we know about young people’s perspective. What was on offer at this time however, was almost 29 Child and adolescent mental health services (CAMHS) deliver services in line with a four-tier strategic framework. Tier 1 being general advice and support provided by non-mental health specialists, Tier 4 for children and young people with the most serious problems needing highly specialised help. 30 OCC. (Oct 2017) Case U SCR Final for NSCB 54 entirely task focussed, rather than relationship focussed and Sibling 1 very clearly rejected that approach. 4.11.15. Research and Serious Case Reviews have regularly identified in recent years the need to pay considerably more attention to working with adolescents. Sibling 1 told this Review very clearly what she needed from professional support and this is reflective of what we know from other young people: i. ‘Someone who listens and then understands’ ii. ‘Someone who does not judge’ iii. ‘Someone who acts and has a plan’ iv. ‘Someone who spends time with you’ v. ‘Someone who talks with you and not at you’ vi. ‘Someone who has the information that you need and knows about the different options’ vii. ‘Someone who gave you choice’ viii. ‘Someone who focussed on all your needs and not just your special problem’ Consultation with a group of 16–17 year olds31 4.11.16. The sparsity of specialised services skilled in working with adolescents who may be experiencing abuse or neglect alongside the difficulties that many other services appear to have in working effectively with this age group, is a nationally recognised problem, not simply an issue for Norfolk. It would be wrong to presume that had one of the professionals developed a trusting relationship with Sibling 1 that this would have inevitably enabled her to disclose the abuse that was taking place. Nevertheless, the lack of such a relationship represented a significant gap in the support and help that could have been offered to Sibling 1. NSFT which provides the CAMHS service has provided information about a range of work it is involved in, including an independent review of safeguarding within CAMHS and also recognised that there could be further improvements to their approach to working with adolescents. However, the needs of this group can only be met by a multi-agency approach and therefore this is subject to a recommendation. Recommendation 3 The NSCB consider the effectiveness of services currently being commissioned, or otherwise provided, to adolescents who are at risk of abuse and neglect and identify how services can best be delivered to meet their needs. 4.11.17. The Police’s response to this family in the earlier period covered by this Review has been clearly recognised as not meeting acceptable standards in investigating allegations of sexual abuse and in terms of the police’s responsibilities to safeguard children. Norfolk Constabulary have made a number of important changes since this time, including a significant increase in the Child Abuse Investigation Unit, adoption of a new data recording 31 Seriously Awkward (101:46) Case U SCR Final for NSCB 55 system and creation of a Complex Case Manager role to ensure the efficient running of complex child abuse investigations and responsibility for working with partner agencies in relation to safeguarding. One further area of concern was the response to the high numbers of Police call outs to the family. Although Children’s Services were routinely notified, no consideration was given by the police to establishing what action had been taken as a result, nor was a referral triggered in relation to the accumulation of ‘minor’ incidents or the concern escalated. Current processes in the MASH now involve the Police identifying such repeated concerns and forwarding them to Children’s Services colleagues for assessment. Norfolk Constabulary have identified a number of other learning points as a result of their involvement with this family, including regarding their response to episodes when Sibling 1 was missing. Relevant recommendations are contained in Appendix A of this report. 4.12 Drift 4.12.1. In considering the response of agencies to this family and the impact this had on the outcomes for the children, what is absolutely central is the degree of drift in planning and response. We know that generally the longer the period of time that children experience sexual abuse the more damaging this is for that child.32 What is particularly disturbing here is that we now know that Sibling 2’s abuse by the father actually increased when she was waiting for a foster placement. 4.12.2. Throughout the period considered by this Review the pattern of delay was a constant. Some of the delay arose, as has already been considered, out of the way the family was understood, particularly in relation to parental engagement with professionals. However, in parallel with this were some very significant organisational influences that at times actively prevented key professionals from ensuring their concerns were heard and acted upon. 4.12.3. The first recorded reference to placing Sibling 1 and Sibling 2 in foster care was in February 2014, although it is evident that this had already been discussed with the mother. However, it was over a year later in March 2015 that Sibling 1 was actually placed in foster care and in September 2015 that Sibling 2 was placed. There was considerable frustration felt by some of the professionals at the constant changing of position regarding the plans to move the children into foster placements. The Safeguarding Lead for the School and Targeted Support Team worker particularly described their disbelief in one meeting when a decision to remove all four children was reversed apparently in order to allow the mother to attend counselling. 4.12.4. Some of the delay arose out of finding suitable placements for Sibling 1 and Sibling 2. In any event, this delay was also linked to the fact that decisions about placements were reliant on agreement by the mother, under S20, which on at least one occasion she would not give. Nevertheless, this was not the fundamental problem. What is clear is that two closely linked features overwhelmingly impacted on the capacity of social care staff to make 32 Ref: OCC (2015:75) Case U SCR Final for NSCB 56 progress. Both of these features were directly related to the quality of service provided by CSC during this period and were: Resources within Children’s Services Strategic level drive to reduce the numbers of children in care. 4.12.5. In 2013 Children’s Services, had been judged to be inadequate by Ofsted and was made subject to an Improvement Notice which was removed in 2017 when the Authority was judged in need of further improvement to be consistently good, and it is not therefore surprising that some features of the practice experienced by this family clearly reflected the very problems that were identified by Ofsted during this period. 4.12.6. Following the 2013 Ofsted report, the authority was subject to a significant number of changes both in leadership and due to restructuring. One of these restructures, included the separation of Child in Need and Safeguarding into separate teams, which created unintended consequences for the management of some cases. The 2 teams were led by different managers who reported to different Heads of Service. The effect of this was to create an artificial barrier making it difficult in practice for children to be progressed from one team to another. 4.12.7. The workload pressures between 2013 and 2015 were intense. Teams were dealing with very high caseloads, unallocated cases, long working hours, rapid staff turnover and reliance on agency staff. The result was that assessments and work had to be completed under pressure, at times impacting on Social Workers’ capacity to build relationships or to regularly reflect and review the work. At the same time, information on computer systems was often limited. The old paper files, with their rich source of history, were almost never accessed, not helped by being stored out of the county. Although the team managers described trying to prioritise supervision, the reality was that there was minimal time for reflection. 4.12.8. The primary strategic driver at this time was to reduce the numbers of children Looked After by the Local Authority as this had been identified in the OFSTED report as being too high. The intention was to manage the funding of Children’s Services by reducing the number of Looked After Children and children on Child Protection Plans. The expectation was that everything possible would be done to reduce the numbers of children moving into Child Protection or becoming Looked After. Evidence to this Review was that when cases were taken by staff to the Panels which made the decisions about placing children in care, this would frequently result in them being asked instead to try further interventions. The result, as in this family’s case, was not to build in constructive opportunities to create change in families, but to build in delay. 4.12.9. The situation as described here was widely recognised outside of Children’s Services, with other professionals commenting on the pressures on their colleagues in Children’s Social Care. What this has highlighted is the impact that decision making in one agency can have on the wider safeguarding system and the need for an agreement amongst the multi-agency Case U SCR Final for NSCB 57 partnership as to how any risks can be mitigated against. A recommendation has therefore been made as follows: Recommendation 4 The NSCB should explicitly develop a shared approach by which partners report on, or seek information about, any significant changes to an agency’s function, resources or practice which could impact on multi-agency safeguarding, in order to enable peer response and where appropriate, challenge. 4.12.12 A major programme of change has been taking place and some significant improvements have been made in response to the sort of weaknesses in practice that have been identified in this report. In particular: Smaller team sizes across frontline teams which means, leading to smaller caseloads for practitioners and fewer cases been overseen by each manager. Child in Need and Child Protection cases are now all held in Family Intervention Teams, with one Social Worker in one team overseeing all children in a family. Quarterly summaries are completed on all children open to a social worker to ensure easy to find updates/overviews on cases. Introduction of a rolling programme of Systemic Supervision training for all managers County-wide implementation of a defined social work approach to intervention. County wide training on Child Sexual Abuse for social workers and team managers. 4.12.13. It is clear that there has been a significant improvement in the services provided to children and families by Norfolk Children’s Services, as has been recognised by the recent OFSTED inspection report. Many of the changes are likely to minimise the vulnerabilities in practice being repeated for future families. This section of the Review has focussed primarily on Children’s Services, which is an inevitable consequence of the processes in which the families were involved. However, other services all had a role to play in relation to ineffective interventions and drift, and there is learning for all these agencies, not simply Children’s Services, which will be reflected at the end of this Review. 4.12.14. However, this has also highlighted the impact that decision making in one of the partners can have a significant unintended consequence on safeguarding practice more widely. 4.13 The response at the time and following disclosure. 4.13.1. This Review was asked not to undertake a full analysis of the period following Sibling 2’s disclosure but to consider the effectiveness of the multi-agency partnership at the point of disclosure and immediately afterwards. The Review had been made aware of conflict between staff in Norfolk Constabulary and Children’s Services at this time and this was recognised as an episode which might hold wider learning. Case U SCR Final for NSCB 58 4.13.2. A crisis response was inevitable when Sibling 2 made disclosures about sexual abuse in the autumn of 2015. Even though both Sibling 1 and Sibling 2 were by now in foster placements until this point the possibility of familial sexual abuse had not been actively considered. The first disclosure related to one of her siblings. As the child concerned was below the age of criminal responsibility, the Police reasonably referred this back to CSC. A strategy discussion took place, a Social Worker spoke to both Sibling 3 and Sibling 4 the same day and a follow up strategy meeting was then planned for the following Monday. This represented a clear plan of action and is of a standard that would be expected. Whilst, it might not have been described as such, the behaviour alleged given the child’s age would come into the category of Harmful Sexual Behaviour, rather than criminal behaviour. Since 2016 Norfolk has in place a specialist Harmful Sexual Behaviour team and practice increasingly has been to access support and advice from this team. In 2015 Children’s Services would have been the lead in responding, but in fact Sibling 2’s further disclosure changed the situation for all the siblings dramatically. 4.13.3. Sibling 2’s disclosure was reported by her foster carer to the Emergency Duty team on Sunday evening. The EDT Social Worker, following discussion with the team manager that evening, checked the records and identified that the children lived with their mother and that father had contact with the children but was at a different address. In the conversation with the manager it was agreed that the Social Worker contact the mother to confirm where the children were and whether any immediate safeguarding action was required before the allocated Social Worker could respond the next morning. The Social Worker phoned the mother who confirmed that the children were with her but did not tell the mother about the disclosures. The information was forwarded to the allocated Social Worker and no further action was taken by EDT as the children were considered to be safe. 4.13.4. What is of concern is that although the records refer to the possible need for both an ABE interview33 and a paediatric examination, there was no actual conversation with the Police that night. The EDT worker specifically noted that she did not tell the mother that there was an allegation about the father, suggesting that she was aware that to do so could compromise any investigation. At the same time, it was accepted that the Mother would be protective. In fact, the simple fact of telephoning the mother out of hours on a Sunday would have alerted her to the possibility that there was some serious concern and there could be no certainty that the father would not then be told. Standard practice in such situations is to seek advice from the Police as to how the situation can be managed best, minimising any further risk to the children and making sure the Police investigation is not compromised. Whilst there is no evidence to suggest that there were negative outcomes, this clearly created a risk. 4.13.5. A similar situation occurred the following morning when the allocated Social Worker spoke to the mother who appeared anxious as to why EDT had called 33 Achieving Best Evidence (ABE): Guidance produced by government regarding video-recorded interviews with vulnerable, intimidated and significant witnesses Case U SCR Final for NSCB 59 her the previous night. The Social Worker told her that Sibling 2 had made some allegations, which she could not tell her about. She went on to say that the father should not have any contact with the children. This evidently suggested that the allegations related to the father. 4.13.6. During the course of that day various actions were taken, including a Strategy Meeting and, eventually, identification of foster placements for Sibling 3 and Sibling 4. The Strategy meeting was organised by the social work team and took place the same afternoon, which although this was felt to be too long a delay by the Police Officer, is in line with standard practice and is not subject to criticism within this Review. What is of concern is that no notes of that meeting have been saved within the Social Care records, which is clearly poor practice. 4.13.7. Both the Detective Sergeant, who was the duty sergeant when the disclosure was reported, and the relevant Team Manager in Children’s Social Care describe having quite a difficult disagreement about what steps needed to be taken to remove the children from the household, and most significantly the urgency of removal. The Police position was that they needed the children to be removed immediately, potentially under Powers of Police Protection. This was both to safeguard the children, but also to ensure that any evidence was preserved. The Children’s Services team manager took an equally robust position that it would be better to achieve a planned move for the children the following day as it was her understanding that mother was protective. 4.13.8. Both positions were clearly based on genuine perspectives about how best to proceed. However, the team manager was wrong in her view that the mother was protective as by this stage the records were clearly identifying that Sibling 1 and Sibling 2 had been significantly harmed by their parenting and that managers were concerned about the mother’s ability or willingness to make changes. The team manager has since recognised that had she seen this information she would have accepted the police position without argument. Children’s Services Records of this episode are limited and the manager, although remembering the argument, could not remember details of what happened or why she had not known the information about the mother that was available in the records at that time. 4.13.9. The Police Officer was understandably concerned that the significance of protecting evidence for criminal proceedings was not fully understood by her colleague in Children’s Services. It is difficult to tell, having spoken to both the professionals concerned whether this was a lack of understanding or rather a mistaken view that the mother could protect and a different perspective about the best way forward. What is clear is that these two strong individuals were involved for too much time in an unhelpful conflict that was in the end resolved by the Police Officer taking (appropriate) unilateral action. Whilst both recognised that their personalities played a part in the conflict, it is also the case that these events can be very pressurised and highly emotive and as such disputes of this nature could be repeated. However, it is not the view of the author that, given what are otherwise generally experienced as effective relationships between Police and Case U SCR Final for NSCB 60 Children’s Services, it would be proportionate recommend that this be a major point for learning and recommendation within this Review. 4.13.10. What is nevertheless a cause for concern is that there was a lack of clarity about the importance of immediate liaison between Social Workers and the Police at the point of disclosure. Commitments have been given by CSC that they will seek to raise awareness about this issue. 5 CONCLUDING COMMENTS 5.1. The purpose of a Serious Case Review is to learn from the case in order that improvements to practice can be put in place to help families in the future. 5.2. It is evident that whilst their individual experiences differ, all four children were subject to chronic and complex neglect as well as repeated sexual abuse of the most serious kind over a significant period of time. The long-term impact for these 4 siblings cannot be underestimated and they should have been much better protected. Despite the commitment and best intentions of many of the professionals involved, the reality is that the multi-agency safeguarding system proved ineffective and too slow in its response. The reality that repeated sexual abuse within the family was taking place as well as neglect was only understood at the point Sibling 2 was removed from the home and felt safe enough to tell her foster carer what had happened to her. 5.3. It is unrealistic to conclude that sexual abuse in this family could have been completely prevented. However, the extent of that abuse and its continuation over such a long period of time could without doubt have been minimised. What is clear is that there has been significant reflection and learning within the group of practitioners who worked with this family, many of whom were highly distressed at what had happened and their apparent inability to prevent it. 5.4. Some significant areas of concern, including response to neglect and working with families effectively below statutory thresholds, have been identified here As has been previously noted where there is evidence of recognition of the concern and action being taken, no further recommendations are being made in this report. 5.5. The experience of these 4 children has also highlighted a significant number of learning points for practice. These practice points will be very familiar to many frontline practitioners, but are worthy of repetition given the impact in this case: Children need to feel safe before they can disclose that they are being sexually abused. Reliance should not be placed on children verbally disclosing sexual abuse. Confidence in recognising and naming sexual abuse as a potential concern must be developed across the workforce if children are to be protected. Case U SCR Final for NSCB 61 Relationship building is particularly significant when working with adolescents. ‘Medical diagnoses’ and other parental concerns can act as powerful smokescreens distracting from children’s underlying problems. Active engagement with and assessment of fathers or other men in a family should be considered as routine. Child Sexual Abuse may be ‘hidden’ behind neglect and there may be links between the two. Understanding of the parenting capacity of all those involved in caring for children in a family is fundamental to assessment of their needs and any risks to them. Full and up to date chronologies are key to good assessment. Regular review is crucial in order to avoid drift. Practitioners need to remain alert to the impact of the emotional content of working in complex safeguarding situations on capacity to focus on the child and maintain critical thinking. 6 RECOMMENDATIONS FOR THE BOARD It is important that a proportionate response is taken when considering what action is required as a result of this SCR. It has been a conscious decision not to focus on SMART recommendations regarding the details of policy, practice and structures or to repeat recommendations that have been made previously and are being taken forward by the partnership. Account has also been taken of the very significant changes made by Children’s Services in the recent past as well as the ongoing priority given by the Board to improving practice in relation to Child Sexual Abuse. As a result it was the strongly shared view of the Review Team, a view supported by the Independent Reviewer, that the focus should be on a small number of recommendations. Recommendation 1 The NSCB and its partners continue developing their multi-agency approach to CSA so as to ensure it is not reliant on disclosure by victims, but on proactive and supported practitioners confident in their knowledge, skills and organisational support. Recommendation 2 The NSCB and Partner agencies review the support provided to front line staff in the light of the learning within this Review regarding the impact of the emotional content of child safeguarding on frontline professionals’ capacity to maintain critical thinking in complex situations. Recommendation 3 The NSCB consider the effectiveness of services currently being commissioned, or otherwise provided, to adolescents who are at risk of abuse and neglect and identify how services can best be delivered to meet their needs. Case U SCR Final for NSCB 62 Recommendation 4 The NSCB should explicitly develop a shared approach by which partners report on, or seek information about, any significant changes to an agency’s function, resources or practice which could impact on multi-agency safeguarding, in order and to enable peer response and where appropriate, challenge. . Case U SCR Final for NSCB 63 APPENDIX A: SINGLE AGENCY RECOMMENDATIONS Each of the agencies who provided individual agency reports also included a range of learning points specific to their own agency. The following agencies also made specific recommendations for their own agencies. Norfolk Children’s Services: Children’s Social Care (CSC) 1. Workers must be curious, skilled and experienced in recognising the environment in which familial sexual abuse takes place. 2. Managers must ensure that workers are given sufficient time in the planning of intervention to consider the history of all of the children in the family 3. All workers must explore with parents their experience of being parented and what impacted upon them 4. Workers must not be overly influenced by medical diagnosis 5. Workers must look beyond behaviour and always explore the cause 6. Managers must ensure that actions discussed in supervision are carried out to avoid drift. 7. Managers and workers must keep an open mind and always consider ‘what else might this mean’? 8. Workers should not necessarily take a parent or child’s account of events on face value. Norfolk Children’s Services: Education To work in partnership with Norfolk Constabulary to ensure that the NSCB Child Sexual Abuse strategy and the profile of CSA in Norfolk is cascaded as widely as possible to education staff through integration into all Designated Safeguarding Lead training during the Spring and Summer Term 2018. Norfolk Constabulary 1. If a child is reported missing the Missing Person Coordinator should check the COMPACT system to research if other siblings have gone missing in the past. If another sibling has previously gone missing this information should be shared with Children’s Services so that the situation within the whole family can be taken into account and the need for a strategy meeting can be considered. 2. Consideration to be given, to review the current policy, in relation to a strategy discussion being triggered following 3 incidents in 42 days. 3. When a child goes missing and they have a long term active social worker, the child should be asked who they would like to do their returns to home interview as they may rather it be done by an independent person. 4. Raise awareness around neglect and Police Protection Orders amongst the workforce. Case U SCR Final for NSCB 64 5. Strategy discussions to be held/reviewed by a suitably qualified Detective Sergeant within the MASH 6. Following Strategy discussions where the outcome is single agency (children services) for the case to remain pending, awaiting update from children services. (This is in relation to cases where Children Services are conducting an assessment of families to establish if any criminal offences have occurred.) Norfolk and Norwich University Hospital Foundation Trust Staff who are treating adult patients should ask about children at home and childcare arrangements if the adult needs to be admitted. This information should be recorded in the notes and any concerns voiced by either the patient themselves, or by staff, should be shared with the Trust Safeguarding Team. Norfolk and Waveney Clinical Commissioning Groups (Recommendations for GPs) 1. Clinical Practice staff should document accompanying adult, parental responsibility and consent where appropriate at all consultations. 2. Clinical staff should use a tool such as the Bio psychosocial assessment to identify the family members and possible impact when seeing an adult with mental health or significant physical health problems. Risk to the patient and others including children should be documented. 3. GPs should hold regular liaison meetings with Healthy Child Programme Practitioners to discuss children of concern. This should include looking at audits highlighting patterns of attendance of concern. The outcome of the discussion should be documented on the child’s record. 4. GPs should not write letters to external agencies at the request of parents without they may be at risk of collusion. 5. Children should be given the opportunity to be seen alone and this offer and whether it was acted on should be documented. Norfolk and Suffolk NHS Foundation Trust 1. To review the NSFT Safeguarding Children Training to ensure that it remains fit for purpose in light of the learning points 2. To incorporate the Learning Points into the Safeguarding module of the internal rolling programme of Quality Workshops. 3. To promote the Learning Points in the internal Patient Safety Newsletter. 4. To promote the Learning Points at Locality/Service Governances Meetings across the organisation. 5. To review the NSFT Safeguarding Children Policy to ensure that it remains fit for purpose in light of the learning points The three learning points referred to are: Case U SCR Final for NSCB 65 The ongoing need to consider the use of the Think Child, Think Parent, Think Family tools/principles, in particular the role of fathers or other key adult males in the family/household. The importance and function of professional curiosity. The risk associated with caseload drift. Cambridge Community Services NHS Trust 1. To improve the use of evidence-based assessment tools for example signs of safety and graded care profile 2. Develop an early warning staffing model to indicate when staffing levels are below full complement to facilitate focus on high level intervention and safeguarding work. 3. To Improve HV/GP liaison in practice 4. Ensure that health practitioners in the Multi-Agency Safeguarding Hub (MASH) participate fully in the MASH activities and cascade information appropriately to staff in the HCP and also inwardly from the HCP to the MASH to improve joint working 5. Prioritise staff Training for neglect and domestic violence 6. Ensure the Graded Care profile is used to assess and evidence neglect 7. Ensure HCP staff are compliant with supervision 8. Review system 1 templates to improve record keeping 9. Complete a record keeping audit annually 10. Develop care pathways and standards related to domestic violence and attendance at A&E 11. Ensure safe and effective transfer of cases between practitioners within the organisation 12. Development of a supervision model based on the signs of safety that encourages practitioners to be curious about the lived experience of the child in the light of the information that is known and received 13. Introduce a method for capturing significant events within the electronic record to facilitate practitioners identifying patterns of events that require further investigation. Case U SCR Final for NSCB 66 APPENDIX B: NSCB Thematic Learning Framework Case U SCR Final for NSCB 67 BIBLIOGRAPHY Allnock, D. and Miller, P. (2013) No one noticed, no one heard: a study of disclosures of childhood abuse. London: NSPCC. Allnock, D. (2016). Exploring the Relationship between Neglect and Adult-perpetrated intra-familial Child Sexual Abuse. RIP/Action for Children/NSPCC Brook Sexual Behaviours Traffic Lights Tool: https://www.brook.org.uk/our-work/the-sexual-behaviours-traffic-light-tool Burton, V and Revell, L. (2017). Professional Curiosity in Child Protection: Thinking the Unthinkable in a Neo-Liberal World. British Journal of Social Work Cossar et al. (2013). It takes a lot to build trust. Children’s Commissioner, Ferguson, H (2017). How Children Become Invisible in Child Protection Work: Findings from Research into Day-to-Day Social Work Practice. Horvath, et al (2014). “It’s a lonely journey” A Rapid Evidence Assessment on intrafamilial child sexual abuse. London: Office of the Children’s Commissioner. Martin, L et al (2014). Social Workers’ knowledge and confidence when working with cases of child sexual abuse. NSPCC & Coventry University Office of the Children’s Commissioner (2015). Protecting Children from Harm: a critical assessment of child sexual abuse in the family network in England and priorities for action. Research in Practice (2016) Child neglect and its relationship to other forms of harm: responding effectively to children's needs: executive summary. Sanderson, C (2015) Survivors’ Voices: Breaking the silence on living with the impact of child sexual abuse in the family environment. London: One in Four Warrington, C. et al (2017) Making noise: children’s voices for positive change after sexual abuse. Luton: University of Bedfordshire. |
NC52312 | Two life threatening episodes, necessitating emergency hospital medical intervention involving a 4-months-old girl in January 2017. Learning: the need to prioritise the needs of vulnerable, premature babies for secure, stable and consistent care, not just the mother's needs; practitioners need full access to historical and current information when working with mobile families and/or those accessing a multitude of services in different areas, otherwise there will be a risk of undertaking holistic assessments based on partial information; when a pregnant woman or parent is a high user of health services, health practitioners should always consider any impact this may have on an unborn baby and/or children in the household including the possibility of self-induced or fabricated illnesses; practitioners working with emotionally unstable personality disorder parents need to have an understanding of the potential impact of this on parenting; professionals need an understanding of the different types of 'mother and baby' resource available to make realistic plans for mothers with mental health problems and their babies; whenever looked after children change placements, consider the need for a looked after child review or other multi-agency planning meeting with the Independent Reviewing Officer (IRO) chaired by social care; when there are welfare concerns about children, practitioners should establish and record the facts of parents' household relationships, including names. Recommendations for the local safeguarding board are included in the learning; makes specific recommendations to NHS England to improve the use of mother and baby units.
| Title: Baby Z SCR. LSCB: Hampshire Safeguarding Children Board Author: Edi Carmi Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Hampshire Safeguarding Children Board Baby Z SCR Edi Carmi 15th March 2019 2 Table of contents 1 INTRODUCTION 3 1.1 Initiation of serious case review 3 1.2 Summary 4 1.3 Structure of Report 6 2 REVIEW PROCESS 7 2.1 Agencies and geographical areas involved with this review 7 2.2 Scope and terms of reference 8 2.3 Review methodology 8 2.4 Practitioner involvement 8 2.5 Family involvement 9 2.6 Limitations to serious case review 9 3 PROFESSIONAL PRACTICE EVALUATION 10 3.1 Introduction 10 3.2 Recognition of child protection concerns: May 2016-June 2016 11 3.3 Unborn baby subject to child protection plan: 24.06.16 – 16.09.16 12 3.4 Baby Z born & in hospital: 16.09.16 – 26.09.16 14 3.5 Baby Z’s first home for 9 days: London 26.09.16 – 05.10.16 16 3.6 Baby Z aged 19 days, in Hampshire: 05.10.16 – 13.10.16 16 3.7 Baby Z’s first hospital admission, 4 weeks old 17 3.8 Baby Z cared for by MGGM: 17.10.16 – 18.10.16 18 3.9 Baby Z and mother: events on 18.10.16 to 31.10.16 18 3.10 Mother in hospital and baby z placed with carers: 01.11.16 – 11.12.16 20 3.11 Care proceedings initiated & mother and baby move to mother and baby unit: 12.12.16 – 31.12.16 22 3.12 Concerns about baby’s Z and mother’s health: January 2017 24 4 FINDINGS & RECOMMENDATIONS 28 4.1 Insufficient focus on Baby Z’s needs as a vulnerable premature baby 28 4.2 Impact of hIgh mobility within the safeguarding system 32 4.4 High usage of health services 36 4.5 Support and treatment of mother’s mental ill health 41 4.6 Mother and baby unit placement 42 4.7 Care planning 47 4.8 Father and partners 48 GLOSSARY OF TERMS AND ABBREVIATIONS 49 APPENDIX 1: 50 3 1 INTRODUCTION 1.1 INITIATION OF SERIOUS CASE REVIEW 1.1.1 Hampshire Safeguarding Children Board [HSCB] initiated this serious case review on Baby Z on 28.06.17, following two life threatening episodes, necessitating emergency hospital medical intervention in January 2017. Baby Z was nearly 4 months old at the first episode and just over 4 months old on the second occasion. 1.1.2 On the second occasion, Baby Z was found to have a partially healed fractured rib, and toxicology reports identified that Dihydrocodeine was present in Baby Z’s urine. This was a medication prescribed to the mother. During a police investigation, the mother was arrested. The investigation into harm caused to Baby Z centred around the offence of administering poison (other destructive or noxious thing) so as thereby to endanger life. Following a police investigation and in early consultation with the Crown Prosecution Service [CPS] it was established there was no possibility of meeting the evidential threshold to enable a realistic prospect of conviction. This was due to a number of factors including; medical and forensic evidence and other lines of enquiry being unable to categorically prove how and by whom the drug was administered and whether it was done so wilfully or accidentally. In addition, it cannot be concluded that the drug found within the baby’s system was the actual cause of the medical episodes suffered by the baby. 1.1.3 Baby Z was subject to an interim Care Order to Surrey County Council at that time, living with her mother in a Mother and Baby Unit within a psychiatric hospital in Hampshire. The Care proceedings continued and have now concluded: Baby Z was not returned to the care of her mother. 1.1.4 Hampshire SCB took responsibility for initiating the serious case review, with the agreement of Surrey Safeguarding Children Board [SSCB], because Baby Z was living in Hampshire at the time of the events mentioned in 1.2 above and there were concerns about the way agencies had worked together to safeguard Baby Z. CASE SUMMARY: WHAT HAPPENED? 1.1.5 This serious case review covers a period of 7 months from late June 2016 to the end of January 2017. The mother in this case moved to Surrey early 2016 when she was pregnant and homeless. She had a history of physical and mental ill health and a diagnosis of borderline personality disorder, also known as Emotionally Unstable Personality Disorder [EUPD]. 1.1.6 During her pregnancy with Baby Z there were concerns about mother’s self-harming and suicide attempts. This led to the making of a child protection plan [CPP] for the unborn baby being agreed in late June 2016, which continued after her birth in September 2016, until an interim Care Order [ICO] was made to Surrey County Council in December 2016. 4 1.1.7 During the pregnancy the mother continued to have frequent hospital presentations reporting physical ill health symptoms and / or overdose of prescribed medication. She moved to Hampshire, which was the family’s permanent address. However, the plan to safeguard the unborn baby involved mother and baby moving to stay with maternal great grandmother [MGGM] in West London, following the birth. 1.1.8 Baby Z was born prematurely and discharged to the mother’s care to MGGM’s address at age 10 days, at the end of September 2016. At age 19 days, Baby Z moved with mother to their permanent home in Hampshire, but 8 days later Baby Z was admitted to hospital for 4 days due to concerns about feeding. 1.1.9 During the next few weeks the mother’s mental health deteriorated becoming acutely unwell and was admitted to a psychiatric hospital. In the meantime, Baby Z had a number of carers including mother, MGGM and a placement with a family friend selected by the mother, following MGGM feeling unable to care for Baby Z. 1.1.10 During this chaotic period in Baby Z’s life the case responsibility for her remained with Surrey Children’s Services [SCS], whilst Surrey mental health service providers provided the mental health support and treatment for mother. The plan agreed in November 2016, was for mother and baby to move to a mother and baby unit [MBU], which is part of a psychiatric facility provided by Southern Health NHS Foundation Trust in Hampshire. 1.1.11 Mother and baby were re-united in early December, the day after an Interim Care Order [ICO] was made to Surrey County Council [SCC} and moved together to the MBU. Within the first day, the MBU decided that the mother did not meet their admission criteria, as no longer acutely mentally ill. In consequence SCS identified a residential mother and baby unit, experienced in providing parenting assessments, as opposed to one providing psychiatric treatment for the parent. This residential unit offered a place subject to mother having no further episodes of overdosing or self-harming. 1.1.12 The move from the MBU was delayed due to both mother and baby ill health in January 2017, with Baby Z’s suffering 2 life threatening episodes requiring emergency medical intervention. The latter of these, described in 1.1.2 resulted in Baby Z being removed from mother’s care and the initiation of this serious case review. 1.2 SUMMARY 1.2.1 One of the major factors in this case was the short period the professionals knew the mother and the difficulty professionals had in obtaining an assessment of the mother’s ability to care for Baby Z in the long term. The mother was new to Surrey in 2016 and frequently presented at different health settings in various geographical locations, often reporting acute medical and psychiatric symptoms requiring urgent responses. During the period under review mother had at least 47 hospital presentations, including routine ante natal care. 5 1.2.2 In this context professionals appropriately responded to the presenting emergencies, but the impact of constant crisis was to limit professional capacity and ability to progress holistic protection assessment and planning for Baby Z. 1.2.3 The mother presented with a variety of self-reported physical illnesses at a large number of different health providers and received medication for a variety of conditions (including cardiac problems and diabetes). What is less clear is whether or not the mother ever co-operated with medical assessments so as to be able to confirm the diagnosis made on her reported symptoms. During the period under review, when such medical investigations were offered at Frimley Park Hospital [Frimley Health NHS Foundation Trust], the mother declined tests or discharged herself from hospital before these were undertaken. 1.2.4 It was challenging for any one health practitioner or agency to obtain a holistic oversight and understanding of the mother’s health because of the high number of practitioners involved in different locations, the relatively short time mother was known in Surrey and the systemic lack of a health practitioner with oversight and knowledge of all mother’s ill health. This led largely to individual responses to mother’s health presentations, relying on her explanations of what was behind her reported symptoms and without consideration of what might be behind such a high usage of health services. One possibility that could have been explored was the possibility of mother fabricating or inducing her own symptoms of illness. Had this possibility been explored, it may have intensified the attempts made at Frimley Park Hospital to fully understand mother’s health history and the causes of her symptoms and greater caution in relation to Baby Z’s safeguarding if in the care of mother. 1.2.5 In the practitioners’ responses to mother’s frequent crises, the needs of a new born premature baby for safe consistent care and nurture were given insufficient priority. The original plan for mother and baby, following a Family Group Conference, was for Baby Z to remain in the family, with help and support from extended family members and that a parenting assessment be undertaken to establish if mother would be able to care for Baby Z in the long term. However, the plan was never fully implemented: mother’s emotional and mental health instability meant that the situation was never sufficiently stable to undertake the parenting assessment. This was perhaps compounded by the plan at that point to transfer social work case responsibility from Surrey to Hampshire: this never happened but the certainty in Surrey that it was imminent may have contributed to a lack of pro-active review during the last months of the pregnancy. 1.2.6 Following further deterioration in mother’s emotional and mental health following the birth, mother was a psychiatric in-patient in Surrey and the hospital made a referral to the MBU. By the time mother and Baby Z were admitted to the MBU in December 2016, premature Baby Z had spent her first 3 months of life moving around, with 3 different carers, in 3 different settings and 2 hospital admissions. 1.2.7 The MBU is a psychiatric ward in Hampshire, where mothers were admitted due to their acute mental health needs, with the admission enabling mother and babies to be kept together, with support provided to develop attachment between baby and mother. 6 1.2.8 Although multi-agency planning at the child protection conference had considered a mother and baby unit [MBU] might be needed, the function and facilities of the chosen unit were not discussed within a multi-agency meeting. Surrey mental health services arranged this psychiatric MBU placement, on the basis of mother’s acute mental health needs. What was not understood by professionals at the time was that it did not have the facility to provide the parenting assessment required by Surrey children’s services [SCS} i.e. one that could advise on mother’s long-term parenting capacity to be used as part of care proceedings, which SCS had by then appropriately decided to initiate. 1.2.9 The social work manager had tried to check that a parenting assessment could be provided but there was a misunderstanding between managers at the MBU and SCS on this issue: the social work manager erroneously understood that such an assessment was possible and the MBU manager did not appreciate that this was required. This error became clear to the social worker immediately after admission in December 2016, when the MBU explained that the mother did not meet the ward’s admissions criteria: she was not acutely mentally ill and would need to move elsewhere. 1.2.10 The social worker identified an alternative specialist mother and baby residential assessment resource, experienced in dealing with child protection risks, and arranged for mother and baby to be admitted. This residential unit specified the admission condition that mother had no more overdoses or self-harm incidents. This planned move however was delayed due to the constant health emergencies for baby and mother in January 2017. 1.2.11 Whilst it is likely that Baby Z would have been safer in such an environment, the lack of full understanding about the mother’s own physical and emotional health meant that not all possible risks to Baby Z if in the sole care of the mother were at this point identified. 1.2.12 In conclusion, in just over 4 months, Baby Z had a large number of moves and different carers including her mother, her maternal great grandmother [MGGM], a ‘family and friends’ placement, her mother in a mother and baby unit and foster carers, as well as 5 hospital admissions. 1.3 STRUCTURE OF REPORT 1.3.1 The remainder of the report is structured as follows: Section 2 explains the review process including the different agencies involved with the family, those participating in the review and the limitations of the process Section 3 provides a fuller account of what happened from the perspective of practitioners, with an appraisal of professional practice Section 4 provides the findings of the serious case review with considerations for action by the LSCBs involved in this review, and their agencies A glossary of abbreviations and terms used is provided at the end of the report The terms of reference for the serious case review are in the appendix 7 2 REVIEW PROCESS 2.1 AGENCIES AND GEOGRAPHICAL AREAS INVOLVED WITH THIS REVIEW 2.1.1 During the period under review mother lived in Surrey and Hampshire, and also stayed with Baby Z’s maternal great grandmother [MGGM] in West London. In consequence there were professionals and agencies involved arising from these locations. Additionally, the mother accessed a variety of health services in additional locations. 2.1.2 Hampshire SCB initially identified agencies known to be involved with mother and/or Baby Z and requested that they each provide a chronology and agency report for the serious case review. On the basis of the information provided further agencies and professionals were identified as having relevant information and were asked for information or to produce a report and chronology. This was a lengthy process and caused delay on this data collection stage of the review. When further information identified limited health involvement with mother, the review has relied on information in the GP chronology and not sought further data. 2.1.3 The following agencies provided chronologies and reports to the review to the review: Surrey and Borders Partnership NHS Trust: provided Surrey psychiatric services to the mother through both community mental health services and acute inpatient services Frimley Health Foundation Trust [FHT] providing the following services in Frimley Park Hospital [FPH]: maternity, perinatal mental health, paediatric, Emergency Department [ED], diabetic and safeguarding services as well as the community midwifery services Hampshire Hospitals NHS Foundation Trust providing services at the Royal Hampshire County Hospital [RHCH] University Hospital Southampton [UHS] Clinical commissioning groups providing GP services to the family during the period of the review Surrey Children & Families Health service providing health visitor in Surrey to the family Southern Health NHS Foundation Trust mother and baby unit [Melbury Lodge] for mother and baby, and health visiting input during this admission Surrey County Council Children’s Services [SCS]: provision of social work services to Baby Z and her mother throughout period under review Surrey County Council Adult Services Hampshire County Council Children’s Services [HCS]: liaised with health and social work services in Surrey, but had no direct involvement with the family Surrey Constabulary 8 Hampshire Constabulary South Central Ambulance Service Cafcass providing Children’s Guardian for the Care Proceedings 2.1.4 Additional information was provided by Capita in relation to the process for transfer of GP records. 2.1.5 The following list of other health services involvement identified from GP records may not be comprehensive. Due to delays in transfer of such records, not all this information would have been available at the time to the GP, or to other professionals – although mother often did share details of these contacts: Baby Z was admitted into hospital in London for 5 days, aged one month: this admission does not appear in records from other agencies Mother attended 7 hospitals (6 in London and 1 in Berkshire) during this period for a variety of ailments, including gestational diabetes and supraventricular tachycardia (SVT) Mother attended 3 urgent care centres in London, a London out of hours health centre and a Berkshire Walk in Centre 2.2 SCOPE AND TERMS OF REFERENCE 1.1.1 The full terms of reference are set out in the appendix of this report. The period under review is from 24/06/2016 – 28/01/2017. In order to have a better understanding the author has also included contextual information from earlier May 2016, when child protection concerns were identified for unborn Baby Z. 2.3 REVIEW METHODOLOGY 2.3.1 The agencies above who provided information to this serious case review did so in the form of a chronology of their involvement and an agency report and recommendations for action. 2.3.2 The serious case review panel, consisting of senior members of the involved agencies, worked with the independent lead reviewer, Edi Carmi, to consider the management reviews, identify and request outstanding information, meet with practitioners and provide feedback to the report written by Edi Carmi. 2.4 PRACTITIONER INVOLVEMENT 2.4.1 The lead reviewer and panel members met with practitioners individually or in small groups so as to understand their perspectives and explanations of what happened. 2.4.2 Arranging practitioner interviews proved extremely challenging, and caused delay. These were finally completed in August 2018. 9 2.5 FAMILY INVOLVEMENT 2.5.1 The author of the review planned to involve Baby Z’s mother, father and great grandmother. 2.5.2 The Board have advised the author that Baby Z’s mother was informed of the serious case review and invited to contribute, however declined. 2.6 LIMITATIONS TO SERIOUS CASE REVIEW 2.6.1 There were limitations to this serious case review through being unable to obtain the mother’s perspective through direct contribution to this review. 2.6.2 The perspective of community and hospital practitioners in London is missing, in terms of learning what understanding they may or not have had about both mother’s health and Baby Z’s needs. There was a need to maintain proportionality of this review, given the growing list of health practitioner involvement with the mother, which emerged during the course of the review. Attempts were though made to include the West London health visitor within the health visitor group, but HSCB received no response. 2.6.3 The lack of response of the Children’s Guardian to contact by the LSCB is extremely disappointing. Her perspective appears to have been different to other professionals, and initially was concerned about the plan for a mother and baby unit placement, wishing this to be discussed within the legal proceedings. However, this did not happen as she discovered that mother and baby had moved into the unit the day before. 2.6.4 A few practitioners had not understood [or possibly not been advised of] the need to prepare for conversations with the lead reviewer, hence they did not recall some events or the rationale for their actions or lack of actions. 10 3 PROFESSIONAL PRACTICE EVALUATION 3.1 INTRODUCTION 3.1.1 Section 1.2 provides a brief summary of what happened during the period under review. Section 3 analyses what happened in more detail, broken into different time periods. The aim of this is to understand and appraise professional practice. 3.1.2 This has been a challenging task due to the constant moves and fast-moving changes of circumstances. A great deal more contact with Baby Z occurred than is apparent from some agency records. 3.1.3 Throughout the report the family are referred to by their relationship with Baby Z, so her mother, her maternal great grandmother [MGGM] and her maternal great aunt [MGA]. Context prior to period under review 3.1.4 Mother presented as homeless and pregnant in Surrey in March 2016, without links in the area. She was provided with temporary accommodation and a referral made to Surrey Children’s Services [SCS] for support. She initiated contact herself with SCS and an assessment was appropriately initiated. 3.1.5 At 15 weeks pregnant in April, mother self-reported to the Surrey midwife that she was booked into both Frimley Park Hospital and Queen Charlotte’s Hospital [West London], the latter associated with her heart condition. Mother highlighted having 2 cardiac arrests at age 17, social care involvement as a child and current mental health involvement. She mentioned 4 previous pregnancies, ending in miscarriages. The midwife appropriately made a multi-agency referral for social care help and support after booking-in – and spoke to a social worker. 11 3.2 RECOGNITION OF CHILD PROTECTION CONCERNS: MAY 2016-JUNE 2016 3.2.1 As explained in 2.2, the author has commenced the period under review from early May 2016, when the first child protection concerns were referred to Surrey Children’s Services [SCS] following mother being found at a railway station, reporting she had cut her wrist, with visible injuries and blood on trousers. She was taken by ambulance to Frimley Park Emergency Department [ED] under s.136 Mental Health Acti and subsequently detained under Section 2, Mental Health Actii 1983. This was the 1st known hospital admission for mother in the period under review. 3.2.2 A s.47 enquiryiii [commonly called child protection enquiry] was appropriately undertaken by SCS. This established a complex history from previous supported housing, perinatal and mental health service providers in London including mother had made 2 previous suicide attempts in February 2016, had a pattern of hiding medication and of keeping sharp objects in her room – risks in relation to overdosing and self-harming. She was reported to not want a mother and baby home, of having changed her GP 13 times and being diagnosed with Borderline Personality Disorder. She had left London and moved to Lincolnshire with a man for 2 weeks – it was not known if he was the father. 3.2.3 The Surrey and Borders Partnership Mental Health Trust received a referral from Lincolnshire. Their report to the SCR refers to mother’s long history of deliberate self-harm and hospital admissions with overdosing, as a way of coping with stressful situations. Also, that she had never previously lived on her own and was scared about this, having been in care or in supported housing schemes. There is no evidence that the social workers ever knew she had never lived on her won before. 3.2.4 An initial child protection conference (CPC) was held by SCS in late June 2016. It was shared at the meeting that whilst on the hospital ward, mother had self-harmed. The social worker’s assessment included the information that mother had made 3 suicide attempts in the pregnancy. There was majority agreement for a child protection plan [CPP] under Neglect, due to concerns about maternal physical and mental health. i Section 136 gives the police the power to remove a person from a public place, when they appear to be suffering from a mental disorder, to a place of safety. The person will be deemed by the police to be in immediate need of care and control as their behaviour is of concern. ii Section 2, Mental Health Act 1983 provides the legal framework for an assessment to take place and can last up to 28 days. iii Section 47 of Children Act 1989, known as a s.47, refers to the local authority duty to make enquiries when they ‘have reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm’. 12 PROFESSIONAL PRACTICE APPRAISAL From the point child protection concerns were identified there was an appropriate response by SCS, initiating a s.47 enquiry, undertaking agency checks and learning sufficient to conclude the need for a child protection conference and plan. The apparently unshared knowledge by the mental health trust of mother never previously living alone would have usefully contributed to post birth planning arrangements. Not all professionals at the conference supported the need for a child protection plan: colleagues in conversations with the author were rightly concerned that two of the practitioners did not recognise the need for a child protection plan. 3.3 UNBORN BABY SUBJECT TO CHILD PROTECTION PLAN: 24.06.16 – 16.09.16 Mother’s health 3.3.1 Mother continued to experience health problems in the remainder of her pregnancy with constant hospital presentations. It appears that mother had 12 hospital presentations / admissions in less than 3 months, but there may have been more at other hospitals, or not specifically itemised within the chronologies. Whilst most admissions were at Frimley Park Hospital [FPH], mother is known to have also presented at 3 hospitals outside of Surrey, with an admission at one. 3.3.2 The admissions concerned reported palpitations, suspected gestational diabetes, abdominal pain, vomiting, low mood, dizziness and hypoglycaemia. She often was brought into hospital by ambulance and self-discharged against medical advice. Sometimes this meant she missed, or possibly avoided, further medical screening / testing in relation to cardiac and diabetes symptoms e.g. glucose tolerance test, repeat BP and pulse examination. 3.3.3 Mother continued to have frequent contact for the rest of the pregnancy with the Surrey community midwife, FPH and GP1 with concerns about reduced foetal movement, antibiotics for chest infection, infective exacerbation asthma, back pain, palpitations, abdominal pain and dizziness and low mood. She also attended a London Urgent Care Centre for a cough and hip pain. 3.3.4 The mother registered at GP2 surgery on 31.08.16. The GP chronology notes 40 previous urgent care attendances in previous 12 months – this demonstrates how long standing this pattern of behaviour was, albeit mainly falling before the period under review and not known to practitioners at the time. 13 3.3.5 On the last FPH attendance just before Baby Z’s birth, the mother walked out of hospital crying and her midwife was unable to convince her to stay. She subsequently would not allow the midwife on duty to see her at home that day. The next day mother reported reduced foetal movement [35 +4/40 gestation], but refused to follow midwifery advice to go to hospital (she had high blood pressure and a high pulse) and declined a further visit the next day. 3.3.6 Throughout the period of the pregnancy there were concerns about mother’s emotional health and welfare, and the welfare of the unborn baby: A hospital consultant trying to establish the reality of mother’s diabetes [see 4.3] Possible misuse of medication Child protection concerns: she told the midwife she had no attachment to the baby and that the baby ‘will be taken away from me’ The out of hours [OOH] GP noted the flat smelled of smoke and was dirty and messy – there was no evidence that these concerns were escalated within health or to the social worker Mother’s refusal to follow midwifery advice at the end of the pregnancy, potentially risking the welfare of her baby Social care planning 3.3.7 A Family Group Conference took place on early August 2016. The plan agreed was for the family to support mother, with professional support. This is one of the few records of SCS involvement since the initial CPC and core group meeting, as opposed to what appears to be virtually daily health involvement. This may reflect recording shortcomings, but also a lack of parenting assessment activity too – see practice appraisal points below. House move to Hampshire: 12.08.16 3.3.8 The mother moved over the border from Surrey to Hampshire on 12.08.16. From this point SCS planned to transfer the case to Hampshire, but this never actually happened [see 3.2]. PROFESSIONAL PRACTICE APPRAISAL There was little progress on the SCS assessment of mother in this critical period. The efforts made to do this are not known to the author, albeit mother’s frequent acute ill health presentations would have been a major obstacle. Also, the first social work manager [SCS] explained to the author that the plan at this point was to transfer the case to Hampshire; this may have discouraged further assessment (see 4.2 for further discussion). The data on the frequency and variety of maternal health presentations is a critical part of any assessment, but within current systems it is not collected together and analysed by any one health practitioner, albeit the GP is informed of the presentations [see 4.2] The role of the CPN was limited to one telephone and 1 direct contact: this should have been a critical time period for CPN intervention and involvement in multi-agency work. 14 The role of the FPH consultant was critical here, as s/he tried to understand what was behind some of mother’s health presentations– see 4.3 for further discussion. The safeguarding children’s team at FPH recognised some of the safeguarding issues and concerns and made significant attempts to explore and understand Baby Z mother’s medical history and make sense of her hospital attendance. 3.4 BABY Z BORN & IN HOSPITAL: 16.09.16 – 26.09.16 Birth and plan 3.4.1 The day after the midwife advised mother to go straight to hospital (16.09.16) Baby Z was born by Caesarean section, 5 weeks prematurely. Mother and baby remained in hospital for 10 days prior to both being discharged to MGGM’s home, in accordance with the original plan formulated at the initial CPC, the family group conference and agreed at the review CPC and pre-discharge meeting in September 2016. Concerns 3.4.2 During this time there were some positive indicators with mother keen to provide care for Baby Z when visiting the neo natal unit and subsequently when mother and baby were reunited in the transitional care unit when Baby Z was 3 days old. 3.4.3 There were though also concerns about the circumstances of Baby Z’s birth and mother’s ability to consistently put Baby Z’s needs first: SCS were notified of the birth and informed about mother’s recent volatility, ignoring advice to return to hospital with high BP and pulse rate – in conversation for this review the midwife recalled perceiving this as mother risking her baby’s safety and placing her own needs and wishes above the health of her baby. Mother did not rouse to see to Baby Z’s needs on 21.09.16 when Baby Z was unsettled, although this may not be that unusual with mothers in the first few days 3.4.4 Concerns arose immediately following the review CPC (see 3.4.7 below): leaving the unit to have a cigarette when it was Baby Z’s feeding time and not understanding the need to wake premature Baby Z for a feed every 3 hours [baby aged 7 days]. Mental health support 3.4.5 Mother requested to see the psychiatric liaison team at the hospital when Baby Z was 7 days old, as she said had had no contact with the Surrey CMHT. Records however show 3 contacts the previous week with the Enabling Independence Worker and also contact on the day of Baby Z’s birth with the CPN -albeit this visit is contrary to what mother reported and not in hospital records. 3.4.6 The assessment by the psychiatric liaison team found no evidence of psychosis or post-natal depression and this was fed back to CMHT. 15 Review Child Protection Conference on 23.09.16 3.4.7 The review CPC acknowledged mother’s failure to prioritise her unborn baby’s needs by delaying receipt of medical support until it was an emergency situation. The meeting also discussed that mother had not been seen by the CPN or a psychiatrist as had been in the original CPP, along with practitioners referring to their difficulty contacting the CPN. 3.4.8 The midwifery report to the meeting noted 20 hospital contacts since last report –including routine maternity appointments. 3.4.9 The meeting unanimously agreed to continue the CPP. It was agreed that Baby Z and mother would go to maternal great grandmother [MGGM], a parenting assessment to be completed and a possible need for a mother and baby unit. The discharge plan confirmed support from all agencies, especially the CMHT as it was noted there had been difficulties communicating with them. 3.4.10 If concerns increased, the plan was for the social worker to request a legal planning meeting – this would be with the aim of considering the use of legal interventions. . Discharge 26.09.16 3.4.11 A discharge meeting held on 26.09.16, confirmed the move to MGGM, despite the concerns that arose following the conference (see 3.4.4). There are no records of the content of the meeting, although the health visitor recorded that a core group meeting was held at same time as the discharge meeting with attendance of the health visitor, perinatal mental health midwife, social worker, CPN and MGGM. 3.4.12 The CSC chronology notes the lack of evidence that MGGM’s local authority were informed. Within health appropriate communication and arrangements were made with the health visitor calling her counterpoint in London. Arrangements were made for the London midwife to visit until Baby Z was 28 days old and hand-over of care was made to the London hospital initially involved and mother’s GP2. 3.4.13 The same day the health visitor undertook the new birth assessment. Baby Z’s father was reported by mother as having no knowledge of or contact with Baby Z. PROFESSIONAL PRACTICE APPRAISAL There was a good structure around planning for the future, with a review conference, discharge meeting and core group meeting all held before discharge. The plan was over reliant on MGGM, without a local professional network to support her and did not provide sufficient clarity around expectations e.g. what was expected of mother and baby prior to a move to Hampshire and over what period – previously 2 weeks had been mentioned which seemed very short given that mother’s own experience of living on her own was limited, and involved frequent health crisis. 16 There is no evidence that the London borough where MGGM lived were informed that a baby subject to a child protection plan was staying in the borough (as per procedures), but health communication was good. 3.5 BABY Z’S FIRST HOME FOR 9 DAYS: LONDON 26.09.16 – 05.10.16 3.5.1 Mother and 10-day old Baby Z stayed with MGGM for 9 days before moving to Hampshire [see 3.6 for discussion about move}. Baby Z 3.5.2 During the 9 days in West London Baby Z was seen at home by a midwife and by the Surrey social worker. Whilst there were no general concerns about her care, when the midwife visited, Baby Z aged 14 days old, had lost weight and the midwife arranged for her to be seen by a paediatrician that afternoon, at a West London Hospital. The Hampshire health visitor received notification from that hospital on 31.10.16, which said the plan was for twice weekly weighing, feeding advice and re-assurance. Mother’s health 3.5.3 During these 9 days, mother had 4 health presentations at Walk in Clinics, an out of hour health centre and a hospital. These concerned a chest infection, repeat medication requests and palpitations. PROFESSIONAL PRACTICE APPRAISAL During these 9 days it is of concern that having sent mother to hospital in relation to concerns about the health of a premature baby subject to a CPP, there appears to have been no follow up by the midwife to check if mother did attend hospital and the outcome. The delay in the Hampshire midwife receiving notification of this meant that could have been no timely follow up, if the mother had herself not sought further help. 3.6 BABY Z AGED 19 DAYS, IN HAMPSHIRE: 05.10.16 – 13.10.16 3.6.1 Mother and 19-day old Baby Z stayed alone for 8 days in mother’s flat in Hampshire (2nd home for Baby Z). This was the only time Baby Z lived alone with her mother. 3.6.2 This was a confusing period for practitioners, with uncertainty if this was a temporary move or not, and if social work case responsibility rested with Surrey or Hampshire, as the Surrey social worker said the case would transfer imminently – see 4.2 for further discussion. The London health visitor understood it to be temporary move, to enable mother to see her GP [which she did], whilst the social worker understood it to be a permanent move, following MGGM’s verbal report that all was going well. 17 Baby Z’s welfare 3.6.3 There were no identified concerns about Baby Z’s care during these days, except that mother needed support as she was anxious about her daughter’s health. After 3 days the mother contacted duty health visiting for advice, and then the GP, as Baby Z was reportedly constipated for 3 days and vomiting after feeds. She explained about Baby Z’s failure to gain weight. The GP noted that Baby Z was settled, well hydrated, clean and advised to continue feedings as per paediatrician’s advice and bring into the health visitor’s clinic twice weekly. The GP contacted the Hampshire health visitor, who provided background information (the CPP and maternal mental health problems) and agreed to contact mother to attend her clinic. The GP also shared with the health visitor (but did not record in GP records nor inform SCS) that a man accompanied mother and Baby Z. Maternal health 3.6.4 Mother presented at Frimley Park Hospital during this period with abdominal pains and bleeding. Oramorph (oral morphine) was given and she was discharged to GP care. PROFESSIONAL PRACTICE APPRAISAL The mother’s decision for her and Baby Z to move to Hampshire was premature and should have been challenged by SCS, even if MGGM felt mother had coped over 9 days. This was an insufficiently long enough period to judge that mother could cope on her own, given her history during pregnancy and that during this brief time she had presented at 4 different health settings. The household composition at this point is not clear, as a man accompanied mother and baby to the GP surgery – nothing was known by health staff of this relationship and impact on Baby Z’s welfare. This relationship should have alerted professional curiosity and exploration, been included within any assessment by the social worker and discussed with professional colleagues. 3.7 BABY Z’S FIRST HOSPITAL ADMISSION, 4 WEEKS OLD 3.7.1 At 4 weeks old, Baby Z had her 1st hospital admission, lasting 4 days. It was prompted due to midwifery concerns about her reported unresponsiveness to feeds, with suspected sepsis and reflux. FPH children’s ward records show that a new male partner accompanied mother, who was mistakenly assumed to be the father. 3.7.2 During this admission concerns about mother’s care of Baby Z were identified. Ward staff noticed minimal interaction between baby and ‘parents’. Overnight on her last night nurses fed Baby Z, with mother getting angry when woken and then leaving the ward to smoke, without first feeding Baby Z. Prior to leaving the hospital mother was noted to be aggressive towards nursing staff. 18 PROFESSIONAL PRACTICE APPRAISAL Baby Z should not at this point have been discharged from hospital without, at minimum, prior discussion with SCS, but this did not happen. No discharge meeting was held either. FPH staff, in conversations for this review, have suggested this was associated with the difficulties experienced in general with getting hold of the Surrey social worker; however, the exact details of communication attempts and responses are not known by the author . Additionally, as discharge was to MGGM, as opposed to mother, it would have been considered as consistent with the child protection plan. 3.8 BABY Z CARED FOR BY MGGM: 17.10.16 – 18.10.16 3.8.1 On 17.10.16 Baby Z was discharged to MGGM’s care. The social worker when informed what had happened by the hospital, had knowledge of the man with the mother, but advised the hospital he should not be present. She explained that MGGM cared for Baby Z overnight because her mother was feeling tired, but returned Baby Z to mother’s care the next day. PROFESSIONAL PRACTICE APPRAISAL By this point there should have been major professional concerns at the thought of a premature 28 day old baby moving around in 3 weeks from hospital to London, to Hampshire, to hospital, to London and back to Hampshire, whilst suffering from an infection and without the security of a consistent carer or home. There was a lack of clarity about the domestic home environment, possibly including a new male figure and worrying reports of maternal aggression and neglect of meeting Baby Z’s needs in hospital. Good practice in these circumstances would have been for an emergency core group meeting to evaluate the safety of the plan and consider what action needed to be taken e.g. change in CPP with longer period with MGGM for assessment and/ or early review CPC, or a legal planning meeting (as had been suggested at the review conference if there was any deterioration in circumstances). 3.9 BABY Z AND MOTHER: EVENTS ON 18.10.16 TO 31.10.16 3.9.1 There is confusion in the information provided to the serious case review about what happened over the next days, where Baby Z was staying and who was caring for her. This reflects the different understandings of professionals and different agencies. It has been difficult to determine the exact sequence of events and who knew what and when. The following is an attempt to do so, but from the conflicting information provided by different agencies it is not possible to be confident of accuracy. 19 3.9.2 During these 13 days concerns increased rapidly about the mother’s mental health and her ability to care for her baby, with at least 7 hospital presentations, including 2 admissions. It is in this period that plans for a mother and baby unit re- emerged, with the recognition that the planned move of Baby Z to mother’s Hampshire flat should not take place at this point, the possible need for legal intervention and consequent inadvisability of transferring case responsibility to Hampshire. Deterioration in mother’s mental health and allied negative feelings towards her baby 3.9.3 The day after Baby Z was discharged from hospital [18.10.16] her mother texted maternal great aunt [MGA] reporting self-harm (lacerations on arm). MGA acted swiftly, taking mother to FPH where she was seen by psychiatric liaison but then sent home. Mother had told MGA that she did not want Baby Z near her and got annoyed or irritated when Baby Z cried or wanted attention and ‘hated her’. 3.9.4 During the remainder of October (less than 2 weeks) mother’s there was increasing concerns about mother’s mental health arising from: 2 incidents when an ambulance was called to mother’s reported self-harm and overdosing 4 hospital presentations -refusing to see psychiatric liaison on 1 occasion and leaving before an assessment on other occasions Mother found by police at a railway station, seen by psychiatric liaison and arranged for home treatment team [HTT] to see her the next day - she refused their visit, although did see them another day, when the unidentified male, her boyfriend, was present Mother was admitted to FPH following an overdose near the end of the month: she was described as ‘absconding ‘, was found by police at a friend’s home and returned to FPH, where she assaulted a member of staff, before being assessed as having mental capacity and discharging herself. 3.9.5 The GP discharge notification refers to mother’s boyfriend smashing up mother’s flat when the ambulance visited on 19.10.16 – it is not clear if the health visitor or social worker were ever informed of this, despite the risk to Baby Z and potential risk to professionals visiting the home. 3.9.6 The letter to the GP from the psychiatric liaison nurse on 28.10.16 additionally mentioned that the mother wanted to go to a mother and baby unit, that the CPN had been informed of discharge and planned to visit the next day. 3.9.7 Another GP discharge summary from FPH mentioned a referral had been made to the mother and baby unit and that mother had kicked a member of staff on 27.10.16. The GP at this point is noted to have appropriately called both the social worker and CPN to discuss the concerns. 20 Baby Z’s welfare 3.9.8 The whereabouts of Baby Z during this period are not clear in the different agencies’ chronologies, but it seems that on 18.10.16 Baby Z was with her mother when the mother texted MGA that she could not bear to touch or hold Baby Z and wished she had not had her, and later said she hated her. Baby Z was then taken by MGA to London and moved to MGGM, where she was visited on the next day by the social worker. 3.9.9 The next day Baby Z was taken to a West London hospital by MGGM with a high temperature and heart rate. She remained in hospital until 24.10.16 and discharged with antibiotics. This was Baby Z’s 2nd hospital admission in her short life – aged just over a month. This information was in the GP chronology and it is not known if any of the professionals knew of this, as the social worker referred to Baby Z being with MGGM in conversation with the health visitor at that time. Case transfer 3.9.10 The FHT safeguarding team liaised fully with both area Children’s Services, so the concerns were fully known within both. At this point Hampshire Children’s Services [HCS] were anticipating case transfer, but with the changed circumstances case transfer was recognised as no longer appropriate and on 27.10.16, in the social worker’s supervision, the decision was made to obtain legal advice. Surrey at this point appropriately accepted responsibility for resolving the future care of Baby Z. HCS closed the case that day. PROFESSIONAL PRACTICE APPRAISAL Although FPH record that a mother and baby home placement was planned at this time, it is not known who was arranging this. There seems to be little evidence of any professional understanding about mother’s current state of mind, what had caused the deterioration and what she was feeling towards her daughter. At this point there was an urgent need to secure Baby Z’s care: she needed a stable, safe placement and for security to be provided by the initiation of care proceedings. It is of note that by 19.10.16, MGGM told the social worker that the mother would be unlikely to ever be able to care for Baby Z, and that she wished to do so in the meantime. 3.10 MOTHER IN HOSPITAL AND BABY Z PLACED WITH CARERS: 01.11.16 – 11.12.16 3.10.1 This 6-week period was one of upheaval in the lives of Baby Z and her mother. Baby Z was aged 6 – 12 weeks old. Mother was in and out of hospital and Baby Z was moved from MGGM, who felt unable to continue to care for her, to the family of one of mother’s friends. Mother’s instability and health planning for mother and baby 3.10.2 During the first 10 days of November, mother overdosed 3 times. 21 3.10.3 On the 1st occasion she was assessed as high risk at FPH and admitted to a Surrey psychiatric hospital ward, where she overdosed again. She had told a friend she wanted to die and written goodbye letters to significant family members. The friend also spoke about mother’s habit of hiding medication, presumably to enable her to overdose. In this period, she was also transferred to Royal Surrey Hospital for a kidney infection, but self-discharged and returned to the psychiatric hospital. 3.10.4 At this point the mother expressed her wish for a mother and baby unit, but the CPN’s view, expressed to the review author, was that such a placement would not be suitable as mother was not depressed and showed no mania or any commitment to stabilise her emotions. The community consultant was said to feel that mother’s presentation was Emotionally Unstable Personality Disorder [EUPD]. 3.10.5 The ward at the Surrey psychiatric hospital sent a referral to the mother and baby unit [MBU] in Hampshire. The MBU responded that the placement was suitable but no beds were available. 3.10.6 Mother was discharged from this hospital after 3 weeks and during the rest of November presented at FPH on 3 occasions with back/kidney pain, chest/back pain and chest pains, arriving by ambulance on each occasion. Baby Z’s welfare and social care planning 3.10.7 MGGM told the social worker on 06.11.16 that she was exhausted and unable to continue caring for Baby Z. Whilst searching for a suitable foster placement the social worker appropriately arranged for a family support worker to care for Baby Z within MGGM’s home. 3.10.8 An alternative ‘friends and family’ placement for Baby Z was chosen by mother with family friends, and Baby Z moved 5 days after MGGM’s decision. Baby Z had contact with mother at a contact centre 3 times a week, increasing following mother’s discharge from hospital to 5 times a week. 3.10.9 At the same time the Surrey children’s social care’s Head of Service agreed that the Public Law Outline [PLO]iv | should be initiated. Some delay subsequently occurred due to pressures in the legal team. The social worker informed mother of the intention to begin legal proceedings on 24.11.16, trying to explain that this was parallel planningv. iv The Public Law Outline (PLO) sets out the duties local authorities have when thinking about taking a case to court to ask for a Care Order to take a child into care or for a Supervision Order to be made. This is often described as initiating public law care proceedings. v When Proceedings are issued, the Local Authority can sometimes have several plans for a child at once. For example, the Local Authority may wish to do some assessments of the parents, if those assessments are positive, then the plan can be that the children are returned. 22 3.10.10 On 08.12.16 the MBU in Hampshire offered a place for mother and Baby Z and they moved in 4 days later on 12.12.16. In the intervening days there had been discussions between ‘senior staff’ at the MBU and the social worker and her team manager in relation to the service to be provided. In particular this centred on the provision of a full parenting assessment. The social worker manager understood that this was provided, but the record shows that the MBU said they provided observational work, but not a parenting assessment. This was a profound underlying misunderstanding. 3.10.11 The friends and family placement arranged occurred during the social worker’s absence. On her return she considered it unsuitable due to her observations of the care and previous knowledge of the family held by SCS. Despite the social worker’s subsequent concerns, management opposed a further move, on the basis that Baby Z had already experienced 3 carers in her short life and the imminent plans to move Baby Z to mother at the MBU. PROFESSIONAL PRACTICE APPRAISAL The different types of mother and baby units was by professionals not understood at the time. The referral was in accordance with the original contingency plan made at the child protection conferences, for the CPN to make such a referral if mother’s mental health deteriorated. However, the selection of mother and baby unit within a psychiatric hospital did not meet the needs of Baby Z or of the assessments required by social care. A misunderstanding had occurred between the social work manager and her counterpoint at the MBU, with records showing entirely different conclusions of what had been said and agreed. The MBU manager thought he had explained that no parenting assessments were undertaken at the MBU, but the social work manager believed that such an assessment was indeed possible, along with the provision of regular reports. This basic misunderstanding highlights the need for multi-agency involvement in such planning, as well as the need for practitioners to understand the different types and functions of mother and baby resources available. The provision of a family support worker within MGGM’s home to enable Baby Z to remain with MGGM was good practice, maintaining stability for Baby Z and reducing her moves. The initiation of care proceedings was a positive move, albeit it took a month to progress from the decision, due it is understood to delays in the legal team. This was very poor practice. The initial decision to place Baby Z with the particular family chosen by the mother was not good practice given information known at that point to SCS, but having made the placement it is understandable that a further move was avoided for Baby Z whilst waiting for the MBU placement. 3.11 CARE PROCEEDINGS INITIATED & MOTHER AND BABY MOVE TO MOTHER AND BABY UNIT: 12.12.16 – 31.12.16 3.11.1 Mother and baby moved into the Hampshire MBU on 12.12.16 and the next day Baby Z, aged 8 weeks old became subject to an interim Care Order [ICO] to Surrey County Council. The Judge is understood to have expressed support for the MBU placement. At this point Baby Z was 12 weeks old and had previously only been in her mother’s care for 8 days from 05.10.16 before being admitted to hospital. 23 3.11.2 Following admission, the MBU confirmed that they do not offer parenting assessments and this could not be done on the unit by others, albeit could be undertaken off site at a children’s centre. Moreover, immediately after mother and Baby Z moved into the ward, the MBU told the social worker that mother was not acutely mentally unwell and so not needing the MBU services, hence a specialist resource may be best option. 3.11.3 On 16.12.16 SCS ended the CPP on the basis of there being an ICO; this is usual practice. Instead of multi-agency core group meetings, looked after children statutory reviews are held, which may be multi-agency. 3.11.4 The MBU consultant psychiatrist wrote to the social worker on 16.12.16, confirming a diagnosis of Complex Traumatic Stress Disorder – also known as Emotionally Unstable Personality Disorder and asking for mother and baby to be allowed out together unescorted and that mother had not having overdosed since admission [4 days]. 3.11.5 On 21.12.16 a specialist mother and baby parenting residential assessment unit on the South coast confirmed a 12-week placement starting 12.01.17, if mother remained stable. However, the placement would end if mother should self-harm or attempt suicide. This plan was agreed at the Care Planning (CPA) meeting the next day, where the social worker and health visitor observed Baby Z to be calm and content in mother’s care, feeding appropriately, clean and well dressed. The issue of mother being able to take Baby Z out unescorted was discussed, but the outcome is not clear, other than SCS service manager said the original decision had been made because mother herself indicated worries about her coping abilities. Although the outcome is unclear in the records, subsequently the MBU proceeded on the basis that this had been agreed and all staff at the MBU who participated in this review understood mother and Baby Z were allowed out unescorted. 3.11.6 Ward rounds and recording generally emphasised the positive progress being made by mother in her care of Baby Z, the interaction between them and her engagement in therapy. Most records state that mother provided all care for Baby Z, but the occasional comment shows that this was not entirely accurate e.g. putting her own needs to go outside for a cigarette for periods, over Baby Z’s needs; sometimes taking a while to respond to Baby Z’s crying and times when staff helped as mother was feeling unwell or dizzy. There is though no evidence that this was ever discussed with the mother, and how she would manage without staff around to assist. Nor is there any evidence this was communicated to the social worker. 3.11.7 Within the records, although not causing staff concern, it was noted that mother was not eating sufficient food herself, possibly becoming more anxious and found it difficult to discuss her feelings, especially in relation to her lack of bonding with Baby Z. Again, there is no evidence this was communicated to the social worker. 3.11.8 Mother’s own physical health caused her problems by the end of the month, with ED attendance on 27.12.16. Mother continued taking a wide variety of medication for pain relief, anxiety and various physical symptoms, including cardiac problems. Her lack of food consumption continued and she reported suffering with gastric problems. 24 PROFESSIONAL PRACTICE APPRAISAL The ending of the child protection plan [CPP] once an interim care order was granted is usual practice. However, this brings with it the loss of multi-agency fora i.e. core groups and conferences (this is discussed further in findings 4.6. No LAC review was held before or following the placement move, on the basis of the move being part of the pre-existing care plan. This meant that there was no formal opportunity to consider the detailed care planning within the MBU, for Baby Z, and to share significant health information. This issue is discussed in findings 4.6. The specialist mother and baby parenting assessment unit was not likely to be suitable for mother and Baby Z, on basis of mother’s previous emotional health, as it required that mother should be stable, not self-harming or overdosing. This was also a realistic requirement if mother was going to be able to make an early success of caring for her baby. Even, if as seemed in December 2016, that mother could be stable, a contingency plan was needed, should matters change. The detailed records from the MBU do provide some potential concerns about mother’s self-care and of Baby Z. These issues were not identified or articulated and were not communicated to the social worker. There appears to have been no link made by MBU staff between concerns about maternal self-care and implications for her ability to care for her baby. 3.12 CONCERNS ABOUT BABY’S Z AND MOTHER’S HEALTH: JANUARY 2017 3.12.1 Throughout January there were constant concerns about the health of mother and Baby Z, which delayed plans for them to move to the specialist mother and baby parenting assessment unit. 1st life threatening event and 3rd hospital admission for Baby Z 3.12.2 On the evening of 04.01.17, Baby Z was increasingly drowsy along with episodes of rapid breathing. She was taken to Royal Hampshire County Hospital [RHCH] where she suffered a cardiac arrest, was resuscitated. The following day Baby Z was transferred to University Hospital Southampton [UHS], on breathing support. She was eventually diagnosed with meningococcal meningitis and returned to RHCH on antibiotics. 3.12.3 Whilst Baby Z was a patient at RHCH, her mother was admitted to hospital with reported symptoms of meningitis and subsequently diagnosed with influenza A. She was discharged the next day, returned to the MBU before staying with MGGM. At this point the MBU were aware of 14 Dihydrocodeine tablets that were missing from the last time when the mother was on leave a few days earlier. 3.12.4 Mother continued to be unwell, attending an urgent care centre with palpitations on 10.01.17 and admitted to a West London Hospital on 10/11.01.17 due to self-reported tightness in her chest and accidental [according to mother’s report to the MBU] overdose of anti-psychotic medication and strong painkillers. The hospital wanted to do a CT scan on her brain because of concern about a possible harm, but mother left before this was done. 25 3.12.5 Whilst the social worker was informed by the MBU of what was happening, there was delay on each occasion. In contrast, UHS staff liaised frequently with the social worker whilst Baby Z was there. 3.12.6 As a result of Baby Z’s illness, the move to the specialist mother and baby unit was postponed till 17.01.17. The social worker noted that mother was quite distressed at this time and the Surrey CMHT were asked to provide support to mother. Baby Z placed with foster carers 3.12.7 Baby Z was ready for discharge on 11.01.17, but because of mother’s illness, she was placed with a foster carer, a nurse for 6 days, until the MBU was able to have them back again. 3.12.8 On return to the MBU, mother was tearful, asking for more time on the MBU to prepare her for the move to the specialist mother and baby assessment unit. Arrangements were made for the psychiatrist to see mother and Baby Z slept in the nursery for 2 nights because of her mother’s anxiety and distress. The report written at MBU on 19.01.17 refers to Baby Z being a ‘protective factor’ for mother, but there is no mention of impact of mother’s mental health on Baby Z (see comment about this below). Baby Z suffering from food poisoning and a 4th hospital admission 3.12.9 On 20.01.17 Baby Z was presented at Royal Hampshire County Hospital [RHCH] having reportedly been unwell for several days and diagnosed with food poisoning [campyolacter], unusual in a child not eating solids. The foster carer reported she had herself been sick the night before Baby Z left and thought it may be food poisoning. The Surrey social worker did not warn the MBU, despite the risk for other babies. 3.12.10 Baby Z remained in isolation for 10 days within the MBU on anti-biotics. It is of note that the stool/vomit chart initiated on 19.01.17 was inconsistently completed, so unable to monitor Baby Z’s health. Staff continued to care for Baby Z at night, albeit Baby Z was in her mother’s room. This continued intermittently during the remaining days, with one mention of mother not waking up when her baby was crying on 25.01.17 3.12.11 Baby Z was taken by ambulance to RHCH with her mother on 22.01.17, as she was unresponsive and not feeding. Medical view was dehydration and she was kept in overnight and discharged with a feeding plan. From the records the MBU did not inform the social worker of Baby Z’s hospital admission, despite the social worker’s repeated requests for updates and information of concerns about Baby Z’s health and welfare. It is not possible to tell if Baby Z was consistently fed according to the plan as the feed charts were incomplete. 26 Mother’s emotional and mental health 3.12.12 Following the 2 bouts of Baby Z’s illnesses, and with the move to the specialist residential mother and baby assessment unit approaching, mother became increasingly stressed and anxious, suffering nightmares and worrying if Baby Z had brain damage or that she no longer liked her mother as she was not laughing and giggling. She was not eating much food herself and walking out of ‘emotional coping skills group’ during discussions of healthy eating as means to increase emotional resilience. 3.12.13 Generally, the judgments of mother’s progress at the MBU were positive, despite frequent recorded descriptions of mother’s worrying behaviour [see 3.12.12] so close to discharge. Instead of identifying risk factors to Baby Z from mother’s state, concern was focused on suggesting that the identified plan be changed and a mother and baby foster placement be provided as an alternative with medications for mother changed/ increased. The MBU advocated this to other professionals and in a letter to the court on 26.01.17, despite the social worker not considering this as a safe option. 3.12.14 Mother declined to see the worker from the specialist residential parenting assessment unit when she visited on 24.01.17, saying she was unwell: in fact this was untrue as she was in the lounge being taught to knit. The MBU did not inform the Surrey social worker of this. The specialist mother and baby assessment unit worker asked the Surrey social worker if the mother was reluctant to leave what was a protected environment and whether mother was involved in any of Baby Z’s recent significant illnesses. Baby Z’s 2nd life threatening event and 5th hospitalisation 3.12.15 On 28.01.17 mother was concerned that Baby Z was sleepy. Staff kept checking Baby Z and the view was that her temperature and breathing were normal and her colour good. She had fed during the day, but the recording is not comprehensive and also contradictory, so the extent to which she fed is not clear. In the evening mother became more concerned but declined the offer of going to the local hospital, RHCH, or obtaining advice from a paediatrician there. Instead she decided that UHS would be better and arranged for a friend to take her there. The friend’s car reportedly broke down, so staff called a taxi for mother at mother’s request. They did not call an ambulance as Baby Z was not judged to be unwell. 3.12.16 By the time mother and baby arrived at UHS Baby Z was critically ill, having seizures with a low temperature and placed on breathing support. Many investigations were undertaken and on 01.02.17 a strategy meeting and child s.47 enquiry was initiated because of the discovery that Baby Z had an unexplained rib fracture, thought to be 10 days old. The health visitor records include that it was considered possible that the fracture could have been a result of CPR at RHCH, or whilst in the care of mother and staff at the MBU. Subsequently there was doubt about the diagnosis of meningitis at Baby Z’s earlier hospital admission at the beginning of January – the cause of her illness then remains unknown. 27 PROFESSIONAL PRACTICE APPRAISAL Communications between the MBU and the Surrey social worker were slow and incomplete during January 2017, despite repeated recorded requests by the social worker for regular and prompt information and regular written reports. MBU staff also experienced some difficulty getting hold of the Surrey social worker by telephone, but this should not have stopped written communications. Conversations as part of this review with staff at the MBU indicate that the lack of such communications was associated with a lack of understanding of the implications when the local authority share parental responsibility and a child is subject to care proceedings e.g. that the local authority need to be informed of any changes in: a) Baby Z’s health and welfare including all hospital presentations. 2. The mother’s deteriorating emotional state and associated need for increased staff involvement in the care of Baby Z in this period The concept of Baby Z being a ‘protective factor’ for mother, whilst a usual term within adult psychiatry relating to protection from the risk of suicide, this was regarded by most of the serious case review panel as an unhelpful concept, which could encourage staff to have a misunderstanding of the priority of the welfare of the child as opposed to the mother. The lack of consistent completion of feed and stool/vomit charts for Baby Z whilst at the MBU in January are a major concern possibly indicating a lack of focus on Baby Z’s health. The open opposition of staff at the MBU to the planned specialist parenting assessment unit in favour of a mother and baby foster placement, is likely to have confirmed maternal opposition to the care plan. The fact this was promoted with mother and at court is an indication of the lack of understanding of Baby Z’s needs as opposed to mother’s needs. The fact of mother taking Baby Z to Southampton hospital in a taxi has been the subject of much discussion within the panel. Whilst this should not have been considered for an ill baby, the view of those on duty that day was Baby Z was not ill, there were no longer restrictions on mother taking Baby Z out alone [although not clear if this change was agreed with SCS] and it was within her rights to take Baby Z to a hospital of her choice. Moreover, staff had no power themselves legally to stop the mother in this action, But SCS did have that power and if they had been consulted may have held a different view. This aspect of child Z’s legal position was not appreciated by staff at the MBU throughout the placement. 28 4 FINDINGS & RECOMMENDATIONS INTRODUCTION With the benefit of hindsight, practitioners appear to have been slow to conclude that the mother at this time did not have the ability to provide Baby Z with sufficiently consistent care and nurturing, within a stable safe environment. However, this was not apparent to any of the professionals at the time, except for the Children’s Guardian. The following findings explore why at the time professionals did not consider that any assessment of maternal parenting capability needed to commence with Baby Z being safe and secure with carers, whilst assessments took place. These would need to address first mother’s ability to keep herself stable and physically well and to fully understand the nature of her ill health, mentally and physically. 4.1 INSUFFICIENT FOCUS ON BABY Z’S NEEDS AS A VULNERABLE PREMATURE BABY 4.1.1 Throughout the period under review, professionals were primarily focused on mother’s needs to be assessed and given a chance to learn to care for Baby Z, as opposed to how best to meet the needs of a vulnerable premature baby, whilst assessing whether or not her mother would be able to provide her with the stability, consistency and care she needed at that time. 4.1.2 Whilst practitioners did not have a full understanding of mother’s history, the available information on her past and on her level of functioning for much of the pregnancy, suggested that she was erratic, impulsive, constantly suffering from poor physical and mental health, subject to self-harming and the taking of overdoses. Critically, at the end of her pregnancy, she demonstrated an inability to follow professional advice to go immediately to hospital, so placing her unborn baby at immediate risk. 4.1.3 These concerns continued throughout the period under review. Whilst mother was able to care for her baby, practically and at times emotionally, for much of the time, there were frequent occasions when she was unable to prioritise 5-week premature Baby Z’s needs e.g. for consistent 3 hourly feeding; feeding even when mother wanted to be asleep or smoking a cigarette. Moreover, the mother was not consistently well enough to care for Baby Z, because of being emotionally stressed and anxious, self-harming and taking overdoses requiring medical intervention. There were also a few occasions when her responses to nurses in hospital were verbally and physically aggressive – such inability to control her feelings and actions should have been identified as a risk to her baby. Most worryingly, there was a period when she felt unable to hold her daughter and spoke of hating her, albeit she did seek help at that point. Mother’s volatility, unpredictability and recourse to physical aggression at times meant a high risk of harm for a baby in her care. 4.1.4 Given such a history, the priority needed to be to provide Baby Z with immediate secure and consistent quality care, whilst assessing if her mother could be emotionally stable enough over a prolonged period prior to be able to care for Baby Z. 29 4.1.5 Instead, whilst waiting for mother to be sufficiently stable to be able to undertake a parenting assessment in the first 4.5 months of her life Baby Z was constantly moved, had 4 different carers. At one point an unknown male (mother’s partner) was known by some professionals to be staying in the household, but the impact of his presence was not assessed, despite a report of domestic abuse causing damage to property within the mother’s home. 4.1.6 Baby Z was herself ill in this period and had 5 hospital admissions, including 2 near death events. In at least one of her hospital admissions she had no carer visiting as her mother was not well herself and staying with MGGM in London. She was therefore totally reliant on hospital staff. 4.1.7 Prior to moving to the MBU, Baby Z had spent 8 days being cared for by her mother alone [at 19 days old] and this had ended very badly, with her mother suddenly behaving erratically: self-harming, getting annoyed or irritated when Baby Z cried and saying she hated her baby. At this point Baby Z was at high risk of harm. She then returned to MGGM care and it is of note that at that point MGGM told the social worker she did not think mother would ever be able to care for her baby. Appropriately these events triggered the local authority to initiate legal proceedings, but the plan remained to return Baby Z to her mother so a parenting assessment could be undertaken. 4.1.8 By that time sufficient information was known about mother’s erratic, impulsive behaviour and the focus should have been on stability for Baby Z, with a move to her mother if and when the mother was able to demonstrate she was emotionally stable and had the ability to put Baby Z’s needs consistently above her own. Instead a placement was arranged which was considered to meet mother’s mental health needs, where she could also learn how to care for her baby. This was not appropriate though to Baby Z’s needs, as the Children’s Guardian recognised [according to the chronology from Cafcass]. DELAYS IN PROVIDING BABY Z WITH CONSISTENT AND SAFE PLACEMENT 4.1.9 From the initial CPC in June 2016, the plan was for mother to have family support, involving mother and baby living with MGGM initially in London. The mother and baby unit was often mentioned to be put in place if things deteriorated, but this was about mother’s mental health needs as opposed to the parenting assessment (see 4.4). 4.1.10 Whilst some professionals have during this review expressed doubts about the family plan, this was not articulated strongly at the time. It is possible the family plan could have worked if there had been a structure around it, with minimum timescales, agreement about roles and tasks and a parenting assessment started before birth and then continued at MGGM’s home. Instead no parenting assessment was undertaken and it was the family decided when mother and baby moved to Hampshire. 30 4.1.11 The manager of the case at SCS in August and September 2016 referred in interview to the lack of evidence to commence the PLO and the need to have transferred the case to Hampshire prior or just after the birth. It may be that the plan to transfer the case was an obstacle to thinking about what measures needed to be in place for the birth of Baby Z, and what assessments needed to be undertaken prior to her birth. By not taking control earlier, the case drifted and Baby Z was subject to her mother’s erratic lifestyle. 4.1.12 Once care proceedings were initiated, the local authority still did not take control, and relied on mother’s mental health practitioners to identify and obtain a psychiatric placement for mother and baby. This may have been based on the hope that mental health treatment would be able to ‘change’ mother’s emotional and mental health sufficiently to parent Baby Z, or alternatively to be able to say this was not possible. This is discussed further in 4.5. 4.1.13 The parenting assessment that was a critical component of the child protection plan and the subsequent care plan was never implemented, due to a misunderstanding about the role and function of the MBU (see 4.5). A child focused plan following the birth of Baby Z would have been to provide Baby Z with the nurturing, stability and care she desperately needed, whilst assessments of mother were first undertaken, and her ability to achieve sufficient stability and insight in her own life, look after herself adequately and establish her ability to prioritise her baby’s needs. SHOULD LEGAL INTERVENTION HAVE BEEN INITIATED EARLIER? 4.1.14 A dilemma in considering practice in this case is if legal intervention should have been decided upon earlier, and if so when that should have been. 4.1.15 It was evident from before Baby Z’s birth that the risk for Baby Z of remaining with her mother alone, was too high, given mother’s mental and emotional instability. Appropriately it was not considered safe for Baby Z to live in the sole care of her mother from birth without further support and a parenting assessment. The latter part of the plan developed from the initial conference was however never attempted. Had it been tried, it would have been evident that there was never sufficient stability within mother’s life to accomplish such an assessment, with the possible exception of the 1st 3 weeks in the MBU (where such an assessment was not available). 4.1.16 The concerns about mother’s parenting ability and the obstacles in her achieving sufficient stability to be able to assess her parenting viability in the long term should have been considered during July and August, before the birth in September. However, with SCS focusing on mother’s move to Hampshire and the transfer of case responsibility, there was no attempt to do such an assessment. Without such an attempt it may have been difficult to have sufficient evidence to initiate legal intervention at birth, although that would have been the only way to provide security for Baby Z. 31 4.1.17 The position was the same at the first review CPC, a week after the birth. By this point the risks for Baby Z should have been identified as significantly high and consideration given to legal advice as to how to secure stability for Baby Z either within or outside of her family, whilst also providing mother with support so as to be able to participate in assessments of her ability to parent Baby Z. 4.1.18 Having failed to do this in September 2016, this should have happened in October 2016, when mother was in even more crisis than she had been earlier and MGGM articulated that mother would never be able to adequately parent Baby Z. The decision was taken shortly after this in October, but there was further unnecessary delay in starting the process, with it taking several weeks to hold a legal planning meeting. 4.1.19 This is likely to have been a systemic issue within Surrey at the time, consistent with the with a lack of management oversight and high thresholds for initiating legal action as described by the Surrey Ofsted inspection of 2018, i.e.: ‘Managers at all levels, including child protection chairs, do not carefully and rigorously evaluate the progression of children’s plans. While regular oversight is largely evident, it is not always responsive to escalating concerns or to a lack of progress, and it does not consistently ensure that actions are completed. This trend is particularly apparent where the level of professional concern for children is likely to warrant legal action to safeguard them.’ FINDING 1: The focus on mother’s welfare, and her need to be given the chance to have her parenting assessed whilst living with Baby Z, meant that premature Baby Z’s needs for an emotionally secure, stable and consistent care were not given sufficient priority in the first months of her life. Following the Surrey 2018 Oftsed inspection there has been a programme of improvement taking place within Children’s Services which are designed to address some of the weak practice noted in this serious case review. Surrey SCB should consider what actions are required to assure themselves of the necessary improvements in child focused practice in relation to: a) Plans relying heavily on family support need to specify timescales, details of who does what in relation to the child, how progress is measured, what outcome is expected and a clear contingency plan if it fails b) Children’s social care plans when there are parental ill health factors, including physical, mental and emotional ill health need to be child focused, not primarily based on the needs of the ‘ill’ parent and routinely based on child and adult services joint planning. c) That whenever a looked after child is admitted to hospital, the local authority ensures s/he is visited regularly in the absence of parents /carers presence in the hospital d) That the implementation and progress of child protection plans are monitored rigorously, with contingency plans and legal planning meetings held when insufficient progress is not made e) That plans to transfer a case to another local authority do not act as an obstacle in assessments and implementation of child protection plans. 32 4.2 IMPACT OF HIGH MOBILITY WITHIN THE SAFEGUARDING SYSTEM 4.2.1 One of the underlying obstacles for all professionals in this case was the difficulty in obtaining a full understanding of maternal physical and mental ill health and the impact this may have on the mother’s ability to care for her baby due to: The mother having moved around prior to arriving in Surrey Living or staying at 4 different addresses during the period under review and Registered with 3 GPs and accessing at least 2 GPs and 14 acute health settings in this period – involving at least 47 hospital presentations during the period under review (including scheduled ante natal appointments) 4.2.2 Section 2.1 explains the extremely high number of agencies and practitioners involved with the mother and/or Baby Z during the period under review due to her living / staying in 4 different places in the 10-month time period and accessing a wide number of health services in even more places. 4.2.3 Such a level of mobility means information is spread over a wider geographical area and amongst a high number of practitioners, some of whom are only involved for a brief period of time. This makes it challenging at times for practitioners to have a comprehensive understanding of both the current situation as well as earlier history. Impact on understanding family history 4.2.4 During the period under review the knowledge of mother’s history was limited largely to what she chose to share of her history, along with the information sought and obtained by the social worker from London in the s.47 enquiry and the information given to mental health services via the referral from Lincolnshire mental health sevices. 4.2.5 This history was sufficient to confirm the need for a child protection conference, but was incomplete in terms of evidence regarding mother’s ability to care for herself and a baby. Particularly concerning was the lack of detail about mother’s health background, and the first social worker at the end of the s.47 enquiry noted mother’s refusal to share any information around her mental health. Specific problems associated with GP records and mobility 4.2.6 There is no record of the GP being approached to contribute information about mother’s health history. However, neither of the GP practices with whom mother was registered had her medical records at the time she was a patient. This was due to systemic problems in relation to the transfer of patient records at that time, which sometimes took a few months to arrive at the new GP. This was compounded, in this case, by GP1 practice apparently delaying sending on the previous records which only arrived at GP1 practice after the patient had already changed GPs. In consequence GP2 practice only received the mother’s records after she had moved to her next GP. 4.2.7 Discussions held with GP1 and GP2 as part of this process highlighted the difficulties individual GPs face. They are NHS Digital not informed of the identity of the next GPs so cannot telephone them to alert them of particular significant information. 33 4.2.8 Discussions with NHS Digital revealed that arrangements have changed since the period under review, with introduction of secure electronic transfer of information, allowing rapid transfer of records and identification of a patient’s GP. There are also streamlined arrangements now for the transfer of non-electronic material, albeit this remains reliant on the individual GP surgery’s response. The author was told that there are now systems to check that records have been obtained in these cases, albeit the effectiveness of this needs to be checked [see recommendation below] . Information sharing 4.2.9 The high and changing numbers of professionals presented real problems in terms of any one individual having a holistic understanding of maternal capacity and needs. Information sharing is especially important in such circumstances. In this case much effort was made by most practitioners to liaise with others and ensure vital information was shared. At times this was particularly problematic because of confusion around which local authority held social work responsibility along with difficulties practitioners reported in contacting the social worker, SCS managers and the CPN. 4.2.10 Overall information sharing was variable. 4.2.11 Particularly commendable information sharing practice was demonstrated by: The Hampshire health visitor’s [HV2] persistence in communicating with her colleagues in health and with CSC, even though Baby Z only lived in HV2’s locality for 8 days. HV2 ensured health visitors in West London knew when Baby Z was staying with MGGM. The Frimley Hospital midwifery service communications, internal and external, along with the safeguarding service, which kept SW2 and the child protection conferences informed of the many hospital admissions and allied concerns. 4.2.12 There were though a large number of critical weaknesses in professional communications during this review period: Lack of SCS formal notification to both Hampshire and the London borough that a baby subject to a CPP was staying /living in their area [as required by Working Together 2015 – now 2018] Child protection conference [CPC] documents were not always received by practitioners– although SCS have told the SCR panel these documents were sent Several instances when professionals were not informed about Baby Z’s movements – albeit usually this information was communicated The Surrey Designated Nurse for Looked After Children [LAC] was not informed about Baby Z’s placements as a looked after child The MBU did not provide consistent and timely communications with the social worker (see 3.12) and did not inform either RHCH or UHS that Baby Z was subject to an interim care order RHCH did not liaise with either the MBU or SCS (in contrast with USH which understood the need to liaise with SCS) 34 Delay in health visitor referral from midwife The health visitor was not provided with information on maternal mental ill health episodes Systemic Improvements to health information sharing 4.2.13 Since the time period under review, the development of NHS Child Protection – Information Sharing (CP-IS)vi is a helpful tool in improving information sharing practice by connecting systems between local authorities and unscheduled health settings e.g. emergency departments, walk in centres, minor injury units and maternity units. This provides an alert accessible to the settings within the NHS Spine to indicate that the child is subject to a CPP or is a LAC. The CP-IS system also sends a notification to the Local Authority who have the responsibility for the child, to alert them to the unscheduled care setting attendance. CSC case responsibility 4.2.14 From the time when mother moved to Hampshire (mid-August 2016), until the point the decision was taken to initiate care proceedings at the end of October 2016, SCS planned to transfer the case to Hampshire and told health colleagues of this imminent intention. 4.2.15 However, this had not yet been agreed with Hampshire and SCS did not complete the transfer process and did not formally start it till mid October 2016. There seem to be a variety of reasons for this including an initial misunderstanding at the time of the move, whereby the social worker thought that Hampshire would not accept the transfer until mother had lived there for a month. There is no evidence how this misunderstanding occurred, but SCS should have challenged and escalated it. This did not happen and the attempts to transfer the case were delayed till October. Unfortunately, the belief the case was about to transfer, contributed to the lack of implementation of the child protection plan and may have also contributed to the lack of effective monitoring of progress of the case. 4.2.16 Mother and Baby Z were only briefly living together in Hampshire for 8 days before Baby Z was ill and admitted to hospital. She never lived subsequently in the Hampshire flat. With uncertainty about her future care and the plan to initiate care proceedings, SCS appropriately maintained case responsibility. vi digital.nhs.uk/services/child-protection-information-sharing-project/benefits-of-child-protection-information-sharing 35 4.2.17 The confusion within the professional network that case responsibility was /had transferred was unhelpful. Police, Frimley Park Hospital, midwifery and health visitors constantly contacted Hampshire MASH or children’s services first, not Surrey children’s services. The information shared reached the Surrey social worker, albeit this led to considerable time and frustration being taken up in communications, compounded by the perception [reported by a number of health staff in both Surrey and the MBU] that the social worker and manager were never available. Measures taken to improve consistency so as to enable better assessment 4.2.18 Overall some practitioners made great efforts to improve communication and understanding of what was happening for mother and baby and overcome the problems posed by her mobility and accessing numerous health services. This was evidenced by: Oversight of the case in FPH by the safeguarding team Maintaining midwife practitioner case responsibility when the mother moved from Surrey, so as to provide better support and better-informed assessments – however, this appears to have had the unintended consequence of initial poor communication with health visiting, who did transfer case responsibility The midwife attended some psychiatric appointments with the mother to be better informed of her mental health problems The safeguarding midwife at FPH identified early on the need to collate a chronology, contacting colleagues in neighbouring hospitals – this was initiated as a substance misuse problem (of prescribed medication) was suspected originally. The safeguarding midwife asking the community midwife to check the GP records about mother’s requests for pain relief from different health settings. FINDING 2 There are systemic problems for practitioners having full access to historical and current information when working with mobile families and/or those accessing a multitude of services in different areas. The main risk in these cases is being able to undertake holistic assessments based on partial information. Surrey SCB to consider how to minimise risks of communication weaknesses where there are a large number of practitioners involved with a mobile family. Particular issues to focus on are: a) That social workers are routinely notifying other local authorities when a child subject to a child protection plan or a care order stays in their area and also that the Surrey Designated Nurse for Looked After Children is notified of the moves b) To establish how well the child protection conference administration is working in terms of all relevant practitioners being sent and receiving conference invitations and records: this includes both the processes of sending the information and the process of circulation within receiving agencies, when not sent to the allocated practitioner c) That GPs are now experiencing timely transfer of medical records d) That adult mental health services inform health visitors as well as social workers of parental mental health episodes and the consequent ability of a parent to care for her/his child/ren 36 NHS England to consider how to be assured that changes implemented at the MBU have led to a staff group who now understand e) the significance of child protection plans and shared parental responsibility in care proceedings in terms of the need to reliably communicate with other agencies, and in particular with social workers, around any circumstances affecting the welfare of the child. 4.3 HIGH USAGE OF HEALTH SERVICES Mother’s ill health 4.3.1 One of the features of this case was the high usage mother made of acute health services, in different geographical areas, for a variety of physical health issues. These were self-reported by mother and she received medication in line with her reported diagnosis. 4.3.2 There was some suspicion mother may have misused her medications and might be addicted to strong pain killers. There were incidents both at FPH and at the MBU of drugs suspected of going astray as well as reports by a friend of hers and a previous housing provider that mother ‘hid’ and stored medication. Partly this was perceived as being to enable her over doses. 4.3.3 At FPH in July 2016 a consultant tried to understand the mother’s physical health and became doubtful of her gestational diabetes diagnosis. In conversation for this review the consultant explained the concerns at this point with the mother having had 2 diabetic hypos, with 3 different hospitals involved and some doubt about the diabetes diagnosis. The consultant asked the mother if she had taken extra insulin at one admission, but mother was adamant she had not. Mother presented again a few days later with 4 hypo episodes, but refused diabetic screening and discharged herself. On this occasion it was suspected she had taken insulin home with her from the ward, but she denied having done so. She continued to decline and/or avoid several attempts made in hospital, in the antenatal clinic and at home to provide diabetic screening. 4.3.4 The consultant wanted to discuss these observations with the GP and telephoned GP1 during 2 different hospital admissions in July 2016 but got no response. On each occasion the consultant subsequently wrote to the GP explaining these concerns and in particular the queries about the diagnosis. The 2nd letter stated clearly that blood checks 24 hours after admission of the last insulin dose suggested that mother, despite her denials, had taken a further dose of insulin whilst in hospital. The letter refers to calls to another hospital, no history of a formal glucose tolerance test and lack of clarity how the diagnosis of gestational diabetes mellitus [GDM] was made. Mother refused to have a glucose tolerance test or home glucose monitoring and was aware that untreated GDM presents risks to the baby. There was though no direct confirmation of GDM apart from a couple of high blood sugar readings by the patient in her monitoring booklet. 37 4.3.5 The consultant explained (as part of this review) of wanting to ensure the GP was used as a central point to verify medical conditions. However, GP1 (in a conversation as part of this case review) said that s/he perceived that the consultant was managing this aspect of mother’s health. In fact, there was a vacuum and no professional actively managed the implication of the consultant’s concerns that the mother may have been fabricating or inducing her own symptoms of ill health. The consultant did not articulate or identify this as a suspicion, because of the need first for further investigation. She identified it as a possible risk to the mother’s health, but not for the unborn child. 4.3.6 The consultant referred to mother being monitored under the ‘safeguarding’ umbrella in the letter to GP1, but without any clarity about what this meant. From the GPs perspective it might suggest that all was in hand. In interview the consultant explained an assumption that colleagues in maternity would inform the safeguarding midwives of such concerns. In fact, the possibility of mother’s s concern was never articulated and any potential risks of this to the unborn child were consequently not investigated further. Hospital midwifery were unaware that there was any doubts about mother’s reported diabetes diagnosis. Whilst all were aware of the more general safeguarding concerns arising from mother’s mental ill health, this potential issue and any possible implications for the (at that time) unborn baby was never discussed or investigated further. Fabricated and induced illness 4.3.7 Fabricated or induced illness [FII] is a condition whereby a child has suffered, or is likely to suffer, significant harm through the deliberate action of their parent / carer and which is attributed by the parent to another cause. 4.3.8 There are three main ways of the parent fabricating (making up or lying about) or inducing illness in a child: Fabrication of signs and symptoms, including fabrication of past medical history; Fabrication of signs and symptoms and falsification of hospital charts, records, letters and documents and specimens of bodily fluid; Induction of illness by a variety of means. 38 4.3.9 Adults are also known to fabricate or induce illness in themselves. There are a number of different terms used to describe this, although FII is not usually used, even though it does describe the behaviour. Other terms used are, factitious diseasevii, factitious disorder imposed on self viii, Munchausen syndromeix, parent fabricating own healthx, 4.3.10 The possible relevance in this case is in terms of the lack of understanding of mother’s own health problems and the 2 near death experiences of Baby Z. It is not known if any illness to mother or baby was in fact fabricated or intentionally induced in either case, but the concern is based upon: The toxicology report that identified that Dihydrocodeine was present in Baby Z’s urine on the day she was presented at Southampton University Hospital ED on the 28.01.17: this was a medication prescribed to the mother Mother presented at a large number of different health settings and reportedly suffered and was given medication for a variety of health conditions, including cardiac conditions and gestational diabetes Baby Z’s ill health 4.3.11 Baby Z suffered 2 life threatening illnesses, recovering quickly once in hospital. The cause of the first incident in early January, is unknown as the initial diagnosis of meningitis, was put aside subsequent to further testing showing there had been a false positive result. On the second occasion test results showed that that Dihydrocodeine was present in Baby Z’s urine when she arrived at Southampton University Hospital [SUH] ED on the 28.01.17: this was a medication prescribed to the mother. 4.3.12 At no time in the period under review was there any suspicion that Baby Z had in any way been subject to having an illness fabricated or induced and there is no evidence that staff should have been aware of this risk. Links between carer fabricating own ill health and fii by carer of child 4.3.13 Had there been any suspicion that mother may have been fabricating or inducing any of her own physical ill health symptoms, practitioners and panel members have all said that this would have alerted them to risks to Baby Z, along with the view that the risk of placing them together in the MBU in all likelihood would have been too high. Staff at the MBU have said if they had known about these suspicions it is doubtful they would have accepted mother as a patient. vii http://sciencenordic.com/feigning-illness-gain-attention viii The perpetrators of medical child abuse (Munchausen Syndrome byProxy) – A systematic review of 796 cases, Gregory Yates, Christopher Bass, Child Abuse & Neglect 72 ( 2017) 45-53 ix http://sciencenordic.com/feigning-illness-gain-attention x http://www.thurrockccg.nhs.uk/about-us/document-library/safeguarding-children-key-documents/691-fabriciated-illness-final-report-nov-14-3/file 39 4.3.14 The literature on FII highlights that the carers of children who have suffered FII often ‘as with many parents who abuse or neglect their children, specific aspects of their histories are likely to have been troubled.’ xi including being victims of childhood abuse, having experienced a number of physical health problems, which may or may not be substantiated by medical investigation, deliberate self-harm, complicated obstetric history and history of mental health problems with some being diagnosed with a personality disorder. 4.3.15 Recent research of perpetrators by Yates & Bass has provided a strong evidence base of the link between the 2 conditionsxii. With the most common psychiatric diagnoses recorded as factitious disorder imposed on self (30.9%), personality disorder (18.6%), and depression (14.2%). The authors conclude that ‘ From the largest analysis of MCA perpetrators to date, we provide several clinical recommendations. In particular, we urge clinicians to consider mothers with a personal history of childhood maltreatment, obstetric complications, and/or factitious disorder at heightened risk for MCA. ……’ 4.3.16 The 2011 study by Bass & Jonesxiii provides an even stronger link, with 64% of perpetrators of FII in children have previously fabricated symptoms. Conclusion 4.3.17 Mother had a high level of acute health presentations for a variety of self-reported physical ill health conditions, including diabetes and cardiac disease. When the consultant at FPH tried to arrange further testing to obtain a better understanding of the causes of the symptoms, mother did not co-operate with such investigations. 4.3.18 It is not known if the mother in this case self-fabricated or induced the symptoms of any of her own reported illnesses. However, given the high level of health services attendance and reliance on self-reported diagnosis, further investigations were needed into the cause of these symptoms. To be able to do this requires medical information from a variety of health settings to be joined together. In this case, the consultant assumed the GP would do this, whilst GP1 assumed the consultant would. xi Safeguarding Children in whom illness is fabricated or induced, DSCF 2008 xii The perpetrators of medical child abuse (Munchausen Syndrome byProxy) – A systematic review of 796 cases, Gregory Yates, Christopher Bass, Child Abuse & Neglect 72 ( 2017) 45-53 xiii Psychopathology of perpetrators of FII in children, Christopher Bass & David Jones BJPsych 2011 40 4.3.19 Another obstacle in establishing the nature of mother’s physical ill health was the short time any individual health practitioner or service knew her; this highlights the increased risk with mobile families and those accessing a multitude of services, because the systems do not facilitate systems to easily obtain and analyse health histories. Whilst GPs may have access to the information [when the records have transferred], few are likely to have the time to do the research and analysis required. 4.3.20 When there are suspicions that a pregnant woman, or a parent or carer, is a high user of acute health services with self reported diagnosis of chronic health conditions there is a need for further investigation and verification of the cause of the symptoms, and consideration of the possibility that the symptoms could be being induced or fabricated, as this could not just be a risk to the health of the woman, but also a risk to the inborn child. 4.3.21 Current improvements in health information sharing via CP-IS (see 4.2.13) will help here if the individual has children linked to her/his records who are either looked after by the local authority or subject to a child protection plan. However, if this is not the case, CP-IS will be of limited help. FINDING 3 When a pregnant woman or parent is a high user of health services, health practitioners should always consider any impact this may have on the unborn baby and/or children in the household. Hampshire and Surrey SCBs to consider: a) how to make practitioners more aware of the possible safeguarding risks to children when parents and/or pregnant women are high intensity users of health services, including the consideration of the potential for self-fabrication or induction of illness b) does this have national systemic implications on the communication and analysis of patient health information, especially in relation to mobile families and those accessing a large number of different health providers? Hampshire and Surrey SABs to consider: c) how adult health practitioners are better able to analyse health information in the context of adults who are high users of health services, including the consideration of the potential for self-fabrication or induction of illness and the impact of the behaviour on the unborn baby and/or child d) the need for a key health practitioner with responsibility to analyse medical and health information in the context of patients over or mis-using health services 41 4.4 SUPPORT AND TREATMENT OF MOTHER’S MENTAL ILL HEALTH 4.4.1 Throughout the period under review, and for a considerable period of the mother’s life, she was in receipt of mental health services. She was diagnosed with having a borderline personality disorder (also known as Emotionally Unstable Personality Disorder). 4.4.2 During the period under review mother’s behaviour was characterised by unstable and impulsive behaviour, self-harming and suicide attempts, aggression at times along with observations that she often was unable to prioritise her baby’s needs over her own needs. This was highlighted by her refusal to go to hospital when advised by the midwife, resulting in an emergency caesarean birth, her difficulty on the ward waking to feed Baby Z and placing her need to go out for a cigarette above Baby Z’s needs for a feed. 4.4.3 Throughout the period under review there seems to be an absence of analysis of mother’s mental health issues and the real prospect of what this would mean in terms of her parenting capacity. The child protection plan did not specify exactly what assessments were required by the mental health practitioners involved, especially in the critical pre-birth period. 4.4.4 In general, mental health staff were supportive of what they felt was the progress the mother made when she was able to undertake the practical parenting tasks, without consideration of how well she would be able to sustain this. In particular if, without staff around, would mother always wake to feed Baby Z, give priority to feeding her when she wanted a cigarette and avoid self-harm and overdosing when upset. 4.4.5 Other health and social work professionals seemed to hope that psychiatric and mental health treatment would be able to help and support mother so that she would then be able to be a good enough parent. Given the long-standing nature of the maternal mental ill health it is likely that such progress would take considerable time and would involve the therapeutic interventions which mother largely avoided when offered in the community and in the MBU – ones that involved commitment and reflection. The CPN explained mother was offered ‘dialectical behavioural therapy (DPT), a new form of CBT lasting 18 months, and needing full patient engagement and 3 hours per week commitment’. However, such commitment was not possible for mother. At the initial CPC mother was described as declining psychotherapy, opting only for seeing the psychiatrist and the independence worker. MBU, staff told the author that mother declined sessions that involved self-reflection. 4.4.6 One of the main challenges in child protection in relation to parental mental ill health in general and EUPD in particular, is evaluating the impact of the parental illness on the child and the likelihood of change. There is no evidence that this was done, with plans being based on hopes of mother becoming well enough, without any evidence at the time that she had the motivation, commitment and insight necessary for such change. 42 4.4.7 The Surrey adult services panel member suggested that the work of the Surrey psychiatric services in supporting and treating the mother would benefit from being subject to an adult review to learn lessons about the co-ordination of services in such cases. FINDING 4 Practitioners working with Emotionally Unstable Personality Disorder parents need to have an understanding of the potential impact of this on parenting, associated risks to the child, what types of treatment are effective in enabling change and the challenges in doing so. Surrey SCB to consider: a) How to increase awareness of parental Emotionally Unstable Personality Disorder and the potential impact on children? ? b) Whether child protection plans involving child/ren [or an unborn child] of parent/s with mental health difficulties need to specifically address the expectations of mental health practitioners to not just provide support to the parent, but to assess the potential for change of the parent, what steps will be involved and the likely timescale for these. c) Referring this case to Surrey SAB for review of the lessons to be learnt in terms of the co-ordination of services. 4.5 MOTHER AND BABY UNIT PLACEMENT How was decision made on this placement? 4.5.1 From the outset, there was a view amongst health staff, both at FPH and within the mental health service, that a mother and baby placement was the desired plan for the mother. Whilst the child protection plan was for family support with mother and baby to stay initially with MGGM, it was always part of the plan for mental health services to make a referral to a mother and baby unit [MBU] should mother’s mental health deteriorate. This happened in October 2016, when mother was an inpatient. The referral (made from the psychiatric ward where mother was an in-patient) was for a unit within a psychiatric hospital, designed for women who have severe mental illness from 24 weeks of pregnancy until a child is one year old. 4.5.2 As discussed in 4.1, this plan was based on mother’s mental health needs and the treatment she was thought to need so as to be able to parent, along with the perceived positive view that this would enable the development of bonds between mother and baby. But there were problems relating to the choice of placement and the admission process. 43 Admissions process 4.5.3 It is now evident that such a placement should never have been made and was based on insufficient knowledge of mother’s mental illness. When the referral was made in October, it is possible she may have met the criteria, as she was acutely unwell, but by December this was no longer the case: mother had been discharged from hospital, therefore unlikely to still be suffering from an acute mental illness. It is not clear why any changes in mother’s mental health since referral was not considered by the MBU prior to admission. Up to date assessments should have been obtained to check a patient satisfies the admission criteria, rather than risk a distressing process for mother and baby of being discharged immediately. The wrong type of mother and baby unit? 4.5.4 Having been admitted to the MBU, the unit itself decided immediately that the mother did not fit the criteria for admission. The social worker also became aware that this was the entirely wrong placement for Baby Z as it was unable to provide the type of assessment needed in terms of making recommendations about whether or not the mother would be able to care for Baby Z in the long term. 4.5.5 It is hard to understand how such a misunderstanding occurred in the first place in the communications between the manager of the MBU and the manager in SCS. However, this discussion should have taken place earlier between Surrey mental health services and SCS, so as to ensure the placement met the needs of both mother and baby. There was also a fundamental misunderstanding about the purpose and functions of mental health provision based around the mother as a patient [with the baby termed at the time as a ‘guest’ on a hospital ward], as opposed to a setting focusing on the needs of the baby, providing mother with support to learn how to parent, but also assessing her capacity to become a good enough parent. 4.5.6 This does though raise the question as to where parents, such as this mother, should be placed with their babies. If psychiatric wards like the MBU cannot offer assessment, are the specialist assessment units able to cope with this type of parental mental disorders? It is significant that the alternative provision that was planned, specified that they could take mother and Baby Z if mother had no further incidents of self-harm or overdose. This needs to be recognised as an indicator of when such assessment is not feasible, and that changes are needed to be made by the parent prior to having care of her child. 4.5.7 It is also significant that when mother reported to the MBU she had an ‘accidental’ overdose in January whilst staying in London (see 3.14.4), this was not communicated to either the social worker, or the planned new placement. If this had happened, presumably the proposed placement would have turned down mother and Baby Z. 44 Should a psychiatric ward MBU have more understanding and provision for assessment as well as treatment and support? 4.5.8 In terms of this case, clearly the MBU was the wrong placement because its purpose was primarily around the mental health functioning of the patient, whilst giving her support to learn and improve parenting skills. Mother did not have the mental health needs for such a placement and the placement could not provide the assessment that was needed for Baby Z. 4.5.9 This does though raise the question whether or not a mental health unit such as this for mothers and their babies should be equipped to routinely undertake such assessments given the potential safeguarding risks that can be associated with parental mental illness. 4.5.10 The need for the MBU to be more involved in the multi-agency safeguarding network has been identified through this case. In talking with staff as part of the review it was evident that they did not fully understand the child protection process, the significance of care proceedings and that the local authority by virtue of the interim care order shared parental responsibility with mother for Baby Z. 4.5.11 This lack of appreciation of the wider safeguarding arena led to unit staff functioning mainly in the role of supporting and helping mother, whilst advocating on her behalf to the social worker. For example, one of mother’s workers with responsibility to set the care plan for mother, understood that mother had ‘gone off the rails’ and the job was to build the bond between mother and baby, not specifically also to assess. She said that the working assumption was the baby was not at risk from the mother, as that was part of admission criteria. She described care plans being developed internally, not with other professionals. She also said she had not personally accessed any information sent by the social worker. 4.5.12 The lack of understanding of the MBU role within the multi-agency safeguarding arena was demonstrated by the lack of regular and detailed written records and communication with the social worker, despite repeated social work request for weekly reports and daily updates. The lack of immediate consultation about, and reporting of, concerns and health events again showed the lack of understanding of the role and function of the social worker in the child protection process. The open opposition to the care plan for the residential mother and baby assessment unit and the advocacy for a foster placement both undermined the care plan and demonstrated a lack of understanding about multi-agency working in such circumstances and the risks in this case in particular. 4.5.13 Staff at the MBU and comments received from managers to drafts of this report do point out that they experienced difficulty in getting hold of the social worker. Whilst such difficulties would make communication more difficult, it does not explain the lack of written emails, progress reports to social workers and timely notifications of medical concerns including hospital admissions. 45 Changes made 4.5.14 As a result of this case the Southern Health NHS Foundation Trust undertook its own Significant Incident investigation, which, along with much internal management and staff reflection. Staff and managers at the unit told the author that this has led to a considerable number of changes to improve safeguarding of babies on the ward including: Babies now have their own separate records – referred to as ‘baby RIO’ documenting feeding chart and general care Babies now classed as patients with their own care care plan [instead of guest] – although not all staff seen were aware of this change of terminology Increase in health visitor time to the MBU to 3 days per week – initially for a year but now confirmed as a permanent arrangement Health visitor now supervises the nursery nurses Separate baby handovers in addition to mother’s handovers. A new policy in development around escorting unwell children to hospital – but in fact unlikely to apply in the circumstances of this case as staff did not identify Baby Z as unwell on 28.01.17 [NB the author was subsequently informed by a panel member that NHS 9England) is not aware of such developments] Where possible an increase of qualified staff on shift from 1 to 2 Training provided on ‘mother infant interaction’ and ‘babies in mind’ Weekly weight and body maps for babies Mother and baby interactions to be included in recording and MDT discussions Group safeguarding supervision commenced 4.5.15 What is not clear though is if these improvements will change the underlying culture in terms of staff understanding their place in the multi-agency safeguarding arena, working together with social workers, developing care plans for mother and for baby jointly and being aware of and understanding the significance of social work information. This will require a shift from their role as supporters and advocates to one that includes their participation in the wider professional safeguarding network. If this is not possible the MBU may not be an appropriate placement for babies’ subject to child protection plans or care proceedings. 4.5.16 Staff also spoke about other improvements that they would wish to see to improve their ability to safeguard babies more effectively including: Be able to discuss and reflect on what happened openly – after the initial period when it was subject to formal discussion, it has felt taboo to discuss what happened Training for those providing safeguarding supervision and consideration of the provision of such supervision being individual rather than group supervision Recording of safeguarding supervision 46 Nursery nurses to work nights, so increasing capacity to 3 staff instead of 2, and including child care expertise 4.5.17 The first bullet point in 4.6.15, is particularly concerning as suggesting a closed culture, which after the initial responses, is not encouraging reflection and openness. FINDING 5 There is insufficient professional understanding of the different types of ‘mother and baby’ resource available, and their different functions, leading to the potential for unrealistic plans being made for mothers with mental health problems and their babies. NHS England to assure themselves that: a) The MBU (in this case) has and follows clear admission criteria and processes, which involve obtaining sufficient current information on a prospective mother and baby so as to be able to offer beds only to those that fit the criteria b) MBU staff have sufficient involvement in multi-agency training which includes information on child protection processes and care proceedings c) That management and staff of the MBU understand the need to read and review the history of patients, including any reports provided by social workers d) The MBU now provides adequate assessment of the mother and baby relationship and parenting, consistent with its functions – and that the level of assessment is clearly articulated in written information for professionals and includes risk assessments relating to the need, or not, for supervision of mother and baby both when in and when outside the unit e) That SHFT and the MBU have a clear pathway for any unwell babies on the unit, including how unwell babies on the unit are managed, how external medical help is sought after for the babies, including when a parent will need an escort from the MBU and what communications need to be made with other agencies f) The changes made in the MBU have been effective in changing the culture so it can work effectively, in partnership with other agencies and particularly social workers, as part of the wider safeguarding arena and also encourages and enables reflective discussions to take place which support staff in their everyday role on the unit. g) There is continued quality oversight and improvements on this unit, to ensure there is a culture that embeds safeguarding as core business for all staff working on the unit (including medical staff) Surrey SCB to consider: a) How to facilitate those making referrals to mother and baby units understand the different types of units available and when psychiatric mother and baby wards are suitable to use if babies are subject to child protection plans and care proceedings? Do such wards have to provide minimum services in relation to care of the babies and assessments of the mother, and if so, what are these? 47 4.6 CARE PLANNING 4.6.1 Section 4.2 discusses the difficulties arising from the large number of professionals involved with the family, with Baby Z staying in 3 different geographical areas and her mother accessing health services in various London boroughs, Berkshire as well as Surrey and Hampshire. 4.6.2 Care planning and delivery will be more of a challenge with a high number of professionals; good co-ordination and planning in such circumstances is essential. A number of individual practitioners tried hard to make this happen, in particular the first community midwife, the Hampshire health visitor and the safeguarding team within FPH. Whilst Baby Z was subject to a child protection plan, the initial and review CPCs, and the core group meetings facilitated the multi-agency co-ordination and care planning. 4.6.3 Once the decision was taken to initiate care proceedings, such multi-agency co-ordination tailed off and with the ending of the child protection plan, following the making of the interim care order, care planning becomes the responsibility of the Looked After Children [LAC] system through the statutory reviews and placement planning arrangements. In this case no LAC review was held prior to the placement at the MBU as the move did not involve a change of LAC care plan. Whilst this is consistent with government guidance for LAC reviews, it had the unintended consequence, in this case, of leaving the details of care planning to the MBU, rather than being discussed at a formal meeting. Moreover, if a LAC review had occurred at the MBU, it would have led to further understanding by MBU staff of concerns, Baby Z’s needs and what was required. It maybe that a SCS chaired planning meeting could have accomplished this task, but the onus here is on CSC to take such a lead when a child is subject to a care order. FINDING 6 Whenever looked after children change placements, consideration needs to be given with the IRO to the need to hold a LAC review or other multi-agency planning meeting, even if the move was part of the care plan. This is particularly important in parent and child residential placements or when children are returned to parental care, to promote and facilitate joint understanding, development and ownership of the care plan. It is important that this is chaired by social care and not the residential unit, so clarifying the legal position with other agencies. When such placements meetings are held without the IRO, the IRO needs to retain oversight and challenge of the implementation of the care plan. Surrey SCB to consider how to be assured: a) that when a placement is changed that the local authority take responsibility for promoting and facilitating joint understanding, ownership and development of the care plan: this is best done by holding a LAC review or another form of planning meeting b) that the IRO retains oversight and challenge of the implementation of plans when there has been a major change in circumstances e.g. change of placement, return to parental care and in the absence of any LAC review 48 4.7 FATHER AND PARTNERS 4.7.1 Practitioners at the time did ask the mother about the identity of the father. She consistently declined to disclose his identity, sometimes saying she was not sure which man he was, sometimes providing one name and at other times another. She spoke of the father variously not knowing of the pregnancy, of him being mentally ill, cheating on her and of having been violent. This information subsequently has turned out not to be true. 4.7.2 It is of note that sometimes practitioner records appear to take mother’s word as fact in relation to the father having cheated on her or of being violent – in much the same way as her reported physical health conditions were accepted as fact. It is important that records distinguish between what is known facts and what is being alleged. 4.7.3 Conversely, when a man was seen at the hospital, staff assumed he was Baby Z’s father without checking his name and identity. The GP also did not check his name nor record his presence in the family, albeit made no assumption about him being the father. When the hospital mentioned him to the social worker, records indicate she already knew who he was and that he should not have been with mother and Baby Z. However, this information had not been shared with the wider professional network. 4.7.4 Overall there appears to be insufficient focus and shared understanding on the role of the various men in the mother’s life, despite the impact this could have on Baby Z. FINDING 7 Staff in all agencies and settings do not always explore the household and relationships of parents when there are welfare concerns about children. Names and relationships need to be established wherever possible and records should not make assumptions [eg of paternity] and distinguish between known facts and what professionals have been told. Hampshire and Surrey SCBs to consider: a) How to change the culture and behaviour of staff in terms of always clarifying and recording the names of partners, being able to distinguish in records the source of information and therefore whether this is known fact or ‘as told to them’. Moreover, they need to be able to understand that service users will not always tell the truth about the paternity of children and identity of partners, and therefore this needs careful and delicate probing. 49 GLOSSARY OF TERMS AND ABBREVIATIONS CMHT / CMHRS Community Mental Health Team/ Community Mental Health Recovery Service CPC Child protection conference CP-IS NHS Child Protection – Information Sharing CPN Community Psychiatric Nurse CPP Child protection plan ED Emergency Department at hospital, previously called Accident & Emergency EUPD Emotionally Unstable Personality Disorder [EUPD]. FPH Frimley Park Hospital Hants Hampshire HCSC Hampshire Children’s Social Care HTT CMHT home treatment team ICO Interim Care Order LSCB Local Safeguarding Children Board MGGM Maternal great grandmother RSH Royal Surrey Hospital SCS Surrey Children’s Services SCR Serious case review Surrey County Council SCC 50 APPENDIX 1: Terms of Reference for Serious Case Review into Child Z Timescales for review; 24/06/2016 – 28/01/2017 (date of presentation to UHS where fractured rib was discovered) Family members to be included in the Serious Case Review (SCR); Child Z Subject Child DOB 16.09.2016 Child Z’s mother Mother DOB 21.01.1994 Areas of focus Professional’s understanding of the situation: o What information was available to agencies to inform strategic decisions and assessments of Mother particularly in relation to her mental health, and how this impacted on her parenting capacity? o Was this information accurate, timely and reviewed at key points? Working across multiple Local Authority boundaries: o Was there an understanding across all agencies that Child Z was subject to a Child Protection plan led by a local authority outside of the area where Child Z lived at the time? Was information from agencies in Hampshire, and elsewhere, shared with the local authority in a timely way to inform their care plans and risk assessments? Was information from that local authority shared with agencies in Hampshire who were working with Mother and Child Z? o Mother, and therefore Child Z, moved around a number of different areas during the timescales of this review, both to live and receive care. What challenges did this present in relation to cross border working and information sharing? Was there a clear picture of the whereabouts and movements of Mother and Child Z during the period of this review, particularly given that Child Z was on a Child 51 Protection Plan during this time? What assessment and consideration was given to the appropriateness of placements Baby Z had with friends and family? Quality of Professional Practice and Professional Challenge: o Was the quality, accuracy and timeliness of referrals / contacts between agencies appropriate? o Did the information included lead to robust and appropriate decision making, and, where appropriate, professional challenge? o What factors informed the decision making each time Mother and Baby Z were placed in an in patient unit? What oversight was given to decisions on placements? Were these decisions always made by professionals or was Mother able to self-refer herself into in patient placements? Professional understanding and awareness of vulnerability and risk factors: o What was professionals understanding of risk and vulnerability of the Mother in this case? Was consideration given to factors including; Her mental health and her extensive engagement with known services including Adult Mental Health Substance Misuse The fact that she was in care for a period / previously known to Children’s Social Care (out of area) when a child. Her frequent moving locations / residences including staying with other family member o What was professionals understanding of the risk and vulnerability of Child Z during this time period? Was Child Z recognised as having safeguarding needs of her own in addition to those associated with her Mother? Was each incident risk assessed individually or was there a review of the whole case at key points to inform a cumulative assessment of risk? o What understanding did staff in the inpatient unit have in relation to caring for babies, including their general health and wellbeing? Were they sufficiently trained to understand and identify risk to babies and safeguarding concerns given that their primary focus was to care for the adults who were resident in the unit? Was there evidence that they understood the safeguarding risks to Child Z given Mother’s mental health? What role did they play in caring for Child Z, and, was this separate to, or, part of their care Mother? Methodology Agencies will be asked to produce an agency report and chronology of events for each child using the current HSCB templates. A Reference Group will be formed to work with the Independent Reviewer. |
NC52255 | Death of a 3-month-old boy in 2017. Child U died after reportedly falling from his parent's bed onto the floor. A skull fracture was evident that had occurred around three to seven days prior to Child U's death. Following Child U's death, two of his siblings were made the subject of child protection plans and care proceedings. Child U lived with his mother, father and siblings. Prior to his death there were no safeguarding concerns about Child U or his siblings. Mother had a long-term dependency on a prescribed pain killer. Ethnicity or nationality are not stated. Uses the Significant Incident Learning Process (SILP) methodology. Learning includes: the need for professionals to ask detailed questions about the use of prescribed or over the counter medication and consider the impact of any dependence on parenting, including the impact of withdrawal; the importance of information sharing about a parent's misuse of prescribed drugs; if there is a lack of certainty in a child protection case, considering a timely high-level meeting of professionals from the main agencies involved. Recommendations include: local substance misuse training covers risks from prescription and over the counter drugs, and the need to share information; consider the government's review of prescription drugs to determine if findings can be used to strengthen local safeguarding practices.
| Title: Serious case review: Child U: review report. LSCB: West Sussex Safeguarding Children Partnership Author: Nicki Pettitt Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. For publication – prior to inquest. September 2020 1 Serious Case Review Child U REVIEW REPORT For publication – prior to inquest. September 2020 2 CONTENTS 1. Introduction to the case and summary of the learning Page 2 2. Process Page 2 3. Family structure Page 3 4. Background prior to the scoped period Page 4 5. Key episodes Page 4 6. Analysis by theme and learning Page 6 7. Conclusion Page 12 8. Recommendations Page 13 1 Introduction to the case and summary of the learning from this review 1.1 This Serious Case Review (SCR) is in respect of a three month old child to be known as Child U. He died after reportedly falling from his parent’s bed onto the floor. A skull fracture was evident that had occurred around three to seven days prior to Child U’s death. A police investigation was undertaken that concluded that no further action should be taken. An inquest will be held in order to confirm the cause of Child U’s death. 1.2 Child U lived with his mother and father, along with a one year old sibling, a school age sibling, and a number of older adult siblings. Other extended family members were also resident on occasion. 1.3 Prior to his death there were no safeguarding concerns about Child U or his siblings. Mother had a long-term dependency on a prescribed pain killer. No other known predisposing risks were identified. 1.4 Learning has been identified in the following areas: • Impact of prescription and some over the counter drugs. • Lack of wide professional awareness of the above, including the impact of withdrawal. • Importance of information sharing. • The need for timely communication and challenge when there is uncertainty in a child protection case. 2 Process 2.1 The WSSCB agreed that this Serious Case Review (SCR) would be undertaken using the SILP methodology1, which engages frontline staff and their managers in reviewing cases and focuses on why those involved acted as they did at the time2. 2.2 It was agreed that the review would consider in detail the period from 27.1.17 – 11.7.17, which was the date that professionals were informed of Mother’s pregnancy with Child U, to the date of the Initial Child Protection Conference held on the siblings following Child U’s 1 The Chair of the WSSCB agreed the SCR, the lead reviewer was appointed, the terms of reference were agreed, agency reports and a chronology were requested, and two events were held to engage with staff in July and September 2018. The lead reviewer is Nicki Pettitt, an independent social work manager and safeguarding consultant. She is an experienced chair and author of SCRs and a SILP associate reviewer. She is independent of WSSCB and its partner agencies. 2 Agency reports are completed where agencies have the opportunity to consider and analyse their practice and any systemic issues. They provide details of the learning from the case within their agency. Then a large number of practitioners, managers and agency safeguarding leads come together for a learning event. All agency reports are shared in advance and the perspectives and opinions of all those involved at the time are discussed and valued at the event. The same group then comes together again to study and debate the first draft of the SCR report. Later drafts are also commented on by all of those involved and they make an invaluable contribution to the learning and conclusions of the review and analysed; and makes use of relevant research and case evidence to inform the findings. This review has achieved these objectives. For publication – prior to inquest. September 2020 3 death. Relevant information prior to these dates was also considered as required, particularly any significant and relevant agency involvement with the parents or older siblings of Child U. 2.3 Early family engagement is required as part of the SILP model of review. The lead reviewer and a representative of the WSSCB met with Mother during the review, and will speak with Mother and Father prior to publication to ensure that they are aware of the conclusions of the review. 2.4 Statutory Guidance expects full publication of SCR overview reports, unless there are particular serious reasons why this would not be appropriate. Working to that requirement, some case detail will not be disclosed in this report, which is written in the anticipation that it will be published. The report contains the information that is relevant to the learning established during this review. 3 Family structure 3.1 The relevant family members in this review are: Family member To be referred to as: Subject child Child U Mother of Child U Mother Father of Child U Father Sibling age 1 at the time Sibling 1 School age sibling Sibling 2 Older adult siblings Older sibling/s 3.2 Any other relevant family members will be referred to by their relationship to Child U. 4 The background prior to the scoped period 4.1 There had been no concerns about the care or parenting of any of the older children in the family prior to Child U’s death. The only historical information of note was that Mother had been arrested for shoplifting in the presence of sibling 2 in 2013. 4.2 Mother was known by her GP to have had a dependence on Tramadol3, which she had been prescribed for headaches for around 12 years prior to the birth of Child U. Those involved during the pregnancy with Sibling 1 had been aware, but this information had not been shared among professionals involved during the pregnancy with Child U. Mother had refused a referral to drug support agencies. Father and other family members were unaware of this dependency. 4.3 There were no safeguarding concerns for Sibling 1 who was receiving a universal health visiting service, or for Sibling 2, who was at school. 5 Key episodes 5.1 The time under review has been divided into four ‘key episodes’. These are periods of intervention that are judged to be significant to understanding the work undertaken with a child and family. They are key from a practice perspective rather than to the history of the child. They do not form a complete history of the case but summarise the relevant activities 3 Tramadol is a narcotic-like pain reliever prescribed to treat moderate to severe pain. It can be addictive. It is not recommended during pregnancy due to the unborn baby becoming dependent in-utero and suffering withdrawal at birth. For publication – prior to inquest. September 2020 4 that occurred, and include the information that is thought to be most helpful in informing the review. Key episodes 1. Information sharing regarding Mother’s pregnancy 2. Birth of Child U 3. Immediate response to the serious event 4. Investigation and actions following Child U’s death Key episode 1: (Information sharing regarding Mother’s pregnancy) 5.2 Mother self-referred late for her pregnancy with Child U. She had requested a termination and was referred on by the GP, but it was too late for this to take place. 5.3 There is evidence that Mother later contacted her GP surgery asking for a repeat Tramadol prescription stating she had gone ahead with the termination, although Mother continues to deny this. Tramadol was refused as the GP wanted to see her face to face before prescribing. A letter was received and filed around a week later stating that Mother had not had a termination. Mother was next seen by the GP around a week later, but this issue was not discussed. 5.4 The GP provided information about Mother’s Tramadol use when referring her to the hospital for a scan, but this was not seen by those providing maternity care to Mother in the community or when Child U was born. 5.5 Mother was seen at 32 weeks gestation by a midwife and was asked questions, including about prescribed medication and drug use. Mother stated that she was not using any medication and did not use drugs. Following the process for Mothers who book late4, the midwife who first saw Mother for her antenatal care made a referral to the MASH5. They were also aware from records that Mother had disclosed domestic abuse from a previous partner. 5.6 The case history provided by the midwife was reviewed by a Group Manager in CYPS and the decision was taken not to progress the referral as there were no known concerns. A re-referral from the same midwife was received a week later and it was agreed that no further action should be taken based on the previous decision making by the Group Manager6. 5.7 In the meantime a health visitor liaison meeting was held at the GP surgery and the case was on the agenda due to the notification of the MASH referral about the late booking. The health visitor was made aware of Mother’s Tramadol use during this meeting. She knew the family, knew that Sibling 1 was on a universal health visiting caseload and there were no known concerns. Mother was offered an antenatal health visiting visit but she declined. The GP and the health visitor assumed that the midwives were aware of the Tramadol use as the information had been forwarded by the GP. 5.8 Mother was referred to and saw a midwife counsellor during her pregnancy, as it was acknowledged that she had requested a termination. There is no record of Father’s views being sought. Key episode 2: (Birth of Child U) 4 https://www.westsussex.gov.uk/media/3700/cs48_concealed_pregnancy.pdf 5 Multi-Agency Safeguarding Hub. 6 Group Managers review decisions at the request of the practice manager. For publication – prior to inquest. September 2020 5 5.9 Child U’s hospital birth was straightforward and he was discharged the same day. Five days after his birth Child U was seen by the midwife to be unsettled, restless, with loose stools and elevated temperature. He was sent to the hospital and was seen for an assessment on the paediatric rapid assessment unit by a paediatrician and appeared clinically well. His presenting symptoms were attributed to possible ‘milk intolerance or sepsis’7. 5.10 The health visitor saw Child U when he was 20 days old, following three previous appointments that were missed by the family. There were no concerns. Child U was also seen at home by the health visitor for his 6 week check, and was weighed in clinic. When asked, Mother told the health visitor she had stopped taking Tramadol during the pregnancy, and the GP records confirm that no more prescriptions were issued. She did not share that she was taking over the counter medication8 daily, or that Father was unaware of this. Key episode 3: (Immediate response to the serious event) 5.11 Parents called an ambulance on a Thursday evening reporting that their three-month-old child was seriously unwell. Mother reported that Child U had been left on the bed between two pillows while she was in another room, and that Father had returned home and found Child U lying face down and unresponsive on the floor. The ambulance service contacted the police, and A&E contacted CYPS. 5.12 At hospital the seriousness of Child U’s condition was established9, and police and EDT10 held an initial strategy meeting including the paediatrician who had examined Child U and was responsible for his care. It was acknowledged that non-accidental injury was a possible cause of the serious brain injury, although there were no bruises or signs of neglect. A second strategy meeting was held during the day on the Friday, and was attended by Child U’s health visitor who shared information about Mother’s previous dependence on Tramadol. Following the meeting it was stated that Child U (who had been transferred to a regional hospital for specialist care) had a skull fracture with an opinion shared later that this had occurred between three and seven days prior to him coming into hospital. 5.13 Consideration was given to ensuring that Child U was safeguarded in hospital, while allowing the parents to be present. Mother told the review that staff at the hospital handled this situation with sensitivity and compassion. Medical examinations were carried out on both child siblings and no concerns of neglect or abuse were identified. Both EDT and CYPS social workers arranged for the children to initially be cared for by their oldest sibling and then by Maternal Grandmother and made the appropriate checks for an emergency situation. Child U died the following day. Key episode 4: (Investigation and actions following Child U’s death) 5.15 Both the criminal investigation and consideration of the need to safeguard the siblings continued after the death of Child U. There was some confusion regarding the presence of a skull fracture, which is considered in the analysis below. 5.16 An Initial Child Protection Conference (ICPC) was held on Siblings 1 and 2 and they were made the subject of child protection plans. Care proceedings in respect of Sibling 1 commenced around 2 months after the conference. 6 Analysis by theme and learning 7 As recorded at the time. 8 Solphadeine Plus. A brand name analgesic medication with paracetamol, codeine and caffeine. This drug should not be taken during pregnancy unless considered essential by a doctor. This can cause withdrawal symptoms in a baby after birth. 9 Hypoxic (lack of oxygen) ischemic injury to his head 10 Emergency Duty Team who provide an out-of-hours social work service. For publication – prior to inquest. September 2020 6 6.1 From the information gained from the agency reports, from the discussions at the learning events, and from the meeting with the family, several key themes have emerged. The following are judged to be most significant and enable us to identify learning for the WSSCB and its partner agencies: Themes 1. Prescription drug dependence 2. Information sharing 3. Protection and care planning when there is uncertainty 6.2 Each theme identifies learning, and each learning point is linked to a recommendation in either this report or within the agency reports. It will be stated if the learning is being addressed elsewhere. Prescription drug dependence11 6.3 Tramadol was first prescribed to Mother for headaches. Within a year of taking the drug Mother contacted her GP for additional prescriptions on a number of occasions, stating her medication had been lost, had been stolen and had been left on holiday. Tramadol is known to be highly addictive, withdrawal is difficult12, and there is a high risk of overdose. Although it is only available on prescription, it can also be bought illegally, including on-line. Tramadol is known to impair judgment and slow down reactions. Advice is given against driving, operating heavy machinery, or doing anything that requires the taker to be alert. 6.4 Mother was able to keep her Tramadol dependence from everyone except the GPs at the surgery, and it appears that they did not entirely agree about how much of an issue it was. Her primary care medical notes had two references in their coding system, Suspected Drug Abuse in 2014 and Drug Dependence in 2016. From 2012 GP’s were discussing with Mother her dependence and recommending she reduce her prescriptions. In 2014 she was formally diagnosed with an addiction. Mother then had conflicting advice and support from the GPs depending on who she saw. Two of the GPs worked towards a clear plan for support and reduction, and another GP issued further prescriptions of Tramadol with no clear evidence that this was being managed as an addiction. The only occasion where concerns were identified for the children was in 2016 when Mother contacted the out of hours GP and was described as very distressed because her Tramadol had been stolen. Sibling 1 was a baby at the time and the GP recorded their concern for the child. There is no evidence that this concern was shared or followed up, and no consideration was given to whether Father should be made aware of the concern. 6.5 The GP practice often relied on Locum GPs to deal with demand for appointments at this time, and this appears to have led to continuity issues with each appointment either being undertaken in isolation or with differing views on the need for Mother to come off or reduce Tramadol. There was a degree of professional collusion with Mother’s Tramadol use which allowed her to play the system and continue to receive prescriptions. However, a clear reduction plan was implemented when Mother was pregnant with Child U. This did not consider whether Mother would then compensate by misusing over the counter medication instead. 11 Prescription drug abuse is defined as self-treatment of a medical condition using prescription medication that was not prescribed to the user, or as the use of prescription medication to achieve the feeling it provides. 12 Withdrawal includes both psychological and physical symptoms of withdrawal, such as: depression, severe mood swings, anxiety, nervousness, aggressiveness, insomnia, nightmares, electric shock sensations, restlessness, muscle pain, stomach cramps, sneezing, sweating, palpitations, tremors, headache, nausea, diarrhea. The symptoms of withdrawal are more noticeable if use of Tramadol is stopped abruptly. For publication – prior to inquest. September 2020 7 6.6 Mother’s use of Tramadol was shared with professionals when she was pregnant with Sibling 1 in 2015 as it was recorded in the written antenatal referral that included Tramadol as a listed prescription and in the summary where ‘Suspected Drug Abuse’ was listed. Those involved were aware of her use of the drug, but at the time they may not have recognised the level of dependence and no reduction was attempted. Sibling 1 was kept in hospital on the post natal ward for observations following their birth, but there is no evidence that they suffered from withdrawal. It does not appear that Father was aware of the reason for the observations, and no conversation was had with Mother about Father’s awareness of her Tramadol use and the possible impact on Sibling post-birth. 6.7 Mother approached her GP in December 2017 asking for a termination. She was referred to BPAS13. She also requested Tramadol, which was refused due to the pregnancy. Mother was recorded to be very unhappy with this refusal. There is no evidence that consideration was given to the potential risks if Mother had withdrawal symptoms. 6.8 Prior to the GP receiving a letter from BPAS stating that the pregnancy was beyond the gestational age at which they can legally provide an abortion and requesting a referral for antenatal care, there is evidence that Mother telephoned the GP requesting Tramadol claiming to have had the abortion. This was clearly untrue and provides evidence of Mother’s dependence and willingness to be dishonest to gain access to Tramadol, although it is acknowledged that Mother denies this happened. The next consultation where Mother was seen by her GP around a month later, when she attended due to concerns that the baby was not moving, would have been the ideal opportunity to discuss her claim to have had a termination in order to get a prescription for Tramadol. There was no discussion about this. This is probably because the GP who saw Mother would have been concentrating on the concern about the baby, and likely because they had not read the record of the telephone call with Mother a month before. This was within the context of a busy practice, with limited appointment times, the system used for filing letters, and locum GPs who do not always know the patients or their history. 6.9 The midwives who were seeing Mother both before and after the birth of Child U were unaware of Mother’s long-term use of Tramadol. The GP had shared this by letter when Mother was referred for a scan, but this was not seen by the midwives. There was limited time for the midwives to check records due to the late booking, there were no known concerns during the pregnancy with Sibling 1 (although those involved at the time were aware of the Tramadol use) and Mother always appeared very plausible. No plan was put in place for Mother’s care to be managed to limit the impact on the baby of her drug misuse. 6.10 In West Sussex there is a system where a mother can book in for her pregnancy on-line. This leads to an automatic summary being sent to the midwives without the GP seeing the pregnant woman face to face. It also means that decisions to refer to a consultant is not considered by the GP, but is left to the midwives. In this case there may have been an assumption by the GP therefore that the midwives would refer Mother for consultant care. The agency report regarding the GP states that once a woman is receiving antenatal care, it is assumed that any additional support or services will be requested by the midwifery team. Without the midwives being aware of the Tramadol use (as they did not see the GP information and because Mother did not disclose her use) this did not happen. 6.11 There is the possibility that the symptoms shown by Child U five days after his birth, were due to withdrawal from Tramadol or over the counter medication. He was stated to be unsettled, restless, with loose stools and elevated temperature. Mother’s previous use of Tramadol and 13 British Pregnancy Advisory Service who provide the service in the area. For publication – prior to inquest. September 2020 8 on-going use of over the counter medication during her pregnancy was not considered by the hospital paediatrician, as they were not aware of it. Child U’s symptoms were thought to be due to ‘milk intolerance or sepsis’14 but they are also common symptoms of withdrawal. 6.12 It was not until the strategy meeting held in Key Episode 3, that the health visitor shared the information that Mother had previously used Tramadol for 12 years. She had believed Mother when she stated that she was no longer using the drug, but did not gain details of how she had detoxified, how she was managing without it after such a long period of dependence, and whether she was instead taking over the counter medication. There is no evidence that it was established if Mother was receiving prescriptions for Tramadol following Child U’s birth, whether the ease of accessing the drug illegally was known or considered, or whether Mother was self-medicating with over the counter medication. There was also no discussion about what Father knew and what support he could potentially provide. 6.13 Only recently has prescription and over the counter medication addiction been identified as an emerging and potentially significant issue for individuals, for public health, and as a child safeguarding issue. Prescription drugs are thought to be misused and abused more often than any other drug except cannabis and alcohol. This growth is likely to be fueled by misperceptions about prescription drug safety, and increasing availability. It is also noted that the user themselves and health practitioners don’t necessarily recognise someone who is addicted to prescription or over the counter medications as a substance abuser/misuser, as they would with someone who misuses alcohol or non-prescription drugs. The Government has commissioned a review of ‘dependence and discontinuation syndrome’ from medicines that are prescribed15 to treat anxiety, insomnia, chronic (non-cancer) pain and depression16. The findings are expected in early 2019. 6.14 There is limited research into the impact on parenting and child safeguarding of the misuse of prescription medications such as Tramadol. Dependence on or abuse of prescribed or over the counter medication is not included in safeguarding training in West Sussex, which will mean that the issue is not always identified and acknowledged. Whilst there was evidence that the GP recognised that there were children in the home, this appeared to be related to the potential risk to children from the medication directly (i.e. if they found the tablets). There is no evidence to suggest that the GP felt that there was any increased risk to the children. They also did not consider the difficulties in Mother coming off Tramadol without help and support when a prescription was denied, and the impact this might have on her parenting. 6.15 Another impact of the lack of awareness and insight into the impact of prescription and over the counter drug abuse is that there is limited availability of specialist services or support to help misusers. Mother was offered support from existing drug agencies to help her stop using Tramadol, but she refused. This is not an unusual situation with abusers of prescription or over the counter drugs, as services are seen as more relevant to users of illegal drugs such as heroin. Mother confirmed to the review that this was the case. Learning: • Many prescription and some over the counter drugs are highly addictive and may have an impact on parenting. This is not widely acknowledged and understood. 14 As recorded at the time 15 It will not include over the counter medications. 16benzodiazepines, Z-drugs, GABA-ergic medicines, opioid pain medications, antidepressants. For publication – prior to inquest. September 2020 9 • Professionals need to ask detailed questions about the use of prescribed or over the counter medication and consider the impact of any dependence on parenting. This includes the impact of withdrawal. This questioning should also consider the other parent, in this case Father. • Current support and treatment services for substance misuse do not meet the needs of those misusing prescription or over the counter medications. Information sharing 6.16 A number of issues with communication and information sharing in this case have been identified. They include: The information about Mother’s Tramadol misuse was not seen by the midwives caring for her during her pregnancy, both in the community and in the hospital. GPs did not identify the information in their own records that Mother had lied about having a termination to get Tramadol, and this was not addressed with her. As it was the midwives who decide to make referrals for additional care during pregnancy, they did not do so for Mother. Midwives were not able to share the information about the Tramadol use with CYPS when they referred the case due to Mother’s late booking, as it had not been identified. The health visitor visited 4 times to ensure she saw Child U after his birth, she accepted Mother’s report that she no longer used Tramadol without checking with the GP. The paediatrician who saw Child U in hospital when he was 5 days old was not aware of Mother’s Tramadol use during her pregnancy. No questions were asked about what Father knew about Mother’s drug misuse. The children’s GP was not informed of the concerns about Child U’s death and when they became aware the child protection concerns were not recorded onto the GP records of Sibling 1 and 2. The children’s GP was not invited to the ICPC. Two Doctors were listed on the invitation list. They were both hospital-based doctors. The police did not attend the ICPC. This was due to a long-standing agreement within Sussex Police that they do not attend ICPC’s if they get less than five days’ notice. In a case such as this, where there has been a serious incident but medical opinions are not entirely clear, it is likely the conference will need to be held in a timely way as soon as some certainty is received and the decision is made. It is also noted that Working Together states that ICPCs should be held within 15 days of a strategy meeting. In West Sussex the rejection of the invitation is made by the civilian staff employed to prepare for and attend ICPC’s without enquiry into the case. This issue has been noted by Sussex Police and changes are being considered. The safety plan for the siblings was not shared with early help or the GP following the ICPC. 6.17 There were also examples of positive information sharing in the case, particularly following the incident, where there was excellent information sharing across almost all agencies. 6.18 Serious case reviews often highlight the importance of information sharing and communication, and this review is no exception. Information sharing between professionals is For publication – prior to inquest. September 2020 10 integral to improving safeguarding. In 2017 a DfE review of 25 serious case reviews involving the Centre of Excellence for Information Sharing17, found that ‘not knowing the bigger picture about vulnerable children and families was cited as a reason that information was not shared’ and that ‘professionals often struggle to understand the purpose for sharing crucial pieces of information that may help protect children without the full context of a family’s history. Without this holistic view, the most appropriate early help and safeguarding interventions may not take place.’ In this case there was information that was not adequately shared. This was partly due to a lack of awareness of the potential impact on parenting of long term Tramadol misuse, partly due to structural administrative issues, partly due to Mother’s late booking and misrepresentation of her use, and the lack of any previous concerns about the older children. Learning: • Information sharing about a parent’s misuse of prescribed drugs is as important as with any other drug dependence. Don’t assume other professionals (or family members) will be aware or that a parent will disclose the information. This learning should be included in WSSCB substance misuse training. Protection and care planning when there is uncertainty 6.19 If a child has a life-threatening illness or injury and it is not certain what the cause is, child abuse may be one of the possibilities being considered. Working in these circumstances is very challenging for all professionals. Despite the on-going uncertainty, the response when Child U was transported to and admitted to hospital had been to consider a differential diagnosis which included non-accidental injury. This ensured that the child’s health needs took precedence, but that their protection and that of their siblings, and the potential need for a criminal investigation, were also considered. 6.20 Those present at the learning events explained that the weekend of the incident was exceptionally busy for partner agencies in regards to child protection work. There had been two child deaths and a suspicious fracture to consider in West Sussex. This case was also unusual, as while the skull fracture was diagnosed following the initial investigations, it was not identified during the postmortem and this created some uncertainty. It is accepted that it can be very hard to diagnose some skull fractures, and be difficult to distinguish an accidental from a non-accidental cause. In this case the position of the fracture in such a young child would raise suspicion of a non-accidental injury. A number of doctors got involved to consider the images taken of Child U’s skull both at the time and in the weeks following the child’s death, and it was eventually agreed that a skull fracture was present. 6.21 After Child U’s admission to hospital, a skull fracture was identified. When a child presents with such an injury, further investigations should be undertaken, both medical and of the wider family circumstances. In this case it became clear that the explanation provided by the parents that Child U had fallen from the bed immediately prior to hospital admission did not fit with the dating of the fracture. The circumstances of Child U’s medical condition on admission and the fracture were considered by the police investigation, a S47 investigation, at a child protection conference and when legal advice was sought in respect of the child siblings. 6.22 Legal advice was sought on the first day by CSC. An application for an Emergency Protection Order was drafted, but this was not necessary as the family cooperated with the 17 Information Sharing to Protect Vulnerable Children and Families. DfE and The Centre of Excellence for Information Sharing 2017 For publication – prior to inquest. September 2020 11 requests of the police and CSC. Further legal advice was sought and advice was given that care proceedings should be commenced in respect of Sibling 1, due to inconsistent accounts by Mother in respect of the injuries to Child U, and the requirement for the parents not to live in the family home with the children. CSC did not apply for an order at this stage, mostly due to the case being further complicated in respect of differing and contradictory medical opinions being received about the skull fracture. 6.23 The ambiguity about the cause of death, and uncertainty about the existence of the fracture following the post-mortem (based on a verbal update from the police officer who attended) continued throughout the next few weeks, with the involvement of a number of experts. Sussex Police have reminded the individual officer of the need to seek absolute clarity regarding what medical professionals are saying prior to sharing that information with other professionals, in order to avoid confusion. Best practice is for the officer to take written notes at the time, and confirm them with the medical practitioner with a signature. 6.24 This uncertainty led to a request from West Sussex County Council Legal Services for a professionals meeting to include the medical professionals involved and to gain clarity about the existence of a skull fracture, due to there appearing to be a number of differing opinions being expressed in respect of the injuries. No meeting was held, but it was agreed that care proceedings should be initiated. This took place in September 2017, around three months after the incident. 6.25 With hindsight it has been agreed that the initial diagnosis should have been enough evidence for the legal process to commence in respect of the siblings. It is not unusual to fail to reach a conclusion on the cause of death in spite of multiple investigations and agencies need to work with this. In this case the uncertainty about the fracture side-tracked the focus from the incident which led to the death of Child U. However, it did not delay the plan to protect the surviving children in the short term. There was a delay in starting care proceedings which appears to be due to the continuing uncertainty regarding the existence of a skull fracture. An earlier legal planning meeting would have been of benefit. Learning • If there is a lack of certainty in a child protection case, consideration should be given to convening a timely high-level meeting of professionals from the three main agencies. This could be facilitated by using teleconference technology. The outcome of the meeting should be communicated effectively to those making decisions and considering the safeguarding of children, and if possible to the family. 7 Conclusion 7.1 Prior to his death, there had been no safeguarding concerns identified for Child U or his siblings. The parents received support from extended family, and were not identified as having any additional needs that required professional involvement. Mother, however, had been concealing her dependence on prescription medication for over a decade from her partner, her family and from professionals, with the exception of her GP, and very recently Child U’s health visitor, who was told by Mother that she no longer used Tramadol, but did not disclose that she was then using over the counter medications daily. Despite this dependence, no concerns emerged about the care of any of the children until the night that Child U was taken to hospital and died shortly afterwards. 7.2 The review has attempted to avoid hindsight bias which “oversimplifies or trivialises the situation confronting the practitioner and masks the processes affecting practitioner For publication – prior to inquest. September 2020 12 behaviour” (Woods et al18). It has identified the learning that is relevant both to this case and to the wider system. Individual agency learning has also been identified and the WSSCB has ensured that a robust consideration of the concerns identified has been undertaken by each agency involved in this matter. 7.4 It is important to also learn from the good practice identified during the course of this review. Good practice across a number of agencies has been acknowledged throughout the report, and includes the following: Positive information sharing between the GP surgery and health visitor during their regular multi-agency meetings. The provision of a midwife counsellor following Mother being unable to have a termination. The timely notifications of the incident from the ambulance service. Two well attended strategy meetings despite them being held over the weekend. This included the health visitor who provided the information about Mother’s Tramadol misuse. Challenge and debate over the weekend between the police and CYPS manager to find a way forward. A pragmatic and sensitive approach was taken to where Sibling 2 should stay immediately following the incident. Commitment by professionals over the weekend to keep the siblings safe. Sensitive supervision of contact with Child U in hospital. The early involvement of a Home Office pathologist to consider the fracture. Information sharing from CSC and from the regional children’s hospital to community health professionals following the incident. Medical examinations were carried out on Siblings 1 and 2. (No concerns were identified.) The long-term support provided by legal services. Legal services sought advice from a senior advocate. 7.5 There has been a high degree of cooperation and engagement from agencies with the SCR process, which has been important in identifying the learning. 8 Recommendations 8.1 Child U died while in the care of his Mother, who had not been open with professionals or her family about her long-term misuse of Tramadol. It is recognised that actions have already been taken in relation to some of the individual agencies’ identified learning, and that changes have been made which will be outlined in the WSSCB’s response to this SCR. 8.3 The agency reports have made recommendations which have largely been completed by the conclusion of the SCR. Some of the learning identified within this report will have been addressed by the single agency actions plans. For example, the Primary Care agency report makes a recommendation that awareness of prescription medication addiction as a potential risk factor for safeguarding children is now included in Level 3 training sessions and shared via email learning bulletins. 8.4 Other changes have been made. This includes the improved response to ICPC initiations by Sussex Police, Midwives covering West Sussex having laptops and mobile access so they can read GP records and a vulnerable pregnancy pathway has been developed. The purpose 18 David D Woods et al. Behind Human Error. 2010. For publication – prior to inquest. September 2020 13 of providing additional recommendations is to ensure that the WSSCB and its partner agencies are confident that any areas identified as being of particular concern, and not included in the single agency plan, or which require an interagency or Board action, are addressed. 8.6 The learning regarding information sharing is being considered by the Improving Practice Group of the WSCB who are undertaking a piece of work on improving information sharing, which will address the issues indentified in this case. No further recommendation is therefore required. Recommendation 1: Due to the delay in a conclusion being reached in the criminal investigation of this case, the WSSCB should give consideration to how the learning from this review is shared in a timely way. Recommendation 2: The WSSCB substance misuse training should be reviewed to ensure that the risks from prescription and over-the-counter drugs are included, along with the need to share information. The Board should then undertake quality assurance activity to ensure that this has an impact on practice. Recommendation 3: The WSSCB should consider the Government’s review of prescription drugs to be published in 2019 (see 6.13 above) to determine if the findings can be used to further strengthen safeguarding practice in West Sussex19. 19 https://www.gov.uk/government/publications/prescribed-medicines-review-report |
NC50707 | Death of a 17-year-old boy in October 2016. Young Person F was stabbed in an attack to rob him of any money and drugs he may have had and died the following day from his injuries. The person charged with his murder was sentenced to life imprisonment. Young Person F had been in foster care with the same family since the age of one, with his older sibling, until the placement broke down and ended in May 2014. Foster family and Young Person F were of White British/Asian ethnicity; mother was White. Findings: where children are placed in a long term placement with a Care Plan, which states their aim as adoption, any changes to this Plan should be managed with sensitivity; lack of urgency in responding to Young Person F when there were reports of drug running and gang involvement, with increasing missing episodes, with risks played down partly due to stereotypical notions of male adolescents; when decisions are made by Panels, the decisions must be informed not only by immediate costs but take into account projected costs if request is denied as this may incur greater costs overall. Recommendations: to ensure that decision making about services can be made swiftly and be responsive to needs of the child or young person; to update current policies and procedures to include references to siblings when they have been placed together and one of them dies or becomes seriously ill; all looked after children should be provided with the option of an independent advisor or advocate.
| Title: Serious case review: in respect of Young Person F. LSCB: Dudley Safeguarding Children Board Author: Birgitta Lundberg Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 1 SERIOUS CASE REVIEWIn respect of YOUNG PERSON FReport by: Birgitta Lundberg, Independent Reviewer and Overview Report AuthorNovember 2017Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 2Contents1. Introduction ..........................................................................................................................42. Decision to undertake a Serious Case Review.......................................................................73. Brief summary of the Terms of Reference............................................................................94. Brief summary of the Review process.................................................................................115. Older sibling and Foster Family views and issues ...............................................................125.1 Information from the visit to the foster home..............................................................12Learning point .................................................................................................................14Learning point .................................................................................................................145.2 Outstanding concerns for the older sibling and the foster carers ................................156. Significant issues, decisions and actions .............................................................................166.1 The impact on Young Person F’s emotional well being.............................................17Learning point .................................................................................................................17Learning point .................................................................................................................18Learning point .................................................................................................................196.2 The impact on Young Person F’s educational development and health...................19Learning point .................................................................................................................20Learning point .................................................................................................................216.3 The impact of the foster placement breakdown on Young Person F........................236.4 The Missing episodes and the vulnerability of Young Person F ................................25Learning point .................................................................................................................26Learning point .................................................................................................................276.5 Criminal activity and links to Gangs ..........................................................................28Learning point .................................................................................................................286.6 The statutory requirements and their effectiveness ................................................297. Findings and Conclusions ....................................................................................................318. Lessons Learnt.....................................................................................................................339. Implementation of Learning ...............................................................................................3410. Learning points and Recommendations............................................................................35Learning point 1 ..............................................................................................................35Recommendation 1 ........................................................................................................35Learning point 2 ..............................................................................................................36Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 3Recommendation 2 ........................................................................................................36Learning point 3 ..............................................................................................................36Recommendation 3 ........................................................................................................37Learning point 4 ..............................................................................................................37Recommendation 4 ........................................................................................................37Learning point 5 ..............................................................................................................37Recommendation 5 ........................................................................................................37Learning point 6 ..............................................................................................................37Recommendation 6 ........................................................................................................38Learning point 7 ..............................................................................................................38Recommendation 7 ........................................................................................................38Learning point 8 ..............................................................................................................38Recommendation 8 ........................................................................................................38Appendix 1: The full Terms of Reference................................................................................40Terms of Reference: Serious Case Review Young Person F................................................40The scope of the review......................................................................................................41Time scale ...........................................................................................................................42Appendix 2: The Review process.............................................................................................43Bibliography ............................................................................................................................44Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 41. IntroductionThis Serious Case Review concerns a young person (hereafter ‘Young Person F’) who had been a Looked After Child since the age of one. During that time Young Person F had been in placements arranged by the same local authority, Dudley Metropolitan Borough Council, and most of that time Young Person F had been placed together with an older sibling. For a period of nearly nine years they had been with the same foster family.When the death of Young Person F took place, a Missing report had been issued from an address in the Birmingham area where he was expected to reside. The placement had been agreed on Young Person F’s release from custody in mid-August 2016 on a Detention and Training Order (DTO) License with Intensive Supervision and Surveillance (ISS). When a young person receives a DTO half of their sentence is spent in the community on a license, which can include specific conditions. Young Person F’s license required compliance with an ISS program. This is an intensive package of support and interventions which is used to try and reduce the risk of further offending. The conditions included a curfew from 8 p.m. to 7 a.m. and daily reporting to the police station. The Youth Offending Service (YOS) Case Manager had applied to Birmingham Youth Court for a warrant without bail as Young Person F’s whereabouts were unknown. Young Person F had been missing for several days. This application was made on the same day that Young Person F died.Young Person F was seriously injured as a result of being stabbed and died the following day from these injuries. Information has emerged that in early October 2016 Young Person F was in the Gloucestershire area selling and distributing drugs, having become involved over the previous fifteen months with a gang based in the Wolverhampton/Birmingham area. On March 9th 2017, the person charged with the offence pleaded guilty to Young Person F’s murder and was sentenced to life imprisonment, to serve a minimum of twenty four and a half years. The judge commented that “it had been a well-planned and callous attack to rob Young Person F of any money and drugs Young Person F might have had.”Another person was investigated in relation to Young Person F’s death in relation to obstructing the course of a criminal investigation. The case was presented in the criminal court for trial, but after the jury failed to reach a conclusion, the case was not continued. It was decided in August 2017 that it was not in the public interest to pursue a retrial. Young Person F had just had his 17th birthday prior to this tragic death. Young Person F had experienced some longer settled periods with foster carers especially between 2005 and 2013, when Young Person F and the older sibling were placed together. The sibling, although now an adult, is still living with the foster family, who as a result of Young Person Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 5F’s death have decided to cease being foster carers. Both Young Person F and the older sibling had chosen to use the foster family’s surname.This Serious Case Review has primarily focussed on the period in Young Person F’s life from the year 2013 to Young Person F’s death in 2016.The reason for exploring and examining the events and services provided specifically during that time is that Young Person F experienced a number of significant changes in 2013. The outcome for Young Person F was an increasing record of risky behaviour and criminal activities and, subsequently , numerous changes of placements, which distanced Young Person F from the older sibling and the foster family and fragmented Young Person F’s education and training. When Young Person F had moved from primary education to a comprehensive school , the sats results were reported to be of ‘national average’ and although there had been some challenging behaviour this had been managed in school. From 2013 his educational progress was affected by increasingly challenging behaviour and multiple placement moves. Young Person F was described by the family and in reports as a child and young person who was friendly, engaged in family and leisure activities , took good care of his appearance and was loved by the foster family.The significant people in Young Person F’s life are noted below and in order to preserve their anonymity in this review they will be referred to as follows on the next page:Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 6DesignationRelationshipAgeEthnic originContact with Young Person FYoung Person FSubject17 years shortly before the deathWhite British/AsianSibling 1Older siblingTwo years olderWhite British/AsianNot much at that time but still in foster carers family home.FC siblingsYounger siblings adopted by foster carers.In foster home when Young Person F was in contact.Foster carersHad been Young Person F’s foster carers for a number of years.White and AsianWere still in intermittent touch with Young Person F.MotherHad not cared for or been active in Young Person F’s life for many years.WhiteThere had been past brief contact on Facebook.Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 72. Decision to undertake a Serious Case ReviewThe serious injuries of Young Person F were reported by the Gloucestershire police to the West Midlands police (WMP) in an email requesting that WMP officers conduct enquires to locate the next of kin details for Young Person F. (See Section 5. Foster family and older sibling’s views and issues.) Following Young Person F’s death the next day the West Midlands police passed the information about the circumstances of the death to the Dudley Safeguarding Children Board (DSCB). As a result the information was considered by the DSCB Serious Case Review Sub-Group and referred to the Independent Chair of the DSCB on 9 December 2016. The Independent Chair agreed on 11 December 2016 that the criteria for a Serious Case Review were met in accordance with chapter 4 in Working Together to Safeguard Children 2015 and Regulation 5 of the Local Safeguarding Children Boards Regulations 2006, which set out the functions of LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5(1) (e) and (2) set out an LSCB's function in relation to serious case reviews, namely:5(1)(e)undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned.(2)For the purposes of paragraph (1) (e) a serious case is one where: (a)abuse or neglect of a child is known or suspected; and (b)either - (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.In accordance with the DSCB Serious Incident Protocol each agency and organisation was required to secure their records and arrange for a formal chronology to be provided in relation to their involvement with the family. They were asked to identify an agency report author as soon as possible.This Serious Case Review was commissioned to be carried out by an Independent Serious Case Review Panel Chair and Report Author and a nominated panel of the DSCB. The DSCB notified Ofsted, the DfE and the National Panel of Independent Experts as per statutory guidance at the time. In addition using the ‘’Notification form for serious childcare Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 8incidents in relation to a Child in Care’’ Ofsted was alerted to the death. The Youth Justice Board was notified in accordance with the Community Safeguarding and Public Protection Incident Procedures ( CSPPI)1 in place at the time as Young Person F was under license and on a YOS case load.1Now updated to ‘Community Safeguarding and Public Protection Incidents (CSPPI) – Standard Operating Procedures for Youth Offending Teams Version 3 March 2017’. Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 93. Brief summary of the Terms of Reference The Terms of Reference were expected to include the generic terms of reference from ‘Working Together to Safeguard Children 2015’ with a particular focus on Young Person F and his experiences as a Looked After Child .The agencies involved with Young Person F were required to examine their decisions and actions and to scrutinise the process of multi-agency working with a view to learning lessons from the case, both of good practice and to make improvements, where needed.The review should examine the effectiveness of practice in line with procedures and the information and management / supervisory systems, both internal to agencies and multi-agency, in place at the time particularly in relation to Looked After children and young people.The time frame for the review was agreed as starting on January 1st 2013 up to the time of death in October 2016. Any significant information that would assist the analysis and learning outside this time frame could be included after discussion with the Review Panel.The foster family and older sibling should be invited to participate in the review and supported to do so. Their involvement with Young Person F had been active in the period leading up to 2014 and had continued with intermittent contact since then. The Review Panel decided that it would not be in the best interest of the learning process for other family members ,who had not been involved in Young Person F’s care since he was a very young child to be spoken to as a part of the review process. Appropriate consideration should be given and reference made to issues of gender, race, culture, religious identity and disability. The key elements that should be addressed were identified as follows:1) Examining how the Local Authority met its responsibilities as a Corporate Parent to Young Person F.2) Considering how Young Person F’s needs were met and how his views and wishes were heard?3) Examining the effectiveness of multi-agency working to meet his needs by:Establishing whether there are lessons to be learnt from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children.Identifying clearly what those lessons are, how they will be acted on, and what is expected to change as a result.Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 10Whether any other action is needed now within any agency.Whether the analysis of the information and the consequent response by all agencies was appropriate.Whether appropriate casework and management decisions were made.Whether Care Plans and Placement plans were in place and reviewed as required.Whether appropriate actions were taken with regard to referrals, reports of ‘missing’ episodes and subsequent placements.For full details of the Terms of Reference see Appendix 1.Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 114. Brief summary of the Review processWhen the decision had been made to proceed with a Serious Case Review, a Lead Reviewer and Overview Report author was appointed by the end of January 2017. A Review Panel of senior professionals in the agencies ,which had been identified as having had contact with Young Person F, was established. The members of the Review Panel had not had direct involvement in the services provided to Young Person F. This Review Panel was chaired by the Lead Reviewer supported by the Dudley Safeguarding Children Board Business Unit. The Chair /Lead Reviewer had not been employed by any agencies in Dudley Metropolitan Borough Council prior to this Review.From the end of January 2017 a number of meetings were held by the Review Panel to progress the work including a briefing with the internal agency Reviewers and authors of the internal Agency reports (generally referred to as IMRs). A part of this process involved examining an integrated Chronology of the involvement of all agencies as documented in records.Once the draft Overview Report had been discussed by the Review Panel a ‘’Consultation and Learning’’ day involving frontline practitioners and managers had been planned. This event was intended to explore the information and findings with practitioners ,who had been involved in the review process, in order to ensure that their views and comments could be heard and discussed with the Review Panel and Lead Reviewer. Any corrections of facts and changes and amendments following on from this consultation process would have been incorporated in to the Overview report prior to the presentation to the Dudley Safeguarding Children Board.The Review Panel decided to change the review format as the key practitioners in question were no longer available in the employment of the local agencies. However, some of the Agency reports ( IMRs) were undertaken with input from the previous practitioners, which was helpful and useful for the learning process. For full details of the process, agencies involved and meetings see Appendix 2.Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 125. Older sibling and Foster Family views and issues5.1 Information from the visit to the foster homeA home visit was arranged to the foster family, where Young Person F had been placed in 2005 with a Care Plan describing it as a ‘’long term fostering placement with a view to adoption’’. The older sibling was a part of the family with a similar plan. The placement for Young Person F broke down during 2013 and was officially declared as having ended in May 2014.The home visit was undertaken by the Chair/ Lead Reviewer and the DSCB Business Manager and was recorded with full agreement of all participants. Respecting confidentiality the recording will be deleted on conclusion of this report. The foster carers and older sibling were present.The conversation ranged from the services provided to Young Person F , to the carers and the older sibling to the feelings by the participants about Young Person F , his death and the events following his death. As a result of the experience of the past few years the foster carers have decided to retire from fostering. It transpired that the foster carers had been part of an Independent Fostering Agency established in 2000, which is also a part of an international group founded in 1988 providing among other services, Health and Social Care services. The foster carers had been approved two years prior to Young Person F and the older sibling being placed with them. The carers had participated in extensive training and were supported by the Agency supervising social workers , education advisors and placement support workers.The placement was planned with a program of introductory visits and as the carers were a dual heritage couple it was judged to be a placement that would meet Young Person F and his siblings needs.There was some hesitancy initially by the practitioners given that the carers belong to a smaller faith group with some specific beliefs. However , the agencies involved assessed that the carers were able to offer a caring environment without their beliefs having a negative impact on their care of the children. The issue of the faith group, its beliefs and practices was discussed in statutory reviews as a part of evaluating the fostering environment. From the conversation a picture of Young Person F emerged as a child and young person, who had been well cared for and loved by the family members. There were photos displayed around the house of family events and holidays with a smiling Young Person F at Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 13different ages. Young Person F was described as being very fond of his family including the more recently placed younger children from another family.These children were placed with and adopted by the foster carers in early 2013, which was an event that the family as well as practitioners at the time, and subsequently, have identified as a turning point for Young Person F. The plan for Young Person F and the older sibling had also been for adoption but the foster carers had requested an adoption financial allowance , which was declined by Children’s Services. The carers felt unable to afford the care of several children without any additional financial support and therefore the plan for Young Person F and his sibling reverted to ‘’ long term fostering’’. The foster family moved to a smaller property to downsize having lost the allowances for the younger children following their adoption and for the first time Young Person F and his sibling had to share a room.The family noted that they had received support from their own agency and Children’s Services during 2013 with a number of strategies being tried out to keep the placement going. However, between the challenging behaviour at home and in school leading to exclusion, Young Person F was becoming more and more reluctant to work with any practitioners or accept any support or authority and was increasingly getting involved in criminal activities. Young Person F now rejected the faith group the foster carers belonged to and started to spend time away without explaining where he was or with whom. By April 2014 the foster carers felt unable to continue in view of the challenging behaviour and increasing episodes of Young Person F ‘going missing’ and felt that it was not safe for Young Person F to remain in the placement. The Independent Fostering Agency gave notice to the Local Authority but agreed to hold off as the social worker was trying to get an agreement for funding for a 12 week therapeutic residential course for Young Person F, which might lead to an improvement and continuation of the placement. The foster carers and Young Person F were told that the funding was not available and this option fell through.It was clear that the foster carers felt that Young Person F had been let down by decisions that had been made based on funding requirements. In their view the considerable number of residential placement moves ,which followed on from the breakdown, must have cost the Local Authority a great deal more and were not in Young Person F’s best interests.The foster carers expressed the view that Young Person F ‘’was going through a bad phase but would be ok once he was 18 and an adult, then he would no longer be ‘ in care’.’’ They had expected that Young Person F would then feel able to become a part of the family again.They were all aware that Young Person F had some involvement with drugs but did not think that it was ‘that bad’ as they had not observed him with drugs.Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 14The foster carers and older sibling expressed anger and distress at the manner in which they were informed about Young Person F’s hospital admission and subsequent death. They were told by the police after Young Person F’s death. They felt that they had been left out and had not been provided with information in good time. They were especially taken aback by the way that the older sibling had been ignored by agencies given that Young Person F and the older sibling had spent most of their lives together. They felt that the agencies by informing the birth mother ,who was able to be by the bedside prior to Young Person F’s death , and who was then assisted to make the funeral arrangements , the older sibling and the foster family had been pushed aside. They expressed the opinion that Young Person F would not have liked the funeral arrangements and invitations the way they were done and the older sibling has considered drawing up a Will to express his wishes to avoid a similar situation. Learning pointThe information sharing when a Looked After Child is seriously injured or dies is set out in the Children’ Services procedures but there is no reference to informing siblings . Similarly , the advice about funeral arrangements and supports make no mention of siblings.http://dudleychildcare.proceduresonline.com/p_death_serious.htmlThe Dudley Safeguarding children procedures in chapter 1.17 sets out procedures for ‘Unexpected deaths’ including for Looked After Children and again there is no mention of siblings.http://westmidlands.procedures.org.uk/ykpzz/statutory-child-protection-procedures/child-deaths# Learning pointThe procedures mentioned above clarify what should be done and who should be informed once one of the key agencies become aware of an unexpected death or serious injury of a child in the local area.However ,the procedures do not clarify the mechanism for hospitals, when a request for finding a next of kin of a child /young person is made to the police, prior to the child’s status as a Looked After Child having been identified. Similarly the procedures do not address the need for the police to ascertain the child’s status with Children’s Services prior to notifying a parent.Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 15 It is at this point that there is a gap where the notification to a next of kin could be mistakenly directed to a birth parent with no recent contact with the child or where the child or young person did not wish to have contact with them.The foster family noted that Victim support services had been very helpful and had engaged with them including arranging a period away for the family .5.2 Outstanding concerns for the older sibling and the foster carersAlthough a manager from Children’s Services had come to visit the foster family two weeks after Young Person F’s death and had apologised for the lack of information about his death and the funeral , the family still feel that there are lessons to be learnt for the future, for other looked after children, their siblings and foster families. There is also an issue about explaining to foster carers how the legal aspects of Care Orders impact when a child / young person is ‘’in care’’ as compared to adopted and the child/young person then dies. Technically the Care Order comes to an end when the child / young person dies but this may not be an aspect that is generally shared with carers.The older sibling noted that they did not feel that they had been kept ‘’ in the loop’’ about Young Person F’s progress and whereabouts ,once Young Person F left the placement, and that more might have been done to promote contact between them especially given the amount of time they had shared together previously. The older sibling would have liked to have been able to see Young Person F in hospital prior to Young Person F’s death.Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 166. Significant issues, decisions and actionsDuring the three year period covered by this Review there were a number of developments which took place in relation to Young Person F and the services provided for his care. There are statutory requirements in place underpinning the services which were provided as well as internal procedures in the agencies, which were involved with his care. The regulations underpin the notion of the local authority as the ‘’Corporate Parent’’ with the responsibilities that it involves: ‘’The role of the corporate parent is to act as the best possible parent for each child they look after and to advocate on his/her behalf to secure the best possible outcomes.’’2For example the Placement regulations for a Looked After Child3 set out the expectations of Looked After Reviews, Health assessments , plans for the child’s education and supports such as Advocates or Personal Advisors. There are clear guidelines for the timescales, frequency and contents of meetings in these regulations. This refers to Independent Reviewing Officers ( IROs) and their appointment and role as well. The Review has explored how the regulations and procedures were implemented and if the implementation led to an outcome that was in the best interest of Young Person F. The Review has identified some significant events and issues which in all probability and with the benefit of hindsight influenced the outcome for Young Person F during this period . The selection of the significant events and issues are based on the analysis by the Overview author through the process of examining internal agency reviews, Review Panel discussions, the information in the integrated chronology and the meeting with the older sibling and foster family. The purpose of this section is to identify the points, where decisions and actions had an impact on the welfare of Young Person F. The aim is to come to an understanding of how and why those decisions and actions were arrived at in the context of the agencies and the policies, procedures and guidance in place at the time.The internal agency reviews, IMRs, have covered a number of issues in detail and the agencies have made changes to systems, guidance, policies and procedures, where there was a need for improvement and learning during the progress of the Review.This Review report should examine the multi-agency aspects of the decisions and actions related to Young Person F and consider if the key agencies worked together effectively to meet Young Person F’s needs.2 The duty to co-operate under section 10 of the Children Act 2004.3 See The Children Act 1989 guidance and regulations Volume 2: care planning, placement and case review June 2015.Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 17The significant issues and events highlighted were:6.1 The impact on Young Person F’s emotional well beingAt the beginning of 2013 a number of events took place which on reflection had a negative impact on Young Person F, who was at that time entering adolescence and becoming more challenging of adults ,especially adults in a role of authority. The same events affected the older sibling , who did not respond to them in the same way as Young Person F, which serves to emphasise how individual children respond to the same events according to their individual circumstances , needs and personalities.Learning pointWhere children are looked after with siblings the importance of assessing the needs of each child separately and devising Plans to meet their individual needs cannot be stressed enough. Their records in all agencies should be kept separately and reflect the progress and development of each child and meeting notes should not be copied and pasted . Their individual Plans should take in to account an overview of their history and current needs and should not focus solely on the current ‘problems’ or negative behaviour .The two most significant events were the changes in the foster placement as the two younger children ,who had been placed more recently, were adopted by the foster carers and the sudden death in May 2013 of the Young person’s Advisor with whom Young Person F had a good, supportive relationship. There was no evidence on record in any agency of support having been provided to address the loss of the practitioner with Young Person F.The process of decision making around the adoption of the younger children followed the agencies’ procedures in place at the time. However, the impact of their adoption whilst the Plan for the adoption of Young Person F and the older sibling was changed back to ‘long term fostering’ caused the practitioners involved serious concerns given the message that this course of action would send to Young Person F and the older sibling. The concerns were discussed in Looked After Reviews and other meetings and services were put in place to counsel and support Young Person F and the older sibling. How effective that approach was can be questioned as the records contain the information that a Respite placement was arranged for both Young Person F and his older sibling as the adoption was formalised. They both protested about having to go elsewhere and the Children’s Services records noted that “ they barricaded themselves in their bedroom to resist being taken to the respite placement” ( April 2013). Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 18The foster carers had requested adoption allowances for Young Person F and the older sibling but this was declined by Children’s Services. The foster carers moved the household to a smaller house in June 2013 to manage financially as they had lost the allowances for the younger children. Young Person F and the older sibling now had to share a room for the first time. During this period Young Person F displayed more challenging behaviour in school with a number of exclusions leading to permanent exclusion in October 2013. Prior to the escalating behaviour in school in 2013 there had been a school counsellor working with Young Person F for the past two years and a request for a referral for a psychological assessment had been made. There was no evidence on record that this referral had taken place or that an assessment had been undertaken. The school counsellor reported during an interview for the Agency review that they had had real difficulties accessing background information, which had been requested from Children’s Services. The counsellor did not escalate the request for information within the agency.This Review also noted that there was no representative from the school attending three of the Looked After Children Reviews ( LAC Reviews) ,which took place in the foster carer’s home. Notes of the meetings were sent to the school SENCO ( Special educational needs Co-ordinator) but it was not clear from the school records, if this information was shared with the school counsellor.Learning pointThe gap in the records at school and in Children’s Services about the involvement over a period of time of the school counsellor with Young Person F demonstrates the need for close communications and collaborative working between all school staff, social workers and foster carers . The school counsellor had been working in isolation from other practitioners. There should have been earlier opportunities to work more effectively with Young Person F to prevent the permanent exclusion ,which was followed by a fragmented education experience for Young Person F from then on.At this time Young Person F ,who had previously been positive and had participated in the foster carers’ faith group and related activities , now became disruptive and rejected the faith group and its structures. Young Person F expressed negative and sometimes offensive views to the foster carers about it. This period saw an increasing pattern of ‘missing episodes’ and criminal activities such as shop lifting as the foster placement was put under considerable strain and the foster carers expressed their worry ‘about keeping Young Person F safe’.Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 19As Young Person F had previously had good support from the Young person’s Advisor ,there was no evidence in the Plans/services provided that another practitioner had been found as a replacement. As young person F was reported to reject any attempts to speak to people Young Person F saw as ‘’authority’’, Young Person F was left to navigate through feelings of loss on his own during this period of many significant changes in his life. Learning pointThe importance of collaborative work across the key agencies for looked after children is demonstrated in this Review as the emotional needs of Young Person F should have been addressed by Children’s Services with Health agencies, Education services and schools.Above all, children and young people need consistent relationships with adults who are committed to loving and caring for them. However, some young people will not experience this stability unless the right support is put in place for them and their carers. This requires services that take an individual approach to understanding children’s and carers’ needs, that give children opportunities to shape their own care, and provide proactive support rather than allowing problems to get worse.Therapeutic services have an important role to play, and must be made more accessible – but this support must be provided in a range of different ways across social care, health and education. Research shows that the everyday environment that children and young people experience in care is central to their wellbeing.46.2 The impact on Young Person F’s educational development and healthOnce the foster placement had broken down there followed a number of placements, some within the Dudley LA borders and some in other parts of England and Wales. The placements included residential services provided by the Dudley LA and private providers as well as other foster placements and placements in Young Offenders institutions. Young Person F was remanded to custody on a number of occasions.The Education Agency report noted that thirteen different educational establishments could be identified in the records. The various places were in different parts of the country where Young Person F had been placed and some of the education services were delivered within 4 Achieving emotional wellbeing for looked after children ;a whole system approach .June 2015 .L.Bazalgette et al NSPCC researchFinal Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 20the residential establishments where Young Person F was living at the time. There were no consistent education plans in evidence after November 2014 when Young Person F was in a residential placement out of borough for two months .Young Person F had been assessed in accordance with statutory requirements as having academic achievements ,which were in line with his peers at the completion of primary education, aged 11 (year 6 Key stage 2). On two occasions there were proposals for referrals for psychological assessments , once while still at school in the neighbouring Local Authority, where the foster carers lived, and once in 2015 when a referral to CAMHS and a proposed assessment for Autism Spectrum Disorder (ASD) by a Clinical Psychologist were not followed through. There was no evidence of an explanation in either instance as to why these proposals had not been actioned. In the interview with the foster carers they were clear that at one point they had at Young Person F’s own request asked, if Young Person F could be home educated as they all thought this might solve some of the behaviour problems. According to the Education Agency report the records had no note of this request. The foster carers recollection was that they were told that it was not possible because Young Person F was Looked After.Learning pointGiven the dates of the emails the references to Home Education have not been clarified but the inquiries as a part of the Review have led to a discussion about the possibilities of a Looked After Child placed in long term foster care receiving Home Education. The Education Service had no records of an instance where this had taken place and queried whether the Local Authority could agree to such an arrangement for a Looked After Child. This issue must be clarified and guidance to practitioners and foster carers provided to ensure that, if this is another option for some children /young people, the services can support this option. If Home Education is not an option for a Looked After Child then the guidance to Fostering services and the relevant practitioners must state this. The outcome for Young Person F was that the number of moves in a short space of time led to his education becoming fragmented and lacking a consistent Plan. As a result Young Person F had achieved no qualifications by the time of his death. The Health assessments as required in statutory guidance followed a similar path. Due to the multiple moves between placements and local authorities the ability of the Looked After Children Designated Nurse to track Young Person F and arrange for services to undertake the health assessments was impeded. Additionally the systems in place to track Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 21looked after children were not securely in place at that time and relied on social workers notifying the Designated LAC Nurse of the child’s whereabouts on form Part A 5. Young Person F underwent only one health assessment from 2013 onwards because the placements subsequently were out of area and all services, whether universal or supplementary, should have been provided in the area where Young Person F was living. The LAC Nursing team should have requested review health assessments to be undertaken in those areas ,when they were sent Part A forms and a current address by Dudley Children’s Services, usually the child’s social worker . However, the Part A forms were often not provided or by the time the administrator had chased up the form Young Person F had moved again.The health assessment in December 2013 took place in the foster home and Young Person F had signed the consent form. The assessment was described as ’’holistic and Young Person F participated in the main ,sometimes needing prompting by the foster carer. Health, school, home and social life were discussed with Young Person F and it was noted that CAMHS were to be involved with Young Person F and the carers.’’ A copy of the report was sent to the GP, social worker and school nurse. As previously noted no follow up can be evidenced in any records with CAMHS.Learning pointThe Agency report ( IMR) by the Named Nurse for Safeguarding Children in the Black Country Partnership NHS Foundation Trust sets out the history and development of the systems for health assessments of children, who are looked after, in detail. The report offers significant recommendations to improve the systems and therefore the outcomes for all children looked after. The importance of the message in the report is that collaborative working and information sharing must be recognised and understood by all practitioners and managers to ensure that Dudley LA and key partners in the Health agencies meet the needs of the children they are responsible for.In August 2015 Young Person F was seen by the YOS Case Manager following a court appearance and the details of the order were explained to Young Person F. Referrals were made to the YOS CPN, YOS substance misuse worker, YOS nurse and the YOS education, 5 Part A is the first part of the British Association of Adoption and Fostering (BAAF) form which details all children’s demographic information and consent for the health review to take place.Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 22training and employment worker (ETE). The YOS case manager emailed the following information to support the referral to the Substance misuse worker: ‘Young Person F admits to drug dealing/ running and personal cannabis use. Staff at the residential placement believe Young Person F may be using other substances‘.The Substance misuse support worker tried to engage Young Person F, who denied that he was using drugs when released from custody and refused to attend the appointment.Young Person F was assessed and offered health support services within some of the placements for example the Secure Training Centre ( STC) from March 2016, where :“Healthcare is provided by G4S under a service level agreement, with appropriate access to community-based services. Education is provided on-site by G4S.”6 The services were declined in a number of instances by Young Person F but the registered CPN using the SASH (suicide and Self Harm) process assessed Young Person F, who had threatened to harm staff and himself. A SASH meeting took place at 2.30 am in response to an incident and: “the decision was made to place Young Person F on a strategic management plan for the rest of the night. There would be constant observations for the rest of the evening with the emphasis on staff trying to talk with Young Person F to attempt to reassure and calm him down to prevent any further self-harming. The self-harming ceased although the decision was made not to open Young Person F’s door given the potential risk to staff , along with the decision that Young Person F was not judged to be an immediate risk of suicide based on his actions and comments to staff. Young Person F openly stated that self-harming was a control mechanism to prevent the transfer out of the Centre the following morning .”7The lack of consistent health monitoring and the slow responses to referrals for specialist services led to a situation where Young Person F became more involved in drug use and may have needed mental health support in view of the losses and confusion in his life. Young Person F was described as presenting as ‘’ neglecting himself ‘’ by the foster carers and older sibling during 2016. The final placement Information report stated that:“Staff had concerns about Young Person F because his personal hygiene started to decline and he wasn’t eating properly.”Young Person F was also placed in ‘one to one’ or segregated situations in some of the placements due to his aggressive and hostile behaviour towards staff and other young people. Taking an overview and looking at Young Person F from a young person ’s perspective he had no’ neutral person’ to speak to about his circumstances and feelings, 6 Agency IMR report STC7 Agency IMR report STCFinal Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 23although there were references in records to the need to appoint an Advisor or Advocate, this was never actioned. The last placement provided an Information report to the Review where they noted that:“ Young Person F was a young man who just really wanted a sense of belonging. Staff witnessed Young Person F call friends asking them to come and see him but they never did, it was clear to the see the disappointment and frustration which would make Young Person F rebel and break unit rules. Young Person F liked to be the centre of attention and liked acting “the big Man”, when challenged for his bad behaviour Young Person F would become aggressive and verbally abusive.” 6.3 The impact of the foster placement breakdown on Young Person FThe various Agency review reports and Panel discussions explored the impact of the foster placement breakdown on Young Person F’s well-being and noted the increase in criminality, missing episodes , challenging behaviour in school leading to permanent exclusion and generally aggressive behaviour, which followed on from that point. However, the placement breakdown did not happen suddenly but over a period of time from early 2013 to May 2014.There were a significant number of meetings between the Children’s Services , the Fostering Agency and the foster carers including the involvement of the Independent Reviewing Officer where interventions to prevent a breakdown were discussed. A formal Placement breakdown meeting was not convened in view of the number of meetings that had taken place to address the issues.The tensions affecting the foster placement arose from Young Person F’s challenging behaviour in all settings towards adults and peers. This challenging behaviour had been described as being managed in the primary school setting and the foster home prior to the change in the Care Plan for Young Person F and the older sibling from its aim of adoption by the foster carers to long term fostering again. Although Young Person F could have demonstrated resentment towards the two younger children who were adopted by the foster carers , he did not. In fact Young Person F had tattooed the younger children’s names on his wrists and spoke of them very positively.During this period Young Person F became more and more involved in criminal activities starting with relatively minor thefts from shops in the locality to more serious involvement in thefts, abusive and threatening behaviour .There was a significant increase in periods of time missing from the fostering placement and then being hostile to the foster carers.The Fostering Agency provided a range of support services to the placement with a view to preventing the placement breakdown. They were willing to wait with closing the placement contract for Young Person F ,if the 12 week Therapeutic resource which the social worker Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 24was pursuing for Young Person F was implemented. However, the LA Resource Panel concluded that the Therapeutic placement was far too costly and it could not be provided for Young Person F.The social worker ,who had been allocated to Young Person F for some time, in the interview for this Review was of the opinion that if more had been done to prevent the placement breakdown it could have worked. For example the decision about the 12 week therapeutic placement was counterproductive as the costs incurred following the breakdown with numerous placement moves must have been higher than the cost of that one resource. A Research report commissioned by the NSPCC in the section, which addressed the costs of care and support services to prevent placement breakdowns concluded for example:‘’These cost estimations suggest that providing improved support for looked after children’s emotional health and wellbeing could avoid costs overall. Local authorities should analyse their own budgets and explore the extent to which they can rebalance their spending to support a more proactive and preventative approach to supporting looked after children’s emotional wellbeing.’’The pattern throughout Young Person F’s time as a Looked after young person after the foster placement breakdown was described in the Children’s Services IMR as “a cycle of “beginning to settle” shortly being followed by the placement giving notice due to their inability to keep Young Person F and others safe.” The integrated chronology has 26 entries referring to placement moves in this review period.The aspect that was not evident in the records throughout this period following the adoption decision and placement breakdown was Young Person F’s own views about his situation and his feelings. The Children’s Services IMR report commented on the fact that the case recording was primarily concerned with incidents prior to the placement breakdown and afterwards with finding placements. The case recording therefore gave a negative picture of Young Person F as all problems were itemised with little positive comment. The social worker agreed that given the overall workload at the time the service had been focussed on reacting to problems as they arose and then talking to Young Person F about the practical aspects of resolving those immediate problems. There had been little scope to explore Young Person F’s feelings about the adoption issues and the possibility of the placement breakdown and what would then follow. As previously noted the absence of a neutral adult ,whom Young Person F could speak to freely , was a significant missed opportunity to offer support and advice to him. An advocate could have provided a pathway for Young Person F’s views to be heard and to feed into planning the services with him. Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 256.4 The Missing episodes and the vulnerability of Young Person FThe Review noted that there were a significant number of reports of Young Person F ‘’ going missing’’ from all the different placements. The missing episodes could vary from a few hours in the early stages to several days or weeks later on during the review period. Young Person F rarely gave an account of his whereabouts or the other people he spent time with. The records evidence that staff in some placements were aware of reports that Young Person F had become involved with a group of people , many older than himself ,who were understood to be part of an organised group distributing drugs across the region. This information was available in records from June 2015 onwards.In addition Young Person F was open about using cannabis himself and services from Substance misuse workers were offered to him on more than one occasion. Young Person F generally declined services with the explanation that he was no longer using drugs. During most of this period Young Person F had one consistent social worker and one consistent YOS case manager. Young Person F became increasingly aggressive and hostile towards both practitioners which led to placement visits and meetings taking place with security measures provided or without Young Person F attending. Both agencies were aware of the circumstances and the matter was discussed in supervision. However , neither agency seriously considered a change of worker in order to try to re-engage Young Person F and/or to protect the practitioners. The difficulties communicating with Young Person F produced an outcome where Young Person F became more and more isolated from practitioners and friends and family. While the practitioners in the agencies were focussing on the practical aspects of arranging and maintaining placements, there was little scope for work aimed at understanding Young Person F’s views and feelings and reasons for ‘going missing’. The Police IMR examined the West Midlands police records in respect of Young Person F and missing episodes that had been reported to them. The report concluded that all policies and procedures at the different times had been followed. However, there were gaps as many ‘missing episodes’ had taken place in other police force areas where Young Person F had been placed ‘out of borough’. It remains unclear just how many times Young Person F was reported as missing by placements. “Young Person F was known to the West Midlands Police ( WMP) both as a victim and perpetrator of crime; however the vast majority of contacts were regarding Young Person F being a perpetrator of crime and a regular absent/missing person. Between 17th March 2014 and 1st June 2016, Young Person F was reported as an absent/missing person a total of seventeen times to WMP. Out of those seventeen reports, Young Person F was classified as absent on eleven occasions, and as a missing person six times”.8Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 26There were two instances where Safe and Well checks were recorded. These checks were carried out by the police when a person had been recorded as missing , not as absent.Safe and Well checks are carried out by the police whilst the Return Home interview is usually carried out by the LA social worker or a practitioner from a specific service commissioned for this purpose. There were no records of Return Home interviews having been carried out by Children’s Services.Learning point“Information from the police’s safe and well checks should be shared with children’s social care services to inform a follow-up interview by a third party (not the police) to explore the reasons for running away and the action that might be taken to prevent it in the future. Under statutory guidance these ‘return’ interviews are the responsibility of the local authority but are often undertaken on behalf of local authorities by voluntary agencies who work with missing children or children at risk of sexual exploitation. These interviews are intended to identify longer-term risks or more deep-seated problems. They are particularly important as children are often unwilling to disclose information to the police, but may offer valuable information if the interview is conducted well by a third party who has the trust of the child. Within the scope of inter-agency arrangements, information from these interviews should inform all relevant agencies’ practice. The return interviews might provide information for the police about likely suspects in cases of CSE or help agencies develop a trigger plan (an agreed inter-agency plan of the action that will be taken and by whom if a child goes missing)”.9The services provided in Dudley when a child/young person goes missing have been updated and the flowcharts provided to the Panel show that a more robust response should be in place now . The multi-agency meetings include a police intelligence and information sharing input with the intention of picking up vulnerable young people at an early stage to develop preventative strategies diverting them from any gangs or organised activity. Another issue emerged as the records and the integrated chronology were scrutinised . There was an increase in missing episodes and criminal activity when Young Person F was in 8 WMP IMR report 9 HMIC Missing children; who cares? The police response to missing and absent children. March 2016.Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 27one particular local residential placement. The Review Panel queried whether the placement had displayed a more lenient approach to males going missing rather than females thus exposing a culture where practitioner and management attitudes about gender differences and vulnerability determined the decisions made and actions taken . The Review Panel was informed that the residential establishment is no longer open. Learning point The Panel members were agreed that the responses to Young Person F’s behaviour could be viewed as being more flexible and lenient than they had expected on a number of occasions. If the same behaviour had been displayed by a female young person it would in all probability have been responded to with more concern about their safety and with a more protective Placement plan.Case supervision in all key agencies should reflect on the responses to young people and consider whether the gender of the young person might be influencing the decision making . In view of the repeat missing episodes, which sometimes covered weeks rather than days, Young Person F was a young person , who should have been considered as vulnerable to child sexual exploitation (CSE). This concern was noted in a multi-agency Missing Strategy Meeting which recommended that the social worker should complete a CSE screening tool . It was not clear from the records if this assessment was completed or if Young Person F was discussed at the Young person Sexual Exploitation Panel (YPSE).Young Person F’s vulnerabilities made him a risk to himself and to other’s. A risk assessment was completed by the YOS Case Manager in March 2016 which recorded Young Person F as a ‘medium risk’. The level of ‘medium risk’ had been determined by the fact that Young Person F did not demonstrate suicidal thoughts or actions. The same conclusion was reached by the YOS CPN in August 2016. There were numerous accounts of abusive and threatening behaviour towards practitioners. Young Person F’s continuing hostility and threats led to a significant time in segregation in some establishments. The asset assessment in May 2016 raised the risk level to high. Young Person F’s case was discussed at an Integrated Offender Management meeting (IOM) in May 2016. This is a multi-agency meeting convened at the YOS by the Supervising Manager to discuss high risk cases. A decision was made to add ISS as a condition to Young Person F’s DTO license.Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 28The overall conclusion from the records and interviews with practitioners was that Young Person F was a rather isolated young person with few close relationships. This left him vulnerable to the influence of others ,who might fill an unmet need to belong to a group. The real difficulty in determining how vulnerable Young Person F was lies in the lack of information about who he spent his time with and what he was doing ,when he was missing from placements.6.5 Criminal activity and links to GangsThe first recorded involvement with the police was noted in October 2013. The criminal activities escalated and accumulated to a considerable list of offences by the time of Young Person F’s death. There were records in some of the placements of references to involvement in a ‘gang’ and in particular in relation to the selling of drugs. Young Person F was also thought to have debts which then ensnared him further in the gang activities. Although there were these pieces of information about gang involvement in the Children’s Services records, the YOs records and the police records there was no evidence of any specific follow up or action taken to address this with Young Person F. There were no records of inter-agency information sharing about this aspect or any action taken to develop a strategy to address the issue and divert Young Person F from this involvement.Learning point The West Midlands Safeguarding Children Procedures which apply for the Dudley children’s workforce have the following useful entry:An important feature of gang involvement is that, the more heavily a child is involved with a gang, the less likely they are to talk about it.There are links between gang involvement and young people going missing from home or care. Some of the factors which can draw gang-involved young people away from home or care into going missing can come through the drugs markets and ‘drugs lines’ activity, There may be gang-associated child sexual exploitation and relationships which can be strong pull factors for girls. Exploitation is at the heart of this activity, with overt coercion taking place alongside the pull factors of money, status, affection and belonging.1010 Chapter 2.1. the West Midlands SCB proceduresFinal Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 296.6 The statutory requirements and their effectiveness The integrated chronology and the Agency reports demonstrate that the statutory requirements such as Looked After Children’s Reviews (LAC reviews) took place at the intervals expected. The attendance was not always as multi-agency as required for example the school representation at one point was noted as ‘not attended’ on three occasions. The review has also revealed that the health assessments, which should be part of the LAC reviews had not followed through after the foster placement breakdown because of the system that was in place at the time as previously noted.The Independent Reviewing Officer (IRO) had raised concerns with the social worker and their manager in the context of some of the LAC reviews about the placement moves and the services being provided. The Children’s Services IMR noted that the IRO’s concerns had not had a positive response and this raises a query about the authority of the IRO role and the systems in place to resolve any differences of opinion between managers and the IROs. Young Person F received more than the required statutory visits by the social worker and the YOS case manager was proactive in visiting and keeping track of Young Person F. A number of Professionals meetings and Planning meetings took place trying to address the tensions in the foster placement. However , the involvement of all relevant agencies was not always as good as it might have been as the health agencies and school representation was sometimes lacking. The reasons for this gap in multi-agency working was not necessarily that those agencies failed to attend but as the invitations were issued by Children’s Services the invitations did not always reach the right practitioner in the agency concerned or with enough time to make arrangements. Where notes from previous meetings had not been provided to the relevant person there was no routine follow through. As there was no formal Placement Breakdown meeting ,because the number of meetings that had been held was judged to be sufficient, it removed a forum for a specific Plan to deal with the breakdown across the agencies. A clear Breakdown Plan should have addressed the health and educational needs as well as the practical placement needs and should have included emotional support to Young Person F.As the police involvement was restricted to responding to criminal activity and reports of Young Person F ‘going missing’ the police were not included in any other meetings or discussions about Young Person F other than the YOS meetings. However, if the concerns about Young Person F’s vulnerability , substance misuse and possible gang involvement had been recognised and acted on ,the police could have offered some specialist knowledge about these issues and a multi-agency strategy could have been put in place to support Young Person F.There were a number of services provided to Young Person F over the period of time for this Review and some practitioners were committed in their attempts to reach Young Person F Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 30for example the foster carers and their Agency , the social worker and the YOS case manager as well as some of the practitioners in the placements Young Person F attended. The question ,which was posed, was whether those services, which were provided, were effective in improving the outcomes for Young Person F? The main stumbling block which emerges from the review is that the services did not succeed in engaging Young Person F to work with them so that he could add his point of view to the Care Plans, which were devised to meet his needs. The outcome for Young Person F would have been more likely to have been positive, if he could have participated in shaping his Care Plans. Participation could also have supported him to develop a more independent and resilient outlook for his own future.Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 317. Findings and ConclusionsThe findings of this review in to the death of Young Person F ,who was stabbed in a planned attack to rob him of money and drugs as a part of an organised drug selling activity in the region, have addressed a number of aspects of the services ,which had been provided to Young Person F with a view to learning lessons and improving services where required. Several lessons and opportunities to improve practice and systems in future have been identified and some learning has already been implemented during the course of the review such as the responses by the Children’s Services and partner agencies to children going missing. Some of the findings have been drawn out in Learning points in section 6 of this report and other findings can be set out as follows:Where children are placed in a long term placement with a Care Plan, which states the aim as their adoption, any changes to this Plan should be managed with sensitivity. The child must be given adequate time to understand the reasoning for the decisions made. The child’s views must be sought and recorded clearly should they request access to records at a later stage.When decisions are made by Panels controlling access to resources such as placements and therapeutic services the decisions must be informed not only by the immediate cost but take in to account projected cost if the request is denied as this may incur greater costs in the long run.Where a child / young person is persistently abusive or aggressive towards a practitioner there must be a discussion between the supervisor and the practitioner. They must consider whether it is in the child’s best interest to continue with the same practitioner by weighing up the positive aspects of stability and consistency of a worker with the negative effect that the practitioner and child are not able to communicate adequately. They must also consider the impact on the practitioner and their ability to deliver a responsive service to the child.In conclusion the death of Young Person F could not have been predicted but some of the risk and vulnerability factors identified in the HMIC research 2016 ’ Missing Children ;Who cares? and some of the case examples are worryingly similar to the issues which affected Young Person F. The particular concerns raised by this Review is that the multi-agency collaborative working and information sharing had not been as effective as could have been expected. This led to some decision making and actions being taken, which were based on inadequate information or gaps in information ; for example the records demonstrated that it was known by some practitioners that Young Person F was involved in selling drugs around the Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 32region sixteen months prior to his death. The information was held but not acted on or shared.The most concerning conclusion is that the services provided were increasingly unable to engage with Young Person F and although time ,effort and commitment were evident on behalf of the practitioners they were not able to find a way to reach Young Person F. The skills ,experience and knowledge required to work with children who are hard to reach may be difficult to access in the workforce. If local authorities and their partner agencies who are responsible as Corporate Parents cannot access specialist services some Looked After Children will continue to fall through the gaps.Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 338. Lessons Learnt This Overview Report has highlighted ‘Learning points’ which should be used to inform the learning from this review. The learning points can be used as case examples in team sessions or supervision to reflect on practice in the agencies. The Learning points and recommendations in both this Report and the Agency IMRs must be followed up to ensure that practice and systems are improved and where practice has already been addressed as a result, mechanisms must be in place to embed and maintain the improvements.The lessons noted in this report and in the individual agency reports will be reflected in the Action Plans and will be monitored regularly by the Serious Case Review Subgroup of the DSCB. Agencies are required to disseminate any learning that is specific to their organisation and the DSCB will facilitate the dissemination of any broader multi-agency learning.Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 349. Implementation of LearningThe learning from this review will be disseminated to all the agencies through the DSCB Learning framework by:Publishing the Overview report on the DSCB website and communicating this to all Board membersProducing a ‘Learning and Improvement Information sheet’ - which summarises the learning from the review - and publishing it on the websiteLiaising with the training coordinator and the ‘Learning and Improvement’ subgroup to identify any specific training events required and how the learning can be incorporated into existing training courses/workshopsUsing the SCR as a case study in the annual Learning from SCR event. Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 3510. Learning points and RecommendationsThe individual Agency review reports, IMRs, have made specific agency recommendations, which will be set out in their Action Plans and progress will be required to be reported to the DSCB Serious Case Review subgroup. The recommendations of this Overview report will form the DSCB Action Plan and will be monitored regularly by the DSCB Serious Case Review subgroup.Arising from the main learning points the following are the specific recommendations by the Overview Report author and they have been drawn up in order to ensure that all relevant interagency learning from the Review is addressed:Learning point 1The overall learning from this review centres on the ‘corporate parenting responsibilities for children and young people looked after by the local authority’. The organisational systems and multi-agency systems that were in place did not reach Young Person F. The systems must ensure that children and young people already by definition vulnerable are detected early enough so that services can be responsive to support them to avoid the drift and pattern of fragmentation of care seen in this review e.g. when one service breaks down all other follow.There must be a route in the organisational systems where an alert can be channelled from the various levels of the organisation up and down to note when a child is at risk . Multi-agency panels are useful but only if the representatives on the Panels then bring the discussions and decisions back to the relevant members of their own agencies for sharing and implementation. The learning from research projects about costing of services for Looked After Children in the short term and longer term should be part of any discussion with Commissioning services and LA members in the context of the Corporate parenting responsibilities and with a view to the best outcomes to LAC children. Recommendation 1The Dudley Safeguarding Children Board should undertake an urgent review with their Safeguarding Partner agencies e.g. the Local Authority , the Police and the Clinical Commissioning Group (CCG) and any other agencies involved in this case of the current system in place to meet the needs of looked after children and young people to examine, if the decision making about services can made swiftly and be responsive to the needs of the child or young person . Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 36The multi-agency review should report back within three months and set out any actions for improvement to the systems for access by all levels of practitioners and for the child or young person’s views to be clearly stated. Learning point 2The sibling of Young Person F and the foster carers raised their concerns about the manner in which they had been informed of the death of Young Person F and the subsequent funeral arrangements which they had found distressing. They hoped that learning could flow from this review to ensure that other families and siblings would not encounter a similar experience.Recommendation 2The current policies and procedures in the relevant agencies should be updated to include references to siblings where there are or have recently been siblings placed together and one of them dies or becomes seriously ill. All multi-agency systems for searching for next of kin for children and young people in the event of a sudden serious illness , serious assault or death should be capable as far as is reasonable of identifying a child who is looked after ,for example the Emergency Duty Service with the local authority.Learning point 3The review has identified the need to balance case recording to demonstrate not only times of difficulties such as the need to find placements but to include a full view of the child or young person and most of all to include the views and feelings of the child themselves.Where there are sibling placements the records and plans must demonstrate their individual needs and plans and information should not be copied across unless relevant.Access to records should always be born in mind as this is the child’s main record , in the case of Young Person F from the age of one years old, and should be a record that can unfold the life events of the child. The lack of detail or gaps in records as this review has demonstrated can lead to information not being actioned such as referrals for specialist services or information about the drugs and a possible gang involvement.Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 37Recommendation 3All managers, supervisors and practitioners should be reminded promptly of best practice in case recording in all agencies involved in this case and the reasons for compliance with the best practice should be integrated in supervision and training. Learning point 4The review noted that the communications between the schools and Children’s Services and within schools had not been effective. There was also a confusion about the option of Home Education for a child looked after. In view of the joint responsibilities and corporate parenting principles the collaborative work between schools, whether located in the local authority or the placement area, and the responsible Children’s Services must be improved to avoid the fragmentation and eventual loss of education that followed with all the moves. Recommendation 4The DSCB must examine ways to improve the systems for Children’s Services and all schools and educational units to work together to safeguard a child’s educational opportunities . A brief joint research exercise to follow a small number of children and young people through the current system to explore where improvements can be made should be undertaken and reported back to the DSCB.Learning point 5The review noted that there was a lack of urgency in responding to Young Person F when there were reports of drug running and gang involvement with increasing missing episodes. The question arose if a female young person would have been responded to more robustly. There was concern by the Review Panel that the vulnerability and risks to Young Person F were played down partly due to stereotypical notions of male young people.Recommendation 5Services involved with young people should reinforce the safeguarding of all children . The services involved in this case must examine their practice and be able to demonstrate to the DSCB that the provision of all services take in to account the needs of the child or young person regardless of gender.Learning point 6The Health assessments systems were of concern as outlined and the comprehensive internal agency review report set out the full details.Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 38Recommendation 6The Agency review report should be followed up by the DSCB in order to improve the current system and embed all improvements so far. The health agencies and local authority must report back to the DSCB about progress regularly.Learning point 7The review noted that on a number of occasions the practitioners, in the different agencies, including the Independent Reviewing Officers (IRO) raised concerns or misgivings about the services being provided and the plans proposed. There was no evidence in the records of any challenges to other practitioners or their managers , which is a common thread in Serious Case Reviews nationally. In relation to the role of the IROs this is of particular concern as it is a part of their responsibilities to follow up from Looked After Reviews. Recommendation 7The current multi-agency and internal agency policies and procedures for challenging and working together must be revisited. A multi-agency working group of front line practitioners and managers including IROs should be set up to explore the obstacles and how to overcome them . Any learning from this group should be disseminated across the agencies and reported back to the DSCB.Learning point 8The lack of a person independent of the direct services to Young Person F after the sudden loss of the Advisor left Young Person F without a support to follow him through the many moves . Although some of the practitioners remained consistent the role of a more independent advocate or advisor could have supported him more constructively. The overall impression from the records and agency reviews was that there was very little time, if any ,given to talk to Young Person F about his feelings about all that had happened since the move out of the foster placement and the run up to the breakdown. There was a lack of recognition that Young Person F had experienced a number of losses during this time; the hope for adoption, leaving the foster home and his sibling well as the younger children, changing schools and where he was living. Services were not responsive to the accumulation of events and their impact on Young Person F.Recommendation 8All looked after children should be provided with the option of an independent advisor or advocate, if declined this option should be repeated at later stages as circumstances can change. Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 39All practitioners must take in to account not only one event at a time but the accumulation of events and the impact on the child or young person and the services provided to them must be capable of responding flexibly. The DSCB must request a report from the local authority Children’s Services to explain the current services of support to looked after children in similar circumstances to Young Person F and to set out any actions that there may be to improve the current services. Birgitta Lundberg , Independent Lead Reviewer and Overview Report WriterNovember 2017Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 40Appendix 1: The full Terms of ReferenceTerms of Reference: Serious Case Review Young Person FThe Serious Case Review will be conducted in accordance with the requirements of the statutory guidance ‘Working Together to Safeguard Children’ (2015), Chapter 4, and the agreed DSCB multi-agency Safeguarding procedures. Young Person F was a young man subject of a Care order to Dudley Metropolitan Borough Council and had been since the age of 1. He was placed within a long term foster family until he was 14, when the placement broke down. In more recent years he had been placed in a number of different foster homes and lodgings. He was stabbed at a Cheltenham address on 2nd October 2016 and subsequently died the next morning 3rd October 2017. As a result the information was considered by the DSCB Serious Case Review Sub-Group and referred to the Independent Chair of DSCB on 9 December 2016 who agreed on 11 December 2016 that the criteria for a Serious Case Review were met under Regulation 5(2)a and b(i). In accordance with the DSCB Serious Incident Protocol each agency and organisation is required to secure their records and arrange for a formal chronology to be provided in relation to their involvement with the family. They will also need to identify an agency report author as soon as possible.This Serious Case Review has been commissioned and will be carried out by an Independent Serious Case Review Panel Chair and Report Author and a nominated panel of the DSCB. The Review will take into account the requirements of the generic terms of reference in Working Together to Safeguard Children 2015 and in order for lessons to be learnt will focus on the young man and his experiences as a Child Looked after with key elements to address: Examining how the Local Authority met its responsibilities as a Corporate Parent to Young Person F.Considering how Young Person F’s needs were met and how his views and wishes were heard? Examining the effectiveness of multiagency working to meet his needs by : Establishing whether there are lessons to be learnt from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children.Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 41Identifying clearly what those lessons are, how they will be acted on, and what is expected to change as a result.Whether any other action is needed now within any agency.Whether the analysis of the information and the consequent response by all agencies was appropriate.Whether appropriate casework and management decisions were made.Whether Care Plans and Placement plans were in place and reviewed as requiredWhether appropriate actions were taken with regard to referrals, reports of ‘missing’ episodes and subsequent placements.The scope of the reviewEach agency should provide a factual chronology of the decisions and actions that were taken in the agency. Each agency should analyse how the needs of Young Person F were met and how decisions were reached and actions taken Agency reports are asked to consider if there were any opportunities within this period for agencies to be alerted to concerns and if those opportunities were missed and why.Each agency’s report should focus on the practice of its own practitioners and managers and compliance with policies and procedures at the time, making recommendations regarding its own practice and/or internal policies and procedures that arise from the review. Each agency should draw out lessons to be learnt and make Recommendations about improvements that should be made.Each agency should draw up an Action Plan to demonstrate how their recommendations will be implemented in practice, by whom and when.The progress of any Actions arising from the review should be monitored and reported to the DSCB. The Independent Lead Reviewer will communicate with family members to support them to contribute to the review, if they wish to.Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 42Time scaleThe time frame to be covered by the review starts on January 1st 2013 up to the time of death. Any significant information that will assist the analysis and learning outside this time frame can be included after discussion with the Review Panel. Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 43Appendix 2: The Review processFollowing the decision to proceed with a Serious Case Review a Briefing and Scoping meeting was convened by the Dudley Safeguarding Children Board Business Unit at the end of January 2017 .The Review Panel and Terms of Reference were drawn up and agencies were requested to identify Agency Review ( IMR) authors . The Review Panel met five times between March and October 2017 ,which included half a day with the Agency Review authors in preparation for the Review. At a later stage the Agency Review authors participated together with the Review Panel in discussing their reports and findings. In early June 2017 the Independent Lead Reviewer /Overview Report Writer and the DSCB Business Unit Manager visited the older sibling and the family ,who had been the foster carers to Young Person F and his older sibling for nine years . They had been informed of the Review and its purpose by letters beforehand and had responded positively to the request to participate in the review process. Their contribution was helpful and provided a more rounded picture of Young Person F as a child and young person than had been available from case records in any agency. Arising from this visit an additional Agency Review Report was requested from the private fostering agency, which they had been part of. The Agency provided a report, which demonstrated that a considerable number of services had been provided to the foster carers and the placement during the period in scope. The intended Learning and Consultation day with the front line practitioners and managers directly involved in the services with Young Person F was reluctantly cancelled as the practitioners in question across the agencies were in the main no longer in the employment of the same agencies. This does reflect the turnover of practitioners in all agencies. However , some practitioners ,who had moved to other employment, were able to participate in their former agency internal reviews . This was helpful as their comments added to the case records which had been examined . They were able to reflect with the Reviewers on the recording practice and the pressure to deal with practical matters such as placement moves and court appointments . The overall learning for them was how with hindsight this had left very little room for a more rounded picture of Young Person F to be present in the records as well as any evidence that Young Person F had expressed any views or opinions himself about anything other than the moves.The Overview Report final draft will be presented first to the Sub Group Serious Case Reviews in November 2017 and subsequently as a final report to the full Dudley Safeguarding Children Board in late November 2017.Final Overview Report SCR YP F – November 2017Restricted – No information in this report may be used, copied or distributed without the prior permission of the DSCB. Page 44BibliographyPreventing gang and youth violence: spotting signals of risk and supporting children and young people an Overview edited by S. Waddell 2015. Home Officehttp://www.eif.org.uk/wp-content/uploads/2015/11/Final-R1-Overview-Preventing-Gang-Youth-Violence.pdfWhat works to prevent gang involvement, youth violence and crime. A rapid review of interventions delivered in the UK and abroad. 2015. Home Officehttps://www.suffolkscb.org.uk/assets/Safeguarding-Topics/Gangs/2016-05-10-Safeguarding-Children-and-Young-People-at-Risk-of-Gang-Involvement.doc.pdfMissing children: who cares? The police response to missing and absent children. March 2016 HMIChttps://www.justiceinspectorates.gov.uk/hmicfrs/publications/missing-children-who-cares/Statutory Guidance: Injunctions to Prevent Gang-Related Violence and Gang-Related Drug Dealing. March 2016 Home Officehttps://www.gov.uk/government/publications/injunctions-to-prevent-gang-related-violence-and-drug-dealingPreventing gang and youth violence: a review of risk and protective factors. 2015 Home Office.http://www.eif.org.uk/wp-content/uploads/2015/11/R4-Risk-and-protective-factors-final.pdfDudley Safeguarding Children Board child protection procedures.http://westmidlands.procedures.org.uk/page/contentsDudley Children’s Services procedures. http://dudleychildcare.proceduresonline.com/index.htmlChild sexual exploitation : Definition and a guide for practitioners, local leaders and decision makers working to protect children from child sexual exploitation. DfE February 2017https://www.gov.uk/government/publications/child-sexual-exploitation-definition-and-guide-for-practitioners |
NC046996 | Non-accidental injuries to a six-month-old baby girl in August 2013 who was admitted to hospital a fractured femur and bruises. Mother became seriously ill following the birth and parents struggled to care for Baby O. History of: missed health appointments and poor home conditions. Baby O and her older sister were removed to the care of their paternal grandmother in May 2013. Grandmother already cared for two children under four years and struggled to look after the two siblings. Following her hospital admission in August 2013, Baby O and her sister became subject of care proceedings. Paternal grandmother was convicted of child cruelty and neglect in 2015. Mother died in 2014 from complex medical condition. Maternal history of: domestic violence; depression, non-engagement with services; and missing own health appointments. Father had history of anxiety and depression. There was a delay in the initiation and completion of the serious case review. Issues identified include: pattern of neglectful parenting not consistently monitored; threshold for Children's Services intervention was high; some positive examples of escalation but also failure to escalate and challenge inaction by Children's Services; lack of clarity about legal and safeguarding issues related to placement with grandmother; mother's vulnerability and health condition and father's involvement not sufficiently shared or considered. Uses a systems methodology. Recommendations include: implementation of Graded Care Profile (GCP) for interagency use in cases of neglect; regular multi-agency workshops; audit of Section 47 enquiries. Highlights some examples of good practice by professionals, in keeping the children as the central focus.
| Title: Serious case review: Baby O: overview. LSCB: Sunderland Safeguarding Children Board Author: Amy Weir Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Serious Case Review Baby O (The SSCB has used a pseudonym to protect the identity of the child and family) Publication Date: 6 September 2016 2 Contents 1. Decision to hold a Serious Case Review (SCR) 3 2. Serious Case Review approach 3 3. Scope and Terms of Reference 5 4. Child’s voice and the Family’s Perspective 5 5. The family as known to agencies 7 6. Areas of Significant Practice (ASP) 10 ASP 1: Children’s Services: Response to Referrals from other Agencies ASP 2: Managerial Oversight and Supervision - Timeliness of completion, endorsement and sharing of assessments ASP 3: Lack of full consideration of history and the consideration of / role of fathers ASP 4: Context in which professionals were working ASP 5: Failure to challenge and escalate concerns ASP 6: Managerial Oversight and Supervision 7. Agency learning and actions taken 13 8. Findings 14 9. Summary 18 10. Recommendations 18 11. Appendices Appendix 1 The SCR Review Team including Reviewer biography 20 Appendix 2 Single Agency Learning 21 Appendix 3 How has the learning from this SCR improved practice? 25 Appendix 4 References 30 Appendix 5 Learning and Improvement Workshops – Impact 31 as described by staff attending 3 1 Decision to hold a Serious Case Review (SCR) 1.1 Baby O was born in February 2013. In August 2013, when she was 6 months old, she was taken to hospital where she was found to have bruising to her body and a transverse fracture of her left femur; these injuries were considered to be non-accidental and the Police and Children’s Services were informed. 1.2 The Case Review Sub-committee of Sunderland Safeguarding Children Board (SSCB) held a scoping meeting on 29th July 2014 and agreed that the circumstances surrounding the injuries to Baby O met the criteria for holding a Serious Case Review (SCR).1 The Independent Chair of SSCB endorsed the recommendation in August 2014. The reason for the delay in the initiation and completion of this SCR is an issue, which is being addressed by SSCB. The SSCB was not notified for some time of the injury to Baby O or of the circumstances in which this occurred. The completion of the review has been delayed by the significant volume of work in respect of other SCRs being undertaken by the Board. In addition, the review has had to wait on the conclusion of criminal proceedings in relation to Grandmother and which concluded in June 2015 and the inquest in respect of Mother. 1.3 Several other reviews relating to the death and injury of babies under the age of one year have occurred in Sunderland in recent years. The SSCB Chair therefore directed that this review should not only consider the learning and recommendation from previous SCRs but also should build on the findings and recommendations from other recent reviews. A major focus for the Board is to identify any improvements in service delivery which will prevent future such injuries and deaths. 2 The approach we used 2.1 It was agreed that the review should be undertaken using a ‘systems methodology’, an approach that recognises that the actions and decisions of practitioners occur through a chain of events and the interaction of a number of factors, many of which are beyond the control of the individuals involved. This is the method recommended in Working Together 2013 and 2015. 2.2 This review therefore was undertaken using an approach that provides a theory and method for better understanding why good and poor practice occurs, so effective supports and solutions can be more easily identified. 2.3 Senior managers from key agencies who had worked with the family or were working with the family at the time of Baby O’s injuries were asked to join a Review Team which met on four occasions during the SCR process. 1Regulation 5 of the Local Safeguarding Children Boards (SSCB) Regulations 2006 requires SSCBs to undertake reviews of serious cases in specified circumstances and to ‘advise the Authority and their Board partners on lessons to be learned’. A SCR is one where: ‘a) abuse or neglect of a Child is known or suspected: and b) either – (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the Authority, their Board partners or other relevant persons have worked together to safeguard the child.’ 4 2.4 Agencies represented on the Review Team were as follows: Amy Weir Lead Reviewer Jan Grey Chair of SCR Panel/Second Reviewer Lynne Thomas SSCB Business Manager Head of Safeguarding Sunderland CCG Lead Nurse Safeguarding South Tyneside NHS Foundation Trust Education Safeguarding Team Manager Sunderland City Council SSCB Legal Representative Sunderland City Council Acting Detective Inspector Northumbria Police Named Nurse City Hospitals Sunderland Head of Safeguarding Sunderland People Directorate2 2.5 Each member of that team was asked to identify the frontline practitioners from their agency who were known to, or had worked with, the family of Baby O. These practitioners met to discuss their experience of the case. 2.6 The Practitioner’s Group consisted of managers and practitioners who had been directly involved with the case. 2.7 The Lead Reviewer was commissioned to carry out this review in October 2014. Within the first few months of the review, the SCR process, the role of the Lead Reviewer and Review Chair and the functions of the Review Team and Practitioner Group were shared and clarified. 2.8 The methodology adopted for the review and the opportunity to be an integral part of a multi-agency review process was still fairly new to some of the professionals involved. Whilst some reservations were apparent at the outset of the review, there was general enthusiasm about the opportunity it afforded for identifying and understanding factors that influenced the nature and quality of their work with this and other families. It is clear from subsequent reporting that all those who participated did regard the opportunity to contribute more directly as beneficial; it provided them with good learning about their own part as well as that of others in the case. 2.9 In this review, there were no individual conversations with practitioners. However, two meetings were held jointly with the practitioners who had been involved. The notes from these conversations together with key documents were the key documents for consideration within the review. 2.10 Further information about the function of the SCR Review Team and the roles and responsibilities of key groups can be found in Appendix 1 and Appendix 2. Comments on the methodological limitations of the SCR model used are attached in Appendix 3. 2.11 The formatting designed by a colleague, Linda Richardson, for previous Sunderland SCB SCRs has been customised to report this review. 2 Previously Children’s Services and remains the term used in this report. 5 3 Scope and Terms of Reference 3.1 Taking a systems approach encourages reviewers to begin with an open enquiry rather than a pre-determined set of questions from terms of reference. This helps the issues which arise to drive the key issues to be explored as opposed to the preconceptions of managers or a review team. Key lines of inquiry for this review quickly emerged around: • Quality and consistency of multi-agency working • Management of concerns about neglect • Impact of organisational change – particularly in Children’s Services • Non-compliance, avoidance and lack of parental engagement • Mother’s neglect of her own health and failure to take medical advice • Involvement of Father and his relationship with Mother 3.2 There have been other parallel processes underway during the course of this review. Paternal Grandmother in whose care Baby O was at the time of the injuries was convicted of child cruelty/neglect in 2015. 3.3 The Local Authority instigated care proceedings in relation to Baby O and her sister. They have subsequently been the subject of care orders and plans have been made for them to live in a new family. 3.4 This review looks at events that took place between 1st April 2011 – following an initial assessment which led to Early Help intervention and 30th September 2013 concluding with Baby O’s serious injury. 4 Child’s Voice and The Family’s Perspective The Child 4.1 Baby O was the second child of her Parents. Her Parents struggled to care for her during the three months she was living with them. Baby O’s early experience was difficult. Although they made an effort at times they were not providing consistent safe care. Her Mother became seriously ill a few weeks after Baby O’s birth and this affected her ability to care for her children not least because she required regular lifesaving medical treatment. In March 2013, Baby O’s Mother had to be admitted to hospital as an emergency and the children spent a brief period with their Paternal Grandmother. 4.2 Most of the child health appointments for Baby O were missed or cancelled by the family, her immunisations were not up to date and Baby O was living in poor home conditions for much of the time. After Baby O was left at home alone in May 2013, she and her elder Sister were removed to the care of their Paternal Grandmother. 4.3 The children were living with Paternal Grandmother from May to August 2013. Grandmother struggled to look after the children – not least because there were already two other grand-children under four years in the household for whom she was responsible 6 as a Special Guardian3. Grandmother seemed to have found Baby O particularly difficult. Baby O was described as crying all the time both day and night. The Health Visitor recorded that Baby O was not smiling and not happy or content. 4.4 In mid-August 2013, Baby O, aged 6 months, suffered a severe transverse fracture to her leg. Paternal Grandmother was prosecuted in relation to this injury. At hospital, Baby O was also found to have bruising on her face, lower back and legs. Clearly, Baby O’s experience was stressful and difficult during these few months. 4.5 Baby O and her Sister moved to foster carers after this. When seen a month later by the Health Visitor, Baby O was described as flourishing, interactive and smiling and she was playing happily with her Sister. With consistent, good care, Baby O was clearly settled and developing well. After her neglected early start and experience of physical abuse, Baby O’s experience has become more positive and her needs are being met. The Family 4.6 Mother seems to have had a series of difficult experiences in her life, including being subjected to domestic violence and suffering depression. Her own Mother died in 2009 but she kept in contact with her Father. Her relationship with Baby O’s Father included a period of separation for over a year when he asked her to leave their home. 4.7 Mother did not engage with much of the professional help and support which was offered to her for the children. She smoked throughout her pregnancies. She was largely unsupported and her care of the children was inconsistent and did not meet their needs fully. 4.8 A few months after Baby O’s birth, Mother had two black eyes which she explained away as having been caused by the baby. After Baby O’s birth, Mother was diagnosed with a life threatening health issue which undoubtedly affected her capacity to look after the children. She did not always accept treatment and missed essential medical treatment and several other appointments. 4.9 In September 2013, she was rushed to hospital with very serious injuries which required emergency surgery. She denied that these had been inflicted on her and she and her partner advised that she had fallen down the stairs. A medical expert reported shortly after her death that the injuries were not compatible with the explanation given and were more likely to have been as a result of a serious assault. Her condition remained serious and she continued not to follow medical advice consistently or accept the treatment which she needed. After further complications arising from her medical condition Mother died in 2014 eight months later. The subsequent Inquest found nothing untoward. 4.10 She appears not to have been able to confide in professionals and is likely to have been isolated. Mother had some contact with family in London but remained in Sunderland. When Baby O’s Sister was born, Mother initially responded to the support provided by 3 A special guardianship order is an order appointing one or more individuals to be a child's 'special guardian'. It is a private law order made under the Children Act 1989 and is intended for those children who cannot live with their birth parents and who would benefit from a legally secure placement. 7 professionals. However, after her separation from the Father, mother became increasingly difficult to engage which resulted in the children not receiving the health care they needed. Professionals sought to gain her confidence and to provide her with support but she avoided health appointments and did not fully engage with professionals. When spoken to she seemed to be coherent, cooperative and stated she was coping – even when she was really ill. 4.11 Unfortunately, it has not been possible to speak to Mother for this Serious Case Review. 4.12 Father saw his GP regularly and is known to have experienced anxiety and depression following the death of a close family member. He received medical support during this time. 4.13 Father attended the antenatal booking appointment for Victoria but not for Baby O. He had very little contact with the professionals who were involved with Baby O. Father and Mother both took Victoria to nursery school and he was involved to some degree with the care of the children. 4.14 It is difficult to understand what Father’s views and experience are from the records as he was not seen very often. Father has declined to be part of this review and without his involvement it has been difficult to understand the wider picture. There are many aspects of what was happening within the family which remain unclear. 4.15 Paternal Grandmother was increasingly involved with the family after the birth of Baby O and after Mother became so ill. There was a brief period of her caring for the children and then the longer period from May to August 2013. 4.16 The basic care provided to the children by Paternal Grandmother was good but it is clear – as Grandmother indicated to some professionals – that she struggled to cope with looking after four children under four years. There were two other grandchildren under five years also living in the household. If more effective, accurate background checks had been completed, the children may not have been placed with her. She was convicted of child cruelty/neglect in June 2015. Paternal Grandmother has also not been part of this review. 5 The Family as known to Agencies 5.1 The Family4 Mother - LO 24 years (died in 2014) Father - MO 25 years Sibling - Victoria 6 years Paternal Grandmother 44 years Baby O 2 years 4Names and some family details have been changed to preserve anonymity. The ages given are the ages at the time of Baby O’s injuries. 8 The SCR covers the period 1st April 2011 to 30th September 2013. April 2011 to Birth of Baby O in February 2013 5.2 LO and MO appear to have been in a relationship since 2008. Early in their relationship LO had a miscarriage at 20 weeks – both she and MO were clearly distressed about this. In 2009, they had Victoria and initially managed well with her care. 5.3 Victoria missed her nine-month development check and her immunisations. At the beginning of 2011, the Health Visitor was having difficulty in seeing Victoria and there was a concern that she had some developmental delay; there were fifteen missed appointments. When Victoria was seen, the house was damp and smelt of smoke; Victoria had nappy rash and was not able to walk unaided. A referral was made to Children’s Services in March 2011, which resulted in an initial assessment being completed by a Social Worker and a CAF5 was recommended. 5.4 Father decided that the couple should separate and LO left with the baby in April 2011. Mother and Victoria were found temporary housing LO was rehoused in May 2011. The Health Visitor made a referral to the Paediatrician as there were some concerns about Victoria’s development. A Family Support Worker started working with the family and a CAF was completed. Several Team around the Child/Family meetings were held from May to December 2011. Despite efforts to engage LO she did not respond and missed many appointments. The Paediatrician saw Victoria in Summer 2011 when she found her to be developmentally delayed and under-stimulated; Victoria was also not registered with a GP. 5.5 LO was now in a new home but there were no carpets and there was a great deal of rubbish around. Due to concerns around the home conditions, Victoria’s development and Mother not working with the plan, the Health Visitor made another referral to Children’s Services in November 2011. An Initial Assessment was completed with some delay because of difficulties in seeing Mother and Victoria. In early January 2012, the Health Visitor raised more concerns and it was agreed this should be a Child in Need6 (CIN) case. The case was not allocated till February and a multi-agency CIN meeting took place in March 2012. The Social Worker was then off sick and limited work was done. The Health Visitor was unable to get access to the family until May 2012 when Mother said she was thinking of getting back together with Father. 5.6 There was no CIN meeting as planned in August 2012. Victoria was not taken to a speech and language appointment. A new Social Worker was allocated in September 2012. By this point, LO and MO were reconciled, but living apart and LO was 20 weeks pregnant with Baby O. The Social Worker visited in October 2012 and the Health Visitor saw some improvement in November 2012 although Mother had missed a Midwife appointment. 5 The Common Assessment Framework (CAF) is a process for gathering and recording information about a child for whom a practitioner has concerns in a standard format, identifying the needs of the child and how the needs can be met. 6 A child in need is defined under the Children Act 1989 as a child who is unlikely to reach. or maintain a satisfactory level of health or development, or their health or development. will be significantly impaired, without the provision of services, or the child is disabled. 9 5.7 In January 2013, the family moved and LO and MO were living together again. Baby O was born in February 2013. Birth of Baby O in February 2013 to 30th September 2013. 5.8 Both the Midwives and the Health Visitor struggled to get access to Mother and Baby O. In mid-March 2013, LO was rushed to hospital in a serious condition. The Health Visitor was very concerned about the family and made a referral to Children’s Services. Paternal Grandmother then looked after the children until early April. 5.9 During April 2013, the family continued to miss appointments. The Health Visitor made a further referral to Children’s Services. Towards the end of April, the school for Victoria reported that Mother, had black eyes. The Social Worker visited and accepted Mother’s explanation that this injury had been caused by the baby flipping her head forward; no examination of the baby was undertaken and this explanation was not sufficiently challenged. 5.10 At the beginning of May 2013 the Health Visitor asked for a Strategy Meeting; and this was held two days later. It was agreed that a Section 47 child protection enquiry should be undertaken with a view to holding an Initial Child Protection Conference. Victoria’s school became concerned that both Parents were bringing Victoria to school but without Baby O. They contacted Children’s Services. In late May, an unannounced social work visit was carried out and when entry could not be achieved, the Police were called. Baby O was found at home alone strapped in her buggy. Police Protection was taken and the Parents were arrested and cautioned. 5.11 The Parents agreed to Section 20 Accommodation and to the children going to stay with Paternal Grandmother. Thereafter the legal status of the children was unclear. In June, a Placement Panel 7 did not agree to an assessment being undertaken of Paternal Grandmother as a connected person and deferred making a decision. This left the practitioners and their manager in an unclear position. The LAC Review8 which had been organised was cancelled because it was now being said that the children were not in care. Between May and August 2013, this remained the position. A few days before Baby O’s injury a Social Worker visited Grandmother and it was agreed the children would stay there until October and Paternal Grandmother would continue to be paid for caring for them through Section 179 money. 5.12 From the first week the children were placed, Paternal Grandmother repeatedly told health professionals and the school that she could not cope with caring for four children. Health professionals and the school informed Children’s Services. Social Workers were not visiting regularly but there were telephone calls with Paternal Grandmother when she said she 7 It is the responsibility of Placement Panels to make timely decisions about the contracting and finance of the placements of children and young people who need to become looked after, and once they are looked after, at key transition stages. 8 A looked-after child (LAC) review is a regular meeting to review the child’s care plan. 9 Children's Services use Section 17 (Children Act 1989) money in order to provide urgent assistance to families, where the child is deemed to be a Child in Need. 10 could cope. There is evidence from Paternal Grandmother stating that she struggled to care for Baby O. 5.13 In August 2013, Paternal Grandmother called the Ambulance Service on 111 saying that Baby O had a floppy leg. She was taken to hospital where a severe transverse fracture and multiple bruising on her body were found. Grandmother denied causing these injuries but she was convicted in May 2015 of child cruelty and neglect as a result of these injuries. 5.14 Baby O and her Sister plus the two other grandchildren living there were taken into care and moved to foster carers. Within weeks Baby O was settled and doing well. 5.15 In September 2013, LO was admitted to hospital with multiple serious injuries. She and her Partner stated that she had fallen down the stairs and denied any violence. She never fully recovered from her condition and failed to accept medical advice or take up the treatment recommended. She died in 2014 from her complex serious medical condition. 6 Areas of Significant Practice (ASP) 6.1 This section looks back at the actions and decisions of professionals working with Baby O’s family and explores why these professionals acted as they did. The ‘why’ questions are important as they helped the Review Team understand what systems were in place at that time to promote good practice and what should have been happening. In this case, there are several examples of shortcomings and gaps in practice. A key factor of a systems review is also to consider whether any system vulnerabilities are still present and how these can be changed. 6.2 From studying key documents and listening to the views and experiences of front line practitioners involved in this SCR process, the Review Team identified five areas of significant practice. These are listed below and are explained in more detail in later section • ASP 1: The pattern of neglectful parenting was not tracked or consistently monitored. • ASP 2: The threshold for Children’s Services intervention was high and, when there was intervention, the practice with the family lacked effective reflection and management oversight. • ASP 3: Context in which professionals were working – There was a failure to escalate and challenge effectively inaction by Children’s Services: Multi-agency working and communication did not effectively protect Baby O. • ASP 4: Children’s Services response from May 2013 to August 2013 was not clear and incoherent and left Baby O and her Sister unprotected. • ASP 5: Mother’s vulnerability and life-threatening chronic ill-health and Father’s involvement was not sufficiently shared or considered in relation to her capacity to care for her children. 11 6.3 ASP 1: The pattern of neglectful parenting was not tracked or consistently monitored Baby O’s Parents clearly wanted their children but they struggled to provide consistent physical and emotional care to their children. This manifested itself in their avoidance of interactions with health professionals and others and the failure to ensure that Victoria, in particular, attended the health appointments which had been made for her. Even when action was promised, it did not follow and Victoria’s development suffered as a result. Baby O was left alone at home though it is clear that both Father and Mother knew that this was not appropriate. 6.3.1 At times the Parents were more cooperative and there were slight improvements. This partial compliance made it more difficult to see the whole pattern. There was no tool in place to help all practitioners track and monitor the patterns of behaviour and actions over time and the impact of what occurred on the children. 6.3.2 Brandon et al10 consider the importance of analysing rather than simply identifying what is known about a family’s history and warns without such an analysis there is a risk of falling into the trap of what is referred to as the ‘start again syndrome’. 6.3.3 Each time there was a difficulty or relapse this was seen as something additional by Children’s Services rather than as a pattern. As the Health Visitor did not have a tool to record the pattern it was not easy to evidence what had been happening over years and months. There is evidence that each report/referral to Children’s Services was seen in isolation from past concerns. 6.4 ASP 2: The threshold for Children’s Services intervention was very high and, when there was intervention, the practice with the family lacked effective reflection and management oversight. As has been identified in previous SCRs, practitioners in the area were clearly working under a great deal of pressure, both in respect of competing demands for time, and the fact that thresholds for intervention were high. This pressure was particularly felt in Children’s Services. The practitioners and managers involved in this review process spoke about the impact of both, commenting that high caseloads could easily encourage professionals to focus more on their own individual responsibilities because multi-agency working can appear to take more time and maintenance. 6.4.1 When concerns first arose in 2011 about the parenting being provided to Victoria, Baby O’s Sister, it was suggested that early help and referral to the family support service with a CAF and regular meetings should be put in place. This was a reasonable response given that Mother appeared to be willing to cooperate and that she seemed to have the capacity to understand the gaps in her parenting. Unfortunately, she did not genuinely cooperate and there was no marked improvement. 10 Understanding Serious Case Reviews and their Impact – A biennial Analysis of Serious Case Reviews 2005-2007. 12 6.4.2 The second referral to Children’s Services in November 2011 eventually resulted in a Child in Need response but only after the Health Visitor continued to chase concerns. Initially, it seemed that the case might be closed. There was delay partly caused by Mother but also because of staff shortages in Children’s Services. Practitioners, who contributed to this review and especially colleagues in health settings, shared this view and concerns about thresholds. It appears that the neglect concerns especially about the failed uptake of health checks may not have been seen as such an urgent concern by Children’s Services. 6.5 ASP 3: Context in which professionals were working - There was a failure to escalate and challenge effectively inaction by Children’s Services: Multi-agency working and communication did not effectively protect Baby O. There were many positive examples of escalation in this case. For example the Health Visitor requested a Strategy Meeting in May 2013. However, there were long periods of inaction and delay without sufficient challenge from partner agencies. When Baby O’s Mother became acutely ill in 2013, there was some communication with the GP about her condition but not all of the professionals involved seemed aware of the need to consider and support her parenting and to safeguard the children. 6.6 ASP 4: Children’s Services response from May 2013 to August 2013 was not clear and incoherent and left Baby O and her Sister unprotected. After the decision was made in May 2013 to follow up the Police Protection by placing Baby O and her Sister with Paternal Grandmother, there was a lack of clarity about the legal underpinning of this arrangement. There was no formal plan in place for the children to ensure that they were formally safeguarded. Although a strategy meeting had been held in May 2013 and a Section 47 enquiry commenced with a view to holding an Initial Child Protection Conference (ICPC)11, there is no further mention of this after the children left their parents’ care. 6.6.1 Several professionals including the Social Worker and his Manager assumed that the children were accommodated under Section 20 Children Act 1989 and placed with Paternal Grandmother as a Connected Person12. However, at a Panel in June this was not confirmed and the decision to assess Grandmother was deferred. It was recorded that the children were not accommodated under Section 2013 and that the placement was being supported under Section 1714. 11 Initial Child Protection Conferences are convened by Children’s Services following an enquiry under Section 47 of the Children Act 1989 which indicates that a decision has to be made about further action under the Safeguarding Children Procedures. 12 A Connected Person is defined as "A relative, friend or other person connected with a child”. 13 Under Section 20 of the Children Act 1989, children may be accommodated by the local authority if they have no parent or are lost or abandoned or where their parents are not able to provide them with suitable accommodation and agree to the child being accommodated. A child who is accommodated under Section 20 becomes a Looked after Child. 14 Under Section 17(1) of the Children Act 1989, local authorities have a general duty to safeguard and promote the welfare of children within their area who are In Need; and so far as is consistent with that duty, to promote the 13 6.6.2 The Section 47 enquiry was not completed and no risk or parenting assessment was carried out in relation to the placement with Grandparents – even though four children under four years were placed there. After the Panel in June, no action was taken for some time. 6.6.3 Although Grandmother’s complaints to other professionals about her stress in caring for the children were passed on to Children’s Services, the ‘placement’ continued and no risk assessment was completed. When Grandmother stated that she had had no financial assistance, a Section 17 payment was made to her in July. It does not appear that the children were visited regularly in the placement by the Social Worker. Just a few days before the injury to Baby O, a Social Worker visited and apparently asked Grandmother to keep the children until October 2013. 6.7 ASP 5: Mother’s vulnerability and life-threatening chronic ill-health and Father’s involvement was not sufficiently shared or considered in relation to her capacity to care for her children. When Mother’s health deteriorated during 2013, she was under hospital care but neither her GP nor her Consultant seemed to have communicated with Children’s Services or other health colleagues about the support she needed or the impact on her ability to look after her children. Her non-compliance with medical advice and non-acceptance of required treatment put her own life at risk and prevented her recovering sufficiently to be able to care for the children. Throughout the history of this case, Father’s involvement was not fully considered and he was rarely seen or sought out. 7 Agency learning and actions taken 7.1 All the agencies involved in this SCR worked with the practitioners involved from their service to produce a Single Agency Learning Report (see Appendix 2). The information contained in these reports highlights that the individuals who contributed to the process either as a member of the Review Team or the Practitioners Group were able to identify learning as well as a greater understanding of the circumstances of other professionals and agencies. 7.2 Not all of the reports identified in detail, how this learning would be transferred to wider practice within individual agencies. Where necessary, the Lead Reviewers have identified or clarified additional actions that should be undertaken and which should be monitored by SSCB. 7.3 The pathway for interventions in relation to services for Baby O was determined by a range of key points and decisions. The significant issues are identified below and are linked to previous case reviews in Sunderland. upbringing of such children by their families, by providing a range and level of services appropriate to those children’s needs. 14 8 The Findings 8.1 The Review Team identified eight findings, which helped the team to understand why some practices happened in the way they did. Each of the findings is explained with a rationale, an indication of its impact on the wider systems in Sunderland and a series of questions designed to enable the Board to strengthen safeguarding by addressing the root causes underpinning the finding. 8.2 The findings fall into different typologies of systems issues, with a clear link between each of the findings and each of the typologies. This is not unusual, as it would be expected to find links between findings when adopting a whole systems approach. There are five findings for the Board to consider, these are covered within: Management of Systems 1. Managerial oversight and effective decision-making is central to supporting critical thinking, challenge and good assessments in multi-agency work and this was not evident in some of the practice in this review. 2. Few interagency meetings were held in this case and this led to a lack of clarity about what action was being taken to challenge the avoidant behaviour of the Parents and the level of care provided to the children. 3. The legal status of the children whilst in the care of their Grandparents was not resolved for many months and nor were they protected through a child protection plan. Professional-Family interaction 4. In this case the co-operation of Parents was very variable and clouded the intervention. Generally the family did not comply with the plans made and therefore did not achieve the progress required to care safely for the children. 5. There was tendency for the focus to be on the adults rather than the children when Early Help and Children’s Services were involved with the family. This resulted in a lack of full appreciation of the impact of neglectful care on the children. Multi-Agency work 6. There were some good examples of joint working and information sharing between the health professionals involved but there was a lack of robust multi-agency collaboration from Children’s Services. The school acted promptly to identify that Baby O was being left at home alone. At the same time, when Children’s Services was involved with the family, the delay in action and lack of challenge to the Parents was too readily accepted by, and not sufficiently challenged by, other professionals. Use of Tools 7. In this case, various assessment tools were used – the midwifery Adult Vulnerability tool, Initial Assessments in Children’s Services but these were not widely shared. A Core Assessment was not completed in a timely way even when a S47 enquiry was required in May 2013. This meant there was insufficient reflection and consideration. 15 8. There is no multi-agency tool for assessing and tracking neglect in place – such as the Graded Care Profile. Finding 1 _________ _____ Management of cases of neglect There was a lack of an effective system and collaborative working and a tool for tracking patterns of neglect over time. The pattern of neglectful parenting was not tracked or consistently monitored. In this case there was evidence of managerial oversight and challenge in some key agencies with specialist safeguarding advice and support in some cases. However, within Children’s Services there were some delays and a gap in allocating and managing the case. There was no multi-agency tool for identifying, tracking and monitoring neglectful care. This could also have served as an established means of establishing together whether the threshold for Children’s Services intervention had been reached. There will always be competing priorities and limited resources will always impact on service delivery. It is therefore important for there to be shared ways of considering risks together and the required actions. Given that much of the neglect concern related to poor uptake of health care and no engagement with health professional, it was important for there to be a shared framework across agencies for assessing the issues and the risks for the children. Finding 2 There was a lack of robust multi-agency collaboration from Children’s Services. There were some good examples of joint working and information sharing between the health professionals involved but there was a lack of robust multi-agency collaboration from Children’s Services. As the case progressed beyond Early Help, there was insufficient multi-agency coordination and planning to address the needs of the children. Child in Need meeting and reviews were not held as required. This left professionals unclear about what was happening and resulted in delay and a lack of intervention with the family and the need for other professionals to make contact with Children’s Services again and again. There was a high turnover of staff in Children’s Services and significant organisational change within Children’s Services and, in this context, there was considerable difficulty for the local authority. 16 Finding 3 Fathers and Extended Family Understanding the presence and role of males in families and the circumstances and history of the extended family is critical to understanding family functioning and assessing risk How was this manifest in this review? SCRs have repeatedly highlighted failures by Social Workers to engage Fathers or significant males effectively in the family and this was clearly evident in this review. In this case it was also important to understand Father’s extended family. The professionals focused mainly on Mother which was clearly appropriate when she was separated from Father but not throughout. From the beginning of 2013, they were living together again but there is still limited information about him and any risks he may have posed. This was particularly crucial when Mother’s health deteriorated and he was necessarily providing more care to the children. This does not seem to have been considered at all even to look at whether he needed additional support to cope. The involvement of Father’s family was not fully understood nor assessed. Paternal Grandmother was clearly very influential in this case. We know now that she made various comments to professionals about LO even before the children were placed with her in May 2013. There was insufficient scrutiny and risk assessment of her and her partner when the children were placed with her. The Police check was inaccurate because the family did not provide full information. Significant information about her background and that of Step Grandfather was not seen or considered. Even when reservations about the placement were voiced, nothing was done to expedite the need to find alternative carers. Finding 4 Working with non-compliant Families – disguised compliance15 Working with this family was complex because Mother - despite her vulnerability – avoided professionals and consistently failed to take the children to health appointments or to attend to her own medical needs. Occasionally, she would cooperate and appear to be willing to change. Several SCRs and the Biennial Reviews have raised concern about ‘resistant’ families who do not change despite intervention. C4EO’s research described these resistant behaviours as follows: • Ambivalence: not sure of need to change or when families are ‘stuck’ at a certain point • Denial/avoidance: not willing to acknowledge abuse and/or purposely avoid practitioners 15 'Disguised compliance' involves a parent or carer giving the appearance of co-operating with child welfare agencies to avoid raising suspicions, to allay professional concerns and ultimately to diffuse professional intervention. 17 • Unresponsiveness: no demonstrable improvements in a timely manner (despite compliance) In addition, in this case, Mother’s own very low self-esteem and sense of worth appears to have led her to following self-destructive behaviours. Finding 5 System failure to plan for and protect Baby O and her Sister. Planning for Baby O (and her Sister) May to August 2013 was flawed and drifted leaving the children insufficiently safeguarded. The legal status of the children was not resolved when they were placed with Paternal Grandmother. In the circumstances in which the children were removed and placed by Children’s Services, a Regulation 24 Assessment16 and management authorisation was not completed. Not all the checks required were successfully completed - the Police check was not accurate because Grandmother did not disclose all her names - and a Connected Persons’ Assessment was not completed. It is possible that they were seeking to mislead with giving incorrect information because they knew that information of concern would have been found. The Section 47 enquiry was not completed and an Initial Child Protection Conference was not held. There was no formal interagency plan in place. There were care proceedings under way but this did not provide an interagency framework for protecting and planning for the children. The Practitioners involved in the Review felt that they had not been provided with the right legal advice or training about Regulation 24 placements. 16 Regulation 24 of the Care Planning, Placement and Review (England) Regulations 2010, which became effective from 1 April 2011, sets out the process for placing Looked After Children with relatives or friends or (Connected Persons) where the carers are not already approved as foster carers. 18 9. Summary The serious injuries suffered by Baby O could have been prevented if there had been more rigorous and timely planning for both Baby O and her Sister, Victoria, and, if the warnings given by other professionals had been heeded. The placement of Baby O and her Sister with Paternal Grandmother was not thoroughly considered by Children’s Services. Errors were made by the local child protection system in this case in checking out the Grandparents’ backgrounds. It appears that Grandmother was providing some misleading information. The legal basis of this ‘placement’ and the decision-making were not clear. The continuing need to have in place a plan to safeguard the children was not managed with neither Child Protection or Looked after Children plans being in place to ensure regular monitoring and visits. Although Care Proceedings had been initiated, a clear plan with timescales for the children was not in place with the sole initial consideration being that of rehabilitation to Father and Mother. Even when several agencies told Children’s Services that Paternal Grandmother said on many occasions that she was not coping with looking after four under four year olds, this was questioned and separate conversations were held with Grandmother. There was no assessment of the needs of all four children. The crisis which led to Baby O suffering such a serious injury as well as other distress was predictable given the strong indications given repeatedly by other professionals of concern about emotional wellbeing. However, it could not be predicted that the crisis would result in Baby O having such a serious injury. There is a great deal of useful learning from this Review for all the agencies to consider and to absorb. There are some areas for improving practice but there was also some good and focused practice by professionals – particularly the Health Visitors – keeping the children as the central focus. Cases of neglect and parents whose compliance and co-operation are unreliable pose particular challenges to multi-agency working and systemic joint approach needs to be set up to overcome the difficulties identified in this case. 10. Recommendations These recommendations are provided to the SSCB to consider. They have emerged from the findings of this Review as areas for continuing and further focus. 10.1 SSCB to implement the Graded Care Profile (GCP) for interagency use in cases of neglect. This should be completed urgently within the next 6 months. The GCP has recently been positively evaluated by the NSPCC. A workshop with external facilitation should be held within 3 months to discuss and plan. 19 10.2 As in the Baby P SCR, SSCB to promote effective joint working through designing and developing regular multi-agency workshops and other opportunities for front-line practitioners and managers to share issues and discuss priorities across local services. 10.3 SSCB to consider carrying out an audit of Section 47 enquiries to test whether cases are proceeding to Initial Child Protection Conference when appropriate. 20 Appendix 1 The Serious Case Review (SCR) Review Team Function To conduct, on behalf of the SSCB, the Serious Case Review, ensuring timely progression and taking responsibility for the production of the final SCR report presented to the Board at an agreed date. One or two lead reviewers, one of whom must be independent of any agency represented on the Review Team, will lead the work of the SCR Review Team. Membership of the SCR Review Team Membership will usually be senior representatives from the various agencies working with or known to the family. They must not have had any direct contact with the family or children or have held decision-making or supervisory role in relation to the frontline practitioners working with the family. Members of this Team will be expected to have the authority to hold their own agency to account to ensure that required reports/documents are made available and key staff supported to take an active role in the SCR process. Responsibilities of members of the Review Team • Represent their agency • Understand the broad details of the case under review • Ensure that a very broad outline chronology is undertaken • Identify key frontline practitioners who were known to the family • Undertake tasks related to data collection and analysis • Take ownership of the contents of the final report in presenting findings to the SSCB Rationale: This SCR Review Team may well involve many of the same managers involved in the SSCB Learning and Improvement in Practice sub-committee, it’s function and purpose however, are different in that its work is solely to lead and work on a specific SCR. Members need to be clear about their responsibilities, as this model requires far greater involvement from senior managers than the previous prescriptive IMR type methodology. 21 Appendix 2 Single Agency Learning 1. City Hospitals Sunderland (CHS) Learning Points and Actions taken: • The Midwife failed to follow up on the ‘housing issue’ as disclosed on the ante-natal VAP and the past pregnancy VAPs were not taken into consideration. The Midwife reflects that this should have been followed through and has identified that the VAP needs to be improved to allow more free text. Improved communication with the HV would have identified the concerns sooner • Where there are no risks identified on the VAP and the GP or HV has information to the contrary, direct communication between themselves and the Midwife should take place • The maternity and acute care is well documented from a clinical perspective, however the observed social factors of the family such as home conditions, presentation of the parents and children, interactions between parents and children also needs to be documented. Action: Full social history to include full name of the males within the child’s life, who attends with patient at all CHSFT attendances and the reason for failure to attend outpatient appointments needs to be documented 2. South Tyneside NHS Foundation Trust (STNHSFT) Learning Points and Action taken: • The implications upon Baby O of frequent HV ‘no access’ visits and failed to attend health appointments remained unchallenged • The emerging pattern over time of Neglect of Baby O’s health and social care needs were not recognised • The use of the significant event form to support early recognition of risks to children was not utilised to its full potential • The impact upon LO’s parenting capacity and caring responsibilities would appear not to have been considered by health professionals • Staff will be reminded of the importance of escalating concerns to or seeking advice from the Safeguarding Team at STNHSFT • Supervision and actions recommended by STNHSFT Safeguarding Team were never re-evaluated or fed back to enable additional action to be provided • Communication between GP practice and Health Visitors regarding vulnerable families, failed access and FTA’s requires review • The contribution health professionals can make to Multi-agency working was felt not to be recognised, leaving assessments, decision making predominantly as single agency decisions 22 The actions being taken by STNHSFT in relation to these points is included within an action plan for all health agencies 3. Learning for General Practitioners Learning Points and Action taken: • Communication and information sharing - There were missed opportunities for the GP to share information with Children’s Services particularly concerning mother’s non-compliance with treatment for a life threatening illness and the impact of this on her ability to effectively parent and meet the health needs of her children; however there was no evidence that the SW contacted the GP for information on Mother’s health needs and compliance with treatment There was a lack of analysis of the large volume of information from the Renal Consultant and safeguarding information from the Health Visitor. GPs need to understand their responsibility to look at the information being shared by other clinicians or professionals and consider this in the context of family functioning • Hidden/Invisible Fathers - When GPs are seeing male adults and they are aware of mental health problems, domestic violence and substance misuse they should enquire if the patient has children and contact or care of children in order to assess risk; indeed it could be argued that this question should be included when taking a history from any male to ensure their parenting/caring responsibilities are documented • Front Line factors - There was a lack of professional curiosity in relation to Mother’s life threatening condition, her non-compliance with treatment, its impact on parenting and exploring the possibility of both possible domestic abuse/control or post-natal depression. Given the life threatening condition and non-compliance of treatment consideration could have been given to undertake a home visit • Mother was not considered as a potential vulnerable adult. Given that she had recently given birth, had a life threatening illness and there was reference to her having a black eye in April 2013 (2 months post-natal) which indicated she may have been a victim of domestic violence, she could have been assessed for post-natal depression had a home visit been undertaken • Criteria for discussing families/children at Practice Multi-Disciplinary Team Meetings (MDT) - There was no information in the GP records to indicate that this family was discussed at the practice MDT though the Practice Manager confirmed the family were discussed at MDT on 22/05/13 and 24/07/13 • Advice and Support - The GPs in the practice did not consult with the Named GPs for Safeguarding Children or Adults for professional advice and guidance, or the CCG Safeguarding Nurses 23 4. Children’s Services Learning Points and Action taken: Multi- agency working • All referrals need to be acknowledged and recorded by staff in Children's Social Care • There needs to be improved communication between Partner Agencies, including informing them when difficulties with staffing and other work issues arise • Agreement needs to be made about who records meetings and how these are circulated after meetings. • Risk assessment tools should be agreed and introduced across SSC practitioners Front Line/Family factors • Staff need to improve their skills in working with challenging and difficult to engage families and invisible fathers • Focus of work needs to be on the voice and needs of children Staffing/Workers/team issues • Work needs to be progressed on the development of an early help offer and single assessment • Consistent and effective case management, evidenced through the introduction of reflective auditing • Consistent and effective casework supervisions with management oversight and timely case discussion • Consistent and effective performance management and quality assurance introduced through the Performance Management Framework • A training needs analysis needs to be undertaken across Children's Social Care and Early Interventions Services • A comprehensive workforce strategy needs to be agreed and shared with staff and managers Managerial issues etc. • There needs to be consistency by managers in overseeing and making decisions related to children, young people and their families, with appropriate levels of supervision in place • There needs to be robust policies in place for Regulation 24 placements with Grandparents and other family members • Context/Organisation Structures • Significant changes in organisations need good planning and communication 24 5. Police Learning Points and Action taken: Multi agency working - Police Checks - need to ensure that full and accurate information is shared and that: • All possible aliases and linked addresses are explored • Consideration to be given for personal documentation to be asked for/supplied by potential carer 6. Children’s Services: Education Learning Points and Action taken: • There are some really good and valuable examples of good practice from the schools involved with Victoria and Baby O e.g. school raised concerns with Children’s Services (Social Care) about Grandmother’s ability to cope with the responsibility of looking after the four children • All three schools appear to have focused very clearly on the needs of Victoria, keeping the child at the centre of practice, but in doing so this led to escalating concerns where appropriate • General learning points for all schools as follows: o Recording even the most insignificant item of concern accurately and immediately o Information sharing with relevant professionals quickly o Following up on actions and pushing for feedback once information has been shared 25 Appendix 3 How has the learning from this SCR improved practice? Sunderland Safeguarding Children Board: • The SSCB is reviewing the compliance with procedures, the quality of S47 investigations and whether S47s are progressing to Initial Child Protection Conferences as required through multi-agency audits to be undertaken in 2016/17. This audit will provide the SSCB with a clear understanding of how effective this part of the child’s journey is • 104 multi-agency staff have attended the SSCB Learning and Improvement Workshop to learn about the findings of the SCRS in Sunderland. Staff attending the sessions report (see Appendix 4) that they have learnt from the sessions and are applying this to their practice • The Board has consulted on its draft SSCB multi-agency Neglect Strategy including the implementation of the Graded Care Profile and it will be agreed at the SSCB in July 2016 • Whilst not a specific recommendation from this SCR, learning has highlighted the need to strengthen the SSCB so the SSCB has strengthened its approach to obtaining assurance about the safeguarding system in Sunderland and its partner agencies through: o Undertaking a Section 11 audit in 2015-2016 which evidenced compliance by partner agencies in respect of their staff supervision arrangements o The SSCB Chair is undertaking assurance work through requesting Board partners to provide assurance of their current safeguarding arrangements and their agency annual safeguarding report for 2015-2016. This will be one element contributing to strengthening the SSCB’s understanding of how effective the safeguarding system in Sunderland is o Refocusing on the behaviours, values etc, that the SSCB wants to be embedded into safeguarding practice in Sunderland o Implemented a learning and improvement monitor which is providing robust scrutiny and high challenge on the implementation of all recommendations from all SCRs the Board is undertaking Sunderland Clinical Commissioning Group: • Large GP practices to identify a GP lead for individual families to deal with the safeguarding issues when there are concerns o This will provide consistent oversight of care to vulnerable children where there are safeguarding concerns o This will ensure a co-ordinated approach to receipt of information and dissemination of information • When taking a social history from men, GPs to establish if they have children and/or care of children o GPs will include men in their assessments of children and families and use the information on fathers/male carers to inform referrals to other services 26 o This has been included in the Level 3 GP Safeguarding Locality Briefings, Time in Time out Sessions, the CCG Quarterly Safeguarding Newsletter for Primary Care and the quarterly support sessions with GP Safeguarding Leads • When parents are neglecting their own health needs GPs must consider how this may impact on their parenting capacity and take responsibility for referring to Children’s Services/other agencies for support o The impact of self-neglect by parent/carers is considered for children in those households o GPs will refer to Children’s Services when it is recognised that self-neglecting parents/carers are not meeting the needs of their children o GPs may then, potentially, identify vulnerable adults and follow adult safeguarding procedures where necessary • MDT meetings must be recorded in a consistent manner, documenting what actions and timescales have been agreed o There will be a consistent approach to recording MDTs in Primary Care o The impact of this will be reflected in improved communications and recording within Primary Care and improved outcomes for vulnerable families o This is included in the safeguarding children annual audit cycle City Hospitals Sunderland: • The Midwife failed to follow up on the ‘housing issue’ as disclosed on the ante-natal VAP and the past pregnancy VAPs were not taken into consideration. The Midwife reflects that this should have been followed through and has identified that the VAP needs to be improved to allow more free text. Improved communication with the HV would have identified the concerns sooner o The ante natal VAP has been reviewed and is now at version 5, due to several other SCR recommendations. Midwifery services have been reviewed and there are 5 permanent Community Midwife Teams, which has supported individual Midwives overseeing complex CP cases • Where there are no risks identified on the VAP and the GP or HV has information to the contrary, direct communication between themselves and the Midwife should take place o Each midwifery team is attached to specific GP practices which have supported their attendance at GP multi-disciplinary meetings where vulnerable adults and unborn are discussed 27 • The maternity and acute care is well documented from a clinical perspective, however the observed social factors of the family such as home conditions, presentation of the parents and children, interactions between parents and children also needs to be documented. Action: Full social history to include full name of the males within the child’s life, who attends with patient at all CHSFT attendances and the reason for failure to attend outpatient appointments needs to be documented o The electronic patient records system ‘Meditech’ has been updated with mandatory fields to ensure the full names of adults attending with children is documented o A failed to attend guidance has been produced and failed to attend out-patient appointments can be seen by all professionals on Meditech Children’s Services (Social Care) • Improved communication and working relationships between Children’s Services and partner agencies at the first point of contact o MASH has now changed its operational structure (04/04/16) to be a multi-agency team who receive the first contact. There are processes built in to share information to determine that the decision making is informed and at the correct threshold o A Strengthening Families Worker is now in MASH full time to progress early help for families who do not meet the statutory criteria but are in need of support to, where appropriate, prevent them entering Social Care • Robust plans for children in need that are reviewed and have managerial oversight to avoid drift and delay o There are revised CIN procedures with built in reviews o Effective plans for children appropriate to their level of need leading to improved outcomes o Child in Need workshops were delivered in April 2016 to embed the procedure and ethos with all staff • Assessments of risk using thresholds/frameworks to support the evidence and that they are inclusive of all family members o Risk assessment frameworks introduced in 2015, Bruce Thornton including the Graded Care Profile o Neglect Strategy now circulated and multi-agency workshops are planned for the end of the year (2016) o A reviewed and revised Quality Assurance Framework has been agreed (July 2016) • For any child being placed with family/connected carers that the appropriate legislation is used and that there is regulation of the placement o The scheme of delegation has been revised (June 2016) and all Service Managers , Head of Service and Director are able to agree Schedule 4 assessments, children will not be placed without the Schedule 4 being 28 completed. The scrutiny by the designated Service Manager flags any practice/non-compliance issues o Regulation 24 workshops have been delivered to all staff during July 2016 • To establish a stable workforce that provides consistency in Social Worker and Manager who are accountable for decisions and planning o The structure of the Children’s Social Care workforce has been revised to reduce the size of the teams and increase the number of managers. Teams are made up of no more than 8 social workers with case loads of 20 Children’s Services (Early Intervention) • New non-engagement policy has been put in place for all workers to follow o All workers are clear of the expectations when trying to engage hard to reach families whilst acknowledging that work at EI is voluntary o Process of closure for non-engagement requires management oversight South Tyneside NHS Foundation Trust (STNHSFT) • The impact upon the child regarding ‘no access’ visits should be re-emphasised with all health visitors o STNHSFT Safeguarding Children Policy clearly identifies the action required when ‘no access’ visits are experienced by health visitors and the potential impact this may have upon the child. This policy has been revisited through Team Meetings, embedded within Safeguarding Training Presentations, and individually with Health Visitors through Safeguarding Supervision • Individual supervision should be undertaken between the lead nurse safeguarding and individual HV o Individual supervision was offered to this professional, but unable to be undertaken as the practitioner did not return to STNHSFT employment • The use of the significant event form to support early recognition of risks to children should be revisited with Health Visitors o Health Visiting and School Nursing Child Health Records all contain a Significant Event Form with a requirement in accordance with STNHSFT Safeguarding Children Policy, this is completed and reviewed at all contacts to support early identification of risk, analysis of information and inform decision making when working with families. The use of the significant event form has been revisited at team meetings, revisited within Safeguarding Training Presentations, and raised individually with Health Visitors and School Nurses through Safeguarding Supervision and discussions. Child Health Records are reviewed by the Safeguarding advisors at Safeguarding Supervision Sessions to ensure compliance with completion of Significant Event Form 29 • The individual roles and responsibilities of health professionals and the safeguarding team in escalating concerns and access for support should be revisited o The specialist safeguarding roles and responsibilities of the Safeguarding Team have been revisited across STNHSFT through Safeguarding Training, Safeguarding Website, Safeguarding Newsletter, and the Safeguarding Forum, with specific reference to supporting professionals with escalation of safeguarding concerns. Safeguarding advisors provide safeguarding support and advice daily through face to face contact, telephone contact with professionals and Safeguarding supervision. The use of Datix Incident Reporting has supported escalation of safeguarding concerns by health professionals to the Lead Nurse, ensuring prompt safeguarding advice and support with regard to escalating concerns • Safeguarding supervision documentation should be reviewed to include identified actions, responsible person, timescales and feedback/review o Safeguarding Children/LAC Supervision Case Discussion form has been amended. Health professionals who are clear of their roles and responsibilities during and following safeguarding supervision prevent delay and drift with interventions for families and children o Communication between GP and HVs to be improved with regard to vulnerable families and non-engagement o STNHSFT Safeguarding Children Policy clearly identifies the action required when ‘no access’ visits are experienced by the Health Visitor. It is an expectation that Health Visitors will contact the family GP when difficulties are experienced with access to children and their families. Sharing information with regard to vulnerable families promotes effective communication, enabling primary care practitioners to share and analyse information to progress the most appropriate support and intervention for children and families Children’s Services (Education) Recording even the most insignificant item of concern accurately and immediately • Information sharing with relevant professionals quickly These messages reinforced through designated persons training, dip sampling file audits as part of preparation for Ofsted, school improvement visits Following up actions and pushing for feedback once information has been shared • Schools now should receive acknowledgement/outcomes of referrals and have been reminded to follow up for feedback if this is not forthcoming 30 Appendix 4 References relevant to this Review Action for Children – The state of child neglect in the UK, Action for Children and University of Stirling, 2013; www.actionforchildren.org.uk/media/5120220/2013_neglect_fullreport Brandon M, Pippa Belderson, Catherine Warren, David Howe, Ruth Gardner, Jane Dodsworth and Jane Black - Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003-2005 Brandon M, Sue Bailey and Pippa Belderson - Building on the learning from serious case reviews: A two-year analysis of child protection database notifications 2007-2009; DFE 2010 Brandon M, Peter Sidebotham, Sue Bailey, Pippa Belderson, Carol Hawley, Catherine Ellis & Matthew Megson - University of East Anglia & University of Warwick – July 12: New learning from serious case reviews: a two year report for 2009-2011 C4EO – KNOWLEDGE REVIEW 1 - Effective practice to protect children living in ‘highly resistant’ families Department for Education – Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children – 2013 DH 2011 Health Visitor Implementation Plan: A Call to Action DH Healthy Child Programme 2009 GMC - Protecting children and young people - The responsibilities of all doctors GMC 2013 NSPCC 2011 - All babies Count Dual Diagnosis Nursing - edited by G. Hussein Rassool (2006) Blackwell Ofsted - Learning lessons from serious case reviews, 2009–2010 (100087), Ofsted, 2010; www.ofsted.gov.uk/resources/learning-lessons-serious-case-reviews-2009-2010 Ofsted In the child’s time: professional responses to neglect – March 2014 Tony Morrison Staff Supervision in Social care,” Tony Morrison, 3rd edition and “The Impact of Supervision on Child protection practice – a study of Process and Outcome” 2003 Wonnacott, Jane; Effective supervision in social work and social care, Professor John Carpenter and Caroline Webb SCIE Briefing 2012 31 Appendix 5 Learning and Improvement Workshops – Impact as described by staff attending Please give one example of how you will embed the content of this training into your role: • I have noted the importance of professional challenge and have encouraged colleagues to use this too • I will ensure I chase up any referrals promptly • To ensure that myself and the staff based in my room are aware of the procedures to follow • I will be feeding back to staff within a staff meeting what was discussed and to look at our own practice and if there is room for improvement to ensure all documentation is consistently recorded and detailed information is being recorded • This has given me the confidence to challenge • I will now be more aware of parents who may have disguised compliance • I will challenge where I feel is necessary, knowing the proper procedure can be followed • If I disagree with the decisions taken in child protection meeting, I will voice my concerns • I might be wary of overly compliant parents who lend lip service to the changes in child care which has been demanded • When seeing children in my GP surgery I will: 1. Always check the relationship of adults bringing the child to the appointment. 2. Speak to the child on their own where appropriate. 3. If I feel uncertain about the truth of the facts presented, endeavour to seek confirmation from another source (eg attendance at counselling) • I have read my trust policy on safeguarding and this is implemented into my practice • It has made me very aware of how I can and should challenge professionals and not accept low standards as the norm • Encourage staff who "have niggles" to take concerns seriously and report and record • Ensure that the voice of the child is heard by relevant professionals • I will not leave a meeting with questions • To further ensure practice remains child centred. To always be mindful of disguised compliance • Reinforced the need to reflect on cases with my supervisor • Future course/ training development • Ensure that I keep up to date accurate records • Making sure that I understand all the factors learnt from serious case reviews and to make sure that I take this into practice • Always recap in meetings to make sure all professionals are aware of their role and actions • If in any doubt, seek further advice • I will ensure that all of the professionals involved with my young people are provided with the relevant information • Be specific in conferences about the expectations of the plan in relation to the safety of the child/ren eg not just tell them to attend a service but to explain what they need to do and learn • I will be more aware of vulnerable babies • Challenging other professionals when appropriate |
NC047187 | Death of a 7-week-old baby boy of mixed parentage whilst co-sleeping with mother, who had consumed alcohol and cocaine. Mother was arrested on suspicion of overlay but no charges brought. Child A's older sibling had died when 2-weeks-old from sudden infant death syndrome in 2007. No concerns about the care of the sibling were identified at the time. Mother was known to police prior to her pregnancy with Child A as both a perpetrator and victim of crime. She was supported by domestic abuse services and her ex-partner received a custodial sentence for violence against her. Mother was also known to the Children and Families Practice, who completed a common assessment framework (CAF). Mother also had issues related to: alcohol and drug misuse, including an unintentional overdose when 15-weeks-pregnant; housing; mental health problems; and lack of engagement with professionals. Uses the Significant Incident Learning Process (SILP). Learning includes: professionals working with adults must understand parental behaviour in terms of the impact on the child; risky behaviour in pregnancy should be seen as a potential child protection issue; high support and high challenge is required when engaging with vulnerable families; and threat of withdrawal from engagement should be seen as an indicator of risk. Recommendations include that the Milton Keynes Safeguarding Children Board's Neglect Group should extend its remit to become an early help development group. Highlights examples of good practice including use of multi-agency referral forms and persistence in contacting the mother after missed appointments. Also outlines changes made to local services and practice since the death of Child A.
| Title: Serious case review: Child A: overview report. LSCB: Milton Keynes Safeguarding Children Board Author: Nicki Pettitt Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Version 29.2.16 1 Serious Case Review CHILD A OVERVIEW REPORT Author and Lead Reviewer: Nicki Pettitt Date presented to the MKSCB: 27 January 2016 Version 29.2.16 2 CONTENTS Summary of the learning Page 3 Introduction to SILP Page 5 Introduction to the case Page 6 Family Structure Page 6 Terms of Reference Page 7 The Process Page 7 Background prior to the scoped period Page 8 Key episodes Page 9 Analysis by theme Page 17 Conclusions Page 27 Recommendations Page 30 Version 29.2.16 3 1 Summary of the Learning 1.1 This Serious Case Review (SCR) is in respect of a 7 week old baby who died after being found with ‘no signs of life’ whilst co-sleeping with his mother. She had been drinking and stated she had used cocaine. An inquest concluded that the cause of death was unascertained, with a narrative from the Coroner that it was a sudden unexplained death of an infant. The fact that Mother had been drinking, that the child was sleeping with her and was face down, and that there was a smoky atmosphere in the house, were noted by the Coroner as factors which heighten the risks of such an unexplained death. Whilst the child’s sad death was not as a consequence of any actions or failures to act by any individuals or organisations, the SCR has identified a number of learning points for the individual agencies involved and for the Milton Keynes Safeguarding Children Board (MKSCB). When considering in detail the involvement of partner agencies with Child A and his family the following learning has been identified: Parents who are misusing drugs or alcohol can be very persuasive. To ensure that potential safeguarding risks are identified, professionals need to seek and consider objective evidence which can be used to confirm or challenge the accounts being given by the parent. ‘Respectful uncertainty’ should be employed, particularly when drug or alcohol abuse is a possibility. The NSPCC published a report in 2010 called ‘Ten Pitfalls and How to Avoid Them - What Research Tells Us.’ Four of the ten pitfalls in regards to assessing families in the community are relevant to this case. They are: o An initial hypothesis is formulated on the basis of incomplete information, and is assessed and accepted too quickly. Practitioners become committed to this hypothesis and do not seek out information that may disconfirm or refute it. o Attention is focused on the most visible or pressing problems; case history and less “obvious” details are insufficiently explored. o Insufficient weight is given to information from family, friends and neighbours. o There is insufficient full engagement with parents (mothers/fathers/other family carers) to assess risk. It is important that all assessments seek an explicit understanding of a child’s lived experiences (or likely lived experience if they are not yet born) combined with a thorough analysis of the known risks and protective factors. When a service user is pregnant and engaged in risky or worrying behaviour (in this case Mother’s overdose of drugs and alcohol) professionals must consider the behaviour as a potential child protection issue. A parent with vulnerabilities requires a positive and understanding response from professionals. When considering their potential to parent the child there should also be robust and honest challenge about the areas and behaviours which would negatively impact on the child. Professionals attending a TAF meeting need to have a shared understanding of the background concerns and risks as well as consideration of the immediate concerns that led to the meeting. This will ensure the best plan is devised for a child. If the meeting is part of a longer term process to develop a clearer understanding of the family, including Version 29.2.16 4 any risks and protective factors, this should be clarified with those in attendance and recorded. It is difficult for professionals to maintain the engagement of a service user who is likely to withdraw their cooperation, or refuse to give consent for information sharing, when they are challenged. The threat of withdrawal from engagement should be seen as an indicator of risk. Professionals need to acknowledge that a service user may not be telling the truth. The notion of ‘high support, high challenge’ should be the aim of engagement with families. It is acknowledged that this is a complex and difficult balance, which to do well requires skilled practitioners, reflective practice and effective supervision. Adult behaviour needs to be understood by professionals, especially those who primarily provide services to adults, in terms of the impact of that behaviour not just on the adult but on their child. This needs to be evaluated accordingly where the adult is about to become or is a parent. Supervision needs to be available and sought to help professionals challenge themselves, each other and family members when there are concerns about lack of engagement. Professionals need to understand and clarify the role and status of any volunteers or advocates before disclosing confidential information or including them in meetings. Information sharing guidance should be a guide to professional practice but not a hindrance to appropriate professional curiosity. Despite a commitment to ensuring families are aware of the need to adhere to safe-sleeping advice, it is not always possible for professionals to identify a family where there is an un-disclosed culture of co-sleeping. GPs are a crucial part of the safeguarding system. Sharing information with them, and seeking the information they hold, should be a standard action in any assessment. All professionals need to understand, through their own agency and MKSCB training and learning, how to have and understand difficult conversations with other agencies and professionals from other disciplines. Any new information gained by a professional should always be considered alongside the information already available. Family members can hold significant information and they should be engaged with and spoken to when making an assessment. As they can also provide important support and care for families, they should be appropriately utilised. The benefits and difficulties inherent in involving wider families in assessments and plans need to be fully evaluated and understood by professionals. Assumptions can be made about the implicit protection provided by wider family members to children. Professionals need to be aware of making such assumptions and recognise the risk of doing so. Version 29.2.16 5 2 Introduction to the Significant Incident Learning Process (SILP) 2.1 The MKSCB agreed that this Serious Case Review (SCR) should be undertaken using the SILP methodology. SILP is a learning model which engages frontline staff and their managers in reviewing cases, focusing on why those involved acted in a certain way at the time. This way of reviewing is encouraged and supported in Working Together to Safeguard Children 2015. 2.2 The SILP model of review adheres to the principles of; proportionality learning from good practice the active involvement of practitioners engaging with families, and systems methodology 2.3 SILP reviews are characterised by the completion of Agency Reports followed by a large number of practitioners, managers and agency safeguarding leads coming together for a Learning Event. All Agency Reports are shared in advance and the perspectives and opinions of all those involved at the time are discussed and valued. The same group then comes together again to study and debate the first draft of the Overview Report. All those involved make an invaluable contribution to the learning and conclusions of the review. 2.4 As required by Working Together 2015, this SCR has been conducted as a systems review which; recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. 2.5 MKSCB recognised the potential to learn lessons from this review regarding the way that agencies work together in Milton Keynes to safeguard children. Working Together 2015 states that serious case reviews should: Identify improvements in the way that agencies work together for the prevention of death, serious injury or harm to children and to consolidate good practice. Clearly identify what lessons are to be learned both within and between agencies and within what timescale they will be acted on and what is expected to change as a result. Version 29.2.16 6 3 Introduction to the Case 3.1 The subject of this review is a child to be known as Child A. He was a much-wanted child who was happy and thriving. Child A lived with his mother and had extensive contact with his maternal family in Milton Keynes, often staying with them along with his mother due to issues with the family’s housing. 3.2 The father of Child A is not thought to have had any contact with him during his lifetime. His details have not been shared by Mother with her family or any of the agencies involved at the time or during this review. Mother had another child who was born in 2007. That child died when it was 2 weeks old due to sudden infant death syndrome. 3.3 The professionals involved with the family during Child A’s life were the police, domestic abuse professionals, midwives, a health visitor, a CONI coordinator1, children’s services (the referral and assessment team (R&A) then the Multi-Agency Safeguarding Hub (MASH)2 after 1 September 2014), children and families practice workers,3 GPs, housing officers, and a victim support advisor providing personal support to Mother. Prior to his birth, Mother also had contact with professionals working in her local hospital and in adult mental health services. 3.4 The child’s mother was initially arrested on suspicion of overlay after the death of Child A, but no charges have been bought. 4 Family Structure 4.1 The subject of this review is to be referred to as Child A. When referred to, Mother’s previous child will be called Sibling. 4.2 The parents of the child are referred to in this report as Mother and Father. Other family members will be referred to by their family title e.g. Maternal Grandmother. 4.3 Child A was of mixed parentage. Mother and her parents are white British. Their only language is English. Father is thought to be of black African/Caribbean origin. This information appears to have been accurately recorded on agency records. Child A had no known physical disabilities. Mother was not working during the timeframe of this review. 4.4 Mother’s previous partner, who was involved with partner agencies during the scope of this review, will be referred to as Ex-Partner in this report. He is not the father of Child A. 1 The CONI programme (Care of the Next Infant) is a care package offered to parents expecting a baby where either parent has previously suffered the sudden unexpected death of a child under the age of 2 years of age. In Milton Keynes the CONI team is made up of staff from the Health Visiting service and is managed within this service. 2 Multi-Agency Safeguarding Hub. The Milton Keynes council website states that it ‘brings together professionals from partner agencies to deal with safeguarding concerns, where someone is concerned about the safety or wellbeing of a child. Information from partner agencies is collated within the MASH to assess risk and decide what action to take. As a result, the agencies are able to act quickly, in a coordinated and consistent way, ensuring that vulnerable children and families are kept safe. 3 Milton Keynes Council website states ‘Children and Families Practices offer early help services for families with additional or considerable needs. These teams are based in local areas to ensure that support is more accessible to children, young people and their families’. Version 29.2.16 7 5 Terms of Reference 5.1 It was agreed that the scope of this review would be from the time that professionals became aware of Mother’s pregnancy with Child A until the date of his death. 5.2 Relevant information prior to these dates was also considered. This included some information that is known to agencies about the death of Sibling, and about Mother between the two pregnancies. 6 Process 6.1 Mother and the maternal grandparents were contacted in order to meet with them to ensure their views were considered and heard as part of the review. A representative of the MKSCB initially visited both Mother and the grandparents to explain that an SCR was being undertaken. They were then visited by the Lead Reviewer and the representative of the Board to explain the process and ask them if they had any views on the agencies involved with the family regarding the way they worked together to protect Child A. Their views will be shared throughout this report. Best endeavors were made to identify Child A’s Father, but it was not possible in this case. 6.2 The Department for Education (DfE) expects full publication of SCR overview reports, unless there are particular serious reasons why this would not be appropriate. Working to that requirement, some confidential historical family information will not be disclosed in this report. It is written in the anticipation that it will be published, and contains all of the information that is relevant to the learning established during this review. The family will be contacted again prior to publication to ensure they are aware of the conclusions of the review. 6.3 The decision to undertaken an SCR was made by the then Chair of the MKSCB and the review was planned at a scoping meeting held on 23 June 2015. Agency reports were requested, along with a chronology of agency involvement. A briefing meeting for agency report authors was held on 28 July 2015, to clarify expectations. The SILP model requires engagement with staff involved at the time, and therefore two events were held to enable the Lead Reviewer to engage with staff. A Learning Event was held on 24 September 2015, and a Recall Event was held on 12 November 2015. Practitioners and first line managers attended and engaged in both events and received all reports. The Overview Report was presented to the Milton Keynes Safeguarding Children Board on 27 January 2016. 6.4 The Lead Reviewer in this case is Nicki Pettitt, an independent child protection manager and consultant who is an experienced chair and author of SCRs, and a SILP associate reviewer. She is entirely independent of MKSCB and its partner agencies. 7. The background prior to the scoped period 7.1 Mother and her family are well established in the Milton Keynes area. Mother attended school locally and although she has moved away in the past she sees Milton Keynes as her home. 7.2 Milton Keynes Council Children’s Services (CS) were not aware of Mother prior to her pregnancy with Child A. When she became pregnant with Sibling she lived in another part of the country and returned to Milton Keynes before the birth. Version 29.2.16 8 7.3 Midwifery and health visiting services were involved with Mother and Sibling in 2007. No concerns were identified at the time or when Sibling died at the age of 2 weeks. 7.4 Little is known about the death of Sibling. The Police were involved, as they are in all cases of unexpected death, but limited records are available. There is no evidence that there were any concerns about the care of Sibling or that the death was preventable. 7.5 Mother was relatively well known to Thames Valley Police prior to her pregnancy with Child A, as both a victim and perpetrator of crime. She has a history of offending and anti-social behaviour and the police have recorded concerns about her alcohol and drug misuse, and associations with those thought to deal drugs. Mother has been a victim of domestic abuse with more than one partner. Most recently, from June 2013, she was identified as at high risk of domestic abuse from Ex-Partner and was subject to the MARAC4 process. 7.6 In between the pregnancies Mother had a number of personal challenges, as described in the GP Agency Report. These were summarised as an ‘inability to work, a previous neonatal death, domestic abuse, personal safety concerns, housing issues and mental health problems.’ There is also reference to ‘long standing anxiety and stress related problems’. 7.7 In 2013 Mother was treated in hospital for a suspected mixed overdose of benzodiazepine5 and alcohol. Mother denied taking the overdose intentionally, but spoke of the breakup of her relationship with Ex-Partner, who had been abusive to her. She admitted taking drugs and drinking vodka. Mother was not asked if she would agree to toxicology tests being undertaken, so the review cannot be clear about what drugs she digested. It was noted that Mother responded well to Narcan6, which is a strong indicator that she had taken opiates. Mother was referred to her GP for support with her anxiety following this incident. No role for secondary mental health services was identified. 7.8 Mother has been a customer of Milton Keynes Housing Services for a number of years, and they were aware of domestic abuse from 2012. 7.9 In 2013 Mother referred herself to MK-ACT, the domestic abuse service for Milton Keynes, but she failed to engage. 7.10 The South Central Ambulance Service had also been called on a number of occasions prior to the pregnancy with Child A, predominantly due to injuries sustained during domestic abuse incidents (often after heavy drinking), anxiety and panic attacks, and the overdose mentioned above. 7.11 Allegations of domestic abuse from Ex-Partner started in 2013. Mother was assessed as high risk due to the serious allegations and the extent of the injuries she sustained. Mother’s cooperation with attempts to prosecute were inconsistent, however criminal proceedings were initiated and Mother made a statement which led to a successful prosecution. She was well supported, was provided with a personal attack alarm7 and a TECSOS8 mobile phone, and was referred for a MARAC. 4 Multi-Agency Risk Assessment Conference 5 Benzodiazepines are a type of medication known as tranquilizers. Familiar names include Valium and Xanax. They are commonly prescribed in the UK. 6 Narcan is a drug used to prevent or reverse the effects of opioids. 7 These are primarily used in domestic abuse cases where a system is installed at a victim’s address with a panic button in the address. This is monitored by the company who alert police with a unique alarm number upon activation. 8 A device which enables a user to push a central button and activate immediate contact with the emergency services, providing details of the location from the handset and triggering an immediate recording of all activity in the vicinity of the device. Version 29.2.16 9 7.12 The staff at the Learning Event who knew Mother before the timeframe of the review confirmed that they were aware of her history of domestically abusive relationships. Some reported that she was often sleepy or drowsy when they saw her and that they thought she was being prescribed diazepam for depression. It was clarified at the Learning Event that this was not a prescribed medication, although professionals assumed it had been. She was also thought to drink to excess, often smelling of alcohol when visited. 8. Key Episodes 8.1 The time under review has been divided into four Key Episodes. Key Episodes are periods of intervention that are judged to be significant to understanding the work undertaken with a child and family. They are key from a practice perspective rather than to the history of the child. The term ‘key’ emphasises that they do not necessarily form a complete history of the case but represent the key activities that occurred, and include the information that is thought to be most helpful in informing the review. Key Episode 1: 8.2 This episode will look at the two months of agency involvement when a number of professionals involved with Mother were alerted to her pregnancy, which was ‘booked’ at 8 weeks. 8.3 The Community Midwife who first saw Mother noted that she was a victim of domestic abuse and that she was due to be a witness in the court case against Ex-Partner. The previous neonatal death at 2 weeks of age was noted along with previous postnatal depression. This information was shared with the relevant Health Visitor through the use of ‘confidential communiqués’9. The identity of the baby’s father was not recorded, as Mother stated he was not involved. She was clear however that Ex-Partner was not the father. 8.4 When she was 15 weeks pregnant with Child A, an MK-ACT worker rang Mother and noted she was very drowsy. MK-ACT had recently been told by Maternal Grandmother that Mother may be misusing valium. The MK-ACT worker could hear a panic alarm going off in the background and could not communicate clearly with Mother. Acting swiftly MK-ACT staff called an ambulance and Mother was taken to the Emergency Department of her local hospital with an alleged overdose of tranquilisers, alcohol, and possibly opiates. It is recorded that this was following an argument with her ‘partner’. It is also recorded in hospital records that Mother had stated that Children’s Services had told her they would take the child away from her when it was born, which led to the overdose. (It is noted that this was not the case as there had been no previous involvement with Children’s Social Care in Milton Keynes.) The hospital records state that the ambulance crew reported two empty wine bottles at the home. The Police were also in attendance and it was confirmed during this review that neither service noted any evidence of drug use, which they stated is unusual when a person admits taking drugs. Like with the previous overdose, Mother responded to the use of Narcan. No toxicology tests were undertaken to establish exactly what substances Mother had consumed. A&E staff did not contact the GP or the Midwives to discuss Mother and unborn Child A. 8.5 Mother was insistent that this was not an intentional overdose, that she had taken extra tablets to relax, and she was adamant that there was no risk of reoccurrence. She was seen 9 A confidential information sharing record used by midwives and health visitors in Milton Keynes. Version 29.2.16 10 by a Speciality Doctor10 and Mental Health Nurse. They noted that Mother had a history of depression and a baby that had died. They were made aware of the domestic abuse and the impending court case. The mental health workers were told that the hospital emergency department was making a referral to the Referral and Assessment Team (R&A). They agreed to refer Mother to the ASTI11 for assessment and treatment for anxiety and to the service’s perinatal lead. The GP was also asked to refer Mother for counselling. 8.6 Around a week later Mother made a 999 call asking for ‘NHS Direct’ due to her being pregnant and bleeding. It was the view of the police operator who spoke to her that she sounded intoxicated. She would have been given the number for 111 (the replacement for NHS Direct) and her details taken, but she hung up. This information was only identified when the Police agency report author checked contacts from Mother’s telephone number to aid this review. This information was not readily available so was not shared at the time. 8.7 Two MARAC meetings were held where Mother was discussed during this period. One was before and one shortly after professionals became aware of Mother’s pregnancy. The first meeting considered an incident around 6 weeks previously where Ex-Partner had pushed Mother down the stairs. The second meeting noted that Mother was pregnant but decided that it was not an appropriate referral to MARAC on this occasion as Ex-Partner was in prison and there was no new incident, just a belated report of an old allegation. 8.8 This is a key episode because professionals were aware of Mother’s pregnancy and had concerns about the historic domestic abuse, the need for her to give evidence against Ex-Partner, and her on-going anxiety. Mother took a drug overdose with alcohol which was stated to be unintentional, but provided evidence of the use of alcohol and tranquilisers which were not prescribed during the pregnancy. Key Episode 2: 8.9 During the next month the R&A team received two referrals, using the MARF12, about the unborn child. Firstly from the hospital emergency department following the overdose, then from the Police Domestic Abuse Investigation Unit (DAIU) after agreeing with MK-ACT that it was more appropriate for them to make a referral. The Health Visitor, who had not yet met Mother and had no direct involvement until later in the pregnancy, also contacted R&A to discuss the concerns at this time, and had a conversation about the case and advising R&A that Mother was still in hospital. This is good practice. The referral from the DAIU included the information that Mother ‘had presented on numerous occasions as being quite lethargic and having just woken up, having slurred speech and to a degree, incoherent’. Police records show that officers were sceptical about Mother’s denial of on-going drug use. The recorded concerns from the referrals and subsequent conversations were in regards to Police and MK-ACT concerns that Mother may be addicted to prescribed drugs (as also asserted by Grandmother), that she was at high risk of domestic abuse, was very anxious about the up-coming court case against Ex-Partner, and her general anxiety following the death of Sibling. 8.10 A number of attempts were made by the R&A team to contact Mother by telephone and by letter, but they were unable to speak to her. They spoke to a Midwife and to MK-ACT. Information sharing between R&A and MK-ACT was good. 10 A doctor in A&E who undertakes psychiatric assessments as well as medical assessments. (CNWL-MK MHHLT) 11 Assessment and short term intervention team for mental health. 12 Multi-Agency Referral Form. Version 29.2.16 11 8.11 The CSC records state that during a telephone conversation between the R&A Social Worker and the Midwife it was understood that the if Mother did not engage with the R&A assessment, the Midwife and MK-Act should continue to support Mother, and that if Mother still had anxiety after the court case there may need to be a further referral to R&A and an assessment to see if she could meet the baby’s needs when born. There was no further communication with the health visitor who had contacted the R&A team after Mother’s overdose. 8.13 No contact was made with the GP by any of the professionals involved at this time, and the GP did not make contact after receiving notification of the overdose. The R&A team stated that in their case this was because there was no consent from Mother to share information with the GP. Mother’s previous GP attended and engaged with the SCR learning events, however the GP involved with Mother during her pregnancy did not attend and it is not clear why she did not make further enquiries after receiving the notification. There was limited consideration among professionals about liaising with the GP in this case, because they stated there was no reason for any of the agencies to question whether or not Mother was being prescribed the medication she was thought to be using at this time. 8.14 There is evidence that a number of attempts were made by the R&A team to speak to Mother, including in the presence of the MK-ACT worker, but this was not successful. There does not appear to have been an attempt to gain Mother’s consent for agency checks via those agencies she was seeing, and it is not clear if this would have included the GP. The agencies involved later reported that Mother appeared more positive and that support was in place. She was refusing a place in a refuge, but wanted to be re-housed. 8.15 Mother made a 999 call to the Police stating she was 6 months pregnant, that she had been drinking overnight with friends, and that her mobile phone had been stolen. She was later suspected of causing criminal damage outside the house of the ‘friend’. The case was not pursued criminally, and the possibility that Mother had been drinking while pregnant was not assessed and nor was the information shared. 8.16 As Mother had stated to MK-Act that she did not want support from Children’s Services, it was decided by the R&A team that a transfer to a Children and Families Practice was not possible, as it relies on consent. The Children’s Social Care agency report states that when assessed using the Levels of Need (at that time the 2nd Issue October 2013), the outcome was that unborn Child A’s case was classified as Level of Need 2 - Additional: “Targeted response alongside universal services using the Common Assessment Framework (CAF) to identify need.” The case was therefore closed to the R&A team. At the time the main focus seemed to be Mother’s anxiety about the court case and the release of Ex-Partner. The concerns about her presentation, the allegations of possible drug abuse from Maternal Grandmother, and indications she may have been drinking while pregnant were not treated as significant. The Police DAIU did not receive any response to their MARF referral and did not follow it up. There is no record that a letter was sent to Mother to inform her of the closure of the case. Meanwhile there was no clear discussion between the agencies who were working with Mother regarding whether there should be a coordinated multiagency response to meeting the needs of this young woman and her baby. It was not clear if the work required going forward should be through a CAF based process or through some similar multi-agency assessment and engagement process with Mother and agreement to a support plan. Version 29.2.16 12 8.17 Things were more positive over the next few weeks. Mother did not have to give evidence due to a change of plea by Ex-Partner. Mother was allocated a new flat in Milton Keynes, despite the reservations from housing professionals regarding the on-going risk to her and her baby of staying in the town. On the day that she moved in however she recognised the neighbours as associates of Ex-Partner and became very anxious. Ex-Partner was then released unexpectedly at the start of a bank holiday weekend. This was due to the amount of time he had spent in prison on remand. Probation originally arranged for him to live in approved premises13 within walking distance of Mother’s new flat, as they were not aware of her change of address. When this issue was established he was quickly moved to other premises in another town. The involvement of a Probation Officer who knew the case from MARAC ensured a swift resolution of the matter. 8.18 MK-ACT made a further referral, via a MARF, to R&A a month later stating their concerns about the on-going risk of domestic abuse from Ex-Partner, Mother’s anxiety about her neighbours links to Ex-Partner, and the fact that he had been recalled to prison following staff in the bail hostel overhearing a phone conversation between him and Mother. Significantly, at this time Mother was stating that she wanted support. She had gone to stay with her parents due to her concerns, and intended to stay there until she was again re-housed. The outcome of the referral was that the case was classified as Level of Need 3 – “Considerable”: The referral was transferred to the Children and Families Practice (CFP) which covered Maternal Grandmother’s address in another part of Milton Keynes. Information from the previous referrals was included, with the exception of the referral from the DAIU which was unintentionally omitted. However the information was known to the CFP manager as they appear to have read the records. 8.19 The CFP recorded that the priority at the time was planning for Ex-Partner’s release. Mother was visited by a duty worker from the CFP who noted the issues as housing, her fear of Ex-Partner, and the death of Sibling. Mother adamantly denied that she used alcohol. She was not questioned about her drinking at the time of her overdose, or the concerns shared that her speech was often slurred. A CFP worker was allocated to unborn Child A and had contact with both Mother and Maternal Grandmother. During the contact Mother stated she was opposed to both drinking and drug use. Mother decided that she had enough support however and stated she did not need to work with the CFP. She told the CFP worker that her main motivation at the time was to be re-housed near to Maternal Grandmother. Mother’s request was accepted and the case was closed. MK-ACT, as the original referrer, was informed. 8.20 The ASTI (Assessment and Short Term Intervention Team) tried hard to meet with Mother, who missed a number of appointments, then stated she was no longer in need of the service as she had arranged counselling. The ASTI discussed the case with the Perinatal Lead, who agreed with the decision to discharge Mother from secondary Mental Health Services. Around the same time a referral had been made to IAPT14 by the GP, and a telephone assessment was undertaken, followed by another contact a week later. The assessment concluded that Mother was feeling low in mood, was unmotivated, isolated, and was 13 Approved Premises offer residential provision for people leaving custody in order to provide enhanced levels of protection to the public and reduce the likelihood of further offending. 14 Improving Access to Psychological Therapy (IAPT) which is a free, NHS service providing psychological treatment for depression and anxiety disorders. Version 29.2.16 13 suffering from on-going fears and anxieties. Mother denied using drugs and alcohol to manage these issues. An agreement was made to refer her to a Psychological Wellbeing Practitioner for cognitive therapy. Mother did not respond to the request to make an appointment however and her case was closed. The GP was informed in both cases of the closure of the case, but not the details of the assessment. The information was not shared with the midwives or Health Visitor. It is presumed that the counselling Mother stated she was receiving was from her previous Victim Support Worker, who at this time continued her involvement on a private basis. This may have prevented Mother from engaging with the other public services being offered. 8.21 Mother had used her personal attack alarm on a number of occasions during this key episode, all inappropriately. She told the police officers responding that she had concern about noise disturbances in the street and about an unknown person heard banging on her door, that she was checking the alarm was working, and that she accidentally activated the alarm. Ex-Partner was in prison on each of the occasions the alarm was used. This has led to the Agency Author from Thames Valley Police questioning in her report if alarms should be removed when perpetrators are in prison. The author concluded that it is accepted practice for the victim to keep the alarm when they are anxious and vulnerable, as Mother was assessed to be. As in this case, there are also times when an offender is unexpectedly released from custody. It was also raised by Mother when she was spoken to as part of this review, that she remained concerned that Ex-Partner would send other people to intimidate her on his behalf while he was in prison. 8.22 This is a key episode because issues were identified that could pose a risk to the unborn child, including potential domestic abuse from Ex-Partner (who had been temporarily released from prison and had been in telephone contact with Mother), Mother’s anxiety and presentation, and the unassessed concerns from Maternal Grandmother about Mother’s use of prescription drugs. An attempt to provide support from the CFP was twice refused by Mother, on the second occasion after she was seen by two CFP workers. A Police DAIU (Domestic Abuse Investigation Unit) Case Investigator and IDVA (Independent Domestic Violence Advisor) from MK-Act remained involved until after the conclusion of the court case against Ex-Partner, but were closing the case at this time. Mother did not engage with psychological services offered, the midwives and housing remained involved, and the Health Visitor was aware of the case. Key Episode 3: 8.23 In the next few months Mother appears to have been living between her own accommodation and her parent’s address. She also missed a number of appointments with the midwives, either due to stated illness, because she forgot appointments, and on one occasion because she requested a change of midwife. Mother had been to see her GP who had concerns about the growth of the baby. Mother then missed a further appointment and did not respond to the GP’s attempts to contact her. The GP liaised with the midwives and an ultrasound was organised. Mother had changed GP and therefore the health visitor early in her pregnancy. There was a swift transfer of records, however the transfer was undertaken electronically, so the receiving Practice were not specifically made aware of the many long standing maternal vulnerabilities and the impact they may have for the unborn child. Version 29.2.16 14 8.24 MK-ACT closed their involvement due to Ex-Partner’s custodial sentence. Mother continued to receive support from her previous Victim Support volunteer, who began work with Mother in an unofficial capacity. She is a trained psychodynamic counsellor. She worked on Mother’s behalf to get her re-housed and supported her at key meetings, for example with Probation regarding Ex-Partner’s release. 8.25 The midwives continued to be concerned about Mother’s lack of engagement, leading to a discussion with a supervisor around 4 weeks before Child A was due. It was agreed that a referral to the MASH would be made if Mother did not engage with appointments and antenatal care. There was no attempt made to have a conversation with the MASH and no direct liaison with the Health Visitor. 8.26 Mother’s engagement improved and she had an ultrasound scan which confirmed unborn Child A’s growth was normal. During the appointment Mother said she had been on Diazepam and anti-axiolytic15 medication but had not used them during her pregnancy. 8.27 The Health Visitor undertook an antenatal visit to Mother due to the history of infant death and the information that was being shared by Midwifery. These visits are offered to all families where there may be a need for additional and targeted support. The Health Visitor discussed the death of sibling with Mother, who agreed to a referral to the CONI programme. Domestic abuse was also discussed and Mother’s mood, which was described as ‘up and down’. 8.28 The CONI coordinator visited Mother. Mother agreed to participate in the programme and to accept additional support around the prevention of infant death. The Midwife, Health Visitor and GP were advised of this. Equipment, including a movement monitor, was provided, and basic life support was demonstrated. Both Mother and Grandmother told the Lead Reviewer that they did not consistently use the monitor, particularly after Child A was two weeks old (the age that Sibling was when they died). 8.29 The week before Child A was born Mother missed another appointment with the Midwife, who then called at the house. The door was answered by man who said he was Mother’s cousin and said Mother was ill in bed with a ‘hangover’. When the Midwife insisted on seeing her, Mother stated that the Midwife was being rude and she did not want to see her again. Midwife noted a strong smell of cigarettes and left the house. She communicated the event to the Health Visitor via a Confidential Communiqué, which stated there were ‘several’ men in the house at the time. There was also a conversation held with the Health Visitor, which led to the health visiting service making a decision to visit in pairs. No consideration was given to the impact on Child A of the concerns identified during the visit. He was born a week later. 8.30 This is a key episode because the midwives were challenged in their attempts to meaningfully engage with Mother, Mother’s housing situation remained of concern to her and her family, and there were further issues identified about Mother’s lifestyle by the Midwife and Health Visitor, which could potentially have an impact on Child A. These issues did not lead to a discussion in safeguarding supervision or with the MASH which was now in place in Milton Keynes, which would have been expected in the circumstances. 15 Type of prescription medication used to treat symptoms of acute anxiety. Version 29.2.16 15 Key Episode 4: 8.31 No concerns emerged about Child A at the time of his birth or immediately afterwards, although it was recorded by staff on the postnatal ward that Mother’s behaviour was ‘challenging’. Further information has been sought regarding this recording, but it has not yet been possible to clarify what was meant by this statement. Mother and Child A went to stay at the grandparent’s home after discharge in order for Mother to receive support from them, and due to concerns about the housing situation. The Community Midwives remained involved until Child A was four weeks old. There is some evidence within the maternal post-natal notes that a management plan was put in place regarding the risk factors surrounding Mother’s anxiety, her potential for depression, and the death of her previous baby. 8.32 When Child A was 10 days old Maternal Grandmother called the Police in the early hours of the morning to state that Mother had been drinking at a family party, and that Grandmother was concerned that she was going to leave with the baby. The police visited and informed Mother that if she did not allow her mother to provide child care that evening Police Protection16 would be taken. The officers described Mother as “drunk”. The incident was recorded as a domestic incident with limited information, and not a child protection incident. This had an impact on what was shared with the MASH, who were unaware that alcohol had been involved or that the row had involved who would care for Child A, who was present at the time. The MASH had requested more information about the incident, but this was not provided. This appears to be because the Police Officer involved completed their report as a domestic incident, not as a potential child protection incident, which involves a separate report that should have been completed. The Health Visitor and the GP were not informed about the domestic dispute at all. A recommendation has been made in the TVP (Thames Valley Police) Agency Report to ensure processes are more robust going forwards. 8.33 The following day Mother left the grandparent’s home and returned to her own home with Child A. 8.34 The Health Visitor had a planned visit to Mother the next week, and prior to her visit she telephoned the MASH to check if there had been any recent concerns or incidents, and she was told the case was not open. She was not informed of the domestic incident the previous week, as the way it had been shared with the MASH by the Police meant it was not recorded on their system. Soon afterwards the 6 week check was completed by the GP who noted nothing of concern, with the GP stating that Mother appeared to be coping very well and Child A was fine other than some snuffles. 8.35 A MARAC meeting was held shortly after the birth of Child A. The incident between Mother and Grandmother regarding the care of Child A was not discussed. A MAPPA17 meeting was also held regarding Ex-Partner’s release and safety planning for Mother and Child A was considered. 8.36 The MASH was contacted by Probation after the MAPPA meeting regarding the risk Ex-Partner posed to Mother and Child A once he was released. This included the risk to Child A 16 Section 46 of the Children Act 1989 gives the Police the power to remove children to or keep them in a safe location for up to 72 hours to protect them from "significant harm". 17 Multi-agency public protection arrangements. Which are multi-agency processes in place to ensure the successful management of violent and sexual offenders. Version 29.2.16 16 when Ex-Partner realised he was not his father. Mother gave her permission for a referral to the MASH. The duty worker spoke to Mother, to the Health Visitor, and to the previous victim support worker who was now working with Mother on an informal basis. The case was classified as Level of Need 3 – ‘Considerable’18 and opened to the relevant CFP. The CFP worker spoke to housing on Mother’s behalf, liaised with others working with Mother, and completed a CAF. 8.37 A team around the family (TAF) meeting was held shortly before Child A died. It was well attended by those involved. Adult mental health services were not invited to attend, and no information from them was considered, although it is acknowledged that they were not involved with Mother at the time of the meeting. Mother attended. The focus of the meeting was predominantly housing, and ensuring the safety of Mother and Child A, as Ex-Partner was due to be released from his custodial sentence. Wider issues such as Mother’s mental health and any issues with alcohol and drugs were not discussed, including the alcohol-fuelled domestic incident at Grandmother’s home, the details of which were not known to those at the meeting. It is possibly significant that the CFP involved at this time were not aware of the information contained within the referral in key episode 2 from DAIU about the observations of Mother’s behaviour and the suggestion this could indicate a possible addiction to prescribed medication. This is due to the information from this referral not being summarised on the referral from MASH to the CFP. While it was contained in records on the wider data base, these were not accessible to the CFP Practitioner. 8.38 The TAF meeting agreed that there were no issues with Mother’s care of Child A, and they were reassured that Mother had no intention of having any contact with Ex-Partner. Housing attended and agreement was given to re-house Mother and for her rent-arrears to be written off to ensure a swift resolution. A further safety meeting was held the next day to plan support Mother may require when Ex-Partner was released, which included the Police DAIU Case Investigator, the IDVA from MK-Act and Mother’s counsellor. A further TAF meeting was to be held the following month. The Lead Reviewer was told that further information about Mother and Child A would have been considered at the second TAF meeting, the date of which had been set. 8.39 Child A died two days later. Mother was visiting a male friend where she drank alcohol and took what she thought was cocaine. Child A was said to have been put to bed in a Moses basket, but Mother’s friend stated to the Police and the Inquest that in the night the baby was in bed with Mother and was later found to not be breathing. Mother told the Lead Reviewer that she was not co-sleeping with Child A when he died. 8.40 This is a key episode because the focus of professionals was on the risk posed to Mother and Child A from Ex-Partner, and information on previous and more recent concerns about Mother’s behaviour was either not available, not shared or not reconsidered at this stage. 18 “Practitioners have serious concerns; Family is socially isolated; Experiencing unsafe situations.” (Level 3) Version 29.2.16 17 9 Analysis by Theme 9.1. From the information deduced from the agency reports, from the discussions at the Learning Events, and from the meetings with the family, several key themes have emerged. These can be summarised as: Mother’s vulnerabilities Focus on the child Multiagency meetings Lack of engagement Co-sleeping Information sharing, consent and evidence Family engagement Each theme will be considered below, with any learning clearly identified. Mother’s vulnerabilities: 9.2 The following potential risks were evident in this case: domestic abuse drugs and alcohol mental health / anxiety housing issues 9.3 Mother had significant issues that were likely to impact on her parenting of Child A. These included her anxiety and depression, the previous relationship with Ex-Partner that continued to have an impact both practically and emotionally, her apparent use of drugs and alcohol, and her more general life-style. A Serious Case Review enables all of the information known to agencies to be seen in one place, often for the first time, and this case is no exception. The benefit of both hindsight and the full information enables the reviewer to see that there was evidence of risk prior to the incident. However, with improved sharing of information and more challenge both of Mother and between professionals, the risks in this case to both Mother and Child A would have been more evident at the time. 9.4 The Health Visitor or CFP Workers did not observe any signs that Mother may have been using drugs or alcohol on their visits, although a number of the visits were undertaken at Grandmother’s home. Engagement remained poor, and Mother continued to miss appointments with a number of professionals, such as with IAPT, Probation, and midwives. 9.5 The overdose when Mother was 15 weeks pregnant was considered by those involved as an understandable reaction to having to give evidence in court the next day. Mother stated clearly that she did not intend to take an overdose, which allayed professional fears for her safety. The fact that she took unprescribed drugs and drank alcohol while pregnant, which was not an attempt to overdose, was not thoroughly considered as a potentially reckless misuse of substances that could be harmful to her unborn child. Most of the professionals involved had been informed that she had taken an overdose of alcohol and sleeping tablets. The overdose of opiates does not appear to have been as widely known, although a number of agencies were aware of it. In agency records, and in the Children’s Social Care and Children & Families Practices Agency Report prepared for this review, this incident was referred to as an ‘accident’ where Mother took too many of her tablets to relax. This was the shared understanding at the time, and was not sufficiently challenged. At the Version 29.2.16 18 Learning Event a number of those involved agreed that they had seen it as an adult protection issue rather than a child protection matter at the time. 9.6 In regards to the concern expressed by Maternal Grandmother that Mother could be misusing valium, there is no evidence this was ever discussed with Mother. The R&A team did not directly discuss the concerns with Grandmother. There was also a dilution of the information over time leading to a shared professional view that Mother may have used valium ‘to relax’ in the past. They accepted Mother’s claim that she had not used any prescription drugs since the overdose earlier in her pregnancy. Grandmother’s allegation, the concern of some professionals that Mother was often drowsy and incoherent when spoken to, and the fear shared by the Police that Mother may be addicted to ‘prescription’ drugs, were not rigorously considered by any of the professionals involved. The GP was not contacted to see what drugs Mother had been prescribed. There was no consideration that the regularly missed appointments and the difficulties in contacting Mother may have been a sign that she may be misusing drugs or alcohol. 9.7 The view shared at the Learning Event was that there was no evidence at the time of any risk to Child A from Mother’s use of drugs, however there was no focused assessment of the concerns or clarification of the potential evidence that was available. Child A did not show any signs of drug withdrawal at birth. Although the professionals involved in this case demonstrated a wider awareness of the risk that parents who are abusing drugs or alcohol will be dishonest about the extent of the issue, in this case it did not impact on their interventions with Mother. 9.8 In key episode 2 those involved felt there was no need to challenge Mother or to question if she was being honest about her use of drugs and alcohol. Mother may have been unwilling to share the probable extent of her drug use at this time due to a concern about what it would mean for her continuing to care for her unborn child, or because of her own needs. Research tells us that ‘for those who have experienced long histories of using substances or where the use has provided significant emotional support, facing the possibility of examining their pattern of substance misuse can be particularly stressful.19’ A drugs and alcohol assessment was not requested or undertaken. MK-ACT discussed it with Mother, but she refused to consider any input of this type, stating she had no current issues with drugs or alcohol. 9.9 Mother received a psychological assessment and offers of therapeutic input after the overdose, but she chose not to engage. The assessment noted some concerns about Mother’s low mood and anxiety, which again were thought to be linked to the on-going risk of abuse from Ex-Partner and, to a lesser extent, to the death of Sibling. However the GP held information that depression was a longer-term issue for Mother, which was likely to have an impact on her care of Child A. 9.10 Housing was an on-going concern for Mother, her family, and the professionals involved who were appropriately worried about the risk to Mother and her child when Ex-Partner was released from prison. This concern appears to have dominated professional engagement with Mother, and large amounts of professional energy were put into finding a solution within tight timescales. The concerns in this case were seen as domestic abuse and housing, and this led to inadequate consideration being given to the other risk factors evident. 19 Parental Substance Misuse and Child Welfare Brynna Kryll and Andy Taylor (2002) Version 29.2.16 19 9.11 The identified learning: Parents who are misusing drugs or alcohol can be very persuasive. To ensure that potential safeguarding risks are identified, professionals need to seek and consider objective evidence which can be used to confirm or challenge the accounts being given by the parent. ‘Respectful uncertainty20’ should be employed, particularly when drug or alcohol abuse is a possibility. The NSPCC published a report in 2010 called ‘Ten Pitfalls and How to Avoid Them - What Research Tells Us.21’ Four of the ten pitfalls in regards to assessing families in the community are relevant to this case. They are: An initial hypothesis is formulated on the basis of incomplete information, and is assessed and accepted too quickly. Practitioners become committed to this hypothesis and do not seek out information that may disconfirm or refute it. Attention is focused on the most visible or pressing problems; case history and less “obvious” details are insufficiently explored. Insufficient weight is given to information from family, friends and neighbours. There is insufficient full engagement with parents (mothers/fathers/other family carers) to assess risk. Focus on the child: 9.12 It is always important for practitioners to understand the lived experience of a child, and to consider the situation from the child’s perspective. The importance of gaining a picture of a child’s lived day-to-day experiences has been consistently highlighted in SCRs. In this case a lack of awareness of Mother’s lifestyle at the time means no real consideration was given to what Child A’s experience was going to be growing up in his family. Child A was very young when he died. Much of his lifetime was spent with his Mother living in his grandparent’s home. After Mother chose to return to her own accommodation following a drunken row with her mother, there is little known about what Child A’s lived experience would have been. It is clear that he continued to be well cared for physically, and that his Mother was loving and attentive to him when professionals were present. On the evening that he died Child A was with his mother at a friend’s house. She was drinking, believed she had used drugs, and she did not heed the advice she had been given about safe sleeping. 9.13 Child A was a much loved child. Mother and Grandparents speak of him with affection and pride. The many photographs of his short life show a thriving and smiling child. Both his mother and his grandparents had well maintained and comfortable homes, and the grandparents were willing and able to care for Child A and support Mother as required. On the occasions when Child A was seen by professionals they had no concerns. Mother’s immediate needs were the priority, and the professionals involved felt they were best meeting Child A’s needs by helping Mother. 9.14 The identified learning: 20 Lord Laming. Enquiry into the death of Victoria Climbie. 2003. 21 Dr Karen Broadhurst, Professor Sue White, Dr Sheila Fish, Professor Eileen Munro, Kay Fletcher and Helen Lincoln. NSPCC 2010 Version 29.2.16 20 It is important that all assessments seek an explicit understanding of a child’s lived experiences (or likely lived experience if they are not yet born) combined with a thorough analysis of the known risks and protective factors. When a service user is pregnant and engaged in risky or worrying behaviour (in this case Mother’s overdose of drugs and alcohol) professionals must consider the behaviour as a potential child protection issue. Multi-agency meetings: 9.15 A number of professionals from different agencies met to consider the case on occasion, with MARAC, MAPPA and TAF meetings held. The focus of all these meetings was the risk posed by Ex-Partner and Mother’s related housing issues. The risk of further domestic abuse to Mother, and the predicted risk to Child A himself when Ex-Partner realised the child was not his, dominated the discussions and plans. The meetings held did not identify and consider the wider risk factors. In the case of MAPPA and MARAC this focus is understandable and the timing of the TAF meeting led to a similar focus. This led to the continued shared professional understanding of what was perceived to be the main issues and risks. As stated in the agency report ‘from the perspective of the Health Visitor, mother’s main issue was being very scared because of the impending release of her ex-partner from prison and where she would be housed.’ The lack of shared information about continuing and concerning elements of Mother’s lifestyle led to these elements not being considered as relevant. 9.16 The focus of the TAF meeting was housing and safety planning for the release of Ex-Partner. This ensured the cooperation and attendance of Mother. She was described as reluctant to attend but appears to have been prepared to attend and engage with professionals who worked to her defined priorities. 9.17 There was good attendance at the TAF meeting which was held three days before Child A died. It included Mother, the CFP Practitioner and Senior Practitioner, the Health Visitor, Officers from DAIU, the MK-ACT Worker, Housing Officers, a Probation Worker and the previous Victim Support Worker who was now supporting Mother independently. Maternal Grandmother did not attend but looked after Child A. The meeting discussed the risk posed by Ex-Partner to Mother and Child A and the housing situation. It was noted Mother had been given a baby monitor, but hadn’t felt the need to use it as she had been living at her parents’ home. This was not rigorously challenged at the meeting, and Mother did not state that she had returned to her own flat. The meeting started a ‘Mapping’ exercise22 which considered the risk posed by Ex-Partner and the need for re-housing. As alcohol or drug use had not been identified as significant issues, and Mother was being supported by the previous Victim Support Worker, her wider needs and any risk from these to Child A were not considered. 9.18 Good attendance at the meeting and attempts to engage with Mother over the timeframe of this review show that the agencies involved appeared to have worked well together to address the concerns about domestic abuse and housing. However the focus of the work was primarily limited to these areas, and there was limited awareness of Mother’s vulnerabilities, which meant a robust assessment and planning around Child A was not 22 Part of the ‘Signs of Safety’ model. Where professionals consider what is working well, what is of concern, and what needs to be done. Version 29.2.16 21 identified as a need at this time. Housing stated that they were not aware of any concerns about Mother’s use of drugs or alcohol despite attending a number of meetings about the case prior to the death of Child A. The CFP were clear however that this meeting was used to discuss the immediate concerns, and there was an intention to extend the remit of their involvement at the next meeting. 9.19 MARAC meetings in Milton Keynes are held monthly and involve all of the key agencies. They look at incidents which have occurred up to 6 weeks previously due to the cut off date for referrals for MARAC. However, agencies generally undertake a number of tasks and assessments between the date of the incident and the meeting. The reason for the meeting is to check relevant information held across agencies, to share updated information, and to problem solve. The inclusion of Mother’s case in the meetings did lead to improved information sharing, however the confusion about whether she should have been discussed at the second meeting where her pregnancy was confirmed has led to a question being raised with the relevant agencies about the process and recording of meetings that is being pursued. 9.20 The learning identified: A parent with vulnerabilities requires a positive and understanding response from professionals. When considering their potential to parent their child there should also be robust and honest challenge about the areas and behaviours which would negatively impact on the child. Professionals attending a TAF meeting need to have a shared understanding of the background concerns and risks as well as consideration of the immediate concerns that led to the meeting. This will ensure the best plan is devised for a child. If the meeting is part of a longer term process to develop a clearer understanding of the family, including any risks and protective factors, this should be clarified with those in attendance and recorded. Lack of engagement: 9.21 Despite the risks, with the support available from her own family and from professionals, there is no reason to believe that Mother could not have successfully parented Child A. However, Mother’s lack of engagement with a number of professionals led to a lack of relevant assessments and limitations in the impact of the support offered. Maternal Grandmother’s help was valuable, but Mother did not always accept or seek her support unless she could see the benefit of doing so. Mother was also happy to accept professional support, for example with housing, but this had to be on her own terms. She did not cooperate when her own behaviour was questioned. 9.22 There were a number of indicators that Mother was resistant to professionals, but this was generally seen as understandable. It was accepted she was very anxious because she was a victim of serious domestic abuse, involved in the difficult court case against ex-partner, and fearful that her child would be removed from her care. The midwives described Mother as ‘jumpy’ when they questioned her, and said she was clearly nervous around them. This could be because of a genuine fear of professionals intervening in her life, or because she did not want her choices being exposed and questioned. Version 29.2.16 22 9.23 Mother’s lifestyle was described as ‘chaotic’ at the learning event, including when she was pregnant. Witness Care at the criminal court recorded Mother as ‘notoriously difficult to get hold of.’ This was a view that all professionals at the learning events could relate to. 9.24 The ‘rule of optimism’ in safeguarding decision-making was first identified by Dingwall Ekeelaar and Murray in 198323. They acknowledged that those in the helping professions may be inclined towards positive interpretations of what is going on, and the propensity to see the best in those they are working with. In this case Mother tended to cooperate with professionals just enough to reassure them that she was compliant. After the overdose in key episode 1 Mother minimised both what had happened and her intent, and reassured professionals that the crisis was a one-off linked to the court case and would not reoccur. Her version of events became the accepted story both at the time and since. There were occasions when she showed disguised compliance, stating that her anxiety after the death of Sibling led her to be nervous around professionals, and that she wanted to cooperate. While there was likely to be some truth in this, the situation was more complex and the acceptance of her reluctance to engage as understandable allowed Mother to avoid difficult conversations about her lifestyle. 9.25 Mother did not respond well to challenge, as the midwife found when she questioned Mother about missed appointments and whether she had been drinking. Anxiety about challenging the service user may stop the recognition or exploration of difficult issues by professionals, such as the potentially problematic drinking and drug use in this case. The health visitor made a decision to visit Mother in pairs due to a concern that Mother was not always truthful. This leads the review to question the otherwise accepted view that Mother was generally honest with professionals. 9.26 Those working with Mother in regards to the domestic abuse expressed their concern about Mother’s vulnerability and the impact contact from social workers from the R&A team would have on her at the time of the criminal trial. They also voiced concern about the impact on their on-going relationship with her when she became aware of them referring their concerns about the potential misuse of prescribed drugs. While this is understandable, it could set a precedent of putting Mother’s needs before the need to consider any potential risk to the unborn child. Those involved however were clear that they did not ask that Mother was not contacted, rather that any contact was made in a sensitive way. The R&A deputy manager decided there would be no further action from CS in relation to the referral as other agencies were supporting Mother and she had stated that she did not want support from CFP. It was stated that there was no evidence that Mother was misusing drugs, so CS did not believe they had the authority to undertake any further enquiries without Mother’s consent. They also did not consider any other evidence that might be available, including a clarifying discussion with Grandmother. It is the Lead Reviewer’s view that there was enough concern at this time to justify further enquiries about the issue. 9.27 Limited support was offered to Mother from community health professionals involved during the pregnancy beyond standard health interventions. Mother stated during this review that it is very hard to get hold of the midwives and that she did try to contact them a number of times and was not called back. When she did see them she stated they did not seem interested in her. The agency report for midwifery services states that there was ‘no 23 The protection of children: state intervention and family life. 1983 Version 29.2.16 23 evidence that consideration was given to the support available to Mother, especially in light of the concerns about her previous child dying, her abusive relationship/s, and her anxiety’. A referral was not made to the bereavement midwife. The postnatal plan made reference to Mother’s history of domestic abuse, depression and anxiety and the need for more regular post-natal visits. However, ‘minimal visits occurred and the records for those visits predominately make reference to the medical activities and not the emotional or social needs’. (Agency Report). It is also noted that staff on the post-natal ward did not discuss with Mother the concerns that were known previously with regard to drinking, smoking and drug taking. 9.28 The GP and the midwives identified Mother’s habitual non-compliance with antenatal care. This led to a conversation with the Named Safeguarding Midwife to discuss a potential referral to the MASH, which was decided against. The information held about Mother’s ongoing depression, anxiety and limited engagement was shared with the Health Visitor but no referral was made to the R&A team / MASH, and there was no liaison or sharing of information with other non-health agencies involved with Mother such as victim support and MK-ACT. It has not been established why this decision was made. 9.29 The probation victim liaison unit had a number of telephone conversations with Mother, wrote to her and then attempted to meet with her. She did not attend any of the meetings arranged however. They considered Mother to be ‘chaotic, rather than not bothered or choosing to actively not engage.’ (Agency report.) Victims have no obligation to engage so no further action was taken. 9.30 The GP was aware that Mother had missed a number of appointments with the midwives, and after a concern had been identified about the size of unborn Child A she missed an appointment with the GP. The GP agency report states that the missed appointments ‘should have been addressed more assertively to ensure the health needs of the unborn child were being fully met’. The rationale relating to the decision not to refer to MASH following the GP’s discussion with the Safeguarding Midwife is not documented within the maternal GP records. 9.31 Mother was regularly accompanied by her counsellor, who had previously been her Victim Support Worker. The counsellor would often speak for Mother at meetings and attended the MAPPA professionals meeting despite it not being appropriate for her to do so, as the meeting is for agency professionals only. There was a lack of professional curiosity about this individual’s role, and it is of concern to the review that the involvement of this individual may have led Mother to refuse the support being offered by agencies. This issue is being pursued outside of this review. 9.32 The identified learning: It is difficult for professionals to maintain the engagement of a service user who is likely to withdraw their cooperation, or refuse to give consent for information sharing, when they are challenged. The threat of withdrawal from engagement should be seen as an indicator of risk. Professionals need to acknowledge that a service user may not be telling the truth. The notion of ‘high support, high challenge’ should be the aim of engagement with families. It is acknowledged that this is a complex and difficult balance, which to do well requires skilled practitioners, reflective practice and effective supervision. Version 29.2.16 24 Supervision needs to be available and sought to help professionals challenge themselves, each other and family members when there are concerns about lack of engagement. Professionals need to understand and clarify the role and status of any volunteers or advocates before disclosing confidential information or including them in meetings. Adult behaviour needs to be understood by professionals, especially those who primarily provide services to adults, in terms of the impact of that behaviour not just on the adult but on their child. This needs to be evaluated accordingly where the adult is about to become or is a parent. Co-sleeping: 9.33 An investigation of the extent to which Mother’s actions on the evening of Child A’s death might be considered criminally negligent has been undertaken by Thames Valley Police and it has been concluded by the Crown Prosecution Service that there is insufficient evidence for a prosecution. Child A’s death cannot be directly attributed to any actions taken or not taken by his Mother, however her life style, her consumption of alcohol, and her intention to use drugs are known risk factors for sudden unexpected death in infancy and are likely to have played a part. No agency or professional could have prevented the death had they acted differently however. Mother was given appropriate advice regarding co-sleeping, and Mother understood the added risks of drinking/drug use, of overheating, and of roll over if sleeping with her baby. 9.34 Co-sleeping was specifically discussed with Mother and Grandmother a number of times, including at the new birth visit. She was also given the safe sleep leaflet. The CONI nurse visited and provided advice about avoiding sudden infant death, and the risks of co-sleeping. It is noted in the GP agency report however that while the death of Sibling was discussed by Mother with her GP, safe sleeping arrangements discussions were not documented in any of the medical notes reviewed. 9.35 When speaking to Maternal Grandmother as part of this review it was clear that within the family co-sleeping was common. She spoke of the family staying up at night and taking turns to hold the baby while he was sleeping, rather than putting him down to sleep in his crib. Their anxiety, which was due to Sibling dying alone in their crib, appears to have led to this practice. There is no evidence that this information was shared with professionals involved at the time. A child who is not used to sleeping alone is likely to be unsettled at night when placed in a cot or crib, leading to the increased risk of co-sleeping when their mother is caring for them alone. This appears to have been the case here. 9.36 The identified learning: Despite a commitment to ensuring families are aware of the need to adhere to safe-sleeping advice, it is not always possible for professionals to identify a family where there is an un-disclosed culture of co-sleeping. Version 29.2.16 25 Information sharing, consent and evidence: 9.37 Communication and information sharing is an issue that is regularly highlighted in SCRs, and this review is no exception. As stated in Learning Lessons from Serious Case Reviews24 ‘for most families a great deal of information was known but it was not coordinated and evaluated until the serious case review was completed.’ This report has made reference to inter-agency communication in this case, much of which is positive, such as information sharing between MK-Act and the R&A team and the Police DAIU. However there were also some problems. They include the limited information sought from and by the GP, the R&A team not informing either the midwife or health visitor about the case being closed to them in key episode 2, the Police not sufficiently sharing information about the incident between Mother and Grandmother, and the limited information shared with the involved housing professionals regarding Mother’s potential misuse of drugs and alcohol. Limited communication with Maternal Grandmother was also an issue. 9.38 The GP was potentially a key contact, particularly as they held a lot of information in regards to the identified anxiety and depression and knew what medication Mother had been prescribed. There was little engagement or information sharing with the GP. This may be because the GP was not proactively engaged or because other professionals do not seek to engage GPs in the day-to-day management of cases. The issue of consent was also an issue. Professionals reported during this review that their understanding is that they are unable to contact GPs without the explicit consent of the client. To ensure optimum information is available for assessments and case management GPs should always be contacted. If explicit consent is not given or is not available due to lack of engagement by the parent, but there are concerns about the impact on a child of a parent’s health or use of medication (as in this case), consideration should be given to requesting information without this consent. This is a fully defensible and legal approach. The government recently published information sharing guidance which emphasises that data protection legislation is a support and not a barrier to the effective safeguarding of children25. Information sharing guidance should be a guide to professional practice but not a hindrance to appropriate professional curiosity. 9.39 There is a clear understanding of thresholds and levels of need in Milton Keynes. They are well publicised and it is acknowledged that a response under level 426 is only undertaken in the most serious cases. None of the individual referrals or the information shared with the R&A team in this case led to a Level 4 response in this case. This appears to have been accepted by the professionals involved at the time as there was no use of the escalation procedure for professional disagreements. Workers from R&A/MASH were clear during the review that had the information which was known by other agencies been shared with them this would have resulted in a Social Work assessment under level 4. However the lack of curiosity about what was shared, such as Grandmother’s concerns and the information from Police about Mother’s presentation in key episode 2, should have led to a more robust assessment by a social worker. 24Ofsted 2008 – 9. 25 Information Sharing Advice for Safeguarding Practitioners. Department for Education. 26 March 2015. 26 Specialist services intervention coordinated through statutory process alongside universal services. Version 29.2.16 26 9.40 There was a need to consider each new concern alongside the known history. Past experiences have a critical impact on present and future behaviour, so the understanding of a person's history must always inform any assessment being undertaken by the professionals working with children and their families. This should lead to a professional assessment of the wider picture, not just what evidence there is of risk from single issues or events. In this case the need to keep Mother on board, the need to address serious concerns about Ex-Partner, and the need to keep Mother and child safe from domestic abuse appears to have led to a focus on the here and now. It also diverted professional attention from risky behaviour, and led to a limited consideration of what else might be important. 9.41 Other issues such as the access by CFP to the client data base used by the R&A team, the use of confidential communiqués in place of conversations on occasion, the need for timely sharing of information from the MARAC with those working with the families (such as housing staff), the lack of information sharing by the Police after the incident at Grandmother’s home, and the lack of detailed information sharing between IAPT and the GP were also highlighted in the agency reports. However it was stated clearly at the Learning Events that information sharing in Milton Keynes is generally very good, that professionals do communicate and do share information appropriately with each other and with the MASH. 9.42 The learning identified: GPs are a crucial part of the safeguarding system. Sharing information with them, and seeking the information they hold, should be a standard action in any assessment. All professionals need to understand, through their own agency and MKSCB training and learning, how to have and understand difficult conversations with other agencies and professionals from other disciplines. Any new information gained by a professional should always be considered alongside the information already available. Family engagement: 9.43 The grandparents of Child A were very involved in his care during his short life. Maternal Grandmother spoke regularly to a number of professionals in housing and domestic abuse services. She shared her concern about Mothers use of drugs, but she was not asked for more information in regards to this, despite her knowledge and the probability that discussing this issue must have been very difficult for her. She was not assertive about her concerns, and they were largely overlooked. The information she may have had regarding her daughter was underutilised in the assessments undertaken and decisions made in this case. The Review was told that audits of CS records generally show very good involvement of family members in assessments and subsequent plans however. 9.44 This review has concluded that despite different reports from Mother to agencies involved at the time, it remains unclear who Child A’s Father is. Therefore it has not been possible to consult with them as part of this SCR. 9.45 The learning identified: Family members can hold significant information and they should be engaged with and spoken to when making an assessment. As they can also provide important support and care for families, they should be appropriately utilised. Version 29.2.16 27 The benefits and difficulties inherent in involving wider families in assessments and plans need to be fully evaluated and understood by professionals. Assumptions can be made about the implicit protection provided by wider family members to children. Professionals need to be aware of making such assumptions and recognise the risk of doing so. 10 Conclusions 10.1. The death of Child A was a tragedy, but it appears that Mother’s lifestyle may have had an impact on the turn of events, as the Coroner stated at the Inquest into the death. 10.2. While it appears that the professional interventions in this case have had no bearing on Child A’s death, this SCR was agreed by the MKSCB as they identified that learning could be gained from the degree of scrutiny an SCR provides. The review has attempted to avoid hindsight bias which “oversimplifies or trivialises the situation confronting the practitioner and masks the processes affecting practitioner behaviour” (Woods et al27). It has consulted with those involved at the time and has sought to understand why actions were taken and decisions were made. 10.3. This SCR has identified statements of learning which were developed from the themes considered above, and have been listed at the start of this report. 10.4. It is also important to learn from the good practice identified during the course of this review. It is acknowledged that there was good practice across a number of agencies in the following areas: Communication and information sharing. Recording. Management oversight. Timely and coordinated responses to concerns. The use of multi-agency referral forms. The persistence of a number of professionals to see Mother when she was missing appointments or not answering her door. The review was assured that this is standard practice within Milton Keynes and recognises the value of this. 10.5. The other agency specific good practice which the review has identified is: When Mother was seen in hospital after the overdose the staff recognised the risk to the unborn child and made a referral to Children's Social Care and contacted the maternity unit. The mental health assessment identified Mother’s history in relation to the “toxic trio” of depression, drug and alcohol misuse and domestic abuse. Police and the CPS put a plan into place for Mother to give evidence via video link from a police station in the trial of Ex-Partner. 27 David D Woods et al. Behind Human Error. 2010. Version 29.2.16 28 The emergency response to Mother’s overdose by MK-ACT, the police and ambulance service. The flexibility of the housing service regarding providing accommodation for Mother and Child A. The CFP staff attempted unannounced as well as planned visits in this case. The CFP Practitioner became involved in a timely way and arranged a TAF meeting to address Child A and Mother’s safety before Ex-Partner was released from prison. 10.6. It is also acknowledged that there has been a high degree of cooperation and engagement from agencies with the SCR process, which the Lead Reviewer has appreciated. 10.7. There have been some changes within partner agencies of the MKSCB since the death of Child A. This reflects the fact that some of the “best learning from serious case reviews may come from the process of carrying out the review” 28 Other changes have happened which were unrelated to the death of Child A but show the continuing improvement culture in Milton Keynes. 10.8. The changes are as follows: The Milton Keynes MASH has an approach to information sharing about lower need cases that is different to that previously applied in the R&A team. This means the information sharing issues that arose around key event 2 are less likely to happen again as the “information package” within the MASH firewall would include health worker liaison with the GP. There has been a change in practice for the Lead Midwife roles for Perinatal Mental Health and Domestic Abuse from being advisory and supportive to case holding midwives to case holding women who are identified as high risk according to the developed risk matrix. The health visiting service has updated service guidance regarding receipt of Confidential Communiqués. Following a change of structure within the housing service all officers within the Moving Home Team have now received additional training in safe guarding (‘MKSCB Everybody’s Business’.) As part of the Housing Options Assessments, case files will be submitted to a Senior Officer or Housing Services Manager for review and agreement of assessment. The three CFPs have the same systems and processes and work in the same way. Previously there was slight variation. CFP policies have been reviewed, including: o A Non-Engagement Policy is being developed. 28 Brandon et al. Lessons from Serious Case Reviews. 2012 Version 29.2.16 29 o A protocol covering the transfer of cases between CSC and CFP, to support smooth transition of cases at the appropriate time, is in place and is currently being reviewed. CFP’s work focuses on cases assessed as Level of Need 3. They no longer work with cases assessed as Level of Need 2, which are now supported by co-ordinated universal services. Management of the CFPs is now within the Children’s Social Care management structure. Health professionals are now located within the MASH. The MASH reports an increased use of the consultation they provide to partner agencies who wish to discuss a case. They also report a healthy culture of debate. For cases which are considered by the MASH to be Level of Need 3, but with a high level of concern, a contingency plan is included in the referral to CFP. For example, if there is a lack of engagement or progress, within a given timescale, the case should be referred back to MASH. Since September 2014 all case recording is located on the Early Help system used by CFPs, unless the case is open to Children’s Social Care or subject to child protection investigation. This allows more access to historic details on a case by staff in CFPs. In April 2015, Milton Keynes Mental Health Commissioners established a Perinatal Mental Health Collaborative group to review and improve perinatal mental health pathways. This will have a significant impact on the work of CNWLMK Mental Health Services in terms of the support they will be able to offer perinatal women and effectively ensure the safety and welfare of children. With the formation of the MASH new processes for Thames Valley Police (TVP) have been introduced, such as the Triaging of Domestic Abuse referrals to Children’s Social Care, including twice weekly multi-agency meetings. Niche Record Management System has been introduced by TVP. This involves new methods of recording including the use of Risk Management Occurrences - a standalone record to detail all the ongoing risk management activity for a domestic abuse case. Development of a process where DAIU staff are expected to create a Child Protection occurrence report in line with front line officers attending domestic abuse incidents and discovering potential child protection concerns. All GP practices now have an identified named GP lead for safeguarding. Additionally the Designated professionals and Named GP run quarterly safeguarding forums for GP leads and Practice Managers to support with safeguarding arrangements within each practice and to update on learning from SCRs. GP practices are being encouraged to hold Monthly Multi Disciplinary Team meetings within their practices to discuss any safeguarding concerns identified. These include the HV and Midwife. Version 29.2.16 30 An electronic template has been created to embed into System One (the clinical computer system used by all GP Practices within Milton Keynes) to support GP’s in identifying and sharing information relating to known vulnerabilities and/or safeguarding concerns when a patient/ family transfers to a new GP Practice. 11 Recommendations 11.1. The final report was discussed at the MKSCB Board meeting and the following recommendations were identified as the key areas of focus arising from the learning: 11.2. It is recognised that actions have already been taken in relation to some of the individual agency's identified learning. In addition the agency reports included some recommendations which had largely been completed by the conclusion of the SCR. 11.3. The purpose of providing additional recommendations is to ensure that the MKSCB and all professionals in the partner agencies of the Board are confident that any areas identified as of concern in this review are addressed. The MKSCB has considered the conclusions and learning from this review and after consulting with the Lead Reviewer have identified the overall significant learning points for the partner agencies of the MKSCB and made recommendations. These recommendations are designed to apply the learning from undertaking this SCR in such a way as to achieve the best outcomes for other children and their families in terms of informing and improving practice: 11.4. Overall Learning Points: a. Professionals who mainly work with adults need to be able to understand the adult’s behaviour in terms of the impact it has on that adult’s child/children, evaluate it accordingly and act appropriately in order to ensure that the child/children are appropriately safeguarded. They in particular need to do so when concerns do not meet the threshold for intervention at level three of the MKSCB Levels of Need. They also need to see beyond the immediate or presenting issues; see the situation in the round; assess the context and the child’s as well as the adult’s needs effectively; understand and thoroughly address identified and assessed risks and ensure any plans appropriately address the whole situation on a multi-agency basis. To do this they need to understand the child’s lived experience, involve the wider family fully and recognise the risks inherent in doing so. b. Staff across all agencies need to confidently and competently exercise “high support; high challenge” when engaging with adults; use respectful uncertainty in their interactions; recognise when engagement or its’ absence is creating risks for a child and ensure that empathy for an adult’s own challenges does not obscure a rigorous focus on those affected by those challenges. c. All those agencies working with adults as well as children need to ensure frontline staff are properly supervised and good management oversight is in place to ensure that professionals retain objectivity, are able to have difficult conversations, challenge each other and constantly review their interactions with adults and their children in the light of changing circumstances and information Version 29.2.16 31 11.5. Recommendations to address those learning points: a. That the MKSCB Neglect group extend their remit to become an early help development group. Jointly working with MKSAB members, the group will develop tools to assist practitioners working with adults to better understand early help services for adults and children, and develop clear pathways for assessing a range of adult and children’s needs at the same time (a family focussed model of intervention). The toolkit will facilitate engagement that is holistic and assertive, based on a sound assessment of the whole context for that family, their strengths and those areas of risk that need addressing, and resulting in a plan for support and change. b. The learning from this SCR is widely disseminated through learning events in each agency as well as through material provided by MKSCB. In addition MKSCB works with partners to develop common learning materials for each agency to utilise which provide tools, research evidence, intervention methodologies and standards for working in a “high support/high challenge” way with vulnerable adults who are also parents. c. In addition partner agencies assure themselves, through their own quality assurance systems, that they have effective systems in place to ensure front line professionals receive appropriate supervision and management oversight, based on the multi-agency standards set by MKSCB 11.6 The outcomes the MKSCB want to see as a result: a. A clear framework for professionals working with both vulnerable adults and children who need early help that ensures adults know what is expected of them when they receive support, what needs to change and why, and that ensure children’s needs are central to decision making when meeting their parent’s needs. b. A shared multi-agency set of tools and methodologies for family focussed restorative practice with vulnerable, challenging or hard to engage parents. This should lead to clear evidence from what those adults and their children tell us, that whilst they may not like everything they hear, they feel supported and are clear about what is expected of them. c. Evidence from audits and reviews of practice that Milton Keynes has confident, competent and well supported front line professionals who work with adults as well as children; who engage in good disagreements; have difficult conversations and understand how to engage with and support families through high support and high challenge; and where the plans in place clearly improve children’s life chances and outcomes effectively and safely. |
NC046217 | Death of a 3-week-old girl in June 2013; coroner classified cause of death as 'unascertained'. Following Child T's death, a home visit found that the family were living in dirty and unhygienic conditions. There had been no previous concerns about the mother's care of her children, and they were not known to children's social care. Issues identified include: confusion across partner agencies about when the Common Assessment Framework (CAF) was open and when it had been closed and a failure to check the room in which the child was to sleep during the community midwife's home visit. Recommendations include: simplify the management system used to track CAFs and introduce as standard a physical check of the room in which the child sleeps in the day and night.
| Title: Overview report of the serious case review concerning the death of Child T. LSCB: Coventry Safeguarding Children Board Author: Felicity Schofield Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 COVENTRY SAFEGUARDING CHILDREN BOARD SERIOUS CASE REVIEW This is an Independent overview report of the Serious Case Review concerning the death of Child T DATE OF SERIOUS INCIDENT: June 2014 Date of report: March 2015 Agreed by Coventry Safeguarding Children Board: 30th January 2015 Independent author: Felicity Schofield SCR Chair: David Peplow 2 Contents Page no. 1. Summary of the case…………………………………………………………………………………..3 2. Terms of Reference…………………………………………………………………………………….3 3. The process……………………………………………………………………………………………….4 4. Involvement of the family……………………………………………………………………………4 5. Background prior to the Scoped Period…………………………………………………………5 6. Ante-natal period……………………………………………………………………………………….5 7. Post-natal period…………………………………………………………………………………………7 8. Examples of Good Practice…………………………………………………………………………..9 9. Action taken since Child T’s death………………………………………………………………………10 10. Findings & Recommendations……………………………………………………………………….11 3 1. SUMMARY OF THE CASE 1.1 The subject of this serious case review (SCR) is Child T, a white British baby girl who died at the age 3 weeks in June 2013. Child T had an older sibling who was 17 months old at the time of Child T’s death. The father had no involvement with the child’s care, his relationship with the mother having ended prior to Child T’s birth. 1.2 The cause of Child T’s death was classified as ‘unascertained’ by the coroner. That is, some abnormalities were found in the post mortem examination and therefore, it was not classified as a Sudden Unexplained Death in Infancy (SUDI). The abnormalities were firstly significant thrush and secondly a congenital viral infection called Cytomegalovirus1. Neither of these factors were considered significant enough to have caused or contributed to Child T’s death. Cytomegalovirus is not associated with poor hygiene. 1.3 There had been no concerns about the mother’s care of either Child T or the older sibling prior to Child T’s death and they were not known to children’s social care. However, when the family home was visited immediately following Child T’s death, it was found to be squalid with dirty nappies, rubbish and food all over the floor. It was very hot and there were flies everywhere. In the police officer’s opinion it was not fit for human habitation. The police investigation concluded that whilst a case for criminal neglect had been established, it was not in the public interest to prosecute. 1.4 This review seeks to analyse the events leading up to Child T’s death, with an emphasis on understanding how agencies worked together and how the organisational context of those agencies may have affected the work of their practitioners. 2. TERMS OF REFERENCE 2.1 The detailed terms of reference are attached at appendix 1. The purpose, framework, agency reports to be commissioned and the particular areas for consideration are all described there. Six agencies contributed to this review. 2.2 It was agreed that the scope of this review would be between October 2012 when it became known that the mother was pregnant and June 2013 when Child T died. 1. Cytomegalovirus (CMV) is a common virus in the Community. It would give most adults nothing more than a cold but can cause problems if it affects an unborn child. It is estimated that one to two babies in every 200 will be born with CMV in the UK. Of these about 13% will have problems when they are born. 4 3. THE PROCESS 3.1 The LSCB’s serious case review sub-committee first considered the circumstances of Child T’s death at a meeting in July 2013 and recommended to the chair of the LSCB that the case met the threshold for a SCR because of the extent of the neglect documented by the police. 3.2 Further advice was sought from both the pathologist and from one of country’s leading experts on death in childhood, Dr Peter Sidebotham. His opinion was that unless there was evidence that the state of the family home was linked to Child T’s death, he would be hesitant to go down the route of a SCR. On this basis, it was decided not to proceed with a SCR. However, the LSCB Chair reviewed her decision in June 2014 and decided that the criteria for a SCR had been met and that a SCR should be commissioned. 3.3 The first meeting of the independently chaired SCR panel was in August 2014. The Chair and Overview Report writer are independent of all professional agencies in Coventry, have had no previous direct involvement with or knowledge of the family who were subject to the review and have had no previous involvement in a professional capacity with safeguarding practice in Coventry. Both are LSCB chairs elsewhere in the country. 3.4 Working Together to Safeguard Children 2013 states that serious case reviews should be conducted in a way which: Recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; Is transparent about the way data are collected and analysed; and Makes use of relevant research and case evidence to inform the findings. This serious case review has been undertaken in a way that ensures these principles have been followed. 4. INVOLVEMENT OF THE FAMILY Child T’s mother and grandmother are aware that this SCR has been commissioned and were visited in order for the process to be explained. Initially, Child T’s mother agreed to contribute further and arrangements were made for her to meet with the lead reviewer and SCR panel chair. However, she did not attend the meeting. Several subsequent attempts to contact the mother have proved 5 unsuccessful and it must be concluded that, for the time being at least, she has decided against any further involvement. 5. BACKGROUND TO THE SCOPED PERIOD 5.1 The mother became known to community health services when she became pregnant for the first time with Child T’s older sibling, who was born in January 2012. At the time of the birth, the mother was 18 years old and living with the baby’s father. Prior to the sibling’s birth there had been no significant contact by children’s social care (CSC) with either the mother or her partner. 5.2 A Children’s Centre offered support to the family from January 2012 following some missed appointments. A Common Assessment Framework (CAF) was completed in February 2012. The focus of the CAF was keeping the home clean and tidy, benefits advice, the provision of safety equipment and access to Children’s Centre activities. The family engaged appropriately and the health visitor (HV) recorded that at a meeting with the mother in May 2012, it was agreed that the CAF would be closed because the mother and older sibling had moved back to live with the maternal grandmother and the father had returned to live with his parents. However, the CAF was not in fact closed by the Children’s Centre until November 2012. 5.3 Throughout this period, the mother sought appropriate advice from the GP for the sibling regarding a number of minor issues. The GP records did not include information about the CAF. Analysis 5.4 There is nothing significant about the background of this family. Child T’s mother was young and on benefits so she would have been regarded as vulnerable and was appropriately offered support from the local Children’s Centre. She was not always easy to either contact or to find, spending time at her mother’s home as well as her own, and she sometimes missed appointments. There were no concerns about her care of Child T’s sibling. Agencies had different views about when the CAF was closed. This is referred to later in this report. 6. ANTE-NATAL PERIOD (October 2012 – May 2013) 6.1 The mother was booked in for her ante-natal care on 9 October 2012 at around 8 weeks pregnant. Knowledge of the earlier CAF, which was recorded as closed, was evident in both the antenatal and delivery records at the hospital. The midwife did not advise the Children’s Centre of the mother’s second pregnancy. 6.2 At 28 weeks into the pregnancy, concerns arose that the baby was not growing well and a decision was made to provide the mother with consultant led care together with frequent monitoring of the baby. In total the mother attended 27 pregnancy related appointments, which is approximately 6 three times the number for a problem free pregnancy. If she was unable to attend, she always contacted the clinic. It was a bus journey away and sometimes she didn’t have the bus fare. 6.3 The mother was offered a new, unfurnished tenancy in October. It was assessed as being in poor decorative state and vouchers were provided for redecoration. On the basis of a self-assessment, the mother was assessed as requiring a low level of support. This consisted of a telephone call approximately 3 weeks into the tenancy to establish if there were any problems and/or if further assistance was required. Repairs to the boiler, which was not working, were carried out at the end of January after a number of missed appointments. It would appear that the mother and older sibling were living mainly with the grandmother up until then. 6.4 An outstanding home safety check by the Children’s Centre worker was postponed pending the move to the new address. However, it was not carried out because the mother did not respond to the Children’s Centre worker’s phone calls. She had previously advised the Children’s Centre worker that she did not need any extra support because she was managing well and had the support of her family. 6.5 At this point, the HV thought the CAF had been closed in May but it had in fact been kept open by the Children’s Centre because the home safety check was outstanding. The CAF was closed at the end of November 2012. There is no record of this decision being discussed by the line manager. The Children’s Centre were unaware of the second pregnancy. 6.6 The GP contacted the HV at the end of November, advised her that the sibling had been seen in surgery and had a sore bottom and a respiratory tract infection and requested a follow up visit. This took place at the grandmother’s home the following day. The HV had no concerns about the home environment. The sibling looked well and was smiling and interacting appropriately. The mother advised the HV that she was pregnant and that she had been offered a new tenancy. 6.7 The mother took the sibling to the GP twice in November because of a viral infection and nappy rash. Following the second visit, the GP left a message for the HV asking her to visit, expressing some concerns about the mother’s ‘mothering skills’. The sibling was seen the next day by the community staff nurse who subsequently left a message for the GP advising that she had provided advice about nappy rash and that she had no outstanding concerns. 6.8 The sibling attended clinic for a routine developmental assessment at the beginning of December 2012. The sibling was assessed as having age appropriate development with no parental concerns. The child’s bottom was clean and healing and the child was clothed appropriately. The mother advised the nursery nurse that she was pregnant. She was recorded as looking a bit unkempt with grubby clothes and this information was passed on to the HV. 7 6.9 In response, the mother was offered further support from the Children’s Centre but she advised the worker that she did not need it. The Children’s Centre worker then contacted the HV regarding the mother’s request to cancel the CAF. In fact the HV had believed the CAF to have been closed in May. On the basis that the CAF had not been closed, the HV requested that it be kept open until the New Year, when she had visited the mother and sibling in their new home. 6.10 The HV did not manage to see the mother in her new home because there was no reply when she called for a pre-arranged visit. There was no further contact from the HV until after Child T’s birth in May 2013. 6.11 Overall, professionals found it hard to make contact with the mother during this period, but both the Children’s Centre worker and the HV were persistent in making contact. The sibling was not seen in the new accommodation. Analysis 6.12 There were no concerns about the sibling’s welfare during this period and the mother was good at keeping her ante-natal appointments, of which there were many because of the baby’s slow growth. With hindsight, the slow growth is likely to have been due at least in part to the Cytomegalovirus. The mother seemed more willing to see professionals outside the family home. 6.13 There was general confusion between the early support services, the health visiting service and the mother about whether or not a CAF was open and when services were being offered by the Children’s Centre but not under the auspices of a CAF. 6.14 The midwife did not advise the children’s centre that the mother was pregnant with her second child which would have been good practice even though she believed the CAF to have been closed in May. The GP was not involved at all with the CAF process. 6.15 There was a gap of nearly 4 months between the tenancy being signed for and the boiler being repaired. This covered the winter period and the tenant had a child who was only a year old. In this case, it seems likely that the mother was not actually living in the tenancy, however, as part of this review, the housing provider has recognised that this was a potential risk and implemented changes which are described later in this report. 7. THE POSTNATAL PERIOD (16 May – 6 June) 7.1 Child T was born on 16 May 2013 following a normal delivery. She weighed 2.44 kg and, by definition, had Intra Uterine Growth Restriction (IUGR). The mother and Child T were discharged from hospital 2 days later following postnatal checks and the provision of safe sleeping advice. They were discharged to the grandmother’s address, but returned to their own home within a day or so. 8 This unexpected change of address resulted in the midwife having to make additional visits in order to ‘find’ the mother, who proved difficult to contact by phone. 7.2 The mother and Child T were visited by the midwife on 19 and 22 May. At the first visit, Child T was fully examined and was found to be well and alert. The second visit was undertaken by the same midwife who recognised the vulnerability of the situation because the mother was young and living on her own and Child T was so small. The flat was sparse but not dirty or cluttered. There was a Moses basket in the living room which was described as ‘lovely’, with pink surrounds. The baby weighed 2.34 kg, was alert and not jaundiced. Her eyes and mouth were clear. 7.3 The mother had been worried about Child T, who was pale and not feeding very well, since shortly after her birth. On 27 and 29 May Child T was seen firstly at a walk-in centre and secondly by the GP, on both occasions because of bilateral conjunctivitis. Reassurance was given to the mother and no other concerns were identified. 7.4 On 31 May the HV carried out a ‘new birth’ visit at the grandmother’s house. Child T had returned to her birth weight. The mother reported that Child T seemed better and no evidence of illness was observed by the HV, with the exception of a possible fungal infection on the child’s buttocks for which it was suggested that the mother contact the GP. Advice was given on safe sleeping and passive smoking. The mother had been staying with the maternal grandmother but was returning home that day. 7.5 The HV assessed that the mother would need some extra support with practical issues such as engagement with the children’s centre but had no concerns about the children. Her intention was to propose a CAF at the next contact and planned to visit in a week’s time, with an appointment booked for 7 June. Sadly, Child T died before that visit took place. 7.6 The mother, the sibling’s father, the sibling and Child T attended the post-natal clinic at the children’s centre on 3 June. Child T had gained weight and was feeding well. The family registered with the children’s centre and as part of the visit informed the children’s centre assistant that the midwife had advised them to take Child T to the GP because she still had thrush and a sticky eye. 7.7 After Child T’s death, the mother advised professionals that Child T had been very unsettled during the night of 4 & 5 June and that she had tried and failed to get a GP appointment. The GP was surprised to hear this because the practice had a policy that if any patient said they needed to be seen on the day, they would be seen ‘no questions asked’. 7.8 The following night Child T appeared well and was put to sleep in her Moses basket. The mother woke and found Child T dead at 5am on 6 June. 9 7.9 On examination, there was no obvious bruising to Child T’s body and a post mortem did not identify any evidence of injury or overlaying. 7.10 Following Child T’s death a joint visit was undertaken to the family home by a consultant paediatrician and a police officer as part of the rapid response to a child death. The property was found to be squalid. There was rubbish and old food strewn across the floors and every cupboard contained bags of rubbish and dirty nappies. A bottle steriliser was filled with stagnant water. There was an electrical socket just above floor level with wires exposed. There was no bedding on the adults’ bed and in the cot there was milk in a bottle which had solidified and turned green with mould. There were toys on the floor in all the rooms. There were flies everywhere (it was very hot weather). On interview, the mother and her partner accepted that the home was unhygienic. They said that the situation had deteriorated over the previous 10 days. They had put all the rubbish into cupboards in an attempt to tidy up. Analysis 7.11 The mother was worried about Child T’s health from not long after her birth, seeking medical advice appropriately on two occasions. In addition Child T was seen by health professionals as part of routine post-natal surveillance on 4 occasions. Therefore during the three weeks that she lived, Child T was seen by health professionals on 6 occasions. On every occasion the mother was appropriately concerned about Child T’s health and Child T presented as being well cared for. There is no evidence to suggest that either the mother or those health professionals could have taken any further action which might have prevented Child T’s death. 7.12 Out of those 6 occasions, Child T was only seen once in the family home. That is not unusual, especially when the discharge address was that of the grandmother, which given the mother’s age and circumstances was seen as a positive move which would have offered the mother additional support in the early days after Child T’s birth. 7.13 When the midwife saw Child T in the family home some 2 weeks before her death, the home was not in the condition that was found immediately after her death. However, when the midwife visited, the mother had only just moved back there from the grandmother’s house. It would appear firstly that the mother had attempted to tidy up the room which the midwife would see when she visited and secondly that there was a rapid deterioration in the overall situation, exacerbated by the very hot weather. 8. EXAMPLES OF GOOD PRACTICE 8.1 The rapid response immediately following Child T’s death 10 A home visit was undertaken jointly by a consultant paediatrician and a police officer from the Child Abuse Investigation Team within hours of Child T’s death. This prompt response enabled valuable information to be gained which subsequently contributed to the criminal investigation and the decision-making regarding this SCR. 8.2 The midwifery & health visiting services Both the community midwife and the health visitors offered good support during the post-natal period. The mother was, and has continued to be, difficult to contact by phone and hard to find at home. This would appear to be caused by her lifestyle and circumstances rather than because she was deliberately avoiding professionals. Nevertheless, both services were tenacious with regard to trying more than one address when she could not be contacted. As a result Child T was still seen very frequently. 8.3 The GP On two occasions the GP followed up low level concerns by asking the HV to offer additional support, which was good practice and was responded to promptly. 9. ACTION TAKEN SINCE CHILD T’S DEATH 9.1 The communication systems between midwives and health visitors have been improved as part of the Acting Early Programme which was introduced during 2014 and which was designed to promote and support integrated working. Specifically, there are now weekly meetings which enable midwives, HVs, social workers and children’s centre staff to share information and discuss vulnerable families. 9.2 The health visiting service now receives notification information from maternity services regarding all antenatal contacts. 9.3 In 2013, CAF practice, processes and procedures were reviewed in order to establish a more consistent approach to service delivery. An eCAF management system has improved case tracking and makes it easier for professionals to establish whether there is a CAF and whether it is open or closed. 9.4 Children’s Centre files are now audited. Between May and July 2014, 43% were judged to be good and 43% to be adequate. 9.5 The housing provider now makes a booking for the boiler test when a tenancy is signed for. They have also commissioned tailor-made safeguarding training for their staff in recognition of their vital role in the protection of children and vulnerable adults. 11 FINDINGS & RECOMMENDATIONS 10.1 The overall findings arising from this SCR are that Child T’s death could not have been either predicted or prevented. There were no concerns about Child T during her short life and her mother sought help and advice appropriately. 10.2 The mother received enhanced ante-natal care as soon as it became known that the baby was growing slowly in the womb and the mother attended the vast majority of appointments, even though they were some distance from where she lived. 10.3 It is likely that being born with Cytomegalovirus contributed to Child T’s vulnerability. CMV is the most common infection at birth, more common than Down’s syndrome, toxoplasmosis or Cystic Fibrosis with as many as 1 in 150 new born babies being born with it. Whilst, the majority of these babies will not have any symptoms, around 1 in 1000 babies born in the UK every year will have permanent disabilities as a result of CMV – around 900 children every year. 10.4 There had been no concerns about the mother’s care of her first born child, Child T’s sibling. As a teenage mother on benefits she had been appropriately offered support from a children’s centre. The mother had accepted the support she was offered and followed the advice she was given. 10.5 There was confusion across partners about when a CAF was open and when it had been closed. It is understood that changes have subsequently been introduced which make the status of a CAF easier to identify. The GP had no record of there being a CAF. Parents and professionals alike need to be clear about when a CAF is in place and, if it is in place, what action is being taken as a result of it. Recommendation 1: The LSCB is assured that the simplification of the ecaf system and processes are having a positive impact on the lives of children and families. Recommendation2: Lead professionals ensure GPs are fully informed of CAF activity in line with existing procedures, which are currently operating within the acting early pilots 10.6 There was a four month gap between the tenancy being signed for and the boiler being repaired. Some of the delay was as a result of missed appointments by the mother. Whilst in this instance the reason was most likely that the mother was staying with the grandmother, the housing provider has recognised that this length of delay could pose a risk to children, had they been living in the property. Steps have been taken to address this issue. 12 10.6 There were no concerns about the care of Child T after her birth and she was seen regularly by health professionals. She was only seen once in the family home, but there had been no previous concerns about hygiene or neglect and therefore there was no specific reason to see Child T at home. 10.7 Safe sleeping advice was given and the place where Child T slept – a Moses basket – was seen by the community midwife, although not the room where she was likely to sleep at night. Two weeks before Child T’s death the home environment was not a cause for concern and there was no information to suggest that it might become so in the future. Recommendation 3: A standard physical check of the room in which the child sleeps in the day and night, and the bed/cot/basket in which the child is sleeping to be undertaken and recorded by UHCW and CWPT. 13 Appendix 1 Coventry Safeguarding Children Board Serious Case Review – Child T Scope and Terms of Reference Principles for SCR The following principles will govern the review and the role and responsibility of the Lead Reviewer: Fairness Impartiality Thoroughness Accountability Transparency As set out in Working together 2013 - The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children. Plan for SCR Process The SCR will be carried out by an experienced, independent Lead Reviewer who has a good understanding of interagency safeguarding including health and children’s social care. The process will include: The SCR Panel to produce scoping document and Terms of Reference for the review Briefing agency report authors on what is required including providing terms of reference Requests to each agency for information, including summary reports where required and individual management reviews Focused interviews with staff involved by agency report authors SCR Panel to receive agency reports and discuss initial findings First draft of Overview report by Lead Reviewer and mapping of findings within the Learning Summary Feedback workshop for managers and practitioners on the findings after first draft has been produced SCR panel to agree final draft of overview report 14 SCR subgroup to agree final draft of overview report Presentation to LSCB and discussion of action required on findings / recommendations Lead Reviewer to deliver final SCR for publication Follow up learning workshop for managers and practitioners The interviews with managers and practitioners will explore: critical points in the case possible reasons for actions taken at the time the significance of these insights for current practice. The critical points in the case that will be considered are: When it was known to agencies that mother was pregnant with Child T The birth of Child T and discharge home Visit to mother and children in her own home before and after the birth of Child T Scope of the Review The Serious Case Review will be from when it became known mother was pregnant with Child T to her death. Agencies should critically review their contact with the family between October 2012 until Child T’s death in June 2013, and to review any relevant previous contact with the family. Information gained from the post mortem examination and police investigation which post-dates this date should also be included where relevant. Terms of Reference: The agencies involved in the Serious Case Review should:- a) Summarise all relevant historical information that falls outside of the period under review b) Detail agency involvement with the child and family. c) Provide an accurate chronology (using the provided profoma)and genogram showing the membership of the family, extended family and household d) The key relevant points/opportunities for assessment and decision making in the case in relation to the child and family. Specifically:- 15 - Comment on the quality of assessment and analysis both pre and post birth. Did this include appropriate information sharing and relevant historical information? - Were previous concerns about neglect or any other risk factors known to agencies, and were they understood and analysed as part of assessments undertaken by agencies in the city - Were thresholds for intervention understood and applied - Did actions accord with the assessments and decisions made? e) Where intervention was delivered were these timely and outcome focused. f) How did agencies engage the family in the assessment and decision making process? Were there any difficulties in communication, information sharing or service delivery. How were these addressed or overcome to meet the needs of the family. g) Did agencies work effectively together to offer support to the family? h) Were relevant agency and interagency procedures and guidance, including any joint working protocols followed? i) When, and in what way were the children’s lived experiences identified and how were these taken account of in the decision making and delivery of services. j) Where there are examples of good practice these should be highlighted. k) Did the agencies consider whether the abilities or disabilities, racial, cultural, religious, linguistic identity of the child/ren or the family have an impact on their situation and have any associated implications within the assessment, planning and provision of services? l) Were adequate supervision and line management arrangements in place and adhered to? |
NC52769 | Neglect of female siblings aged 11-months-old, 1-year-old and 6-years-old. A home visit found the two younger children living in significantly neglectful circumstances with unexplained injuries. The eldest child was not in the accommodation at the time and was found to be physically unharmed. Findings include: the importance of professionals working in a culturally competent way; the importance of robust consideration of the need for pre-birth assessments and pre-birth early help and support plans; the need for a proactive, holistic, and robust response to domestic abuse to increase safety for survivors and their children; the need for professional recognition and response to the early signs of neglect of young children by their caregivers; and an analysis of responses to referrals, completion of assessments, child in need processes and multi-agency working. Recommendations include: produce guidance on working in a culturally competent way, including information about the culturagram framework; the Child Safeguarding Practice Review Panel look into why neglect tools developed over the last ten years are not having an impact on practice; seek information from the Child Safeguarding Practice Review Panel on what work is underway to address the lack of guidance about the appropriate response to referrals and information from family, the public and anonymous sources; and seek clarity about when and in what circumstances child and family assessments are shared with agencies who will be supporting children subject to child in need plans.
| Title: Local safeguarding practice review: Sara, Edvina and Danuka. LSCB: Bradford Children’s Safeguarding Partnership Author: Jane Wiffin Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Local safeguarding Practice Review Sara, Edvina and Danuka Jane Wiffin 2 1. Introduction Reason for the Local Child Safeguarding Practice Review (LCSPR1) 1.1 This independently led LCSPR was commissioned by Bradford Children’s Safeguarding Partnership regarding three sisters, Sara (aged 11 months), Danuka (aged nearly two) and Edvina (aged 6). In December 2021 the children were living with their mother (aged 22) and her partner, Teo, in temporary accommodation. The family were subject to a Child in Need plan2 and Mother had been found to have no settled status3. A referral was made by a voluntary sector organisation regarding concerns of Mother and what she described as her husband Teo’s drug use, poor care of these young children and domestic abuse and violence. The initial response was not sufficiently urgent, but after two weeks at a home visit the two younger children were found to be living in significantly neglectful circumstances; mother and her partner were under the influence of illegal drugs. Child protection medicals were undertaken, and Danuka and Sara were both observed to be in significant pain due to injuries. Danuka had fractured ribs and bruising on different parts of her body, she also was found to have unexplained liver damage. Sara had some problems with her leg and such severe nappy rash that it had advanced down her legs. Edvina was not in the accommodation at the time and was found to be physically unharmed. The social worker who visited at this time is commended for her swift response, and in ensuring that Sara and Danuka were quickly taken to hospital for medical care and attention. About the children and their Family. 1.2 Mother was born in Eastern Europe4 and the maternal family heritage is Romani. Mother told professionals that she either did not know who the children’s fathers were, or they were not involved, or different men’s names were provided to different professionals. There remains a confused picture with a lack of clarity about the father of each child. The Mother moved to the UK when she was 11 with her parents and younger siblings, though little was known about them during the time under review. It has become clear that the children 1 A Child Safeguarding Practice Review (previously known as a Serious Case Review (SCR)) is undertaken when a child dies or has been seriously harmed and there is cause for concern as to the way organisations worked together. The purpose of a child safeguarding practice review is for agencies and individuals to learn lessons that improve the way in which they work, both individually and collectively, to safeguard and promote the welfare of children. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Working_together_t o_safeguard_children_inter_agency_guidance.pdf 2 why-do-i-have-a-child-in-need-plan.pdf (proceduresonline.com). The Child in Need Plan must identify the lead professional, any resources or services that will be needed to achieve the planned outcomes within the agreed timescales and who is responsible for which action and the timescale involved. Child in Need Planning Meetings will follow an assessment where the assessment has concluded that a package of family support is required to meet the child's needs under Section 17 of the Children Act 1989. The Planning Meeting provides an opportunity for a child and his or her parents/carers, together with key agencies, to identify and agree the package of services required and to develop the Child in Need Plan. 3 Settled Status means that an individual has the right to live, work, and remain indefinitely in the UK, free of immigration control. It also means that the holder can access public funds (e.g., benefits), and after 12 months, apply for British citizenship. 4 No country is given to provide confidentiality for the children. 3 lived itinerant lives, moving between at least five addresses, with a constant move back to mother’s family home. Edvina lived for much of the time with maternal grandmother. Mother had at least six different adult men in her life, but the nature of the relationships in most situation is not known. The review does not refer to them all as partners because the nature of this involvement is unclear; there was known concerns about domestic abuse, but also indications of exploitation, but without any clarity about this. The following table in included to make clear who each adult male was so that readers can navigate the narrative which follows and what was known about their links with mother and the children. Although mother talks of some of these men as being the children’s father, it is not clear if this is the case. Person 1: Bogdan: Eastern European Mother and Edvina (as a baby) moved to live with him and his family when mother was 14 for some brief periods of time. Bogdan is referred to in 2020 as Danuka’s father. Person 2 Jarra: Eastern European When mother was 17, she took Edvina to live with Jarra and this relationship lasted for around 3 years. She ended the relationship at around the time she was pregnant with Danuka. Person 3 Karl: Eastern European Mother was said to be in a relationship with Karl from early 2020, just when Danuka was born, but she always denied this, despite describing him as her boyfriend to some professionals and the extended family also saying this. Person 4 Peta: Eastern European Peta was reported to be Karl’s brother and mother said she was in 4 a relationship with him. There is no evidence whether this was the case. Mother lived with both Karl and Peta’s parents outside Bradford during COVID public health requirements and before Sara was born. Person 5 Paul: White/British and aged 52 (he is the only male who was older than mother). There is no information about Paul, how he knew mother or what their relationship was. He was at times referred to as Danuka’s father by mother and there was a couple of call outs to the police for harassment in 2020. Person 6 Teo: Eastern European It is unclear when and how mother met Teo, but he was introduced by her to professionals as her husband in 2021. It is not known if this was accurate. Process of the Review 1.3 This review has been led by Jane Wiffin, an independent person with no practice links to Bradford. The methodology used was the significant incident learning process (SILP5). This process is consistent with the requirements laid out with Working Together 2018 for the conduct of an LCSPR. 1.4 The review process was overseen by a panel of senior managers/safeguarding professionals representing all the agencies who had contact with mother, Edvina, Danuka and Sara. They have acted as a critical friend to the independent reviewer, and helped with local knowledge, analysis of data and considering key lines of enquiry which form the themes at the end of this report. The independent reviewer would like to thank them for their hard work, 5 SILP Reviews – Review Consulting 5 reflections and responses to the many questions asked in seeking to understand the children’s world. 1.5 Individual agency reports were commissioned, which provided an analysis of the services provided to the siblings and their family and within these there are single agency recommendations. 1.6 It was unfortunate that many of the frontline professionals who worked with the family had left and so only two were able to come together with other representative professionals as a group to reflect on the emerging learning and to review the draft report. It is not always easy to review your own practice response to a family, but these two professionals have done this with openness, intelligence, and most of all as a commitment to wanting the best for these children and children in their circumstances. The independent reviewer would like to thank them for their time and help. Family Involvement 1.7 Mother and her partner remain subject to criminal proceedings and the wider extended family have ongoing involvement with children’s services which means that meeting with them at this time would not be appropriate. 6 2. Timeline of Edvina, Danuka and Sara’s journey through services Background information. 2.1 When Mother arrived in the UK she lived with her parents and five siblings. There were concerns about neglect of all the children, poor school attendance and concerns that mother was being sexually exploited which were assessed and support provided. 2.2 When Mother was 13/14, she spent some months in her country of origin. When she returned aged 14, she was 5 months pregnant. She reported that she did not remember how she got pregnant due to ‘being drunk’. A pre-birth assessment6 was completed, specialist support was provided by the specialist teenage midwife and a Child in Need plan put in place for a short period of time to support Mother and Edvina. Mother did not return in any meaningful way to school from this point. 2.3 When Mother was still 14 and Edvina a few months old they moved in with a man called Bogdan who Mother said was Edvina’s father. There were concerns about his problematic alcohol use and domestic abuse. Mother and Edvina returned to live with the family. The whole family’s engagement with health services was intermittent and between April 2016 and October 2018 they were held on the ‘missing’ caseload as their whereabouts were unknown. 2.4 When Edvina was 3, mother 17, they moved to live with Jarra (22) about whom there were concerns of sexual abuse and exploitation. Mother was persuaded to return home because of child protection enquiries. They quickly moved back to live with Jarra and there were two police call outs due to verbal disputes and threats of violence by Jarra. Professional Involvement with the family. June 2019 to December 2021 2.5 At the age of 19 Mother was pregnant with her second child (June 2019). She and Edvina were still living with Jarra. Mother initially sought to have the pregnancy terminated but did not attend the appointments. During the first four months of the pregnancy there were three police call out’s due to verbal arguments and Jarra’s theft of some of mother’s property. Sara was present and described as upset. Bradford Children’s Social Care (BCSC) were informed. 2.6 Mother sought midwifery care when she was 5 months pregnant (September 2019), and an interpreter was used. This was the first indication that Mother was not proficient in English as her second language, something that was 6 The purpose of a pre-birth assessment is to identify any potential risks to the new-born child, assess whether the parent(s) are capable of changing so that the identified risks can be reduced and if so, what support they will need. Assessments (proceduresonline.com) 7 inconsistently recognised in mother’s future contact with practitioners. This is picked up in Theme 1 about cultural competency. 2.7 The midwife asked about domestic abuse and use of drugs and alcohol; mother said that she did not know the father of the unborn baby well (called Martin) and he would not be involved in the future; this was not further explored, and this is picked up in Theme 4. Mother said that she did not drink or take drugs, had good family support and was happy to be pregnant. Contact was made with BCSC because Mother reported earlier involvement as a child. BCSC confirmed this, but information about the police call outs in recent years, was not provided. This meant that the midwife did not have a full picture of the vulnerability of this young mother. BCSC should have given some thought to whether a pre-birth assessment was required. This is discussed in Theme 2. Mother failed to attend subsequent midwifery appointments, although she was seen in hospital with pregnancy related health concerns when 7 months pregnant. 2.8 There were two police calls outs regarding domestic abuse, and the second included threats to kill by Jarra when Mother was 7 months pregnant. Jarra was arrested and gave a no comment interview. BCSC were notified and it was agreed that Mother would move back to live with her mother (maternal grandmother). 2.9 There was an antenatal visit by HV1 in December 2019 when Mother was 8 months pregnant. This took place in maternal grandmother’s home. The only concerns noted were overcrowding, a cluttered environment, and Mother raised worries about benefits. She did not have a bank account and she said her benefits went into her stepfather’s account. There is no recorded information about any evidence regarding preparations for the new baby. 2.10 In the week before Danuka was born, Mother attended her second midwifery appointment. Mother’s reasons for her non-attendance are not recorded and the meaning of this in terms of both her feelings and trust in services and her ability to think that the ante-natal care was equally about the baby’s well-being, indicating possible early signs of not being able/not understanding the need to put her child’s needs before her own was not explored. 2.11 Danuka was born at home in January 2020; routine postnatal visits were undertaken and there were no concerns. HV1 saw mother Danuka, and Edvina (aged nearly 6) at a new address (this was the flat she had previously lived with Jarra; address 2). This accommodation was described as untidy, cluttered, but clean. HV1 noted ‘warm and caring’ interactions between Mother and both children. Mother said Edvina lived mostly with maternal grandmother but was often at home with Mother and Danuka. 8 2.12 Over an eight-week period from February to April 2020 there were nine incidents of concern. Five were either shared with BCSC or police notifications received. Four further incidents were contacts with the police. • The police were called by mother’s landlord with concerns that she was using drugs. No evidence was established but the incident was shared with BCSC. • BCSC received two anonymous referrals that Mother was in a relationship with a dangerous and violent man named Karl and there were concerns that mother was using drugs. The duty social worker (DSW) asked HV1 to discuss the concerns with Mother at her next visit, but no one was at home. HV1 was told Mother moved back to live with her family; this address was visited, and a family member said that Mother was out with her boyfriend, Karl. HV1 shared this information with BCSC. • A week later BCSC received another anonymous referral about Mother taking crystal meth in the street with Danuka present. The DSW initially asked for a police welfare check to be completed, but this request was declined. HV1 was asked to complete a visit and Mother was not at home. The DSW concluded that the anonymous referral was malicious due to information that Mother had been in a dispute with her landlord. • There was a referral to BCSC from a man who said he was Danuka’s father (no name was given) reporting concerns about Mother not seeking medical advice for Danuka and that she was involved with a dangerous man called Karl. HV1 undertook a planned appointment and there was no one at home. Contact with the GP suggested there were no health concerns except missed immunisations. It was decided no further action was necessary. 2.13 There were four incidents involving the police that do not appear to have been shared with BCSC: • Mother reported harassment by Paul (aged 52) to the police, caused by their breaking up; she refused to provide a statement. The police records show that Mother was now living at a new address (address 3). Danuka was present. • The police were called to an incident where a neighbour reported that Mother and her partner Karl had made threats to kill him. There was a further reported incident a few weeks later where the police were called because the neighbour was said to have barricaded Mother in her flat after a party and further conflict. These were all at address 3. • The police visited address 3 in connection with a third party suspected of involvement with drug crime. This person was not found, but Mother was there with a man named Jed who was described as her boyfriend, the brother of Karl and his parents were present and described as Danuka’s grandparents. No drugs were found. 9 2.14 Mother was pregnant with her third child when she was 21, four months after giving birth to Danuka. She spoke to her GP via telephone7 and said she did not know who the father was, and she was living back with her family. Midwifery contact was made via telephone, with an interpreter included. Midwifery contacted BCSC because of mother’s previous history and they reported no current involvement with mother and her children; recent referrals were not shared. It seems that Edvina may again have been spending much of her time living with maternal grandmother, whilst mother moved between addresses. The exact details are not known. 2.15 Mother then sought to have the pregnancy terminated and informed midwifery of this. She failed to attend the termination appointment and sought midwifery care seven weeks later. She did not attend subsequent appointments and home visits were undertaken without success. She attended a midwifery appointment when she was seven months pregnant and reported that she had moved back to live with her family. The midwifery team had been visiting address 3 and so had no found her there. 2.16 Soon after this in October 2020 BCSC received a referral from school about Mother being in a relationship with Karl and being pregnant by him. It was agreed that a Child and Family assessment (known in Bradford as a ‘single assessment8) would be completed. Mother said that she was in a relationship with Bogdan (partner 1 from when she was 17) not Karl. The assessment would be ongoing for the next ten weeks. 2.17 Mother failed to attend her next midwifery appointment, a home visit was undertaken, and the midwife was told that Mother had moved (address 5) to the home of Karl’s parents. The midwife appropriately made an urgent referral of concern to BCSC and discovered that a Child and Family Assessment was underway. The midwife also liaised with HV1 and the GP surgery. 2.18 Mother attended two midwifery appointments in December 2020, a few weeks before Sara was born. There were no concerns about her health, but the issue of all the missed appointments and the reason for these do not appear to have been discussed. 2.19 The Child and Family Assessment was completed two weeks before Edvina was born in December. The conclusion was that Karl did pose a risk to children but there was no conclusive evidence that Mother was in a relationship with him. The plan was for a Child in Need process and plan9 to be instigated and 7 Due to COVID public health requirements 8 A key aim of the Single Assessment is to set out clearly the assessment plan and will: Aid relationship building with children and their families. Consider the balance between managing and reducing risks and promoting resilience • Assist in explaining to children and families why social workers are involved in their lives. 9 The Child in Need Plan must identify the lead professional, any resources or services that will be needed to achieve the planned outcomes within the agreed timescales and who is responsible for which action and the timescale involved. 10 for Mother to seek her own tenancy/accommodation. The issue of the lack of reflection on the recent history and the poor analysis within this assessment is discussed in Theme 5 alongside the poor-quality Child in Need plan which was proposed. The first Child in Need meeting10 was held remotely via telephone in December; midwifery, the GP and HV1 were not invited. Mother did join the call and it was agreed that the social worker would do direct work with Edvina because she had not been seen as part of the assessment, Mother was asked to keep all health appointments for the children and engage with support without there being an analysis of why this had not happened previously; it was proposed that Mother would seek her own tenancy, but in the meantime she would move back to her family home away from Karl’s parents at address 5. There was said to be a safety plan in place, but it is unclear what this consisted of beyond moving back to Bradford. 2.20 A community nursery nurse completed Danuka’ 9–12-month developmental check over the telephone due to COVID requirements. Mother said there were no concerns about domestic abuse or substance misuse but said she still smoked outside. She said that she had not taken Danuka for her immunisations due to concerns about COVID public health requirements. Mother said she would be moving back to Bradford. 2.21 Sara was born at the end of December in a hospital outside Bradford. Hospital staff had no knowledge of Mother or her circumstances. Contact was made with Bradford Emergency Duty Team and a discharge plan was agreed. Midwifery follow up was provided by the Bradford team because Mother and the children were now back in Bradford. There were no concerns. 2.22 HV1 visited Mother and the children at her family home at the beginning of January. HV1 observed warm and caring interactions between Mother and the children. The house was described as very overcrowded with at least eight people living there. The extended family were noted to be supportive. Mother reported that’s she was not currently in a relationship. She said she was concerned that her benefits had stopped, and information was provided about where to seek advice. HV1 tried to contact the new social worker to ask about the next Child in Need meeting but got no reply. 2.23 The next (and last) Child in Need meeting was held at the end of January 2021. This was a conference call, joined only by representatives from Edvina’s school; no other professionals were invited. The minutes suggest there was some 10 Child in Need Planning Meetings will follow an assessment where the assessment has concluded that a package of family support is required to meet the child's needs under Section 17 of the Children Act 1989. The Planning Meeting provides an opportunity for a child and his or her parents/carers, together with key agencies, to identify and agree the package of services required and to develop the Child in Need Plan. 11 confusion about where Edvina was living. There were no changes made to the plan and the minutes do not give an outline of the children’s circumstances. 2.24 Mother was not at home for the next visit by HV1 but was seen at the beginning of February 2021. HV1 noted that Mother behaved in warm, caring ways to the children. A man left the home when HV1 arrived, and Mother said this was Bogdan, her partner. There is no further information or reflections about this man, given on the face of it he was a new relationship. This man was confirmed to be Karl by the social worker, who reported there were no ongoing concerns regarding him and consequently no role for BCSC. 2.25 Between February and March 2021 there were escalating concerns about Danuka and Sara ’s unmet health needs including: • HV1 was notified by the neonatal hearing team that Sara had not been brought for five appointments. • The GP surgery shared that there were numerous outstanding immunisations for the children. • Mother did bring Sara for her eight-week developmental check; the GP surgery telephoned her several times as a reminder, they also sent texts and offered for mother to attend without the need to make an appointment. This was good practice. • There were concerns about Sara (aged 10 weeks) having an ear infection with an awful smelling discharge. Danuka (aged 13 months) had a scalp infection. Anti-biotics were prescribed and further follow up appointments were made. These follow up appointments were not kept. Mother brought Sara to see the GP at the end of March and such was the concern about her health needs, Mother was asked to take her to hospital the following morning. Mother attended but left before being seen. HV1 was informed. 2.26 HV1 attempted some home visits because of the health concerns without success but in March she was able to see Mother and the children. Mother said she would take the children to the GP, though this did not happen. The home environment was seen to be chaotic and overcrowded. Warm interactions were observed between mother and the children. HV1 was concerned that when she was parked outside the house, there were signs of drugs being bought from the house by young women. This was shared with the social worker. It led to no action. 2.27 HV1 and the Advanced Nurse Practitioner (ANP) from the GP surgery shared concerns and they completed a comprehensive chronology of all the missed health appointments, unattended developmental checks, lack of immunisations and they sent this to the social worker. This was followed up by phone calls and email, without any reply from the social worker. 12 2.28 In April 2021 the social worker discussed these health concerns with her manager. It was felt that the Child in Need process was not working, and a child protection plan11 would also not work because Mother would be unlikely to engage with it. The plan was to end the Child in Need process. 2.29 HV1 undertook an unplanned visit to see the children in April 2021. Mother was at home, and the children were seen. Sara ’s ear infection had healed, as had Danuka’s ’s scalp infection. Mother said her benefits had been stopped. HV1 suggested seeking advice from the benefits agency and provided contact details. 2.30 The Child and Family Assessment was updated at the end of May. A safety plan was said to be in place whereby the children were not to have unsupervised contact with Karl’s family; described as paternal grandparents. The decision was made to step down to an early help plan, with HV1 being the lead professional. HV1 was not informed of this decision. 2.31 In June 2021, sexual health services visited mother at home. They were concerned at the state of the house, which was infested with cockroaches and a Stanley knife was on the floor in reach of the children. The sexual health team contacted early help who said they were not working with mother but that HV1 was the lead professional and was undertaking an assessment. HV1 was contacted by sexual health, the concerns about home conditions were shared and HV1 was told that mother had recently had a termination. HV1 agreed to visit to discuss the early help assessment. 2.32 HV1 visited two weeks later. She stayed on the doorstep due to COVID requirements; Danuka was in the garden and Sara was reported to be asleep in the house. Mother was asked if she wanted early help support and she declined this. HV1 moved the family to universal provision. 2.33 At the beginning of September 2021 a member of the public noticed mother, a man she described as her husband (Teo) and two young children sleeping in the park late at night; Danuka was now twenty months old and Sara nine months old. BCSC emergency team were contacted, and emergency housing provided. Mother was given the number for housing and using a member of the publics phone (she did not have one) she made an appointment for the next day. 2.34 The housing assessment concluded that because Mother did not have settled status, she had no entitlement to housing assistance. Mother reported that she 11 Where social workers and professionals feel that a child is at risk of significant harm, the local authority will arrange a Child Protection Conference and the child may be made subject to a child protection plan. This plan will set out what decisions were made in the conference to keep your child safe, what needs to be done and what support will be provided. 13 had been living at address 6 with Teo, her partner and two young children. They had been evicted and she said she had lost contact with her family. They said they had been street homeless for the last three weeks. Mother reported living on £140.0 per month child benefit, and some cash in hand money earned by Teo for small jobs like gardening. 2.35 A social worker was allocated to complete a Child and Family assessment. The family were provided with temporary accommodation. This was two rooms in a hostel accommodation inhabited by single adult tenants who were also homeless caused by substance misuse and some were sex working. There was a shared bathroom and kitchen. 2.36 At the end of September Mother called the police because Teo had punched her in the face when she had woken him to ask for money to buy medicine for the children. The police attended and were very concerned about the state of the accommodation, which they considered was not suitable for young children. There were no cots for them, and Sara was asleep in a buggy. The electric sockets were uncovered, and Danuka was crawling around, attempting to put her fingers in them. BCSC emergency duty team were contacted but said this was a housing issue and suggested completing a Multi-Agency Referral Form (MARF12). This was done. Sara started to have breathing difficulties and an ambulance was called. The police called an ambulance, but because of the lack of availability the police took Sara and mother to hospital. The police left, and Mother then left before Sara was seen. The Accident and emergency staff contacted the social worker and health visiting service. 2.37 The social worker went to see mother, Teo and the children. Mother and Teo were seen together to discuss domestic abuse and Teo blamed Mother for starting a fight. A ‘safety plan’ which did not address the concerns was formulated. The children were seen and looked unclean and unkempt; Sara looked underweight. Edvina was noted to be living with them because maternal grandmother had started working. The family were provided with travel cots and other essential items. Mother requested a food parcel. 2.38 The social worker asked if HV1 could undertake a visit and complete a height and weight check. This was agreed, but HV1 was unable find the property. HV1 then handed over to the health visiting team in the area Mother and the children were now living. A general handover was provided which did not highlight the urgent need for Sara to be weighed; HV1 said that the mother and the children were receiving universal health visiting services13. This meant the receiving health visiting team could not see there was a need for an immediate visit and a new health visitor was not allocated until the end of October 2021. The lack 12 The MARF is the local process for alerting professionals about concerns regarding a child. 13 Under the Healthy Child Programme this level of support indicates there is no need for any further support that routine health visiting support. HCP - Pregnancy and the First Five Years of Life (publishing.service.gov.uk) 14 of Sara’s weight being checked was not challenged by the social worker or followed up. HV2 tried to complete a home visit some weeks later but could not find the property. HV2 did not ever visit. 2.39 The child and family assessment was ongoing through October and November. Mother regularly sought financial support from the social work office. BCSC received a phone call from the Landlord of the temporary accommodation reporting that Mother was begging for food from other tenants. He also said that Mother and Teo had been allocated two rooms but had sublet to a couple (male and female) and so this room was taken away from them. They were now all living on one room. 2.40 The child and family assessment was completed on the 10th of November. The assessment focussed on the family’s immigration status and housing. It was acknowledged that the children looked unkempt, that the housing conditions were inappropriate, that the children did not receive adequate food or milk, but the conclusion was that their needs were adequately met. The assessment describes, but does not analyse the domestic abuse incident, and there were no immediate plans to move the family, given the unsuitability of the housing. Recent concerns by the landlord were not mentioned, nor the impact of three children living in one room. 2.41 The first Child in Need meeting was held in November with a focus on housing. The second at the end of the month. This was attended by the social worker and HV2, Edvina’s school and the Butterflies project worker (specialist immigration advice and support) sent their apologies. At this meeting it was reported that the social worker had been unable to meet with the family or contact them. The concerns from the landlord were discussed, alongside outstanding health needs. There were plans for a new social worker to be allocated. 2.42 At the beginning of December 2021, the social worker received an email from a worker from the local Project working with sex workers sharing information from one of her clients about mother and Teo using drugs, domestic abuse, the children being left home alone and several different men visiting the rooms. The social worker went to the hostel twice in the next two weeks and no one was at home. This was not a sufficiently robust response. Two weeks after the original concerns had been shared the children became the responsibility of a new team and there was an appropriate review of their circumstances. There was an immediate home visit where mother and Teo denied the concerns and there was no evidence of drug use. This was followed up by another visit the next day, where mother and Teo were found to be under the influence of drugs and there was evidence of drug paraphernalia. The police were called. Sara and Danuka were present and found to have unexplained injuries. Mother and Teo were arrested, and the children placed with foster carers. 15 3. Analysis and Key Findings 3.1 The purpose of any child safeguarding practice review (LSCPR) is to review the circumstances of one family and consider whether this suggests that there are improvements that need to be made locally and nationally to safeguard, promote the welfare of children more generally and to seek to prevent or reduce the risk of the recurrence of similar incidentsi. There are several themes that emerge from a review of Sara, Danuka, and Edvina’s circumstances. Finding 1: The importance of professionals working in a culturally competent way. 3.2 All the professionals who had contact with mother and the extended family were aware that the family heritage was Romani and they had moved to the UK from Eastern Europe. Understanding of language and literacy skills 3.3 Professionals were also aware that mother’s first language was not English, but there was a lack of clarity or precision about how well mother, her family and more latterly her partner, Teo, communicated in English or what their literacy skills were. 3.4 The police and midwifery demonstrated good practice by providing an interpreter for mother, but the need for this was not recognised by others. mother often said she could converse in English comfortably. This was not the same as having important conversations about addressing the children’s health needs, why mother did not engage with support or attend appointments, making enquiries about domestic abuse, understanding sensitive issues such as the reasons for the requests for termination of pregnancy and trying to make sense of issues of neglect and the quality of care provided to these young children. It has now become clear through the school that Sara attends that maternal grandmother and mother both have very limited understanding or use of English. It remains unclear Mother’s level of literacy overall, but she did not have a good grasp of written English. Professionals should have asked about language and literacy skills and made the reasonable adjustments required by the Equalities Act 2010ii. Understanding the Families Cultural context 3.5 There is little information available from the records about the cultural context of mother or her family. There is no information about the family’s reasons for immigration, what that journey was like, their experience of living in England, 16 whether they experienced discrimination and racism, and what was important to them in their own cultural context, including health beliefs and family norms. 3.6 The GP surgery did think about how the family’s cultural context might impact on bringing children for health appointments and sought to provide support. There was a danger overall, however that professionals may have understood the poor engagement with services as being connected to a broad concept of their cultural context, as opposed to evidence of neglect or a family that was not fully coping or had other pressures. Talking to families about their cultural context is critical to understanding their circumstances, strengths, and pressures and to be able to target services appropriately. Legal Status 3.7 In September 2021 it became apparent that mother had no settled status and was not entitled to public funds or housing. The family were living on child benefit because mother’s universal credit had been stopped a year earlier. The first child and family assessments recorded that the immigration status for mother was unknown. HV1 did ask about benefits and sought to provide advice, but no one professional had asked about this crucial issue. It appears that assumptions made that because Mother has been living in the UK since she was aged eleven that her immigration status was established. All professionals involved in this review process have reflected on the importance of establishing the immigration status of those children and adults they work with as part of establishing support and need, but also in recognition of understanding the cultural context of the family. 3.8 During the second Child in Need planning process in 2022 a specialist third sector support organisation services was asked to help mother and Teo sort out their immigration status. This was good practice, but their involvement was not seen as an opportunity to gain insight into cultural issues that the family might face. Why is this important 3.9 The Romani and traveller community in the UK experience the same level of personal and institutional racism and discrimination as any other Black and minoritized groups. There is evidence of poor health outcomes, inequality in the labour and housing market, poor education outcomes and low literacy rates, an overrepresentation of referrals to children’s social care and other institutions. Bradfords own report refers to the discrimination that Romani communities face in Bradford (European Roma Communities: A Strategy for Bradford District 2021 – 2025iii). There is also a community support organisation that mother could have been linked intoiv. 17 3.10 Legislationv, Guidancevi and researchvii highlight the importance of identifying a child and their families’ cultural context and heritage, as well as their experiences of racism and discrimination alongside family strategies to address this. In other words, to be culturally competent professionals. 3.11 Cultural competence is defined as the ability and confidence of all professionals to explore and ask questions about the cultural context and practices of the different children and families that they work with. This includes understanding and addressing racism and discrimination and recognising that cultural identity will be treated with understanding and respect. It does not mean that professionals can fall back on simplistic notions of culture to avoid making difficult decisions about when and whether to intervene with families or to allow stereotypes and discriminatory attitudes to influence practice. Culturally competent workers recognise every individual as unique and equally worthwhile. The culturagram tool can be a helpful tool in exploring these issues. 3.12 Cultural competence needs to be supported by an organisational framework, which demonstrates a value to professionals working in this way, providing guidance, training, and support. A handful of Safeguarding partnerships have practice guides or frameworks for culturally competent practice. Bradford have done work in this area in the past, but the toolkit/framework no longer seems to be available. What can be done about it? Recommendation 1: The Bradford Safeguarding Children’s Partnership should seek reassurance from partner agencies that they are ensuring that their workforce are being equipped and required to work in a culturally competent way. Recommendation 2: The Bradford Safeguarding Children’s Partnership should produce guidance on working in a Culturally competent way including information about the structured framework the Culturagram and implement its use across the workforce. Finding 2. The importance of a robust consideration of the need for a pre-birth assessment and pre-birth early help and support plan. Considering Pre-birth assessments 3.13 The safeguarding partnership has a pre-birth assessment policy which outlines the importance of undertaking a pre-birth assessment in the context of vulnerability and where the safety and wellbeing of parents and the unborn baby might be compromised.; this policy sets the criteria for a pre-birth assessment 18 and mother met the criteria for four out of 13 (if you include late booking/avoidance of ante-natal care alongside denied pregnancy – though this is not currently made clear in the guidance). 3.14 Mother was pregnant in April 2019 at age 19 with her second child. She had a child aged 4 to look after. She booked her ante-natal care late due to seeking a termination of pregnancy which she then did not go through with, something she explained to the midwifery service. Mother said that she had had previous children’s services involvement and contact was made with them. They reported no current involvement; known concerns about domestic abuse spanning 2017 and more recently in June and August 2019 were not shared. 3.15 There should have been a consideration of the need for a pre-birth assessment by BCSC given this known information; the booking midwife would have been more able to evaluate Mother’s circumstances if these risk factors had been shared with them. Mother denied any domestic abuse or drug/alcohol use. Mother only attended two midwifery appointments and one emergency attendance at hospital. There was an incident of domestic abuse including threats to kill in the 4 weeks before Danuka was born, and BCSC were informed; this was not shared with midwifery the health visitor. The lack of sharing of this information, providing the context for mother and the unborn baby’s vulnerability meant no pre-birth or early help assessment was completed. Their needs were located at universal service provision. 3.16 Mother reported she was pregnant with her third child in April 2020 at the age of 21 and 4 months after Danuka was born. She attended the initial midwifery appointment and contact was again made with BCSC and they reported no current involvement. This was technically accurate; between February and March 2020 there had been five incidents of concern including domestic abuse, Mother’s drug use, housing instability, association with a known dangerous individual with concerns about sexual exploitation and abuse and harassment. BSCS had been informed of these concerns through anonymous referrals, but again these did not lead to a discussion about whether a pre-birth assessment was required. 3.17 Without this information the midwifery team could not evaluate mother’s, Danuka’s and the unborn baby’s vulnerability. Mother decided to have a termination of pregnancy which she did not go ahead with; she sought pregnancy care late and did not attend any appointments until October 2020, some six weeks before baby Sara was due. The midwifery service worked hard to contact her without success, and in November they made an appropriate urgent referral to BCSC. They found that there was already an ongoing assessment. Information was exchanged, but there was no assessment of the needs of the unborn baby. 19 3.18 There clearly needed to have been more consideration about the need for a pre-birth assessment for both Danuka and Sara. This would have been an opportunity to understand the chaos in Mother’s and her children’s lives, her constant moves between households and the many men who were domestically abusive to her. This information was never brought together. Why is this important? 3.19 Pregnancy and the first year of life are an extremely important time because of the complete physical and emotional dependency that the unborn baby/ baby has on their parent and these early developmental stages lay the foundations for later life. There is an increasing body of evidence about the risk factors during pregnancy that are associated with likely developmental and emotional harm (particularly complex attachments) to the unborn baby lasting into adulthood and with possible future maltreatment of the baby in the early years of life by parents/adults. The factors during and after pregnancy include mothers and fathers with complex childhood histories, poor adult mental health, substance misuse, poor parental emotional and behavioural regulation, stress, anxiety, domestic abuse and living with the pressures of poverty. These risk factors are evident in the number of critical incident notifications involving serious harm to very young babies and the growth of care proceedings for babies in the first few days and weeks of life. This is a critical issueviii. 3.20 Pregnancy is the opportune time to identify these risks, support parents to take action to address factors that will impair a baby’s development during pregnancy, promote an understanding that this is baby’s first home “the womb” which needs to be safe and secure and to start the process of building attachments; poor attachment in pregnancy is a predictor of poor attachments in babyhood and beyond. It is an opportunity to assess parental behaviours and factors which put the baby at risk of significant harm following birth. Part of this process is considering ‘reflective functioning’ or the ability of parents to understand and respond to all their baby’s needs, and their ability, motivation, and capacity to make changes in their behaviour in the best interests of their baby. Pre-birth assessments provide an opportunity to consider factors which will impact on safety and wellbeingix. What can be done about it? 3.21 The review by the Child Safeguarding Practice Panel of Star Hobson in Bradfordx highlighted the importance of consideration of pre-birth assessments and a recommendation has already been made regarding this. This Recommendation is: A review of the Partnership’s Pre-Birth Procedures to ensure that the assessment of parental and family risk factors are explored, and decisions are appropriately documented. Any barriers to implementation should be identified. 20 Finding 3: The importance of a proactive, holistic, and robust response to domestic abuse to increase safety for survivors and their children. 3.22 There is a long history of mother being subject to domestic abuse, incidents described as disputes, threats to kill or harassment and being sexually exploited from when she was 14 years to the date of the critical incident, a period of seven years, involving six different men. Except for Karl, nothing is known about the circumstances of these men. The information about domestic abuse and disputes was known to the police who were called out on many occasions, and they shared many of the incidents with BCSC in the form of a domestic abuse notification; mother was often pregnant or had just given birth. This information was noted by BCSC, but it was agreed on most occasions that no further action needed to be taken. Each incident was treated in isolation, and no cumulative picture was developed. This meant that those other agencies working with mother were not aware of these concerns. 3.23 The one place this history of concerns about domestic abuse was held was in the two child and family assessments completed by BCSC in December 2020, just before Sara was born and November 2021. These assessments were not shared with any other agency. There remains confusion about when and in what circumstances the child and family assessments should be shared with agencies working with the children about whom they are about. There is no legal or procedural impediment, but custom and practice has grown up locally (and nationally) that this is a children’s services document; these assessments were intended (see Assessment Framework 2000 Guidancexi) to be led by children’s services, but to be multi-agency in approach and their outcomes was to help build a multi-agency support plan to address unmet needs of children. 3.24 The midwifery and health visiting services routinely asked mother about domestic abuse in line with national and local expectations which was good practice. Mother mostly said she was not in a current relationship. The midwifery appropriately contacted BCSC on the two occasions when Mother was pregnant. The information about domestic abuse concerns was not shared. 3.25 The first Child and Family assessment took place in October 2020. This provided a summary of the domestic abuse notifications, but the assessment itself did not analyse this information; there is no evidence that Mother was asked about domestic abuse in the context of the known history. Those notifications would have shown that mother was being harmed by several different men, at different addresses, when she was pregnant and when Edvina was present. The impact on the unborn baby and real likelihood of harm was not considered. The Child in Need plan did not mention domestic abuse and the likely impact on the safety of the children and mother not mentioned. 3.26 Over the period under review mother sought to have a termination of pregnancy on four occasions. Although women have the right to make choices about 21 pregnancy, if the midwifery and health visiting team had known about the domestic abuse, they might have been able to reflect on whether mother was subject to sexual violence in the context of domestic abuse. There is good evidence that forced pregnancy is a feature of domestic abuse, coercion, and control. 3.27 In February and March 2020, when Danuka was four/eight weeks old, there were two anonymous referrals about mother being in a relationship with a dangerous and violent man, Karl. At this time the focus was on the risk he might pose to children. The possibility that he might be domestically abusive and coercive and controlling of mother was not considered. There was said to be uncertainty about whether mother was in a relationship with this man. Mother denied this was the case, she said that she was in a relationship with his brother, Peta and it became known in the period before Sara was born, she was living in Karl and Peta’s parents’ home, referring to them as paternal grandparents and this was the description of them in the completed assessment. HV1 saw Karl leaving Mother’s home and shared this with the allocated social worker. The completed child and family assessment describes mother as ‘not being open’, but the possibility that she was being coerced and controlled by any members of Karl and Peta’s family was not considered. Although the subsequent Child in Need plan talked about the need for the children to be supervised when with the Karl and Peta’s family, there is no actual written plan and there does not appear to have been any action to address this issue of safety. There was said to be a safety plan in place, but there is no information regarding what this focussed on. 3.28 In September 2021 Mother was living with her new partner of 5 months, Teo. Mother called the police to report that Teo had punched her three times in the face. The police were called, sought a prosecution, but mother would not support this. 3.29 BCSC were already in the process of completing a child and family assessment and this continued. Mother and Teo were seen together to discuss the domestic abuse incident. This was inappropriate and falls outside of best practice; it does not take account of coercion and control and increases the risk for the victim. Mother was not given an opportunity to talk about the domestic abuse without the perpetrator present and Teo was not held responsible for his behaviour. Teo disputed the detail and alleged that Mother had started the fight, and this explanation is included in the assessment, alongside Mother’s original statement to the police which gave a different story. There is no subsequent analysis or conclusion about domestic abuse, the risk to Mother or the impact on the three children who were present. The children were not identified as victims. This was seen as a one-off incident of conflict and there were no onward actions to address these concerns. The domestic abuse was not addressed, the impact on Mother as an adult and parent not considered, the 22 impact in the short term and long term on the children as victims of domestic abuse as outlined in the Domestic Abuse Act 2021 was not considered and Teo was not held responsible as a perpetrator. 3.30 Across the records where the domestic abuse incidents are described, such as in the historical chronology of the child and family assessment, they are referred to as ‘domestic abuse between Mother and another person suggesting that both were equally involved. The information tells us this was not the case. Mother and her children were the victims of domestic abuse. This obscuring of the victims of domestic abuse by using phrases such as ‘domestic abuse within the family’, ‘domestic abuse relationship’ ‘domestic abuse between the couple’ leaves victims feeling unsupported and perpetrators without responsibility. 3.31 Across the period under review the domestic abuse of Mother was responded to by the police, it was not addressed by BCSC, despite the many notifications, two assessments and two Child in Need plans; other agencies were unaware of the specific concerns and were not included in multi-agency meetings, so Mother and the children’s circumstances were never fully considered. Why does it matter? 3.32 Each year over 2.3 million people in the UK suffer some form of domestic abusexii, and two thirds of these are women. Women are more likely to experience repeated and severe forms of violence (including sexual violence), and are also more likely to experience sustained physical, psychological, and emotional abuse. Research suggests that the victims/survivors of domestic abuse sought help from professionals on average 5 times in the year before they received effective help to stop the abusexiii. 40% of victims report difficulties with their mental health because of domestic abusexiv. Multiple studies describe how babies and children who are exposed to domestic violence experience greater levels of trauma, anxiety, and depression, as well as increased behavioural and cognitive problems which can last through childhood and into adulthoodxv. They are also at risk of physical harm which can be fatal. 3.33 Given this reality it is essential that there are systems and processes in place to address domestic abuse effectively for children, victims and perpetrators. Researchxvi has shown that this is a complex area of practice which requires professionals to enable survivors to safely talk about the abuse they experience, recognition of the needs of babies and children alongside support and interventions and processes to enable perpetrators to be held responsible for their behaviour and to be enabled to change and stop the abuse (Ofsted Joint Targeted Area Inspections of Domestic abuse (2016 xvii). 3.34 The Triennial analysis of serious care reviews published in 2016 noted: ‘The impact of all domestic abuse is harmful to children and a step-change is required in how we understand and respond to domestic abuse. There is a need 23 to move away from incident-based models of intervention with domestic abuse to a deeper understanding of the ongoing nature of coercive control and its impact on women and childrenxviii’. 3.35 The recent Child Safeguarding Practice Panel’s review of domestic abusexix found professionals often use the term ‘domestic abuse’ without full exploration, assessment or understanding of the nature of the abuse and its impact on the child and family. This was evident within multi agency meetings, plans and case records. There appeared to be an assumption that simply naming ‘domestic abuse’ as a concern for a child is enough for all practitioners to understand the situation and respond appropriately. This is an overly simplistic, optimistic and, at times, dangerous assumption that leads to potentially avoidable harm to children and non-abusing parents. What can be done about it? The National Panel review of the death of Star Hobson in Bradford raised concerns about the response to domestic abuse and made recommendations about the action to be taken. This recommendation is: to Jointly review and commission domestic abuse services to guide the response of practitioners and ensure there is a robust understanding of what the domestic abuse support offer is in Bradford. This should lead towards a coordinated community response by providing a bridge between services. Immediate action should be taken to provide multi-agency practitioners with guidance and/or training, supported within supervision, to enquire about domestic violence. There is no need to make further recommendations given this work is under way. Finding 4: Professional recognition and response to the early signs of neglect of young children by their primary caregivers. 3.36 There was evidence across the timeline of both the early signs of neglectful care provided to these babies/children by mother and possibly other adults and that this neglect became more serious over time. The sporadic nature of mother’s engagement with professionals, the difficulties over time of working out where she, Sara, Danuka and Edvina were living and with whom, meant that there was a lack of a clear picture of ‘what life was like’ for the children and what their experience of being parented was like. Edvina was said to be largely cared for by her maternal grandmother and no professional during the period under review spoke to maternal grandmother about this, despite two child and family assessments being completed, and there was minimal contact with the school Edvina attended. Speaking to the school during this review process has highlighted that Edvina was a happy and well cared for child, but there were times when mother was due to have her for the weekend and was supposed to 24 collect her from school. Mother either did not arrive, or was late, and at these times maternal grandmother would come and collect her. This evidence of a lack of attention by mother to Edvina’s needs was not know because no one spoke to maternal grandmother. Neglect of unborn babies; the womb as babies first home 3.37 Mother’s poor engagement with ante-natal care was an early indicator of neglect. Ante-natal care is as much about meeting the needs of the baby, ensuring they are safe and well as it is about the well-being of mother’s and parents. The reasons for mother’s poor engagement were not explored (there was little opportunity to do so) and without a pre-birth assessment process, either under early help or the pre-birth procedures, it was not known if this was evidence of mother struggling to put the needs of the unborn babies before her own or there were other pressures such as the impact of domestic abuse, financial problems, lack of awareness of the need for these appointments etc. That is why exploration of these issues mattered. 3.38 The perinatal period is a crucial time for human development and provides a good opportunity to engender a love for the unborn baby for parents facing multiple adversities. The national and local policy entitled “The best start for life: a vision for the 1,001 critical days”xx recognises that pregnancy, and a baby’s first 2 years, are a critical phase during which the foundations of a child’s development are laid. If a child’s body and brain develop well then, their life chances are improved. Exposure to stresses, parental mental ill health, domestic abuse, substances, such as illegal drugs, alcohol and tobacco during this period can result in impaired development and significant harm. For babies, because of their complete dependency on care givers, the risks of living with neglect can be fatalxxi. Instability as a form of neglect 3.39 The next period of professional involvement was when a further referral was made regarding Mother’s contact with Karl who was said to be a drug dealer, a sex trafficker, and a risk to children. A Child and Family assessment was completed and led to a Child in Need plan. There was a lack of focus on whether the children’s needs were being neglected in the context of constant changes of housing, and possibly living in circumstances where drugs maybe be being used and dealt. Sara was born and the family circumstances were perceived to be more settled, with mother back at maternal grandmother’s home. There was a lack of reflection that there was a pattern of calm, and then periods of chaos. During the times of calm, professionals who had contact with mother (HV1 and social workers) thought the children were looked after appropriately, and warm and caring interactions were noted. During times when mother moved accommodation (and the reasons for this remain unknown) professionals were 25 not able to see the children because they either went to the wrong house, such was the confusion about where the family was living, or no one was at home. There was not a very clear picture of this instability held by any one agency. Neglect of health needs 3.40 Mother did not bring Danuka and Sara to routine health appointments; this was not the same for Edvina, who was largely being parented by maternal grandmother. Health professionals worked hard to support mother by recognising her cultural context through reminders, texts, and phone calls. In the period between February and March 2021, there were considerable concerns about mother not taking Danuka and Sara for appointments to treat their health conditions leaving them both in likely pain; on one occasion mother was asked to take Sara (a small baby) to hospital and mother attended but left without being seen. Health professionals were concerned about this medical neglect, and as a consequence the GP surgery completed a chronology which they shared with BCSC. They followed this up with phone calls and emails but received no response. They were informed that HV1 had seen the children, whose health needs were addressed, and they were well, and BCSC also contacted them to say they were ceasing the child in need planning process. The GP surgery and HV1 worked well together to ensure that professionals were made aware of children’s health needs and sought to address concerns through active support for Mother and alerting professionals of concerns. 3.41 At this time the children were all subject to Child in Need plans which highlighted the importance of Mother prioritising the children’s health needs. However, health professionals were not part of the Child in Need process and their view that this was a serious issue was not heard. It was decided by BCSC that because mother was not engaging with the plan it would end, without any other support in place. HV1 was said to be the lead professional but no one told her this. HV1 visited the family and found that both children’s infections had cleared up. At this point the chronic concerns and crisis were seen as resolved and professionals stepped back without any action being taken to understand the root cause of these children’s health needs not being met and to consider the overall pattern of care they were receiving. The Child in Need process did not take this lack of engagement by mother with health appointments seriously, did not identify this as neglect which was having a negative developmental impact on these very young children, and which needed responding to robustly. Unsafe housing and lack of attention to children’s needs 3.42 The sexual health team visited mother in June 2021. They were concerned about the physical state of the home and the lack of safety for the children. This information was shared with HV1 via the early help team; it was agreed that a home visit would be undertaken to see if mother need any support and whether 26 she would agree to an early help assessment. Mother and Danuka were seen in the garden and due to COVID public health requirements the accommodation was not viewed; Sara was said to be asleep and so was not seen. This meant that the safety hazards raised were not addressed and worries about neglect not addressed. Mother said she did not need an early help assessment or another support. HV1 had seen Danuka and Sara at address 1 and although there were concerns about overcrowding, HV1 always noted that mother had a warm and caring relationship with the babies/children when she was present. This demonstration of warmth and care in the moment clearly influenced HV1’s analysis of the family circumstances. However, she needed to have reflected on all the known available information, such as Mother’s poor engagement with health services which risked serious harm, anonymous concerns about adult men of concern and known worries about drug use, housing instability and avoiding contact with professionals. This represented a picture of child neglect which needed responding to. Parenting or mothering in the context of neglect: where are the men? 3.43 Up until September 2021 mother was viewed as a single parent who was parenting Danuka and then Sara alone. Mother told midwifery she was no longer in a relationship with the father of any of the children and provided no names or details. If midwifery had been told of the domestic abuse concerns when they contacted BCSC this would have provided a different picture. 3.44 Mother also told HV1 that she had no contact with the fathers of any of the children. Over time it became known that Mother was in a relationship with either Karl or his brother Peta, leading to an assessment and a period of Child in Need planning but there was no discussion about the role either of these men played in the children’s lives, despite living for some of the time with these men’s extended families. These men made themselves ‘invisible’, and no professional challenged this or asked questions about it beyond a discussion about who mother was in a relationship with. What this meant for the children, their parenting, their attachment relationships and their stability was not considered. 3.45 Edvina lived with her maternal grandmother for most of the period under review, until around October 2021. There is no information about how she was being parented or progressing or her relationship with mother. This was despite there being an assessment and Child in Need process which included her. The role of the extended family, who were ever present when professionals visited, was not considered in the context of parenting, and meeting these children’s needs. Their views were never sought. 3.46 This chimes with the Child Safeguarding Practice Panel review ‘The Myth of Invisible Menxxii’ which highlighted that professionals continue to hold engrained 27 stereotypes and expectations about men, women, and parenthood. Women continue to be regarded as the prime and sometimes only carer for their children and men are not always engaged with meaning men are marginalised or enabled to be absent. The review suggests a cultural shift is needed including an ‘organisation-wide approach to including fathers and working with other agencies and joining up principles; it means starting with a belief that fathers matter too, and engaging them in the early years sector, schools, children’s services and health services. This also needs to include recognition of the wider extended family who were absent in professionals thinking about Sara, Danuka and Edvina. 3.47 In September 2021 mother, her new partner Teo, Danuka and Sara were homeless and living on the street; it remains unclear why neither of the adults sought professional help, rather than sleeping in the park with these young children, because no one directly seems to have asked this question; mother did say she had lost contact with her family, something that was inaccurate. It was noted at this time that the family were living on a low income and had no settled status and therefore no entitlement to hosing. They were housed in temporary accommodation through the local authority’s responsibilities to children and families without recourse to public funds and a child and family assessment was started. 3.48 Three weeks later the police were called by mother because she was assaulted by Teo. The police found the accommodation to be completely unsuitable for the children. They had no beds to sleep in, there were safety hazards and a poor physical environment; the police made an appropriate referral to BCSC. It remains unclear why this situation had gone on for so long without being addressed as part of the early contact with the social worker. The lack of bedding was addressed over the next few days, but there was no action taken to address the inappropriateness of this housing for three young children (Edvina (aged 6) had moved back to live with mother and Teo. 3.49 The police also found Sara was very unwell, and they transported her to hospital. The police left and mother did not wait to be seen. This was shared with HV1 and the social worker but led to a no action to address this lack of focus on Sara ’s health needs. It was not linked to previous concerns or identified as a neglect of health needs. 3.50 The assessment was ongoing, and over time the family were provided with food parcels and one-off payments. This was not at this stage parental neglect, but a family who needed help. This was provided in a piecemeal and uncoordinated way which provided the parents with no dignity and the children with no safety and lacked a focus on their physical and emotional wellbeing. At the same time there were emerging concerns about parental behaviours that put the children at risk of harm, such as mother and Teo subletting one of the two rooms they 28 had been given. This was not challenged or addressed. Sara was noted to be underweight and the health visiting service was asked to complete a developmental check. This did not happen, and the child and family assessment was completed without clarity about Sara’s physical wellbeing This was caused by an unclear handover from one health visiting team to another, highlighting the importance of these handover processes, and a lack of follow up by the social worker or challenge regarding why it had not been completed. The conclusion of this assessment was that there were no concerns about the children’s wellbeing and safety. A conclusion that was out of step with the available evidence. The focus was entirely on the adults. This meant that the emerging concerns about neglect were not acknowledged, so were left unaddressed. 3.51 In December there was a further referral of concern about mother and Teo’s drug use, Teo’s domestic abuse and the children being left with inappropriate adults. More evidence of growing concerns about the neglect of these three children which was not responded to in a timely way, until a new team took over. The possibility that the growing evidence of neglect might indicate the possibility that these children were being harmed in other ways was not considered. It is critical that professionals consider in the assessment and analysis ‘what other abuse does neglect enable’. Sara and Danuka were found to have a number of unexplained injuries which were causing them significant distress. Understanding the child’s lived experience as opposed to being adult focussed. 3.52 Child neglect is defined as the failure of parents/caregivers to meet a child’s physical, emotional, educational, supervisory, stability and educational needs; this failure can be intentional or unintentional. Regardless of this intentionality, there is clear evidence of the short and long-term impact on babies and children’s development and wellbeing. Identifying the neglect of children by their primary carers requires a focus on the child’s lived experience, thinking about a parent’s attitude towards their child and their ability to respond to their needs in an appropriate and timely way. 3.53 There is little information about the lived experience of any of the children. HV1 did write her records with a focus on what Danuka and Sara needed from their mother, in the context of their health needs. This was good practice. Overall, though, there was little evidence of discussion between professionals of what the younger two babies, who were pre-verbal might be feeling about the constant moving from place to place, having untreated infections which will have caused pain and the impact of different adults, often described as dangerous, in their life. What the implications were of the concerns about drug use by mother and evidence of drug dealing from one of the houses she lived 29 in. The implications for them were not recorded. There is no indication of what the day-to-day life for the children was like or that their lived experience at the time had the potential for physical harm due to lack of supervision and domestic abuse. The neglect they experienced was clearly linked to the significant physical harm that they were subject to (the perpetrator of this, mother or Teo is not known). When thinking about the neglect of any child, the link to physical harm and abuse must be considered. Why does it matter? 3.54 The neglect of children by their parent(s) (primary caregivers) is a serious issue which has a significant and long-lasting negative effect on children’s developmental outcomes, their safety, their emotional wellbeing, and the impact often lasts into adulthoodxxiii. Child neglect is a complex area of practicexxiv which requires a structured and analytical approach with a focus on persistence and pervasiveness, how likely, capable, and willing are parents to change the circumstances for their children, the type of neglect and its impact across the developmental spectrum of children’s needs, and then what has caused the neglect to establish the most suitable interventions. These elements were not evident in the professional response to Sara, Danuka and Edvina. When the early signs of neglect are not identified and responded to unhelpful patterns of negative parenting strategies can develop, the neglect worsens over time and the harm cumulative and corrosive in nature. 3.55 Research and the national reviews of SCR’s and LCSPR’s has highlighted that when working to address the neglect of children and adolescents, one of the barriers is multi-agency working, differences of opinion and the lack of respectful challenge between professionals. In this case there were times when challenge was necessary. HV1 became aware that she had been named as the lead professional without her knowledge. This should have been challenged. Professionals were not invited to Child in Need meetings, did not receive assessments, and did not receive minutes of meetings. When those professionals became aware of the various Child in Need processes, they needed to challenge, and to use the Partnership escalation process if they were unsuccessful. What can be done about it? Recommendation 3: Bradford Children’s Partnership has noted that there have been a number of LCSPR’s locally where there was an ineffective professional response to addressing and responding to the neglect of children, despite a strategy and neglect framework being in place. The Partnership Neglect subgroup group is reviewing why this is and what action needs to be taken. This working group will need to take the findings of this review into account. 30 Recommendation 4: This is one of many LCSPR’s nationally that have been completed or are in the process of completion where there has been an ineffective professional response to addressing and responding to the neglect of children and adolescents, despite local neglect strategies and neglect framework being in place. This suggests this is a widespread national systemic issue which requires a specific look by the National Panel on why the neglect tools that have been developed over the last ten years are not having an impact on practice. The Bradford Children’s safeguarding Partnership has published an LCSPR recently a recommendation from that report is relevant here and means no further recommendation is needed. Recommendation: All agencies should review their existing training programmes to ensure that it is clear to practitioners that all children should have a voice, including those who are pre- or non-verbal. Finding 5: Response to referrals, completion of assessments, Child in Need processes and multi-agency working. Response to referrals 3.56 Over the period from June 2019 to December 2021 there were fourteen different contacts with BCSC expressing concerns about mother and the children. Five were from the police, three from anonymous sources, one from a family member and the rest from organisations/professionals. Police call outs. 3.57 When mother was pregnant with Danuka in 2019 and Sara was sometimes in her care the police were called to three incidents where there were concerns that mother had been subject to domestic abuse and on at least one occasion Edvina was present and upset. There were several different addresses, involving at least three different men. Prosecutions were sought on two occasions, but mother was not willing to support a prosecution. There was a fourth notification in March 2020 when Danuka was two months old. In line with local protocols (is that right) these incidents were shared with BCSC front door. They led to no further action, though the police were told that the March 2020 incident had been allocated to a social worker to make some further enquiries; this was not the case. This meant that beyond the incident itself, neither the children’s welfare were assured. Response to anonymous/family calls 3.58 In the period between February and April 2020 there were five contacts with BSCS. These all related to similar issues. One from the police who had been told by mother’s landlord that she was misusing drugs, two anonymous calls that she was associating with a known drug dealer and dangerous adult who was involved in sex trafficking, one concern from a family member about associations with this man and one further anonymous referral about Mother 31 being seen taking drugs on the street with baby Danuka present. There were different responses to these concerns, and no coordinated picture was formed about both the drug use and the associations with dangerous adults. Further information was sought by the front door, and for some of these referrals they were noted to be ‘malicious’ and so not requiring a response. This strategy lost sight of the fact that the referrals could have had a malicious intent, but that did not mean they were untrue. 3.59 On other occasions HV1 was asked to complete her routine home visit and establish whether the concerns about Mother’s drug use and links with a dangerous adult were accurate. This was not appropriate and HV1 made this clear. It would have been reasonable to ask a health visitor to share any concerns that emerged from her routine visits as part of multi-agency enquiries, but nothing else. HV1 attempted to visit, without success although she became aware that mother was said to be in a relationship with Karl, because the family told her this. Health enquiries were undertaken in response to the family members concerns, and because Danuka had been seen recently at the GP surgery the concerns were said to be unsubstantiated. The children were never seen, and mother was never asked about drug use or whether she was being coerced and controlled by other men (the link with the police notifications was not made). The impact of this was those concerns about drugs use, the subject of four of the referrals, were never established, and wrongly seen as unsubstantiated on this basis. This lack of focus remained when a year later HV1 spoke about witnessing young people buying drugs from the house, this was simply disregarded. 3.60 The first referral by a professional was in October 2020 when mother was pregnant with Sara. This was from the school attended by Karl’s children; there were concerns that Karl was the father of the unborn baby and that he was involved in sex trafficking, sexual abuse and drug dealing. Like the concerns given by the anonymous referrers. This was responded to by a child and family assessment; given the connection to recent concerns a strategy discussion should have been convened. The lack of this meant that no one professional really understood what the concerns about Karl were, and once again there was no focus on the issue of drug use/dealing or likely domestic abuse. 3.61 A referral was made to the out of hours service in September 2021 when mother, Teo and the children were found to be homeless. This appropriately led to a child and family assessment. Whilst this was ongoing the police raised concerns about neglect which were incorporated into the assessment process. 3.62 The final referral of concern was from a specialist voluntary sector organisation sharing concerns about drug use, domestic abuse, and inappropriate adults in contact with the three children. They were all subject to Child in Need plans, but much like the earlier concerns, home visits were undertaken, and no one was present. There was a lack of urgency in establishing the safety and 32 wellbeing of the children. This was resolved when a new team was allocated to work with the family. Prompt action was taken and the concerns about the children taken seriously. 3.63 Each of these notifications/referrals of concern were responded to in isolation, despite the consistency in what was being reported. The label of maliciousness served to minimise concerns, without sufficient enquiries being completed and without the children being seen. This echoes with the findings of the National Panel’s Review into the death of Star Hobson and the recommendations from that review reflect the issues raised here. Child and Family Assessments 3.64 There were two Child and Family assessments regarding the three children. The first was in response to the referral from school and took place between October and December 2020. This was completed by two different teams due to the pressures on BCSC at this time. The completed assessment takes no account of the recent history of concerns, does not build a picture of the family’s circumstances, and focusses exclusively on the narrow information in the referral translated as ‘concern about Karl’. There is a lack of reflection on the needs of the unborn Sara, little information about Edvina who was not living with mother, but there was no contact with the extended family. The issue became about mother’s assertion that she was not in a relationship with Karl and the social work view that this could not be proven either way; an entirely adult focussed response. Concerns about domestic abuse, instability and drug use/dealing were not addressed. A Child in Need plan was agreed but focussed on mother keeping the children safe from the Karl and Peta’s family, without a clear outline of what the risks were or how they were to be managed. 3.65 The second Child and Family assessment started in September 2021, and this also focussed on the narrow terms of the referral, which was about housing and immigration status. These were important issues, but there were known concerns about domestic abuse, growing concerns about neglect, children’s presentation and weight, non-attendance at routine health appointments and not attending health appointments for acute child health symptoms, and known worries about previous possible drug use. These were not included or analysed in the assessment, and issues of neglect underplayed, despite the clear available evidence. 3.66 There was little multi-agency input to the assessments, and crucially they were not shared with any agency providing a service to the family. Good assessments matter. They are the way in which the multi-agency network can understand the needs of children and their families and the risks they face to address these. Child in Need Processes. 33 3.67 As a result of the two completed child and family assessments in 2020 and 2021 there were two periods of child protection planning. 3.68 The first period took place over an eight-week period. The plan was narrowly focussed on undefined issues of safety from Karl’s family. The health visitor, GP or midwife were not told about the Child in Need plan, and not invited to the Child in Need meetings. They were therefore unable to share their concerns about poor attendance at health appointments and their worries about what that meant for the children, including GP concerns about neglect. Edvina’s school was involved in one meeting but did not know about the reason for the original assessment or the Child in Need plan. They were invited purely as information providers to one virtual meeting. The Child in Need plan was closed without any consultation with the multi-agency network, despite known concerns form the GP surgery and HV1 through the sent missed health appointments chronology. It was agreed that there would be a stepdown to early help support with HV1 as the lead professional who would undertake an early help assessment. She was never informed of this, and so unsurprisingly this only happened because of a further referral of concern to the early help team. 3.69 The second Child in Need process started in 2021 and would be ongoing until the critical incident. The focus of the plan was housing and immigration status. Appropriately a voluntary sector organisation was asked to support mother in her applying for settled status. Housing were not included in the plan or process despite the emerging concerns about the suitability of the accommodation for young children. The plan did not change with emerging concerns about domestic abuse, no specialist service was asked to provide support or interventions. The issues of Sari’s low weight were left with the health vising service and were not addressed due to a change in teams because the family had moved areas. Edvina’s school were unaware of the concerns and were not invited to the meetings. 3.70 Overall, both periods of Child in Need planning lacked a multi-agency approach and a poor focus on the real needs of the children. Multi-agency working and information sharing. 3.71 Section 3.55 above covers some of the gaps in multi-agency working which impacted on the response to this family. There was some good practice: • The GP, AP and HV1 liaised well when there were concerns about Danuka’s and Edvina’s health needs not being met. • The midwife liaised well with HV1 and BCSC. • The police made a good referral to BCSC outlining their concerns. 3.72 There was a significant gap in multiagency inclusion in the Child in Need process, which undermined both assessments and child protection planning. 34 This was during the time when BCSC were under significant pressures, as outlined within the Star Hobson national review. Why does it matter? 3.73 It is critical that these routine processes, of identifying the risks facing children and their families, understanding their needs and establishing what the key issues are as to intervene effectively. This did not happen for Edvina, Danuka, and Sara, for whom there was an unclear picture formed of their circumstances and needs; despite the available evidence. What can be done about it? There is a recommendation within the Star Hobson national review which addresses some of these concerns: Partners should work together to ensure that: • Decisions not to proceed following a referral are based on a review of previous history, background checks and a chronology of prior concerns • No referral is deemed malicious without a full and thorough multi-agency assessment, including talking with the referrer, and agreement with the appropriate manager • All staff are compliant with information sharing protocols • Risk assessments are always informed by multi agency information gathering which includes listening to family and friends and an assessment that goes beyond self-reporting • Supervision is always used to test assumptions and alternative hypotheses Recommendation 5: This recommendation from the Child Safeguarding Panel Review does not address the issue that although members of the public, children, family and friends are encouraged to see ‘safeguarding as everyone’s businesses and alert public authorities about concerns they have about children, there remains a lack of clarity about how they can receive feedback about the actions to be taken, whether their concerns have been heard and what they can do if they are unhappy with the response. It is recommended that The Bradford Children’s Safeguarding Partnership to enhance the existing advice to family members, community members and anonymous referrals. Recommendation 6: The Bradford Children’s Safeguarding Partnership should seek information from the national panel about what work is underway to address this lack of guidance about the appropriate response to referrals and information from family, the public and anonymous sources which remains a national issue of concern. 35 Recommendation 7. There needs to be clarity about when and in what circumstances child and family assessments will be shared with those agencies who will be supporting children who are subject to Child in Need plans. The Bradford Children’s safeguarding Partnership has published an LCSPR recently and a recommendation from that report is relevant here and means no further recommendation is needed. Recommendation: The Bradford Partnership should undertake a systems review to ensure a robust approach to Child in Need arrangements. 36 References i Working Together 2018 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Working_together_to_safeguard_children_inter_agency_guidance.pdf ii Equality Act 2010: guidance - GOV.UK (www.gov.uk) iii Roma Strategy Research Report Final_0.pdf iv Connecting Roma CIC Connecting Roma CIC - Welcome to Bradford (welcomebradford.org) v Children Act 1989 www.legislation.gov.uk/ukpga/1989/41/contents vi DOH (2000) Framework for the assessment of children in need and their families http://webarchive.nationalarchives.gov.uk/20130404002518/https://www.education.gov.uk/publications/eOrderingDownload/Framework%20for%20the%20assessment%20of%20childre n%20in%20need%20and%20their%20families.pdf vii Thoburn, J et al (2004) Child Welfare Services for Minority Ethnic Families: The Research Reviewed: Jessica Kingsley press. viii HM Government (2021) The Best Start for Life A Vision for the 1,001 Critical Days The_best_start_for_life_a_vision_for_the_1_001_critical_days.pdf (publishing.service.gov.uk) ix childrens_sb_pre-birth_assessment_web.pdf x The Child safeguarding Practice Panel (2023) Child Protection in England National review into the murders of Arthur Labinjo Hughes and Star Hobson Child Protection in England - May 2022 (publishing.service.gov.uk) xi Framework for the Assessment of Children in Need and Their Families - Guidance Notes and Glossary.pdf (bettercarenetwork.org) xii https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/bulletins/domesticabuseinenglandandwalesoverview/november2020#:~:text=According%20to%20the%20Crime%20Survey,last%20year%20(Figure%201). xiii https://safelives.org.uk/policy-evidence/about-domestic-abuse/how-long-do-people-live-domestic-abuse-and-when-do-they-get xiv https://www.mentalhealth.org.uk/statistics/mental-health-statistics-domestic-violence xv https://www.womensaid.org.uk/information-support/what-is-domestic-abuse/impact-on-children-and-young-people/ 37 xvi Fraser A & Irwin-Rogers K. (2021). A public health approach to violence reduction: Strategic Briefing (2021). Dartington: Research in Practice. xvii https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1062330/JTAI_domestic_abuse_18_Sept_2017.pdf xviii Complexity and challenge: a triennial analysis of SCRs 2014-2017 (publishing.service.gov.uk) xix Multi-agency safeguarding and domestic abuse (publishing.service.gov.uk) xx “The best start for life: a vision for the 1,001 critical days”, Department of Health and Social Care, March 2021 https://www.gov.uk/government/publications/the-best-start-for-life-a-vision-for-the-1001-critical-days xxi The Role of Neglect in Child Fatality and Serious Injury. Marian Brandon, Sue Bailey, Pippa Belderson, Birgit Larsson. First published: 27 August 2014 xxii The Myth of Invisible Men (publishing.service.gov.uk) xxiii file:///C:/Users/richa/Downloads/Childhood_neglect_and_abuse_comparing_placement_options%20(1).pdf xxiv Brandon, M. et al., 2014. Missed opportunities: indicators of neglect–what is ignored, why, and what can be done? London: Department for Education, DFE-RR404, 46pp. |
NC51181 | Death of an 8-month-old girl in 2017. Rose was transported to hospital by ambulance and shown to have a subdural bleed reflecting severe brain trauma. Two days later life support was withdrawn due to the severe brain injury. Mother charged with her murder as well as offences from 2004. Mother known to services since 2015 when pregnant with Daisy, Rose's sister. Father had a learning difficulty. Rose born in 2016 after a concealed pregnancy. Mother was suspected of serious injuries to a child in 2004, but after police investigation Mother was not prosecuted for any criminal offences at the time. Learning includes: consider opportunities to ensure disguised compliance and focus on children to be examined regularly in staff supervision meetings and reviewing desired outcomes for children; develop and implement guidance relating to looked after children who sustain injuries, including who should be informed and what action should be taken; consider options for ensuring continued and meaningful engagement of GP services throughout safeguarding processes; consider how non-statutory voluntary organisations can be identified and included in safeguarding processes; consider requiring the local authority to complete and share the outcome of an analysis of children placed at home, the circumstances and decisions which led to placements being initiated and how compliance is monitored, to ensure the safety of all children who are subject to home placement agreements. Ethnicity and nationality not stated. Review does not include any recommendations.
| Title: Serious case review: overview report: Child LK. LSCB: Lancashire Safeguarding Children Board Author: Amanda Clarke Date of publication: 2019 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 * NB: In order to protect identities, pseudonyms have been used throughout this report Serious Case Review Overview Report Child LK Author: Amanda Clarke Date: 15/02/2019 Publication Date: 19 February 2019 2 * NB: In order to protect identities, pseudonyms have been used throughout this report CONFIDENTIAL-This Report should not be shared without the permission of the Chair of Lancashire Safeguarding Children Board Foreword The untimely death of a child is always tragic and this is no exception. Rose's birth had been premature and the pregnancy concealed up to that point. Rose's mother had a history going back some years, which involved an incident of harm to a child. When she reported her pregnancy with Rose's sibling, services became actively involved and, following assessment, she was judged to be a person who could be trusted to care for her daughter, Daisy, although with the support of a care order. When Rose was born she had complex needs, due to her prematurity, and was also made subject of a care order on the basis of support to her mother to care for both children at home. Sadly, Rose died in 2017 and her mother was subsequently convicted of her murder. A support package was in place at the time of Rose's death. This report sets out the findings of a review of multi-agency practice in respect of the support offered to Rose, and her sibling Daisy. The publication of the review has been delayed by legal constraints associated with court proceedings. The purpose of the review is to identify any lessons arising from the case and the report seeks to pull out areas of good practice as well as areas where practice improvements need to be made. It covers a period of two years and 3 months in 2015-17, but also looks back at a connected situation which involved the mother in 2004. Findings from the review are set out in detail in the report. A number of the lessons which arise from the scrutiny of this case have been identified in other Reviews, either here in Lancashire or elsewhere. Bringing about changes in professional practice is not an easy task but I know readers of this report will reflect on the implications for the conduct of their own work. While responsibility for Rose's death sits with her mother, it is always possible, with the benefit of hindsight, to identify opportunities to improve practice. The author of the report has made 17 recommendations for the Safeguarding Children Board to consider. In addition a number of agencies have developed their own single agency action plans. These, together with actions agreed by the Board, are monitored regularly and many are already complete. It is my hope that actions taken will contribute to the reduction of risk in the future. Jane Booth Independent Chair Lancashire Safeguarding Children Board 3 * NB: In order to protect identities, pseudonyms have been used throughout this report Child LK “Rose” Died 2017 This serious case review was commissioned by the Independent Chair of Lancashire Safeguarding Children Board (LSCB) on 24 May 2017 in agreement with the recommendation of the LSCB Serious Case Review Sub Group that the circumstances surrounding the death of a child met the criteria for a serious case review (SCR). Subject of the review Child LK: Rose Rose is not the real name of Child LK but the review will refer to her in this name to protect her real identity. The name has been chosen in consultation with Rose’s father and his family. Sadly Rose died in 2017 after being seriously harmed. She was aged 8 months. Rose had a sister who was also the child of father and the same mother together. The sister will be referred to as Daisy throughout the review, which is again a pseudonym chosen in consultation with her father and his family. Daisy was nearly 2 years old at the time of Rose’s death. Legal Context A serious case review was commissioned by Lancashire Safeguarding Children Board, following agreement at Lancashire Serious Case Review Sub Group in accordance with Working Together to Safeguard Children (Department for Education 2015), which was the version of Working Together relevant at that time. Regulation 5 of the Local Safeguarding Children Boards (LSCB) Regulations 2006 sets out the functions for LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5(1) (e) and (2) set out an LSCB's function in relation to serious case reviews, namely: 5. (1) (e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. (2) For the purposes of paragraph (1)(e) a serious case is one where: (a) abuse or neglect of a child is known or suspected; and (b) either (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. Cases which meet one of the criteria (i.e. regulation 5(2)(a) and (b)(i) or 5(2)(a) and (b)(ii)) must always trigger an SCR. Regulation 5(2)(b)(i) includes cases where a child died by suspected suicide. Where a case is being considered under regulation 5(2)(b)(ii), unless there is definitive evidence that there are no concerns about inter- agency working, the LSCB must commission an SCR. 4 * NB: In order to protect identities, pseudonyms have been used throughout this report Methodology The methodology used was based on the Child Practice Review process (Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews, Welsh Government, 2012). This is a formal process that allows practitioners to reflect on cases in an informed and supportive way. Documenting the history of the child and family is not the primary purpose of the review. Instead it is an effective learning tool for local safeguarding children boards to use where it is more important to consider how agencies worked together. The detail of the analysis undertaken of the case is not the focus of the reports which are succinct and centre on learning and improving practice. However, because a review has been held, it does not necessarily mean that practice has been wrong and it may be concluded that there is no need for change in either operational policy or practice. The role of safeguarding boards is to engage and contribute to the analysis of case issues, to provide appropriate challenge and to ensure that the learning from the review can be used to inform systems and practice development. In so doing the boards may identify additional learning issues or actions of strategic importance. These may be included in the final review report or in an action plan as appropriate. The opportunity to conduct serious case reviews in this, and other ways, is as a result of the change in statutory guidance following The Munro Review of Child Protection: Final Report: A Child Centred System, May 2011. Munro suggests that local safeguarding children boards should use any learning model which is consistent with the principles in the Working Together to Safeguard Children Guidance: Learning and Improving, HM Government 2015. Following notification of the circumstances of the death of Rose, and agreement by the chair of the Lancashire Safeguarding Children Board to undertake a SCR, a review panel (to be known as the Panel) was established in accordance with guidance. This was chaired by Detective Inspector Allen Davies of Lancashire Constabulary (to be known as the Chair). The Panel included representation from relevant organisations within Health, Children’s Social Care, the Police, the National Society for the Prevention of Cruelty to Children (NSPCC) and the Children and Family Court Advisory Service (CAFCASS). Information was also provided for the Panel to consider by the National Probation Service and an independent sexual health organisation. Amanda Clarke, an independent reviewer from Derbyshire (to be known as the Reviewer) was commissioned to work with the Panel and to undertake the review. The Panel identified the review timeframe as commencing 01/01/2015 and ending 21/04/17 which was when Rose died. The Panel had agreed that this was an appropriate period to review services relating to Rose and her sibling Daisy, on the understanding that historical information would be considered and shared where relevant, and to provide context. A connected set of circumstances to which Mother was linked, involving a different young child in 2004 was also examined by the Panel. Some, but not all, agency records from the events many years before were available for scrutiny to inform the review. Full terms of reference for the review are included as Annex 1. All relevant agencies reviewed their records and provided timelines of significant events and analysis of their involvement for the identified review timeframe. These were considered by 5 * NB: In order to protect identities, pseudonyms have been used throughout this report the Panel and provided opportunity for Panel members to raise questions and clarify understanding of the circumstances of the case and of the separate services provided. The agency timelines were merged and used to produce an interagency timeline. This was carefully analysed by the Reviewer with the Panel and informed of the areas of interest that required further exploration and consideration. The process also allowed for the identification of the key practitioners required to attend a learning event in order to understand the detail of the single and interagency practice in this case. The practitioners’ learning event was held in March 2018 and was attended by fifteen professionals. Most practitioners attending had had direct involvement with Rose and/or Daisy. Unfortunately, due to the non recent period during which the injuries were caused to the other child most professionals involved in 2004 were not available to take part in the learning event in 2018. The Reviewer facilitated the learning event assisted by the Chair of the Panel and officers from Lancashire Safeguarding Children Board. Those attending who had not worked directly with the children were able to provide the position and perspective of the service delivered to the family. The event was organised in line with Welsh Government guidance (Child Practice Reviews: Organising and Facilitating Learning Events, December 2012) and minutes were recorded. With the support of Panel members and the Lancashire Safeguarding Children Board team, further enquiries were made with professionals who were unable to attend the learning event, and this information is included in the report. Following the practitioners’ learning event, the Reviewer collated and analysed the learning to date for discussion with the Panel. Practice issues and themes originally identified by the Panel were re-examined in the light of the findings of the review. This provided opportunity to identify issues requiring further clarification with practitioners or managers. In reviewing the findings, the Panel gave consideration to what could be done differently to further improve future practice. A draft report was provided to the Panel in advance of the Panel meeting in July 2018. The report contains learning themes for the Lancashire Safeguarding Children Board to consider in developing an action plan to ensure learning from the case is embedded in future practice. Circumstances and history resulting in the review In September 2004 serious injuries were discovered to a very young child who cannot be identified for legal reasons. There was suspicion that the person this report is referring to as Mother, who was involved in the care of the child at the time, was responsible. Mother did eventually make some partial admissions as to responsibility for the injuries being caused. After a police investigation the Crown Prosecution Service were consulted in 2004 and 2005. After the evidence had been considered, including the direction that certain information was inadmissible, the person known as Mother was not prosecuted at that time for any criminal offences relating to the injuries. The NSPCC were commissioned to undertake a specialist risk assessment of the person known as Mother and judgements from the assessment are reflected where relevant throughout the report. Services became aware of Mother being pregnant with Daisy, the sibling of Rose, in early 2015. Daisy was born in 2015. Mother gave birth to another child, Rose in 2016 after a concealed pregnancy. In 2017 Rose sadly died and subsequently Mother was charged with 6 * NB: In order to protect identities, pseudonyms have been used throughout this report her murder. At the same time she was also charged with serious assault offences for the injuries caused to the child in 2004. In 2018 Mother was convicted on all criminal charges relating to the two separate children. The following is a summary of key episodes and involvement of services with Mother and the children during the identified review timeframe. Analysis is included later in the report. Date Incident or involvement January 2015 Mother booked as pregnant with (unborn) Daisy, the elder sibling of Rose. She disclosed to the community midwife her previous involvement with children’s social care in 2004 regarding injuries caused to another young child. An immediate referral was made to children’s social care about the unborn child. 9 March 2015 A pre birth assessment was completed. 30 March 2015 Initial child protection conference1 held regarding the unborn child (Daisy). The decision of the conference was to place the unborn child on a child protection plan2 under the category of risk of physical abuse. 10 April 2015 After an initial core group meeting Mother disclosed to the allocated early help outreach worker that she had felt suicidal at the fear of having the baby removed from her care. 14 April 2015 Pre proceedings3 meeting where it was identified that Father had a learning difficulty which required further assessment. It was also concluded that Mother had not acted on any recommendations made as a result of the NSPCC risk assessment in relation to addressing concerns which related to the incidents in 2004. 30 April 2015 Antenatal contact by health visitor to Mother’s home which was described as warm and appropriately furnished. Mother disclosed she has very little support from family or friends, and that the pregnancy was as a result of a “one night stand”. Mother said she was undergoing a parenting assessment by children’s social care. 5 May 2015 Core group meeting4. Father had had three assessment sessions. It was alleged by Mother that he was in a casual relationship with another woman and there may 1 The purpose of an initial child protection conference is to bring together family members, the child (where appropriate), supporters/ advocates and those professionals most involved with the child and family to share information, assess risks and to formulate an agreed plan of management and services, with the child's safety and welfare as its paramount aim. 2 A child protection plan is put in place when a network of agencies considers a child to be at risk of significant harm. 3 The pre proceedings stage aims to try to intervene and help families before getting to the stage of making an application to the court regarding the child/children. 4 The core group meeting will be made up of relevant professionals involved with a family who meet regularly if a child is on a child protection plan. 7 * NB: In order to protect identities, pseudonyms have been used throughout this report have been some history of domestic abuse. Father’s learning difficulties were said to be being explored. Mother presented as “adamant” that she wanted to be assessed as a single parent. She had at that time attended all ante natal appointments. A decision was made to enquire about supported mother and baby placements. 27 May 2015 A care planning meeting5 was held resulting in a decision to recommend a mother and baby foster placement and an application for an interim care order as soon as the baby was born. 4 June 2015 At a review child protection case conference the unanimous decision was for the unborn baby to remain on a child protection plan. XX XX XX The sibling of Rose was born, to be known as Daisy. 12 June 2015 A multi disciplinary discharge planning meeting was held. Decision made to discharge both Mother and baby to a foster placement out of the local area and an application was to be made to court for an interim care order. Supervised visits to the baby had taken place by Father on the ward. 15 June 2015 Mother and baby Daisy commenced placement at the foster carer’s home. A strict working agreement was in place including that the baby would sleep in the foster carer’s room and that contact between Mother and baby would always be supervised. 16 June 2015 Liaison took place between the social worker and health visitor regarding the placement resulting in communication with health visiting services in the placement area. 15 July 2015 An initial court hearing took place regarding the care order application at which a psychological assessment on Mother was presented. The report reflected on Mother’s history. Mother was upset by this as in her view it was negative with a focus only on non recent events. Mother was seeking a second opinion and the local authority agreed to fund a reassessment after cognitive behaviour therapy6 (CBT) had taken place with Mother, which was recommended in the psychological report. 29 July 2015 Mother made contact herself with her own GP surgery to update that she was living away from the area in a foster placement with her baby. 15 September 2015 At a review child protection case conference the baby’s name was removed from a child protection plan as an interim care order7 was now in place and reviews would take place under child looked after procedures. Weekly CBT sessions were at the time taking place with Mother. 5 A care planning meeting is held after a decision that a child/children should become Looked After. 6 Cognitive behaviour therapy is a talking therapy which can help a person to manage problems by changing the way they think and behave. It is most commonly used to treat anxiety and depression but can be useful for other mental and physical health problems, www.nhs.uk 7 An interim care order is an order that can be made by the court before a final hearing, when all the evidence is put before the Judge and a final decision is made about a child’s future. 8 * NB: In order to protect identities, pseudonyms have been used throughout this report 12 October 2015 A statutory visit8 took place and the placement was described as continuing to go well, with Mother said to be ensuring all the baby’s needs were met. 15 October 2015 The psychologist completing the reassessment advised that it was time to reduce supervision of Mother with baby in a planned way, to give Mother chance to use her coping strategies whilst still having the safety net of the foster placement. As a result short spells of unsupervised contact were agreed and arranged by the social worker. 20 October 2015 The GP was informed by letter that the child protection plan had been discharged and that an interim care order was in place. 10 November 2015 A new social worker was allocated due to illness of the previous social worker. A statutory child looked after visit was undertaken by the social work practice manager until an introductory visit by the new social worker could take place. 12 November 2015 Foster carers reported a positive attachment between Mother and baby and that there were no concerns at the placement. 14 December 2015 Mother and baby moved into their own property in the original local authority area following positive assessments in foster care. A visiting plan was put in place commencing with daily visits then weekly from Christmas time. This was arranged to be reviewed at the next child looked after review in February 2016. 17 December 2015 At the final court hearing a home placement order9 was granted. 02 March 2016 The child looked after review took place at Mother’s home. Support was discussed with additional support also being provided by a voluntary church organisation and by Lancashire Intervention for Families Team (LIFT)10. At the review it was agreed that Mother would supervise Father’s weekly contact with Daisy and this contact would no longer be required to take place at the contact centre. 29 March 2016 The looked after child health assessment took place at home with the health visitor. The child was noted to be progressing well and was seeing Father. 31 March 2016 On a routine contact by the early help outreach worker it was disclosed by Mother that the church group volunteer had suffered a close family bereavement and was unable to visit. Arrangements were made for more frequent visits by the outreach worker for the next three weeks. 06 April 2016 Mother attended the GP surgery to request contraception as she said was back in a relationship with Father. 8 Statutory visits are a requirement for social workers when children are subject to child in need plans, child protection plans or are children looked after. 9 A home placement order is when a final care order has been made at court but the care plan is for the child to remain at home. 10 Lancashire Intervention for Families Team is a mentoring scheme whereby foster carers work with birth families to offer additional support when children are deemed as looked after. 9 * NB: In order to protect identities, pseudonyms have been used throughout this report 03 May 2016 During a home visit by the early help outreach worker Mother was upset as Daisy’s Father had been arrested whilst allegedly “drunk”. Mother was concerned how this might have affected contact arrangements. On the same visit it was observed that Daisy had a bump to her nose and left cheek which Mother explained that the child had fallen and bumped her face on the TV unit. 12 May 2016 During a home visit by the health visitor Mother disclosed that Daisy had had some facial bruising due to falling against the TV unit on the 2nd May. Mother said she had seen the GP about this the next day (not in GP records). 17 May 2016 In a supervision meeting for the allocated social worker a decision was made that the family support worker and early help outreach worker should reduce and conclude their involvement with Mother and Daisy due to the good progress which had been made by Mother. 02 June 2016 Email contact was received by an independent sexual health service from Mother who was requesting advice about a termination. Information was provided by Mother regarding her involvement with children’s social care and the history leading to that involvement. 12 June 2016 Mother gave consent for the independent sexual health service to contact her GP for medical information regarding her plans for a termination. 16 June 2016 During a home visit by the early help outreach worker Mother was upset and shared that Father was alleging he had resumed a sexual relationship with Mother and that she was pregnant. Mother denied this and said she had “stopped the contact” between Father and Daisy. 20 June 2016 A statutory visit by the social worker took place, no safeguarding concerns were recorded. 21 June 2016 At the child looked after review Mother was reported to be engaging well with professionals. Father’s contact was discussed and Mother disclosed he was unreliable and sometimes abusive. The recent arrest in May was highlighted, and Father’s mental health was explored. The family support worker shared that Father had alleged Mother was pregnant with his child but this was denied by Mother at the meeting. The independent reviewing officer11 (IRO) requested that a contact agreement was drawn up within 5 working days and for this to have an early review to check progress. 27 June 2016 The GP received a contact for medical information from an independent sexual health service regarding Mother’s request for a termination of pregnancy. 15 July 2016 Mother did not attend her termination appointment. 4 August 2016 A supervision meeting took place between the allocated social worker and manager. The record shows the alleged pregnancy was discussed but that Mother had denied being pregnant. 4 August 2016 The health visitor conducted a home visit. Also present with Mother and Daisy was the church group volunteer and another friend with a child. Mother disclosed that 11 The Independent Reviewing Officer chairs reviews for children looked after to ensure the care plan for the child reflects the child’s needs and the child’s wishes and feelings are given full and due consideration. 10 * NB: In order to protect identities, pseudonyms have been used throughout this report Daisy had bumped her head on the DVD player. During the visit Mother spoke about difficulties regarding Father’s contact and alleged a family member of his had raised unsubstantiated concerns about Mother’s parenting to children’s social care. Notes from the visit state Mother was mostly in a positive mood but became tense when the child seemed tired and needed a nap. Advice was given to manage behaviour. 22 August 2016 The involvement from early help was closed after children’s social care had advised support was no longer needed. Mother was informed by a letter from the early help outreach worker. 7 September 2016 The ambulance service was called to the home of Mother, who was in labour. Mother said she thought she was around 24 weeks pregnant and gave some history of her family circumstances to the ambulance crew. 8 September 2016 Rose was born in hospital. The baby was thought to be approximately 23-24 weeks gestation and was transferred to the neonatal unit. The birth was noted as an un-booked pregnancy and the emergency duty team for children’s social care were informed by the enhanced support midwife. Rose was described as “very poorly”. 8 September 2016 A discharge planning meeting took place regarding Mother’s discharge from hospital. Both Mother and Father in attendance. The prognosis for Rose was not yet known. 21 September 2016 Legal advice sought by Children’s Social Care as the home placement agreement for Daisy had been broken by both Mother and Father. Advice was to go into pre proceedings in order that Mother can benefit from legal advice. The case was described as “about support and not about hostile proceedings”. 22 September 2016 Letter received at the GP practice highlighting the concealed pregnancy and birth of a 24 week old baby who remains on the neonatal unit. 10 October 2016 Rose said to be making good progress in terms of respiratory effort and is slowly gaining weight. Further specialist review of brain images was to take place. 17 October 2016 Mother attended the GP for post natal check. Mother disclosed Rose was still in the high dependency unit (neonatal) at hospital. Contraception was discussed and Mother reported her “partner” was visiting evenings and weekends. 21 October 2016 Legal advice sought by children’s social care. 11 November 2016 Information received from the neonatal ward expressing concerns that Mother “had held Daisy’s toe with her finger and thumb for 30 seconds – the child had not cried and went quiet”. A discussion took place with the police and a section 4712 enquiry was initiated. Single agency enquiries were made by children’s social care and Daisy and Mother were seen at hospital. No injuries were noted on the child and Mother denied the allegation. She stated she had a poor relationship with the nurse who had made the allegation. No other concerns were raised by nursing staff regarding mother's parenting ability on the ward. 12 A section 47 enquiry means that children’s social care must carry out an investigation when they have reasonable cause to suspect that a child id suffering, or likely to suffer significant harm. 11 * NB: In order to protect identities, pseudonyms have been used throughout this report After enquiries had been made the allegation was recorded as unsubstantiated with no further action taken. 18 November 2016 The social worker updated the health visitor that the allegation received from the neonatal ward about Mother pinching Daisy was unsubstantiated. 2 December 2016 Pre proceedings legal meeting held. 7 December 2016 A social work statutory visit took place and public law outline13 (PLO) letter was delivered to Mother to share with her solicitor for a meeting on 14.12.2016. Daisy was seen during the visit and no concerns for her welfare were noted. 13 December 2016 A supervision meeting was held with the manager and social worker. Discussion took place around whether there was the necessity for an initial child protection conference to be held given that Rose is safe in hospital and the local authority plans to issue care proceedings in respect of her once she is well enough for discharge. The manager stated that a child protection plan is not thought necessary at this time given the plans of the local authority. 14 December 2016 Pre-proceedings meeting held to advise Mother and Father of the local authority's intention to issue care proceedings in relation to Rose. Parents were also to be advised of the assessment process regarding Daisy and plans that this would complete in 2 weeks. Arrangements to feedback the outcome of the assessment and the local authority's intention for Daisy were discussed. The parents should have been sent a letter regarding proceedings in order for them to obtain free legal advice but Father’s letter had not been issued. The meeting notes show the parents were informed a foster placement for Mother and both children was not an option. It was clear that the local authority were now considering removal of Daisy and Rose. 20 December 2016 The health visitor recorded receiving a telephone call from Mother who was very upset. She had been informed that children’s social care would be making an application to remove Daisy, and Rose once she was fit for discharge, due to the concealed pregnancy. There had been discussion about Mother’s ability to care for both children, particularly as Rose has additional needs. Mother was obviously shocked and upset and was advised to seek legal advice. 22 December 2016 A hand delivered letter was left at Mother’s address to give notice to remove Daisy from her care. Mother was not home at the time. 5 January 2017 The child and family assessment was completed by children’s social care which recommended removal of Daisy. The assessment outcome for Rose was to seek further legal advice. 12 January 2017 Father attended his GP supported by family members feeling low in mood and with suicidal thoughts. The health of Rose and relationship with Mother were noted as “life stressors”. 13 The public law outline (PLO) sets out the duties the local authority have when thinking about taking a case to court to ask for a care order to take a child/children into care. When a PLO letter is sent this is before court proceedings and asks parents to attend a meeting. 12 * NB: In order to protect identities, pseudonyms have been used throughout this report 12 January 2017 The health visitor called children’s social care for an update on the case and was informed a new social worker had been allocated. 18 January 2017 A legal meeting was held with a children’s social care senior manager. The decision was no threshold was met now to remove Daisy; an interim care order for Rose was to be applied for with home placement agreement. 31 January 2017 Father attended a review appointment with the GP, he was noted as “feeling better, sleeping better, mood appears better” and that his baby was “due for discharge”. 1 February 2017 An initial court hearing was held but was adjourned. Further detail was required in documentary evidence of the support and monitoring that was to be put in place before a home placement could be considered and approved by the court and the children's guardian. 2 February 2017 A discharge planning meeting was held for Rose. Plans were being made for the child to be discharged on a home placement order. A tight package was to be in place and included daily visits from children’s social care, a minimum 3 weeks of overnight cover from agency support staff, a part time nursery place for the elder sibling Daisy and visits from health professionals as indicated by Rose’s health and medical needs. 6 February 2017 Court hearing, short adjournment required for further clarity regarding support plan. 10 February 2017 Care proceedings were issued and home placement agreement granted at court. 16 February 2017 Mother attended two days of oxygen training in preparation for Rose coming home. 24 February 2017 Father attended to see his GP. Noted to be feeling low again, not sleeping, his mood appears to be linked to his daughter. Medication dose increased with review planned in four weeks. 28 February 2017 The home placement agreement was signed by the children’s social care team manager, senior manager and both parents, to be implemented upon Rose’s discharge. The agreement gave clear details of expectations and plans for support within the home, including which professionals and agencies would be visiting, and when. 15 March 2017 Discharge planning meeting held with both parents attending. Positive feedback shared regarding Mother managing well when she stayed in the transition unit with support from Father with the sibling Daisy. Mother also reported to have coped well at night with both children. The discharge was planned for 20.03.17 with a tight social care plan for support at home from that time. 15 March 2017 Review GP appointment with Father, noted as feeling better in self, medication working. Father spoke about his daughter and “plans to discharge home to mum”. 17 March 2017 A child looked after health assessment was undertaken by the health visitor at home for Daisy. No concerns were recorded with the child’s growth or presentation. 20 March 2017 Rose’s discharge was delayed due to the Daisy being unwell. 23 March 2017 Rose was discharged from hospital to home with a package of support in place. 13 * NB: In order to protect identities, pseudonyms have been used throughout this report 24 March 2017 Mother contacted the ambulance service reporting Rose as having a coughing fit and high temperature. The child was admitted to hospital. 30 March 2017 Daisy was unwell with a cough and was taken to the GP where Mother shared information that the younger sister, Rose, was also in hospital with coughing symptoms. 05 April 2017 Rose was discharged home from hospital after a discharge planning meeting. 10 April 2017 During a home visit Mother disclosed to the family support worker that she was in debt regarding non-payment of council tax. 11 April 2017 A joint visit took place to the home by the social worker and the family support worker to discuss the amount of £550 now owed to the enforcement agency. Mother failed to answer the door and telephone for a long period before eventually coming to the door looking very tired. Daisy was seen to have a “full nappy which needed changing”, however Rose “looked fine”. Mother had not informed children’s social care of the debt issue which had been ongoing since May 2016. The social worker informed the manager via a case note that the debt breached the home placement order and may have a detrimental effect on the placement should Mother not be able to pay. The social worker also highlighted that the 11 April 2017, which was that evening, was the last night for the planned overnight support cover under the home placement order’s seven day arrangements. The support agency in their daily records had noted that “Mother was tired last night” (10 April 2017) and “a smell of cannabis” was suspected in her room. The social worker informed the manager he was concerned and proposed the end of the support at home should be delayed. His professional opinion was that Mother needed monitoring for another week. 12 April 2017 Children’s social care reviewed the level of support in place at home in a meeting with Mother and Father. Other professionals were not involved but the health visitor arrived during the meeting, for a planned weight review of Rose This weighing was rearranged for the next day. At the meeting Father said he was unhappy with the amount of contact he was allowed with Rose. Other contact arrangements were explored. The overnight support at the home had ended but was re- introduced to reduced evening support from 18.00 to 23.00, for a period of a further week. 13 April 2017 The health visitor attended the home address for the rearranged plan to weigh Rose. Both children were seen with Mother but weighing did not occur as Rose was unsettled. She eventually went to sleep during the visit. A note was left for the professional attending the next day to weigh Rose. 13 April 2017 The amended evening cover for support at the home commenced on this date, from 18.00 to 23.00. 18 April 2017 Rose was taken to the GP with oral thrush, and a prescription was given. 19 April 2017 At 00.19 Mother called the ambulance service via the 999 system. Mother stated that Rose had vomited and then became unresponsive with no signs of life. Basic 14 * NB: In order to protect identities, pseudonyms have been used throughout this report life support was carried out by Mother under instruction of the emergency call taker before she was transported to hospital by ambulance. 19 April 2017 Rose was transferred at 06.30 to children’s paediatric intensive care unit. A CT scan14 performed prior to transfer had showed subdural bleed15, and was considered severe brain trauma. The police were informed. 21 April 2017 The police were notified of the decision to withdraw life support from Rose due to the severe brain injury. 21 April 2017 Rose died. 21 April 2017 A child protection medical examination took place with Rose’s sibling Daisy. There was no evidence of non accidental injury to Daisy. Family involvement Involvement of significant family members in a review process is important to gain an understanding of the family’s experiences of the services offered to them. Specifically, in this case, family members provided feedback relating to services provided to the children Rose and Daisy, and themselves as adults involved during the review timeframe. The carers of the child in the connected non recent incident were also able to contribute. A summary of the views of family members is given below. Other comments are included in the analysis section of the report where relevant. Views are the personal opinions of individuals who have contributed. The carers of the child injured in 2004 The Reviewer and Chair of the Panel met with the carers of the child who had suffered injuries in 2004. They cannot be identified for legal reasons. They recalled being told only brief details at the time about the injuries, despite becoming responsible for the care of the child. They became aware of, and were upset to hear, the full extent of the severity of the injuries during the criminal trial in 2018. The carers recalled several changes in the allocated social workers who were involved with the child over the years, which they felt prevented a trusting and positive relationship being built. They had limited involvement with other professionals around the time of the injuries being found and investigated. They did however have detailed knowledge of the person known as Mother and her lifestyle, which was knowledge they had in 2004/2005, some of which they shared in court during the 2018 trial. They described Mother in their opinion, as aggressive and manipulative. The carers spoke very positively of the police officers who reinvestigated the 2004 injuries to the child. These enquires took place after Rose had died. In particular they said they felt well informed and sensitively treated, especially through the court process. 14 A computerised tomography (CT) scan uses x-rays and a computer to create detailed images of the inside of the body, www.nhs.uk 15 A subdural bleed (haematoma) is a serious condition where blood collects between the skull and the surface of the brain, www.nhs.uk 15 * NB: In order to protect identities, pseudonyms have been used throughout this report The child who was injured is fortunately now well and has been kept informed of the review process by the carers. Father Father of Rose and Daisy met with the Reviewer and the Panel Chair, accompanied by his own mother and step father (paternal grandmother and step grandfather to the children) The sister of Father (aunt of the children) was present for part of the meeting. She is currently the carer for Daisy and therefore the Reviewer and Chair were fortunate to be introduced to Daisy before the meeting with family took place. Father has learning difficulties and attended a school for children with special needs. He finds reading and writing a challenge but with some support was able to articulate his thoughts and feelings. He does not originate from Lancashire but described how he met Mother through her being a lodger where he was living in Preston. They commenced an “on and off” casual relationship which after about a year resulted in Mother becoming pregnant with Daisy. This was unplanned. Father said he had become aware of Mother’s previous relationship with a man before him, which allegedly had aggression on both sides. Mother had also told him in brief about the historic incident with the child who was injured many years ago. However, it wasn’t until services became formally aware about the pregnancy that Father says he was told by a social worker about the seriousness of the injuries to that child. Father was clear in his opinion that he thought social workers involved with Mother did not feel that he was a suitable carer for the child soon to be born. He said this opinion of him never changed and that all social work staff treated him as if he was a danger to his children. He admitted to having some previous convictions for mostly drink related offences and problems in a previous relationship but he had no history of serious offences in his opinion, and nothing compared to what Mother had allegedly done to the child many years prior. He felt his chances of being a proper father were always dismissed. Father said this was demonstrated by the children’s social care decision to have all his contact with Daisy supervised. He felt this was unfair under the circumstances particularly as he felt he was considered more of a risk to Daisy than Mother was, even with her known history. Father disclosed that he knew that Mother was drinking alcohol and smoking “weed” (cannabis). Mother was also allowing Father to see his daughter Daisy outside of contact arrangements. This meant both Mother and Father were knowingly breaching the home placement agreement which was in place. Father alleged Mother often threatened him to pay her money or she would stop his contact with Daisy. Father explained the conception of Rose was a “one off incident” although at the time he would have liked to have “made a go” at being a family as he wanted to be with his children. Father said Mother told him about the pregnancy straight away and he paid for the morning after pill which Mother said she took at a pharmacy. However, the pregnancy continued and when Mother tried to stop Father’s contact with Daisy around the time of the child’s birthday he told separate social work professionals that Mother was pregnant. Father alleges the response to him by one professional was that she called him a “liar”. Father continued to tell social work professionals that Mother was pregnant but he says he was not believed or taken seriously. He knew that Mother was denying this when asked and 16 * NB: In order to protect identities, pseudonyms have been used throughout this report Father thought Mother was believed. He said he thought she always seemed to be able to convince the workers that she was telling the truth about everything. Father recalled that when Mother went into labour with Rose he was at her address with Mother and Daisy. Therefore the home placement agreement was being breached by both parents again. Once Rose was born Father described the contact arrangements with Daisy as inconsistent. Sometimes he was allowed unsupervised contact with his eldest daughter but other times he was not. Father said he still felt Mother was trusted more than him even after she had concealed the pregnancy. Father said throughout the timeframe of the review he was invited to some processes, such as meetings or reviews. He said he was not offered the services of an advocate to help him understand. Father’s sister said she had been concerned about his ability to make sense of some of what was happening but when she asked if she could attend to support him this was declined. Father signed a number of children’s social care documents including the home placement agreement, but Father’s own mother said it was unlikely that he would have been able/ or have taken the time to try to read the documents properly. Sister of Father wrote to children’s social care to express concerns about her brother’s (Father’s) learning difficulties and the lack of support being offered. Father said he felt unclear about the legal process regarding the care of his children. He was told they were being removed from Mother’s care then this soon changed to her being allowed to take both children home. Father’s sister said she had been very upset and worried about the home placement decision, and she expressed her opinion about Mother not being able to cope to the social worker in charge of the case at the time. Father spoke of being contacted by the Police when the injuries had occurred to Rose leading up to her death. He was at home and the Police took him to hospital. Father’s own mother, the children’s grandmother spoke of her distress at not being allowed by professionals, who she perceived to be children’s social care staff, to kiss her baby grandchild goodbye once life support was withdrawn for Rose. Overall the family collectively felt that they were never properly listened to by children’s social care. They shared emails with the reviewer that the sister of Father had sent to children’s social care, throughout the review timeframe, but said they had received no response. The family said they felt due to Father being labelled a risk that Mother herself was able to convince professionals that she herself was no risk to the children. They had concerns about the number of social workers allocated to the case and that the lead worker changed regularly which in their view was not helpful. They also had concerns that a support worker within children’s social care was allowed too much responsibility throughout the case in regards to decisions made. They felt she had become too close to Mother. Father and his family did provide very positive feedback regarding the police team who worked on the investigation when Rose was injured and after she died. The family praised their professionalism, care and sensitivity. 17 * NB: In order to protect identities, pseudonyms have been used throughout this report Mother The Mother of Rose and Daisy was visited in prison by the Reviewer and Chair. Mother described her upbringing as having what she wanted in terms of material things but that she was devoid of love and attention. She said she had not received support from any close family members for many years as an adult. Mother said she met Father when she had become homeless after the breakdown of a long relationship. Similar to Father, she described their relationship as casual. When she became pregnant with Daisy she felt that she would have the baby taken from her once born, due to her history. She said she had tried her best to do all she could to comply with children’s social care in order that she might be able to keep Daisy. Mother spoke about her general lack of trust of most professionals who she came into contact with. She said this was made worse, in her opinion, with the family social worker constantly being changed. She did not feel properly supported by children’s social care and “was petrified” that they would remove Daisy. This was the main reason she failed to disclose the pregnancy even when asked by professionals. Mother said she recalled when Father had reported that she was pregnant. She felt this was due to her not allowing him to take Daisy swimming on her birthday. She said children’s social care staff asked her if she was pregnant and because she was frightened she denied she was. Mother said no further enquiries were made of her about the pregnancy. When asked about Father’s contact with Daisy, Mother said she felt social workers were “very harsh” with him. She could not understand why he was only allowed the limited contact with his daughter and said contact was often cancelled due to other commitments of workers who were involved in the arrangements. Mother admitted that she had allowed Father more contact with Daisy than what was in the home placement agreement. She also highlighted that the contact arrangements with Father became inconsistent after the birth of Rose. He was allowed extra contact with Daisy whilst Rose was in hospital but then this reverted to strict contact arrangements once more when Rose was discharged home. Mother said she had been confused by the legal processes before Rose was discharged. She believed that as soon as children’s social care thought that Rose would survive that they made plans to remove both children. This resulted in a letter being posted through her door at Christmas time to give notice of the imminent removal. On receiving this letter Mother had no opportunity to discuss the decision due to the Christmas leave period. Soon after she discovered that the decision had changed and the children would be allowed to live with her on the home placement agreement. Mother was unclear as to how and why decisions were made in the legal process relating to the children. She felt that this was not transparent and “thought that secret meetings often took place within children’s social care” alongside meetings where she and Father were invited. Although pleased to have the children at home when this was eventually agreed, Mother found the placement arrangements were challenging. In particular she said the plan resulted in different individual support workers attending overnight which was difficult to work with. She had to try to get to know a different worker every night, which was not easy due to her trust issues, and felt she had a stranger in her home for each session. She said this was particularly difficult for Daisy as a toddler to get used to. Mother gave an example that one night Daisy woke up in the early hours and the male support worker came into the room. 18 * NB: In order to protect identities, pseudonyms have been used throughout this report This caused Daisy some distress as he had arrived for the night shift after Daisy had gone to bed therefore was an unfamiliar person to the child. Mother said she felt unable to raise concerns about the home placement support arrangements as she didn’t want to give the impression she was not cooperating. Overall she felt the support workers “just watched her and noted her every move” rather than offering any assistance. Mother had limited feedback to share regarding health professionals who had worked with her throughout the review timeframe. Her view was that she rarely needed to seek medical advice from the GP surgery for her or the children’s health needs. Mother did acknowledge the support which the family, Rose in particular, had received from the neo natal staff. Mother felt they provided good care and were non judgemental of her history. All meetings with significant family members provided a valuable insight into the children’s and family’s experiences. Information from those seen was shared with Panel members and account was taken of the views when writing the final report and formulating learning considerations for action by Lancashire Safeguarding Children Board. The Reviewer is grateful for all contributions by family members. ANALYSIS: Practice & Organisational Themes Identified Rose, her sibling Daisy and the family had received services from a number of agencies during the period of the review. Scrutiny of the timeline, information shared and reflections at the Panel meetings and the learning event have provided an opportunity for wider learning to emerge about the ways in which services work together. Some areas of positive practice have also been highlighted within the report. The history of Mother and her involvement in injuries being caused to a young child many years ago has been considered by the Reviewer and Panel and has provided useful context for the more recent events. Some, but not all agency records from 2004/ 2005 were available to be examined to inform the review. Unfortunately, as stated earlier due to the non recent period when the injuries were caused most professionals involved at the time were not available to take part in the practitioners learning event. The following, in no order of priority, is an analysis of the learning themes identified regarding Rose, Daisy and the child injured in 2004: Disguised compliance Mother did generally demonstrate cooperation and engagement with professionals and services throughout the review timeline. An example of this compliance is during the antenatal period with the unborn child Daisy and when Mother and Daisy were placed in a foster placement out of area, until the baby was six months old. This cooperation and willingness to change was confirmed as observed by the professionals who were involved with her at that time. There was what was perceived to be continued cooperation with services once Mother and Daisy were living independently back in the original area from December 2015. What is known now is that Mother was not complying with the agreement made with children’s social care, having resumed a relationship with Father as early as March 2016. Father admitted to the Reviewer he was regularly visiting Mother and Daisy, and that they both knew this was not 19 * NB: In order to protect identities, pseudonyms have been used throughout this report allowed in the agreement. By April 2016 Mother was pregnant with Rose and did not disclose the pregnancy; this being evidence of a clear breach of the home placement agreement. In fact Mother continued to regularly see professionals, most of whom she had known for several months, and gave the appearance of a person engaging with services. In June 2016 when Father raised the concern that Mother was pregnant she immediately denied this. Mother was believed, which may have been due to the cooperation and compliant behaviour she had shown previously, supported by the rapport and close relationships that had been built with some professionals. It should be noted that Mother was describing Father at that time as unreliable and abusive, with mental health issues, which also had an impact on how Father was judged in terms of the allegation he was making about the pregnancy. Involvement of fathers is discussed later. The NSPCC Information Service Summary of Learning from Case Reviews suggests “disguised compliance involves parents giving the appearance of co-operating with child welfare agencies to avoid raising suspicions and allay concerns”. Published case reviews highlight that professionals sometimes delay or avoid interventions due to parental disguised compliance. 16 By complying on most occasions to meet and see professionals and by attending formal safeguarding processes such as meetings, Mother gave an impression of cooperating with agencies, therefore showing disguised compliance. Mother herself told the Reviewer she did all she could to comply, and whilst not admitting to disguised compliance, this demonstrated her intention was to make professionals believe she was willing to work with them. As a result this appears to have added to the optimistic view of some professionals of Mother’s intention and capacity to cope and change, and therefore to improve the lives of the children. Furthermore, disguised compliance can lead to a focus on adults, in this case predominantly Mother, rather than on achieving safer outcomes for children. For all professionals, disguised compliance should be included as a key area of concern when assessing risk to a child, and therefore be included in supervision discussions about decisions and risk analysis. Professionals must consider disguised compliance, even in cases where families appear to be making progress and where there is full cooperation. Of course this means professionals need to have awareness of the issue in order that it may be properly explored as a risk. If the issue of disguised compliance in families is not brought to the attention of managers or if managers do not routinely include it as a supervision agenda item, then the impact of disguised compliance and subsequent risks will not be addressed. Learning consideration 1 The Lancashire Safeguarding Children Board should consider, through the learning and development team a training analysis to examine how disguised compliance is included in current learning opportunities, and where inclusion of the issue can be enhanced, to ensure all staff across the partnership has sufficient awareness of disguised compliance as a significant risk to children. Focus on children Two children are subjects of this review. One is Rose the child who died, the other is the sibling Daisy. Both children were too young to verbally communicate their own wishes and feelings 16 Learning from reviews highlights that professionals need to gather evidence about what is actually happening in a family, rather than accepting a parent’s presenting behaviour and assertions. By focussing on outcomes rather than processes professionals can keep the focus of their work on the child”, March 2014. 20 * NB: In order to protect identities, pseudonyms have been used throughout this report to professionals and therefore the children were reliant on professionals acting for them, in their best interests with focus on their needs to keep them safe and well. When Rose was born at around 24 weeks of the pregnancy she was seriously unwell requiring full time care in hospital for the first six months of her life. There is no doubt from information available in agency records and from professionals’ involvement at the learning event that the focus of health professionals within the hospital setting was absolutely and unequivocally on Rose. Similarly there was focus on Daisy whilst Rose was in hospital in that a nursery place was arranged for Daisy within the vicinity of the hospital. Overnight accommodation was also made available to the family in order that Mother and Daisy could be close to Rose. Another example of focus on the children was when a member of neonatal staff reported a concern she witnessed on the ward when Mother allegedly pinched Daisy’s foot. This incident is scrutinised later. Daisy, as a child looked after, received statutory health checks by the health visitor throughout the review’s timeframe and other statutory multi agency child looked after reviews took place as required indicating focus was on the looked after child at those times. Mother and Daisy were regularly seen by other professionals; in particular a family support worker and early help outreach worker were both closely involved with the family for several months. There is evidence to show that these professionals did their best to support Mother and the children throughout the review timeframe. Recording by these professionals evidences focus on Daisy, and positive interventions before Rose was born included arrangements made for Mother to attend local provision of parenting groups which would have been of some benefit to Daisy. It is acknowledged that working alongside families with complex histories and needs, such as in this case, can be very difficult. Professionals need to build trust, particularly when adults have had limited opportunity to build positive relationships in their own lives. However with a person like Mother, who herself was vulnerable in many ways with no real family support, it was evident at times that the focus shifted to supporting her first. Whilst this often provided indirect support to the children due to Mother having care of them it still appeared that focus and attention was prioritised on Mother’s needs with the children’s needs sometimes being secondary. An example was when Mother was upset by the findings of the psychologist’s report for court proceedings whilst she was living in foster placement with Daisy in October 2015. Mother spoke about this when meeting with the Reviewer. She voiced her concerns that the same clinician who was involved in the assessment process from the incident in 2004 was also involved after Daisy’s birth. As a consequence Mother received support and reassurance from children’s social care and eventually an alternative clinician was commissioned. The findings were different and more sympathetic to Mother’s circumstances, being positive about progress she had made. The psychological assessments are explored later. Other decisions and interventions, whilst indirectly beneficial to the children, did appear focussed on Mother and what she wanted. For example Mother wanted Father to have more unsupervised contact with Daisy soon after she had returned to the home area to live independently with the child. This was around the time the couple’s relationship was resuming, but was unknown to all services involved, and was a breach of the agreement made with children’s social care. Whilst the benefits of a child seeing their father more cannot be dismissed, the contact arrangements had been made for what was perceived by some professionals as good reason after an assessment of Father. It appears it was Mother’s persuasiveness of professionals 21 * NB: In order to protect identities, pseudonyms have been used throughout this report with whom she shared good rapport which appeared to result in the contact arrangements becoming more flexible in favour of Mother and Father’s wishes. Notes from the legal gateway meeting17 soon after Rose’s birth further highlight focus on Mother’s needs in that Mother was viewed sympathetically regarding how the pregnancy occurred, with blame apportioned to Father for allegedly persuading Mother to resume their relationship when she was lonely, resulting in Mother getting pregnant. Having met both Mother and Father it is the Reviewer’s professional opinion that it was unlikely that Father had the persuasiveness skills to coerce Mother into a relationship if she had not wanted one. There was continued focus on Mother rather than the children’s needs in legal advice provided. This is evidenced in notes which state “the fact that Mother has had a baby without telling the social work team shouldn’t go against her”. This was noted as the consensus for the social work team involved in the legal gateway meeting, who shared the view that the pregnancy was “not the more common concealed pregnancy scenario that we normally see, which can often signal non- cooperation by parents in the future”. This opinion is questionable even without the history of Mother, particularly as she had numerous opportunities with professionals with whom she shared good relationships to admit she was pregnant. Non-cooperation and non-compliance with the home placement agreement had taken place by Mother, and Father, and therefore could absolutely be expected in the future. Responses to the concealed pregnancy are explored below. It appears Mother’s ability to influence and manipulate judgements on her circumstances by being the focus for support continued throughout the timeframe of the review. Overall, Mother’s needs were always for the children to remain in her care and control. Professionals worked very hard to ensure her needs were met despite the overwhelming history of concerns and associated risks, which resulted at times in a lack of prioritisation and focus on the children themselves. The children’s lived experience and desired outcomes for them often seemed overlooked. Learning consideration 2 The Lancashire Safeguarding Children Board should consider opportunities to ensure disguised compliance and focus on children, are identified as key areas of scrutiny for every case, to be examined regularly for example in staff supervision meetings and when identifying and reviewing desired outcomes for children. Concealed pregnancy Rose was born prematurely in September 2016 after Mother had concealed the pregnancy to all professionals involved. Father of Daisy was also the Father of Rose and he had known about the pregnancy himself since at least May 2016. Records indicate Mother made enquiries regarding a termination in early June 2016. In what is now thought to be an attempt to deflect attention and scrutiny she also informed a professional in mid June 2016 that Father was alleging she was pregnant but went on to deny the pregnancy to that worker. Father told the Reviewer that he was not believed when he tried to tell children’s social care professionals about the pregnancy. Between June 2016 and when the premature birth occurred Mother was seen separately by the health visitor, social worker, family support worker, early help outreach worker and the 17 The purpose of the legal gateway meeting is to provide advice to children’s social care regarding the legal options available to safeguard and promote the child’s welfare. 22 * NB: In order to protect identities, pseudonyms have been used throughout this report church volunteer. Mother also attended a looked after child review for Daisy within that period. The pregnancy was denied by Mother to at least three professionals separately and was not disclosed by Mother despite the opportunities she had to ask for support. Lancashire Safeguarding Children Board are currently finalising a concealed and denied pregnancy protocol which defines a concealed pregnancy as when a woman knows she is pregnant but does not tell any health professional; or when she tells another professional but conceals the fact that she is not accessing antenatal care; or when an expectant mother tells another person or persons and they conceal the fact from all health agencies. The implications of concealment and denial of pregnancy are wide-ranging and include a lack of antenatal care meaning that potential risks to mother and baby may not be detected and underlying medical conditions and obstetric problems will not be revealed. Concealment and denial can also lead to a fatal outcome, regardless of the mother's intention. When Mother gave birth to Rose correct procedure was followed at the hospital in that an urgent referral was made to the emergency duty team of Children’s Social Care. The action then taken is explored below. The Pan Lancashire multi agency pre-birth protocol (refreshed in March 2017 after previously being published in 2012) was not followed when suspicions about the pregnancy were initially raised in June 2016. The protocol is clear that where any professional has concerns about concealment or denial of pregnancy, they should contact any other agencies known to have involvement with the expectant mother so that a fuller assessment of the available information and observations can be made. This would also be expected practice. A contact with the GP, a professional who had involvement with Mother and Daisy, as part of enquiries into the possible concealed pregnancy should have revealed that Mother had sought advice from an independent sexual health organisation regarding pregnancy and termination. Patient confidentiality would not have been an issue as the welfare of the unborn child should override a mother's right to confidentiality. Mother had also attended the GP for contraception advice in April 2016 and had volunteered that she “was back in a relationship with Father”. If enquiries had been made with the GP such information would also have strengthened suspicions that Mother was possibly pregnant. Furthermore, the breach of the home placement agreement would have then been identified. It is not clear what specific enquiries, if any, did occur once the allegation of a pregnancy had been made, other than asking Mother if she was pregnant. It is positive that Mother was challenged and that the concealed pregnancy was discussed in supervision of the social worker. However, with consideration of Mother’s history and what is now known about Mother’s propensity for disguised compliance there should have been more proactive professional curiosity used to help assess the concealed pregnancy concern. In circumstances of suspected concealed pregnancy or delayed presentation to ante-natal services the protocol states “a referral to Children’s Social Care is not automatic but must be made if, after consideration of the reason for the delay or concealment, there are concerns about complex/ serious needs or evidence of significant harm”. Discussions are ongoing now within antenatal services to amend the protocol to include requirement for an automatic referral to be made. In Mother’s case there was evidence of significant harm to a child in her care previously. The protocol says “a referral to children’s social care for a pre-birth assessment must always be completed if there is a reasonable cause to suspect that the unborn baby is likely to suffer significant harm before, during or after birth”. 23 * NB: In order to protect identities, pseudonyms have been used throughout this report Another section of the protocol which relates to Mother’s specific circumstances was that “the parent, (or their partner/potential carer) has children that have been made subject to a child protection plan, or care or supervision order at any time in the past (or if proceedings are ongoing)”. Mother’s child Daisy was on a care order at the time the pregnancy was suspected. Research suggests there is no clear profile for women who conceal or deny pregnancy and there are clear challenges of predicting and identifying women likely to conceal or deny a pregnancy (Denial of pregnancy, Jenkins et al, 2011). However, Mother’s circumstances and history could have reasonably been expected to arouse strong suspicion once another person, albeit an estranged partner, was continually voicing concerns about a pregnancy. The issue when the pregnancy was first being spoken about was whether the disclosure of the pregnancy was taken seriously. For reasons discussed in this report, regarding focus on children and involvement of fathers, Mother’s denial was readily accepted, Father’s claims were dismissed and consequently there was no consideration for a referral to children’s social care under the pre birth protocol. The outcome was that the pregnancy remained concealed until the actual premature birth of Rose. It has not been possible to attribute the premature birth to the lack of antenatal care accessed by Mother. The newly introduced concealed and denied pregnancy protocol includes clear expectations of what action should be taken when a pregnancy is first discovered at the point of a birth of a child. However the pre birth protocol was not followed regarding the information provided regarding the suspected pregnancy. Learning consideration 3 The Lancashire Safeguarding Children Board should consider the viability of an exercise to explore all known cases of concealed and denied pregnancy within the county over a designated period before and since the concealed and denied pregnancy protocol was introduced, to ensure there is compliance with the guidance and in particular appropriate use of linked procedures is occurring, such as the pre birth protocol, when criteria and threshold has been met. Opportunities for multi agency working In this case the concealed/ denied pregnancy and how it was assessed appears overshadowed by the very premature birth of Rose and subsequent intensive treatment and care which followed. Initially it was not known whether the baby would survive, which may be a reason that immediate safeguarding processes for Rose were not instigated. However, within five weeks Rose was making good progress in terms of respiratory effort and was slowly gaining weight. As a result of the concealed pregnancy and birth there was clear evidence that significant harm could be properly suspected of having been caused to a child, Rose, by Mother. Rose was very ill and may not have survived, which is absolute proof of significant harm. Despite this, a strategy meeting18 was not convened and a section 47 investigation was not commenced. Whilst accepted the concealed and denied pregnancy protocol for Lancashire was not finalised at the relevant time, professionals involved should have had sufficient 18 A strategy meeting (or strategy discussion) is normally held when an initial assessment indicates that a child has suffered significant harm. It should be a multi agency process to establish whether there should be further child protection investigation. 24 * NB: In order to protect identities, pseudonyms have been used throughout this report awareness of agreed thresholds and procedures and applied this to the circumstances for Rose. Unfortunately, this did not occur and subsequently a child and family assessment was not commenced for Rose in her own right as soon as it was known that she would live. At the review’s learning event health professionals who were involved in the first weeks of Rose’s life described the “chaotic circumstances” in terms of who knew what information and what action was being taken. A strategy meeting, which should have formed part of formal safeguarding processes, would have ensured timely, appropriate multi agency information sharing and planning. It has been reported that the neonatal staff caring for Rose and having significant contact with both parents were initially unaware of the full history of Mother. At the learning event neonatal staff who had been involved said that Mother herself disclosed the previous history after “about three weeks” on the ward. As Mother had not booked her pregnancy with services no previous information was on health records. Consequently at the safety huddle meetings19, the history of Mother’s involvement in an assault on another young child was not discussed as it was not known. Health professionals providing one to one care to very sick children will have close contact with parents and carers at hospital. It is a necessity that relevant staff are aware of all historical information in order that children can be protected and risks appropriately managed. In this case due to formal safeguarding processes not being initiated for Rose as an individual in her own right there was a missed opportunity for some involved professionals to be fully informed of the whole circumstances enabling better protection of Rose. Children’s social care records for the initial period of Rose’s life indicate that she was not recorded as an open case as an individual in her own right. This was also the position much later when Rose was four months old. Notes from a legal gateway meeting in January 2017 state she “has no status (in Lancashire), she is not subject to a child protection plan, or child in need plan, and there is no child and family assessment.” Much of the early social care recording related to the sibling Daisy with a focus that the home placement agreement for Daisy had been breached by Mother. This was clearly a priority for children’s social care as during this stressful time for the family whilst Rose was considered to be in a safe environment in hospital, Daisy was still living with Mother and having contact with Father. A legal gateway meeting was held within two weeks of the birth where discussions took place between children’s social care professionals about the circumstances for Rose, Daisy’s home placement and Mother’s history. Legal advice was provided and a further legal meeting planned in five weeks. There is recorded evidence on the review’s timeline that regular liaison was taking place at that time between the social worker and Daisy’s health visitor but it is unclear what information and plans was shared with other key professionals, outside of children’s social care, who were also involved in the lives of both children and the parents. As normal child protection procedure and activity did not commence for Rose, meaning a strategy meeting, section 47 investigation and initial case conference did not take place, there was no opportunity for formal information sharing, multi disciplinary planning and collective consideration of risk. The processes above, which are integral to any response to suspected significant harm to a child create a mechanism for ongoing involvement of multi agency professionals. In this case, compliance with safeguarding procedures would have helped all relevant professionals to be 19 Safety huddles are meetings held twice a day on the ward to discuss any important past issues. 25 * NB: In order to protect identities, pseudonyms have been used throughout this report aware of history of the family and developments in such a complex set of circumstances and provided an opportunity for current pertinent information and views to be shared to help ensure the safest outcome for both children. Learning consideration 4 The Lancashire Safeguarding Children Board should consider an audit with an emphasis on open/ongoing cases of families with multiple children and/or siblings where new concerns arise to ensure expected procedure is followed in terms of status and recording of those children, and that agreed processes take place such as strategy meetings and section 47 investigations which enable a multi disciplinary approach to help ensure focus is maintained on all children involved. Responses to minor injuries to looked after children On two separate occasions in the review timeline Daisy was said to have sustained minor facial injuries. The first incident was in early May 2016 when Daisy was eleven months old. The injury was described as a bump to the nose and left cheek. Mother told the early help outreach worker that the child, who was toddling at the time, had fallen and bumped into a TV unit which was considered a plausible explanation. Just over a week later the health visitor saw the child with Mother, and Mother told her (the health visitor) about the bump to Daisy’s face. Mother said she had taken the child to the GP the day after the bump but there is no record of an appointment. The second incident was in early August 2016 when Daisy was 15 months old. The health visitor was told by Mother that the child had bumped her head on the DVD player. It is unclear whether an injury was visible to the health visitor. In the same visit Mother spoke about an unconnected allegation believed from Father’s family, which had been made to children’s social care about her alleged poor parenting of Daisy, which Mother denied. She also spoke about Father not having contact for about six weeks. These additional issues for Mother could have been viewed as stress factors for her but in records she was described as in a mostly positive mood during the visit. Whilst accepted that both incidents and the injuries sustained were minor, with plausible explanations provided, Daisy was on a care order with home placement when both incidents occurred. In addition, Mother’s history should have been known to the professionals involved in each episode. This should have resulted in Daisy being considered as a vulnerable child who also, by reason of age was not able to speak for herself and give an account about the incidents. In the Serious Case Review Child LB, Lancashire Safeguarding Children Board (as yet unpublished) several minor injuries were noted by professionals to a child within a short time frame. Possible explanations were given by the carers involved and no action was taken. Eventually serious non accidental injuries were found on the same young child. Best practice regarding the minor injuries to Daisy would have been to explore and record the incidents thoroughly. More robust enquiry may have elicited a response from Mother which either fully satisfied the professionals, or aroused more concern relating to each injury. Either way a reasonable expectation would also be for the allocated social worker of a looked after child to be informed of any injuries incurred. This did not happen for either incident. Furthermore, the anomaly of Mother saying there was a GP attendance for the first injury was never explored. Professionals must be prepared to enquire without apology when circumstances present, however minor, which could have an alternative and more concerning explanation. Sustaining 26 * NB: In order to protect identities, pseudonyms have been used throughout this report a positive professional relationship with families must include challenge when necessary to ensure children are continually safeguarded. Regarding balancing support and challenge in Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final report: May 2016, Peter Sidebotham, Marian Brandon et al, it states “without professional curiosity professionals fail to recognise risks, downplay them, or focus on parents’ needs to the detriment of the child’s”. Learning consideration 5 The Lancashire Safeguarding Children Board should consider the development and implementation of guidance relating to looked after children who sustain injuries, including who should be informed and what action should be taken/ recorded. In November 2016 when Rose was two months old and still in hospital an incident was witnessed by a member of nursing staff when Mother allegedly pinched the foot of Daisy whilst they were on the ward. The concern was referred on appropriately and a section 47 enquiry took place. The child’s foot was examined with no visible injuries, and due to her age sibling could not give an account herself about what had occurred. Mother was questioned by the social worker but strongly denied any wrongdoing. She was immediately believed by professionals leading to no further action being taken. As in the two incidents referenced above, at the time Daisy was a looked after child but unlike the incidents at home the social worker for the children was informed about the allegation on the ward. The difference with the incident at hospital is that there was an independent witness to the alleged behaviour by Mother to the child. However, Mother’s account was accepted over the account of a professional and no further action was taken. The nurse involved attended the practitioner learning event and maintained that what she had seen was accurate. The response to the referral gives a further indication of Mother’s ability to influence the judgement of professionals to believe her and empathise with her position as a mother of a very poorly, premature baby. That was despite the known history of Mother’s concerning behaviour previously regarding physical abuse, and her proven history of misleading professionals exampled by the concealed pregnancy. Focus on children and disguised compliance was explored earlier. Learning consideration 6 The Lancashire Safeguarding Children Board should consider issuing a reminder or further promotion of the resolving professional disagreements policy, for neonatal and other similar staff groups who may not routinely experience the need to make a safeguarding referral or escalate concerns, to ensure all staff has awareness of the pathway to professionally challenge decisions made impacting on the safety and wellbeing of children. Consideration of fathers Rose and Daisy had the same birth father but the relationship between Mother and Father was not permanent. When Mother became pregnant with Daisy she described this as due to a casual encounter. Father also described the relationship as “on and off”. Prior to becoming pregnant with Rose the couple were still not in a stable relationship but had been in regular communication due to the contact arrangements for Father to see Daisy, and also the unofficial contact which is now known to have been occurring. The opinion and account of 27 * NB: In order to protect identities, pseudonyms have been used throughout this report both parents regarding their relationship was reflected in detail earlier, and is largely consistent, particularly about contact. Children’s social care records show the contact arrangement for Daisy with Father was due to concerns relating to Father’s mental health, alcohol use, his previous convictions and allegations made by Mother about his aggressive behaviour. At a point later in the review timeline Father spoke to his GP when feeling particularly low. He claimed to have access to a firearm but this was not substantiated. Father was identified as being a significant person in Daisy’s case from the initial child protection conference for the unborn child (Daisy) at the end of March 2015. Professionals became more involved with Father from this point and a parenting assessment was commenced with him. It is positive that support was offered for his alcohol use and there was signposting to housing services. However, Father had a learning difficulty, and despite this being considered when he was assessed he was not offered support to ensure he fully understood the ongoing safeguarding processes. Father’s own close family could not easily provide him face to face support due to the area where they all lived, which was several hours’ drive away. Although reassuring that Father was included in formal processes such as case conferences and reviews it is of concern that despite Father’s limited ability to read and write he was asked, without any assistance being offered, to read and sign formal children’s social care documents relating to his children. The Reviewer on meeting Father, and on speaking to his own Mother about Father’s education, was of the opinion that Father would have required an advocate or supporter to assist him with the complicated safeguarding processes of which he was an integral part. The Police, when interviewing Father as a witness after the death of Rose, used an appropriate adult to support Father and to ensure he understood what was happening during the criminal investigation. Father’s contact initially with Daisy was supervised in a formal arrangement at a contact centre. After some positive feedback from Mother about Father in early 2016 the contact changed to being supervised by Mother. This highlights the trust that professionals had in Mother as an individual and in her parenting capacity, that she should be viewed as the more responsible parent, with less risk to Daisy, than Father. What is now known is that this was the period when Rose was conceived but neither Mother nor Father declared their developing relationship to professionals. A common feature in some serious case reviews nationally is that fathers are not routinely considered by some professionals working with families. There is evidence in records for this case relating to both children that agencies did involve Father. Mostly they did try to ensure he was a part of the children’s lives with restrictions, and in decisions being made relating to the family, albeit he may not have fully understood the ongoing process. Additional support which should have been provided to Father to assist his understanding is discussed above. Despite the positive practice of Father being invited to and included in many of the safeguarding processes for the children there was an obvious difference in the way he was judged by some professionals, in comparison to Mother. This is a view shared by Father and his own family, and evidenced in much of the information now collated from records for the timeframe of the review. Even Mother shared her opinion with the Reviewer that the way Father was treated by children’s social care, particularly regarding contact, was “harsh”. The concerns about Father, which were properly considered and assessed, are detailed above. However similar concerns also existed for Mother in terms of mental health issues, alleged cannabis use, past alcohol misuse and of more significance the known previous incidents of physical abuse. Regardless of this information about Mother, and the 28 * NB: In order to protect identities, pseudonyms have been used throughout this report assessments which took place, professionals believed her to be the more responsible, trustworthy and less risky parent of the two. Furthermore, Mother appeared able to hold the attention of some professionals in raising further concerns about Father’s behaviour, for example allegations of verbal threats, concerns which were generally not corroborated. In Hidden Men: Learning from Case Reviews, NSPCC, March 2015 it is highlighted that professionals can sometimes “rely too much on mothers to tell them about men involved in their children’s lives. If mothers are putting their own needs first, they may not be honest (about the risk these men pose to their children)”, or as in this case the risk they themselves pose. In the Summer of 2016 when Mother’s pregnancy denials and allegations about Father’s verbal abuse were being believed, she was manipulating professionals with her lies, whilst Father’s claims were not properly listened to and were dismissed. This is further indication of the faith and trust which professionals had in Mother over Father. The NSPCC Hidden Men study suggests professionals may not always talk to other significant people involved in a child’s life which can result in them missing crucial information and failing to spot inconsistencies in a mother’s account. In this case Mother’s circumstances were that she had no family and friends, which limited the amount of additional information from others which could be considered. However Father, who offered information about the pregnancy and his relationship with Mother, was not taken seriously. Furthermore, close relatives of Father told the Reviewer that they tried to report concerns about Mother’s parenting but they did not feel properly heard. These were missed opportunities for professionals to consider a wider perspective on the family as a whole, and to keep a more open mind about possible risks to the children. Learning consideration 7 The Lancashire Safeguarding Children Board should consider requiring an audit of cases which include contact arrangements as a significant issue to explore that fathers are being heard, involved and provided with appropriate support in order that they are given the same opportunities as mothers when exploring best outcomes for children. Assessments Mother, as a known perpetrator of physical abuse to a child previously, was subject to formal assessment processes relating to her parenting capacity of Daisy. It was positive that assessments commenced for the unborn child, Daisy, as soon as the pregnancy became known to services. This was not the position for Rose as the pregnancy was concealed; responses relating to the pregnancy were discussed earlier. As a result of the injuries to the child in 2004 an independent assessment was commissioned by Lancashire County Council which was undertaken by the NSPCC in 2004/2005. The assessment was comprehensive. A conclusion was that there was limited change for Mother within the assessment period, which was over several months, and the assessor “could not predict Mother’s ability to sustain or develop her skills for parenting long term”. A key finding was the view that Mother’s own poor childhood experiences had impacted on her deeply as an individual, but most significantly if she was ever to parent a child. It was highlighted that “these experiences had left her with limited ability to meet the needs of children for nurture, stability, routine, care, socialization and boundaries”. To reinforce what has been highlighted earlier about Mother’s more recent disguised compliance the NSPCC report in 2005 identified Mother as appearing to be working with 29 * NB: In order to protect identities, pseudonyms have been used throughout this report agencies on the surface, but that she had difficulty internalising information and advice given. It was judged that she would find it difficult to benefit from groups and classes aimed at parents and carers, because she was inconsistent in her responses and understanding of what the role of parent/ carer entails. It was of concern to the NSPCC that throughout the assessment Mother had minimised her involvement in inflicting the serious injuries to the child. The NSPCC shared all information and professional judgements collated within the assessment process with Lancashire County Council. Therefore the full information was retrievable from children’s social care records when the pregnancy of unborn Daisy was reported in 2015, and for subsequent interventions regarding the family. The GP medical records for Mother contain some historical information that highlighted her own adverse childhood events. This included dysfunctional family experience, maternal alcohol misuse, being a victim of suspected physical abuse as a young child, suspected failure to thrive and bereavement of her own Mother at a young age. Such significant adverse experiences may be judged as impacting on Mother’s future parenting capacity. There is no note in GP records that suggests information sharing was requested or took place in terms of the content of Mother’s medical records that may have contributed to any risk assessments or parenting assessments of Mother. GP involvement in child protection processes is explored in more detail later. It is positive that the child and family assessment for unborn Daisy in early 2015 contains some information about Mother’s experiences in her own childhood and adult life. There is reference to disclosures which Mother made to children’s social care for the assessment in 2015; Mother shared details of her own unhappy childhood and spoke about alcohol and drug misuse whilst an adult, and some mental health difficulties. The disclosures were consistent with information shared by Mother for the NSPCC assessment in 2005. The outcome of the children’s social care assessment relating to the unborn Daisy was that a care order was applied for and as soon as the baby was born and discharged from hospital Mother and child went to live in a foster placement away from the home area. During this time two psychological assessments of Mother took place to inform the overall assessment of Mother’s parenting capacity. The findings of the psychological reports are considerably different despite both assessments being conducted over a short period of time during 2015. The assessment by the first clinician, who had also been involved after the previous incident of significant harm in 2004 concluded that any progress by Mother was due to the artificial environment of the highly supported foster placement. That clinician raised the concern that no significant work recommended after the NSPCC assessment in 2004/2005 had been undertaken by Mother to address her behaviour. The second clinician was the professional responsible for Mother’s cognitive behavior therapy, arranged by children’s social care after the first clinician’s assessment was being challenged, whilst Mother was still living in the foster placement. The second clinician concluded that Mother “had engaged well and openly with the psychological therapy, that she showed insight into her previous difficulties and had motivation to make further changes”. Overall the second clinician felt with ongoing support Mother could provide safe care for her child. 30 * NB: In order to protect identities, pseudonyms have been used throughout this report It is unclear in children’s social care recording how the very different professional opinions were managed. However it can be assumed the more positive findings of the second psychological assessment were accepted and informed the decisions to allow the home placement agreement regarding Daisy in late 2015 to be made. Whilst Mother and Daisy lived in the foster placement, which was away from the home authority it was positive that statutory visits took place as required. Mother was assessed by children’s social care professionals as generally making good progress. Unfortunately within a few months of returning to live independently with Daisy, Mother had breached the home placement order by resuming the relationship with Father, thus allowing him contact with Daisy which was outside of the formal contact arrangements. He himself had been part of the assessment for the unborn Daisy in early 2015 when a number of risks regarding Father were considered leading to the formal contact arrangements for him, as explored earlier. Statutory reviews did continue to take place for Daisy as a looked after child. There is evidence that professionals conducted health reviews and multi disciplinary liaison occurred as required to inform the looked after child review process. However, once Mother and Daisy were living independently from early 2016 the frequent interventions by a number of different professionals appeared often to focus on the needs of Mother, without assessing holistically the needs of Daisy and without full consideration of the wider circumstances including the significant history of Mother. Working Together to Safeguard Children, HM Government, March 2015 suggests “a good assessment is one which investigates three domains: the child’s developmental needs, including whether they are suffering, or likely to suffer, significant harm; parents’ or carers’ capacity to respond to those needs; and the impact and influence of wider family, community and environmental circumstances”. This is commonly known as “the assessment framework”. It was regularly documented that Mother had little close family support and limited ties within the community. Her personal life in terms of relationships was complicated, with only a casual relationship with Father, which was allegedly volatile at times. It has also been suggested that aggression was a factor in Mother’s previous relationship. As explored earlier, Mother became pregnant but went on to conceal the pregnancy until the premature birth of Rose. It is now accepted that Mother was intent on deceiving all professionals regarding the pregnancy, whatever her reasoning for this. However, it was highlighted before that a more robust response to Father’s claims about the pregnancy, including increased scrutiny and assessment of Mother should have occurred. After the birth of Rose and once her condition improved, assessments to inform the important decisions of where and with whom Rose and Daisy would live, should have included full exploration of the history for Mother including a return to the original NSPCC assessment findings. Sufficient scrutiny and weight was not given to the original judgements relating to Mother’s ability to parent, and the substantial adverse childhood experiences which Mother herself had disclosed. 31 * NB: In order to protect identities, pseudonyms have been used throughout this report The clinician from the 2004 circumstances had the benefit of a psychological reassessment of Mother in 2015 whilst she and Daisy were in the foster placement. However the follow up psychological assessment findings were overlooked in favour of an alternative clinician’s findings, who was commissioned after Mother was unhappy about the original clinician’s opinion of her progress. There appears little evidence that the differences in the two professional judgements to inform the assessment was scrutinised. The assessment leading to the final decision that both children should return to Mother’s care on a home placement agreement did not appear to take into account the clear breach of the first home placement agreement which occurred less than 12 months earlier. When Mother allowed Father into the home to visit herself and Daisy, outside of agreed contact times this was a breach of the order and showed Mother to be untrustworthy and non compliant in terms of her daughter’s needs and the formal expectations of children’s social care. The assessment leading to the home placement failed to consider a challenge to the decision by the children’s Guardian20 as evidenced in Children and Family Court Advisory and Support Service (CAFCASS) records. The Guardian shared her concerns and suggested a mother and baby/child foster placement arrangement but this was overruled. The requirement for assessments to focus on the needs of the child seemed overlooked in terms of the faith placed in Mother, despite all the information known about her and her history. Some professionals still feel the need to respond to a perceived expectation that a child or children must be placed with a birth parent, more often the Mother, which can lead to a less robust assessment of the whole circumstances and even a dismissal of overwhelming evidence to indicate this is not in the child’s best interests. It was clear that Rose’s health needs included the necessity for intense care and support from Mother as a result of the premature birth. The assessment of Mother’s parenting capacity that she would respond well to such complex needs, whilst also providing sole care for Daisy as a toddler, was at best over optimistic, at worst, flawed. Another area explored in the review was the capability of the home placement support workers to assess Mother during the time spent in her home, including overnight, as part of the home placement package. Mother spoke about daily changes to the support workers who attended and that this was a challenge in her view as there was no opportunity for any rapport or knowledge of routines within the home to be properly developed. Mother said workers did note her actions, such as when she fed the children or changed a nappy. However recording what occurred is only the first part of any assessment; applying professional judgement informed by experience, training and reinforced by research should follow. A case note completed by a support worker in the final days leading to the significant incident which caused Rose’s death recorded a smell of cannabis at the home and Mother being tired. Other notes for the dates when support was provided within the home have not been made available. 20 The Guardian is the independent voice of the child in court, they are experienced social workers but do not work for the local authority or the court www.cafcass.gov.uk 32 * NB: In order to protect identities, pseudonyms have been used throughout this report It is positive that action was taken by the social worker after the observation by the support worker as detailed above A request was made for an extension to the planned involvement of support workers in the home placement package, which had been due to end around that time. However it is unknown what other concerns may have been observed within the home, which were not noted, actioned and properly assessed. Assessments, particularly when relating to safeguarding, should be an ongoing process. Every contact with a family by any professional is an opportunity to assess for strengths, for areas requiring additional support, and most importantly for risk. Of paramount importance is keeping the child or children at the centre of any assessment, and sharing on any identified concerns. Learning consideration 8 The Lancashire Safeguarding Children Board should consider requesting assurance and evidence from commissioners of external providers of support workers, such as in the case of Rose (Child LK), that safeguarding training and awareness programmes for staff are mandatory, fit for purpose and whether packages include assessment and recording as standard. GP involvement in safeguarding processes The GP could be described as the central health professional in the life of the children in this case, and Mother. All were registered at the same local practice which Mother had used for many years. GP records should contain recording of all contacts between the GP and patient but also normally a wealth of other health information including contacts and treatment of the patient by other health providers. Additionally, for this family the GP records contained information and flags alerting the reader to safeguarding information about the children. This is a routine occurrence for most GP practices. For example, there was a flag attached to Daisy’s record when she was made subject to a child protection plan and later when a care order was granted. Mother told the Reviewer that she “did not feel the need to use the services of the GP very much as she and the children were mostly well”. The records show that Mother generally used the GP service appropriately and actually notified the surgery herself when she was moving to the out of area foster placement with the new born Daisy. Other information shared later by Mother with the GP service is relevant to the review’s circumstances. Once back in the home area with Daisy on the first home placement agreement Mother attended the GP service in April 2016 for contraception advice. Records show she disclosed she was “now back with Daisy’s Father.” The records for Daisy were flagged for her being a looked after child and would have been linked to Mother’s record but the GP service had not been part of the decision making leading to the home placement agreement or been informed of the specific conditions of the agreement. Therefore, it may have been reasonable for the GP to assume the status of Daisy as a looked after child meant she lived away from Mother, which was obviously not the case. Mother’s attendance at the GP surgery for contraception and her admission that she was resuming the relationship with Father should have raised concerns, had the GP service been fully informed of the home situation. The information should have been shared with children’s social care, as the developing relationship was evidence that the home placement agreement may be being 33 * NB: In order to protect identities, pseudonyms have been used throughout this report breached putting Daisy at risk of possible harm, but the GP involved had not been provided with sufficient background information to enable this judgement to be made. When Mother made contact with the independent sexual health service to explore options regarding being pregnant she gave permission for a routine contact to take place with her GP for medical history to be shared. The GP records contain a written contact by the independent service at the end of June 2016 which clearly states Mother is pregnant. There is no information regarding the Father’s identity but the letter should have aroused concerns within the GP service had the service been aware of the detail of the ongoing processes for Mother and Daisy. Unfortunately, the GP service was not aware of the full circumstances for Daisy as a looked after child and no information was shared with children’s social care or other agencies. The response by children’s social care professionals to Father’s claims that Mother was pregnant was explored earlier. No enquiries were made other than with Mother therefore the content of the GP records was not known. This was a missed opportunity for Mother’s pregnancy to be confirmed. The GP service received notification of the birth of Rose two weeks after her premature birth. This was highlighted with significant events comments21 that the baby’s sister was subject of a care order. At this point had the GP service had full knowledge of the home placement of Daisy and the other family circumstances in addition to the standard notification of a looked after child from children’s social care for flagging purposes, then full information of Mother’s recent medical history could have been shared. This information included the developing relationship with Father and the concealed pregnancy. Furthermore, had the GP service had the opportunity to contribute to professionals’ meetings being held at hospital around that time this valuable evidence relating to the actions of Mother in the months leading to the birth should have had a significant impact on the assessment of Mother and her future parenting capacity. There is no indication that the information held in GP records for Mother during 2016 was ever requested or considered even after the birth of Rose. Mother attended a GP appointment for a post natal check in October 2016 and records show that contraception was discussed; Mother said that “partner visits evenings and weekends”. For the circumstances at the time this was again very useful information being casually disclosed by Mother. Unfortunately, the GP service was not aware of the detail of what had been agreed in terms of the contact between parents and more importantly Daisy as a looked after child. Therefore the information was not considered relevant and was not shared. The GP service involvement and information held on GP records through 2016 cannot be underestimated in terms of its value to the ongoing safeguarding processes and assessments after the birth of Rose. GPs and the information they hold must be seen as an integral part of any safeguarding process and particularly in complex cases with high risk. GP involvement in safeguarding processes has been regularly scrutinised by local safeguarding children boards across the country and in many serious case reviews. The issue in this case is not simply whether GPs contribute to, or attend case conferences and similar meetings, which is of course important and necessary. What this case demonstrates is that 21 Significant events comments are summarised in GP patient records and include noteworthy episodes for a patient, for example the birth of a child. 34 * NB: In order to protect identities, pseudonyms have been used throughout this report the GP service became aware of, and held in records, significant information relating to the family but due to a lack of involvement in the ongoing processes did not make the link that the information was important and needed to be shared. Other health professionals with continuing involvement in formal safeguarding processes will have a structured professional connection to GP services. The health visitor for Daisy was regularly in contact with the family due to Daisy being a looked after child. There was documented multi agency liaison between the health visitor and children’s social care professionals which indicates the health visitor was in touch with some, if not all, activity within the case. In some areas regular safeguarding meetings take place within GP surgeries or GP clusters. The meetings enable key health professionals connected to a surgery’s area and patients to share information and progress on the most complex cases, children and adults, linked to the GP service. The nominated GP safeguarding lead in attendance is then in a position to disseminate relevant information to GP colleagues. When operating effectively, such a process should ensure that other GPs are better equipped to manage sensitive information and disclosures which may be presented to them in appointments. It was reported that within the GP practice where Mother and the children were registered monthly meetings take place at the surgery where information is shared between the health visiting service and the GP service about children and families. This is a positive arrangement but if information is not known to be relevant, as highlighted above regarding Mother, then it will be not be shared. GPs can often be in the unique position that patients will disclose key information to them which has not been disclosed elsewhere or may have even been hidden from other professionals. Mother’s trust issues were well documented and she herself even admitted to problems trusting professionals. Despite this she spoke to the GP about her relationship with Father when discussing contraception. She also gave consent for the GP service to be contacted when exploring a termination of the pregnancy which she was trying to conceal. Father was also regularly attending a different local GP service after Rose’s birth due to anxiety, low mood and some suicidal thoughts, all identified by Father as connected to his family circumstances at the time. There is no information that Father’s GP service was included in the safeguarding processes for the children despite Father’s continuing relationship with the surgery, and the ongoing parenting assessments of Father which included assessment of risks. The issues of Mother’s GP service not being fully aware of the detail of the case and of the home placement agreement have been explored above. However, Father’s interaction with his GP was also relevant and useful for other professionals to be aware of when decisions regarding contact and risk were being considered. As demonstrated in this case the GP surgeries connected to both Mother and Father held key information within records which would have informed assessments and decisions relating to the children. Children’s social care professionals must routinely involve GPs of both parents to ensure all information relating to children is available for consideration. 35 * NB: In order to protect identities, pseudonyms have been used throughout this report At the same time and especially in cases where there is long term involvement of children’s social care, GPs should remain professionally curious to the circumstances which patients present, even when the full detail and history is unclear, to ensure all vulnerabilities of the patient, or others connected to them may be properly addressed. Learning Consideration 9 The Lancashire Safeguarding Children Board should consider, in consultation with local CCGs and other partners, options for ensuring the continued and meaningful engagement of all relevant GP services throughout safeguarding processes and particularly for those cases with additional complexities to ensure information sharing is continuous, effective and can inform assessments and decisions, including in legal proceedings, relating to the wellbeing of children. Consistency of professionals involved with families Mother was fortunate to have had experience of a number of professionals who remained involved with her and the children over a long period. Families often comment that it is difficult when constant changes are made to key professionals with whom they are expected to form sound working relationships. In this case individuals with long term knowledge and experience of supporting the family included professionals from midwifery and health visiting, who had contact with Mother due to the births of both children and antenatal period for Daisy. The family support worker was involved with the family from the period when Mother and sibling lived in the foster placement, until the death of Rose. Other support provided regularly over an extended timeframe to Mother was from professionals and volunteers with whom she was able to develop strong relationships, for example the early help outreach worker and the church organisation volunteer. There is no doubt that many professionals worked hard to develop a good rapport with Mother to try to support her and the children. The ability of professionals to build positive working relationships with Mother should not be overlooked particularly as Mother, from her own adverse childhood experiences had difficulties in developing trust and connecting with others on a personal level. Unfortunately, it is now known Mother had the propensity to manipulate professionals using disguised compliance, discussed earlier. Such behaviours may have been more challenging for some professionals to identify in Mother, particularly those with whom she had developed good longstanding relationships. However, as long as professionals maintain the skills to offer support with respectful challenge, a stable longer term involvement should be more beneficial to children and families receiving a service. Due to the circumstances of the case there was considerable children’s social care involvement, with Mother and the children receiving social work support. Through the timeframe of the review the social worker involved for the pre birth period and foster placement for Daisy and Mother remained allocated to the case until a month before Daisy and Mother returned to the home area to live independently. 36 * NB: In order to protect identities, pseudonyms have been used throughout this report A different social worker was then allocated who remained involved throughout 2016, through the concealed pregnancy period until around the time of the birth of Rose. At this point another social worker took over the case until the end of 2016, being replaced, due to a routine team transfer, by an agency social worker at the early part of 2017. This social worker was involved leading up to and including the time that Rose was discharged from hospital under the home placement agreement. When the incident occurred in April 2017 leading to Rose’s death another change in allocated social worker had been agreed, with a different agency social worker taking responsibility for the case up to and including when the child died. In summary five social workers were allocated during the review timeframe, a period of 28 months. It is acknowledged that statutory requirements in terms of reviews, core groups and other formal processes were met and not impacted by the social worker turnover. However, the frequent changes in social work allocation to the family is unsatisfactory for such a complex case particularly in the significant period of the timeframe after the concealed pregnancy was discovered with the birth of Rose. Any social worker newly allocated to this family with its complicated chronology would need protected time to familiarise themselves sufficiently, especially regarding Mother’s concerning history. Unfortunately, the tragic events which unfolded for the children clashed with the period of highest turnover of social work allocation within the case. Therefore, the detailed familiarisation and analysis of the case chronology would have been a challenge for any new social worker leading to the probability that assessments and decisions relating to placements and risk for the children were not fully informed. Father of the children told the Reviewer that he did not find it easy to work with the constant changes in social workers particularly towards the end of the review timeframe. Father and other members of his family held the opinion that the family support worker, who had been allocated long term, was “leading the case in terms of children’s social care involvement towards the end of Rose’s life”. Whilst accepted that this professional had extensive knowledge of the family history, she was not a qualified social worker and therefore not responsible for key decisions and actions relating to the children. Mother’s views regarding the challenge that frequent changes to allocated social workers presented to her has been detailed earlier. Turnover and changes in social workers allocated to the non recent case of the injuries to the other child was also highlighted as a negative issue by the family members who contributed to the review regarding their experiences. A number of articles have been written about the issue of social work retention, which obviously links to consistency of social work allocation for families. In Social work recruitment and retention; S.Bowyer/ A,Roe, www.rip.org.uk (research in practice), July 2015 a number of factors were identified which result in workers leaving the role/profession. These include lack of clarity about roles, high levels of stress/burnout, “blame culture” and overly bureaucratic systems. High numbers of agency social workers and the impact of such arrangements have also been subject to scrutiny in many local authorities. A professional who was involved long term with Mother and the family commented that she was surprised an agency social worker was 37 * NB: In order to protect identities, pseudonyms have been used throughout this report allocated to such a challenging case, when complexities within the case were at the highest level. The Reviewer was told that there had been a requirement for the Authority to use high numbers of agency staff to ensure the needs of the service were met. This is not unique to one local authority but is a common requirement throughout the country. Unfortunately, agency social workers by the temporary nature of their roles do frequently move on. If agency staff have been allocated to complex cases invariably this means that cases need to be reallocated leaving families with the challenge of building new relationships with different workers. This was an experience which both parents of Rose and Daisy spoke about. However, the key issue to question is the movement/ change of social workers, whether permanent or agency staff, on this complex case and specifically at significant points when high risks to the safety and wellbeing of very young children were being managed. Little information has been shared to indicate that the reason for changes in social work staff in this case was due specifically to retention within the authority. Those responsible for organising allocation of social workers to complex cases must consider the needs of the children and family as a priority. Managers should plan accordingly to ensure, other than in extenuating circumstances that experienced, permanent social workers are allocated to provide the highest quality of service to those most in need. Good practice in complex cases would be for managers to record a reason or rationale for a change in a lead professional on the case record. Learning consideration 10 The Lancashire Safeguarding Children Board should consider requiring assurance and evidence from the Director of Lancashire Children’s Services that allocation of lead professionals to complex cases is being managed effectively particularly when there is a need for transfer of cases, with rationales for changes in allocation being clearly recorded. Safeguarding awareness and responses in non statutory organisations During the review timeframe Mother and Daisy were in contact with numerous professionals and some volunteers. Whilst accepted that safeguarding may not have been the main reason for the involvement of those individuals, or their core business, the full circumstances for Daisy, Mother and Rose (pre and post birth) were very much linked to safeguarding including management of risk. A church volunteer accessed the home of Mother and Daisy regularly and was said to have developed a strong bond with Mother. She was often present when other professionals attended the address to carry out health and developmental checks and social work statutory visits. When the second minor injury had occurred to Daisy in the summer of 2016 the volunteer was present when the incident was discussed by Mother and the health visitor. The voluntary group to which the volunteer was linked was a local Christian family support organisation. Unfortunately, the group is no longer in operation and records are not available 38 * NB: In order to protect identities, pseudonyms have been used throughout this report but there is general evidence for the specific timeframe that some volunteer training took place and volunteers were subject to criminal records checks. Mother, in her meeting with the Reviewer, explained that her relationship with the volunteer developed into more of a friendship over time. Due to the closure of the organisation it is unclear whether the volunteer was still in contact with the family during the latter part of the review timeframe in an official voluntary capacity or by personal choice as a friend. Families involved in safeguarding processes from early help level to complicated child protection cases, such as the circumstances of this review, can benefit positively from the involvement of voluntary organisations which provide additional support. Mother said that the volunteer she knew did “grow into a friend who provided help with a house move” and other assistance. Unfortunately, there is limited evidence of information sharing or inclusion in the formal multi agency safeguarding processes which were ongoing for the family by the volunteer. This includes at key points in the review timeframe when concerns such as minor injuries to Daisy, contact issues and the concealed pregnancy were evolving. Mother recalled that she thought the volunteer was involved early on, in formal review processes for Daisy but not later, which may have been due to the closure of the voluntary group. It is essential that any organisation with volunteers or staff, having face to face access to vulnerable children and families operates safe recruitment, and that staff and volunteers are appropriately trained in safeguarding. If, as may have happened here volunteers then choose to continue personal involvement with families after volunteering has ended they will hopefully work within safe boundaries and still benefit from and utilise safeguarding awareness they have received should concerns occur. Mother also became engaged with an independent sexual health organisation when seeking support and information regarding a possible termination of the concealed pregnancy. Engagement with this service was not face to face as Mother failed to keep an appointment which was offered. However, Mother did have some telephone and email contacts with the service and discussed personal details including medical history. Mother also volunteered some history regarding her involvement with children’s social care in the past and informed the clinical service advisor with whom she spoke that she had a child (Daisy) on a care order. Records show that the organisation made contact with Mother’s GP surgery requesting medical history. This is routine after a request for a termination. There was no other contact by the organisation with any other professionals known to be providing a service to Mother and her family. Therefore, the information which Mother shared with the organisation to inform the process prior to a termination was the family position from her point of view and personal experience. It is unlikely that full details of all risks were provided, and it is not known whether Mother spoke specifically about Father, with whom she had formally agreed with children’s social care to not have contact, apart from organised contact arrangements. From records shared Mother clearly spoke to the clinical service advisor about restrictions as to who she could arrange to care for Daisy whilst any appointment regarding a termination took place. The independent sexual health provider has shared all information from the contacts with Mother. Details have been provided of the safeguarding arrangements and procedures which the organisation has in place. A safeguarding children and young people policy states how 39 * NB: In order to protect identities, pseudonyms have been used throughout this report advice is available through safeguarding named nurses for the organisation with safeguarding leads based in each centre. The policy includes information on types of abuse, information sharing and confidentiality. All clinical service advisors undertake safeguarding training to appropriate levels. In assessing Mother on the information provided no further advice was requested by the clinical service advisor from a centre lead or named nurse for safeguarding, despite Mother disclosing significant history with children’s social care and having a child on a care order. As a result, no information sharing or raising of concerns was forthcoming from the independent provider, and the pregnancy remained concealed. Safeguarding is not the core business of the independent sexual health organisation, but as proved by this case the service was contacted by an adult (Mother) who was involved with her child in a complex and protracted safeguarding process. Other similar circumstances may arise for the independent organisation, due to the sensitive nature of the service and therefore all staff would benefit from awareness of the circumstances of this specific serious case review. Learning consideration 11 The Lancashire Safeguarding Children Board should consider a request to the independent sexual health organisation involved that they review the contents of this report and in particular encourage the use of safeguarding centre leads and named nurses within the organisation to advise when similar circumstances are disclosed, including when there is extensive involvement of children’s social care within a family and when a child is subject to a care order or other legal proceedings. Professionals for whom safeguarding is a key part of their work must be aware of the need to seek out and involve all relevant parties known or suspected to be offering a service or support to a family in order that they can contribute to safeguarding processes including assessments and where necessary formal processes such as children’s reviews. For some cases this may include services or individuals outside of the standard agencies routinely involved In the case of Mother the organisations and individuals above, albeit involved with the family for very different reasons, could have contributed usefully. For the reasons explored this did not happen; at all for the independent health provider and did not continue to happen for the volunteer/ voluntary group. Learning consideration 12 The Lancashire Safeguarding Children Board should consider an exercise to explore how non statutory organisations, including voluntary or independent agencies who may not be routinely involved with families, can be identified and included in safeguarding processes to ensure valuable information which they may hold regarding children and families can be contributed to inform assessments and decisions. Decisions relating to legal proceedings Legal proceedings were ongoing throughout the timeframe of the review due to Mother’s concerning history with another young child many years ago. There was a substantial gap of significant children’s social care involvement with Mother, between 2006 and 2014. This was 40 * NB: In order to protect identities, pseudonyms have been used throughout this report due to Mother not being known to have significant contact or care of any children during that period. An interim care order was granted for sibling in the summer of 2015 and the decision made for Mother and baby to be placed in a foster care setting. Supervised contact between Father and sibling commenced from this time. The decision to place with foster carers after Daisy was born was a sound judgement to ensure the protection of the child and support for Mother whilst further assessments of Mother’s parenting capacity took place. In late 2015 Mother returned to the original area and a home placement was agreed for Daisy to live with Mother independently. This was largely due to Mother’s perceived good progress in the foster placement and the positive second psychological assessment by the second clinician. The differences in the two psychological assessments, consideration of the findings and the subsequent outcome was explored earlier, but in summary Mother was assessed to have made fundamental progress over a very short time frame. This progress was perceived as positive but it is unclear if Mother’s position of living in a highly controlled environment when the therapy and second psychological assessment took place was properly considered, or compared to the very different, chaotic settings of Mother’s recent past. Supervised contact with Father continued as part of the home placement agreement, and this has been explored throughout the review. During the first home placement Mother concealed the pregnancy resulting in Rose’s premature birth. Legal meetings are known to have taken place regularly after Rose was born with children’s social care appropriately seeking legal advice. The status of Rose as a child in her own right and subsequent safeguarding processes was explored earlier. Some records from legal meetings were shared with the Reviewer during the review, but not all records were available. Strenuous efforts to locate documents continued after the review was complete, with the search for records overseen by children’s social care senior managers. Eventually some notes from legal meetings were traced in February 2019 and were shared with the Reviewer. The Reviewer has been assured that all notes and minutes made at the time have now been found. Children’s social care recording of legal meetings evidencing key decisions and clear rationale regarding the future of the children should have been completed and uploaded in a timely manner. Recording at this significant point in the case did not meet expected practice which is unacceptable. Legal advice was provided on the basis of information and assessments collated by children’s social care. The quality of some assessments and subsequent decisions throughout the review has been questioned earlier. Both Mother and Father said they were confused over legal decisions made once it appeared that Rose was making progress and would survive. Both parents spoke separately but similarly about their frustration of how decisions were made and then changed regarding removal and placement of the children. Mother, in particular gave the example that she received a letter around Christmas 2016 informing her of the local authority’s planned intention to remove Daisy from her care. At this time Rose was still in hospital and as such was considered to be in a safe environment. 41 * NB: In order to protect identities, pseudonyms have been used throughout this report Within two weeks this decision was overturned and Daisy whilst still on the care order remained living with Mother. Over the weeks which followed the detailed home placement plan for both children was developed and agreed. The rationale for the change in direction and decision regarding the immediate future of the children was not made clear to Mother. Father and his family said they were also not informed of the reasons for the change of plan. The sister of Father recalls specifically her distress on discovering the decision to return both Daisy and Rose to Mother’s sole care. The Reviewer and Panel have attempted to explore the change in direction for the planned arrangements for both children. The documents for the period December/ January 2016 were finally located and shared with the Reviewer in February 2019. These indicate the decision to inform Mother of the planned removal of Daisy was made by the local authority as a result of the child and family assessment completed in December 2016. It appears the plan to remove was not endorsed by legal advice at that time. Information submitted by children’s social care to the review Panel indicates that a legal meeting with a senior manager took place on 18 January 2017. There was a delay in locating children’s social care notes of this meeting but these were finally traced. The legal notes were located much later and supplied to the Reviewer in February 2019. The children’s social care notes from 18 January 2017 and the legal notes submitted to the Reviewer in 2019 have been examined. It is clear that the legal advice on 18 January 2017 was in direct contrast to the suggested action which the local authority had outlined to Mother in December 2016. The legal notes state “firm advice is that the test for removal is not met in respect of either child”. The children’s social care notes from 18 January 2017 suggest there “was no threshold to remove Daisy as the care by mother was reported to be good”, which was very different to the conclusion of the child and family assessment completed the month before. It was suggested further information should be obtained from the psychologist regarding Mother’s ability to care for two children. The plan was for a full risk assessment to be completed once a further psychological report was available. At a court hearing on 6 February 2017 the interim care order and home placement agreement was not granted by the Judge or children’s guardian due to lack of detail and clarity regarding the support plan and contact plan for Father. A short adjournment led to the agreement of the home placement on 10 February by the Judge, children’s guardian and local authority with a detailed support plan in place. Further scrutiny of this key point in the review timeframe indicates the court expressed the view that it would not be appropriate for the same psychologist to be the appointed expert in the case as she had been a treating clinician for Mother previously. The court invited the parties to consider the identity of an appropriate expert for Mother and whether there should be an up to date assessment of the Father. Unfortunately, there is no further evidence on file to demonstrate that an updated psychological assessment of Mother took place by any other expert within the care proceedings. Therefore, no further professional clinical opinion was obtained about Mother’s parenting capacity prior to both children being returned to her care, despite being requested at court. 42 * NB: In order to protect identities, pseudonyms have been used throughout this report Furthermore, the significant change in the children’s social care opinion of Mother from the assessment concluded in December 2016 to the legal meeting on 18 January 2017 has not been sufficiently explained. Of note is that this period was one of the points within the case that a change in allocated social worker took place. The outgoing social worker who had been involved since the birth of Rose attended the review’s practitioner learning event and was clear that her assessment at the end of 2016 was for Daisy to be removed and for further legal advice to be obtained regarding Rose’s future. The newly allocated agency social worker contacted her in January 2017 to share that decisions had now changed and that a home placement agreement was being requested. The outgoing social worker was clear that this had not been the outcome of her assessment and suggested the new social worker would need to write a new statement and care plan in his own name. Due to the re-allocation of social workers to the case, as discussed earlier and above, some of the children’s social care professionals involved at the time are no longer employed by the authority and cannot contribute to the review. The social worker allocated in January 2017 was an agency worker who has now left. It is regrettable that the review has been unable to completely unpick the key decisions and changes in direction for the case in January 2017, regarding the future of both children. This was in part due to records not being easily retrievable and available, and also due to the lack of recorded rationale by children’s social care to explain the decisions made. The view of other professionals involved longer term and at that period was also one of confusion as to the apparent sudden change in direction for the case and placement of the children in January 2017. Health professionals in particular voiced their concern to the Reviewer that both children were returned to Mother’s care at home. The Reviewer, having examined notes which were found in February 2019 was then able to see that all professionals in attendance at legal meetings were from children’s social care. Legal meetings of this nature are for children’s social care professionals to obtain advice and guidance from local authority legal departments to ensure the safest outcomes for children. The very nature of cases being placed in the legal arena indicates the seriousness of the circumstances and vulnerability of the children involved. Specialist legal advice can be requested and arranged if necessary but it is not routine and was not obtained in this case. In circumstances such as for Mother and the children the legal advice provided was for children’s social care. In the legal meetings for Rose and Daisy all those attending were in a children’s social care related role with some involvement in the case. The purpose of assessments completed to inform processes where legal action is being considered is to ensure a holistic picture of the family’s needs is presented to include information from all agencies. Children’s social care should share all current and non recent assessments, professional judgements and other information from partner agencies to enable legal advice to be formulated from all available evidence. However, as the review has illustrated, large numbers of multi disciplinary professionals were closely involved with the children and family, some with alternative views of what might be in the best and safest interests of the children. Such opinions may not have been voiced as robustly by professionals presenting information on behalf of other colleagues or read from summaries in assessment reports. Furthermore, not being present in meetings gives no 43 * NB: In order to protect identities, pseudonyms have been used throughout this report opportunity for others to emphasis a particular concern, to challenge advice given or decisions made, or for a different course of action to be suggested and properly considered. Learning consideration 13 The Lancashire Safeguarding Children Board should consider requesting that the Director of Children’s Services issues a requirement that all legal meetings whatever their status are recorded by children’s social care to include at a minimum- attendees, advice given, a rationale for decisions and actions, and uploaded to the Lancashire County Council recording system for the relevant case. Learning consideration 14 The Lancashire Safeguarding Children Board should consider encouraging Lancashire Children’s Services and partners to explore options to enable key involved professionals, or one lead professional to represent multi agency partners, to be included in legal meetings where advice is being provided to children’s social care relating to family court processes, to ensure the views of partners regarding safest outcomes for children are fully considered. Use of home placement agreements Throughout the review’s timeframe the use of home placement agreements or orders has been scrutinised in detail. The Reviewer and Panel have queried throughout the review process the assessments and decisions which led to both children being returned to the care of Mother in March 2017. The Reviewer was informed about a piece of work undertaken nationally which identified that the North West (including Lancashire) have higher percentages of home placements than the rest of the country. It was explained that this has also been raised with the designated family judge in Lancashire but was stressed that each case was considered on its own circumstances before important decisions regarding placement of children were made. The position in the case of Daisy and Rose being returned to Mother’s care with home placement agreements has been examined closely. A number of issues have been highlighted which relate to final decisions leading to the home placement of the children and whether this was the appropriate and safest option for the family. Learning consideration 15 Lancashire Safeguarding Children Board may consider to require the local authority to complete and share the outcome of an analysis of children placed at home, the circumstances and decisions which led to placements being initiated and how compliance is monitored, to ensure the safety of all children who are subject to home placement agreements. Criminal investigation regarding the non recent incident in 2004 44 * NB: In order to protect identities, pseudonyms have been used throughout this report As stated at the start of the review, and connected to this case, serious injuries to another young child were investigated in 2004/ 2005. For legal reasons the full circumstances of the incident are not for inclusion in this report or for publication. It is clear that a criminal investigation commenced immediately after the injuries to the other child were identified. Mother was interviewed under caution but denied any responsibility for the injuries. Other adults were also interviewed but it could not be proved who caused the significant harm to the child. Advice was received from the Crown Prosecution Service that there was insufficient evidence to charge Mother or any other person. In February 2005 Mother made some partial admissions during other proceedings and the police were informed. An application to the court was made by the police to obtain a copy of the admissions along with copies of medical expert reports relating to the injuries caused. A judge granted the application but stated that the admission could not be used against Mother in any criminal proceedings. There is clear case law outlining the admission and use of evidence which has been found during other proceedings outside of a criminal case. The police did not re-interview Mother, despite the new information providing grounds to do so. The Crown Prosecution Service were consulted again and advised that there was still insufficient evidence to for a criminal prosecution. Mother went on to confirm her admissions during the NSPCC assessment commissioned by Lancashire children’s social care in 2005. In the initial meeting for the assessment in May 2005 she admitted responsibility for the injuries. All findings and information were included in the assessment report provided by the NSPCC to Lancashire in July 2005. It is not known if the further detailed admissions made by Mother to the NSPCC were shared for consideration by the police, as this was after the second consultation with the Crown Prosecution Service had taken place when the admissions in February 2005 had been made. When the death of Rose occurred in 2017 the non recent incidents involving the other child and Mother were reinvestigated. Mother was eventually charged with the 2004 assault offences on the other child and the 2017 murder of Rose. In the 2017 police investigation, a witness statement was obtained from a health professional to whom Mother made an admission of being responsible for the injuries to the other child. The admissions were made in 2006 during a health assessment of Mother. Mother did not have care of or contact with any children at the time, and the information was not shared. As is shown in the timeframe of the serious case review, from 2015 Mother spoke quite openly to a number of safeguarding professionals about the injuries caused to the other child. It is commendable that the police were able to compile sufficient evidence to secure convictions for Mother relating to the separate incidents involving Rose and the other child. Furthermore, as detailed earlier, Father and his family, and the carers of the child assaulted in 2004 were all very positive regarding their experience with the police investigation team who brought the whole case to trial. It could be questioned what was the reasoning for Mother not being re-interviewed under caution once the information was known that she had made some admissions, despite the challenge of family court information being inadmissible. Mother was not provided with an opportunity to give a different explanation to investigating officers, despite the knowledge that 45 * NB: In order to protect identities, pseudonyms have been used throughout this report she was openly admitting responsibility for the injuries to other professionals. Had Mother changed her account to the police in a further interview, the view of the Crown Prosecution Service regarding action which could have been taken may have different. However, it is a subjective decision for any senior investigating officer leading a complex enquiry whether to re-interview a suspect about additional information. The Panel was informed by experienced officers that different police senior investigating officers may reach different decisions as to re-interview or not, but all would be based on a clear, recorded rationale. The police at the request of the Reviewer have researched the earlier investigation into the other child’s injuries. Unfortunately, due to the length of time elapsed since the 2004/2005 incidents there are only limited records still available within the police and no relevant Crown Prosecution Service documentation has been retained from that period. Lancashire Constabulary were inspected in October 2017 by Her Majesty’s Inspectorate of Constabulary and Fire and Rescue Services, part of a rolling programme of inspections of child protection of all police forces in England and Wales. Findings published in March 2018 said “the Lancashire Constabulary demonstrates a clear commitment to providing a good service for vulnerable children in need of protection. However, it needs to provide better protection for those children most at risk”. Learning consideration 16 The Lancashire Safeguarding Children Board may consider a request to the Lead Officer for Criminal Investigation, Lancashire Constabulary to provide assurance and evidence to the Lancashire Safeguarding Children Board that there is a clear, recorded rationale behind decisions and actions for current investigations into complex child abuse allegations carrying most risk and that cases are being managed in a timely and effective manner. Learning consideration 17 The Lancashire Safeguarding Children Board may consider sharing the content of the serious case review for Child LK with the Local Family Justice Board(s) in Lancashire to ensure there is awareness of the position which occurred in 2005 when admissions by an adult in proceedings were ruled inadmissible in a criminal investigation leading to no further action at that time against a person who continued to make admissions of physical assault, and was eventually convicted of that assault, and another, many years later. Family Justice Boards and other partners may wish to explore the issues raised which may help to reduce the risk to other children in similar situations in future. Conclusion The circumstances in any serious case review are tragic. The prelude to the timeframe of this review was a serious assault many years ago on a young child, who fortunately survived. The Mother of the subjects Rose and Daisy was involved in the care of the child and after initially denying responsibility for the harm caused made partial admissions, including to professionals, to having caused the injuries. Unfortunately, there was insufficient evidence to charge Mother at that time. 46 * NB: In order to protect identities, pseudonyms have been used throughout this report When Mother reported she was pregnant with Daisy in early 2015 services immediately became involved due to the risk of physical abuse after the historical incident. Mother gave the appearance of cooperating with professionals but was using disguised compliance. She was judged as a changed person, making progress, who could be trusted to care for her daughter at home. Father of Daisy had learning difficulties and some alcohol related convictions. Despite Mother’s known background of harming another child, Father was assessed as a higher risk and granted only supervised contact. By 2016 Mother was living independently with Daisy on a care order with home placement. Unknown to services Mother resumed the relationship with Father whilst breaching the home placement agreement allowing him extra contact with Daisy. The resulting pregnancy was concealed and Father was dismissed and disbelieved by the professionals he told, who made no enquiries other than asking Mother who denied she was pregnant. Rose was a premature baby with Mother giving birth around 24 weeks in September 2016. The pregnancy was concealed until this point. Legal advice was obtained by children’s social care regarding Daisy’s future, and Rose’s once it was known she would survive. The legal position was complicated and swayed from sympathising with Mother to the planned removal of Daisy. Some records to explain key decisions and a clear rationale for action taken were not readily available to the review. Eventually in February 2017 a care order was granted for Rose but with the decision that both children, a toddler and a baby born premature with complex needs, would live with Mother on a home placement with a robust plan of support. This included commissioned overnight support workers staying at the address. The overnight support was amended to evenings at a time when some concerns had been raised regarding Mother’s lifestyle. Unfortunately, in April 2017 within only a short period of the new support arrangements, the support worker had left for the night when Mother called an ambulance reporting Rose was unwell. A serious head trauma was diagnosed to Rose suspected to have been caused non accidentally. Rose sadly died and Mother was arrested. After an investigation she was charged and subsequently convicted after a trial in 2018, of the murder of Rose and the non recent serious assault on the other child. The findings of this serious case review identify missed opportunities which if acted upon or responded to differently may have altered the outcome of the case. However, working with families in complex circumstances is continually challenging, made more difficult when individuals who professionals are working hard to support, have intent to manipulate and deceive. Some organisational issues throughout the review timeframe were also identified as areas for development. Scrutiny of practice always provides an opportunity to reflect on ways in which services can improve and be further enhanced. As a result of the significant incidents in the lives of Rose and Daisy there is an opportunity for Lancashire Safeguarding Children Board and its partner agencies to consider learning from the case and ways by which services and practice may continue to be developed. 47 * NB: In order to protect identities, pseudonyms have been used throughout this report Considerations for learning The following considerations for Lancashire Safeguarding Children Board have been made based on the learning from the case: 1. The Lancashire Safeguarding Children Board should consider, through the learning and development team a training analysis to examine how disguised compliance is included in current learning opportunities, and where inclusion of the issue can be enhanced, to ensure all staff across the partnership has sufficient awareness of disguised compliance as a significant risk to children; 2. The Lancashire Safeguarding Children Board should consider opportunities to ensure disguised compliance and focus on children, are identified as key areas of scrutiny for every case, to be examined regularly for example in staff supervision meetings and when identifying and reviewing desired outcomes for children; 3. The Lancashire Safeguarding Children Board should consider the viability of an exercise to explore all known cases of concealed and denied pregnancy within the county over a designated period before and since the concealed and denied pregnancy protocol was introduced, to ensure there is compliance with the guidance and in particular appropriate use of linked procedures is occurring, such as the pre birth protocol, when criteria and threshold has been met; 4. The Lancashire Safeguarding Children Board should consider an audit with an emphasis on open/ongoing cases of families with multiple children and/or siblings where new concerns arise to ensure expected procedure is followed in terms of status and recording of those children, and that agreed processes take place such as strategy meetings and section 47 investigations which enable a multi disciplinary approach to help ensure focus is maintained on all children involved; 5. The Lancashire Safeguarding Children Board should consider the development and implementation of guidance relating to looked after children who sustain injuries, including who should be informed and what action should be taken/ recorded; 6. The Lancashire Safeguarding Children Board should consider issuing a reminder or further promotion of the resolving professional disagreements policy, for neonatal and other similar staff groups who may not routinely experience the need to make a safeguarding referral or escalate concerns, to ensure all staff has awareness of the pathway to professionally challenge decisions made impacting on the safety and wellbeing of children; 7. The Lancashire Safeguarding Children Board should consider requiring an audit of cases which include contact arrangements as a significant issue to explore that fathers are being heard, involved and provided with appropriate support in order that they are given the same opportunities as mothers when exploring best outcomes for children; 8. The Lancashire Safeguarding Children Board should consider requesting assurance and evidence from commissioners of external providers of support 48 * NB: In order to protect identities, pseudonyms have been used throughout this report workers, such as in the case of Rose (Child LK), that safeguarding training and awareness programmes for staff are mandatory, fit for purpose and whether packages include assessment and recording as standard; 9. The Lancashire Safeguarding Children Board should consider, in consultation with local CCGs and other partners, options for ensuring the continued and meaningful engagement of all relevant GP services throughout safeguarding processes and particularly for those cases with additional complexities to ensure information sharing is continuous, effective and can inform assessments and decisions, including in legal proceedings, relating to the wellbeing of children; 10. The Lancashire Safeguarding Children Board should consider requiring assurance and evidence from the Director of Lancashire Children’s Services that allocation of lead professionals to complex cases is being managed effectively particularly when there is a need for transfer of cases, with rationales for changes in allocation being clearly recorded; 11. The Lancashire Safeguarding Children Board should consider a request to the independent sexual health organisation involved that they review the contents of this report and in particular encourage the use of safeguarding centre leads and named nurses within the organisation to advise when similar circumstances are disclosed, including when there is extensive involvement of children’s social care within a family and when a child is subject to a care order or other legal proceedings; 12. The Lancashire Safeguarding Children Board should consider an exercise to explore how non-statutory organisations, including voluntary or independent agencies who may not be routinely involved with families, can be identified and included in safeguarding processes to ensure valuable information which they may hold regarding children and families can be contributed to inform assessments and decisions; 13. The Lancashire Safeguarding Children Board should consider requesting that the Director of Children’s Services issues a requirement that all legal meetings whatever their status are recorded by children’s social care to include at a minimum- attendees, advice given, a rationale for decisions and actions, and uploaded to the Lancashire County Council recording system for the relevant case; 14. The Lancashire Safeguarding Children Board should consider encouraging Lancashire Children’s Services and partners to explore options to enable key involved professionals, or one lead professional to represent multi agency partners, to be included in legal meetings where advice is being provided to children’s social care relating to family court processes, to ensure the views of partners regarding safest outcomes for children are fully considered; 15. Lancashire Safeguarding Children Board may consider to require the local authority to complete and share the outcome of an analysis of children placed at home, the circumstances and decisions which led to placements being 49 * NB: In order to protect identities, pseudonyms have been used throughout this report initiated and how compliance is monitored, to ensure the safety of all children who are subject to home placement agreements; 16. The Lancashire Safeguarding Children Board may consider a request to the Lead Officer for Criminal Investigation, Lancashire Constabulary to provide assurance and evidence to the Lancashire Safeguarding Children Board that there is a clear, recorded rationale behind decisions and actions for current investigations into complex child abuse allegations carrying most risk and that cases are being managed in a timely and effective manner; 17. The Lancashire Safeguarding Children Board may consider sharing the content of the serious case review for Child LK with the Local Family Justice Board(s) in Lancashire to ensure there is awareness of the position which occurred in 2005 when admissions by an adult in proceedings were ruled inadmissible in a criminal investigation leading to no further action at that time against a person who continued to make admissions of physical assault, and was eventually convicted of that assault, and another, many years later. Family Justice Boards and other partners may wish to explore the issues raised which may help to reduce the risk to other children in similar situations in future. References • Working Together to Safeguard Children (Department for Education 2015) • Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews, Welsh Government, 2012 • The Munro Review of Child Protection: Final Report: A Child Centred System, May 2011 • Child Practice Reviews: Organising and Facilitating Learning Events, Welsh Government, December 2012 • The NSPCC Information Service Summary of Learning from Case Reviews • Pan Lancashire multi agency pre birth protocol (March 2017) • Denial of pregnancy, Jenkins et al, 2011 • Serious Case Review Child LB, Lancashire Safeguarding Children Board (as yet unpublished) • Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final report: May 2016, Peter Sidebotham, Marian Brandon et al • Hidden Men: Learning from Case Reviews, NSPCC, March 2015 • Social work recruitment and retention; S.Bowyer/ A,Roe, www.rip.org.uk (research in practice), July 2015 50 * NB: In order to protect identities, pseudonyms have been used throughout this report • Her Majesty’s Inspectorate of Constabulary and Fire and Rescue Services, programme of inspections of child protection of all police forces in England and Wales: Lancashire Constabulary, March 2018. Statement by Reviewer REVIEWER Amanda Clarke (Independent) Statement of independence from the case Quality Assurance statement of qualification I make the following statement that prior to my involvement with this serious case review- I have not been directly concerned with the s ubject children or s ignificant others connected to the children, and have not given professional advice on the case. I have had no im m ediate line m anagem ent of the practitioner(s ) involved. I have the appropriate recognised qualifications, knowledge and experience and training to undertake the review. The review was conducted appropriately and was rigorous in its analys is and evaluation of the issues as set out in the terms of reference. Reviewer (Signature) A.Clarke Name Amanda Clarke Date 15/02/19 |
NC048448 | Death of a 15-month-old child in January 2015 as a result of multiple non-accidental injuries. Child S had been brought to live in the UK by his mother from the Czech Republic who abandoned him to the care of his adult half sister and her partner. He was not known to any services. The couple had a history of substance misuse and domestic violence. During the three months that he was in their care, he sustained significant injuries that led to his death. A number of friends and relatives were aware of the injuries to Child S but did not report it. The partner was sentenced to life imprisonment for murder and the child's half-sister was imprisoned for 5 years. Learning points identified include: the importance of using interpreters when working with families whose first language is not English; the need for information in a number of languages; the challenges of international migration for safeguarding children; the work needed to address the lack of knowledge or trust of professionals and services within migrant communities. Makes a number of recommendations related to working with migrant families.
| Title: Serious case review: BSCB2015-16/04: born in 2013: died on 1st January 2015 aged 15 months. LSCB: Birmingham Safeguarding Children Board Author: Jim Stewart Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Independent Author: Jim Stewart Serious Case Review BSCB2015-16/04 Born in 2013 Died on 1st January 2015 aged 15 months 2 Contents Page 1. Reason for the Review 3 2. Methodology 3 3. Independent Lead Reviewer 5 4. Family Composition 5 5. Ethnicity, Culture and Identity 5 6. Family Background 5 7. Parental and extended Family Involvement 6 8. Criminal and Care Proceedings 6 9. The Local context 6 10. Summary of Key Events 7 11. Analysis 11 12. Conclusions and Lessons Learned 19 Appendices Terms of Reference Bibliography Acronyms 22 24 25 3 1. Reason for the Review 1.1 Child S died on 1st January 2015 at 4.25 pm; aged 15 months old and had been living in England for approximately 6 months. An ambulance was called at 15.45pm to the flat where Child S lived latterly in the care of TL, TL’s partner MH and the couple’s 10-month old child SH. Child S arrived at hospital in cardiac arrest and could not be revived. Medical examinations and tests highlighted that Child S had experienced a number of injuries as a result of blunt force trauma. 1.2 A child protection medical for SH, was arranged on 1st January 2015 and this did not reveal any injuries. SH was placed in foster care and has been safeguarded through care proceedings. 1.3 Child S travelled to England with their mother in June/July 2014. Child S was abandoned and left in the care of AL and TL by their mother in September 2014 when she left England suddenly and returned to the Czech Republic where Child S had been born. 1.4 MH was found guilty of murder and sentenced to life imprisonment. TL was convicted of allowing the death of Child S and sentenced to 5 years’ imprisonment. 1.5 In February 2016 the Independent Chair of Birmingham Safeguarding Children Board requested that the Lead Reviewer undertake a Serious Case Review into Child S’s circumstances based on a desktop review of the information available from case records which West Midlands Police are able to provide from their investigation and the subsequent criminal proceedings. 2. Methodology 2.1 A Serious Child Care Incident Notification was made in respect of Child S on 1st April 2015. 2.2 Initial scoping undertaken identified which agencies had had involvement with Child S and the immediate family. The following agencies provided background information about Child S’s circumstances: Birmingham Community Health Care Foundation Trust Birmingham Women’s Hospital Foundation Trust Birmingham South Central Clinical Commissioning Group Birmingham Early Years Heart of England NHS Foundation Trust 2.3 West Midlands Police had no knowledge of the family before Child S’s death and West Midlands Ambulance Service and Birmingham Children’s Hospital only became aware of the family through the emergency call response and Emergency Department involvement on 1st April 2015. The family were not known to the Housing Department, National Probation Service, Sandwell and 4 West Birmingham NHS Foundation Trust or the United Kingdom Border Force. 2.4 The Independent Chair of Birmingham Safeguarding Children Board received reports on 29th January 2015 from the Serious Case Review Sub-Group and a further report presented on 20th May 2015 following further scoping and an updated recommendation from the Sub-Group. 2.5 The Independent Chair corresponded with the National Panel of Independent Experts on Serious Case Reviews about this case and an original decision on 24th June 2015 not to complete a Serious Case Review was given as there was nothing known at all about Child S, other than the details from the Police investigation and trial, that no agencies were aware of Child S’s existence. There is no record of Child S having come into the country. Child S was not registered with universal services and there had been no concerns identified or referrals made to any agency. In addition, there is no evidence the other child living in the household had said anything. 2.6 The Independent Chair reviewed the decision upon the advice of the National Panel and on 2nd September 2015 agreed to ask the Lead Reviewer for another Birmingham case under review involving a migrant family of a different nationality but also from Eastern Europe to undertake a parallel review of Child S’s case at the same time. 2.7 This is an unusual Serious Case Review because Child S was not known to any agencies in Birmingham or apparently in England before their death. SH was registered with a GP and known to the Health Visiting Service. Child S was never registered with a GP and never seen by any health professionals. There were no home visits by any professionals to the family’s address during the period Child S lived there and there were no referrals to Children’s Social Care about Child S. It is understood that Child S travelled to England with their mother by aeroplane, but is not known to the United Kingdom Border Force. The information available to this review has come from the Police investigation of Child S’s death (including reference to Facebook posts between TL and other family members and friends), the criminal trial, and assessments by Children’s Social Care in respect of SH. The Lead Reviewer has also met MH in prison, who confirmed the information available from the Police investigation, Children’s Social Care assessments and other information gathered for the care proceedings in respect of Child S. This included some information provided to the Police and Children’s Services by authorities in the Czech Republic. 2.8 The Lead Reviewer has discussed the detail of a draft of this report with the Serious Case Review Sub-Group and made final revisions in the light of the feedback and further information received from members of the group. 5 3. Independent Lead Reviewer 3.1 Jim Stewart is an Independent Social Work Consultant with over 26 years’ experience of working in children’s services, child protection practice and management, including the coordination of complex case investigations and the conduct of Serious Case Reviews. He qualified as a Social Worker in 1986 and is registered with the Health and Care Professions Council. 4. Family Composition Subject (Child S) Born 2013; died 1 January 2015 Mother (SL) Born 1977 Putative Father (MB) Date of Birth Not known Half-sibling (AL) Born 1997 Half-sibling (TL) Born 1995 TL’s partner (MH) Born 1987 Niece of Child S (SH) Born 2014 Father of TL and AL (JL) Born 1976 5. Ethnicity, Culture and Identity 5.1 Child S, their mother SL, TL, AL, MH and JL were all born in the Czech Republic, a European Country which is a member of the European Union. MH is Roman Catholic, but does not practice his faith. MH comes from a gypsy background but the family had lived in houses for many years. MH also stated that JL is of Roma descent. There is limited information available about the cultural background of Child S and their family members. 6. Family Background 6.1 In interviews undertaken for Birmingham Children’s Services, relatives stated that SL had worked in Germany and that a previous partner had looked after her older children, TL and AL, in the Czech Republic for a period of their childhood. 6.2 MH told the Lead Reviewer that he and TL moved to England because JL lived here and they wanted a better life. MH had found some building work initially a few days a week. 6.3 Information received from the authorities in the Czech Republic following Child S’s death indicates that MH had been arrested for robbery with accomplices in 2004 and driving without a licence in 2007. 6.4 MH had used cannabis in the Czech Republic and told the Lead Reviewer that his parents had helped him to come off drugs without any involvement from health services there. 6.5 When AL moved to live with the couple, AL did not work but MH felt that she was good company for TL. 6 7. Parental and Extended Family Involvement in the Review 7.1 Agencies in Birmingham have had no contact with SL in relation to this Review. The Lead Reviewer met with MH as part of the review process but TL and her father JL chose not to be involved. 8. Criminal and Care Proceedings 8.1 MH was found guilty of Child S’s murder and sentenced on 22 October 2015 to life imprisonment. TL was convicted of allowing the death of Child S contrary to Section 5 of the Domestic Violence, Crime and Victims Act 2004 and was sentenced to 5 years’ imprisonment. 9. The Local Context Birmingham Census Information 9.1 The census in 2011 reported that: 1.073 million people lived in Birmingham. The city has a young population with 66% aged under 44 and 19% within the 20-29 years’ age group. Birmingham is the ninth most deprived of the 354 local authorities in England. Birmingham is the most ethnically diverse city in the United Kingdom. 9.2 An Overview of the Joint Strategic Needs Assessment for Birmingham 2012 organises information around the six Marston Review policy areas and the first is ‘Give Every Child the best start in life’. The subsection ‘Starting well: conception and childhood’ provides the following information: Birmingham has high rates of perinatal and infant mortality. The infant mortality rate is 7.7 per 1,000 live births, compared to the England average of 4.7. Rates are significantly higher in ethnic minority groups. 10% of babies born in Birmingham weigh less than 2.5kg compared to 7.5% in England. Low birth weight is as high as 29% in some areas of the city. Breast feeding initiation in Birmingham is low at 68.1% compared to 74.6% nationally. Immunisation rates vary across the city. Rates of measles, mumps and rubella vaccination are lower in the south Birmingham area compared to the rest of the city. 7 9.3 The Joint Strategic Needs Assessment (JSNA) also highlights the following information about worklessness in the city: The worklessness rate is 18.5% – higher than a year earlier (18.0%). It is higher compared to the West Midlands and England, 13.7% and 11.9% respectively. Of the eight core cities, Birmingham’s worklessness rate is the second highest, and it is nearly two-thirds higher than the England rate. Worklessness is highest in the wards with the highest deprivation rate (IMD), such as Shard End (27.2%), Washwood Heath (26.9%), Nechells (26.3%), Sparkbrook (26.3%), Lozells and East Handsworth (26.0%), Soho (24.8%), and Aston (23.5%). The Czech Republic 9.4 Child S was born in the Czech Republic. In 2010, the country introduced a National Action Plan for the Transformation and Unification of a System of Care for Children at Risk. In 2012 the Government approved a National Strategy to Protect Children’s Rights and an associated action plan. 9.5 It is not clear whether Czech child protection procedures bear much resemblance to those in England or if Child S had been subject to any legal order or child protection status when SL brought Child S to England in 2014. Children’s Services there had returned Child S to SL’s care after a period of time in an infant care facility due to her substance misuse and the need to assess her capacity for change. 10. Summary of Key Events 2002 Child S’s maternal grandfather, moved to live in England. March 2012 TL and MH moved to England looking for work. MH clarified that they travelled by aeroplane. MH told the Lead Reviewer that they had been encouraged to move to England by JL. The couple originally lived with JL in Solihull and eventually her father paid half of the money required for their own tenancy. Within weeks of moving to England, TL found out that she was pregnant. 2013 May AL moved to England. 20 September Child S was born in the Czech Republic. SL is alleged to have been involved in prostitution and substance misuse for many years. MB is named on the Child S’s birth certificate but SL 8 subsequently stated that he was not the real father. 27 September TL and MH moved into the tenancy in Birmingham where they lived until Child S’s death. 20 October Child S was registered with a Paediatric GP in the Czech Republic. 21 October SL denied substance misuse, but tested positive for methamphetamines and opiates. Child S was placed into an infant care facility in the Czech Republic. 5 November Czech town’s Children’s Services visited SL at home and assessed it to be clean and tidy. 6 November Czech town’s Children’s Services returned Child S to the care of their SL. 28 November Child S was reviewed by a Paediatric GP; Child S was due to be reviewed monthly and was seen in December 2013 and then February, March and April 2014. 2014 1 January SL’s cooperation with Czech town’s Children’s Services reduced. 18 March SH, the child of TL and MH was born in Birmingham. May AL moved to Birmingham. 26 May MB, Child S’s putative father reported to the authorities in the Czech Republic that SL had moved out of her address. She was wanted by the Czech authorities and was located living in a hotel in a nearby town. SL then failed to attend an appointment as agreed. 2 June MB attended the offices of a Czech town’s Children’s Services stating that he intended to apply for the custody of Child S. June/July SL and Child S came to England. MH recalled that SL had travelled in a taxi from London and expected them to settle a bill which cost approximately £150. MH recalls that the taxi driver called the Police before the fare was settled. 21 July MB informed the authorities in the Czech Republic that Child S and SL had moved to the United Kingdom. June/July - September MH has told the Lead Reviewer that the presence of SL and Child S caused considerable friction in the flat. The Lead 9 Reviewer was told that SL allegedly took drugs in the flat and outside where she was involved in prostitution. SL regularly came back to the flat under the influence of drugs. SL argued with TL and did not listen to anyone. MH stated that SL made the house dirty and on occasion she would feed Child S with the same spoon she used for drugs. SL regularly promised to stop taking drugs but then continued to go out. MH stated that they bought all the food and things for the flat. MH asked SL to leave every few days. MH went out a lot to avoid having to listen to SL. AL told SL to look after Child S. The situation at home led to a lot of arguments at home between TL, MH and other family members. 13 June SH was seen and weighed at baby clinic. 25 June SH received immunisations. 10 July The court findings at a Czech District Court confirmed that MB’s application for custody of Child S was not successful. 19 July An ambulance was called to the family’s address in Birmingham for a forty-year-old male, but no link between him and the family has been established. 23 July SH received immunisations. August TL and MH had rent arrears of £1,400. From this point, rent was paid directly to the landlord. JL, TL’s father, received a short custodial sentence for domestic abuse offences. 22 August SH was taken to the Health Visitor Clinic. 28 August SH was seen and weighed at clinic. September SL left Child S in the care of AL, TL and MH. She told her children that she was going shopping and did not return. There was no discussion about her plans to return to the Czech Republic or any arrangements made for the care of Child S. MH stated that he telephoned others about SL and his grandmother confirmed that SL had been seen back in the Czech Republic. 9 September Child S missed a scheduled appointment with a paediatric GP in the Czech Republic. 10 September SH received immunisations. 10 7 November SH was taken to the Health Visitor Clinic and weighed. 18 November In his summing up, the judge in the criminal trial of the couple highlighted that Child S was seen by a witness on this day with hair at the top of his head torn away; this had occurred within 10 days of TL and MH assuming sole care of Child S. 21 November TL sent a Facebook message to a friend stating ‘How is it here do you pay something. I can’t really go. I have to wait for the bruises to be gone or they will lock me up or they will think god knows…’. At the end of November TL went to stay with JL with Child S and SH for a few days after JL had seen ‘damage’ to Child S during a visit to TL’s flat. When TL and the children returned home on the 26th November, it is stated that most of the marks had gone. 4 December TL complained to JL through Facebook that she and MH were arguing. 7 December TL complained to JL through Facebook that MH was complaining about ‘Child S’ and ‘he just beat me up’. (TL subsequently retracted the latter allegation). 15 December MH’s cousin and neighbour sent a Facebook post to JL father stating that MH was going to purchase a coffin for Child S, and TL should remove Child S otherwise he was going to kill him. By 21 December Medical and other information considered at the criminal trial suggested that, by this date Child S had a fractured right big toe, other fractured bones, an avulsion (trauma/detachment) of the nail and significant loss of hair. TL made excuses to prevent JL from seeing Child S in this condition when he offered to care for the child for a period of time. Late December A few days before Child S’s death TL responded to Child S crying out and saw MH holding Child S arm tightly causing marks and noticed marks around Child S’s mouth. 29 December TL sent a message to AL by social media stating ‘you (AL) have to take Child S home. I will pay Mom’s plane ticket on Wednesday so that she can come for Child S. I can’t do it no more I swear. Child S has bruises all on his face again.’ 31 December TL and MH had a small New Year celebration in their flat attended by an aunt, her partner and their child. 2015 1 January An ambulance was called at 3.45 pm to the flat, Child S was 11 transported to the Emergency Department where Child S arrived in a state of cardiac arrest. Cardio pulmonary resuscitation was continued but Child S could not be revived and died. Child S had bruising to the face, chest, back and limbs. A skeletal survey revealed fractures to the ribs, both arms and right big toe. Child S was also subsequently found to have had significant injuries to the diaphragm, lungs and liver and to be vitamin D deficient and malnourished. The Consultant Paediatrician reported that these were the worst injuries to a child they had seen in many years of practice in this field and health experts have confirmed that Child S will have experienced significant pain. Child S died at 4.25 pm; aged 15 months old. 2 January Child S’s mother SL sent a Facebook message to TL stating ‘you what have you done to (Child S) you monster’. 11. Analysis Child S’s life in England, legal status and care arrangements 11.1 Child S was brought to England from the Czech Republic by his mother and left in the care of the half-siblings. This was a private care arrangement precipitated by SL without the prior agreement of the AL, TL or MH and eventually the couple TL and MH were left to care for Child S on their own. 11.2 TL informed the Police during the criminal investigation that MH took on the care of Child S. He would not allow TL to bathe or dress Child S and on occasion would go to a different room to do this. This is contradicted by MH’s statement to the Lead Reviewer that they shared Child S’s care. A friend or relative described bathing Child S on occasion. 11.3 It has only been possible to form a limited picture of Child S’s life in Birmingham. There was not always food in the house (Child S was malnourished and vitamin D deficient when taken to hospital) and appears to have had no personal belongings. Child S lived in a house where substance misuse and domestic abuse impaired the care they received. Child S was the victim of regular and escalating physical abuse after AL returned to the Czech Republic and Child S experienced significant pain. 11.4 The United Nations Convention on the Rights of the Child contains the following definitions: A separated child is ‘a child who has been separated from both parents, or from their previous legal or customary caregiver, but not necessarily from other relatives. This may therefore include a child accompanied by other adult family members’. 12 An unaccompanied child is ‘a child who has been separated from both parents or other relatives and is not being cared for by an adult who by law or custom, is responsible for doing so’. Child S clearly became a separated child. 11.5 Ms Knaus, a Senior UNICEF Policy Adviser, reported to the House of Lords European Union Committee in 2016 that ‘we need inclusive child protection and integrated responses. We need a framework that works for all children so that trafficked children, unaccompanied children and children in families have their rights. We also know that children fall between categories. They move from one category to the next.’ Child S child arrived in England in the care of their mother but was left by her. Child S was then living with two half-siblings initially, but eventually with a half-sister who had had only a limited level of contact or relationship with Child S and her boyfriend, who was not a relative and neither had expressed any wish to care for Child S. 11.6 Agencies in Birmingham had no knowledge of Child S and were therefore unaware that Child S had been subject to welfare or child protection involvement in the Czech Republic. 11.7 MH told the Lead Reviewer that he and TL did not consider seeking help with Child S from authorities. The situation was very hard but MH emphasised that the couple’s loyalty to family influenced their decision not to seek help at any point. Invisible or missing children: children not known to agencies in England 11.8 There are a number of child deaths documented where children had had no contact with professional agencies prior to their deaths. Their circumstances vary. For example, in 2010 Kristy Bamu (a 15-year-old boy from France) was accused of using witchcraft and killed after days of abuse whilst he and siblings were visiting his sister and her partner in London for a holiday. 11.9 There have been a small number of cases reported in this country of concealed pregnancies where mothers have not made agencies aware of their pregnancies or children’s births before the discovery of a deceased baby. A number of these cases have resulted in Serious Case Reviews. There are also isolated cases reported where slightly older babies have died and agencies had no knowledge of their existence until the discovery of a body. For example, the body of a boy aged between 12 and 18 months old was found near the A66 in Cumbria in 1989 and the body of a 6-month old girl was found on a path in Edinburgh in 2013 and Police have not been able to identify either child or their parents. 11.10 There is increased recognition that children can be brought into the country covertly by families or trafficked by criminal organisations but consequently there is little reliable evidence about the extent of such practice and the number of children involved. In 2001 there was significant coverage of the case of ‘Adam’, a young Nigerian child whose torso was recovered from the 13 Thames; in 2013 a woman came forward to claim that he was a child whom she had looked after for weeks in Germany before he was taken to London. 11.11 Although Child S was never known to agencies in this country, it has also been useful to briefly consider a number of well-known cases where agencies had lost touch with children and one high profile case where a child’s life history in other countries had not been known to professionals. The case of Victoria Climbie and the Inquiry held following her death in February 2000 drew attention to the fact that a child had been brought into the country and their circumstances were not clearly understood by agencies and the limited efforts to contact agencies in France had been ineffective. However, a number of agencies and London councils had known Victoria. This case highlighted the practice of private fostering where children are cared for by someone other than a close relative. Khyra Ishaq died in Birmingham in May 2008; she was described as extremely malnourished with severe wasting and her death was caused by bronchial pneumonia and septicaemia with meningitis. Kyra and some siblings had been removed from state education during December 2007 with a stated intention by her mother to educate them at home. The children educated at home were also effectively removed from health surveillance. Hamzah Khan died in Bradford at the age of 4 years old in late 2009 as a result of fatal neglect but his death did not come to light until September 2011. The Serious Case Review commissioned by Bradford Safeguarding Children Board highlighted ‘the extent to which Hamzah was unknown and invisible to services throughout his short life.. …. Hamzah was invisible to services largely because neither of his parents participated in the routine processes such as ensuring he saw health professionals on a regular basis or was enrolled for early years to educational provision.’ In October 2009 Hamzah, his siblings and his mother had been removed from the register of the GP practice because the younger children had not been brought for routine health and developmental checks and immunisations. The legal requirement was that Hamzah should have attended school from September 2010. Another case, the death of Dylan Seabridge at the age of 8 years old in 2011 in a remote rural community in Wales, is a slightly more recent example of how children can live ‘under the radar’ with no contact with agencies. Dylan died from a long term vitamin C deficiency (commonly known as scurvy) an easily treatable condition; he was found to have had anaemia and loose teeth. Media reports (for example in The Guardian) described Dylan as ‘invisible’ but his birth had been registered and his parents chose to educate him at home from 2006. Dylan was registered with a GP and a dentist but was not seen by either service and was not taken to a developmental assessment in 2006. In 2010, Pembrokeshire Council were alerted to the fact that Dylan and his 14 brother were being home educated but the boys’ parents denied professionals access to the children. 11.12 Child S came into the country with SL and apparently travelled with her from London to Birmingham. Child S did not come into contact with any childcare agencies in Birmingham at any time. Child S will have been known to a travel company and to the border agencies in the Czech Republic and England if Child S had travelled legitimately with SL from the Czech Republic; it has been suggested that they travelled by aeroplane. 11.13 The House of Lords European Union Committee has considered the situation of unaccompanied migrant children in the EU. It heard that at least 10 000 unaccompanied migrant children are missing in the European Union. The term ‘unaccompanied minor’ describes all foreign nationals below the age of 18 who either arrive in the EU unaccompanied by a responsible adult or who are left unaccompanied after their arrival.’ 11.14 Child S’s presence in Birmingham was known to some people in the local community and to family and friends who saw, and some discussed, the injuries he suffered on Facebook. An obvious question for this Review to consider is why no adult alerted the authorities when concerns about the care of Child S emerged. TL was concerned that the authorities might intervene and remove her child if they were aware of the injuries to Child S and the care Child S was receiving. It is not clear how the other Czech people living in Birmingham who knew Child S viewed local agencies but they either did not think of informing the authorities or rejected such a course of action. (This is considered further on page 16). The role of the Border Force 11.15 Border Force is a law enforcement command established in March 2012 and situated within the Home Office. It secures the UK border by carrying out immigration and customs controls at 140 sea and air ports across the UK and overseas to facilitate the legitimate movement of individuals and goods, whilst preventing those that would cause harm from entering the UK. This work clearly presents challenges. The service held no information about the arrival of SL or Child S into this country or SL’s departure without Child S. Health care in the Czech Republic and in England 11.16 Child S’s circumstances in the Czech Republic and the move to England were not known to agencies in England prior to Child S’s death. Child S had been routinely monitored by a paediatric GP in the town Child S was born in and had missed an appointment thereafter Child S moved to England. 11.17 Child S was not registered with a GP and had no contact with any health agencies in Birmingham. Although SL talked on at least one occasion about taking Child S to Accident and Emergency, Child S was never taken to hospital. 15 11.18 MH did not register with a GP in England. He told the Lead Reviewer that health care appointments were free in the Czech Republic but, as in England, medication had to be purchased. He stated that he did not seek any medical advice or treatment for himself in England but did attend some ante-natal appointments with TL. 11.19 TL registered herself with a GP and SH had regular contact with a Health Visitor at the local clinic. SH was seen for a new born screening on 26 March 2014 and for a 6 to 8-week old assessment on 13 June. SH was seen seven times at clinic between June and November for routine assessment, developmental monitoring and immunisations. TL did not make health professionals aware that Child S had joined her household and contacts at clinic provided at least five opportunities to do so. It is not clear if the Health Visitor asked about any changes in the family’s circumstances. It appears unlikely that TL would have volunteered any information about Child S if she had been asked. Working with fathers and male partners 11.20 MH told the Lead Reviewer that he had attended ante-natal appointments with TL. The Heart of England Foundation Trust have confirmed that MH had been used as an interpreter when TL was an inpatient on the Delivery Suite during the birth of her baby. 11.21 There was very limited contact with MH by health professionals but it is reasonable to expect that his presence at appointments or during home visits would have been routinely recorded and possibly that it could have been established if he was registered at a GP practice. The treatment of Child S by TL and MH: The meaning of the child 11.22 The circumstances in which Child S died are distressing and difficult to comprehend. It is striking how often TL and MH and others refer to Child S by gender only (not referring to Child S’s actual name) in their references online after mother had abandoned Child S in Birmingham. For example, TL sent the following messages: ‘why are you writing to (X) and telling her that I’m beating up the child’. ‘the child wakes up crying because he is hungry and (MH) shouts at them’. 11.22 The Lead Reviewer acknowledges that there may be a cultural dimension to the language used or an issue with translation but there were clearly issues around the relationships between TL and Child S and particularly MH and Child S. 11.23 In their books Beyond Blame (1995) and Lost Innocents (1999), Reder and Duncan highlighted and developed the concept of ‘the meaning of the child.’ They wrote: ‘some children in the household had been at greater risk of abuse than others because they acquired a particular psychological significance for their caretaker(s). It was as though the children acquired an undeclared script 16 or blueprint for their life that submerged their personal identity and characteristics and the meaning came to dominate the parent [carer]- child relationship.’ 11.24 The meaning of the child includes ‘conscious and unconscious determinants of the parent’s [carer’s] attitudes to, feelings about and relationships with the particular child’. Note: the Lead Reviewer has added the text in brackets within these quotes. 11.25 Reder and Duncan went on to consider the meaning of a child to fathers and the Lead Reviewer suggests that this can be extended to male carers. They note ‘that ‘the child may be experienced as a ‘stranger’ competing with him for the mother’s [in this case it would be female carer’s] attention and giving him nothing emotionally in return.’ 11.26 SL’s view of Child S is not known. She had not been the primary caregiver for TL or AL for periods of their childhood. She came to Birmingham and allegedly abdicated responsibility for Child S’s care and then abandoned Child S with TL and AL. 11.27 TL and MH were left to care for Child S when AL returned to the Czech Republic. There is little evidence of any positive relationship between either TL or MH with Child S. SL had come to their home without invitation and they then struggled with the additional responsibility of caring for Child S. 11.28 Police investigating Child S’s murder reported that there were no pictures of Child S in the home and no appropriate children’s clothing for them. The Relevance of Religious Beliefs 11.29 There has been increasing awareness of child abuse linked to faith and belief in this country over the last twenty years. This is reflected in national guidance; Safeguarding Children from Abuse linked to a Belief in Spirit possession (DfES 2009) and the National Action Plan to tackle child abuse linked to faith or belief (DfE 2012). It follows a number of cases where parents, carers or relatives have sought to justify ill-treatment because of a belief in witchcraft or spirits. In the case of Child S, TL and MH apparently tried to blame ghosts or spirits for causing injuries and bruising. 11.30 Media reporting of the trial of MH and TL highlighted the references the couple made to ‘duch’ (a Czech word for ghost or spirit) in communication with others about the injuries to Child S. MH had allegedly talked about a neighbour saying that a woman and child had died in a fire in the flat in the 1980s. The couple also reportedly spoke about TL’s recently deceased grandmother. TL reportedly told people that there were ‘ghosts and spirits in the bedroom’ and that Child S was targeted because the child slept in a bed on their own. 11.31 The Lead Reviewer has not been able to discuss this issue with TL but MH has indicated that TL did not believe that this was the real cause of Child S’s injuries. The Police heard in the course of their enquiries that JL and other 17 people had told her that MH was responsible for the injuries to Child S and that she was naive for believing that such injuries had been caused by spirits or ghosts. Knowledge of the treatment of Child S within TL’s and MH’s wider family and social networks 11.32 A small number of family, friends and relatives observed bruising and injuries to Child S during visits to the family’s flat in November and December. TL and MH had told them that some of them were caused accidentally and as described above talked about spirits on other occasions. One friend had bathed Child S once in November and once in December and informed the Police that they did not observe any bruising on those occasions. TL also communicated with family and friends using private messages on Facebook. 11.33 She had a number of Facebook ‘friends’ including family members and friends amongst the Slovakian community in Birmingham. On 21st November 2014, maternal grandfather, asked TL what had happened to the child because he had seen photographic evidence of bruising on Child S’s face. He also agreed to TL and the children spending some time with him after visiting the flat. Also in November 2014, TL asked her sister AL (who was back in Slovakia) why she was telling people ‘I’m beating up the child’. Maternal grandmother also sent a message to TL asking ‘why are you beating the child up like that’. 11.34 It is not clear why the adults who were aware of the injuries to Child S did not report the matter to either the Police or Children’s Social Care or to Health professionals whom they had contact with. 11.35 Birmingham Safeguarding Children Board considered the issues of community trust in public services and community engagement raised in the Serious Case Review completed in 2010 following the death of Kyra Ishaq. The review noted the great diversity of the population within the community where Kyra’s family lived and also reports that many residents, particularly those who have arrived recently from other countries, (were) fearful and mistrusting of engagement with authority figures at any level. The Review recommended that ‘The Children’s Trust in conjunction with the Birmingham Safeguarding Children Board should initiate an education campaign with supporting literature, to build public trust and confidence in ways to effectively safeguard and protect other people’s children’. It also suggested engagement at a community level and particularly with the younger members of the various communities. The review’s author highlighted the potential role of nurseries, crèches, playgroups, community health and schools and proposed that the production of key community safeguarding messages in a range of languages for adult audiences, which young people could reinforce, may be beneficial. Birmingham Children’s Trust and Safeguarding Children’s Board oversaw a public awareness campaign in 2011 in response to these recommendations. A campaign evaluation report was to be shared with the Children’s Trust and Birmingham Safeguarding Children Board but no information has been provided to this Review; this calls into question the progress made. 18 Housing and Finances 11.36 MH described the accommodation that he and TL lived in as poor. He had had an argument with his landlord about a failure to make improvements and rent arrears during a home visit from the Midwife who was visiting his child. 11.37 MH told the Lead Reviewer that a friend had helped him to navigate the benefits system. MH had received Housing Benefit, Jobseeker’s Allowance, Child Benefit and Tax Credits. 11.38 On 1 January 2015, there was very limited food in the flat and the fridge freezer was broken. Language and communication 11.39 The Heart of England NHS Foundation Trust have reported that records do not state whether an interpreter was used at the initial booking appointment. An interpreter was booked for the 2nd antenatal clinic appointment; however, TL did not attend this appointment. The interpreter was used instead to relay information to her by telephone from the clinic and inform TL of her next appointment. There are no further entries which suggest an interpreter was used again. 11.40 Staff had used MH as an interpreter when TL was an inpatient during the birth of their child. There is a current discussion at the hospital re using partners to interpret at this point given that this is a personal time and there is a view that it is not appropriate for strangers in the room or to use telephone interpreting at this time. 11.41 MH told the Lead Reviewer that there were no offers of interpreters by health professionals and no information offered in their first language. He spoke a little English when they first moved to England and his English has steadily improved; TL could not speak any English when they first moved. 11.42 There has been no indication by the Health Trusts involved with SH that TL and MH received any written information about local services in their first language. Communication between agencies in different countries 11.43 The issue of communication between Children’s Services in England and their equivalent services in other countries was considered by the Victoria Climbie Inquiry. It was only following Victoria’s death that it was established that ‘she was known to French Social Services and Victoria’s school in Paris had registered a Child at Risk Emergency Notification with the French education authorities on 9 February 1999, because of Victoria’s repeated absences from school’. The Climbie Inquiry recommended that Directors of Social Services must ensure that social work staff are made aware of how to access effectively information concerning vulnerable children which may be held in other countries. 19 11.44 There is a well-established procedure and alert system in England to implement when a child or children subject to child protection enquiries or a child protection plan goes missing from a Local Authority. Custodians of lists of children subject to a child protection plan and lead health professionals are informed when these children go missing. There is also newer guidance, Working with Foreign Authorities (Department for Education July 2014), in respect of communication with other countries when social workers are working on child protection cases or with children subject to care proceedings or orders. Communication with Embassies is recommended when children are made subject to care proceedings or child protection plans and also liaison through the International Child Abduction and Contact Unit (ICACU) when a child moves to another country or a placement abroad is being considered or proposed. 11.46 Birmingham Council and its partners did not receive any communication or information about Child S from the Czech Republic. This Review has provided an opportunity to consider what additional specific procedure or guidance may have been available to workers if any request for information or intervention had been made. The Association of Directors of Children’s Services has highlighted Lincolnshire Local Safeguarding Children’s Board procedure on Cross Border Child Protection Cases under the Hague Convention as an example of good practice because it also includes a section on handling requests for assistance from other contacting States when they are made. Birmingham Safeguarding Children Board procedures currently include a section of practice guidance about Children and Families moving across Local Authority borders. Birmingham Children’s Services internal procedures include a link to the Department for Education (DfE) 2014 Working with Foreign Authorities guidance but not to the DfE 2012 guidance about Cross-border child protection cases: the1996 Hague Convention. 12. Conclusions and Lessons Learned 12.1 Child S suffered extensive and fatal physical abuse and neglect when he was abandoned by his mother and left alone in the sole care of TL and MH. These adults had had involvement in Child S’s care for three months by this time, but had not agreed to be the child’s carers. MH has described considerable tension between the adults in the home following mother’s and Child S’s move to Birmingham. Health professionals had no concerns about TL and MH’s care of their own child but, with hindsight, it is clear that there was domestic abuse and paternal substance misuse which is likely to have compromised the parenting of both children. The couple lived in poor housing and had very limited finances. 12.2 As the House of Lords 2016 report states, all children needing protection have the legal right to receive it regardless of immigration status, citizenship or background. Dorling’s report for the Coram Children’s Legal Centre in 2013 about the rights of undocumented migrant children in the UK noted that ‘Many undocumented children are brought into the UK by a parent or guardian…. Some come to the UK, lawfully when they are very young…. In some cases, 20 family relationships may break down, leaving children abandoned and left to be taken into the care system’. Agencies in Birmingham were not afforded the opportunity to safeguard or promote the welfare of Child S as they were never aware that he was living in the city. There was no professional involvement with Child S for this Review to consider. 12.3 This case highlights the considerable challenge to child care agencies presented by international migration particularly when parents and carers, extended family members and members of the community do not understand how to, or choose not to, engage with professionals. The mobility of children and families between countries in Europe has been the subject of considerable national discussion as has the increased international migration of people around the world as a consequence of global events in the last few years. 12.4 Child S had spent time following birth living away from SL in state care in the Czech Republic whilst she was expected to address her substance misuse. This Review has not received any information about the quality of the assessments undertaken in respect of Child S and SL . Child S was also the subject of private law proceedings in the Czech Republic and the application for custody by a putative father was rejected. It is clear that agencies in the Czech Republic had expected SL to cooperate with them and to make herself and Child S available for appointments. There has been no information presented to this Review to suggest that Child S was subject to any formal child protection planning process or legal status when taken out of the country by SL. If the Czech authorities had shared the reports that Child S had moved to England and their concerns about Child S’s care with agencies in England, there is no guarantee that professionals in Birmingham would have been able to establish contact with Child S; however, a request could have been made for the Police to make enquiries with the half-sisters if information had been provided about them. 12.5 Routine health services were provided to TL and her child. This case serves as a reminder that family and home circumstances change and that it is important for professionals to periodically ask about any changes. It also highlights the mistrust of professionals by some parents and carers and members of the community and the fact that some families will actively avoid information sharing or contact with professionals who wish to support families and safeguard children. 12.6 Agencies in Birmingham have been attempting to build links with the diverse range of communities in the city to promote safe parenting and child protection for a number of years. The Lead Reviewer recognises the difficulty of evaluating any campaign by a Safeguarding Children Board to convey safeguarding messages to, and to influence the behaviour of, members of the community and also that due to the changes in our communities that any such exercise would need to be repeated periodically. 21 Learning Points 12.7 This Review has highlighted a number of learning points for the Birmingham Safeguarding Children Board to consider further and to highlight through internal agency and LSCB multi-agency safeguarding training: 1. The absence of any reference in local procedures or the current version of the Working with Foreign Authorities guidance to circumstances when child protection enquires have been recently undertaken or are ongoing in respect of children moving countries or recognition. Any future revision of the guidance could usefully acknowledge that good communication and joint working are important in these situations as well as when implementing child protection plans. 2. The importance of using interpreters when working with parents, carers and children whose first language is not English to ensure understanding and informed consent. 3. The need to provide information in a number of languages and to consider translation when introducing leaflets particularly for new arrivals to the country. 4. The complexities and challenges of international migration for work with families and safeguarding children. 5. The work still required to address the lack of knowledge or trust of professionals and services within migrant families and communities. 6. The importance of professional curiosity and potential value of periodically enquiring about any changes in a child or family’s circumstances. 7. The need to identify fathers and include information about them in assessments and records. 8. The key roles of the Home Office, Immigration and Visa Service and Border Force and the contribution they can make to assessments of migrant and asylum seeking children and families. 9. The importance of community engagement and the potential for future LSCB campaigns and evaluation reports to encourage discussion and understanding about the early help offer in the city and child protection referral processes and the tragic case of Child S. Birmingham Safeguarding Children Board will consider the actions necessary to take forward the learning from this Review. Jim Stewart Lead Reviewer 28 February 2017 22 Appendices Terms of Reference BIRMINGHAM SAFEGUARDING CHILDREN BOARD TERMS OF REFERENCE SERIOUS CASE REVIEW Date of birth: 2013 Date of death 01.01.2015 The Chair of Birmingham Safeguarding Children Board confirmed to the Lead Reviewer on 23 February 2016 that the terms of reference are to: 1. Review everything that is known from the case records about Child S until the point of Child S’s death 2. Review everything that West Midlands Police are prepared to release pertinent to the investigation and subsequent legal processes that may add learning in relation to Child S. 3. Address the following questions: a. Why was Child S never recorded as entering the country, if it can be established b. Identify what, if anything, is required of migrants from Eastern Europe entering the UK in relation to their children c. Establish whether there is any advice provided to migrants in relation to their children in terms of registration with the NHS through a GP and school attendance requirements, nationally or by any agency in the city d. If provision exists, how migrants are identified to initiate this provision. e. Establish whether the criminal investigation identified whether there were any referrals, queries or concerns made by neighbours, those using social media, or professionals about Child S. f. Establish whether there is anything to be learnt about the actions or absence of actions by public sector services in relation to Child S. g. Establish from police records whether any learning in relation to Child S about how agencies worked together to safeguard children. h. Identify potential ways to apply that learning for the Council, the Birmingham CCG’s, West Midlands Police, Border Force, housing providers, other Government Agencies and National Government i. Prepare a report for publication on Child S, which forms part of a larger publication in relation to Child S and another case. 23 j. Utilise any themes arising from Child S as part of a wider short thematic review of the needs of migrant eastern European children coming to live in Birmingham 24 B. Bibliography Birmingham Council/ BDP Service Development Team, Planning and Regeneration - International Migration in Birmingham 2012-13 (2015/01) Birmingham Health and Wellbeing Board - An overview of the Joint Strategic Needs Assessment for Birmingham (2012) Coram Children’s Legal Centre/ Dorling K - Growing up in a Hostile Environment: The rights of undocumented migrant children in the UK (November 2013) Department for Education - Cross-border child protection cases: the1996 Hague Convention Departmental advice for local authorities, social workers, service managers and children’s services lawyers (October 2012) Department for Education - Working with foreign authorities: child protection cases and care orders Departmental advice for local authorities, social workers, service managers and children’s services lawyers (July 2014) EU Migration to and from the United Kingdom – The Migration Observatory/University of Oxford (October 2015) House of Lords European Union Committee - Children in crisis: unaccompanied migrant children in the EU HL Paper 34 (July 2016) National Institute for Health and Care Excellence – Pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors. NICE Clinical guideline CG110 (September 2010) Ofsted - Ages of concerns: learning from Serious case reviews (October 2011) Reder P, Duncan S and Gray M - Beyond Blame Child Abuse Tragedies revisited (1993) Reder P and Duncan - S Lost Innocents A follow-up study of fatal child abuse (1999) Research in Practice – Confident practice with cultural diversity: Frontline Briefing (July 2015) University of East Anglia/NSPCC/ Brandon M, Bailey S, Belderson P and Larsson B Neglect and Serious Case Reviews (January 2013) Websites Ministry of Labour and Social Affairs of the Czech Republic International Child Abduction and Contact Unit 25 C. Acronyms BSCB: Birmingham Safeguarding Children Board DfE: Department for Education DfES: Department for Education and Skills ICACU: International Child Abduction and Contact Unit (ICACU) JSNA: Joint Strategic Needs Assessment LSCB: Local Safeguarding Children Board |
NC046492 | Rape of a 15-year-old girl in early spring 2014. Child R, who was in foster care at the time of the assault, reported that she had met the man in a hotel after a friend gave him her telephone number. The man involved was arrested and found guilty of a lesser offence against another young person. Child R was born in her mother's home country and remained there in her grandmother's care until moving to London to live with her mother and siblings around 2007. Family had been known to police and children's social care since 2002, following referrals concerning criminality in the household, drug-dealing and child neglect. Child R was made subject to a child protection plan in 2009 under the category of physical abuse. Child R requested to be taken into care in 2010, after reporting that her mother had beaten her; Child R's siblings were taken into care shortly after. Whilst in care, Child R had periods of: going missing, highly disruptive behaviour, multiple placements and exclusions from school. Issues identified include: lack of professional knowledge and understanding of Child R's history and vulnerabilities; Child R's lack of engagement with and mistrust of professionals; and repeated failure by professionals to find her a suitable long term placement. Uses the Welsh Model for case reviews. Makes recommendations including: police and children services to explore options for keeping children safe in emergency situations; and looked after children's reviews should identify a named person who is best placed to communicate the child's wishes and feelings.
| Title: Serious case review report: Child R. LSCB: Southwark Safeguarding Children Board Author: Sally Trench Date of publication: [2015] This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. SOUTHWARK SAFEGUARDING CHILDREN BOARD Serious Case Review Report Child R Author: Sally Trench Independent Lead Reviewer 2 CONTENTS 1. Circumstances that led to this Serious Case Review 4 2. Terms of Reference and the Welsh Model 4 3. Family History 9 4. The Review Period (February 2012 to April 2014) 11 5. Practice and Organisational Learning 13 A. Ascertain whether previous relevant information or history about the child and/or family members was known and taken into account in professionals’ assessment, planning and decision-making in respect of the child, the family and their circumstances. Establish how that knowledge contributed to the outcome for the child. 13 B. Evaluate whether the care plan was robust, and appropriate for R, the family and their circumstances 18 C. Ascertain whether the plan was effectively implemented, monitored and reviewed and whether all agencies contributed appropriately to the development and delivery of the multi-agency plan 18 D. Identify the aspects of the care plan that worked well and those that did not work well and why. Identify the degree to which agencies challenged each other regarding the effectiveness of the care plan, including progress against agreed outcomes for the child. And whether any protocol for professional disagreement was invoked 18 E. Establish whether the respective statutory duties of agencies working with the child and family were fulfilled 27 F. Identify whether there were obstacles or difficulties in this case that prevented agencies from fulfilling their duties (this should include consideration of both organisational issues and other contextual issues) 27 G. How well did professionals understand and manage the different risk factors influencing this case and the particular vulnerabilities of R, during the two years under review? 31 H. Review of the application and use of children missing from home and care protocol 31 I. How well did professionals hear the voice of the child in their work with R? And to what extent were her unique diversity needs met by services? 38 J. Review of the application and use of the e-safety policy in this case 40 3 References 44 Glossary 45 Appendix 1: Terms of Reference 46 Appendix 2: Genogram 51 4 1. Circumstances that led to this Serious Case Review 1.1 R is a 15-year old girl, who came into care aged 10, and has been looked after by the London Borough of Southwark for the past 4 ½ years. She lives with foster carers in Greater London and attends school locally. In early spring 2014, R was invited to meet an older, predatory male at a hotel, where he allegedly raped her. The antecedents of this meeting remain uncertain, but R said that a friend of hers had given the man her telephone number, so that he could contact her. The alleged assault was reported by R to her carers the same day, and police action was taken to find and arrest the man. A criminal investigation and court process have now concluded, in which the perpetrator was found guilty of a separate, lesser sexual offence against another young person. The offence of rape against R remains untried, but is held on the man’s records as a not-guilty plea. 1.2 Southwark Safeguarding Children Board (SSCB) decided to undertake a Serious Case Review (SCR), as the following criteria had been met: (a) abuse or neglect of a child is known or suspected; and (b) (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.1 2. Terms of Reference and the Welsh Model 2.1 The SSCB drew up its terms of reference for this SCR in April 2014, and circulated them to the DfE and Board agencies. They outline the model and process to be used for the SCR, the agencies involved, the learning areas to be addressed, and expectations about completion and publication of the report. (The full terms of reference are attached as Appendix 1.) 2.2 The Welsh Model for case reviews 2.2.1 The ‘Welsh Model’ refers to Welsh Government guidance for multi-agency ‘child practice reviews in circumstances of a significant incident where abuse or neglect of a child is known or suspected’.2 1 Working Together to Safeguard Children, 2013, and Local Safeguarding Children Boards Regulations, 2006 (Regulation 5) 2 Protecting Children in Wales – Guidance for Arrangements for Multi-Agency Child Practice Reviews, The Welsh Government, January 2013 5 It is intended to be used in conjunction with Working Together, 2013. The model can be used for all levels of case reviews, including SCRs. The emphasis is on promoting ‘a positive culture of multi-agency child protection learning and reviewing in local areas, for which LSCBs and partner agencies hold responsibility’.3 2.2.2 In a shift from the approach in traditional ‘Part 8’ SCRs, this model focuses on the involvement of agencies, staff and families ‘in a collective endeavour to reflect and learn from what has happened in order to improve practice in the future, with a focus on accountability and not on culpability’.4 Other key features include: • A more focused, streamlined process with a shorter time period to be reviewed • Consideration of the context in which professionals work in agencies, including ‘culture’, policies and procedures, and resources • A Learning Event for all those involved in the case • Exploring not only what has happened, but why • Recommendations and actions to improve future practice 2.3 Individual Management Reviews 2.3.1 The SSCB requested Individual Management Reviews (IMRs) for this SCR, as well as a comprehensive multi-agency chronology. Both of these are features of the ‘Part 8’ methodology under the previous Working Together (2010). As a consequence, this SCR is a ‘hybrid’ of two models for case reviews. The IMRs have produced extensive data from agency records about their activities in the two-year review period. The IMR authors, who are independent of management responsibility for this case, have also interviewed staff, with a particular emphasis on avoiding hindsight, instead trying to get a feeling for what it was like working with the young person at the time, and what was the context for their work. The scope and quality of the data have resulted in a longer Overview Report than would normally be the case for a Welsh Model review. 3 Ibid, Para 1.3 4 Ibid, Para 1.4 6 2.4 Time frame for review The Welsh guidance recommends a review period of no longer than two years. This is so that the learning is about recent, rather than historical, practice, procedures and agency circumstances. In this case, the time span chosen was just over two years: 1st February 2012 to 27th March 2014 This allowed the SCR to include an ‘unsettled’ period of placement disruptions, as well as the two subsequent longer and more stable foster placements. The end point of the review, just after the alleged sexual assault, was extended briefly to include initial agency actions in response to the incident. A Summary Timeline of significant events was made. 2.5 Practice and organisational learning areas 2.5.1 The Welsh guidance offers a set of generic practice areas for exploration and analysis, and these have been adopted by the Board for this review: • Ascertain whether previous relevant information or history about the child and/or family members was known and taken into account in professionals' assessment, planning and decision-making in respect of the child, the family and their circumstances. Establish how that knowledge contributed to the outcome for the child; • Evaluate whether the care plan was robust, and appropriate for R, the family and their circumstances; • Ascertain whether the plan was effectively implemented, monitored and reviewed and whether all agencies contributed appropriately to the development and delivery of the multi-agency plan; • Identify the aspects of the care plan that worked well and those that did not work well and why. Identify the degree to which agencies challenged each other regarding the effectiveness of the care plan, including progress against agreed outcomes for the child. And whether any protocol for professional disagreement was invoked; • Establish whether the respective statutory duties of agencies working with the child and family were fulfilled; • Identify whether there were obstacles or difficulties in this case that prevented agencies from fulfilling their duties (this should include consideration of both organisational issues and other contextual issues).5 5 Ibid, Para 6.15 7 2.5.2 Further relevant questions were identified by the SSCB in relation to the individual case: • How well did professionals understand and manage the different risk factors influencing this case and the particular vulnerabilities of R, during the two years under review? • How well did professionals hear the voice of the child in their work with R? And to what extent were her unique diversity needs met by services? • Review of the application and use of children missing from home and care protocol and e-safety policy in this case. 2.6 Lead Reviewers 2.6.1 There are two external Lead Reviewers for this SCR, both independent of Southwark. Sally Trench has a background in local authority mental health social work and children’s social care, principally child protection. She is the author of many Serious Case Reviews, and has also chaired SCR Panels. She has been trained in traditional ‘Part 8’ SCRs and in the Social Care Institute for Excellence systems model ‘Learning Together’. Victoria Philipson has a background in local authority children and families social work, also principally child protection. She was a regional director for Cafcass, where she completed a number of Individual Management Reviews. She has been trained in conducting traditional SCRs. 2.7 Review Panel 2.7.1 This is made up of senior representatives of the agencies who were involved in the case. The names/roles listed below comprise the membership of the Review Panel for this SCR. Name Role Pauline Armour Head of Service: Early Help (interim), Education, Southwark Children and Adults Services Jackie Cook Head Of Social Work Improvement & Quality Assurance, Children’s Social Care, Southwark Registered Manager & Head of Compliance & QA Independent Fostering Agency Ann Flynn Southwark Safeguarding Children Board (SSCB) Development Manager Tina Hawkins Senior Administrator, SSCB Ros Healy Designated Doctor Safeguarding, Guy’s and St Thomas’ NHS Foundation Trust (GSTFT) 8 Mark Hine Detective Inspector, Child Sexual Exploitation Team, Metropolitan Police Interim Service Manager Safeguarding, Quality Assurance and Learning Development, Greater London Children’s Social Care Gwen Kennedy Director of Quality and Safety for Southwark Clinical Commissioning Group Russell Pearson Specialist Crime Review Group, Metropolitan Police Child Protection Manager Children’s Charity Debbie Saunders Head of Safeguarding Children Nursing, GSTFT 2.7.2 ‘The Review Panel manages the review process and plays a key role in ensuring the learning is drawn from the case’.6 In this instance, the panel have worked with Lead Reviewers, to read and review the relevant documentation and analyse the material from the integrated chronology and the IMRs. The learning generated from the panel was considerably enriched by its mixture of representatives from core statutory services, and private and voluntary organisations. Panel members are also responsible for supporting members of their agency to take part in the learning event. 2.8 Learning Event A full-day learning event in early September 2014 was attended by over thirty professionals involved in this case, as well as the Independent Chair of the SSCB. The day was used to gather their information and views, via multi-agency small group discussions. Written feedback from the participants reflected a general appreciation of the opportunity to reflect on the case with colleagues from across agencies. In response to the question ‘What did you find useful about today?’, here are two representative comments: • Being able to hear the different perspectives from the agencies involved. Being able to reflect on one’s own practice – how I can improve it. It enabled discussion without looking at blame in that gaps could be identified. It also allowed for reflection on how everyone can improve. • Being able to discuss with different agencies and colleagues openly and honestly the difficulties and challenges around LAC and Child R in particular. We are all saying the same thing but implementing it is the problem. Finance/IT Systems/ geography being some of the issues. Attendees were also asked to contribute ideas about ‘key messages’, and how to implement the lessons from this SCR. Their feedback was valuable, and demonstrated how multi-agency learning can be generated by such an event. 6 Ibid, Para 5.20 9 2.9 Involvement of family members R and her mother have been informed about this SCR. R has been invited to give her views about the services she received in the review period, and any other messages she would like the Review Panel and Lead Reviewers to have from her. So far, she has not wished to participate. This means that a significant avenue for learning is missing. 3. Family history Family member Address Mother London Father Abroad Subject R Foster placement, Greater London Older sibling London Half-sibling Foster care Half-sibling Foster care Half-sibling Foster care Maternal Grandmother Lives abroad/visits London Members of the family have settled in the country at different times. Child R and her older sibling lived abroad until she was about 8 years old. At a later date the maternal grandmother settled in this country A genogram is attached as Appendix 2. 3.1 Little is known of R’s father. Child R and her older sibling were born in their mothers home country. R was left there in the care of her maternal grandmother as a baby, when her mother came to live in London. The family was fully reunited in this country by about 2007, with three younger half-siblings also being born during this period. 3.2 From 2002: The family had no secure housing or finances in London, and often stayed with other relatives or friends. This meant that they moved a lot, resulting in instability for the children. Both Police and Children’s Social Care (from 2002, when Mother’s first child initially arrived in the UK) received referrals about criminality in the household, largely related to drug-dealing and other acquisitive offences, and neglect of the children. R was the main target of her mother’s abuse, which included emotional rejection and physical assaults. She was neglected and left in charge of her younger siblings; she was exposed to many adults who could have posed a risk to her. 10 R was made the subject of a Child Protection (CP) Plan in 2009. She ran away early in 2010, asking to be taken into care because her mother had beaten her. Her siblings were removed shortly after this, and all the children have been looked-after under Care Orders from that point onwards. 3.3 From 2010 (R’s entry into care): (NB, This summary does not include further information about the other children of the family, save to say that the younger children remain looked-after and are in long-term foster care. R’s older brother is a care-leaver and lives independently in London.) R has had an unsettled time in terms of placements, experiencing eight moves in care. There was a stable placement (spring 2010 to late summer 2011), which was followed by a period of highly unsettled behaviour and placement disruptions. In addition, R has now had a total of ten allocated social workers. R was well supported for the move from primary to secondary school, and she did well in Year 7. A subsequent dramatic deterioration in her behaviour, both in school and in non-compliance with her foster carers, seems to have been prompted by reconnection with her mother and maternal grandmother, who arrived in the country in this period. School staff reported that R began Year 8 presenting and behaving in an entirely different way. Throughout the rest of 2011 and into 2012, she went missing from her foster carers on a regular basis, and her defiant and provocative behaviour in school gave rise to concerns about her vulnerability to sexual exploitation and to ‘gang activity’. R was subject to an increasing number of fixed-term exclusions from school. R’s contact with her family – Mother, Grandmother and siblings – has been fragmented and at times entirely absent. This may be because she was, initially at least, blamed for all the children coming into care. However, especially during 2011, when her grandmother arrived in the UK, R began to return to her mother’s home on a regular (but unregulated and unsupervised) basis. She continued to decline the proposed arrangements for contact with her younger siblings. At the point where this case review begins, the school had made a complaint about the persistent lack of response from CSC to their concerns, in what appeared to be a breakdown in communication. R had had three disrupted placements, and one planned move, in the previous six months. 11 4. The Review Period (February 2012 to March 2014) A brief narrative 4.1 At the beginning of 2012, R was in her 4th foster placement since coming into care. All of these had thus far been within Southwark, and this meant she did not have to change schools. R was going missing on a regular basis from her foster home, and was often out very late – sometimes being dropped off by an older man. Details of her time out of placement were unknown, but it was believed that R was spending regular time at her mother’s home, and/or staying out with friends. She had a poor relationship with her single foster carer. 4.2 After a placement breakdown in late February, a similar pattern developed in another local foster placement, with a couple. In addition, R’s disruptive behaviour at school meant that she was at risk of a permanent exclusion. The school’s concerns about the apparent risks to R – and her own risk-taking behaviour – led them to press CSC for a decision to move her away from London for her own protection. This move eventually happened, via another placement breakdown, in the summer of 2012. 4.3 R was next placed with white foster carers in a shire county, provided by the Independent Fostering Agency (IFA). This was R’s first trans-racial placement. Shortly after this move, the carers’ pre-arranged holiday meant that R was required to go for a fortnight to respite carers. She refused this move, and instead absconded to stay with her mother – as it transpired, for five weeks. Mother and daughter now insisted that they both wished for R to be discharged from care. An assessment to this end was considered by the local authority, but they argued that R should first be returned, via a Recovery Order, to her new foster carers, followed by an assessment of the viability of R returning to her mother. The Judge in these proceedings granted the Recovery Order, but also recommended that the LA find the means to move R closer to home. 4.4 At this time, Mother stated her intention to make an application to discharge the Care Order. This plan did not in fact transpire, and R stayed in her 6th placement without further disruption for two school terms (until April 2013), with only one further missing overnight episode, early on. She attended local school and appeared generally to settle well, and her foster carers supported her to make some local friends. Her relationship with her foster carers and their family improved and she did not continue to go missing. Contact with her family and home area was infrequent, at her own request. 12 At R’s LAC Review in February 2013, R had written down her wishes and feelings, at the encouragement of her foster carers. She said she was ‘unhappy with her life’ and again expressed her wish to return to her mother, or at least move nearer to her. However, she did not want to have ‘supervised’ or organised contact with her (this was proposed as weekly). In April 2013, R went missing for a week, during which time she apparently stayed, or based herself, with her mother in Southwark. Upon her return to her foster carers, she made an allegation of physical ill-treatment against the female carer (later retracted), which prompted the end of the placement. R was moved to her current foster carers, in Greater London; this is also a trans-racial placement, provided by the same IFA. 4.5 R has remained in this same placement since that time. She attends a local secondary school, and has until recently used a Children’s Charity in her familiar part of Inner London once a week. Her school attendance and performance are good, as are her behaviour and general responsiveness in her foster home. It is clear that R has a solid and positive relationship with these carers – the main carer being the male of the couple. Up to March 2014: Despite the stability that developed in this placement, R continued to stay out later than allowed on a regular basis, and went missing overnight on 12 occasions, once remaining absent for two nights. Her carers continued to work with her on keeping herself safe, and informing them of her whereabouts. However, in this placement, as in all others before, R remained unwilling to disclose any details about the identity of her friends, or about where she goes when she is missing. Thus, the risk of harm to her has remained unknown, and possibly very high – especially in light of the incident which led to this SCR. 4.6 In early spring of this year, R missed school – something which was entirely out of character for her – and agreed to go to a hotel to meet an older man, someone she didn’t know. Reportedly, he had telephoned her and said he had got her number from a friend of hers. They met in a hotel, where he was said to have raped her. During this encounter, R made telephone contact with her foster carer, who notified the police; both foster carer and police spoke to R on her mobile phone whilst she was missing, and to the taxi driver who brought her home, thus retrieving some details about where R had been. The police were able to identify the man and to arrest him within the next 3 days. (The details of how the man knew, or knew about, R and how he made contact with her have not been verified and remain unclear to the Review Panel. R has declined to talk to anyone about this.). R was persuaded by her foster carers later that same evening to attend one of the Haven centres for the victims of sexual assault; she was seen and interviewed by staff there, but did not agree to full forensic examination. 13 The following day, R did not attend school, but did leave the foster home for several hours, from the afternoon through early evening. She stated this was because she did not want to undergo further questioning by the police. The same happened the next day, when R was out and not at school. Police were able to establish that the alleged perpetrator had been in telephone contact with her, and had put pressure on her not to talk to Police. Thus, she was at risk of witness intimidation, if not other threats to her safety. When she returned home on that second day, the Police determined that she could not be kept safe in this placement. They had considerable concerns for her wellbeing (especially because the alleged perpetrator was not yet in custody). Thus it was decided that Police should exercise their Powers of Protection, by removing R from the foster home to the police station, and proposing that she should be placed in Secure Accommodation. This was not agreed by the LA, and she was returned the following day to her foster carers. A Strategy Meeting was held to consider the investigation of the alleged sexual assault, as well as how to promote R’s ongoing safety. R had spent the night in the police station (not in a cell, but in a communal area). The LA emergency duty team were able to send a social worker to be with her through the night. Both R and her foster carers had asked for the male foster carer to accompany her to the station, but this was not permitted. The reasons for this prohibition have not been explained within the Police IMR. 5. Practice and organisational learning A. Ascertain whether previous relevant information or history about the child and/or family members was known and taken into account in professionals’ assessment, planning and decision-making in respect of the child, the family and their circumstances. Establish how that knowledge contributed to the outcome for the child. 5.1 What historical records and knowledge were available? Mother moved to the UK in 1999, but most services, apart from the Police, had no contact with her and the family until 2002. At that point, R’s older sibling came to join his mother in London; this led to serious concerns about his welfare, due to his exposure to criminality and drug activities in her household. CSC intervened, firstly to accommodate him, and then to return him to his maternal grandmother when she was living abroad. Details of R’s developmental and care history from birth in 1998 to 2007 (care given by her maternal grandmother when she was living abroad) have not been recorded in any agency files and remain largely unknown. By 2007, there were younger children in the family, when R and her older brother were reunited with their mother. 14 From this point, the family were known to universal services in London (schools, health), and to CSC and Police because of intermittent CP referrals, investigations and assessments. In 2009, there were reports relating to Child in Need Plans (for the younger siblings) and the CP Plan for R. The Police have records regarding raids on the various households where Mother lived, and charges against her and her partner(s) for a variety of offences, mainly to do with dealing in drugs and theft. 5.2 As often happens, the care proceedings in 2010/11 required the preparation of specialist assessments. In this case, a very full psychiatrist’s report was especially useful in that it captured previously unknown information about the family history, obtained directly from the mother, grandmother, and children. It also highlighted the psychiatrist’s assessment of R, and the impact of the abusive care she had experienced, as well as her exposure to other traumatic experiences as a young girl – e.g., being used to prepare and deliver drugs to customers, witnessing adult violence, and being left alone to care for her younger siblings. Anyone reading this report, and the judge’s use of it in his final judgement, can be left in no doubt about the damage done to R and her degree of vulnerability (including to child sexual exploitation), as well as her need for therapeutic help. 5.3 What was known about R’s history, and how was it relied upon in making plans for her? This question will largely be answered in relation to CSC, where most of the relevant history was recorded and kept. The importance of records was particularly significant, because R was, and continues to be, reluctant to talk openly about her past and her family. The CSC IMR found that the workers and managers directly responsible for R did not access the relevant records held by them which provide an account of her history. These included key documents: the earlier CP reports for CP conferences, the CP conference minutes, the assessments of R and her siblings, and the legal documents referred to above. As a result, R’s psycho-social history, her own and her family’s experiences, and the degree and nature of her vulnerability (including to child sexual exploitation) were poorly understood by those acting as her ‘corporate parent’, as well as by their multi-agency partners. This affected plans and decision-making, which in many instances appeared to be reactive rather than considered and based on knowledge of R’s complex needs. The social workers relied on the records of R’s recent LAC Reviews. These are essential documents, as they include the young person’s wishes and feelings, and details of the current care plan. However, they do not include a picture of the child’s history before coming into care, or the full journey in care. 15 5.4 In the view of the Review Panel and the Lead Reviewers, it is good practice for the allocated social worker to read and consider a child’s history, especially where that child is looked-after by the local authority. 5.5 Without this basis for his/her care planning, the LA and partners are unlikely to achieve the best possible outcomes for the child. Learning Point Knowledge of a child’s psycho-social history is essential for effective assessments and planning for children. Recommendation 1: CSC managers should use every opportunity (induction, supervision, training) to embed the requirement for the allocated Social Worker to read and understand a child’s history, and for the worker’s manager to prioritise and protect the time needed to do so. This message should be supported by guidance about key documents and the use of chronologies, to support better understanding of history and patterns. A means of monitoring whether this has been done should be put in place for all children who are subject to a Child in Need Plan, Child Protection Plan, or Care Plan as a looked-after child. Recommendation 2: The audit template for CSC cases should include a question about the consideration of personal/family history in assessments. 5.6 The Review Panel wanted to know whether not reading a child’s history had become accepted ‘custom and practice’, in a busy and pressured work environment. The responses we got suggested that, although this may have been an extreme example, it is not uncommon to work with a child or family without an informed and solid understanding of their history. (Other SCRs indicate that similar practice occurs very widely; this is not a Southwark-only problem.) Why should this be so? • Many paper files are archived, so there is a bureaucratic process, and some delay, involved in obtaining them. • A number of key documents have not previously been scanned onto the Southwark electronic system (CareFirst). This is now improving, with stronger administrative support in the new structure (Social Work Matters). 16 • Social Workers and their managers are very busy and may not prioritise reading the child’s history. 5.6 Specific team factors (The problems in the Looked-after Children Team, and their impact, are described here, but are equally relevant to several of the other questions posed by the SCR, in the following sections.) Severe difficulties in the Looked-after Children Team, during the time frame for this review, meant that their work was not carried out as it should have been. Sickness levels were high, and this included one of the two main social workers for R (allocated during 2012), who was off sick for a lengthy period, a practice manager (for several months in late 2012/early 2013) and a service manager (mid-2012). Overall, the team had a sickness rate of 20 to 25%. Perhaps not surprisingly supervision was irregular for the SWs working with R during 2012 and 2013. This inevitably compounds the difficulties for a worker, who has less opportunity to reflect on her cases and to receive managerial guidance and support to prioritise and complete tasks. The template for recording case supervision includes a question at the top of the page: ‘Have you reviewed the case records since the last supervision?’ In the records reviewed for R, this is consistently left blank by the supervisor, and again suggests a lack of the supervisor’s time for careful file review.7 As a ‘knock-on’ effect of absences in the team, R’s next allocated social worker was assigned an unrealistically high caseload – partly because she was covering cases for several absent colleagues – and was given insufficient guidance about what tasks she was expected to cover. There were no transfer summaries or full chronologies to support this additional work (See Para 5.14.6 below). To make matters worse, the team manager post changed several times during this same period, so that there was little continuity in the supervision and oversight of cases. Two of the acting managers were agency staff who were unfamiliar with Southwark. The Review Panel has not been told how or whether more senior managers took responsibility for assessing the risks to the team (staff and service users) during this extended period. The impact of staff sickness and serial changes of managers in the LAC Team (2012 and 2013) clearly affected the service provided to R, her carers and other partners – and no doubt others as well. But while these circumstances account 7 One other oddity is that several recordings, filed as ‘Supervision’ on CareFirst, contain a variety of different records, including emails, and minutes of meetings. This means that a list of ‘supervisions’ on CareFirst can mislead about the timing and number of actual supervision sessions with the worker to discuss the case. 17 for many of the lapses in practice, they do not suffice as an answer to ‘what went wrong’. The responsibility lies with the wider organisation to ensure that the highest priority statutory work continues to be carried out, even when services are under strain, and this clearly includes its duties towards looked-after children. All organisations must anticipate the times when – inevitably – any team may become highly vulnerable, as in this case. This can happen for a variety of reasons, the most common being high sickness levels, or an unexpected degree of turnover, in workers and managers (both were true for this team). These circumstances are risky for all concerned, but especially for service users. It is the responsibility of individual team managers to deal with these matters routinely and to risk-assess the impact on the service provided. Senior managers need to receive reports to enable them to monitor and prepare for more critical situations in teams. The recommendations given below try to set out what kinds of preparations might be needed. But there will be different circumstances in every organisation, and in every crisis, which means that details will have to be developed as required. This is even more challenging when resources are already under pressure. The main point is that these situations should not come as a surprise to anyone, and that organisations must develop ways to minimise the detriment to service users and colleagues (and the team members themselves). The Review Panel were told of the system in GSTFT Safeguarding Assurance Board, which has a regular item on its agenda about safeguarding team vacancy rates and how these are being managed. Learning Point In any agency, high turnover and sickness among workers and managers in a team carry the risk of loss of knowledge about cases and potential failure to carry out statutory duties. Recommendation 3: In order to manage the risks which arise from gaps and vulnerabilities in teams, managers in all agencies should have in place the following: • Communication to all levels of management (including the SSCB) when a team is experiencing high levels of sickness and/or rapid turnover of personnel. • A template for risk management of work which is not being covered in the absence of team members. • Communication about staff absence to service users and colleagues, in answer-phone and out-of-office messages, with alternative names, numbers and addresses for anyone trying to make contact regarding a case. More pro-actively, a letter should be sent to the child, family and members of the network when a worker is on long-term sick. 18 • Support for staff in a team experiencing extreme difficulties, as part of the ‘risk assessment’ of the team’s circumstances. B. Evaluate whether the care plan was robust, and appropriate for R, the family and their circumstances; C. Ascertain whether the plan was effectively implemented, monitored and reviewed and whether all agencies contributed appropriately to the development and delivery of the multi-agency plan; and D. Identify the aspects of the care plan that worked well and those that did not work well and why. Identify the degree to which agencies challenged each other regarding the effectiveness of the care plan, including progress against agreed outcomes for the child. And whether any protocol for professional disagreement was invoked. (The IMRs’ and the Review Panel’s analyses of these three areas of practice overlap to such an extent, that it seems best to comment on them together in one section.) 5.7 R’s Care Plan was comprised of most of the required elements, touching upon her health, education, practical and emotional needs; a gap has been noted in relation to the attention given to her sense of ‘identity’. Both her current and future care was thought about at her LAC Reviews. In terms of wider planning, a clear and pro-active approach to R’s placements was lacking, as most of these were unplanned and appeared to rely on ‘what was available at the time’. (See also Para 5.13). There was a muddled decision to proceed with a ‘Placement with Parents’ assessment when R refused to leave her mother’s home for five weeks (August 2012). This appears to have been proposed without a proper risk assessment of Mother’s household, possibly because the LA was unsure of obtaining a Recovery Order for R, in order to return her to placement. In fact, Mother was staying in a friend’s house, and she was sharing a bed with R. The possibility of Mother applying to revoke R’s Care Order continued to be mentioned at R’s LAC Reviews for the next year, indicating to all concerned that her future as a LAC was still in some uncertainty. The Review Panel were told that R continues not to understand her Care Plan, and has a persisting anxiety about whether her current placement will be ‘permanent’. It is likely that, while professionals may understand the idea of permanence conferred by a Full Care Order, permanency about a placement can be blurred. And we know that for R, the future security of any placement has become difficult to believe in. In addition, there may be a further obstacle to assuring a young person like R that she will remain in a placement with an IFA, because of funding implications. LAC Reviews should be as transparent as possible about the longer-term commitment to a placement where the child 19 might remain until age 18, and this message should be clearly conveyed to the child. R’s Care Plan was reviewed at the required frequency. However, there was a delay for most of these in sign-off by the Team Manager, and it must be assumed that they were not uploaded onto CareFirst in a timely way. A section below (Para 5.9) deals with the lack of sharing of these records with relevant partners. R’s LAC Reviews benefited from having a consistent IRO, who knew the case well. It is she who recognised R to be ‘an emotionally vulnerable young person…despite her external bravado’. However, the Review Panel has found that there were significant factors which affected how well the plans for R were implemented. These are described below. 5.8 R’s lack of participation R is of an age and understanding to be an active partner in her care planning, something which can help professionals immeasurably in trying to do a better job for a young person (YP). R has attended her LAC Reviews and listened to what was being said, but she has been unable or unwilling to participate actively in this process. There have been examples of her last two sets of foster carers helping her to write down her wishes and feelings, and these have been important contributions. In relation to the actions which are proposed in order to meet her needs, she has refused or postponed most of these (counselling, life story work, use of an independent advocate and contact with family members). Working with R to engage her more positively is addressed in more detail in Para 5.22 below. Many professionals involved with R have commented on her reticence, her lack of engagement, and her stated mistrust of professionals from the core statutory agencies. Perhaps because of her ambivalent feelings about her care status, she has been especially resistant towards her social workers and the IRO for her LAC Reviews. This has not been helped by R’s changes of social worker in the past 4 ½ years (there have been 10). The level of turnover in inner London CSC social work teams is very high (NB, not currently true for Southwark), and we have already noted that the team in question previously had particular pressures which led to even greater inconsistency in the allocated worker. It would be hard for any young person to develop trust and a more open relationship with her key worker under these circumstances. It has emerged from the Learning Event that R responds better to workers in some settings, such as the specialist staff from the Independent Fostering 20 Agency, who have conducted many of her ‘return interviews’, and who have done one-to-one ‘life style’ work with her. She has also been more open and positive in how she works with mentors from the Children’s Charity. It may be that these organisations are perceived by R as having less authority over her, so that she can retain a sense of her own control and privacy. Her current foster carers have invested a huge amount of time and effort to building a good relationship with R, on the principles of trust and respect. This has borne fruit, in that R has settled well with the family and is beginning to ‘open up’ to her main carer about her time outside the home. She now spends most of the time at home with her foster family, and her school attendance continues to be excellent. She has at least one significant local friendship – a new development. Learning Point Many looked-after adolescents find it hard to trust and communicate with professionals who are tasked with planning for them, and helping to keep them safe – especially when their key worker changes frequently. This can significantly constrain the ability of workers (and the local authority, as ‘corporate parents’) to respond to the young person’s wishes and feelings, and to meet their needs. Recommendation 4: Looked-after children’s reviews should identify a named person who is best placed to enable the child or young person to communicate their wishes and feelings. That person should be able to link closely with the child’s key worker in children’s social care, who represents the local authority’s responsibility for the child or young person. 5.9 Care Plan not shared among multi-agency partners This was a significant finding in this case review8. R’s last two foster carers received little background information about R from CSC upon her arrival, and were never provided with a copy of her current Care Plan (as reflected in her most recent LAC Review). This left them without the full information they needed to care for R in the best possible way. This changed little over time: although they participated in each LAC Review, they often did not receive a record of the decisions made (although they kept their own notes of these meetings). 8 A similar finding was found in a recent review, London Borough of Southwark Safeguarding Children Board: Child P: An Overview of Services Provided, Smith F, July 2013 (unpublished report), Para 7.3.3. 21 Key information was not regularly shared by CSC among the partners working with R, and as a consequence other agencies remained working in their own ‘silos’ and not in-putting to the Care Plan. They operated without a shared understanding of R’s history and experiences of abuse, change and loss, and even of her current circumstances. This was true for health professionals (e.g., the GP who carried out her Review Health Assessment in 2013) and for her schools, especially the school outside London which had no contact from CSC, and inexplicably did not receive R’s education file. They relied on R’s foster carers for information about R. Some Personal Education Plan (PEP) meetings were held for R, but none resulted in a written-up plan over the two years covered by this case review. This meant that the record of decisions was not distributed and available for use as a working document for R. It seems inescapable that many essential partnership activities, not least all kinds of communication, work less well when a child is placed out-of-borough. The IMR for Guy’s and St. Thomas’s NHS Foundation Trust noted that ‘LAC Health Assessments of children placed out of borough in 2011/2012 seemed fragmented’, and the Review Panel were told that this continues to be the case. CAMH Services are not offered to looked-after children who are placed out of borough, nor is CareLink, a service which works to support foster carers. Generally, establishing good working networks and reliable delivery systems for these children is a major challenge, given that between 70/80% of looked-after children from inner-London authorities are placed outside of their area. 5.10 Limited membership of LAC Reviews 5.10.1 In recent years, local authorities have aimed to make their practice with looked-after children less formal and more ‘child-centred’. As a consequence, LAC Reviews have usually become smaller, reflecting the child/YP’s wishes about who should be included in something as personal as their LAC review. This is defined as good practice in the IRO handbook (national guidance). In this case, we have been told that R was not comfortable with being a ‘LAC’, and was distrustful and even resentful of professionals, at least those in the statutory agencies. For all these reasons, most of R’s six-monthly reviews included only her foster carers, R herself, and her social worker (in one instance, school was represented and Mother also attended). For recent LAC reviews, the Independent Foster Agency carers have completed a set of reports and presented these. Other agencies, including those significant for R (e.g., the Children’s Charity involved) were not part of the discussions, and it is unclear what, if any, reports they were asked to contribute. CSC instigated little communication with the Children’s Charity, the agency who probably knew the most about R and her peer group back in Southwark. 22 What we do know, as noted above, is that the network of agencies involved with R were not made aware of the plans made in these reviews – plans which would almost certainly reflect their actions with R. R’s social worker was said (by the IRO) to have consulted with R’s mother before each LAC Review, ‘to feed her views into the review, but there is no record of these consultations in the LAC review records and it is not clear whether this actually happened’.9 5.10.2 The child-focused format of LAC Reviews creates a systems problem, when a wider meeting of professionals in the network is needed but there is no routine occasion for this to happen. In this case, R was the subject of serious and on-going concerns in several of the agencies who worked with her. The professionals from these agencies – workers and their managers – held often discrete sets of information, and needed an opportunity to share these and their concerns arising from their contact with R or her family. Because the LAC Reviews did not serve this purpose, a separate meeting was required, along the lines of a Team around the Child (TAC), or simply a professionals meeting. Learning Point Effective care planning for looked-after children requires input from all partners in the form of either attendance or appropriate reports for the LAC Review process. However, LAC Reviews, as smaller, child-centred meetings, do not provide a suitable forum for the full professional network of those who know about and are working with the child. Thus, there may be no regular opportunity for this network to share significant information and concerns. In addition, the LA needs to ensure that foster carers and the professional network are given full and good information about the determined needs of the child and the current plans, as well as relevant history. These actions can become more difficult for children placed out of borough. Recommendation 5: The allocated Social Worker should provide the most up-to-date Care Plan for a looked-after child to carers upon placement, along with a current risk assessment (regarding missing from care). 9 IMR from CSC, Para. 8.3 23 Recommendation 6: For each looked-after child, Children’s Social Care should maintain a list of partner agencies who are working directly and regularly with the child, in order to a) obtain a report for the LAC Review, where appropriate; and b) send a copy of the child’s updated Care Plan after each LAC Review. This should include private and voluntary organisations. Recommendation 7: The DCS should undertake an evaluation of the support for and active work with LAC placed out of borough, to establish whether these children receive an equitable service compared with children placed within Southwark. Recommendation 8: CSC should arrange for a separate meeting for the child’s professional network, outside the LAC Review, in the following circumstances: • The child’s move out of borough (where possible, to include ‘old’ and ‘new’ professionals in the child’s network) • The child going missing on a regular basis (as a Missing from Care Strategy Meeting) • The need to share serious concerns and information about the child, including significant lack of progress in elements of the Care Plan, which means that the child’s needs are not being met. Such a meeting can also be requested by any member of the network. This meeting could take the form of a pre-meeting in conjunction with the child’s LAC Review. 5.11 Lack of progress on actions from LAC Reviews The Review Panel noted that some elements of R’s care plan remained the same, but without any progress, over the time span of several reviews. In some instances, this was because of R’s reluctance to accept services. In at least one other case, it was because there had been a delay of several months in the Social Worker making a referral (for additional tutoring for R). It may be helpful in future to make it clearer in the LAC review records why some items continue to appear over time, without being implemented. 24 The IRO for R explained that she ‘rolled over’ a number of uncompleted actions so that they would not be forgotten, and so that they could be discussed at each review. She did ask for the completion of outstanding processes, such as the Review Health Assessment. Where there is lack of progress, the reasons for this need to be made clear, so that they can be challenged or escalated as required. 5.12 Limited communication by CSC with partner agencies The staffing problems and workload pressures in the LAC Team (described in Para 5.6 above) inevitably affected how well social workers and their managers were able to communicate with partner agencies. The IMRs from Education and Independent Fostering Agency describe a persistent and depressing pattern of trying and failing to get responses from Southwark CSC, regarding their concerns about R. During Year 8, R’s first secondary school regularly contacted CSC about incidents and behaviour by R which suggested that she was possibly involved in ‘gang-related activity’, and at risk of sexual exploitation. She had a number of fixed-term exclusions and was at risk of permanent exclusion, based on her disruptive behaviour in school. The Education IMR notes seven instances of formal, and increasingly serious, communication about R from the school to CSC, where there was ‘no evidence of action and feedback following the sharing of these concerns’. After several months, a letter from the Vice Principal of the school, to the CSC Service Manager, and a formal police notice (Merlin) sent to CSC finally resulted in a ‘high risk case/strategy meeting’, including Police, school and carers. This was an appropriate use of ‘escalation’, though it could have happened sooner. At this meeting, one decision was that a ‘Missing from Care Strategy Meeting’ should be held; this did not happen. Shortly after, R moved away from London and from this school. For those working with R, frustration about not getting a response from CSC staff generally resulted in arrangements for bilateral foster carer/school communication, and this became the default position during much of the next two placements, including the first move out of London. At this point, the concerns about R’s behaviour had reduced, and there was perhaps a sense that she was now safer at some distance from London. After the initial Placement Planning Meeting, and a LAC Review, there was no contact at all from CSC with the child, the carers, or the school for a period of almost three months. The school had no information about R’s history, either from CSC or from the (missing) school file, apart from that provided by the foster carers. A recent Southwark case review (Child P, 2013) noted similar ‘poor communication between agencies’ as a recurring issue. In that case, the placement distance out of borough was even further and more difficult to manage. 25 The Review Panel discussed why there may be a reluctance to use escalation procedures, perhaps because of reluctance to ‘get colleagues into trouble’, or a feeling that it wouldn’t do any good. This is an issue which needs greater attention, given the impact of letting an unsatisfactory situation continue. The outcome for the child is likely to be worse and relationships among professional partners likely to deteriorate. Recommendation 6: For each looked-after child, Children’s Social Care should maintain a list of partner agencies who are working directly and regularly with the child, in order to a) obtain a report for the LAC Review, where appropriate; and b) send a copy of the child’s updated Care Plan after each LAC Review. This should include private and voluntary organisations. Recommendation 7: The DCS should undertake an evaluation of the support for and active work with LAC placed out of borough, to establish whether these children receive an equitable service compared with children placed within Southwark. Recommendation 8: CSC should arrange for a separate meeting for the child’s professional network, outside the LAC Review, in the following circumstances: • The child’s move out of borough (where possible, to include ‘old’ and ‘new’ professionals in the child’s network) • The child going missing on a regular basis (as a Missing from Care Strategy Meeting) • The need to share serious concerns and information about the child, including significant lack of progress in elements of the Care Plan, which means that the child’s needs are not being met. Such a meeting can also be requested by any member of the network. This meeting could take the form of a pre-meeting in conjunction with the child’s LAC Review. 5.13 R’s placements R has had 7 placements (plus two respite placements) since her entry into care in January 2010. The joint authors of the CSC IMR are strongly critical, and comment that ‘The clearest failing of the care plan has been in finding a suitable long-term placement for R.’ (CSC IMR, Para 8.4) 26 They suggest that some of R’s carers were not suitable to meet her needs, but were likely chosen because they were the only local resource available when the previous placement disrupted. The Review Panel were told by CSC colleagues that this is often the case for older children, especially those deemed ‘hard to place’, in comparison with the more careful matching of younger children with their carers. Such decisions are inevitably constrained by capacity in the service. Resources issues (staff and placements) represent significant challenges to all local authorities, and inner-London boroughs probably contend more than most with a lack of local placements, because of the availability of housing space. There is thus a tension between a desire to keep a child within her local network/school, and the ability to achieve this with suitable and skilled carers for the most vulnerable children. In R’s case, her vulnerability was now, as an adolescent, expressing itself increasingly as demanding, non-compliant and aggressive behaviour – something which most of her carers were ill-equipped to deal with. This supply/demand imbalance was reflected in the numbers of older children for whom an IFA placement is sought; Independent Fostering Agency reported that most of their referrals are for LAC aged 11 to 15, with complex needs and challenging behaviour. Clearly, a proper assessment at the outset of R’s high level needs (which were fully explored and set out during the care proceedings) should have guided the choice of placement. This might have led to more stability for R. But even this is hard to state categorically, as R herself was torn between her feelings about her family and friends, and a desire to settle in foster care. The use of the Independent Fostering Agency for the last two placements has been positive, as this IFA has experience and skills in working with children and young people who are hard to reach, distressed, and affected by experiences of poor and abusive care in childhood. Their carers are very well supported by a team of professional colleagues who provide extra input to the child in placement, if needed. In this case, Return Interviews have regularly been carried out by a consistent person from the Independent Fostering Agency, and the same member of staff has done successful ‘Life Style’ work with R. Learning Point The choice, and timing, of local authority placements available for looked-after children does not always allow a matching of the child’s needs to the ability of the carers, especially for more complex and ‘hard to place’ adolescents. Recommendation 11: Every LAC Review should set out the child’s needs and how well the 27 placement is meeting these, including identity and diversity needs. This information should be collated so that the LA can monitor its responsibilities as corporate parent. E. Establish whether the respective statutory duties of agencies working with the child and family were fulfilled; and F. Identify whether there were obstacles or difficulties in this case that prevented agencies from fulfilling their duties (this should include consideration of both organisational issues and other contextual issues).10 5.14 The previous sections have outlined a number of deficits in how (principally) CSC acted as corporate parent to R. The following duties were carried out appropriately. • LAC Reviews were held as required. • With some exceptions, boarding-out visits were made to R every six weeks, as required during the first year of a placement. • Apart from one extended gap between placements, R’s schooling has been provided and has been a positive part of her care experience. Her attendance in her last two schools has been excellent, and she is learning well. Other statutory duties have not been fulfilled, and these are described below, with some analysis of why this should be so. 5.14.1 Annual Personal Education Plans (PEPs) were not completed during the case review period. PEP meetings were held (apart from during the period in School 2), but the agreed decisions and plans were not written up, distributed to those attending, or uploaded onto CareFirst. There is no explanation for this omission, apart from the workload pressure on workers, or the absence of the allocated social worker on sick leave. The CSC electronic recording system CareFirst has a section (‘Assessments/Forms’) which lists the statutory requirements for looked-after children, with templates for recording these actions. This window in CareFirst enables the worker and manager to see what is due to be completed, and whether this has happened, and when. The Review Panel were unable to discover how or whether this is used as a performance management tool, but consider that it offers a means of supporting effective work both in individual cases and more broadly, and of tracking the completion of required duties towards a looked-after child. 10 Ibid, Para 6.15 28 5.14.2 Gaps in LAC annual Review Health Assessments The IMR for Guy’s and St. Thomas’ NHS Foundation Trust covers the provision of LAC medicals (called either the Initial Health Assessment, or the annual Review Health Assessment, or RHA11). The author states that: The statutory duties with regard to R’s Health Assessments were not fulfilled. The Designated Doctor’s LAC health records had no indication that the 2011 and 2012 RHAs had been completed; this goes against the statutory guidance. This is a systems issue in terms of monitoring and tracking of assessments.’ She goes on to speculate that systems difficulties are greater when the child/YP is placed out of borough. The LAC Health Team have tried to instigate a system which would allow them to track all Southwark LAC, but have not had the resources to develop a system with CSC. In relation specifically to R, it appears that she did have a RHA in 2011, but not in 2012. It is the responsibility of the SW for the child to request this from the designated doctor for LAC/community paediatricians or from the GP or specialist LAC nurse as indicted on the child’s previous IHA/RHA. In 2013, R had a further RHA. This was sent to the Specialist Child Health LAC team in a timely way so that the “Part C” health summary could be written, but the Health Summary was not completed and distributed to partner agencies for a further four months. Similar to the problems in the CSC LAC Team, there were significant periods of sickness absence in the specialist child health LAC medical and administrative teams during the period under review. These circumstances appear to echo those of a similar Southwark case reviewed in 2013 (Child P). The independent author of that case review made the following recommendation: Children’s Social Care should, in co-operation with Health and Education partners, review current arrangements under the Care Planning, Placement & Review (England) Regulations 2010, for forwarding of child health records to 11 For looked-after children under 5 years old, the RHA is required 6-monthly; for over 5s, it is done annually. 29 the relevant ‘area authority’ and arrangements for health assessments (initial and review)…for children placed out of borough.12 5.14.3 The Greater London borough where R now lives was not informed of her placement in that area, as is required.13 In Southwark, a member of the placements team normally sends the required notification letter to the local authority where the looked-after child or young person has been placed. At the same time, the details of the placement are loaded onto CareFirst, and a record is kept of the letter to the other local authority. These are routine tasks which were not done when R moved back into the Greater London area; there is no explanation for this omission. An exactly similar omission was noted in the recent case review of Child P (Para 7.3.3). The Head of Social Work Improvement and Quality Assurance has since requested that the Placements Team Manager audit 20 recent placements to find out how compliant the system is generally, and whether there any weaknesses which might lead to omissions, such as occurred in this case. 5.14.4 Gaps in records The IMR for CSC highlights the following gaps: • There is no chronology or genogram on R’s file. Both of these are expected to be provided for all children who are clients of CSC, but they are often not completed or updated and on file. • There are no fostering records during R’s placement (29/11/11 to 25/2/12). This leaves in doubt the support which the carer at that time was receiving from the fostering service. • The CSC records, for the critical 5 weeks when R was absent from care (August 2012), are unclear. The plan for this unauthorised arrangement included twice-weekly visits, announced and unannounced, as a way of monitoring the risk to R. The records do not say whether these visits happened. • Generally, minutes of meetings, including LAC Reviews, were not uploaded onto CareFirst in a timely way. This meant that, in the absence of the 12 London Borough of Southwark Safeguarding Children Board: Child P: An Overview of Services Provided, Smith F, July 2013 (unpublished report) 13 Where a Child Looked After is placed in the area of another local authority (regardless of the type of placement), the Arrangements for Placement of Children (General) Regulations 1991 (Regulation 5) requires that notification is made by the placing authority to the local authority's children's social care service where the child is living. (The education service and the relevant health trust for the area in which the Child Looked After is placed must also be notified.) The notification will include the address where the child is placed. 30 allocated SW or manager, there was insufficient up-to-date ‘guiding’ information for anyone needing to know about or take action in this case. (The CSC representative on the Review Panel could not comment on whether this was individual weak practice, or more widely the case in the service.) • There are no written transfer summaries, a real problem for the different social workers who took on R’s case. The case review of Child P (2013) recommended that ‘The extent to which case transfers are informed by a written handover and briefing requires monitoring, if necessary by means of amending existing case audits schedules’. (Recommendation 4, p.51) Learning Point Children and families cases will inevitably transfer to a number of different social workers and managers over time. For their work to be effective, case records need to include a genogram, an up-to-date chronology and a transfer summary. Recommendation 12: The CSC case audit template used by the QA team should include questions about compliance with the departmental requirements for genograms, chronologies and transfer summaries. The quality of transfer summaries should be monitored. 5.14.5 Problems in transferring information between schools The author of the IMR for Education comments on the ‘lack of effective systems to document and track the transfer of school files’. R’s moves of schools (she attended three schools during the case review period) revealed various problems in transfer of information. School 1 say that they sent R’s education and CP files to School 2 (outside London), who never received these. School 2 did not provide transfer information to School 3. However, the ‘missing’ files from School 1 eventually turned up in School 3, without material about the intervening two terms in the shire county. The IMR author for Education has done everything possible to try to find out about how R’s files went astray, without success. Learning Point The systems for sharing and transferring information about a looked-after child who moves schools do not always operate in a transparent and timely way. 31 Recommendation 13: The Director of Education and education team managers should agree and then implement a protocol in relation to the transfer between schools of Looked After Children's education records to ensure that a robust, well tracked procedure is in place across all Southwark schools. The protocol should include a clear line of communication and escalation should information not be received in a timely manner by the admitting school. Ideally transition meetings between professionals from the outgoing and the new school should be built into the process to ensure that learning and support needs are shared prior to the child joining the new school. 5.14.6 Missing from Care procedures were not followed No Missing from Care Strategy Meetings were held during the two-year period of this case review. The required ‘return interviews’ were carried out by R’s social workers when she lived in Southwark, but these did not continue when she moved out of borough. These issues are explored below, from Para 5.16 onwards. G. How well did professionals understand and manage the different risk factors influencing this case and the particular vulnerabilities of R, during the two years under review? and H. Review of the application and use of children missing from home and care protocol 5.15 Understanding of R’s particular vulnerabilities The first point, remade here, refers back to the initial question in the Terms of Reference (Paras 5.1-5.6): Was previous relevant information or history about the child and/or family members known and taken into account in professionals’ assessment, planning and decision-making? Because this was not the case, those involved with R had a limited understanding of the degree and nature of her vulnerability. R was undoubtedly affected by her troubled personal history, contributing to her lack of secure attachments, mistrust of those in authority, and a weak sense of her own worth. All these underlie her vulnerability, which was heightened when she was missing from care, and her whereabouts and her activities were not known. Sadly, she has for some time been resistant to the idea of therapeutic help regarding her childhood experiences. Better engagement by CSC with the Children’s Charity (where there was early on a very strong attachment from R) might have allowed the LA to build on R’s positive relationship with the workers there in order to facilitate R’s agreement to therapeutic help. 32 There has been little apparent awareness of R’s risk of sexual exploitation when missing, despite her previous sexualised behaviour and the concerns this raised at the time. 5.16 Missing from care episodes 5.16.1 Southwark Safeguarding Children Board has a multi-agency Missing from Care policy (2012), which is being updated in response to the Metropolitan Police’s pan-London protocol, 201414. The current policy covers good practice in relation to reporting missing episodes; the role of carers, CSC and Police in responding to the return of a missing child/YP; the guidance given to children at risk of going missing; and the maintenance of an updated risk assessment for each child/YP. The section below addresses how well this policy has been followed in relation to R. What is clear is that she has received consistent advice about keeping herself safe, from her carers and other the Independent Fostering Agency staff, her social workers, police officers, her Independent Reviewing Officer (IRO), and staff at the Children’s Charity. Arrangements were in place to transport her safely15 to the evening group she attended back in Southwark on a week-end night (though, oddly, not home again afterwards; this has now been rectified). 5.16.2 During the two years under review, R’s patterns of going missing from care varied considerably. From early 2012 until her move away from London, she was regularly outside the care and control of her foster carers. She frequently returned to her placement very late, or was missing overnight (or longer). There was some evidence of potential CSE (R having unexplained amounts of money, being ‘dropped off by an older man’). Police responded to all incidents as required – by visiting R and speaking with her, and also by creating a Merlin report for CSC. However, records from this period suggest that Southwark’s Missing from Care Protocol16 was not being followed in other respects, and this omission was noted in a ‘High Risk Case Meeting’ held in June 2012. The required strategy meetings were not being held, and return interviews by a social worker17 were not being carried out consistently, especially when R moved out of borough. The LA was reminded that a strategy meeting is required when a looked-after child is missing for more than 24 hours, and should be considered when there is an on-going pattern of shorter ‘missing’ events. 5.16.3 R’s foster carer (from April 2013 onwards) regularly notified the Police when R was missing. Police records show that they produced Merlin reports and carried out return interviews on every occasion, apart from a handful when they were 14 Pan-London Child Sexual Exploitation Operating Protocol, Metropolitan Police, February 2014 15 Ladycabs, a taxi firm using female drivers, are routinely used in such instances. 16 Southwark Safeguarding Children Board – Multi-agency Protocol for children missing from home and care, January 2012, Para 8.2 17 An independent organisation has recently been contracted to provide this service – see below, Para 5.16.5. 33 informed that she had returned within a few minutes of having being reported as missing (out later than her required time of return)18, and the record of the report had not yet been formalised. What was routinely missing was the second, independent Return Interview by the young person’s social worker, which is designed to provide a more in-depth picture of the missing episode and levels of risk, as well as giving an opportunity to offer support and guidance to the young person. In some instances for R, this was conducted by a dedicated worker from Independent Fostering Agency, where this service has been developed (see Para 5.16.6 below). Major resource implications for Police The growing incidence of missing episodes – locally, across London and nationally – has major resource implications for the Police. In the case of R alone, there were 20 missing episodes reported between 2010 and 2012; during the review period, there were a further 33 reports, all of which required a police response. Considering the numbers of looked-after children in Southwark alone, as well as around London and across the country, this is a major burden in terms of capacity for Police, not least because it may often involve officers at night when there are other pressing matters to be dealt with. 5.16.4 In August 2012, R was away from her placement for 5 weeks and staying with her mother. This situation was minimally assessed, with a Police check, not from the usual source of CAIT, about the household where Mother and R were staying. This provided a less rigorous and in fact misleading account of potential risks, given Mother’s past police record and the findings in the Care Proceedings the previous year. There was no risk assessment completed for R. Guidance for such an assessment is given in Appendix 4 of the Missing from Care Protocol. 5.16.5 There followed the placement outside London, when, with one brief exception, R did not go missing for 8 months. Her school attendance was very good and she settled well with the foster family. In April 2013, R suddenly absconded for a week, communicating by text with her carers that she was staying with her mother. R was visited (a welfare check) by Police who found her to be safe and well. R was also seen in the local Southwark CSC office once during this period, when she was advised to return to placement. She was not visited at home by a SW, nor was there a ‘return interview’ by a SW upon her return to placement. Was this because she was not seen as ‘missing’? As before, there was no risk assessment of the care Mother was providing, or indeed whether R was actually staying with her mother most or all of her time. (In fact, R absconded from her mother’s home for 24 hours during this week, and the records state that ‘no one is aware of her whereabouts’ – CSC files.) 18 Agreeing definitions of ‘missing’ and ‘absent’, and the respective roles and expectations of different services should be clarified within the local Missing from Care protocol. 34 The current Southwark Missing from Care policy describes who should carry out Return Interviews (‘an independent person…who is able to build up trust with the young person’19). Recent change: Southwark CSC has just commissioned this service, commencing 1st October 2014, from St. Christopher’s, a voluntary organisation experienced in working with young people in this area. 5.16.6 In R’s next (current) placement, in the 12 months to the end of April 2014, she stayed away overnight 11 times, and was away for 2 days on one occasion. The management of these episodes has included an agreed rule about reporting R missing (‘when she is 10 minutes late home’). This was based on her continued refusal to tell her carers or anyone else where she goes, and with whom, when she is absent from her placement. Her foster carers reported her missing scrupulously, and Police carried out welfare visits when she was returned (and sometimes telephone ‘debriefs’ with her while she was missing). As already stated, return interviews have not been consistently undertaken by the local authority Social Workers. The Independent Fostering Agency uses a specialist worker on a regular basis to conduct these, and two members of their staff have offered this service to R and made a good connection with her. However, the Independent Fostering Agency have not viewed this as a substitute for the local authority’s responsibility to conduct such interviews. 5.17 Assumptions made The Learning Event highlighted what had already been suggested in the IMRs, which was a belief that ‘R wasn’t really missing’. For one thing, her behaviour was in many ways typical of most teen-agers, who want more independence and who are not always obedient to their parents’ wishes. In R’s case, the lower sense of risk seems to have been because a) she always (almost always) returned to her placement; b) she kept in communication with her carers (usually) ; and c) she had a plausible and consistent story about where she was – either with her mother or with friends. But these stories were not verifiable, and none of these circumstances meant that R was known to be safe. There are two other flaws in the assumptions about what was happening to R when she was absent from her placement: • Information about Mother and her care of R described a poor relationship and abusive and neglectful care. R was at risk of exposure to criminality relating to drug-dealing. There should not have been an assumption that Mother could act as a safe carer in a safe household. • R’s friends were not identified, so it was not known where she was staying and in what circumstances. 19 Southwark multi-agency protocol for children missing from home and care, Southwark Safeguarding Children Board, January 2012 35 Various partners, including the Police and possibly foster carers, may take a different view of risks, depending on what they have been told about the child’s likely whereabouts. The Review Panel were told that Police may see a child as lower risk if they go missing a lot, but also regularly return to placement. These different views need to be discussed in a multi-agency forum in order to be shared and challenged – especially in the light of increased understanding (e.g., from the Rotherham Inquiry20) of the risks for looked-after children who are regularly away from placements late at night or overnight, as was true for R. 5.18 Lack of risk assessments and Strategy Meetings Perhaps partially as a result of the assumptions above, the required ‘Missing from Care’ Strategy Meetings were never held, and an up-to-date risk assessment regarding Missing from Care was not placed on R’s file. (A similar failure was identified in the case review of Child P21, where missing episodes were not recorded on CareFirst.) This seems an extraordinary omission, given the frequency of R’s time away from placement (either coming home very late, or staying out overnight), and her degree of vulnerability. It seems that each incident was regarded in isolation, and the pattern of going missing was not understood and evaluated by the network. LAC Reviews discussed R’s time out of placements, and the IRO recorded that her ‘frequent unplanned contact with Mother and grandmother was a cause for concern’; but this did not lead to a risk assessment of the contact or any other related action. The reasons for this are not known, apart from the (already outlined) lack of capacity in the LAC Team. When R was still placed in Southwark (2012) and when concerns about CSE were emerging, a referral was made for her to be discussed at the Multi-Agency Sexual Exploitation (MASE) Panel. This was turned down because at that time, a case without a named perpetrator would not be considered. The Review Panel has learned that the way the MASE operates has been altered, in response to the Metropolitan Police Operating Protocol, 2014. There are now two levels of this structure: a multi-agency strategic group, and a multi-agency panel which will continue the work of the previous group. The remit of the latter panel is being revised to include general concerns and patterns suggesting risk to children like R, even though there may be at that point no suspected perpetrator. The Southwark Missing from Care Protocol provides a very helpful template for both independent return interviews and risk assessments, both of which are part of the process of safeguarding vulnerable young persons. 20 Independent Inquiry into Child Sexual Exploitation in Rotherham, 1997-2013, Professor Alexis Jay, August 2014, Para 6.37 21 Para 7.3.3 36 Learning Point Children missing from care are at greater risk of sexual exploitation, not only because of being outside of (corporate) parental control, but also because of the power and reach of social media. Recommendation 14: Every looked-after child should have an up-to-date ‘missing from care’ risk assessment on their CSC file. Carers, CSC and Police should contribute to this, as appropriate, and it should be shared within the LAC Review group and any other key safeguarding partners involved with the child. Recommendation 15: In particular, high priority should be given to making sure that there is a risk assessment on the file of every child at risk of sexual exploitation. (This recommendation is taken from the Rotherham Inquiry) Recommendation 16: The internal CSC audit and the SSCB multi-agency audit should include a question about compliance with Missing from Care procedures for every looked-after child. 5.19 How the incident of alleged rape was dealt with 5.19.1 The Review Panel for this SCR were initially gravely concerned about how R was dealt with by the Police, on the second night after her alleged rape. The Police IMR has been helpful in explaining the Police’s assessment of risk and why they decided to use Police Powers of Protection: • R had decided not to cooperate further with the police investigation (possibly because of threats from the alleged perpetrator, with whom she was known to be in contact). • She continued to leave her foster placement and refused to let her carers know where she was going. This was at a time when the alleged perpetrator was still at large and was believed to be intimidating R as a witness, and to offer further risks to her safety. She was in contact with him. • In these circumstances, the foster home was not deemed to be a secure placement for her. The Police IMR author sets all this out clearly and takes the view that the protective actions were correct. However, the use of the police station (not the initial intention of the police) overnight was in his view not appropriate. He makes no recommendation about this. The Review Panel have discussed the impasse which arose between Police, who were asking for a different placement to keep R safely on this night, and the local authority refusing either to place her in Secure Accommodation or any other unit. It was their view that she had a perfectly good placement to which she could be returned. 37 This is a situation which is likely to occur again, and these agencies need to consider how disagreements about high risk young persons can be mediated and dealt with in a child-focused way. A concern from the Review Panel: was R dealt with differently because she was a looked-after child, rather than someone living with her own parents? Learning Point There are potential tensions between Police and Children’s Social Care, regarding their respective roles and responsibilities in relation to a looked-after child at high risk of harm. This can result, as in this case, in an impasse and an outcome which is not appropriate for the child, even in the short-term. Recommendation 17: The relevant senior managers from Police and CSC should explore the options for keeping children and young people safe in emergency situations, in particular considering how differences between agencies about appropriate placement can be resolved. It may be useful to use case studies to illustrate the most contentious and complex situations, and how they might be handled. 5.20 Looked-after children and the risk of CSE 5.20.1 The known link between going missing from care and CSE is highlighted in much research evidence and key reports. For example, Barnardo’s 2012 report about the risk of CSE provides a list of ‘Key indications of vulnerability (to CSE)’ 22. First on its list is ‘Going missing for periods of time or regularly returning home late’. (p.5) This link has provided a focus for this SCR, and was already a priority for the work of the SSCB. In August 2014, the Rotherham Inquiry was published, giving an abundance of useful data and analysis, not only about the cases in that area, but more generally about the risks of CSE to young girls who go missing from care. This will add to the learning from this SCR and support the work of the SSCB in this challenging area of safeguarding. 5.20.2 In early 2013, based on the outcomes of seven earlier Management Overview Reports, Southwark Safeguarding Children Board identified three priority areas for strategic development: • Safeguarding of adolescents and older children • Safeguarding issues pertinent to looked-after children • System-wide understanding and practice regarding sexual exploitation and abuse of young people. 22 Cutting them Free: How is the UK progressing in protecting its children from sexual exploitation?, Barnardo’s Policy, Research and Media, January 2012 38 The Reports clearly pointed to the greater vulnerability of looked-after children, compared with their adolescent peers: a message which is significant in the case of R, and needs to be further disseminated regarding the cohort of Southwark’s adolescents in care. The link between going missing and risk of CSE needs to be embedded in the thinking and practice of staff at all levels, including front-line practitioners, who are working with looked-after children aged 10 and upwards. 5.20.3 In September 2013, the SSCB produced a comprehensive review of data, both locally and nationally, to inform their safeguarding work in relation to CSE. The links with ‘going missing from care’ were very clear – both within Southwark and elsewhere: • Numbers of LAC going missing for over 24 hours was up 36% in 2012/13, compared to the previous year. (However, this rise has now been wholly attributed to a different way of recording missing episodes. The number of LAC going missing has remained steady for the past two years.) • The amount of time spent missing, by the same cohort, rose by 100%. • Over 80% of missing episodes were among children placed out of borough. An audit of 5 young women (LAC) who were believed to be at risk of CSE found that, like R, the majority had experienced multiple placements, including out of borough. Again like R, the majority had been removed from families at a late stage, after on-going histories of neglect. As we become more aware nationally of the nature of such ‘familiar stories’, a more pro-active and protective response should be adopted at a strategic level – across the local safeguarding children network – to reduce the risk to this group. Work already commenced The Review Panel were told that the SSCB is considering and responding to the recommendations of the Rotherham Inquiry, including Recommendation 3, which suggests that ‘Managers should develop a more strategic approach to protecting looked after children who are sexually exploited. This must include the use of out-of-area placements.’ The SSCR are using the ‘See Me, Hear Me’23 principles and framework for protecting children from CSE to guide the work in this priority area for the SSCB. I. How well did professionals hear the voice of the child in their work with R? And to what extent were her unique diversity needs met by services? 5.21 Professionals have tried to listen and respond to R’s wishes and feelings, whilst needing to balance these with their responsibility to make decisions which support her and protect her from harm. This has not been a straightforward task, for a number of reasons: R was not always consistent in her stated wishes and feelings 23 Office of the Children’s Commissioner’s Inquiry into Child Sexual Exploitation in Gangs and Groups, Final Report, November 2013 39 (e.g., about contact with her mother, or returning to live with her mother), and she has been reluctant to talk at any length about these. This has limited her input into her LAC Reviews, which have generally heard from adults rather than from R. Nonetheless, the LA and partners have continued to fulfil their corporate parental duty to her, in the following ways: • R’s links to her family are clearly important, and the LA has consistently tried to arrange for safe contact between R and her mother, grandmother and siblings. • R’s wish to live nearer to her mother was supported by the Judge who made the Recovery Order, and by R’s IRO. R’s move to her current placement was also noted to be a better match for R, providing a greater degree of diversity than the shire county where she was previously placed. (But it remains less diverse and less like ‘home’ than Southwark, where R, until recently, continued to return on a regular basis.) • R’s links with her familiar area of inner London have been supported by safe arrangements (taxis) for her to attend the Children’s Charity weekly. • R’s experiences of bullying – in all three of her secondary schools – have been addressed by the schools and carers, and she has been enabled to attend and achieve well. 5.22 As has been noted elsewhere, there were gaps in the SW service offered to R, largely but not entirely related to sickness and lack of capacity in the LAC team. R is an adolescent who was already unlikely to trust those in authority over her, and who has had a sequence of changing social workers, then some who did not visit her consistently, and some who were slow to follow up on actions agreed on her behalf (e.g., a referral for extra maths tuition, which took several months to progress). In these circumstances, R has remained disappointed and resistant to communicating with professionals within CSC. The Review Panel have speculated that, had R had the same SW from the time she came into care aged 10, this relationship might have flourished and allowed R to trust and tell her wishes and feelings. Sadly, the turnover in the SW workforce has not allowed for this to happen. R’s most recent SW was chosen because of her noted ability to ‘get through’ to young people; in addition, she is a black woman like R (as is R’s IRO). She has sought the advice of CAMHS colleagues to help her develop the relationship, and has been advised to persist in offering R an attentive and reliable service – even though rebuffed. This has so far not succeeded, but it is regarded as the best way to demonstrate the role of a responsible parent: one who does not give up on the child, but who sometimes has to take decisions which the child doesn’t like. 5.23 Like all young people, R would benefit from a trusted and consistent adult whom she can tell her wishes and feelings. 40 This role has been slowly and painstakingly developed by her current foster carers, especially the main (male) carer. They have worked hard to build a relationship with R, based on trust and – very slowly – on her willingness to give more information about her time spent out of the home. This remains a work in progress. Other workers, from the Independent Fostering Agency and from the Children’s Charity, have described R’s willingness to talk to them more freely than to her SW. This may suggest that she naturally views these private or voluntary agencies differently from the LA, with its unwelcome authority over her. In particular, the Education Advisor/Special Project Consultant from the Independent Fostering Agency has made a good professional link with R, within which messages about her self-worth, welfare and safety can be conveyed. However, it remains the case that R does not readily share her wishes and feelings with the adults in her life. In this, she is no different from many adolescents living with their own families, who only confide in their peer group. 5.24 Professionals who attended the Learning Event for this review speculated about whether social workers tended to have more skills and confidence for working with the birth-to-12 year age range, than with resistant teen-agers. It was suggested that a ‘tool kit’ would be helpful for trying to engage with adolescents. 5.24 The consideration of R’s identity and her ‘unique diversity needs’ has not been clearly recorded in her LAC Reviews, or elsewhere, apart from the acknowledgement that the diversity of the London area provides a more suitable environment for her placement. But it is clear that the LA has tried to match black carers and workers with R. R’s first five placements were local (Southwark) and were a racial match for her. Unfortunately, the last two of this series of placements were with very elderly carers who struggled to work with R, who at that time was increasingly troubled and disruptive – and was spending more and more time out of the placement. The choice of these last two placements was quite likely to have been because they were ‘the only ones available’. This is a real resource issue, common to all inner-London authorities. 5.25 R’s last two placements have been with white carers, and she herself has expressed her preference for a trans-racial placement. Her last two SWs, on the other hand, and her IRO are all black women. Thus, the local authority has tried to ensure R’s heritage is reflected by those representing her corporate parent. J. Review of the application and use of the e-safety policy in this case 5.26 The sources and means of possible CSE have expanded hugely as a result of the technological revolution in social media. This worldwide phenomenon shows no signs of slowing, and it undoubtedly leaves many adults – professionals included – far behind in their awareness and understanding of increased risks for children and young people. 41 Barnardo’s ‘Cutting them free’ report describes why those in positions of care towards young people – including all parents – need to be concerned about the role of technology in exploitation. The following passage describes their experience in this field: Exploited young people and children are typically abused in person, but sexual exploitation also takes place over the internet, through mobile phones, online gaming and instant messaging. This is not surprising given how central technology is now to young people’s lives, and the issue has long been a major concern for our services. However, the services reported that the scale of online and mobile abuse has markedly increased even since 2010. Almost all services reported it as an increasing priority, and some have identified that the majority of their service users were initially groomed via social networking sites and mobile technology. …Young people, parents/carers and professionals need to be more aware of how such technology can be used by abusers. (p.7) 5.27 It has been very hard to comment about the application of an e-safety policy in this case. We do not know its specific relevance in relation to the trigger incident for this case review. This is because the circumstances leading to the alleged attack on R remain unknown, and R is unwilling to say any more about this matter. She has previously stated that the man contacted her on her mobile telephone, the day before they met, and that a ‘friend’ of hers had given him her mobile telephone number. Police have been unable to uncover any communication between R and the man online, or any evidence of a process of grooming. 5.28 R’s foster carers have put in place sensible precautions regarding her use of mobile phone and the internet. Her phone is on a contract which allows professionals to track calls when necessary (as in the recent incident); and her oyster card also enabled them to see where she was travelling. R’s telephone is not allowed in her bedroom at night, but is left in the kitchen of the foster home. These actions are in line with the guidelines in the Independent Fostering Agency e-safety policy. Those responsible for R are aware of the power and lure of the internet and social media more generally, and have talked to R about the risks arising from these. As for all young people, it is impossible to know whether, how and when R continues to use the internet, and potentially to place herself at risk of harm, especially from CSE. 42 Learning Point The power and lure of electronic social media carry a risk of harm, particularly to vulnerable young people, which cannot be removed by professionals working with these young people. Recommendation 18: The SSCB should co-ordinate the e-safety ‘statement of principles’ across the local safeguarding children partnership. These should focus on supporting and educating young people to keep themselves safe. 6. Conclusion 6.1 R is a young person in care who has struggled with the status of being ‘looked after’. She entered care as an older child, with a complex history which included neglect and abuse by her parent, and which left her with powerful feelings of rejection and blame by her family. She went on to have a series of 10 different social workers and 7 placements – a difficult and increasingly unsatisfactory experience of being looked-after and cared about, which would only further diminish her sense of self-worth. 6.2 R is like most other teenagers in many aspects of her behaviour, wishes and feelings: the importance of her peer group of friends, her mistrust of adults and her desire to push boundaries. These make it hard for parents and carers generally to keep their adolescents safe and to know what is happening with them. But R is also different, and more vulnerable, because of her earlier traumatic experiences and her number of moves in care. She continues to suffer from the loss of her family, including her siblings, and misses the closeness of friends in her home area. 6.3 This case review has found that the professionals responsible for R’s care as a looked-after child have not had a sufficient understanding of her history and of her level of vulnerability – a vulnerability which continues to expose her to significant risk of harm, especially when she is missing. One consequence has been a lack of alertness by these professionals about the risk associated with R’s patterns of going missing. It seems R was often regarded as ‘not really missing’, because she was believed to be visiting her mother or staying out with friends. These stories were perhaps usually true, but the reality was that no one in CSC really knew where R was for most of the times she was missing. This meant they could not know that she was safe. 6.4 The Review Panel has explored the explanations for the inconsistent service by CSC to R, and why Missing from Care procedures were not followed. 43 The principal reason given is that the team in which R’s case was held underwent a period of many months when both SW staff and managers were off sick, and the work of the team suffered as a result. There were periods of time when R was not visited at the required frequency. Partnership work was neglected, and communication across agencies suffered from there being no multi-agency forum for sharing vital information and concerns about R. These omissions, and their consequences, should have been picked up by more senior managers, and one of the main messages of this report is that organisations must anticipate and plan for periods of serious weakness in parts of their service. Other agencies, when they experience the lack of partnership working and the response to their concerns, should more readily and positively use escalation procedures, in order to achieve a better service to the child. 6.5 The major issues of safety for children and young people raised in this case review have been highlighted on the national stage in the past two years. As a result, there is a renewed focus on children missing from care, linked to a much keener awareness of the risks of CSE, especially for looked-after children and even more so for LAC placed away from their home area. In Southwark, the emerging lessons will hopefully be reflected not only in a better handling of the risks for R, but for all adolescents in their care. The LA and partners need to work together to help these young people develop the appropriate tools to protect themselves, and to offer non-punitive responses when they return home. Sadly, no parent, corporate or otherwise, can achieve this without the young person’s engagement and their wish to keep themselves safe. 6.6 In R’s case, it is encouraging that she now appears to have found a home where she would like to stay until she is 18, and carers to whom she can attach and trust. Schooling continues to be very important to her, and her attendance is excellent. These are the building blocks which may allow for a better understanding of recent events for R, and therefore further means to increase her safety in future. The professionals involved in her care have participated very positively in this SCR and by doing so will have already changed their perception and understanding of the issues of going missing from care and risk of CSE. More widely, it is hoped that the lessons from this SCR will contribute to the SSCB’s learning and improvement in its priority areas for safeguarding adolescents and older children, including the children for whom the local authority is the corporate parent. 44 REFERENCES Berelowitz, S., Clifton, J., Firimin, C. MBE, Gulyurtlu, Dr. S., Edwards, G., ‘If only someone had listened’, Office of the Children’s Commissioner’s Inquiry into Child Sexual Exploitation in Gangs and Groups, Final Report, November 2013 (This report includes the ‘See me, hear me’ material.) Cutting them Free: How is the UK progressing in protecting its children from sexual exploitation?, Barnardo’s Policy, Research and Media, January 2012 Jay, Professor A. OBE, Independent Inquiry into Child Sexual Exploitation in Rotherham, 1997-2013, August 2014 Local Safeguarding Children Boards Regulations, DfE, 2006 London Borough of Southwark Safeguarding Children Board: Child P, An Overview of Services Provided, Smith F , 2013 (unpublished report) Multi-agency Protocol for children missing from home and care, Southwark Safeguarding Children Board, January 2012 Pan-London Child Sexual Exploitation Operating Protocol, Metropolitan Police, February 2014 Protecting Children in Wales – Guidance for Arrangements for Multi-Agency Child Practice Reviews, The Welsh Government, January 2013 Working Together to Safeguard Children, DfE, 2013 (and previous editions) 45 GLOSSARY Cafcass Children and Family Court Advisory and Support Service CareFirst Electronic recording system for Southwark CSC CP Child Protection CSC Children’s Social Care CSE Child Sexual Exploitation DCS Director of Children’s Services DfE Department for Education GSTFT Guy’s and St. Thomas’s NHS Foundation Trust IFA Independent Fostering Agency (operating as a profit-making business) IMR Individual Management Reviews (for a Serious Case Review) IRO Independent Reviewing Officer (for looked-after children) IRO Handbook Statutory guidance for independent reviewing officers and local authorities on their functions in relation to case management and review of looked-after children (DfE) LA Local Authority LAC Looked-after child LSCB Local Safeguarding Children Board MASE Multi-Agency Sexual Exploitation Panel NHS National Health Service PEP Personal Education Plan School 1 School 2 School 3 In Southwark In shire county In Greater London SCR Serious Case Review SSCB Southwark Safeguarding Children Board SW Social Worker TM Team Manager YP Young person 46 Appendix 1: Terms of Reference Re: Serious Case Review – Child R Southwark Safeguarding Children Board has decided to undertake a serious case review following a serious incident affecting Child R aged 15 years old. The review was agreed under guidelines within Working Together (2013) and regulation 5 of the Safeguarding Children Board Regulations 2006. Reason for the serious case review Child R alleged she was held at a hotel by an unidentified male. On Sunday 16th March Child R reportedly agreed to meet with friends she had met via the Children’s Charity. She returned late to her placement which she said was due to losing her phone. She then returned to SE London on Monday 17th March to retrieve the phone. She did not go to school on the Monday and did not return to the placement and was reported missing. On the phone she informed her carer that she was being held at a hotel by an unidentified male. The police were informed and via mobile phones Child R and the man were tracked. The male put Child R in a cab to return to placement. When she returned she disclosed to her carer that she had been raped. Child R was supported by her carer to disclose to police, provide forensics and attend Haven. She refused an ABE interview. A strategy Meeting was held on 20/3/14 at a Sexual Exploitation Unit, linked to the Metropolitan Police. The police subsequently arrested a male, alleged perpetrator. He is said to have been on Bail for a similar offence. Child R is currently being supported in her foster placement. Family structure: Mother 35 London Father May live abroad Subject 15 Foster placement Sibling 19 London Sibling 11 Foster care Sibling 8 Foster care Sibling 5 Foster care Family Background Child R and her family have settled in the country at different times. Child R and her older sibling lived abroad until she was about 8 years old with the maternal grandmother. At a later date maternal grandmother settled in the country. Southwark social care involvement with Child R and her siblings started in December 2008, following receipt of a police notification stating that a member of the public had reported concerns about Child R’s older brother drug running for his mother, and that she was dealing drugs and prostituting. This triggered an initial assessment. 47 During the assessment Child R made a disclosure that she repeatedly got hit by her mother with a mop and belt. She said she was treated differently to her siblings, and presented as sad and withdrawn. A subsequent medical examination found evidence of physical abuse including bruises and burns. Child R was subject of a Child Protection plan from 03/06/09 to 03/11/09 under the category of physical abuse. On 02/01/10, Child R presented herself at a care home saying she had been beaten by her mother, had packed and escaped out of a window. Following this she was accommodated with her mother’s consent on 4/01/10 under S20 CA 1989 On 19/03/10 Child R was made the subject of an Interim Care Order CA 1989, ‘following a series of events involving her mother, drugs, the police and her siblings.’ She was made subject of a full Care order on 22/07/11. Her three youngest siblings are all currently in foster care. Her older brother was previously looked after. Care History Child R has had around 9 different foster placements since being in care. Her placement breakdowns were largely attributable to her behaviour – she has a history of returning late from school and going missing from care. In addition she has been reported in the past as being rude, disrespectful and occasionally intimidating to carers. Child R has been in her current placement, which is an Independent Foster placement, since 24/04/13. She had to move from her previous placement following making an allegation that her previous carer had pushed her in placement. She then went missing from 12/04/13-19/04/13. In a Looked after review in March 2012 she was described as showing sexualised and gang-related behaviour in school. Child R has had regular supervised contact with her mother and grandmother. When she absconds she is often found at their home. Decision making by the SSCB The serious incident relating to Child R was discussed at a meeting of Southwark Safeguarding Children Board on 1st April 2014 and a decision was made to proceed with a Serious Case Review on the basis Child R was a Looked After Child who was ‘seriously harmed and there is cause for concern as to the way in which the authority, board or partners or other relevant persons have worked together to safeguard the child.’ This is specifically in understanding the management of Child R’s episodes of missing from her care placement. The purpose of the Serious Case Review (SCR) The purpose of the serious case review will be to cover the key areas of inquiry as set out in Working Together (2013) and to follow these principles and those of the Welsh model (2013) 48 http://wales.gov.uk/docs/dhss/publications/121221guidanceen.pdf Electronic guidance for arrangements for multi agency practice reviews. This is to identify improvements that may be needed and to consolidate areas of good practice. Any findings from the review should be translated into programmes of action leading to sustainable improvements. The SCR should be conducted in a way which: • Recognises the complex circumstances in which professionals work together to safeguard children • Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did • Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than just using hindsight • Is transparent about the way data is collected and analysed and • Makes use of relevant research and case evidence to inform the findings The serious case review will: • Seek contributions to the review from Child R and appropriate family members and keep them informed of key aspects of progress • Produce a report for publication available to the public and an action plan The report will include an analysis of the following, including what happened and why: • Ascertain whether previous relevant information or history about the child and/or family members was known and taken into account in professionals' assessment, planning and decision-making in respect of the child, the family and their circumstances. Establish how that knowledge contributed to the outcome for the child; • Evaluate whether the care plan was robust, and appropriate for Child R, the family and their circumstances; • Ascertain whether the plan was effectively implemented, monitored and reviewed and whether all agencies contributed appropriately to the development and delivery of the multi-agency plan; • Identify the aspects of the care plan that worked well and those that did not work well and why. Identify the degree to which agencies challenged each other regarding the effectiveness of the care plan, including progress against agreed outcomes for the child. An whether any protocol for professional disagreement was invoked; • Establish whether the respective statutory duties of agencies working with the child and family were fulfilled; • Identify whether there were obstacles or difficulties in this case that prevented agencies from fulfilling their duties (this should include consideration of both organisational issues and other contextual issues). Further relevant questions in relation to this case 1. How well did professional understand and manage the different risk factors influencing this case and the particular vulnerabilities of Child R, during the two years under review? 49 2. How well did professionals hear the voice of the child in our work with Child R? And to what extent were her unique diversity needs met by services? 3. Review of the application and use of children missing from home and care protocol and e-safety policy in this case Action required Relevant agencies to secure and check their records to see if they have any contact with Child R and her family, and inform the SSCB development manager. An independent management review should then be commissioned by senior management, based on a chronology and analysis of the agency’s involvement for agreement by the single agencies chief management team and submission to the SSCB serious case review group, within the agreed timescale. The Welsh model is a new methodology to this Board. There is a need for a timeline (in this case for a period of two years before this incident) and a genogram. Family history is important in this case and agencies are asked to review information from the time of their agencies involvement as a brief summary up to 01/02/2012, the beginning of the period under detailed review. The focus on the preceding 2 years will help understand how this information was taken into account for current decision making. The period in scope is 01/02/2012 to 27/03/2014. It has been extended to the date of arrest of the alleged perpetrator following the traumatic incident. For this final period, there will be a particular focus on whether the police support a protection and expectation that Child R attend school the following day was proportionate to the concerns raised. The panels concern was that her post incident care was informed by her care status. The timeline should be submitted to Ann Flynn SSCB development manager by 23rd May 2014 The agencies final agreed independent management review endorsed at Chief Officer level should be submitted to Ann Flynn SSCB development manager by 21st June 2014. Agencies that need to contribute to the review Independent Fostering Agency Child and adolescent mental health services (CAMHs) Children’s Charity A Greater London Children’s Social Care Met Police Met Child Sexual Exploitation Unit Met police Southwark Children’s Social Care Southwark Education Department Southwark looked after children doctor Review panel and reviewers There will be a review panel managing the review process and will play a key role in ensuring understanding about the case. There will be two reviewers. Both will take responsibility for scrutiny of the issues and one reviewer will take responsibility of completing the report. Working Together (2013) requires the SCR to be completed within six months and will be published. 50 Learning event At a later date there will be a learning event facilitated by the reviewers. This event is planned for 8th September from 9.30 – 3 pm and further details will be advised at a later date. The event will seek to engage differing levels of staff who worked with the family. The purpose of the learning event will be to start the process of learning and improvement at the earliest opportunity. Final Report The date for completion of the final report will be by 31 October 2014 51 Appendix 2: Genogram Serious Case Review Child R SSCB Response Agreed By the SSCB February 2015 Published July 2015 The Southwark Safeguarding Children Board received the Serious Case review at a meeting dated 24 February 2015 and endorsed the findings of the review. Further guidance was given at this meeting as to preparing the report for publication given the sensitivity of the issues and the report needed robust anonymisation to protect Child R A criminal investigation and court process have now concluded, in which the perpetrator was found guilty of a separate, lesser sexual offence against another young person. The offence of rape against R remains untried, but is held on the man’s records as a not-guilty plea. Southwark Safeguarding Children Board and its partners have sought to learn from Child R’s experience. This response should be read alongside the Serious Case review which gives fuller detail of the background in the two years leading up to the serious incident, the methodology of the review and its findings. The review found that no one could have predicted that this serious incident would have happened when it did. The review also found that the professionals responsible for R’s care as a looked-after child have not had a sufficient understanding of her history and of her level of vulnerability – a vulnerability which continues to expose her to significant risk of harm, especially when she is missing. One consequence has been a lack of alertness by these professionals about the risk associated with R’s patterns of going missing in this period. Child R is a young person in care who has struggled with the status of being ‘looked after’. She entered care as an older child, with a complex history which included neglect and abuse by her parent, and which left her with powerful feelings of rejection and blame by her family. She went on to have a series of 10 different social workers and 7 placements – a difficult and increasingly unsatisfactory experience of being looked-after and cared about. The methodology of the review involved as many of the practitioners and their managers as possible in a ‘learning event’ where themes emerging from agency reports and chronologies were used as discussion and challenge points. The event was based on a systems model and looked at whether the findings were unique to this case or could be used as a ‘window’ on the local child protection and care system. The ‘learning event’ was well attended and the Board is grateful to the practitioners for their openness in the review process. The process also sought to engage Child R and her mother although the family felt they could only be involved in a limited way. The Serious Case review identified eighteen learning points. An action plan has been implemented to address these points. The learning points are highlighted below: 1. Knowledge of a child’s psycho-social history is essential for effective assessments and planning for children. 2. In any agency, high turnover and sickness among workers and managers in a team carry the risk of loss of knowledge about cases and potential failure to carry out statutory duties. 3. Many looked-after adolescents find it hard to trust and communicate with professionals who are tasked with planning for them, and helping to keep them safe – especially when their key worker changes frequently. This can significantly constrain the ability of workers (and the local authority, as ‘corporate parents’) to respond to the young person’s wishes and feelings, and to meet their needs. 4. Effective care planning for looked-after children requires input from all partners in the form of either attendance or appropriate reports for the LAC Review process. However, LAC Reviews, as smaller, child-centred meetings, do not provide a suitable forum for the full professional network of those who know about and are working with the child. Thus, there may be no regular opportunity for this network to share significant information and concerns. 5. In addition, the LA needs to ensure that foster carers and the professional network are given full and good information about the determined needs of the child and the current plans, as well as relevant history. These actions can become more difficult for children placed out of borough. 6. Partners in safeguarding networks continue to struggle about the timing and appropriate use of escalation procedures, often leaving unsatisfactory situations going on for too long. 7. The choice, and timing, of local authority placements available for looked-after children does not always allow a matching of the child’s needs to the ability of the carers, especially for more complex and ‘hard to place’ adolescents. 8. Children and families cases will inevitably transfer to a number of different social workers and managers over time. For their work to be effective, case records need to include a genogram, an up-to-date chronology and a transfer summary. 9. The systems for sharing and transferring information about a looked-after child who moves schools do not always operate in a transparent and timely way. 10. Children missing from care are at greater risk of sexual exploitation, not only because of being outside of (corporate) parental control, but also because of the power and reach of social media. 11. There are potential tensions between Police and Children’s Social Care, regarding their respective roles and responsibilities in relation to a looked-after child at high risk of harm. This can result, as in this case, in an impasse and an outcome which is not appropriate for the child, even in the short-term. 12. The power and lure of electronic social media carry a risk of harm, particularly to vulnerable young people, which cannot be removed by professionals working with these young people. In the period of the review agencies started to address the concerns they identified as part of the review process. Notably Children’s Social Case has commissioned a service to offer return interviews to young people who are missing from care, research was commissioned to understand the barriers to young people who go missing from care returning back to their carer, health have increased their resources offered to looked after children, the CCG undertook a review of arrangements for looked after children’s services. The learning points have been shared in a cascade event with partner agencies and this will be repeated in September and in further cascade events later in the year. |
NC047196 | Death of a four-year-old girl, "Sophie", killed by her father in March 2014. He was convicted of her murder in May 2015 and sentenced to life imprisonment. Sophie was removed from her mother's care by Bedford Borough Council and placed with foster carers. Four months before her death, Luton County Court granted Sophie's father a Residence Order and she moved to Hertfordshire to live with him. A Supervision Order was made by the Court to Hertfordshire County Council. Father's son "Joe", Sophie's half-brother, and his siblings had been subject to a child protection plan under the category of neglect. Father and Joe's mother were involved in a child custody dispute. Concerns included: Sophie's mother's chaotic lifestyle and substance misuse; father's violence towards partners and his mental health problems; foster carers' reports of Sophie's fearful reaction to contact with her father. Findings include: assumptions about the rights of the birth family in court proceedings contributed to acceptance of a limited assessment which did not focus on the needs of the child; there were shortcomings in the response to suspicions of child protection risks which left Sophie at risk of harm. Recommendations include: assessments of friends and family as carers should be conducted with the same rigour as assessments of foster carers and adopters; establish a clear framework for the consideration of independent assessments conducted as part of legal proceedings - agencies should be prepared to challenge conclusions when necessary.
| Title: Serious case review ‘Sophie’: overview report LSCB: Hertfordshire Safeguarding Children Board Author: Edi Carmi, Jane Wonnacott Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Hertfordshire Safeguarding Children Board Serious Case Review Sophie Edi Carmi & Jane Wonnacott 11.05.2016 CONTENTS 1 INTRODUCTION 1 1.1 The reason for this serious case review 1 1.2 Agencies and geographical areas involved with this review 1 1.3 Review methodology 2 1.4 Scope and terms of reference 3 1.5 Family involvement 3 1.6 Practitioner involvement 3 2 SUMMARY OF WHAT HAPPENED 4 2.1 Introduction 4 2.2 Summary of key events 5 3 EVALUATION OF WHAT HAPPENED 10 3.1 Introduction 10 3.2 Sophie subject to an interim care order: June 2012 to September 2013 10 3.3 Father granted a Residence Order and Sophie accommodated by Bedford Borough October 12 3.4 Sophie accommodated by Bedford Borough Council and subject to a Supervision Order to Hertfordshire County Council: November - end of December 2013 13 3.5 Sophie living with her father and a Supervision Order to Hertfordshire: End of December 2013 - mid March 2014 14 4 FINDINGS AND RECOMMENDATIONS 16 4.1 FINDING 1: The assumptions about the rights of the birth family within family Court proceedings contributed to acceptance of a limited assessment and a lack of focus on the needs of the child. (Bedford) 16 4.2 FINDING 2: The confusion within the professional network about the role of an expert within care proceedings, led to insufficient challenge of the quality and conclusions of the independent social workers report (Bedford) 18 4.3 FINDING 3: All parties in the Court arena failed to appropriately consider the implications of the September 2013 psychiatric report, and consequently did not argue for a delay in the final hearing so as to develop a care plan better able to meet Sophie’s needs. 20 4.4 FINDING 4: Weaknesses in management within and between different local authorities and social work teams led to a lack of full understanding of potential risks (both Bedford Borough and Hertfordshire) 21 4.5 FINDING 5: The Child in Need planning and service delivery in this case did not provide co-ordinated multi-agency involvement (Hertfordshire) 24 4.6 FINDING 6: Shortcomings in the response to the suspicion of child protection risks may have left Sophie at risk of harm. 25 4.7 FINDING 7: Following a change of carers, contact with previous non abusing carers and siblings will usually be in the interests of the child's emotional well-being: this did not happen in this case 28 APPENDIX: TERMS OF REFERENCE 30 1 1 Introduction 1.1 The reason for this serious case review 1.1.1 This serious case review concerns the death of a four year old girl (known throughout this report as Sophie) who was killed by her father in March 2014. He was convicted of her murder in May 2015, sentenced to life imprisonment and ordered to remain in prison for 21 years before being considered for release. 1.1.2 Sophie had previously been removed from her mother’s care by Bedford Borough Council and placed with foster carers. Four months before her death, Luton County Court had granted Sophie’s father a Residence Order and she moved in with him at the end of December 2013. Sophie's father lived in Hertfordshire and a Supervision Order was made by the Court to Hertfordshire County Council. 1.1.3 Statutory guidance1 requires that when a child has died and abuse or neglect is known or suspected, the Local Safeguarding Children Board must carry out a serious case review. As Sophie was resident in Hertfordshire at the time of her death, the chair of the Hertfordshire Safeguarding Children Board commissioned this review. Although led by Hertfordshire Safeguarding Children Board the review has taken place with full cooperation from Bedford Borough Safeguarding Children Board. 1.2 Agencies and geographical areas involved with this review AGENCY ROLE Agencies linked to Bedford Borough Council area Bedford Borough Council Children’s Services Provision of social work services to Sophie and her siblings. Independent Review of plans for Sophie whilst she was placed with foster carers. Bedford Borough Council Legal Department Legal advice and services to the Local Authority in relation to public law proceedings for Sophie and her siblings. Independent social work service Provision of expert assessment for the Court in relation to Father’s parenting capacity. Independent fostering agency Provision of foster carers for Sophie and her siblings. Community pre-school Pre-school in area where foster carers lived (unnamed unitary authority). Cafcass Provision of children's guardian for the Court proceedings in respect of Sophie Community Health Trust Provision of community health services in the area where the foster carers lived Bedfordshire Police In relation to an incident in November 2013 1 Working Together to Safeguard Children 2013 (updated in 2015) 2 Agencies linked to Hertfordshire County Council area Hertfordshire County Council Children’s Services Provision of social work service to Sophie and her siblings, prior to her mother’s move to Bedford Borough. Provision of social work service to Sophie’s half-brother Joe. Provision of social work service to Sophie after a Residence Order was awarded to her father. Provision of children’s centres. Provision of nursery school for Sophie. Hertfordshire County Council Legal Department Legal advice and services to the Local Authority in relation to proceedings for Sophie and for Joe Hertfordshire Community NHS Trust Health visiting services. Hertfordshire Partnership University Foundation Trust Mental Health services for Father. NHS England GP and primary care services Hertfordshire Police Involvement in domestic violence allegations against Father in relation to Sophie's and Joe's mothers 1.3 Review methodology 1.3.1 Once the decision to carry out a serious case review had been made careful consideration was given to the best method of conducting the review taking account of the principles set out in statutory guidance at the time. A further consideration was the ongoing criminal investigation. 1.3.2 A review panel consisting of senior managers from Bedford Borough Council and Hertfordshire County Council was appointed and chaired by Keith Ibbetson, Independent Consultant and standing chair of the Hertfordshire serious case review subcommittee. Two experienced independent lead reviewers, Edi Carmi and Jane Wonnacott were commissioned to work with the panel to carry out the review and produce the final report. 1.3.3 The panel received reports from most of the agencies identified in section 1.2 above. Information was gathered directly through conversations between the lead reviewers and the foster carers, the foster care agency, the pre-school Sophie attended when she was living with her foster carers and the children's centres in Hertfordshire. 3 1.4 Scope and terms of reference 1.4.1 The full terms of reference are set out in the appendix of this report. 1.5 Family involvement 1.5.1 Family members contributed to this review through meeting with the lead reviewers: Sophie’s mother, maternal grandmother and aunt, Sophie’s father, the mother of Sophie’s half-brother Joe. 1.6 Practitioner involvement 1.6.1 Practitioners participated in the process through: interviews with the authors of the individual agency reports, lead reviewers meetings with staff groups: o children's centre o pre-school in the unnamed unitary authority o nursery school in Hertfordshire o social workers in Bedford Borough, Hertfordshire and the independent social work agency o all practitioners involved with the family lead reviewers’ individual meeting with: o foster carers o supervising social worker o ex member of staff from Bedford Borough Council 4 2 Summary of what happened 2.1 Introduction 2.1.1 This serious case review concerns the death of a four year old girl killed by her father in March 2014. This was less than three months after she moved to live with him following the decision at Luton County Court to grant him a Residence Order. The child's father was convicted of her murder in May 2015. 2.1.2 The child, called Sophie for the purposes of this review, was one of a sibling group of three children. Sophie was born in Hertfordshire, where there were concerns for the children in the family because of domestic violence incidents relating to the mother's partners. This included a violent incident with Sophie's father, which was reported to police and children's social care. Mother was advised by children's social care to separate from Father. 2.1.3 Mother and siblings moved to Bedford Borough and from this point there was only one further contact with Sophie's father whilst Sophie lived with her mother. 2.1.4 Bedford Borough Council removed all three siblings from their mother in March 2012, due to mother's continuing chaotic lifestyle, substance misuse and domestic violence in the home. An interim care order was obtained and Sophie and siblings placed together with foster carers in another unitary authority. 2.1.5 When care proceedings are initiated, other family members must be considered as potential alternative carers; consequently Sophie's father was located, expressed a wish to be her carer and became subject to an assessment. By this point he had been involved in another relationship and had another child, called Joe for the purposes of this serious case review. The father and Joe's mother lived in Hertfordshire, but did not live together. Joe lived with his mother, but had regular contact with his father. 2.1.6 This review relates to a complex set of circumstances involving two family groups, two local authorities and foster carers residing in a third area. One of the local authorities is a large shire county and the other two are unitary authorities covering much smaller geographical areas. 2.1.7 In order to assist the reader, the table below sets out the relationships and names used in the report. These are not the real names of the individuals concerned. Term used in report Relationship with Sophie Age at March 2014 Home address in March 2014 Sophie Subject of review 4 years Hertfordshire Sophie's mother or Mother Mother of Sophie Bedford Borough Council Sophie's father or Father Father of Sophie Hertfordshire Siblings Maternal half siblings Joe Younger paternal half sibling 21 months Hertfordshire Joe’s mother Mother of paternal half sibling Hertfordshire Joe's siblings Joe's maternal half siblings Foster carer/s The people Sophie and her 2 maternal half siblings lived with prior to Sophie's move to her father Unnamed 'Unitary authority' 5 2.2 Summary of key events 2.2.1 The following table provides the key events within Bedford Borough and Hertfordshire County Council. Bedford Borough Hertfordshire 2009-2010 Mother pregnant with Sophie. Living in Hertfordshire. Domestic violence incidents relating to partners included a violent incident with Father reported to police and children's social care. Mother was advised by children's social care to separate from Father and his contact with Sophie ceased in Hertfordshire. 2010 Sophie born and lived initially in Hertfordshire with Mother and elder half sibling before the family moved to Bedford Borough. Mother was advised by children's social care to separate from Father and mother and children subsequently moved to Bedford Borough. Father’s contact with Sophie ceased in Hertfordshire. 2011 Father began a relationship with a new partner, another woman with children. March 2012 Sophie and siblings placed with foster carers and care proceedings initiated by Bedford Borough Council. June 2012 Joe, Father's child with his new partner was born in Hertfordshire. Parents separated in August. Joe remained with his mother but had regular contact with Father. November 2012 Father became party to the care proceedings in respect of Sophie after DNA tests confirmed his paternity and the Court ordered there should be an assessment of his suitability to parent. January 2013 Domestic violence incident between Father and Joe's mother led Hertfordshire social work team 1 to undertake assessments of Joe's welfare: The case was “stepped down” to a CAF2 when assessments ended in March 2013. February 2013 Expert assessment of Father commenced in early February, followed by the first contact session between Father and Sophie later that month. The social worker for Joe in Hertfordshire social work team 1 became aware that Father was being assessed as prospective carer for Sophie. March 2013 Father’s psychiatrist became aware that Father was trying to “get custody” of his 2 Stepped down to a CAF is the process when children's social care cease to be involved working with a family as the lead professional and refer to other agencies to provide support 6 daughter. The psychiatrist assessed Father as stable and functioning well. May 2013 Sophie’s foster carers expressed concerns at a Looked After Child review about Sophie’s reaction to contact with Father. An interim report on the parenting assessment was completed by the Court appointed expert. This recommended that Sophie should be offered the opportunity to be placed with Father but further work was required. June 2013 Further concerns about Sophie’s reactions to contact with Father were expressed by the foster carers at the Looked After Child review. Joe’s mother confirmed to her social worker that her relationship with Father had resumed, although immediately after this both she and Father raised concerns about each other’s behaviour, which led to a child protection conference. A private law application was made by Joe’s mother for Residence and Prohibited Steps Orders in respect of Joe, to prevent Father from removing him from her care. Eight days later Father also made an application for a Residence Order and Prohibited Steps Order for Joe. The day after Father’s application, Hertford County Court made a Contact Order specifying that Father should have contact with Joe from 7.30am on Saturdays to 7.30pm the following Tuesday (starting at the end of June) i.e. Joe would spend half the week with his father and half with his mother. The Contact Order was timetabled for review in September 2013. Early July 2013 Luton County Court made a number of directions designed to provide sufficient additional information from Father's medical records, Hertfordshire Police and Hertfordshire County Council (children's social care) in order to assess Father’s capacity to parent Sophie. Late July 2013 A child protection conference in Hertfordshire made Joe and siblings subject of a child protection plan (category neglect). August 2013 Extended contact arrangements between Father and Sophie began: this decision was taken at 'professionals' meeting between the children’s guardian and the independent social work service. A legal planning meeting in Hertfordshire decided against legal proceedings in respect of Joe and half siblings but to work with the child protection plan. 7 Early Sept 2013 Final report by the Court appointed expert providing the parenting assessment which states ‘I believe that we are at the point when Sophie should move to her father’s care’ and ‘I am concerned that the toing and froing will start to have an impact on Sophie and that decisions need to be made to progress the matter forward’ One day later a psychiatric report commissioned by Father’s solicitor was filed. The latter report (from a locum psychiatrist in the team treating Father) raised concerns about Father’s behaviour in the interview with the psychiatrist. Late Sept 2013 Bedford Borough social worker filed a statement agreeing with the independent social work assessment: Sophie should be placed with Father as soon as possible. 4th October 2013 Luton County Court made a Residence Order to Father in respect of Sophie and an Interim Supervision Order to Bedford Borough Council. Hertfordshire County Council were directed to confirm whether they would accept a final Supervision Order in their favour by 18th October and file and if so file an addendum care plan. 1st Nov 2013 Final Court hearing in respect of Sophie. Residence Order and Parental Responsibility Order made in favour of Father and Supervision Order to Hertfordshire County Council for 12 months. Sophie to be accommodated under s20 and remain with her foster carers until Father had suitable accommodation. Sophie was allocated in Hertfordshire to a student social worker in social work team 2 (called allocated worker team 2). 14th November 2013 A private law hearing in respect of Joe at North and East Hertfordshire family Proceedings Court resulted in a Contact Order specifying Father should have contact with Joe from 7pm Sunday to 7pm Tuesday. A section 7 report3 to be prepared and a review hearing to take place in February 2014. Middle November S.47 enquiry by Bedford Borough social worker following report from foster carer that Sophie had told them that she had 3 Under Section 7 of the Children Act 1989 a Court may ask the local authority for a welfare report when they are considering any private law application. 8 2013 been hit by Father during contact. The enquiries concluded that no further action was needed. Dec 2013 The foster carers and fostering support worker informed Bedford Borough of their increased concerns about Sophie’s move to Father. The Bedford social worker replied saying that Father and Sophie would need support as a “Child in Need”. End Dec 2013 Sophie moved in with Father. Early Jan 2014 Sophie’s case file closed to Bedford Borough. Jan 2014 Sophie started new nursery school in Hertfordshire. Father was visited by two workers from children's social care in Hertfordshire, one in respect of the section 7 report (team 1) and another in respect of the Supervision Order (team 2). The school also carried out a home visit in early January. Early Feb 2014 The Hertfordshire social worker from social work team 1 filed the section 7 report in Court. This did not support Father’s application for the Residence Order and Prohibited Steps order. Father disputed the reports contents. 11.02.14 Sophie’s allocated worker (team 2) e-mailed Bedford Borough Council alerting them that the 'placement' might break down, and requesting a professionals meeting: this was agreed for 19.03.14 12.02.14 The allocated worker (team 2) wrote to Father to make an appointment for a home visit to Sophie and Father for 24.02.14 14.02.14 Sophie's last day at school: school broke for half term Father telephoned to speak to the allocated worker's manager (team 2) to cancel visit for 24.02.14. He also tried to speak with Joe's worker's manager (team 1) to express his anger at the s.7 report. 21.02.14 and 25.02.14 Joe's mother advised by allocated worker (team 1) that she could stop contact between Joe and Father if she has concerns 26.02.14 Sophie did not return to nursery on 24th February after half term, but Father emailed 9 the school on 26th to say they were away and Sophie would return the next week on Monday / Tuesday. Supervision decision that allocated worker (team 2) should not visit or speak to Father alone. Agreed case to be transferred to another worker in team 2 28.02.14 Supervision note (team 2) to hold professionals meeting with Joe's allocated team 1 worker and arrange a CIN meeting for Sophie. 03.03.14 Father cancelled arranged home visit by the allocated worker (team 2) 04.03.14 Supervision of allocated worker (team 2): agreed to undertake joint visit the next day. Re-iterated previous supervision decisions. 05.03.14 Unannounced home visit by allocated worker and team manager (team 2) - no one answered door. The allocated worker visited Sophie's school and spoke of arranging a Child in Need meeting 06.03.14 (school records) Father contacted school to say they were still in Leeds. School 'record of concern' completed and children 's social care (team 2) informed that school had concerns for Sophie's safety 07.03.14 (children's social care records) Call from the school to social work team 2 to 'discuss concerns' that Sophie not yet returned to school. No action recorded. 10.03.14, 11.03.14 and 12.03.14 (school records) and 11.03.14 (social care records) Father emailed the school again to say he was still in Leeds. The school logged a record of concern on each of the 3 days, and the social work team was contacted daily with concern for Sophie's safety and chasing up arrangements for the Child in Need meeting (Source is school records). Social care records show a call on 11.03.14 from school with concern for Sophie's safety 12th March Father calls emergency services for assistance. Sophie died later that day 10 3 Evaluation of what happened 3.1 Introduction 3.1.1 The period under review is from 13.06.12 (the date of Joe's birth) to Sophie's death on 12.03.14. Information about prior events has been considered insofar as they could or should have affected practice with Sophie during the review period. 3.2 Sophie subject to an interim care order: June 2012 to September 2013 3.2.1 During this period Sophie was living with foster carers in another unitary authority, along with her siblings and throughout this time she remained the subject of an Interim Care Order to Bedford Borough Council. 3.2.2 The focus of work was identifying a permanent placement for Sophie and as part of this process her birth father was appropriately identified and located. He expressed an interest in parenting her and a viability assessment4 of Father as a potential carer was undertaken by a social worker at Bedford Borough Council. This assessment was comprehensive, identified the significant issues for further consideration and should have provided a good basis for subsequent assessments. 3.2.3 In November 2012 Luton County Court directed that an expert assessment should be carried out to evaluate Father’s capacity to parent Sophie. An independent social worker service (agreed by all parties) was instructed to provide an expert assessment for the Court. All parties agreed to the particular expert concerned. 3.2.4 This expert assessment was of Father, but needed to run alongside a full understanding of Sophie and her needs. This did not happen. There was reliance by Bedford Borough Council on the independent social worker to address all aspects of social work with Sophie. This resulted in a significant gap in the overall assessment process from the start. 3.2.5 The letter of instruction agreed between all parties in the legal proceedings did not include all the relevant issues identified by the viability assessment and Bedford Borough Council Children's Services did not clearly establish the role and boundaries of the independent assessment vis a vis other aspects of the social work task. There was limited social work input from the local authority social worker and social work assessments that should have been undertaken for Sophie and her siblings as a foundation for care planning did not take place. 3.2.6 There were intermittent concerns by the foster carers. Following the introduction to her father, increased contact and overnight stays with him, Sophie exhibited disturbed behavioural patterns. The view taken by the independent social worker undertaking the expert assessment was that, in the context of her earlier childhood experiences, the recent changes had led to the return of such indications of inner trauma, rather than the disturbed behaviour being caused by the contact with Father itself. Whilst this was possible, it was an assumption and was not adequately investigated or challenged by any other professional. 4 A viability assessment is a short but detailed assessment, which gives an overview of whether further assessment is warranted of a potential carer for a particular child, usually a parent, relative or family friend. 11 3.2.7 The assessment was completed in September 2013 and recommended that Sophie should move in with her father. The assessment was limited in its scope, relied largely on self-reported information and observation of the father/child relationship in supervised contact. It did not address all the questions in the letter of instruction, did not gather information regarding Father’s history of domestic violence and involved limited triangulation of information provided, as could have been obtained through discussion with father's ex-partners and relatives (see 4.3 for further discussion). 3.2.8 Father's solicitor had requested a report of Father's mental health from the team responsible for his treatment. This was undertaken by a locum psychiatrist, who whilst not knowing Father previously, provided a highly relevant report to the proceedings (see 4.3 for further discussion). 3.2.9 The content of this report should have called into question Father’s ability to manage stress, describing how he became so angry that a colleague overheard and knocked on the door to check on the 'safety' of the psychiatrist. Father's anger continued to such an extent that the psychiatrist felt 'intimidated' by him. When the psychiatrist tried to end the interview, Father would not leave. The psychiatrist's colleague joined the interview to calm Father down. This took 45 minutes. It is of note that the accounts that Father gave during this interview were inconsistent, and the anger was partly his response to challenge on such inconsistencies. 3.2.10 What is surprising is the apparent insufficient scrutiny of this report by all those involved in the legal proceedings. This was partly because it was filed late, after the assessment of the independent expert. However, the report ends with a judgement that the prognosis for Father was good on the basis of his stable employment and consistent use of medication in the previous year. It has been suggested that this positive prognosis may have contributed to the lack of full consideration of the implications of the content; however, that statement referred to the prognosis of Father's mental health (the purpose of the report) as opposed to his parenting. In fact the cautionary suggestion of possible psychological input to help him work on his difficulties 'in a deeper way', mentioned with this prognosis, should have alerted the reader to the need for further assessment. 3.2.11 Meanwhile, a social worker in Hertfordshire (team 1 allocated worker) was the social worker for father’s son. Father had a relationship with his son's mother after his relationship with Sophie's mother ended. This boy (called Joe for the purposes of this review) was aged one year old in the autumn of 2013. After Father applied to the Court for a Residence Order and Prohibited Steps order in respect of Joe, a Contact Order was made by Hertford County Court in June 2013. This stated that Joe should spend from Saturday morning to Tuesday evening living with his father and the rest of the week with his mother. Joe was also subject to a child protection plan as a result of allegations made by Father of his ex-partner's parenting. No safeguarding checks were requested by the Court at this point as would have been expected practice. This appears to have been due to an administrative error. 12 3.2.12 The high level of contact that Father had with Joe should have been fully understood in relation to the assessment of him as a carer for Sophie, but during this period there was limited contact between social workers in Bedford Borough and in Hertfordshire. The independent social worker undertaking the expert assessment of Father did not obtain information on Father's background from Hertfordshire, nor any feedback from his attendance at Children's Centres in Hertfordshire (where he went to increase his parenting skills). It is not clear if either the independent social worker, or the Bedford Borough social worker appreciated that Joe was spending half his week with Father and that Father had applied for a Residence Order for him. Most critically, the advice provided to Father by practitioners in Bedford Borough to give priority to Sophie, did not take account of Father's strong desire to have his son live with him and perhaps his inability to do as advised. 3.3 Father granted a Residence Order and Sophie accommodated by Bedford Borough October 3.3.1 All parties to Sophie's Court proceedings (Bedford Borough Council, the child via the Cafcass Guardian, the legal representatives for Mother and Father) agreed to recommend to the Court that: Father should be awarded a Residence Order in respect of Sophie, giving him parental responsibility She should move in with him as soon as he was able to find suitable accommodation Hertfordshire County Council should have a supervision order for 12 months. 3.3.2 Father was awarded a Residence Order by Luton County Court in October 2013 and an Interim Supervision Order was made to Bedford Borough Council. This interim order was in place whilst agreement was sought from Hertfordshire County Council that it would accept the Supervision Order, as father lived in their area. The Court asked Hertfordshire to provide an addendum to the care plan. Sophie remained with her foster carers and Father agreed that she should be accommodated under s.20 Children Act 1989 by Bedford Borough Council. 3.3.3 Arrangements for Sophie at this point required close work across local authority and health boundaries in order to keep her safe and develop a clear transition plan. This was because: Sophie resided with the foster carers in the unnamed unitary authority and father now held parental responsibility: this was a significant change in Sophie’s legal status as it meant that if the local authority were sufficiently concerned about Father and felt that Sophie should not move to him, they would have to return to Court for a further order (unless Father agreed with the local authority). Sophie was a looked after child and as such Bedford Borough Council were responsible for planning for her care; Bedford Borough Council had also been awarded an interim Supervision Order. The ultimate plan was for Sophie to live with her father in Hertfordshire with a Supervision Order managed by Hertfordshire children's social care. 3.3.4 The close working across boundaries that was required at this stage did not happen. There was a lack of clarity as to who had overall responsibility for driving the transition plan forward, and this did not get rectified in the transitional period before Sophie moved at the end of December 2013. 13 3.4 Sophie accommodated by Bedford Borough Council and subject to a Supervision Order to Hertfordshire County Council: November - end of December 2013 3.4.1 The final hearing which made the Supervision Order to Hertfordshire County Council was on 01.11.13. Sophie remained with her foster carers in another unitary authority, until the end of December, still accommodated under s.20 Children Act 1989 to Bedford Borough Council. There remained at this point services from three different local authorities. A student social worker from Hertfordshire social work team 2 was allocated the case (allocated worker team 2). 3.4.2 During this period the foster carers continued to raise concerns about the move to Father and the impact contact with him was having on Sophie and on one occasion this involved an allegation from Sophie that her father had hit her. This was investigated by Bedford Borough Council and it was concluded that there was no need for further action . The conduct of this enquiry had shortcomings (see 4.6), with a lack of multi-agency strategy discussion, lack of involvement of the Hertfordshire team 2 allocated worker and seven days delay before Sophie was asked about the incident. 3.4.3 Meetings were held in both Hertfordshire and Bedford to plan the transition; however the meeting in Hertfordshire (13.11.13 )took place without representation from Bedford Borough Council (the Bedford Borough social worker was unavailable as she was investigating Sophie's allegation) and the one in Bedford ( 9.12.13) had no Hertfordshire County Council representation. At this last meeting, following Father's cancellation of two contacts with Sophie, according to the supervising social worker, Father expressed his view he was not yet ready to have Sophie to live with him. 3.4.4 The foster carers and their supervising social worker5 raised concerns again about the planned move for Sophie in an email to the Bedford Borough social worker on 20.12.13. This referred to Sophie's ongoing references to Father having smacked her (on the one occasion), her reluctance to go to contact with him, her subsequent disturbed behaviour and Father missing or being late for contact since the granting of the Residence Order. Also mentioned was how Father would cope given that he also had his son for three nights a week and that Sophie would be likely to have an increased need for attention, after the move. 3.4.5 The Bedford Borough Council's social worker's response to this communication referred to Sophie continuing to be supported as a Child in Need and to the fact that the independent social work service (which had provided the expert assessment at Court) had given positive feedback in relation to a recent supervised overnight contact. There was more value being put here on what was regarded as independent observations of the father-child relationship, as opposed to the foster carer accounts, perhaps because it was consistent with the perceptions already held of Father and a view of what was best for Sophie that had been formed early in the assessment . 3.4.6 There is no evidence that the foster carers concerns were communicated to the Hertfordshire team 2 allocated worker, despite the fact of the Supervision Order. 5 Supervising social worker is the social worker who has the role to support the foster carers: in this case the foster carers were provided by a private fostering agency and the supervising worker was employed by that agency 14 3.4.7 Meanwhile, the Court hearing in respect of Joe in June 2013 had not asked for any safeguarding checks by Cafcass (as would usually be the case) and it was only at the further hearing in November 2013 that the Cafcass officer in Court that day informed the Court of the child protection plan for Joe. At this point the Court requested that Joe’s social worker (team 1 allocated worker) prepare a section 76 welfare report. 3.5 Sophie living with her father and a Supervision Order to Hertfordshire: End of December 2013 - mid March 2014 3.5.1 Sophie moved into Hertfordshire to live with her father between Christmas and New Year 2013 and the Hertfordshire allocated team 2 worker visited her shortly after this in early January, along with the Bedford social worker. Bedford Borough Council then closed Sophie's case and there was no further contact between Sophie and her former foster carers and siblings. Contact was intended to resume once Sophie was considered to be settled. Although this plan was made in good faith and believed to be in Sophie’s best interest the evidence base for this decision is not clear (see 4. 7). 3.5.2 Although Hertfordshire allocated worker team 1 filed the section 7 report with the Court in early February 2014 the significance for Sophie of its conclusion (that Father should not be awarded a Residence Order in respect of Joe) was not considered by either the team responsible for her, team 2, or the team responsible for Joe (team 1). 3.5.3 Father responded angrily to the section 7 report, disputing some of the content. This content included an allegation that Father kicked an elder sibling of Joe under the table in a restaurant and that he had hit Joe's mother's head against the wall. The father expressed his anger on the phone to Sophie's allocated team 2 worker, who heard him being verbally abusive to Joe (aged 18 months) during the call. She reported this to Joe's allocated team 1 worker. 3.5.4 The Hertfordshire allocated team 1 worker supported Joe's mother in stopping contact between Joe and his father on the basis of his reported behaviour and anger. Meanwhile, due to increasing concerns that Sophie may not be able to remain with Father, Sophie’s allocated team 2 worker tried to arrange a meeting with Sophie's previous social worker at Bedford Borough Council to discuss the possibility of Sophie being included in plans for her half siblings on the basis of a likely 'placement' breakdown. A meeting to discuss the concerns was arranged for mid March: the delay was due to finding a time when the Hertfordshire allocated worker (team 2), the Bedford Borough social worker and the Bedford Borough consultant social worker were all available. 3.5.5 At this stage, Father's behaviour was perceived (by allocated worker team 1) to be a concern for Joe, such that ceasing contact was warranted. In team 2, whilst it was considered that discussions were required about Sophie's future with Bedford Borough Council, there was no perceived urgency to intervene. See 4.6 for further discussion of this response. 6 Section 7 report: A Court may ask the local authority for a welfare report when they are considering any private law application under the Children Act 1989; 15 3.5.6 Meanwhile Sophie's school were unaware of father's history of domestic violence and mental health difficulties or of the subsequent developments regarding the Residence Order for Joe. Sophie continued to attend school until half term, but did not return following this holiday and her father contacted the school providing explanations involving visiting relatives 'up North' and car problems (see chronology of key events p.11 and p.12). 3.5.7 The first the school knew about Father's history was by chance through another Children's Centre on 03.03.14. Mention was made of Father's domestic violence history and possible changes in his access to his son. The other Centre's staff member advised to avoid seeing Father on his own because he 'may twist what is said'. 3.5.8 Father cancelled home visits with the allocated team 2 worker on 24.02.14 and 03.03.14. By this point there had been a decision within team 2 that the worker should not visit on her own due to 'escalating verbal aggression and serial telephone calls/texts/VMs'[VM presumably refers to voice mails] and for a Child in Need meeting to be held along with a professionals meeting with Joe's allocated worker (team 1). A joint visit by the allocated worker and her team 2 manager was undertaken on 05.03.14, but there was no answer and the father's car was not there. The allocated worker (team 2) called at the school to check if Sophie was attending, learnt she was expected back that day and left a message about arranging a Child in Need meeting. 3.5.9 The next day Father contacted the school to say he was still in Leeds. The school completed a 'record of concern' and according to their records stated the school had concerns for Sophie's safety. However the call is logged in children's social care on 07.03.14, without mention of concerns for Sophie's safety, just the information she had not yet returned to school. 3.5.10 When Father emailed the school again on 10.03.14 to say he was still in Leeds, the school logged a record of concern and left messages on the allocated team 2 worker's phones (landline and mobile). The school's chronology indicates that they communicated concern for Sophie's safety as well as chasing up the prospect of a Child in Need meeting. 3.5.11 The next day (11.03.14) the school again called the allocated team 2 worker, who returned the call and was told about the concerns for Sophie's safety. The school referred to the advice they had recently been given about not seeing Father on his own, as well as the issues around contact with his son stopping. The allocated worker (team 2) was planning to follow up with Joe's allocated worker (team 1), to check if she had had any recent contact with Father. At this point school staff understood Sophie to still be in Leeds, in accordance with the information Father had provided. 3.5.12 The father telephoned emergency services for help the next day, 12th March 2014. Sophie died later that day. 3.5.13 Through the criminal investigation it was subsequently discovered that Sophie and her father, although they had travelled during half term, returned to their home and Sophie's father deliberately misled professionals and avoided contact with social workers. 16 4 Findings and recommendations Introduction With hindsight one of the puzzling aspects of professional practice in this case was consensus within the professional network in Bedford Borough and in the care proceedings that Sophie should move to live with her father permanently, despite the fact that she had not known him previously, and that there had been allegations against him of domestic violence in Hertfordshire with both Sophie’s and Joe’s mothers. Moreover, in the face of Sophie’s disturbed behaviour following contact, the lack of consideration of alternative options appears as difficult to comprehend. Findings 1, 2 and 3 explain why practitioners and their managers made such decisions at the time and why the course of action was at the time perceived to be in Sophie's interests. The rest of the findings focus on explaining why, following the making of the Residence Order to Sophie’s father, the risk to Sophie was not sufficiently recognised and acted upon before her death. 4.1 FINDING 1: The assumptions about the rights of the birth family within family Court proceedings contributed to acceptance of a limited assessment and a lack of focus on the needs of the child. (Bedford) 4.1.1 This finding concerns the pressure described by practitioners to place a child with a birth parent unless there is overwhelming evidence to indicate that this is not in the child’s best interests. They believed that in this case there was insufficient information to indicate that it was not in Sophie’s interests to live with her father. This appears to have contributed to a fixed view that Father would be able to care for Sophie, with insufficient analysis of his history of domestic violence or consideration that he may not be sufficiently skilled to be able to look after a child with Sophie’s particular needs. 4.1.2 If a child is placed with foster or adoptive carers, the carers will have undergone a rigorous assessment process, which will include taking references, speaking to relevant family members, ex-partners and being approved by a panel of experts. By contrast assessment of family members can be less thorough, with the process to some extent varying between different local authorities and dependent on the circumstances of the case. However, there is generally a belief that the benefits of retaining a child within the family, will lead to a view of what is ‘good enough parenting’ as opposed to the particular skills required by foster parents to be able to parent a child who may have experienced trauma. In this case, the legal representatives present at Court when the Residence Order to Father was made, noted that everyone present was delighted that Sophie would be getting the opportunity to live with her father and within her birth family. 4.1.3 In some cases this approach may be acceptable when a child is moving to someone they know, who has previously been successfully involved in her/his care and about whom there are no known concerns. In this instance though Sophie’s father had no prior relationship with her before he was assessed. Moreover there were known concerns about him in Hertfordshire, with new ones arising during the assessment process. 17 4.1.4 The pressure perceived by practitioners to place a child with a birth parent unless there is overwhelming evidence to indicate this is not in the child’s best interests, partly led to less rigour in the assessment. Notable in this, was the acceptance of Father’s self-reported explanations relating to the circumstances of domestic violence, without triangulation of evidence from Hertfordshire files and without speaking face to face with family members (Father’s parents and siblings) and ex-partners. Given that Father suggested he would, as a single parent, receive help and support from his siblings, the lack of such corroboration is a major omission of the assessment process. 4.1.5 The early view that Sophie should be placed with her birth father, contributed to an assessment approach which started from the father’s capacity to parent based mainly on observations of the two together. This is in contrast to an assessment of Sophie’s needs and the qualities this would require in a parent. This meant that there was inadequate consideration given to: Sophie’s particular needs and the skills required to help her overcome her traumatic earlier life experiences, as evidenced by a report from an educational psychologist in April 2013, which advised that Sophie’s previous abuse and neglect led to her difficulties socialising and her destructive behaviour; this report recommended she be provided with a consistent environment Father’s ability to cope with the stress of being a single parent managing such difficult behaviour and in particular his response to challenge: the report from a psychiatrist in September 2013 which expressed concern about his agitated, angry and distressed behaviour in a meeting. Father’s conflicting intentions with regard to his application for a Residence Order for his son Joe was not sufficiently explored, especially the implications of how father’s different emotional commitments to the children and Joe living half the week with him would be compatible with Sophie’s needs 4.1.6 The view that the Court would expect Sophie to be placed with her father led to insufficient understanding of Father’s motivations to look after both her and Joe, and the extent to which both of these desires needed to be understood together. The advice apparently provided as part of the assessment process to put Sophie before Joe was naïve, ignoring the existing bonds between father and son which had yet to develop between father and daughter. 4.1.7 The foster carers told the authors that as time went on they thought it became clear that Father's priority was with his son: this was particularly evident when his contact with his son ceased in November 2013 during the child protection enquiry following Sophie's allegation that he had hit her. He expressed this anger to the carers. However, by this time the Residence Order was already made. Sophie’s foster carers and their supervising social worker become increasingly convinced that a move to Father was not in Sophie's best interests and this was communicated to the Bedford social worker However, whilst they anticipated that Father would be unlikely to be capable of parenting Sophie in the long term, and therefore let it be known that they would be happy to have her returned to their care, neither foster carers nor anyone else considered Sophie to be at risk of significant physical harm. 18 Recommendation 1 Bedford Children's Services to review whether the assessments of friends and family as carers for children are conducted with equivalent rigour to the assessments of foster carers and adopters current policies, guidance and procedures for assessment of friends and families adequately supports this requirement Hertfordshire LSCB to consider if this recommendation is also relevant to the County Council. 4.2 FINDING 2: The confusion within the professional network about the role of an expert within care proceedings, led to insufficient challenge of the quality and conclusions of the independent social workers report (Bedford) 4.2.1 A central problem with the assessment process was the lack of challenge to the expert assessment undertaken by the independent social worker. One of the contributory factors to this was a misunderstanding and confusion about the expert’s role in relation to Sophie, the Court and to the Bedford Borough Council's social work service. 4.2.2 The nominated expert was an independent social worker from a private provider, an independent social work service. The provider (and the particular independent social worker) had other contracts with Bedford Borough, being used for a variety of functions including assessments and contact supervision. 4.2.3 In this case the expert was instructed by all the parties involved in the legal proceedings. The agreed letter of instruction itself had shortcomings in terms of specifying what needed to be assessed, but was clear that this was an assessment as part of the legal process. 4.2.4 The assessment itself was predominantly based on self-reported information by father as well as observation of him and Sophie together. As mentioned in finding 1 the assessment did not involve triangulation, and involvement of family and ex-partners, nor full information from other involved agencies with Sophie or with Father. Given these weaknesses, it is puzzling on the face of it why others involved in the legal proceedings all accepted its recommendations without challenge. 4.2.5 A major factor behind this was the role confusion around the status and function of the assessment and of the independent social worker. 4.2.6 Firstly it was the only assessment undertaken as part of these proceedings, and as such seems in the eyes of the practitioners to be seen as being the assessment to determine Sophie’s future, as opposed to one limited to the father’s parenting capacity. The local authority did not undertake its own assessment of Sophie’s needs and hence there was insufficient weight in the decision making given to Sophie’s particular additional needs as identified by the educational psychologist (see 4.1.6), foster carers or nursery she attended. 19 4.2.7 Secondly the independent social worker’s role and authority grew as she appears to have become involved in case decision making beyond the brief of the assessment. There were many examples of other practitioners referring to the independent expert as ‘the’ social worker and referring to her views as opposed to those of the local authority case holding social worker. A clear example of the blurred boundaries was a professionals meeting in August 2013, when two members of the independent social work service along with the children’s guardian effectively made the decisions about the care plan7, without the case holding local authority social worker, who was unable to be present at the meeting. The independent social worker told this review that s/he understood that such decisions were recommendations to the local authority social worker, but others perceived this as the forum at which the decisions were made. For considerable periods records show there to have been limited social work contact by the local authority as opposed to the independent expert. 4.2.8 A third factor in the lack of challenge was a perception communicated by practitioners to the author of the Bedford Borough Children's Services management review, that because the expert was independent the practitioners should not influence the content. However, there is a difference between influencing the views of an independent expert and that of challenging the quality of a report or of taking a different viewpoint. The Bedford Borough Independent Reviewing Officer (who chaired Sophie's statutory reviews as a Looked After Child) did in fact challenge the quality of the independent report in early summer 2013, which helpfully did (along with new concerns about Father’s relationship with Joe’s mother and Sophie’s response after contact) help to further areas being defined for the final assessment report. 4.2.9 The children’s guardian is appointed to safeguard the interests of the child in care proceedings; the role is to ensure that the child’s situation is well assessed and to challenge on behalf of the child if decisions and assessments are not in the child's best interests. In this case Cafcass failed to do this. Cafcass has identified that this was due to the performance of the individual guardian, but when set within the multi-agency context, it can be seen that the guardian shared the common mind-set in this case, in which all those involved appear to have accepted the view of the independent expert without sufficient scrutiny. This should have been challenged and explored within Cafcass's supervisory and management arrangements. Recommendation 2 Bedford Borough Council Children's Services and legal services should establish a clear framework for the consideration of independent assessments conducted as part of legal proceedings. Where appropriate agencies have a responsibility to challenge the conclusions of the assessment. Recommendation 3 Hertfordshire LSCB to ask Cafcass to demonstrate how supervision and management processes have improved since this case and if this is effective in supporting guardians to retain their focus on the child, challenge expert assessments and maintain their independence from the local authority. 7 The Children’s Guardian is appointed by the Court to represent the rights and interests of children. 20 4.3 FINDING 3: All parties in the Court arena failed to appropriately consider the implications of the September 2013 psychiatric report, and consequently did not argue for a delay in the final hearing so as to develop a care plan better able to meet Sophie’s needs. 4.3.1 Finding 1 refers to the assumptions by practitioners that the Court would expect a birth parent to be given care of a child unless there is substantial evidence that this would not be in the child’s best interests. This finding refers to the lack of delay at the end of the legal proceedings to adequately take into account the evidence in Court papers and in particular to the psychiatric report submitted in September from the mental health service responsible for the father's treatment. 4.3.2 The care proceedings were protracted largely because of its complexity and because the father was identified some months after the start of proceedings. Practitioners and their managers told the authors that because of the earlier delays, any further postponement of the final hearing would not be tolerated by the Court. The case had by then been in progress for much longer than the 26 week time limit introduced in 2013 as part of the piloting of the revised PLO8, which subsequently came into effect in the Children and Families Act 2014. 4.3.3 This perception that no delay was possible in the legal process was articulated to the foster carers and their supervising social worker at the time, in response to foster carers' concerns about Sophie's reactions to contact. They recognised how anxious Sophie was following the increased contact with her father and advocated taking things more slowly in planning Sophie's move. 4.3.4 Significant information was received near the end of the legal proceedings on 10.09.13.and should have, but did not, cause constructive delay. This new information was contained in a report from a psychiatrist (in the service providing Father with treatment) in response to a request by Father’s lawyer for a report on Father's mental health. The report mentioned Father being agitated and anxious, changing his account frequently, becoming angry and it taking 45 minutes to calm him down. Most significantly, the psychiatrist referred to being intimidated himself by Father’s behaviour. 4.3.5 Such information should have caused immediate alarm bells: if Father was able to intimidate an adult male professional by his behaviour, his risk to a child was of great concern. However, although the social worker and her managers did see the report, the contents were not seen as alarming at the time. This appears to the independent serious case review authors to be surprising. Social workers and managers in both Bedford Borough Council and Hertfordshire County Council told the authors that their understanding at that point was there should be no delay in making the Final Order and it is likely that this will have impacted on the lack of detailed consideration given to the report’s contents. 4.3.6 A further reason for the report being insufficiently considered was its conclusion of a good prognosis of Father's mental health (see 3.28 - 3.2.10), which may have mistakenly been confused with his parenting prognosis. Whilst this was a report about his mental health, and not about his parenting, the content indicated further consideration was needed about his ability to parent a young, disturbed child, who may test a parent's abilities to the limit. 8 PLO is the Public Law Outline introduced in 2008 to reduce unwarranted delays in family Court cases 21 4.3.7 This rush at the end of the legal proceedings was compounded by the case holding social worker being on holiday and then on another three week Court hearing for another case in August and September, along with the solicitor being on leave in September. 4.3.8 It would appear that the legal process had a daunting effect on those involved; this can be positive to the extent it discourages drift, but should not have meant that the plan and the actual move was rushed and ignored significant and worrying new information that was emerging at the end. 4.3.9 In theory target timescales may be achieved by the parties working harder, faster and smarter. In practice a trade off between efficiency and thoroughness will arise in many cases. In some it may lead to additional risks, particularly if the local authority and other parties are not aware that they are entitled to challenge what they perceive to be inappropriate timescales. Recommendation 4 Bedford Borough Children and Legal Services to review the current training provided to social workers and lawyers to ensure that this provides the necessary skills and authority to be able to represent the child’s best interests in Court. Such training to emphasise the need to retain a sense of challenge at all stages of the process, even if this involves lengthening the legal process in the child's best interests. Recommendation 5 Hertfordshire LSCB and Bedford LSCB) to ask the Local Family Justice Boards in Hertfordshire and Bedfordshire to consider the findings of this review and consider how, in future, cases will be identified where decision making is being adversely affected by the pressure to avoid delay, or further delay. The groups should work with the local authority, Cafcass and others to reduce the risk of this having an adverse effect on welfare of children. 4.4 FINDING 4: Weaknesses in management within and between different local authorities and social work teams led to a lack of full understanding of potential risks (both Bedford Borough and Hertfordshire) 4.4.1 This case was challenging for professionals due in large part to the complex family compositions and the movement of Sophie between three different local authorities. There was a need for close working across team and local authority boundaries, consistent information sharing and joint planning at all stages. This did not happen and there was insufficient management oversight to support practitioners in working with this level of complexity. This was particularly critical given the allocation to a student social worker. 4.4.2 This meant that none of the social workers had an understanding of the whole case: Bedford Borough focused on Father as a carer for Sophie with insufficient understanding of his history in Hertfordshire and his involvement with his son. Social work team 1 in Hertfordshire had the best understanding of Father and the risks he posed to children as evidenced by the section 7 report and the support provided to Joe’s mother’s in stopping contact with Father in February 2014. 22 Social work team 1 in Hertfordshire, whilst recognising the challenges for father in parenting two children instead of one, did not consider what the content of their assessment meant with: o Regard to his parenting only one child [Sophie] and o Continuing to parent two children if Joe continued to spend half his week with Father Hertfordshire social work team 2 had initial reservations about Father as a potential full time carer for Sophie prior to her move to him in December 2013 and in February 2014 they appropriately initiated discussions with Joe’s social worker and raised concerns with her following Father’s display of anger during a telephone conversation - however, team 2 were unaware of the decision to cease Joe’s contact with his father, so could not consider what impact this may have had on his emotions and any consequent increase in the risk for Sophie. 4.4.3 Good management and supervision would have helped practitioners to stand back and reflect on the case as a whole and It would have also helped practitioners to manage competing demands on their time. There is little evidence that this happened in either authority. 4.4.4 Within Bedford Borough Children's Services, supervision was task focused and did not promote the level of critical analysis required in a case such as this. The supervisor carried his own caseload and this meant that he struggled to provide cover when the social worker could not attend meetings as he had meetings for children on his caseload to attend. This was significant as one of the issues in this case is the difficulty of setting up meetings between Bedford and Hertfordshire staff, at a time when there could be representatives from both organisations. 4.4.5 Across the two authorities, planning at the point of transition to Father’s care was limited and the meetings (one in Hertfordshire and one in Bedford) were only attended by practitioners from the 'home' authority. Managers in both authorities should have ensured representation and attended themselves if the workers were unavailable due to other professional commitments. The result of the lack of transition planning was a limited understanding in Hertfordshire of the concerns being expressed by the foster carers and their supervising social worker during this period. Whilst no-one perceived Father to be a physical risk to Sophie, the foster carer and supervising social worker did not consider him to have the parenting skills Sophie needed, and the supervising social worker thought that he would not be able to cope and Sophie would return to the foster carers. 4.4.6 As well as problems with the quality of the direct supervision of the social worker in Bedford Borough, there was a lack of management oversight within Bedford Borough of the totality of the planning process for Sophie. There is no evidence that any manager at any level grasped the significance of the complexity of the case and this was one reason why important aspects of the planning for the future of Sophie and her siblings were lost. Of particular significance was the lack of any follow through of plans for contact between Sophie, the foster carers with whom she had a close relationship and her siblings (see 4.7). 23 4.4.7 Within Hertfordshire, the involvement of two teams and the allocation of the case to a student social worker (allocated worker team 2) presented further management challenges. It is possible that the impact of the Court decision having been being made so recently suggested to managers in Hertfordshire that Father's capacity to parent had been looked at thoroughly and there needed to be time to see how he coped. However, this is not supported by the evidence. The social work team 2 manager and allocated worker expressed a level of concern about the Court decision at an early stage which was re-iterated in the section 7 report written by team 1's allocated worker. This expressed doubts about the conclusions of the section 47 enquiry undertaken in November 2013. 4.4.8 Whilst Father registered Sophie with a GP, sorted out a school placement and up to half term took her there every day, there was no multi-agency Child in Need planning process initiated to help support the family as well as monitor progress. Given the allocation to a student social worker, this should have been addressed by social care managers. There was a lack of management presence at a key professionals meeting in February 2014 when information was shared between Joe’s allocated worker (team 1) and Sophie's worker (team 2). As a consequence there was no documented plan to integrate the findings of the section 7 process into the work with Sophie, despite it having identified significant concerns about Father’s parenting. There is no evidence that the eventual report was shared and the depth of concern expressed about Father within this report considered by the team responsible for Sophie. 4.4.9 As well as management oversight from the team manager, because she was a student, the work of the allocated worker (team 2) was overseen by a practice educator, responsible for assessing her professional development. Handwritten notes of these meetings are kept separately from the 'child specific supervision forms' maintained by the team manager yet they contain important observations such as the worker had “already picked up a concern as to whether there is a right decision by Luton Court” (5.11.2013). This was a very important and insightful comment that was not followed through by the practice educator in formal discussion with the team manager. Recommendation 6 Bedford Borough Children's Services to provide evidence to Bedford LSCB that steps have been taken to embed reflective supervision within social work teams. Recommendation 7 Hertfordshire children's social care should review case management arrangements for student social workers in order to clarify roles and responsibilities of practice educators and team managers. Recommendation 8 Hertfordshire children's social care to review case management arrangements so that the allocation of each child who is a full-time or part-time member of a household to the same caseworker is always considered. When household members are allocated to different caseworkers, the respective social workers must keep themselves aware of the care plans for each child so that these are consistent and the work is well coordinated. 24 4.5 FINDING 5: The Child in Need planning and service delivery in this case did not provide co-ordinated multi-agency involvement (Hertfordshire) 4.5.1 This finding addresses the practice in Hertfordshire subsequent to the making of a Residence Order to Sophie’s father in October 2013 and the Supervision Oder to Hertfordshire in November 2013. 4.5.2 A care plan was put in place at the point that the Supervision Order was made outlining the responsibility of the Local Authority. Initially there was an attempt to initiate multi-agency involvement with a meeting held with Father, team 2 team allocated worker and the manager, a SENCO and a housing officer. It was also meant to include the Bedford Borough social worker, but she was unable to attend. This meeting focused on Sophie's move and Father's housing needs. At that point Father was waiting for housing and hence it was not known where the family would live; for that reason there was no involvement of health visiting or of the as yet unknown education provider. 4.5.3 Once it was known where the family would live and which nursery school Sophie would attend there was no evidence of further consideration of the need to take a multi-agency approach to the provision of support to Father and no indication that the Local Authority saw itself as taking a lead role in this respect. 4.5.4 Sophie at this point was a Child In Need and the plans within Hertfordshire should have involved working with professionals and with her father to develop an agreed Child in Need plan, with multi-agency meetings and a co-ordinated team around the child. It is not entirely clear why this did not happen, but there was no communication with education services and no liaison with health. 4.5.5 The result of a lack of multi-agency Child in Need planning meant that Sophie’s school, where she attended the nursery class, were unaware of significant aspects of her history or how they could most effectively work with social workers and other professionals to meet her needs. They were therefore working with a child with additional needs, who had experienced a recent significant change in her living arrangements and was subject of a Court order, without the information needed in their day to day work with her. When Sophie missed days at school, just prior to her death the school did alert Hertfordshire children's social care after the absence became prolonged. Sophie was not yet of statutory school age and the head teacher has queried whether this can influence thinking when a child misses school. A Child in Need plan would have enabled all professionals to have been aware of the role that school played and the significance of her absence. 4.5.6 This situation was exacerbated within the heath visiting service where there was no formal notification to Hertfordshire health visitors of Sophie’s move into their area as the health service had not been told by Bedford Borough social workers of the move. This meant that there was no advance planning, no handover, notification was delayed and detailed reports were not transferred about Sophie's additional needs. 4.5.7 Health visitors attending meetings relating to Joe heard informally that Sophie had moved but this did not prompt any further exploration of how a health visiting service would be provided. A factor which potentially contributed to Sophie becoming lost at this point was significant organisational change, including team mergers and redistribution of caseloads within Herts Community Trust. 25 4.5.8 A health visiting assistant did become aware from the GP that Sophie had moved into the area and at that point acted promptly to obtain the records and send Father a routine transfer-in letter. However, without the records, any handover from the previous health visitor or information from children’s social care, the Hertfordshire health visiting team were not aware of Sophie’s additional needs and there was no formal planning to address her health needs as part of an overarching Child in Need Plan. Recommendation 9 Hertfordshire LSCB to initiate multi-agency audits to establish whether the practice in this case is unusual, or if there is a systemic problem around the quality of multi-agency child in need service planning and delivery. The audits to include interviews with staff, so that the reasons for any weaknesses in multi-agency practice are explored. Recommendation 10 Hertfordshire children's social care to introduce systems so that all Supervision Orders are routinely subject to Child in Need planning and review processes . 4.6 FINDING 6: Shortcomings in the response to the suspicion of child protection risks may have left Sophie at risk of harm. 4.6.1 There were two occasions when there were concerns or incidents which in the view of the authors of this report were sufficient to lead social work managers to initiate child protection procedures in the form of a multi-agency strategy discussion and if required a section 47 enquiry 9. These were when: Sophie alleged in November 2013 that her father had slapped her and Concerns accumulated in February 2014 following Father learning he was not going to get a Residence Order for Joe. 4.6.2 On both these occasions there were shortcomings in the responses to the concerns, albeit for different reasons. November 2013 4.6.3 In November 2013, Bedford Borough did initiate a section 47 enquiry in response to Sophie's allegation, but this was done without a multi-agency strategy discussion and the involvement of other agencies in planning or undertaking enquiries (even though Sophie was by this point subject to a Supervision Order to Hertfordshire). 9 Section 47 Children Act 1989, requires local authorities to undertake enquires where a child in their area is suffering or is likely to suffer significant harm 26 4.6.4 Critically the social worker did not see Sophie until over a week after the allegation, which was a long time for a four year old child, especially one with a range of additional behavioural and emotional needs. Sophie gave an account of being hit but this was not believed, largely because the community pre-school's account that she sometimes lied about being hit was uncritically accepted as the explanation for this particular allegation. The reason for the conclusion of no further action was not provided to the allocated team 2 worker in Hertfordshire; if it had it might have alerted Hertfordshire to potential risks relating to physical abuse. February - March 2014 4.6.5 During the latter half of February and March 2014 Hertfordshire County Council did not initiate a strategy discussion, nor any other type of multi-agency forum to consider the emerging concerns about father's emotional responses, and possible implications for Sophie. 4.6.6 In February 2014, following Father learning he would not obtain a Residence Order for his son Joe, he expressed his anger in telephone conversations and voice mail messages to both Sophie's allocated team 2 worker and Joe's allocated team 1 worker. The allocated team 2 worker reported to Joe's allocated team 1 worker of hearing Father swear at Joe: this led to advice to Joe's mother that she could stop Joe's contact with his father if she had any concerns. Unfortunately, there is no evidence that Joe's allocated worker (team 1) told social work team 2 of this decision, so that consideration could be given to any potential impact on Sophie's welfare. 4.6.7 Father’s 'escalating verbal aggression and serial telephone calls/texts/VMs' towards allocated team 2 worker and his allegation that she had lied about him led to the decision that she should not visit the home on her own. Her manager also decided to transfer the case to a full time social worker, hold a professionals meeting (with Joe's allocated worker) and a Child in Need meeting. Moreover Hertfordshire County Council alerted Bedford Borough Council that the placement with Father might break down and the need to consider alternatives was agreed and a meeting arranged. 4.6.8 At this point, in the opinion of the authors, these concerns should have led to consideration of what this might mean immediately for Sophie and recognition of a 'reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm'. This should have triggered a strategy discussion with multi-agency partners to consider whether to initiate a section 47 enquiry to assess the risk and the urgency of the situation. This did not occur because of differing interpretations as to the meaning of 'reasonable cause to suspect' and a tendency to use strategy discussions primarily where there is an obvious risk of physical or sexual abuse rather than an accumulation of concerns. In this case, whilst there were long term concerns about the sustainability of the placement, the managers at the time did not perceive an immediate risk of harm to Sophie. 4.6.9 If the view at that point was that this threshold had not been reached, at the very least there needed to be an expedited professionals meeting or child in need meeting, or failing that communication with Joe's allocated team 1 worker, the school, GP and health (albeit the latter were not involved). 27 4.6.10 If such multi-agency discussions had occurred it is by no means certain that a section 47 enquiry would have been initiated, but it would have shared the concerns across the professional network, enabled the school to know of the accumulating concerns, team 2 to learn about Joe's contact with Father being stopped and enabled more informed decision making of the level of risks to Sophie. Although the health visiting service had not yet made contact with the family, it had by this point received Sophie’s health records which set out fuller details of her developmental, emotional and behavioural difficulties. This information would have strongly underlined her vulnerability. 4.6.11 There was no professional contact with Sophie during the last four weeks of her life. The cancellation of visits by Father and Father’s explanations for the reason that Sophie had not returned from school after half term, with hindsight, reflect the extent to which Father went to keep Sophie away from professionals. 4.6.12 School records and social work records for this period differ around the communication of concerns for Sophie's safety by the school to social work team 2, but it is clear that from the 7th March onwards social work team 2 were regularly informed of Sophie's continuing absence, and both agencies concur that on the 11th March this was expressed in terms of concerns for her safety. However, the combination of Father’s avoidance of social work contact coupled with Sophie's lack of school attendance should have raised the level of concern. 4.6.13 The fact that Father was maintaining contact with the school about his plans to be away, gave false re-assurance to the social work team as he had not previously been identified as devious and he was thought to have kept the school informed of his movements. Action was therefore not taken to expedite multi-agency consideration of any need for more assertive intervention through the child protection process prior to Sophie’s death. Recommendation 11 Hertfordshire and Bedford Borough LSCBs should review with all partner organisations whether there is a routine use of multi-agency strategy discussions to decide whether to initiate a section 47 enquiry whenever 'there is reasonable cause to suspect that a child .... is suffering, or is likely to suffer, significant harm'10, and not only when an incident has occurred which appears to provide evidence of harm. Such discussions should be used not just for incidents of suspected abuse, but also for accumulation of concerns, as more typically found in cases of emotional abuse or neglect. 10 Section 47, Children Act 1989 28 4.7 FINDING 7: Following a change of carers, contact with previous non abusing carers and siblings will usually be in the interests of the child's emotional well-being: this did not happen in this case 4.7.1 A major indication of the lack of child focus in this case was the absence of professional attention to Sophie's needs for contact with her siblings and foster carers. Given that Sophie's relationship with her elder sibling was the most enduring relationship in her life and that this sibling remained with the foster carers, such ongoing contact should have been a very important part of Sophie’s future. 4.7.2 However, Sophie had no contact with either her foster carers or her siblings after she moved, despite an understanding by the carers and the supervising social worker that they would see her for the first half term holiday and subsequent school holidays. The carers' understanding is consistent with the Care Plan provided by Bedford Borough to the Court (dated 23.09.13) which included for Sophie to have contact with her elder half sibling six times a year in school holidays. As her sibling lived with the carers, this was equivalent to the carers' understanding. 4.7.3 The reasons for this lack of contact arise from: A confused view in Bedford Borough around the advisability of contact in the early stages of a new placement The fact that a Supervision Order does not provide the legal basis for the supervising authority to arrange contact - this legally was the father's responsibility and as a result Hertfordshire's amended care plan offered 'support and advice during regular Child in Need meetings which will assist in reviewing the contact needs’ Confusion around contact arrangements in Bedford 4.7.4 The Care Plan by Bedford Borough Council provided for contact with Mother three or four times a year; with elder sibling and carers six times a year in school holidays and letterbox contact with the younger sibling as he would be adopted. Before this plan there had been various other plans put forward: the Bedford Borough independent reviewing officer at Sophie's last Look After Child statutory review at the end of October recommended that Sophie spend one week-end a month at the carers' home to provide respite for Father, maintain the relationship between siblings and monitor Sophie's welfare: the Bedford Borough Council team manager agreed this, but it was not included in the care plan Sophie's foster carers and supervising social worker both understood the plan was for contact to occur with Sophie's sibling and the carers during the first half term and in subsequent school holidays: this is not in the records of either Bedford Borough or Hertfordshire County Council, 4.7.5 Father himself has no recollection over the contact plans, other than he and Mother would arrange this between them. He did tell the authors he would have welcomed the plan for Sophie's regular staying contact with the foster carers, although this is hindsight and we are not sure in reality that he would have facilitated this at the time. 29 4.7.6 The first contact, understood to be arranged for February 2014 half term by the foster carers and the supervising social worker, was (they recalled) cancelled. The carer and her supervising social worker both said that they were informed of this by the Bedford Borough social worker (during her contacts with them about Sophie’s half siblings). The reason given was that Sophie was not settled. The Bedford Borough social worker concerned has no recollection of this. Was there a mistaken belief that contact should only occur when a child has settled ? 4.7.7 The Hertfordshire team 2 allocated worker has explained she understood from the Bedford Borough social worker that there would not be contact until Sophie was settled, not before Easter. Discussion with the Bedford Borough team manager has confirmed that this used to be the culture in Bedford Borough Council Children's Services (and from the lead reviewers experience in many other places). This stems to a long standing (and flawed) belief within some social work teams and departments, now largely discontinued, that children would settle better with new carers if they had no contact with their previous carers until they are attached to their new carers. 4.7.8 Whilst there may well have been an argument to delay contact with Mother, as seeing her did upset Sophie, the lack of ongoing contact with her sibling and foster carers must have been very difficult for her to comprehend. Being 'unsettled' should not mean a cancellation of contact following a move - in fact it may mean a greater need for it! It certainly should have acted as an indication that a social worker should check on Sophie’s welfare . Hertfordshire County Council responsibility as part of the Supervision Order 4.7.9 Given that the Supervision Order was to Hertfordshire and not Bedford, the team 2 allocated worker and her manager did have a responsibility to challenge such fixed thinking about contact and to have considered Sophie's needs as part of a Child in Need plan. However, without any Child in Need meetings (see finding 5) this did not happen. Recommendation 12 Bedford Borough Children's Services to review current guidance and practice norms around children's contact arrangements following a move to a new permanent placement: contact with people of psychological importance to a child should not be delayed until the child is judged to be 'settled. 30 Appendix: Terms of Reference The terms of reference were fully addressed by the individual management review authors. The serious case review report authors then analysed the information supplied and in their report addressed the issues most relevant to professional safeguarding practice within Hertfordshire and Bedford Borough Council. TERMS OF REFERENCE FOR THE SCR ON SOPHIE v3 - KI 12/5/2014 Factual matters to be established 1. What contribution did agencies make to the decision that Sophie should live with her father? 2. What background and historical information about Father was scrutinised by agencies (individually and collectively) in order to inform recommendations and decision making about Sophie? 3. What information from the contemporary private law proceedings in relation to Joe (another child of Father) was scrutinised by agencies in order to inform their work in relation to Sophie? 4. What assessments informed the recommendations made to the court in relation to Sophie? Did the recommendations make fully reflect the information available? 5. What risk assessment was carried out and what plan of support was in place in order to assist Father to assume the care of Sophie? 6. How was the plan of support implemented? Were new risks identified during the period when Sophie was in the care of her father and if so what action was taken? Evaluation of professional practice and services provided for Sophie 7. What was the quality of the assessments provided in order to inform decision making? 8. Were additional assessments considered and could they have contributed positively to decision making? 9. Were the recommendations made to the court concerning Sophie appropriate in the light of the information held by professionals? 10. Was the work of professionals in relation to the court concerning Sophie effective? Evaluation of factors that shaped professional practice 11. What contributory factors (at individual, team and organisational level) shaped professional practice and decision making by individual agencies and in the multi-agency network? 12. How did the case law and current public policy in relation to family court proceedings concerning Sophie impact on the work of the professionals? 13. How effectively did agencies and professionals work together across geographical boundaries? (i.e. between Bedford Borough, Hertfordshire and unnamed unitary authority) Findings for the LSCBs 14. What do the findings in relation to the care provided for Sophie tell the LSCBs and member agencies about the strengths and vulnerabilities of wider arrangements to safeguard and promote the wellbeing of children? 15. What steps should the LSCBs or member agencies consider taking in order to improve services for vulnerable children? |
NC52715 | Serious injury to a 3-month-old baby in April 2019; baby was taken to hospital twice in one day firstly following a reported choking episode and secondly with seizures. The baby was later diagnosed with a subdural haematoma and a healing rib fracture, which were determined to be non-accidental. Learning includes: information regarding parental history and any information on the children known by all agencies should be sought, shared and considered; there needs to be clarity across agencies when a case is closed to Social Care regarding what should happen if any concerns emerge or if the family do not continue to cooperate with any agreement made at closure; impact of parental risks and vulnerabilities should be considered in assessments and when working with a family; when none of the injuries in themselves are likely to meet the threshold for a child protection intervention, consideration of the wider picture may be helpful; if the case is not yet allocated to a midwife, information should be shared with the safeguarding nurse for the midwifery service if a pregnancy is known or suspected; at the point of closure information should be shared with those continuing to work with the family; GP information should be considered as part of a strategy discussion and additional information sought as part of the assessment; strategy discussions should include consideration of whether siblings require a Child Protection Medical; and professionals should be alert to whether assumptions are being made about a family and whether any professional disagreements need resolving formally. Recommendations are embedded in the learning.
| Title: Local child safeguarding practice review: Alex: review report. LSCB: Hartlepool and Stockton-on-Tees Safeguarding Children Partnership Author: Nicki Pettitt Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Local Child Safeguarding Practice Review Alex REVIEW REPORT Considered by the Hartlepool & Stockton-on-Tees Safeguarding Children Partnership on 1.11.19 and 20.1.20 Contents 1 Introduction to the case and summary of the learning Page 2 2 Process Page 2 3 Family structure Page 3 4 Background prior to the scoped period Page 3 5 Key episodes Page 4 6 Analysis and learning Page 6 7 Recommendations Page 14 1 Introduction to the case and summary of the learning from this review 1.1 This review is in respect of a three-month-old baby to be known as Alex1. Alex was taken to hospital twice on 2 April 2019; firstly following a reported choking episode and secondly with seizures. The baby was later diagnosed with a subdural haematoma (bleed on the brain) and a healing rib fracture, which were determined to be non-accidental. 1.2 Alex had been born prematurely. The parents and older sibling were already known to a number of agencies in Stockton-on-Tees, having recieved early help support and a social work assessment following a domestic abuse incident. When Alex was born the support being received by the family was largely universal and those involved had no concerns. 1.3 The learning identified from this review is in relation to: 1 The name Alex was chosen with the parents. It was specifically chosen as the HSSCP did not want to identify the gender of the baby. 2 Information sharing, seeking and clarifying, including of information provided by family members The need to reflect on the cumulative impact of all known information and concerns 2 Process 2.1 Following a rapid review process2 and consultation with the Child Safeguarding Practice Review Panel, the HSSCP recognised the potential to learn lessons regarding the way that agencies work together to safeguard children by undertaking this Local Child Safeguarding Practice Review. 2.2 It was agreed that this review would be undertaken using the SILP methodology, which engages frontline staff and their managers in reviewing cases and focuses on why those involved acted as they did at the time, avoiding hindsight bias. Agency reports are completed where agencies have the opportunity to consider and analyse their practice and any systemic issues. They provide details of the learning from the case within their agency. Then a large number of practitioners, managers and agency safeguarding leads come together at learning events3. All agency reports are shared in advance and the perspectives and opinions of all those involved at the time are discussed and valued. 4 2.3 The review considered in detail the period from 1 August 2017 – 16 April 2019, which covers the pregnancy with Alex’s older sibling, until two weeks after Alex’s injuries. The review was extended beyond the date of the injuries in order to consider the professional response, including the safeguarding of Alex’s older sibling. 2.4 Detailed family information will not be disclosed in this report5, only the information that is relevant to the learning established during this review. 2.5 Early family engagement is required in the SILP model of review. The lead reviewer spoke to Alex’s parents during the review and at the end of the process. Their views have been considered at each stage and are included in the report where relevant. 3 Family structure 3.1 The relevant family members in this review are: Family member To be referred to as: Subject child Alex Mother of Alex Mother Father of Alex Father Older sibling Sibling 3.2 Any other family members considered will be referred to by their relationship to Alex, for example ‘Paternal Grandmother’. 2 A rapid review is undertaken in order to ascertain whether a local child safeguarding practice review is appropriate, or whether the case may raise issues which are complex or of national importance and if a national review may be appropriate. The decision is then made by the national Child Safeguarding Practice Review Panel. 3 The lead reviewer was appointed, the terms of reference were agreed, agency reports and a chronology were requested, and two events were held to engage with staff in September and October 2019. The lead reviewer is Nicki Pettitt, an independent social work manager and safeguarding consultant. She is an experienced chair and author of serious case reviews and a SILP associate reviewer. She is independent of the HSSCP and all local agencies. 4 The same group meet again to study and debate the first draft of this report. Later drafts are also commented on by all of those involved and they make an invaluable contribution to the learning and conclusions of the review4. 5 Statutory Guidance expects full publication of local child safeguarding practice review reports, unless there are significant and justifiable reasons why this would not be appropriate. It is important to ensure the anonymity of the family within this report. 3 3.3 Alex lived with both parents and Sibling after spending time in the hospital neonatal unit. Both children are currently in the care of the Local Authority. It is not yet possible to state the impact that the injuries will have on Alex’s longer-term health and development. 4 The background prior to the scoped period 4.1 Neither parent was born in the area. Father moved to the area prior to starting secondary school, and Mother moved when she met Father in her late teens. There was social work involvement with Mother when she was a child, including a period on a child in need plan. She lived independently in temporary hostel type housing at age 16. Some professionals involved with the children had it recorded that Mother had been in care or a looked after child, but there is no evidence that this was the case. 4.2 As children, both parents lived in households where there was domestic abuse. It was not known prior to the injuries on Alex that domestic abuse was an issue in Father’s early childhood. Mother also had a previous intimate relationship where domestic abuse featured. 4.3 Mother had a history of anxiety and depression. Father had physical health issues that impacted on his ability to work and on his mental health. 5 Key episodes 5.1 The time under review has been divided into five ‘key episodes.’ These are periods of intervention that are judged to be significant to understanding the work undertaken with a child and family. The episodes are key from a practice perspective rather than to the history of the child, so they do not form a complete history, but will summarise the significant professional involvements that informed the review. Key episodes 1 Early help 2 Response to domestic abuse concerns 3 Sibling’s attendances 4 Birth of Alex 5 Response to the injuries Key episode 1: (Early Help) 5.2 The reported financial difficulties during Mother’s pregnancy with Sibling led to early help support from a Citizen’s Advice Bureau (CAB) worker after the family were signposted by the health visitor. They were later referred on to the Children’s HUB (CHUB)6 by the CAB worker when the financial difficulties led to a risk of homelessness due to rent arrears and benefit issues. Appropriate advice was given to the referrer and financial support was provided. 5.3 Mother reported to the health visitor that the couple’s relationship with Father’s parents had broken down, apparently in part due to Father’s financial issues and their concern about Mother’s pregnancy. Mother alleged that there had been an incident where Paternal Grandmother physically assaulted Father during an argument. 5.4 In the months following sibling’s birth there were no concerns regarding the baby’s care from either parent. 6Local authority children’s services, police, health, education and domestic abuse professionals work together in the CHUB. They consider the needs of children who are referred to them against the threshold document ‘Providing the Right Support to Meet a Child’s Needs in Hartlepool and Stockton-on-Tees’. The CHUB is the front door to support from children’s social care. 4 Key episode 2: (Response to domestic abuse concerns) 5.5 Concerns were first shared about domestic abuse in the relationship in March 2018, when an anonymous referral was made to the CHUB. It alleged that Father was controlling, isolated Mother from her family, and that Mother wanted to leave him. The health visitor was asked to speak to Mother about the concerns, as she was involved with the family at the time. On her next visit in May the health visitor discussed domestic abuse with Mother and had no concerns. She was aware from a previous visit that Mother had been concerned that there may be a malicious referral made. 5.6 In June 2018 Mother rang the police and reported a domestic incident, stating that Father had left the home but was still outside the property. The couple told the police officers who attended that there had been an argument regarding whose turn it was to feed seven-month-old Sibling. Father allegedly threw water from the baby bottle at Mother. Father agreed to leave the vicinity at the police officers request. No further complaint was made by Mother, although she told officers on the scene that Father sometimes struggled to control his emotions. 5.7 Following the incident, Father contacted the police and the Emergency Duty Team (EDT) saying he needed to return to the family home. Mother had attended hospital for pregnancy related concerns and had been told that she would not be released without reassurance she had support at home. As a result of this hospital attendance a further referral was made to the CHUB by A&E, who recognised that Mother had a child, was pregnant, and that there had been a domestic abuse incident. A strategy meeting was held followed by S47 enquiries and a social work assessment7. 5.8 During the single assessment that followed Mother said there had been unreported domestic abuse in their relationship in the past when Father had on one occasion pushed her and on another kicked her. She stated that he also sometimes struggled as Sibling could be difficult to feed, and that he had once ‘force fed’ Sibling. Despite this, Mother was insistent that she believed Father to be a really good partner and parent. 5.9 A Signs of Safety meeting was held with both parents, which also involved the paternal grandparents, social care and the health visitor and incuded a safety plan. The plan8 included an expectation that both parents attend individual counselling with Starfish Health and Wellbeing9. It stated that they would be referred for sessions at Harbour10, a local domestic abuse support service, when they had completed their counselling at Starfish. It was part of the plan that they would have support from the health visitor with feeding, and that they could attend appropriate parent and child groups and a weaning group. The midwifery service was not formally involved, this was because Mother had not yet booked in for the pregnancy with Alex. 5.10 The case was closed to CSC, with the parents stating that they did not wish for further support via child in need. Shortly afterwards another anonymous referral was received. The information shared was about domestic abuse and the risk they believed this posed to Sibling. It was also stated that the paramedics had been called to the home as Sibling had ‘gone limp’ when Father had ‘refused to let go’ of Sibling. The Children’s Hub completed checks with the ambulance service and they advised that they did indeed attend, and that 7 Child in Need assessment S17 Children Act. 8 The safety plan refers to a section of the signs of safety meeting which was undertaken as part of the on-going assessment. 9 Starfish deliver Primary Care Psychological Therapies for Adults including evidence-based Interventions for common mental health problems, such as depression and different forms of anxiety (e.g. OCD, panic and social anxiety). They also deliver treatment for trauma, such as EMDR. 10 Harbour offers an adult outreach service, a children's outreach service, refuge, a preventions programme and the Freedom Programme. 5 it appeared to those involved that Sibling was simply exhausted from crying. They had no concerns. As the assessment which had recently closed had explored domestic abuse and did not identify any safeguarding concerns, a decision was made by CHUB to close the referral without further action. The information was not shared with the health visitor or midwife who were involved. Key Episode 3: (Sibling’s attendances) 5.11 Sibling was taken to either the Urgent Care Centre (UCC) or Accident and Emergency (A & E) on 17 occasions. On five of these occasions, when Sibling was between 6 months and 11 months old, a head injury or a report that he had bumped his head was either the primary reason for the visit or spoken about during the visit. (For example on one of the occasions he had been brought to the department for vomiting and Mother reported that he had hit his head two days previously.) None of the attendances were considered a safeguarding concern, either due to physical abuse or lack of supervision. Key Episode 4: (Birth of Alex) 5.12 Alex was born prematurely at 31 weeks gestation and was in the neonatal unit for 26 days. There were no concerns expressed by staff on the unit about the family. Following discharge, a neonatal nurse visited the family a number of times and liaised with the family health visitor (but not the GP). It is reported that both parents were always present at home visits and there were no concerns. The health visitor undertook a primary visit and it is documented that the parental relationship was positive and that interaction between parents and baby was ‘warm and loving’. Key Episode 5: (presentation at hospital) 5.13 When Alex was three months old, they were taken to A&E by Father after reportedly being floppy and unresponsive following choking on milk during an early morning feed. After being admitted to the paediatric ward, appropriate observations and checks were undertaken. No marks or bruises were evident and there were no other concerns. It was thought that Alex had reflux and they were discharged home after successfully feeding and appearing well. Alex was given open access to the ward for the next 24 hours. 5.14 Alex returned with Father around two hours later suffering from seizures, which were observed on the ward. The baby was intubated and ventilated then transferred to a regional hospital with a Paediatric Intensive Care Unit (PICU). The PICU team requested that a CT scan be performed prior to transfer, but this was not possible due to the equipment being temporarily out of service. When the CT scan was undertaken following transfer, acute subdural haematomas11 were identified. This led to the appropriate referrals being made and a timely strategy meeting between the police and EDT (as it was outside of office hours). Further imaging undertaken when Alex was well enough found a rib fracture. This was thought to have been caused around 10 days previously. 5.15 Sibling was staying with Maternal Grandmother while the parents were at the hospital with Alex. Checks were undertaken with the EDT for their home address and it was said that while there were no concerns about Sibling staying that night, a long-term placement would not be appropriate. 5.16 A child protection medical examination was undertaken on Sibling a week later. 11 Blood clots on the brain 6 6 Analysis and learning 6.1 From the information gained within the agency reports, from the discussions at the learning events, and from speaking to family members, the following analysis enabled the review to identify learning for the HSSCP and local agencies. It was recognised that learning was identifiable in two areas, firstly in the response to the known risk and vulnerability and secondly in the response to concerns that emerged at the time. Each learning point is linked to a recommendation in either this report or within the agency reports. Themes Response to known risks and vulnerabilities Response to concerns Response to known risks and vulnerabilities 6.2 There are factors in a parent’s background which can potentially present a risk to a child. These include issues that were evident in this case, such as domestic abuse, parental mental health, adverse childhood experiences, young motherhood12, and estrangement from the new mother’s own parents. Pathways to Harm, Pathways to Protection; a Triennial Review of Serious Case Reviews (SCR) 2011–1413 points out that risk factors like these ‘appear to interact with each other creating cumulative levels of risk the more factors are present’. As well as the need to reflect on the cumulative impact of the parents own vulnerabilities, there was a need to consider the cumulative impact of what was happening in the family prior to Alex’s injuries. This is considered in the second theme below and led to learning from the review. 6.3 Domestic abuse featured in both parent’s childhoods, in Mother’s previous relationship, and in their relationship. The Triennial Review found that ‘domestic abuse is always harmful to children’ and that ‘professionals should not rely on victims of domestic abuse to act for their own or their children’s protection’. Father did not disclose his own childhood experiences until after Alex’s injuries. When Mother met with the midwife to book in for her pregnancy with Sibling, she told her midwife that there had been domestic abuse in her own family and with a previous partner. This was documented within the antenatal records. Mother disclosed the domestic abuse incident between Mother and Father during the early pregnancy with Alex when she booked in for her second pregnancy, and this was recorded. There is no evidence that Mother was asked directly whether she may be suffering from on-going abuse in the relationship with Father during either pregnancy. The agency report is clear that Father was present for nearly all antenatal contacts which would have made asking the question difficult. However, there was no evidence of a documented plan to see Mother alone, as is expected. Women should be informed at booking that she will be seen on her own at least once in pregnancy, and there should be a visit on or around 16 weeks to ask about domestic abuse. A single agency recommendation has been made to review the current pathway and should improve practice in this area. 6.4 The agency report for the midwifery service also notes that there is minimal information regarding Father in the midwifery notes, although it is recorded that he was in attendance for the majority of Mother’s antenatal appointments. During Mother’s pregnancy with Alex there was a change in midwifery caseloads and staff sickness which may have had an impact. 12 It was known that the parents were young (aged 18 and 19) and in a fairly new relationship when Mother became pregnant with Sibling. The average age of first-time mothers whose children were the subject of a SCR was age 19 (the same age as Mother in this case), compared to the national average of age 28 for first time mothers. 13 P. Sidebotham and M. Brandon et al. (2016) 7 Alex was also born prematurely at 31 weeks which reduced the timescales for visiting, assessment, and supervision. One of the midwives involved was aware that support was being provided by the CAB worker and she spoke with her, there was no conversation between the health visitor and midwife however. This would have been particularly useful following the domestic abuse incident during the pregnancy with Alex. (Learning point 1) 6.5 Mother didn’t share any information about domestic abuse between her and Father with any professional until she was spoken to following the domestic abuse incident in June 2018, when she shared that Father could get angry and struggled to manage his emotions, and that she had been pushed once and kicked once by him in the past. She told the lead reviewer that the relationship was not generally abusive. At the time those involved believed that Father took responsibility for not always managing his feelings, including when he was spoken to by the social worker who undertook the single assessment. Signs of Safety was used during the assessment and both parents agreed to attend counselling sessions at Starfish. There is some confusion about whether the parents missed appointments following the individual assessment sessions that were completed. The parents told the review that there were issues at Starfish at the time and that they were not informed of changes to the appointments. There is no evidence that their lack of attendance was shared with any other agency except the GP, and they did not share it further. The health visitor was not informed of any issues with attendance, although the parents had told her that they had cancelled an appointment when Alex was born early. The health visitor did not contact Starfish directly as she believed they would not discuss the case with her. It is likely they would have provided information if asked, and if the health visitor had the parent’s consent. This was not pursued. The learning from this review highlights the need to check information provided by parents, with their consent (Learning point 1) and consideration about who will be responsible for supporting the family to enable them to continue with the agreements made during the signs of safety process on case closure to Social Care. In this case there was limited consideration of the impact of both parents receiving counselling and what this might mean for their relationship and parenting. (Learning point 2) 6.6 In the second pregnancy the midwife has documented that Mother was receiving support from Starfish. It is acknowledged that the size of midwife’s caseloads and the restrictions of clinics mean that not all information provided can be checked, and there was no reason in this case to believe that sessions were not being provided to the family. As the planned attendance at Harbour to address the domestic abuse was to happen following the completion of the Starfish sessions, the success of the Starfish support was significant. Until Harbour was able to get involved no work was being undertaken with the parents regarding the domestic abuse. The review was told that there is a view locally that Harbour will not provide a service if clients are receiving counselling from other services14. In this case it was considered that the couple needed to complete individual counselling before they attended domestic abuse support. There was no agreement at the end of Social Care involvement regarding if and how attendance should be monitored and what should happen if the parents did not attend Starfish. (Learning point 2) 6.7 Father had physical health issues that were often problematic to manage, with no effective treatment. His ill-health impacted on his ability to work and he reported feeling depressed because of this and the resulting financial difficulties. He was prescribed antidepressants by his GP while Mother was pregnant with Sibling. The health visitor was aware of the impact on his mood, and told the review that they discussed this regularly, although this isn’t recorded. 14 And vice versa. Other counselling services wouldn’t work with people who are receiving support from Harbour. 8 The health visitor said that they do not record sensitive information about partners in a mother’s notes, but if there is an impact on the child this should be recorded in the child’s record. The health visitor was clear however that it was her view at the time that the parents were managing well and that there was no negative impact on the child/ren. The review has found that Father’s health issues are part of the cumulative vulnerabilities within the family at this time however. (Learning point 3) 6.8 The 2011 thematic report on learning from Serious Case Reviews, Ages of Concern15 focused on babies due to the high proportion of reviews that are completed on children under one. The report identified recurring messages from the reviews and found that the ‘risks resulting from the parents own needs were often underestimated, particularly given the vulnerability of babies.’ The report also found that there was a need for improved assessment of, and support for, parenting capacity. At the time of Alex’s birth, the family had two children under 13 months old. The time following discharge was potentially going to be stressful for the family, and Alex had been born prematurely, had a low birth weight, and developed difficulties with feeding due to intolerance of cow’s milk. This added to the potential cumulative risks in the case. The agency report completed for this review that considered the 0-19 service states ‘the pressures of caring for an unsettled premature baby would have been emotionally demanding particularly when the parents also had a 14-month-old baby and limited family support.’ The health visitor acknowledged the potential issues and visited them more regularly than most families to support them at this time. 6.9 Mother had been prescribed medication for anxiety and depression in the past. She was not thought to be suffering with post-natal depression although she was in a high-risk group for this. The health visitor undertook screening of Mother at the appropriate times and there were no concerns. Less was known about how Father was managing with the transition to becoming a parent. This is something that is rarely discussed with men in a family, with the professional focus usually being on the mother. There is evidence that the health visitor engaged with Father however, and he was due to get support from Starfish as it was acknowledged in the safety plan and by Father himself that he required therapeutic support. In this case Father appears to have been seen as a co-parent by those involved, and the safety plan considered the need for both parents to receive support. This is good practice. There is increasing evidence of father’s suffering with post-natal depression16 and they also require support and the opportunity to meet with professionals, including on a one to one basis. Learning: 1. Information regarding parental history and any information on the children known by all agencies should be sought, shared, checked and considered. This includes checking information provided by parents, sharing information with the safeguarding nurse for the midwifery service if a pregnancy is known or suspected, and robust information sharing between midwives and health visitors. This is particularly important when there has been previous involvement from Social Care. 2. There needs to be clarity across agencies when a case is closed to Social Care regarding what should happen if any concerns emerge or if the family do not continue to cooperate with any agreement made at closure. This should include the midwifery 15 Ofsted 2011 16 Research available from the National Childbirth Trust found that more than 1 in 3 new fathers (38%) are concerned about their mental health. In general, studies have shown that one in 10 fathers have PND and fathers also appear to be more likely to suffer from depression three to six months after their baby is born. 9 service if there is a pregnancy. 3. The cumulative impact of parental risks and vulnerabilities should be considered in assessments and when working with a family. Good practice: The extra support provided by the health visitor. Father was acknowledged as an equal parent. He was included in assessments and provided with support. Response to concerns 6.10 There were a number of occasions where concerns or potential concerns had to be responded to by professionals. They were: The ‘anonymous’ allegations of domestic abuse from a family member The domestic abuse incident Mother’s allegation of domestic abuse Mother’s allegation of ‘force feeding’ Siblings attendances at UCC and A&E with ‘head injuries’ Alex’s hospital admissions in April 2019 Consideration of both children following the above They will be considered individually. 6.11 The plan recorded by the CHUB on closing the case following the first anonymous allegation was that the health visitor would speak to Mother about the allegation was a proportional one. Professionals are aware that speaking to a potential victim about domestic abuse while the potential perpetrator is present can exacerbate risks, so telephoning Mother out of the blue about the issue was not necessarily appropriate. The health visitor was known to be providing regular support, so it was a good plan for her to find a way of discussing it with Mother. There was a recorded contingency plan that if the health visitor was unable to do, or if she was concerned about the family, she should re-refer to the CHUB. Mother had previously told the health visitor that that a family member might make malicious allegations, but the health visitor made sure that she saw Mother alone the next time she visited and recorded that Mother had made no disclosures. 6.12 The second anonymous referral was made via a third party, but it was known that the information was being shared by the same person who had made a referral before. As the case had recently been closed with a safety plan in place and checks with the paramedics had not raised any concerns, it was agreed to take no further action. The information shared and decision made was not communicated with those who were continuing their involvement with the family however, such as the health visitor, the midwife or the GP. A new baby was due, and research shows that domestic abuse can increase when a woman is pregnant. This means that the midwife was particularly key. She would be seeing Mother through her pregnancy. As the midwifery had not been involved at the time the safety plan was drawn up, they may not have been aware of the plan, and they were not informed that a new referral had been made. They were therefore potentially working with the family without the benefit of knowing the history and vulnerabilities. If the case is not yet allocated to a midwife, information should be shared with the safeguarding nurse for the midwifery service if a pregnancy is known or suspected. (Learning point 5) 10 6.13 During the domestic incident response in June 2018, a DASH17 Risk Assessment was completed by the attending police officer. The couple were categorised as Medium Risk by the officer and this was agreed by the supervisor. Medium risk is where ‘there are identifiable indicators of risk of serious harm. The offender has the potential to cause serious harm but is unlikely to do so unless there is a change in circumstances, for example, loss of accommodation, relationship breakdown, drug or alcohol misuse.’ This appears to be an appropriate grading. Mother told the officer about historic previous violence from Father to her, which involved him pushing her. This is the first indication she had given any professional of any physical abuse in the relationship. The officer was also aware that Mother was pregnant. 6.14 In the meantime, Mother had attended hospital with unrelated abdominal pains the day after the incident. The hospital made a SAFER referral as they were aware there had been a domestic abuse incident. However, the midwife was not informed of this attendance despite the hospital ‘attendance in pregnancy pathway’ stating they should be. This means the midwife (or safeguarding nurse for the service if the case had not yet been allocated) was not made aware of the incident. No referral outcome was shared with the hospital and the hospital staff did not follow the referral up, despite the safeguarding children policy stating that referrals should be followed up by the hospital within 48 hours. 6.15 A strategy meeting was held which led to a S47 enquiry. After the enquiries were completed within child protection procedures and it was agreed the case did not meet the threshold for a child protection conference, Sibling became subject of a child in need single assessment, to be completed by the social worker, which was appropriate. Both parents were engaging, and a number of positive and protective factors were identified. When the assessment was completed, which included a signs of safety ‘safety plan’18 devised with the parents and the paternal grandparents. There was a recommendation that on-going support be provided to the family with Sibling as a Child in Need, but the family did not believe they needed this, and consent is required. The health visitor was involved in the signs of safety meeting. The GP records for Sibling and both parents had details of the domestic abuse incident and response. This is good practice. The absence of information sharing with the midwifery service was a gap however. 6.16 Despite sharing that Father had been physically abusive on two occasions when he pushed and kicked her, Mother stated during the social work assessment that she was happy in the relationship and that Father was a good partner and parent. Father showed a degree of insight into his need to manage his emotions and agreed to get support. Mother had told the social worker that Father struggled when feeding Sibling and that he had ‘force fed’ the baby. It was known that Sibling had intolerance to cow’s milk and feeding issues following their birth. Clarification was sought by the social worker completing the section 47 enquiry and single assessment. Father denied force feeding Sibling, and Mother said she meant that Father had tried to get the child to eat by placing the food against the baby’s mouth. The social worker undertook a clear interview with Mother and made sure she described exactly what had happened. They concluded that that there wasn’t any undue force used, and there was no visible injury. Taking into consideration Sibling’s reflux and milk allergy it was recommended that the health visitor should provide advice and guidance with feeding, which she did. 17 Domestic Abuse, Stalking and Harassment and Honour-based violence risk identification, assessment and management model. 18 Using the Signs of Safety model of intervention. 11 6.17 The parents were regular attendees at the UCC based at their local hospital and at A&E. The review was told that families living in the locality have a tendency to use the UCC at the local hospital as an alternative to accessing primary health care at the GP surgery. This is likely to be attributable to the close geographical location between where the family lived, and the UCC and A&E (which is in the same location). On five of the occasions in fairly close succession Sibling had recorded injuries to the head, for example a red mark to the top lip on one occasion and an abrasion to the forehead on another. The review considered these a high number of injuries in a child who is not walking. Each injury or reported incident was considered and the explanations were thought acceptable. 6.18 The first presentation resulted in the appropriate consideration of whether the injury was non-accidental and whether the Bruising in Immobile Baby Procedure19 should be followed. As Sibling was said to be rolling over and therefore considered mobile, the ‘injury’ was not significant, and the nature of the injury was consistent with the reported mechanism20 use of the procedure was not required. 6.19 The review has found that while none of the injuries appear to be suspicious, ACHILD21 was not completed following all of the presentations and therefore there was no opportunity for them to be considered for any pattern. To enable the 0-19 service to consider cumulative concerns, they have an existing significant events process that should have flagged Sibling’s attendance to A&E and UCC, therefore leading to a risk assessment and informal supervision to consider possible safeguarding concerns. Single agency learning and a recommendation has been made in relation to this. (Learning point 3) 6.20 When the second of Sibling’s recorded head injuries was seen at A&E, the case was open to the social worker following the domestic abuse incident. No details of the attendance were passed to the Social Worker, who was told about the attendance by the parents during a subsequent home visit. They told the social worker they had been told that there was nothing to worry about, so no checks were undertaken by them. There is no system in place in A&E or the UCC that will flag or provide alerts if children have a child in need plan or are open to children’s social care. Hospital staff are reliant on parents to inform staff that they have a social worker involved. Completing ACHILD would provide a prompt for practitioners to enquire if there is social care involvement. The review was told that if A&E staff become aware that there is social care involvement then a 'sharing of information' form is usually completed. The child’s GP and the 0-19 services are notified of all attendances and receive a discharge letter after each attendance, but this did not result in a consideration of the wider picture for Sibling, despite there being a new baby on the way. According to the health visitor this is because at the time any notifications on children not receiving a targeted service were scanned onto the child’s record by an administrator and are not always brought to the attention of the health visitor. There was previously a ‘significant events pathway’ that flagged on the system if there were over 3 attendances in a short period of time. The system became overwhelmed however because of the number of attendances at UCC particularly, so this no longer happens. This does create risk in the system as important information can be missed by those working with children and families. 19 The procedure states ‘Any injuries are unusual in this age group, unless accompanied by a full consistent explanation’. 20 The Tees 'Immobile Baby Procedure' clearly defines what would class as immobile. https://www.teescpp.org.uk/specific-issues-that-affect-children/bruising-on-non-mobile-babies/ 21 A&E screening tool to identify potential safeguarding concerns 12 The relevant health service was asked to consider this dilemma and they have made an additional single agency recommendation22. 6.21 When there are a number of issues over time it is important to a child to consider whether there is a safeguarding issue emerging, for example rough handling or lack of supervision. While none of the injuries in themselves were likely to have met the threshold for a child protection intervention23, consideration of the wider picture would have been helpful, along with looking at the incidents together to consider if there were cumulative concerns. This will not always be possible in an acute setting, so there is the need to ensure that those in community health services are aware of the attendances. (Learning Point 4) 6.22 The parents in this case are likable and plausible. They come across as open and honest and they have a loving relationship with each other and with the children. Regardless of what is being seen, professionals need to ensure they triangulate what parents are saying by establishing the facts, gathering evidence, and communicating well with all involved. There is a need for all professionals to have a conscious and healthy scepticism24. While there were examples of good information sharing in this case, there were also areas where this could be improved and where there could have been clarification or checks. It is important that professionals share information and communicate to ensure that they do not solely rely on parental self-report. (Learning point 1) If information is not shared, professionals need to question this and challenge each other. It is recognised that there are a number of barriers such as time, staffing, and navigating data systems. (Learning Point 8) 6.23 The GP was not spoken to during the S47 investigation following the domestic abuse incident, despite Mother and Father having lived elsewhere and the GP records being the only likely place where relevant background information was available. GPs should always be consulted to inform a strategy discussion and subsequent investigation/assessment. (Learning point 6) 6.24 When Alex was seen in hospital on 2 April 2019 systems were checked and there were no alerts on the health care records. Sibling’s records were not checked, as it is not practical to do this in all cases when a baby is admitted. It is clear however that even if those making decisions about Alex on the first presentation had information about the domestic abuse (and potentially about Sibling’s repeat presentations with head injuries), it is unlikely that a different decision would have been made regarding the discharge of Alex after an appropriate period of observation. 6.25 Alex was very unwell on the second presentation and appropriate medical interventions took place. Following the results of the CT scan and the acknowledgement of the possibility of the issues being due to a non-accidental injury, there was a timely safeguarding response. Sibling was considered and a proportional decision was made to leave them with local members of the family overnight. There followed a disagreement about when to undertake a medical on Sibling. The Social Care position was that until there was certainty about Alex’s injuries being non-accidental there were no grounds to undertake a medical (and potentially a scan) on Sibling. However there is rarely complete certainty regarding a non- 22 A related issue was that it took some time during the review to establish the number of attendances and this was largely due to the information systems used in A&E and the UCC. This is likely to have an impact on the ability of professionals to be able to look at cumulative concerns and patterns during and following a presentation. 23 It should be noted that all of the attendances were considered by a medical expert during the care proceedings and none were thought to be non-accidental injuries. 24 Lord Laming. The Victoria Climbie Inquiry. (2003) 13 accidental injury. As stated by Munro in 201025, “uncertainty pervades the work of child protection.” 6.26 While there were no concerns for Sibling’s health at the time, it was important to the investigation and their well-being to see if Sibling had any injuries. CSC had ensured Sibling’s protection by agreeing that they should not remain with family members beyond the first night. They then completed the required checks of the alternative family members who took on care and supervised contact with the parents. In regard to the medical there was some confusion about what was being requested. The Social Care team believed that an ‘intrusive’ skeletal survey was being requested rather than a ‘non-intrusive’ child protection medical. The exact nature of the expected medical should have been clarified at the time and agreement reached to avoid the delay. (Learning point 7) 6.27 Alex was appropriately safeguarded when they were well enough to leave hospital. Learning: 6. The cumulative impact of any incidents or concerns should be considered. This requires information sharing and peer discussion, effective systems for reviewing any notifications, and reflective supervision. 7. At the point of closure information should be shared with those continuing to work with the family. Including midwives, if there is a pregnancy. Any new information that emerges, including further anonymous allegations, should also be shared. 8. GP information should be considered as part of a strategy discussion and additional information sought as part of the assessment. 9. Strategy discussions should always include consideration of whether siblings require a Child Protection Medical as per the the Tees Child Protection Medical Procedure. 10. Professionals should always be alert to whether assumptions are being made about a family and whether any professional disagreements need resolving formally. Good practice: Well considered and timely responses from the CHUB The referral from A&E when Mother attended following the domestic abuse incident The care of Alex during their admissions to the local hospital were timely and responsive, and the Consultant Paediatrician sought advice from the Named Doctor for Safeguarding Good communication between agencies and across borders in key episode 5 Contact between Alex and the parents was sensitively supervised in hospital Open access was given to the paediatric ward for 24 hours, so that the baby did not need to return to A&E if there were further concerns Checks were undertaken with another local authority out of hours Good attendance at strategy meetings Thresholds are well understood and upheld There has been a high degree of cooperation and engagement from agencies with the review process, which has been important in identifying the learning 25 The Munro Review of Child Protection – Part One: A Systems Analysis; Department of Education 2010 14 7 Recommendations 7.1 The rapid review process that recommended this review identified a number of issues that required consideration. They included information sharing, Sibling’s attendances, and parental history. The review has found that while it was known that Alex and Sibling were living in a home where domestic abuse and low level parental mental health were known to be a factor, they also appeared to be well and lovingly cared for and their home was clean and warm. The parents stated they were willing to work with professionals and came across as open and honest. The review has considered the known parental history, the emerging concerns including the domestic abuse incident and allegations, the families financial and health stresses, a number of presentations with Sibling at A&E and the UCC, and two very young children with reported feeding issues. The review has found that none of these concerns would have met the threshold for an on-going child protection response, even if considered cumulatively. There were however opportunities for improved information sharing, for more focused support of the family, and for agreement about how the parent’s engagement with on-going therapeutic support would be monitored. 7.2 It is recognised that actions have already been taken in relation to some of the individual agencies’ identified learning in this case. For example work is already underway within the hospital trust to improve completion rates of ACHILD which includes robust audits and increased visibility of the safeguarding team within UCC and A&E. 7.3 The agency reports have made recommendations which have largely been completed by the conclusion of the review. Some of the learning identified within this report will have been addressed by the single agency actions plans, which are being monitored by the HSSCB ‘Engine Room’. They include recommendations such as community midwives needing to be reminded that pregnant women should be seen alone at least once in pregnancy to enable routine enquiry regarding domestic abuse to take place, and that they need to be made aware of when to seek advice and guidance or safeguarding supervision from the safeguarding team. 7.4 The following recommendations have been agreed by the HSSCP in response to the learning identified during this review: 1. That HSSCP continue to reinforce via workforce development the importance of: o understanding parental history and how this informs known risk and vulnerability (Learning Point 1) o consideration of cumulative impact within assessments (Learning Point 3) o information-sharing at case closure and if new information emerges (Learning Point 5) o GP information being sought (Learning Point 6) 2. That HSSCP produce a ‘Seven Minute Briefing’ for the multi-agency workforce which outlines the learning from this case review, to be disseminated and promoted across all agencies. 3. That the HSSCP audit cycle should continue to review best practice in relation to assessment, including the consideration of cumulative concerns. |
NC50850 | Death by suicide of a 16-year-3-month-old girl in January 2017. Rachel lived with her mother and younger sister; she had frequent support from her father and his partner. Her family, school and local Child and Adolescent Mental Health Services had been concerned about her wellbeing for some time including a risk of self-harm, suicidal ideation and acts. She became known to her GP, the local Emergency Department, ambulance services, police and children's social care. The family is White British. Findings: the reliability of a young person taking prescribed medications and the possibility of secreting medication to use later to overdose; the LSCB should seek to learn from the wider picture and research into adolescent self-harm and suicide to consider prevention and treatment options in the commissioning and provision of local services; teachers may not have had training in young people's mental health especially acute mental ill-health and its management; the need to increase understanding of the impact of social media on young people's decision-making and actions. Recommendations: expedite publication of a Local Strategy for Prevention of Suicide by Young People and whether this should be a Strategy to prevent harm and suicide by young people; to raise awareness and learning between schools about children's mental health and risk; to seek reassurance from partners that there is a robust and coordinated response to suicide by a young person, to identify and mitigate the impact on other children and young people.
| Title: Multi-agency case review: Rachel. LSCB: City and Hackney Safeguarding Children Board Author: Malcolm Ward Date of publication: 2019 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Multi-Agency Case Review Rachel March 2019 Malcolm Ward Independent Reviewer 1 Contents page Background Summary 2 Synopsis of Events from December 2015 to January 2017 4 Family views about services received, what may have helped Rachel, lessons learned and possible actions 24 Practitioners’ Views 36 Findings 41 Recommendations 60 Appendixes: The City & Hackney Safeguarding Children Board Response (CHSCB) and Partner Agencies’ Responses to Rachel’s death 63 Relevant findings from research into suicide by children and young people 64 Reading 68 Useful Organisations / Resources 69 2 This multi-agency review seeks to learn from the tragic death of Rachel who took her life in January 2017. It also makes recommendations to the City and Hackney Safeguarding Children Board and its partners to seek to improve responses to children and young people’s mental health, self-harm and suicide. Rachel was 16 years and 3 months when she died. Her family, school and local Child and Adolescent Mental Health Services (CAMHS) had been concerned about her well-being for some time; including a risk of self-harm, suicidal ideation and acts. She had also become known to her GP, the local Emergency Department, the London Ambulance Service, the Police and Children’s Social Care. Rachel lived with her mother and younger sister. She had frequent contact with and support from her father and his partner. The wider maternal family, including Rachel’s uncle, aunt and grandparents, also provided regular direct care and support. The family is White British, of professional background. Rachel attended a local secondary school where she progressed well and was seen to be bright and academically able; she was predicted to do well. She was also involved in local youth activities, in sports, in politics, and she played music. She had a close group of friends at school. 1. Background Summary 1.1. Concerns about Rachel’s emotional wellbeing were first raised at primary school in 2005 by her Mother who questioned whether Rachel had some form of autism. Rachel was referred to the Child and Family Consultation Service (a forerunner to CAMHS) for soiling and concerns about her reaction to her parents separating. She was seen by a Nurse Practitioner. 1.2. In autumn 2009 Rachel, age 9, was referred to First Steps, a tier-two Psychology Service, which was part of the local Primary Care Trust Services. There was concern about her behaviour, including fighting with her younger sister and challenging parental control by threatening to jump off a balcony. Her mother questioned whether she may have Asperger’s Syndrome, however, it was noted that she was able to show empathy for friends. She was assessed to have secure attachments and a good family support network. There were meetings with Rachel, Rachel and her mother and finally Rachel, her mother and sister. These were to help Rachel’s parents develop strategies to manage Rachel’s behaviour, for Rachel to learn to manage her emotions, such as anger, and to improve the relationship with her sister. Rachel’s mother was offered the opportunity to return for further assessment 3 after four months if these approaches had not worked. Rachel did not wish to follow up with a different practitioner; the original person she had seen was on family leave. 1.3. It is noted in later health records that in 2011 there were several incidents of Rachel ‘running away’. 1.4. Rachel’s mother informed this review that in 2013 she had spoken with the school as Rachel was unhappy and wished to move school. Rachel’s mother had asked the school for help. Rachel’s mother gave a background of Rachel having called the police when she was upset with her mother. The school was also advised of Rachel having run away and of concerns when Rachel was at primary school and that she had been referred to First Steps while at primary school. 1.5. In July 2015, Rachel’s mother raised with the secondary school whether some of Rachel’s behaviour may have a link to autism. Rachel was seen by the school counsellor from October 2015 to discuss this and other matters; she attended three sessions but did not attend two others. Rachel said that she did not wish to continue the meetings. She was not referred by the school for further testing as she was not judged to be showing autistic behaviour. This was not what the family had understood from their feedback from the school, at the time. Later tests show that Rachel did not score highly on the autistic spectrum scale. 1.6. In early December, Rachel attended her GP, alone, reporting low mood / depression and self-harm over the previous six months. Rachel also disclosed an overdose of aspirin, two days previously. Rachel had concealed the ongoing self-harm from her mother. She had been encouraged to attend the GP by a friend. 1.7. From this point Rachel became a patient of CAMHS, she was provided with community adolescent mental health services, was for periods a day patient or an in-patient of an adolescent psychiatric service and continued to go to school. At critical points when she self-harmed or attempted to take her own life she became known to the ambulance service, the local emergency department and the police. 4 2. Synopsis of Events from December 2015 to January 2017 December 2015 – end of January 2016 (Rachel 15 yrs 3 months - 15 yrs 4 months) Recognition and increasing concern about Rachel’s emotional state, self-harm and suicide risk and its management in the community 2.1. The GP appropriately referred Rachel to CAMHS and discussed with Rachel the need to inform her mother of the symptoms; to which Rachel agreed. CAMHS saw Rachel two days later for an urgent assessment; her mother was present. A Safety Plan was agreed, pending the start of treatment in CAMHS in three weeks. 2.2. Two weeks later, just before Christmas, CAMHS responded to Rachel’s father’s request for information about the treatment plans and agreed to keep him informed. 2.3. At the end of December 2015, Rachel was seen with her mother. The initial assessment was that this was a depressive episode of moderate severity with underlying perfectionistic traits. There was also a question about possible autistic spectrum disorder. A Safety Plan was agreed with Rachel and her mother about emergencies and safety at home. Treatment options to be considered were medication (Rachel’s mother was not sure about medication at that point but agreed to consider it in the future if necessary) and cognitive behavioural therapy, minimum weekly. Rachel was to be assessed for social communication as part of an autism assessment. The Multi-Disciplinary Team was to be consulted about options. 2.4. In the first week of January 2016, Rachel and her mother attended CAMHS. Rachel described finding everyday self-care as difficult and was anxious about how she would cope with the rest of the academic year and education over the next few years. She had found the return to school difficult. She had not been sleeping well, had continued to self-harm most days and had had suicidal thoughts. The Safety Plan had deterred her from acting on those thoughts. The Safety Plan was revised after separate discussions with Rachel and her mother and then agreed with by both. Rachel was to speak with her mother if she felt anxious. The overall view was that Rachel had insight and was slightly improved from her assessment in December 2015. She was thought to have experienced a moderate depressive episode with possible autistic spectrum traits. Options for treatment were discussed and Rachel’s mother expressed a preference for psychotherapy rather than 5 medication (fluoxetine1), which CAMHS had suggested; although Rachel’s mother agreed to look further into this. Rachel agreed to a psychotherapeutic approach. Options for day or in-patient care were also discussed if the risks were to increase further. An autistic spectrum assessment was completed by Rachel’s mother on behalf of Rachel. Rachel’s father attended the assessment, unexpectedly. It was agreed with him that he would not join but would be updated after it. In that later conversation he stated that he thought that Rachel had autistic traits. It was agreed how CAMHS would keep him informed about future appointments. 2.5. During the weekend, Rachel was very anxious about returning to school on the Monday, she was not sleeping well. During the night she had barricaded herself in her room and cut herself; she refused to go to her father as planned. Her mother contacted CAMHS by phone on the Monday morning to report this. She also wanted more information about the proposed medication. She was uncertain about keeping Rachel safe. An urgent appointment was made for that afternoon with mother and father; Rachel did not attend. 2.6. In that appointment the parents’ concerns about the possible side-effects of medication (including suicidality) were discussed, and written information was given about possible side-effects. It was agreed to start fluoxetine at 20 mg, alongside psychological therapy. Hospital admission was also discussed, and it was agreed that Rachel’s parents would talk with her about this because of the seriousness of the situation and suggest that she visit the Adolescent Unit. The Safety Plan was revised; Rachel was not to be left alone, she should either be at school or under adult supervision and hospital admission should be considered if there was further risky behaviour. The family established 24 hour a day supervision. 2.7. CAMHS monitored the situation the following day by phone, there was some improvement. Rachel went to school. On the next day Rachel was seen at CAMHS, with her mother. She had started the fluoxetine and reported feeling ‘no worse’. She was anxious about not missing lessons at school and about the potential impact on her exams. Rachel was still self-harming and had suicidal thoughts three to four times per week but did not think she would try to take her life, unless things became worse. She disliked the increased adult supervision and did not want hospital in-patient treatment but accepted that it would be considered if things were worse. Rachel agreed to try and talk more with her mother and was happy to be referred to the CAMHS Adolescent Team. It was agreed that Rachel 1 Fluoxetine is a type of antidepressant known as an SSRI (selective serotonin reuptake inhibitor). It can be used for children over 8. https://beta.nhs.uk/medicines/fluoxetine/ https://www.nhs.uk/conditions/antidepressants/ 6 would have weekly CAMHS appointments and that a Care Coordinator would be appointed to meet her twice per week. The Safety Plan was updated, a family member would stay over the weekend to support Rachel and her mother. It was noted that the self-harm and risky behaviours were escalating, and that hospital admission may need to be considered. 2.8. The same day Rachel’s mother confirmed by phone to CAMHS that she had updated the school. The school had requested information direct from CAMHS about Rachel. Rachel and her mother agreed that they would provide copies of the CAMHS update reports to the GP to the school. 2.9. The following Monday, Rachel’s mother contacted CAMHS requesting an urgent appointment as Rachel had suffered from nosebleeds, was having difficulty waking in the morning and mother thought that Rachel may prefer to discuss her dark thoughts with someone other than her. She wondered if these factors may be side-effects of the fluoxetine. An appointment was arranged for that afternoon. 2.10. Rachel was initially seen alone by the Care Coordinator; they were later joined by mother. There was evidence that new cuts to Rachel’s arms were more serious than previously seen. Rachel saw the self-harm by cutting as a relief and ‘one of the things that kept her alive’. The Safety Plan was revised. 2.11. Rachel was seen mid-morning by a CAMHS Medical Doctor (Speciality Trainee in Psychiatry), with her mother, and was assessed to be in an agitated state. Rachel thought the violent thoughts of self-harm she was having were increasing – but on further exploration it was assessed that they were similar to those before she commenced fluoxetine. She had also shown some suicidal behaviour. It was agreed to continue the fluoxetine but to monitor closely and for mother to inform CAMHS of any further incidents. The risk was seen to be increasing and admission to an in-patient unit was to be considered if the situation became worse. 2.12. Mother contacted CAMHS after the weekend asking for an urgent appointment. There were questions as to whether Rachel was having a negative reaction to the fluoxetine, with a physical reaction and increased suicidal thinking. 2.13. Rachel and her mother were seen later that day by the Care Coordinator. Rachel was keen to continue the medication. She had cut her arms more seriously. The Safety Plan was reviewed. The family was continuing to monitor Rachel during the night. 2.14. In the early hours of the following morning, Rachel’s mother contacted the Mental Health Trust Crisis Line as Rachel had attempted to use a ligature round her neck. Rachel’s aunt 7 had found and cut Rachel down from a shower fixing. Mother agreed that the situation could be managed at home, monitoring Rachel at all times with another adult rather than taking Rachel to the Emergency Department. 2.15. Rachel and her mother were seen by CAMHS that afternoon. The risk was seen to have increased, with Rachel having planned to kill herself over some days. Although the parents had hoped to keep Rachel out of hospital it was agreed to admit her as a day patient to the Adolescent Unit, as soon as possible. On further clinical advice it was agreed to stop the fluoxetine. Rachel’s father was also consulted, he also agreed to the admission. That evening it was agreed with Rachel and her mother to prescribe Promethazine2 to help Rachel sleep. Sertraline3 was also considered as a replacement for fluoxetine (but not prescribed). Admission to the Day Unit was being planned. 2.16. Two days later Rachel and her mother were seen by the Care Coordinator. The situation was described as worse with Rachel having strong suicidal thoughts and agitation. The previous night Rachel was found to have hidden a lanyard under her pillow. Rachel’s mother hoped that the day unit would be preferable to in-patient admission, in the first instance. 2.17. Rachel’s father contacted CAMHS to discuss his worries and question whether Rachel should be admitted to hospital, especially if new medication (sertraline) was to be tried. He was advised that Rachel and her mother did not want Rachel to be admitted to a unit outside London. 2.18. The next day a meeting was held at the Adolescent Unit with Rachel and both her parents to plan her admission to the Day Unit three days later (with the possibility of the family ringing the Acute Unit over the weekend, if necessary) over the weekend. February 2016 – mid-April 2016 (Rachel 15 years 4 months to 15 years 7 months) Rachel as a day patient in the Adolescent Day Unit 2.19. Rachel first attended the Adolescent Day Unit at the beginning of February 2016, five days per week, with 24/7 back-up cover. Rachel initially said she felt “down all the time”, she wished to reduce her fluctuating thoughts of self-harm but was pessimistic that she could. Her thoughts were heightened at school and in the evenings. She was prescribed 2 Promethazine can be sued for insomnia and has sedative and non-psychotic inducing properties https://bnf.nice.org.uk/drug/promethazine-hydrochloride.html 3 Sertraline is a type of antidepressant known as an SSRI (selective serotonin reuptake inhibitor). https://beta.nhs.uk/medicines/sertraline/ 8 mirtazapine4 for low mood, anxiety, and prolonged sleep onset latency; and a week of Zopiclone5 to aid sleep – with the aim that this would enable her to take part better in psychological therapies. She was to have regular 1:1 Cognitive Behavioural Therapy (CBT), and Rachel, her parents and sister were to take part in Family Therapy. 2.20. During her time in the Day Unit there were several episodes when Rachel cut herself superficially, but these reduced in frequency towards her discharge. 2.21. On the first Sunday of March 2016, Rachel cut her arms many times and took an overdose of six fluoxetine, which she had stored from before it was stopped. She told her mother about the overdose after four hours. Rachel’s mother took her to the local Children’s Emergency Department. In assessment Rachel reported no particular trigger to this episode but said that she had wanted to end her life. She also said, despite adults in the family being protective, that if she had the chance she would do it again. She had experienced general low mood “for a year” but some days felt better. She found trying to “keep up” and “being best” at school difficult. 2.22. After this overdose attempt Rachel improved and following adjustments to her school programme she was able to commence re-integration into school a few days a week and continue at the Day Unit the other days. A Care Programme Approach (CPA) Meeting was held mid-April 2016 and Rachel was discharged back home under the care of the CAMHS Adolescent Team. She was diagnosed with mixed anxiety and depressive disorder and continued on mirtazapine. Mid-April 2016 – end of August 2016 (Rachel 15 years 7 months to 15 years 11 months) Regular treatment, return to school, exams, holiday – symptoms continue but appear to be less acute 2.23. Five days after discharge, Rachel’s mother emailed CAMHS to seek advice about particular behaviours observed in Rachel over the past ten days, including: not eating or eating then purging. Rachel’s mother queried the impact of vomiting on medication which may not be fully ingested. Other concerns included an episode of Rachel hyperventilating, occasional self-harm, worrying about school, and possibly not taking her medication (which had been observed but denied by Rachel). Mother said that Rachel had good days with friends and family but was also at times moody and argumentative. She did not want to take her 4 Mirtazapine is an anti-depressant https://www.nhs.uk/conditions/antidepressants/ 5 Zopliclone is used to treat insomnia. https://beta.nhs.uk/medicines/zopiclone/ 9 medicine as she thought it made her gain weight and meant she could not drink at parties. 2.24. Rachel met with the Care Coordinator the next day. They discussed eating and purging, Rachel saw it as an alternative to self-harm and was also worried about her body image. They agreed to do further work on this area of distress and on emotional dysregulation6. 2.25. Later that week Rachel was reviewed by the psychiatrist, both parents were present. Rachel had low mood, was binge-eating and vomiting, and self-harming when stressed. She was worried that the medication was making her gain weight. It was agreed to cease the mirtazapine and commence sertraline; information was given about sertraline. However, sertraline was not started – melatonin was increased, instead. Rachel’s parents were advised how to deal with crises. Rachel was to be reviewed a week later. 2.26. Two days later, Rachel was admitted to the local hospital following an overdose of 25 mirtazapine; she had been secretly storing her medication for some time. The overdose was on ‘impulse’ rather than planned; Rachel was upset that she had not qualified for a youth run and also felt that she was not being allowed to assist the event as a helper. At the time of the overdose Rachel had hoped to end her life. Rachel also said that she was stressed at school, particularly about exams. She had friends that she could talk with. It was noted that this was the third suicide attempt and that Rachel was regretful of her action. Rachel’s mother was surprised at the incident as Rachel had seemed happier and more positive recently. She was treated medically for the overdose and then later reviewed by psychiatry. Rachel’s mood became stable with no evidence of psychotic symptoms or active self-harm or suicidal intent. Rachel did not wish to return to the Adolescent Unit as she wished to be at school to complete her exams. She had insight into her situation and was willing to continue to engage in treatment. Rachel was assessed at mid-risk for self-harm and the increase in suicide attempts was noted. It was agreed that she could be discharged home and a Safety Plan was agreed with her parents (medication and sharps to be locked away and Rachel to be monitored overnight). Rachel was due to meet with her Care Coordinator the following day. 2.27. Children’s Social Care (CSC) was informed by the hospital and contacted Rachel’s mother. CSC agreed that there was no role for them as CAMHS was fully involved. Permission was given for CSC to liaise with the school. 2.28. Rachel was reviewed by CAMHS the next day. Rachel had stored medication for three weeks. She was worried about gaining weight, even though she had not, and was unhappy 6 Emotional dysregulation refers to difficulty in managing emotions, which may interfere with daily life. 10 about not being permitted to take part in a marathon. There was disagreement about the proposed change of medication. Rachel was willing to try but her mother wished to try non-pharmacological approaches. Rachel denied having a razor. 2.29. At the end of the session Rachel’s father asked privately for support for himself. He was advised about this. 2.30. The Adolescent Multi-Disciplinary Team (MDT) reviewed Rachel’s case. It was noted that Rachel was only taking her sleeping medication not her anti-depressants. Medication was to be discussed at the next psychiatric review. 2.31. The next day Rachel met with her Care Coordinator – they worked on positive body image. They met again the following day and started a programme of Cognitive Behavioural Therapy (CBT). 2.32. Rachel’s mother emailed that day and again a week later, seeking advice on how to manage low points at home following an argument when Rachel had binged and vomited. The Care Coordinator advised Rachel’s mother that she would follow this up with Rachel and also referred Rachel to the dietician. 2.33. In the first week of May 2016, Rachel was again discussed at the Adolescent MDT. The working diagnosis was ongoing anorexic conditions, vomiting and diet restriction, emotional dysregulation with ongoing suicidal thoughts and a query of emerging personality disorder. 2.34. Rachel was seen by the Care Coordinator and eating was discussed. Rachel was irritable and tired. Rachel’s mother emailed to say that she was at a loss and from what she had been reading she felt that quick action was needed. Rachel’s father’s partner raised concerns about the impact on family dynamics and whether she should be included in family meetings. She was not included. 2.35. The following week Rachel was seen for psychiatric review. Emotional dysregulation was identified with self-harming urges, poor sleep, restriction of diet and excessive exercise. She was assessed as low risk to herself and others. The melatonin dose was increased. Weekly sessions for Rachel with the Care Coordinator and Family Therapy were agreed. The Care Programme Approach assessment and plan was updated. In the same week Rachel and her mother met with the dietician. 2.36. The following week Rachel met with the Care Coordinator. She had self-harmed and was to be seen by the GP for a superficial laceration to her arm. Rachel discussed family issues. 11 2.37. The following day the Care Coordinator discussed Rachel in clinical supervision. The supervisor was to seek further advice about treatment options. Rachel was seen as very unstable. 2.38. By the end of May 2016, there was improvement in Rachel’s eating. At the beginning of June 2016, there was a review with the psychiatrist. Rachel’s mother was worried as she had found rope in Rachel’s room. Rachel had had fleeting suicidal thoughts but said that she had none at the time of this review. The melatonin was increased, and the Safety Plan was revised. Rachel was seen over the next two days by CAMHS practitioners to discuss her progress and the ‘noose’ that was found. 2.39. The following week Rachel and the Care Coordinator met for CBT about stress intolerance. Rachel worked well and showed some insight into her behaviours. The next day Rachel’s parents met the Family Therapist and before Rachel joined them, they discussed Rachel’s experimenting with cannabis use and whether it impacted on her. They had different views about this. (Rachel’s mother later told this review that she did not think that Rachel used cannabis a lot.) 2.40. In the session a week later with her Care Coordinator, Rachel discussed stress intolerance and was able to demonstrate that she could think about what upset her and why. 2.41. The next day Rachel’s mother emailed to say that she had found two suicide notes in Rachel’s room. Rachel had said that she would kill herself after her GCSE exam. The Care Coordinator spoke with both mother and father to consider the implications and options. An urgent CAMHS appointment was offered for that afternoon but later declined after Rachel’s parents had met her at school and satisfied themselves that she was alright. Mother had informed school of the risk. One of the school counsellors ensured that Rachel stayed in school all day. 2.42. The following week Rachel was again discussed at the Adolescent Multi-Disciplinary Meeting. It was agreed to refer her to the Eating Disorders Team for September. 2.43. The next day in a Family Therapy session the parents talked about the stress of Rachel’s recent suicide notes and these were then discussed with Rachel when she joined the session. 2.44. Two weeks later in the first week of July 2016, Rachel met with her Care Coordinator. She was stressed by the mock exams and because a friend was unwell. Rachel engaged well, and the possibility of dialectical therapy was discussed with her. She was willing to try it. In the Family Therapy session, the next day, Rachel, her mother, father and sister discussed 12 family dynamics. 2.45. Throughout the rest of July 2016, Rachel continued to meet her Care Coordinator to work on distress intolerance and discuss her worries about her body image and eating. She was planning to go to Europe with a friend’s family. In the Family Therapy session at the end of the month, Rachel’s mother questioned if Rachel was eating less in preparation for her holiday. 2.46. There were no problems reported while Rachel was away on holiday with another family. 2.47. In the middle of August 2016, Rachel did not attend the planned session with her Care Coordinator. Rachel was described as being truculent since her return from her holiday. Her mother wondered if she was worried about the upcoming exam results. Rachel was seen by the Coordinator in the afternoon. Rachel had been worried about her body while on holiday, and since her return she had been self-harming and making herself vomit. Her mood was low, and she was anxious. Rachel wanted to find a medication that was different to fluoxetine and mirtazapine. 2.48. In the last week of August 2016, Rachel was seen by her Care Coordinator for a review. Rachel’s exam results were due the next day. Rachel said she would kill herself if she did not get an A*. The Care Coordinator alerted Rachel’s parents to Rachel’s threat by email as she could not reach them by phone and she recommended a Safety Plan. Rachel was offered an extra session for the following day. 2.49. In the following day’s session Rachel was lighter in mood as she had achieved two As in her GCSEs. The family had devised a surveillance plan to keep an eye on her and noted that Rachel was really unhappy with her result. End of August 2016 – mid-October 2016 (Rachel 15 years 11 months to 16 years 1 month) Serious overdose, self-harm, admission to Adolescent Mental Health Unit as an inpatient and later day patient 2.50. Over the Bank Holiday Rachel overdosed on 64 paracetamol tablets. (This is a very large dose) Her mother called for an ambulance, but Rachel was taken by family to the local Emergency Department, where she was also found to have new superficial cuts to her arms. The overdose was initially described as an anxious response to disappointment with exam results. She had intended to kill herself. Rachel actively planned the overdose by buying tablets from different shops. After taking the tablets Rachel told her mother as she felt guilty about how her mother would react to her death. Rachel then regretted telling her mother. Rachel later gave a different account of the overdose saying that she had actively 13 planned it after an argument over drinking alone and taking laxatives, however, she had been having suicidal thoughts since her exam results. 2.51. Rachel was treated medically under the national guideline7 for a significant paracetamol overdose, and the possible impact on her liver was monitored. The hospital noted Rachel’s recent psychiatric history in its assessment and treatment. It was noted that Rachel reported drinking alcohol occasionally with friends and that she had smoked cannabis ‘a week ago’. The hospital checked with CSC and was informed that Rachel was not a current case. 2.52. The psychiatric assessment noted the impulsivity of the act. Rachel was alert, orientated and not agitated. She described mild insomnia, and fluctuating appetite with bingeing and vomiting. She was disappointed with the exam results but unconcerned about the suicidal act. There was no evidence of thought disorder or hallucination. She did not have current intent or a plan to attempt suicide. She was assessed as a high risk to herself. Rachel’s mother was concerned about how she could set appropriate boundaries for Rachel, such as challenging her drinking. 2.53. Rachel’s parents were worried about Rachel’s impulsivity and what seemed to be an escalation when Rachel had seemed to be ‘getting better’. Rachel and her parents agreed to Rachel being admitted as a voluntary in-patient to the Adolescent Mental Health Unit. Rachel’s father agreed with medication. They were keen to get a diagnosis for Rachel. Rachel transferred to the Unit the following day. 2.54. The Emergency Department referred Rachel to CSC which agreed to undertake a Child and Family Assessment. Rachel and her sister were both seen as part of this assessment and Rachel’s mother was consulted. It was agreed that there was no role for CSC as CAMHS was working intensively with the family, there were no safeguarding concerns in terms of family relationships, home environment or parenting and that the family was able to provide appropriate supervision (it was noted at the time of the assessment that Rachel was an in-patient). 2.55. Rachel settled well in the Adolescent Unit and formed good relationships with staff and peers. She participated well in therapies and other activities and with the psychology team. Rachel and her family continued with the Family Therapy. In mid-September 2016, Rachel had her first overnight home visit. Despite suicidal thoughts she did not act on these as she 7 Treating paracetamol overdose with intravenous acetylcysteine: new guidance; Dec 2014 https://www.gov.uk/drug-safety-update/treating-paracetamol-overdose-with-intravenous-acetylcysteine-new-guidance 14 was worried that it would cause an extension of her stay as an in-patient. Rachel also demonstrated that she was aware of techniques to use to prevent her harming herself. There were no subsequent reports of her having had suicidal thoughts during home leave. At the end of September 2016, it was noted that Rachel was unkempt and that she had not been showering; she also reported self-harm and fluctuation in eating and vomiting. 2.56. Rachel transferred to the Adolescent Day Service at the end of September after the CPA was updated. She started a gradual re-introduction to school and was back at school full-time within two weeks. Rachel and her parents started Group Dialectical Behavioural Therapy (DBT)8. Rachel was discharged from the Adolescent Unit back to the CAMHS community-based service in the second week of October 2016; the Family Therapy was to continue under the community service, as before. Her medication had been reviewed and she continued on melatonin only. 2.57. The school and GP were kept informed of Rachel’s overdose and subsequent care and treatment. The Adolescent Unit Education Department liaised with the School about Rachel’s school work and exam preparation. There was good contact between the two agencies. A member of staff from school visited the Unit. Mid-October 2016 – mid-December 2016 (Rachel 16 years 1 month to 16 years 3 months) A further serious overdose, self-harm, discharge back to community, further self-harm, change of key CAMHS workers, anxiety about exams, consideration of medication 2.58. Rachel and her family continued with DBT sessions and Rachel had individual sessions with her Care Coordinator. In the week after her discharge from the Adolescent Unit no concerns about self-harm or suicide were noted. 2.59. However, 10 days later, at the end of October 2016 in the late evening, Rachel attended the local Emergency Department with her mother having again overdosed on 64 paracetamols. There was also evidence of recent cutting to her arms. Rachel had argued with her sister and later gone to a party where she had got drunk, before buying the paracetamol and taking the overdose. (Rachel’s mother believes that Rachel planned the overdose before the party.) Rachel called an ambulance and was assisted by a passer-by who called her mother. At hospital, she was treated medically for the overdose and seen for a psychiatric review. Rachel described feeling “low” lately. Her affect was flat but there were 8 Dialectical behaviour therapy - a talking treatment based on cognitive behavioural therapy (CBT), but adapted to help people who experience emotions very intensely. https://www.mind.org.uk/information-support/drugs-and-treatments/dialectical-behaviour-therapy-dbt/#.WxvSEPZFzIU 15 no concerns about her orientation or her mental state and she had insight into what had happened. This was again seen as a serious overdose. There was a question about whether Rachel had been taking her melatonin – she reported that she was not good at taking it when on school holidays, as there was no regular routine. The concern about eating and vomiting was reduced. Rachel was assessed to be at high risk of self-harm but there was no evidence that Rachel intended to kill herself with this overdose. Her low mood and alcohol were factors in the overdose, but she had sought help quickly. 2.60. It was agreed with Rachel and her mother that Rachel would return home; she did not wish to return to the Adolescent Unit. Rachel and her mother were to agree ‘crisis plans’ and Rachel was to be seen by CAMHS again the next day. Rachel and her mother met the next day with the Care Coordinator and a psychiatrist who was newer to Rachel, as the previous Consultant had left the Trust. The weekend admission was reviewed again. Rachel had been affected by the recent suicide of a young person from her school. She had no current plans to end her own life and wished to continue working with the CAMHS Community Team rather than go back to the Adolescent Unit. The possibility of re-starting medication was discussed; Rachel was only prescribed melatonin at this time. The Care Coordinator agreed to work with Rachel and her mother to support re-integration to school. 2.61. Four days later, at the beginning of November 2016, Rachel and her mother attended the DBT group and met afterwards with the Care Coordinator. The impact of the other young person’s death was discussed by Rachel in the DBT group. Rachel’s mother talked with the Care Coordinator about the impact on her of Rachel’s health. The Care Coordinator advised Rachel and her mother that she would be leaving the Trust and there would be a careful handover and parallel working with a new Care Coordinator for several weeks. Rachel and her mother were upset by this; the psychiatrist had recently changed, too. 2.62. Rachel met Care Coordinator 2 the following day with Care Coordinator 1. They discussed Rachel’s ‘perfectionism’ and that she was worried about being behind with her school work. Approaches to this were discussed. (Rachel’s mother believes that Rachel was not necessarily a perfectionist but was responding to academic pressure.) Three days later in a further session, Rachel and Care Coordinator 1 looked together at some school homework, which was overdue, to plan how it could be managed. The following day both Coordinators met with the Family Therapist, Rachel, her mother and her sister; they discussed tensions in relationships and how much Rachel could be prompted or challenged at home without upsetting her. 16 2.63. Two days later Rachel attended her sixth DBT session – a ‘resource tool box’ 9 was discussed to help her self-manage the heightened anxiety and feelings. 2.64. The next day, a Friday, the school contacted CAMHS to say that Rachel wished to speak with Care Coordinator 1 urgently. Rachel was crying and had had a sudden dip in mood. She was seen that afternoon, she was unkempt, and her hair was not washed. Rachel was worried about the approaching mock exams and was worried that the new US President had been elected. A plan was agreed for how Rachel would manage over the weekend and it was agreed that they would meet again on the Monday for a review with the psychiatrist. (Rachel’s mother has noted, in retrospect, that it was from November when she was probably not really coping – with regard to this issue she remembers feeling numb and not knowing how to respond.) 2.65. On the Monday Rachel attended CAMHS alone, she was unkempt; there were signs of superficial cuts to her arms. Options for continued treatment were discussed – continue in 1:1 therapy with the new Care Coordinator alongside Family Therapy, restart mirtazapine as it had no dangerous side-effects or to try a different medication. Rachel was reluctant to resume mirtazapine as it made her gain weight. It was agreed to discuss medication at the next CPA Meeting when her parents would be present. 2.66. After the psychiatric review Rachel and Care Coordinator 1 continued discussion. The cutting was discussed. Rachel explained that it served multiple purposes – ‘to de-intensify feelings, to change her mood and as an escape’. 2.67. In the early hours of the next morning Rachel was brought to the Emergency Department by her father, at mother’s request (Rachel’s mother has said to this review that she was struggling by this time, which is why she had asked Rachel’s father). Rachel had cut her forearm with a pencil sharpener blade, deeper than usual – saying “but I’ve done worse”. This was noted as part of an increasing pattern of self-harm; however, the pattern of self-induced vomiting had lessened. Rachel had poor sleep when she ‘forgets to take her melatonin’. She said that she had had a bad two weeks with the death of a school friend (whose funeral was that day), news about the change of her Care Coordinator and the death of her cat. Rachel was also worried about her upcoming mock exams. Medication was to be considered ‘after Christmas’. There was no current suicidal ideation. Rachel was assessed as having emotional dysregulation with a chronic risk of self-harm and 9 The tool box in DBT: the young person is encouraged to develop a tool box for self-soothing i.e. identify all sensory activities that can assist with self-soothing during times of crisis, utilising all senses. The concept is to do activities that assist in reducing distress and help with the passing of time without resorting to maladaptive coping strategies. Examples include looking serene pictures, touching a fluffy object, listening to music, smelling a nice scent or tasting chocolate. 17 suicide rather than acute risk. It was noted that the frequency of incidents was increasing, possibly as a reaction to recent stressors – but that the risk was not worse than previously. It was assessed, with father, as safe for Rachel to return home to her mother that night. CAMHS was informed. 2.68. In the CAMHS DBT session two days later Rachel’s mother shared that she was finding the situation with Rachel challenging and would welcome an opportunity to speak with other parents.10 2.69. The following Monday, Rachel met with Care Coordinator 1 and described a very volatile mood that day. They explored her friendships, what Rachel enjoys and possible triggers to low mood – of which chocolate was identified. The Consultant Psychiatrist spoke with Rachel’s mother on the phone to propose starting Rachel on medication following her mock exams after Christmas, so that she could be monitored closely. Mother enquired if there was a diagnosis for Rachel and it was agreed that this would be discussed at the next CPA Meeting. 2.70. That week Rachel’s mother contacted the GP to ask for a prescription of melatonin. She described Rachel as improving since her most recent overdose, going to school most days and wanting to get better. 2.71. There was a Family Therapy session the next day – mother could not attend as she was away with work. In the 1:1 DBT session later that day Rachel talked about going to hospital as she had cut herself. The next day Rachel met with the two Care Coordinators as part of the handover between them. Future sessions with Care Coordinator 2 were agreed. 2.72. The following Tuesday Care Coordinator 1 returned a call to Rachel’s grandmother who had care of Rachel while Rachel’s mother was out of the UK. Rachel had had a bad day and refused to go to school on the Monday. She had gone to school with the support of the school support officer on Tuesday. The grandmother was worried about how little Rachel was eating. Care Coordinator 1 agreed to raise this with Rachel at their next meeting. They met the following day, Rachel maintained that there was nothing to worry about regarding her eating. They talked about pressures at school and how Rachel might use future sessions at CAMHS. Rachel wanted to be less anxious and low in mood and she wanted 10 The parent DBT group ran in parallel to the young persons’ group on a fortnightly basis. It covered developing the awareness of the impact of stressful environments on children and the level of sensitivity their children have to stressful emotional experiences. It provided group support amongst the parents which aimed to reduce feelings of isolation and shame in their experience of having a child with such a high level of mental health difficulty. Parents were also given an overview of the skills that their child was being taught so that they could reinforce them at home i.e. skills in mindfulness, interpersonal effectiveness, emotional regulation, tolerating distress and "walking the middle path" (instead of getting caught in polarised family dilemmas). 18 the medication to work. 2.73. The next day mother and Rachel attended a group DBT session, which they both said they found helpful. Rachel’s mother shared the challenges of how to care for Rachel when Rachel was anxious and how far she could push Rachel – for example when Rachel did not shower. 2.74. The following week, the second week of December 2016, Rachel and her mother met with both Care Coordinators. Rachel was low in mood, she had opened a school report that had been sent to the house without warning, her grades had dropped significantly. Mother was due to meet with the school to discuss an education plan for Rachel. It was clear that Rachel had recently self-harmed as blood could be seen on her shirt, but she refused to discuss this. 2.75. The same day Care Coordinator 1 and the Psychiatrist met to consider Rachel’s medication plan. It was proposed to prescribe sertraline daily. The family was said to be concerned about use of medication because of the previous adverse reaction to fluoxetine. Possible side-effects and support were discussed. 2.76. Two days later Rachel met with Care Coordinator 2 and the School Counsellor. It was agreed that Rachel would not sit any mock exams and a Safety Plan was agreed; a copy was sent to Rachel’s mother. Rachel was to use some work sheets to help her resist self-harming. Rachel also attended a DBT session. 2.77. In the third week of December 2016, Rachel had her final meeting with Care Coordinator 1. Rachel later met with Care Coordinator 2. They agreed a Safety Plan of who to contact as Care Coordinator 2 was going to be on leave and Rachel’s mother was also going to be away. They reviewed strategies that Rachel had learned previously to cope if she felt overwhelmed. Rachel stated that she had some suicidal thoughts but that she was not planning to act on the thoughts. The Safety Plan was emailed to Rachel’s mother and it was noted that Rachel would be in the care of her grandparents while Rachel’s mother was away for work. Mid-December 2016 – early January 2017 (Rachel 16 years 3 months to 16 years 4 months) A further serious overdose, monitoring, Safety Plans for the holidays, a serious overdose, self-harm and anxiety about returning to school; finally, Rachel took her life 2.78. The next day Rachel was brought to the Emergency Department by her aunt and the police under Mental Health Act 1983, section 136, in the evening. She had gone missing and her family had found a suicide note. Rachel’s computer showed that she had researched how 19 to kill herself. They reported her missing to the police. Rachel called the CAMHS Crisis Line mid-evening to say that she had taken Sudafed (which contains ibuprofen) and was feeling unwell, she did not wish to go home and she had intended to kill herself. The Crisis Line called an ambulance. A member of the public also called the police when they saw Rachel in a dangerous situation. When Police found Rachel, she told them that she had taken 36 Sudafed tablets with the intention of killing herself. 2.79. Rachel tried to abscond from hospital several times overnight; police remained and prevented her. She was admitted and treated medically for the overdose. She reported several stressors including the departure of Care Coordinator 1, her mother being away, worries about a peer who was unwell and exam stress. She had been ambivalent about ending her life the previous day and prevaricated between taking tablets and calling the CAMHS Crisis Line or ChildLine. Mother has said that Rachel used the ChildLine online service on several occasions but would never give her full identity; this did not become clear until Rachel’s computer was accessed by family after her death. At the time of this assessment, Rachel was accepting treatment and did not wish to end her life. The initial plan was to transfer Rachel to the Adolescent Unit as an in-patient under the mental health section. 2.80. The next day, while still in hospital, Rachel was assessed by the CAMHS team. She was discharged from the section 136 and continued to be monitored on the ward under the supervision of a mental health nurse while she was being medically treated for the overdose. She was re-assessed by a psychiatrist the next day with her father present. Her father had requested an in-patient bed at the Adolescent Unit as a voluntary patient or under section. This was not agreed as it was thought Rachel would be better treated in the community with continuing DBT. Rachel was discharged to her grandparents’ care, with additional adult supervision in place. 2.81. CSC was notified by the police of the incident. CSC spoke with CAMHS and with Rachel’s mother and it was agreed that CAMHS was the appropriate lead agency and that there was not a role for CSC. Young Hackney11 resources were suggested for Rachel’s younger sister, to support her. Rachel’s Mother said that she was receiving support from her GP. 2.82. Rachel was reviewed psychiatrically at CAMHS, with her mother present, in the week before Christmas. There had been no more suicidal ideation, but Rachel had self-harmed. There was no serious adverse reaction to the sertraline, although Rachel had had a 11 Young Hackney provides a range of resources for children and young people; including activities, advice and community involvement. https://www.hackney.gov.uk/young-hackney 20 nosebleed. A plan was agreed about how mother should respond if Rachel was feeling suicidal. The Safety Plan agreed was: In a situation where Rachel felt suicidal: The first step would be using a DB strategy; the second step would be planning - with the hope that the feelings would pass; the third step would be using a crisis line. Finally, Rachel could seek help from an adult, using a yellow card to say that she needed some support, e.g. supervision for up to an hour, joining the adult in what they were doing or a red card to say that Rachel wanted or needed to go to A&E. If the situation did not improve then the Emergency Department could be used. 2.83. Rachel was reviewed again two days later. She felt more stable, was less suicidal and was self-harming less (Rachel’s mother has queried whether this is an example of Rachel telling staff what she thinks they want to hear). Rachel was anxious about the Christmas break. The medication was discussed, and a question was raised as to whether Rachel’s recent overdose related to worry about the new medication, but this was not conclusive. It was agreed to increase the dose after Christmas. She was also worried that her DBT sessions were coming to an end. The Safety Plan was re-confirmed. 2.84. The next day Rachel attended her last DBT session. The following day, the Friday before Christmas, the psychiatrist and mother spoke on the phone to discuss the plans for Christmas and a Safety Plan was agreed. 2.85. Rachel’s Mother has told this review that Rachel used the yellow card on Boxing Day night. In the early morning, the day after Boxing Day, Rachel was taken to the Emergency Department by her mother, after self-harming. She had multiple lacerations to her arms. She had tried to use the DBT techniques which had been helpful over Christmas, which she had found stressful, but that day she had not been able to follow the techniques. However, she had told her mother about the self-harm after the event. The cutting made her feel better. She did not feel suicidal but was having frequent thoughts of self-harming. It was agreed that it was safe for her to go home under supervision and the Safety Plan. It was noted that Rachel had frequent self-harm, poor coping mechanisms, fluctuating moods and emotional unstable personality disorder. 2.86. The next day Rachel and her mother met with Care Coordinator 2 at CAMHS. The sertraline dose was increased. Mother was worried that Rachel’s self-harming was increasing in both intensity and the areas of her body that she was cutting. Rachel was seen to be more energetic. She said that cutting made her feel better. She denied any suicidal thoughts. The Plan included the Care Coordinator monitoring Rachel by phone over the next few days because of the increase in medication. 21 2.87. In the Family Therapy session, the next day with Rachel, her mother and sister, the stress on family members ‘needing to walk on egg-shells’ was discussed. 2.88. The day after the New Year 2017, Rachel was seen by Care Coordinator 2. Rachel had a good new year in with friends. Therapeutic work was done in the session and Rachel was given some therapy tasks to work on at home. 2.89. The next day Rachel met first with Care Coordinator 2 and later they both met with the Psychiatrist and Rachel’s mother. Work was undertaken on positive approaches and how to respond to texts from friends (Rachel’s mother has said that she understood the texts between a group of friends to have been about exam worries). It was agreed that Rachel would return to school the following day (Thursday) – a Safety Plan was agreed around this. There were no current suicidal thoughts. She was using coping strategies effectively to manage her thoughts about self-harm. There were no major side-effects to the increase in sertraline, but Rachel did report headaches. She was concerned about returning to school the next day and had planned to contact the school counsellor in advance. 2.90. The next day Rachel went missing instead of going to her father’s house which had been arranged as she felt that she could not go back to school, as planned. She rang her mother and told her that she had taken 30 paracetamol and codeine tablets. She did not want the police involved and did not want to go to hospital. She was found and taken by police, with mother, to hospital on section 136. It was also suggested that she had taken 40 tablets and that 35 tablets were unaccounted for. Rachel was seen alone initially but later with her mother and father. Rachel had taken the pills in the local park. She had been anxious about returning to school, rather than low in mood. At the time Rachel was thought to have acted on impulse. Rachel’s mother has said that a suicide note, which had been written the night before, was later found on Rachel’s computer. At the time of the overdose she had intended to die but, in the Emergency Department assessment Rachel said that she was glad that she had not died. She was also anxious about the change of Care Coordinator. The view formed was that the sertraline was seen to be helpful as it had increased her responsiveness, but this was to be closely monitored because of a possible parallel increase in self-harming thoughts. Rachel maintained that she was no longer actively suicidal, although she had previously told a nurse that she was still suicidal and had a plan. When later asked about this statement to the nurse, Rachel denied that she was suicidal. Rachel had mental capacity and insight. She was assessed as not being sectionable. Rachel did not want to be admitted as a voluntary patient, although Rachel had previously told the nurse that she wanted to be admitted as an in-patient. This was discussed with the psychiatrist and parents, but Rachel did not confirm it. It was assessed that it was safe for her to return home under the supervision of her parents. She was to be 22 followed up by CAMHS and the sertraline was to be reviewed as there is a risk of it increasing suicidal thoughts and behaviour. It was also recommended that the Adolescent Team followed up Serotonin Syndrome 12 regarding possible increase in anxiety. The psychiatrist noted that Rachel was to remain at home under the supervision of her mother, or other family adults. Rachel’s mother says that she was not advised by the psychiatrist whether Rachel should go to school or not, but that this changed later when CAMHS staff decided that Rachel would continue to attend school and called the school pastoral counsellor about this, from the hospital, before Rachel was discharged home. An appointment was made for Rachel to meet with the school pastoral counsellor the following day, Friday. 2.91. No new safety plan was agreed. The plan in place was thus a continuation of the plan previously agreed in December (see paragraph 2.80 above). The Care Coordinator was to follow up by phone the next day with Rachel and her mother. An appointment with Rachel was agreed for the following Tuesday. 2.92. CSC was informed of Rachel’s attendance at hospital and the circumstances. 2.93. The next day (Friday) the Care Coordinator 2 checked Rachel’s well-being by phone. Rachel had been to school to meet with the School Counsellor to plan her return. She felt better. She was planning a quiet weekend with her mother and did not feel anxious about returning to school on the Monday. A safety plan was agreed with Rachel to speak to her Care Coordinator on her work mobile if she felt anxious, or the crisis line if her Care Coordinator was not available. Rachel was to go to school if she felt able and see the School Counsellor; and was to text her mother on arrival and departure from school. Her Care Coordinator would check in with her at the end of the day. Mother was informed of the plan. It was confirmed that Rachel and the Care Coordinator would meet the following Tuesday. 2.94. On the Saturday evening Rachel was taken to the Emergency Department by her mother as she had self-harmed and a metal staple was lodged in her wrist. She had low mood but was not suicidal. The staple was removed, and Rachel was seen by a psychiatrist. Rachel had previously secreted the staple as a ‘back-up’ as she was denied access to other sharps. She had told her mother about the staple as she could not remove it herself and was anxious about it. Rachel was assessed as not being suicidal; coping strategies and a Safety Plan were agreed with her for either thoughts about self-harm or suicidal thoughts. 12 Serotonin Syndrome https://www.nhs.uk/conditions/antidepressants/side-effects 23 She planned to meet with Care Coordinator 2 on the Tuesday to continue their therapeutic work. Rachel was discharged home in the early hours of Sunday. (Rachel’s mother has told this review that Rachel made a point of seeing friends and family that weekend.) 2.95. On the Monday Rachel said that she felt able to go to school. She met initially with the School Counsellor. The Counsellor was off-site for the rest of the day. Rachel became too anxious to join lessons and used the agreed Safety Plan to go to a quiet area where she could sit reading in a room where there was an administrator. At lunchtime she went out of the school. She did not return. Rachel called her Care Coordinator 2 but the call cut out. The Care Coordinator rang back several times but was not answered. The school contacted Rachel’s mother and informed her that Rachel had not returned to school after lunch. Rachel’s mother tried to contact Rachel unsuccessfully. Police were informed. Rachel was later found in a building in a local park where she had hidden and hanged herself. The police and paramedics attempted resuscitation, but it was unsuccessful. 2.96. The Inquest into Rachel’s death, completed in July 2017, determined that Rachel died as a result of suicide, by hanging and that at the time of that act she intended to die. The Coroner did not give an Article 2, narrative judgement, to seek to learn lessons from Rachel’s death. 24 3. Family views about services received, what may have helped Rachel, lessons learned and possible actions 3.1. Rachel’s parents and family were invited to contribute to this review. The Independent Reviewer met separately with Rachel’s mother; with Rachel’s younger sister, maternal uncle and aunt – together; and with Rachel’s maternal grandparents. Rachel’s mother has provided several documents for the review and a written statement. She also signposted the reviewer to a BBC programme13 in which she had taken part about research into prescribing anti-depressants to adolescents; to other media items relating to the research; and to her own submission to the Consultation on the Green Paper about adolescent mental health14. 3.2. It is clear from the meetings with family members that they all greatly loved Rachel, wanted her to be well and wanted ‘treatment’ to work for her. There was frustration that after a year of treatment Rachel was not better. Rachel’s mother took the major role in her care, supported by Rachel’s father and local uncle and aunt, and at times grandparents (who were not local) who would stay when mother had to be absent or work. They found looking after her over this period, especially 24-hour supervision, and living with her stressful and challenging. Rachel’s grandparents said that initially they were not aware of how serious things were and that they were probably being protected, at first. Family members have commented on how stressful holding the lead responsibility was for Rachel’s mother. They also felt that they had to rely on Rachel’s mother for information about assessments, treatment and Safety Plans instead of being part of a whole family care team sharing her care. It was only in crisis that they had direct contact with services in Rachel’s mother’s absence. They did not feel that they had a complete picture. 3.3. The adult family members attended the 5 half-days of the Inquest and had been frustrated about its outcome, not feeling that it had answered their questions or addressed the lessons which they felt should be learned for other young people like Rachel. 3.4. Rachel’s mother, in a written statement to this review, has said that it is the family’s view that Rachel’s death was ‘both predictable and preventable’. In summary the family views 13 BBC The Doctor who Gave up Drugs Series 2 https://www.bbc.co.uk/programmes/b0b578bd 14 Transforming Children and Young People’s Mental Health Provision: a Green Paper, Dec 2017 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/664855/Transforming_children_and_young_people_s_mental_health_provision.pdf 25 are that at the time of her death it was known that Rachel was at high risk. She had been brought to hospital five days prior on a police mental health section after she had tried to kill herself. Rachel had not followed the Safety Plan on that occasion (and did not know why she had not) and so there could be no guarantee that she would follow a revised Safety Plan on her return to school a few days later. 3.5. School was known to be a stressor for Rachel and she was anxious about her school work. The pressure of upcoming exams, after missing several weeks of school, in the family’s view added to her stress. 3.6. There had been a change of Care Coordinator. Rachel had strong trust in the first Care Coordinator who had left the Trust mid-December 2016. 3.7. Rachel was started on a different SSRI medication (sertraline) at the beginning of December 2016. Such medication was known to have possible side-effects in adolescents. The re-starting of SSRI medication and building up to a full dose had been planned gradually to seek to prevent an adverse reaction. It was thought that in February 2016 Fluoxetine (the first SSRI medication tried with Rachel) had been the cause of a negative reaction and suicide attempt; and as a result, that medication had been stopped. Following the prescribing of sertraline in early December 2016, the family noted the following incidents: a suicide attempt mid-December and self-harming at Christmas. The dose was increased at the end of December 2016 followed by a further serious suicide attempt in early January 2017 where the assessing psychiatrist (not Rachel’s own psychiatrist) noted that consideration would have to be given to a risk of ‘serotonin syndrome’15. 3.8. The family’s view is that Rachel’s death could have been prevented by hospital admission. Rachel was not ‘sectionable’ but was compliant and could have been told that she needed to be in hospital. A conversation with one of Rachel’s friends after her death revealed that Rachel did not understand why she had not been admitted to hospital on this occasion and thought that she should have been admitted, but Rachel had managed to avoid it saying that she ‘had got away with it’. 3.9. The family’s view was that the Safety Plan on Rachel’s discharge home after the suicide attempt in early January 2017 should have included the family watching Rachel all the time and that Rachel should always have been monitored in school and accompanied to and from school by family and not allowed out on her own. 15 Serotonin syndrome https://www.nhs.uk/conditions/antidepressants/side-effects/ 26 3.10. The family has also suggested that, on her last day, if Rachel had been spoken with at school by a trained person (a medical practitioner or someone trained in ‘zero-suicide’ conversations16) her death may have been prevented. Rachel’s mother has also raised the question of whether someone at school could have had a conversation with Rachel that day about how she was feeling and whether that would have made a difference. Information has become available, retrospectively, that Rachel had posted an ambivalent message on a social media group about whether she wished to live or die. 3.11. There is a further question for the family as to whether the Safety Plan was updated adequately after Rachel’s suicide attempt in early January 2017. The psychiatrist who discharged Rachel from the section 136 that day did not know that Rachel would return to school within a few days. The need for Rachel to be fully monitored at school was not noted and so was not communicated to the school. The Care Coordinator was on a course on the fatal day and so was unreachable by phone when Rachel tried to ring her. 3.12. Rachel’s mother’s view is that she had become a conduit for communication between CAMHS and the school rather than them speaking direct to ensure that the school was fully aware of the Safety Plan. 3.13. There is also a question for the family about whether the risks of returning to school for Rachel, and how they should be managed, were fully thought through by the CAMHS team. Rachel’s mother thought, at the time, that the pros and cons of Rachel’s return to school had been assessed but in retrospect believes this not to be the case. The school was unaware of the risks. On communicating with the school that final morning Rachel’s mother thought that there was a team of people keeping a close eye on Rachel. 3.14. Considering the longer-term factors in reflecting on the lessons from Rachel’s death, Rachel’s mother has noted that Rachel had shown mental health concerns previously – particularly in the year preceding the year when she became a patient of CAMHS. Rachel’s mother believes that as Rachel was a good and well-behaved student these concerns did not get picked up. There was a question about whether Rachel had autistic traits, but this was not followed up. 16 https://www.zerosuicidealliance.com/faqs/ 27 3.15. Rachel was also greatly troubled by external and environmental factors, for example, reports of mass killings, the deaths of celebrities who she admired and as a politically sensitive young person, she was worried by Brexit and Trump’s election. Rachel was not thought to be a big user of social media; however, she was influenced strongly and emotionally by the news which she monitored regularly – including during the night. Rachel’s mother has queried whether she should have been given more advice about Rachel’s access to news media or You Tube and how as a parent you can decide what content may be a harmful to a young person like Rachel. This raises the question of how a parent could enforce or monitor viewing. 3.16. Some of her close friends and acquaintances also had emotional health issues which impacted on her. Rachel’s mother believes Rachel was susceptible to peer pressure. 3.17. A particular issue noted by several family members, including Rachel’s sister, was the stress of exams and the new GCSEs, and the continual pressure brought by schools and the system to push children to achieve. Rachel’s mother saw stretch targets and predicted grades as factors which can push students to work harder. Being expected to achieve A*s was stressful to Rachel; her peers are also said to have commented on how stressful it was. Rachel had high predicted grades, and these contributed to her being emotionally overwhelmed easily. 3.18. Rachel’s mother questions whether alternative forms of education could have been considered for Rachel – such as home tuition – as Rachel found school particularly stressful. 3.19. A further question for the family is how well-equipped the school was for understanding Rachel’s needs. The school did not realise how serious her situation was. There seemed to be no way to take her mental health into consideration in the marking of her GCSEs; the view was that she could re-sit them the following year if she did not do well. It was not clear to the family that there was enough understanding in the school about mental ill-health, or the possible side-effects of SSRI medication. Given the increasing numbers of young people with mental health problems in schools, the family’s view is that it is important that schools have access to sufficient knowledge or expertise in this area. 3.20. The family believes that they needed more assistance and direct contact with CAMHS without Rachel being present. At times Rachel’s mother and father met staff with Rachel but felt inhibited from talking about issues or asking questions in front of her as this would often trigger a negative reaction. They would have welcomed the chance to meet 28 professionals without her present. Wider family members felt that they did not have access to CAMHS staff but that it would have been helpful for them to do so, especially as they were part of the care team. The family’s view is that this would have helped provide CAMHS with a reality check on what Rachel was saying to staff in her private sessions with them, including at times of acute risk assessment, as she did not always convey how she was actually behaving and the risks that she was taking. There was a family view that Rachel would say things that staff wanted to hear. Rachel did not respond well to the CPA process and CPA meetings which further inhibited the parents’ ability to share their observations and concerns and seek help and detailed guidance that they might need, in front of her. 3.21. Rachel’s mother said to the Independent Reviewer that she may have given an impression of coping and being able to manage but that this was not the case. The wider family was also concerned about the impact on Rachel’s mother and her ability to cope, when she also had stresses at work and another child to care for. Independent Reviewer comment: A Carer’s Assessment would have been an avenue to explore this. 3.22. Rachel’s mother said, “Living with a suicidal teenager is dreadful”. Having to discuss the pros and cons of managing the risk safely at home and whether you can/will take the young person home after a suicide attempt (in front of the young person who does not wish to be in hospital) was very hard. The family did not feel that they could say ‘no’; but they did not feel equipped to manage Rachel’s risk and behaviours. The family was ‘treading on eggshells’ for a year. If Rachel was upset she would make an attempt on her life and so the family tried not to upset her; she also ran away, banged her head on hard surfaces, self-harmed and shouted. “To manage such behaviour and risk at home requires training and support from the health team.” 3.23. The family’s view is that CAMHS did not get to the bottom of Rachel’s illness. They ask if the case should have been escalated for a second opinion. They believe that the change of lead doctors over the year and the change in Care Coordinator meant that there was no long-term view. This is supported by the Joint Trust Serious Untoward Incident Review see section 5.2 onward of this report. They have questioned the depth of experience of some of the lead practitioners. There seems, in their view, to have been no clear diagnosis or treatment plan. The relationship with the first Care Coordinator and the pilot DBT Group seemed to be helpful but both came to an end in December 2016 and Rachel seems to have deteriorated after that. 3.24. The family has questions about the use of medication, including from some family members 29 strong views against the use of medication at all. They believe that medication raised Rachel’s hopes for being better but then dashed them when it did not work. Rachel’s mother has raised the question about research into the possible negative side-effects of SSRIs on Rachel and other young people and whether the medication and its possible impact was monitored sufficiently. Also, she questions whether Rachel’s disappointment that the medication was not having a better impact was considered. 3.25. The Independent Reviewer spoke with family members about how Rachel was supervised in taking her medication, as it had become known that she secreted tablets and several family members noted that they had caught Rachel pretending to take the tablets and conceal them. There is no clear picture of how big an issue this was. (Reviewer comment: This raises questions about whether the supervision of medication should be addressed in Treatment Plans.) 3.26. Rachel’s mother’s view was that the CPA Process and Reports were inadequate, especially from early December 2016. There was a systems issue with this, accepted by the Trust, as a new computerised system was being piloted. No CPA report was provided for the family or school updating the diagnosis or treatment plan, including re-commencing SSRI medication from the early December 2016 meeting. Rachel was said to have been looking for this report just before her death. A system print-out provided posthumously was thought by mother to be inadequate. 3.27. In addition to the statement provided by Rachel’s mother which has been summarised above, the family members raised the following issues. After the police returned Rachel’s phone and computer (taken for examination after her death), the family was able to access Rachel’s use of the internet and media, which had not been possible before. This raised the question of how much Rachel may have used social media that was not previously known about. It was also subsequently discovered, after the Inquest, that she had been part of a social media group of young patients from the Adolescent Unit where she had been a day and an in-patient. Rachel had also accessed websites in favour of euthanasia. 3.28. The family wondered if Rachel had been planning the suicide from her discharge after the overdose and section 136 in early January 2017. Over the weekend she had made a point of meeting with or talking to family members and friends and had seemed affectionate, including getting into bed with her mother for a conversation, which was unusual. Rachel had said that one of the things that had stopped her taking her life on the Thursday was that she had not said goodbye to people. 30 3.29. The family’s view, in hindsight, was that it was wrong for Rachel not to have been admitted to hospital in early January 2017. The decision should have been taken out of Rachel’s hands. They have questioned if she could not be ‘sectioned’ could she have gone as a day patient or a voluntary in-patient. They believe staff should have been more directive with Rachel saying that they recommended that she should be in hospital. Her family saw her as compliant and said that if strongly advised to go she would have gone to hospital. They also questioned whether Rachel should have been allowed to go back to school at that point. 3.30. The notes of the last CPA Meeting, in early December 2016, were not distributed to parents or the school. There was a question about whether there should be a different CPA Process for children and young people. Rachel found it difficult to take part in the CPA meetings. 3.31. The family have asked whether more could have been done to look into whether Rachel had autistic traits as she had unusual reactions to stimuli. 3.32. The family thought that the DBT treatment was helpful to Rachel and that she responded well. But they question how much of her behaviour had become engrained. 3.33. The second SSRI medication was a planned risk. Rachel had reacted negatively to the fluoxetine – a nosebleed which was rare for her, shaking and violent thoughts. However, Rachel was keen to take the medication as she hoped it would make her better. Her mother thought that she took the tablets and she was usually supervised – but it was accepted that she also pretended and hid medicines, at times. Rachel stopped taking her mirtazapine as she was worried it was making her gain weight. 3.34. Mother has questioned whether she should have been entitled to a Carer’s Assessment in her own right. There was no professional support for the wider family who played key roles in caring for Rachel and who relied on mother to share the thinking from the CAMHS Team. They said that there was a lot of weight and stress on mother’s shoulders. Being responsible for Rachel 24-hours a day was stressful, especially in terms of sleeping, family assisted with ten-minute watches. 3.35. The family was too scared to argue with Rachel over normal issues. She dominated the house. It was not easy for the family to talk to each other when Rachel was in the room. Parents and families need guidance on how to communicate with young people with mental health issues and also with each other about and around the young people. 31 3.36. Other family members have questioned whether enough attention was paid to the possibility that Rachel may not have been truthful in her responses to professionals, especially during risk assessments. They thought that she could be manipulative. They also saw Rachel as compulsive and reactive to things rather than able to take control. In their view she was unable to control her emotions. She could be obsessive about some issues. 3.37. Rachel would search on-line about mental health and about medication and what it does – including the medication that she took in overdoses. She worried about world issues and read books on mental health – including one on ‘Reasons to stay alive’. They believe that she lived her life for the future. Rachel had said to her grandparents, “I just want to be normal.”. 3.38. The wider family did not think that medical staff had taken a longitudinal view in making assessments of risk in the final crises and questioned whether some of them were aware that Rachel had attempted hanging previously. 3.39. They questioned whether there was a view that self-harm by cutting was ‘allowed’. When seeking advice about this during periods of monitoring Rachel they believed they had been advised that Rachel having a screwdriver was probably not as serious as her having something sharper. They would have expected more detailed guidance about day to day management of Rachel in times of crisis or heightened risk. They thought they were working ‘blind’. The grandparents did meet with the first Care Coordinator after one suicide attempt and received advice on distraction therapies but overall the wider family did not feel that they knew what was happening between Rachel and her therapists and how to support her around this. They would have welcomed a wider family meeting to get guidance and advice over the whole period. 3.40. The wider family believed that communication between CAMHS and schools should be improved. Rachel’s sister thought that schools should be automatically informed when young people had been admitted to Emergency Departments. 3.41. They questioned that Rachel had been described by some professionals as a ‘perfectionist’ as one of her traits. In their view, this was not the case as in some areas she let standards fall, personal hygiene being one of them. The stress of her studies and exam pressures were not, in their view, perfectionism but worry. They questioned, especially Rachel’s sibling, whether too much emphasis is placed on young people about exams and the need to study hard and the impact that this has, with no enjoyment. 32 3.42. Rachel’s mother and separately other family members questioned whether the family should have had more support from Children’s Services. Mother asked, “what could they have done to help me?” She had agreed that as the family were caring for Rachel and receiving services from CAMHS there was not a role for CSC. She noted that she had not seen a copy of the CSC Child and Family Assessment. 3.43. When questioned Mother said that religious faith had not been a significant issue for Rachel. 3.44. It was not thought that Rachel had been a serious user of cannabis by the family but that she may have experimented. In response to seeing a draft of this report Rachel’s family made the following additional points: 3.45. ‘Zero Suicide Approach’ Rachel’s family feels, in hindsight, that Rachel’s suicide was predictable. Service planning and service provision should take into consideration risk of critical incidents, such as suicide and learn from other professions (such as the aircraft industry) about risk avoidance. The family advocates the introduction of a zero suicide approach. A high number of UK Health Trusts and CCGs have adopted this approach, first developed in the USA. The approach does not accept that some suicide is inevitable but strives to provide those who come in to contact with service users with the skills to deal with and prevent it, so that no-one, especially a child, dies as a result of suicide.17 3.46. Supervising patients who have a high risk of self-harm or who attempt suicide The family’s view is that the safety plans in place from December 2016 did not meet the increasing levels of risk. In particular, they believe that greater guidance should have been placed on close supervision of Rachel, including escorting her to and from school, and monitoring and observing her in school. 3.47. Leadership There is a need in cases like Rachel to ensure a ‘bigger picture’ view of the risks and any patterns over time. There was a discontinuity of care (as professionals changed or responses were provided by different services, e.g. in crisis). The family believes greater oversight was needed. The family is not clear what oversight there is above the consultant in longer term cases (e.g. over nine months). A recommendation 17 Zero Suicide Alliance UK https://www.zerosuicidealliance.com/faqs/ and https://www.england.nhs.uk/mental-health/case-studies/zero-suicide/ 33 about this is made by the family below. 3.48. Medicine and Healthcare Products Regulatory Agency (MRHA) 18 and SSRI Medication use in children The family has questioned whether enough is being done nationally to monitor and collect data about the side-effects of SSRI medication in children. They believe that professionals and service users are not fully aware of the ‘yellow card’ scheme19 which can be used to notify the MHRA of side-effects of medication; and that this should be promoted more widely. 3.49. Rachel’s mother’s family statement also presented a separate paper on the use of medication in Rachel’s treatment and its side-effects and findings of recent research about the possible impacts of SSRI medication in adolescents. 3.50. In a final meeting with the Independent Reviewer in response to the draft of this report Rachel’s mother made the following points: 3.51. At the time of Rachel’s assessment, on section 136 of the Mental Health Act, in early January 2017 Rachel’s mother did not understand why the advice for Rachel to stay at home under supervision was later changed to allow Rachel to go to school if she felt able to do so. However, she did not question it at the time, assuming that professionals were saying that Rachel was well enough to go to school, if Rachel felt well-enough to do so. On reflection Rachel’s mother has thought that it would be helpful for there to be clarity about when advice is being given or when a parent is being given an instruction, she would have found it helpful to have been told clearly whether or not Rachel should have returned to school, rather than it being left to her or to Rachel to decide. The question of attendance at school or not, and under what conditions, was not spelled out in the Safety Plan. 3.52. Looking back, Rachel’s mother believes that she needed more direct guidance on how to manage Rachel’s (challenging) behaviour, including daily management skills of a young person with such mental health issues, including how and when to supervise Rachel closely. 3.53. Rachel’s mother has also raised the following questions: 3.54. Could there be alternatives to Emergency Departments that could be used for young people in crisis, such as ‘havens’ as promoted by Young Minds? 20 18 MHRA https://www.gov.uk/government/organisations/medicines-and-healthcare-products-regulatory-agency 19 MHRA Yellow card scheme https://yellowcard.mhra.gov.uk/ 20 “Young Minds is calling for more safe places where children and young people can go in a crisis, such as 34 3.55. If a young person does not require a mental health section and does not wish to be a voluntary in-patient could there be a ‘middle way’, such as a ‘wrap around’ community-based service, possibly including home tuition; where school is a possible stressor? 3.56. Is there a point at which the mental health team should discuss with a parent when a child needs more care at home than a working parent can easily give and whether help may be needed to think about taking time off or ceasing work, if practicable? We acknowledged that this would be an issue for consideration as part of a Carer’s Assessment – not usually a task of the mental health team; also, that professionals formed a view of Rachel’s mother as knowledgeable, coping and being able to manage. However, towards the end this was not how she felt, she would have preferred more guidance and direction. (See paragraph 5.21) 3.57. Rachel’s mother’s written statements on behalf of the family make a number of suggestions about actions which should be taken by local services to seek to support other young people like Rachel. These are: a. A review of Safety Plan principles and standards by CAMHS. b. The Hackney Suicide Strategy should be reviewed to include a ‘Zero Suicide’ approach. c. Hackney should sponsor or undertake a study into the incidence, nature and reported causes of self-harm episodes, suicide attempts and suicides of young people in the borough over the last 5/10 years by gender in order to build up a greater picture of factors and causality; inviting other boroughs to do similarly. d. Given the incidence of adolescent mental ill health appoint psychologists to larger schools or clusters of smaller schools to ensure that schools have access to a mental health specialist. e. CAMHS should arrange mandatory regular meetings with parents as part of the CPA Process, in which the young person is not present. safe havens in the community, so that they are no longer forced to rely on A&E. For those that do arrive in A&E, the charity is calling for dedicated mental health liaison and referral support, so that young people don’t end up in a cycle of returning to A&E in a crisis.” See https://youngminds.org.uk/about-us/media-centre/press-releases/ae-attendances-by-young-people-with-psychiatric-conditions-almost-doubled-in-five-years-new-figures/ 35 f. Provide training for the parents of young people who are suicidal so that parents can be more able and confident in talking with them. g. When SSRI medication is prescribed ensure that there is increased vigilance to monitor not only the possible negative side-effects but also the possible negative impact on the morale of the young person if they believe the medication is not working. h. Review and calibrate the Care Programme Approach processes to ensure that diagnosis and treatment plans are shared properly. i. CAMHS services to ensure that longer term cases (e.g. nine months or more) where there are continuing high risks to be reviewed by a different or more senior consultant (a second opinion) to monitor longer-term view of risk, treatment, progress and (dis)continuity of care. Such a review to include the family and young person. j. Hackney should ask the MHRA for current data on SSRI use in children. Information should be promoted to staff in Hackney services across health, social care schools/education and the police, and also to the public about the MHRA yellow card scheme. 36 4. Practitioners’ Views 4.1. As part of the review methodology, a Practitioners’ Focus Learning Group was arranged for as many of the Practitioners who had worked with Rachel and her family as possible, to consider the services offered and lessons learned. The Independent Reviewer and Designated Nurse (a Member of the Review Panel) met with the Practitioners. Practitioners and Managers from CAMHS, the Adolescent Treatment Unit, the School and Children’s Social Care were in attendance; the Acute Hospital and GP Service was not represented. Some of the Practitioners who had worked with Rachel and her family had left the services and were not available. In addition, the Independent Reviewer also met separately with the School Counsellor, Head Teacher and Deputy Head Teacher. 4.2. The following information, questions and thoughts about lessons came from the Practitioners’ Focus Group. Health Services 4.3. CAMHS has introduced a daily crisis briefing of ‘Red Ragged Cases’ to help the crisis team and duty team have continuity for young people over time and have early recognition of increasing frequency and presentations of risk. (This was introduced after Rachel’s death) 4.4. The Trust generally had lower use of SSRI medication for adolescents than some other Trusts. Their prescription is guidance based. In Rachel’s case it would have been questionable not to use them. 4.5. When assessing young people, practitioners take into account the reliability of what they are saying based not just on content but by observing the young person’s affect, their mental state, their behaviour, congruence with what is known, seeking corroboration and reviewing the history. 4.6. A psychologist who worked directly with Rachel and who assessed her did not believe her to be on the Autistic Spectrum. This was based on the face to face work with Rachel and information about her neuro-developmental history. Rachel did have rigid thinking but this was seen as part of her emotional dysregulation – rigid thinking can be associated with this. 4.7. The impact of Rachel’s behaviour on the family and how to manage this was discussed in the DBT Groups. The Trust would take the lead from the parents on deciding who to involve 37 from the wider family in assessments and treatment. If it was assessed that a parent was not having difficulty coping with the young person’s behaviour this issue would not be pursued – this may be a systems issue that needs to be looked into, to enquire how parents or carers are coping. It was acknowledged that Rachel’s mother was seen as a key communicator. Rachel’s mother has stated that she was unaware that the Trust was ‘taking the lead’ from her and feels that there should have been a greater exploration of the family dynamics, which in her view were not fully explored. She also believes that this impacted on the value of the family therapy. 4.8. Rachel’s use of social media and the influence of her peers were also discussed in the DBT Group sessions. Ground rules about social media and its risks were agreed, including the risks of sharing information between peers and the skills needed to understand social media. The group also discussed the impact of the suicide of another young person and how to manage this. 4.9. In responding to possible systems issues about how to support non-mental health staff in this area, a school practitioner noted the benefits of the ‘WAHMS Project’ 21 as a Transformation Plan for working more closely with schools. This had been put in place after Rachel’s death (and the suicide of another young person in the same school). The Schools’ response to Rachel and Adolescent Mental Health 4.10. The school has said that they did not become aware of the concerns about Rachel in early 2016 until she was admitted as a day patient to the Adolescent Unit in February and the Unit’s Education Department requested information about Rachel and school work for her in relation to her exams. Rachel’s mother has advised this review that she and Rachel’s father attended the school prior to Rachel’s admission and shared information about Rachel’s previous behaviour. The school had been unaware that Rachel was found with a ligature around her neck in January 2016. They had not been aware that she had been assessed as high risk but they were aware that she was very vulnerable. 21 The WAMHS (Wellbeing and Mental Health in Schools) Pilot had two key strands. A Wellbeing Audit tool to be completed by all 40 schools in the pilot, supported by Wellbeing Framework Partners (Leadership and Management Advisers from Hackney Learning Trust). Areas for development would be agreed from this and an Action Plan devised. This was supported by a CAMHS worker allocated to work strategically in the school for between one day per month and one day per week, depending on school size. The CAMHS worker’s role and activity will be defined by the Action Plan; they will not hold a caseload or do ongoing, direct clinical work with children. The aim of the pilot was to promote Academic Resilience and grow capacity within the school, as well as establishing excellent working relationships and communication across schools and CAMHS. 38 4.11. The School was familiar with CPA Meetings but has learned the importance of MDT Meetings (multi-disciplinary team meetings) when a young person at risk is being reviewed at CAMHS. The School Counsellor attended CPA Meetings. 4.12. When Rachel returned to school from the Adolescent Unit she agreed her attendance with the School Counsellor and came in at different times if she was feeling too anxious or overwhelmed. A team of staff was in place to support Rachel including the Counsellor, the Head of Year and the School Office. If she was too anxious to attend lessons Rachel would sit in a quiet space and read. 4.13. The school sought to work closely with CAMHS to understand what was causing Rachel’s anxiety and how to help her manage it; breathing techniques, walking techniques learned by Rachel at DBT, etc. The Head Teacher’s view is that there was a good working relationship between the School Counsellor and Care Coordinator 1. The school supported Rachel by using the same techniques used in sessions at CAMHS. Rachel was herself very much part of the approach of how the school planned her support. 4.14. The school had a good relationship with family members and felt able to talk with them about Rachel without difficulty. They monitored Rachel’s daily presentation and noted if she was tired or anxious. They trusted the family’s judgement about whether Rachel was well enough to be in school. Rachel did not attend school for the last two weeks of the 2016 Autumn Term. 4.15. The School Counsellor attended the CPA Meeting at the beginning of December 2016. 4.16. On the fatal day, the school was not sufficiently aware of the intensity of the level of risk and would have wanted to be fully involved in discussions about how this should have been managed. The school had been informed on the Friday of the most recent incidents by mother who brought Rachel to school for the meeting with the school counsellor. They assumed that CAMHS was saying that Rachel was well-enough to be in school. 4.17. The school saw Rachel’s mother as very competent and assumed that she would communicate the assessments and plans from CAMHS, if necessary. There was also direct communication between the school and CAMHS. A lesson for the school is: What would help a parent be able to say to a school or other service ‘I need help, I am finding it hard to manage this?’ 4.18. The School commented on the need for increased capacity in schools and training about 39 mental health and how this is negotiated with all agencies. 4.19. Schools do not have an understanding of ‘impulsivity’ as an issue in adolescent mental health and behaviour. 4.20. A key question for the school was ‘Who makes the decision about a student’s mental and emotional capacity to attend school when they have mental ill-health?’ There is a need for shared risk assessments with sign-off by suitably senior staff from all relevant agencies. Schools need to be able to assess how they can manage high risks and whether additional resources would be needed for a student with mental ill-health; and when the school can say that the risk is too great for the student to attend. 4.21. A question that has arisen for the school is: Is there a wider systemic issue that schools may be under-diagnosing students with autism when those students are seen as intelligent and articulate? 4.22. The practitioners were aware that children and young people conceal issues and cover things up and queried whether this is disguised compliance? (Reviewer comment: Or is it normal adolescent behaviour? Children and young people often tell adults and professionals what they think the professionals want to hear.) 4.23. The School noted the following lessons and questions for itself and possibly other schools: The importance of good contact with parents where young people have mental health difficulties. The need for clarity about how a young person with such levels of risk can be managed at school and if they can be managed in school; including an understanding of the significance and possibility of impulsive actions. Being clear about what can and cannot be done with differing levels of risk. This may include awareness of when the mental ill-health meets the level of a disability under the Disability Discrimination Act, 2010. The need for greater clarity about confidentiality and what can be shared between different agencies to ensure good exchange of information about risk. Could the school be automatically notified about young people who have attended an Emergency Department? Could schools be routinely advised about young people who are receiving services from CAMHS? 40 How much a young person with mental ill-health should be allowed to self-determine decisions? The need to seek advice from health experts. A good relationship with CAMHS including CAMHS being aware of the school’s knowledge. Skills and capacity in this area. Given the high incidence of young people in schools with mental health difficulties the need to have in place a Disaster Recovery Plan to help the other students, staff and school to deal with the impact of a serious incident, like a suicide. 4.24. Overall, the practitioners who attended the Focus Group were in agreement with the emerging lessons that the Review Panel had suggested. These are discussed in the next section. 41 5. Findings 5.1. Rachel’s death is tragic. The purpose of this review is to learn lessons to influence future practice with adolescents who are experiencing anxiety which is leading them to self-harm or consider taking their own lives. It is not to undertake a forensic examination of all the actions taken; nor is it to make a judgment of whether her death was predictable or preventable. The Review Panel has noted the following findings which will be of assistance to practitioners, agencies and families working to support young people like Rachel. Key Line of Enquiry 1 Diagnosis, risk assessments and treatment of adolescents who self-harm and who have chronic anxiety and impulsivity with acute suicidal ideation or behaviour, including self-harm – including use of SSRI medication for low mood Serious Untoward Incident Review22 5.2. Following Rachel’s death and prior to the Inquest, The Mental Health Trust which had treated her throughout 2016 and up to her death undertook an independent internal Serious Untoward Incident Review, which is standard NHS practice. This was done jointly with the Acute Hospital Trust where Rachel had been treated in the Emergency Department following her suicide attempts or for self-harm. The school also contributed to the SUI review. The SUI Review’s main findings are: Two examples of notable practice ‘The level of support provided to Rachel and her family by the staff in the Adolescent Mental Health Team is particularly impressive in terms of their responsiveness, flexibility and accessibility. The care package included pharmacotherapy, family therapy, DBT and other individual therapies. … The team sought always to take into account the wishes and concerns of Rachel and her family in treatment and decision-making.’ In January 2017 when Rachel had taken an overdose, ‘a Staff Nurse from the Emergency Department was very concerned about the possibility of Rachel being returned home and queried the decision of the Consultant Psychiatrist, given that Rachel had told her that she 22 NHS Guidance: Serious Incident Framework 2015 https://improvement.nhs.uk/documents/920/serious-incidnt-framwrk.pdf 42 wished to be admitted to a mental health unit. Both the Consultant Psychiatrist and the Staff Nurse discussed these comments with Rachel and her mother in a further assessment of Rachel.’ Other examples of good practice were: Meticulous record keeping in both NHS Trusts for this case. ‘There were no concerns about any aspects of care provided by the Acute Hospital Emergency Department during any of Rachel’s presentations. Engagement with Rachel and her family by the staff concerned was of a uniformly high standard.’ The Acting Adolescent Mental Health Team Consultant sought advice about medication from another Consultant in the trust with special expertise in psychopharmacology. He also consulted a Senior Pharmacist who specialises in CAMHS. In November 2016, Rachel’s case was discussed anonymously at a trust wide CAMHS consultants’ meeting and the consensus was that a low dose of SSRI with careful monitoring was the correct management strategy. Rachel and her parents participated in a 12-week pilot Dialectical Behaviour Therapy (DBT) Group. Rachel and her family experienced this as a very23 helpful treatment for her. In early January 2017, following Rachel’s suicide attempt and five days prior to her death, the Consultant Psychiatrist undertook a very careful assessment; including Rachel’s mental capacity. The Consultant consulted fully with the Approved Mental Health Practitioner and took into consideration the view of the Emergency Department Nurse who was concerned about Rachel being allowed to return home. Admission was considered but not possible under the Mental Health Act, 1983 because of Rachel’s presentation. Rachel was seen by the Consultant Psychiatrist on three separate occasions before it was agreed that she could be discharged from the Emergency Department. 24 The assessment undertaken by the (Psychiatric) Core Trainee supported by the CAMHS Higher Trainee/Registrar on call was thorough (and documented in detail). 23 Rachel’s mother has commented to this review that they found the techniques helpful but not ‘very’ helpful. 24 Rachel’s mother has stated that the possibility of voluntary admission was not fully explored, in her view. 43 5.3. The SUI Review noted the pattern of increasing frequency and seriousness of episodes of self-harm in the final months of Rachel’s life as denoting increasing risk to her life and wellbeing. The (SUI) Panel have addressed the concern that the risk assessments may have underestimated risk in this case’. 5.4. ‘The overarching conclusion of the (SUI) Panel is that, for different reasons, Rachel’s depressive episodes were undertreated (especially in terms of psychopharmacology) over this time period. The Panel are struck by the dissonance of Rachel’s reassurances to staff and family about her health, well-being and lack of suicidality being frequently followed within a very short time by serious and potentially fatal overdoses and of her latterly being placed twice by the police on section 136’. 5.5. Particular issues that were considered by the SUI Panel but not thought to constitute care delivery problems include: Prescription of Fluoxetine at a starting dose of 20mg 5.6. The SUI Panel’s view was that “Recognised guidelines do not unambiguously support the contention that commencing fluoxetine at 20mg was inappropriate. The NICE guidelines do provide the possibility of starting fluoxetine at doses of more than 10 mg for children of higher body weight or when an early clinical response is prioritised although the Maudsley Guidelines are more circumspect. Furthermore, Rachel did not develop serotonergic syndrome and it cannot be concluded that her adverse reaction to fluoxetine was dose dependent”. Should admission have been considered for Rachel after the overdose in mid-December 2016 or after the overdose in early January 2017? 5.7. The SUI Panel note ‘that on both occasions Rachel was brought to hospital under Section 136 and assessed by a Consultant Child and Adolescent Psychiatrist and an Approved Mental Health Practitioner, among others. On both occasions Rachel was noted to have capacity. Admission was considered and not thought to be helpful by Rachel, staff or family members with the exception of Rachel’s father, who did ask for admission to be considered after the December overdose. Rachel was not considered to be detainable under the Mental Health Act 1983 and was agreeing to her ongoing treatment plan. Under the circumstances the (SUI) Panel thought that it was reasonable not to push for admission at these times. Risk assessments were noted to be thorough at each assessment’. 44 Should Rachel have returned to school for the Spring Term 2017? 5.8. The school reported to the SUI Review that they were insufficiently aware of the level of risk presented by Rachel, particularly following the mid-December overdose. The school questioned whether Rachel should have been allowed to return for the Spring Term. The school says it was not informed that Rachel should not have been allowed to leave the school premises at lunchtime. 5.9. The (SUI) Panel’s view was: ‘This was a very finely balanced decision. Rachel had wanted to go to school and different risks would have pertained if she had remained at home, unsupervised 25 , rather than attending school. Given the previous discussion about admission, this would have been the only option. Furthermore, the school had been in possession of the agreed Safety Plan. Given the available information at the time, it is the view of the SUI Panel that the risk to Rachel was not greater from being at school than from being at home’. The Christmas holiday would have impacted communication with the school staff over the holiday period. Problems with Care Delivery 5.10. ‘Anti-depressant medication should have been more strongly pursued following discharge from the Adolescent Unit in April 2016 (as recommended by the then Acting Adolescent Mental Health Team Consultant Psychiatrist)’. 5.11. At discharge from the Adolescent Unit in October 2016 there seem to have been conflicting views regarding Rachel’s diagnosis – Unit staff focussing on emotional dysregulation with no need for pharmacological treatment as opposed to clear evidence for moderate to severe depressive episodes in the past. The (SUI) Panel also note the presence in the discharge summary of an incorrect diagnosis “F12.1 Mental and behavioural disorders due to use of cannabinoids; Harmful use”. The SUI Panel agree with the family that the lack of clarity and explanation about a diagnosis which could include the possibility of a picture of emerging personality disorder with depressive illness and anxiety symptoms was unhelpful and confusing for the family and especially for Rachel. 25 Review Author comment: It is not clear why it was thought that Rachel would have been unsupervised had she remained at home that day. The family had regularly made arrangements to supervise her when she was unwell and unable to attend school. Rachel’s mother has confirmed to this review that if Rachel had not gone to school the family would not have left her at home unsupervised. 45 Problem with Service Delivery 5.12. During her contact with the Adolescent Mental Health Team where her case was transferred in January 2016, Rachel was under the care of several different Consultant Psychiatrists. The substantive Consultant left the team in April 2016 to work elsewhere in the Trust. Since then there have been three different Consultant Psychiatrists for the Adolescent Mental Health Team in either acting or locum positions, the most recent taking up post in October 2016. It is acknowledged that the service have done everything possible to recruit a permanent member of staff. Overall conclusion of the SUI Review 5.13. The root cause of this incident relates to the mental state of Rachel at the time of the death. The available evidence at this time is that Rachel intended to make a serious suicide attempt and that she concealed her plans and used a more instantly lethal method (suspension) than as previously (mostly) overdoses. The (SUI) Panel note that her death occurred at a time when she was increasing her dose of sertraline to therapeutic levels and was being closely monitored. Her family believe that this was a relevant factor in her choice of a more lethal and faster method of suicide. In the past it has been suggested that anti-depressants can potentiate and activate suicidal thoughts and behaviour through increasing energy and motivation. However, recent studies provide differing risk/benefit conclusions in relation to the use of fluoxetine and sertraline in adolescence. Gibson et al (2012) did not find significant effects of treatment on increasing suicidality, Bridge et al (2007) concluded that a small increase in suicidality was mediated by the efficacy of treatment in major depressive illness. 5.14. ‘The (SUI) Panel have been asked to consider whether this incident was predictable and preventable. It is the view of the Panel that it was predictable that Rachel would make further suicide attempts. She had a history of self-harm; increasing in frequency and severity. The role of medication in her choice of method in her final attempt remains unknown’. 5.15. ‘It is possible that the incident could have been prevented (at least in the short term) by hospital admission but that would have depended on the agreement of Rachel, her family and the Adolescent Unit staff for informal admission and for the Mental Health Act, 1983 to have been applicable should she have refused admission’. In the longer term, the best hope of prevention of further suicide attempts would have been effective treatment of her 46 recurrent depressive episodes with remission of her symptoms and the ongoing use of DBT strategies and other support to help Rachel manage her emotional dysregulation. This was in fact the treatment plan in place at the time of her death.’ 5.16. ‘Lessons learned in this (SUI) review relate to identified care and service delivery problems and highlight the need for stability of staff in taking a longitudinal view of illness and risk and in being able to challenge patient’s wishes and need to normalise with a clear understanding of previous contrasting behaviour’. City and Hackney Safeguarding Children Board (CHSCB) Multi-Agency Learning Review learning in relation to the diagnosis and treatment of Rachel, in addition to the Trusts’ SUI Report 5.17. This CHSCB Multi-Agency Review notes the SUI findings summarised above. In addition, it proposes the following additional lessons: 5.18. A holistic family view The CAMHS Adolescent Mental Health Team, Adolescent Unit and Acute Hospital Trust could have taken a wider view of ‘family’ than either mother or father, being those who had parental responsibility for Rachel. Other key family members played an important role in supporting Rachel and her mother and sister. It is not clear how the views of the wider family members and their roles were taken into account when assessments of Rachel’s care at home in the community was being considered, given that Rachel’s mother was a single working parent whose work occasionally took her abroad. Was there over reliance on Rachel’s mother communicating risk, supervision and treatment needs to other family members who were at times acting in loco parentis? 5.19. Supporting Parents/Carers Rachel’s mother is of a professional background and was in a responsible job which showed personal competence. It is not clear that there was a sufficient assessment of how and whether she was coping and whether she was able to continue to cope with the stress and the increasing difficulties that Rachel was presenting after a year. The Parents’ DBT group worked in parallel to the young persons’ pilot group to support parents in understanding young people’s behaviour and the treatments being offered to them. It is not clear if it also sought to assess parents’ ability to cope with and manage the behaviour and risks. Rachel’s mother’s view is that this was not explored in the DBT group; she understood that the group was to advise parents about supporting their children. 5.20. Parents’ worries and observations Rachel’s mother has raised the difficulty of seeking advice for herself and expressing her worries in sessions where Rachel was also present. 47 She and Rachel’s father were able to find ways of communicating privately to staff by email or orally to express their concerns about Rachel without stimulating a reaction in Rachel but Rachel’s mother felt inhibited in this as there was no clear structural way to do this. The Trust’s view was that the DBT Parents’ Group was a place where parents could raise their concerns and seek advice and support, including from other parents. It is important to note that Rachel’s mother did not see it in that way. While respecting a young person’s right to privacy and confidentiality it is important that their parents or carers are clear about how they can express their concerns to the practitioners and how this will be managed in relation to the young person’s right to know what is being said and their welfare and safety. 5.21. Rachel’s mother was entitled to be considered for a Carer’s Assessment26 under the Care Act, 2014. This did not happen. The reasons for this are not clear. The Trust has said that this should be usual practice. The SUI did not address this matter. An issue in this case is perhaps that Rachel’s mother (and father) were both seen as competent and well-able to manage Rachel’s care. However, the stress that they were under and its impact on them required a parallel and separate assessment. This could have included clarity about how they could communicate their observations and concerns about Rachel’s behaviour without triggering outbursts or set-backs. A Carer’s Assessment is the responsibility of the local authority not the health trust. A systems issue which needs to be considered is that within children’s services carer’s assessments are usually undertaken by specialists in children with disability services. There may not be a clear pathway for considering the need for an assessment where CSC are not involved with the child or family. 5.22. Impulsivity Some of Rachel’s worrying behaviour was impulsive although it has also become clear in hindsight that she did search websites to inform her about medication and other areas of mental health. This raises a question about how impulsivity as a dynamic is understood and assessed in young people who are at risk of self-harm or suicide; especially by parents and non-health staff. After each event Rachel was able to help analyse it and show some rationality; her treatment through DBT was to help her overcome overwhelming thoughts and feelings so that she would seek alternative strategies to self-harm. Rachel had shown insight and rationality in assessments after self-harm or suicidal behaviour but had then later acted impulsively again. The possibility of impulsive thoughts and actions needs to be held in mind in risk assessments; especially based on a longer-term view of a young person’s previous behaviour pattern. Rachel’s family’s view is that some of Rachel’s self-harm or suicidal behaviour was planned rather than impulsive – but when questioned 26 Carer’s Assessment https://www.nhs.uk/conditions/social-care-and-support-guide/support-and-benefits-for-carers/carer-assessments/ 48 Rachel said they were impulsive. 5.23. Related to this is the possibility of disguised compliance and that young people in mental health (or other) treatments learn from each other or from professionals how to make the system work. There is a question about whether Rachel said what she thought the professionals assessing the levels of risk wanted to hear, especially after self-harm or overdoses. (Rachel’s family believes this to be the case.) The reports to this review and the practitioners’ comments at the Focus Group were clear that practitioners are aware of this dynamic and use different ways to assess genuine responses and intentionality. But such compliance can be persuasive. Rachel’s family members were of the view that Rachel sought to hide her true thoughts at times. It is a useful reminder, however, for practitioners to bear in mind that there needs to be respectful scepticism and evidence seeking (including from the family) to corroborate what a service user is saying. As part of that it is important to test against known history and behaviour in previous similar circumstances. A systems challenge is that it is sometimes practitioners who are new to the service user who are undertaking risk assessments in crises. Attention to known history, previous patterns and the observations of family/carers is therefore an important part of testing reliability and plausibility. 5.24. Peer influence, social media, internet use and media As a young person Rachel could be influenced by peers. She had a number of friends and acquaintances who had their own emotional problems. It is not clear how much these and social media impacted on her. There are suggestions that she was affected negatively by comments on social media, on at least one occasion, but it is not clear how much these were explored with her to help her develop strategies to deal with them. Given that social media and internet use are integral to usual teenage life it will be important to consider with a young person who has emotional dysregulation how to manage their use, including the possible negative impact of specialist websites, which young people may access for advice. 5.25. SSRI Medication for Adolescents Rachel’s mother and family have raised the issue about the use of SSRI medication and whether this increases the risk of suicidality in young people. This is addressed in the Trusts’ SUI Report. Recent media and articles27 and the TV programme that Rachel’s mother took part in refer to recent meta-research (2016) questioning the efficacy and possible risks of SSRI medication suggesting that only one – 27 See for example https://www.bbc.com/news/health-44821886 or The Independent 21 July 2018 https://www.independent.co.uk/news/uk/home-news/children-antidepressants-prosac-school-age-drugs-pills-brain-doctors-a8458236.html 49 fluoxetine is effective28. The Royal College of Psychiatrists’ leaflet for parents, carers and those who work with young people about depression in adolescents, updated in March 2017, says that some SSRI medication can be helpful.29 The National Institute for Health and Care Excellence (NICE) guidance30 on the treatment of depression in children and young people, published in 2005 and updated in 2015 and again in 2017 (after Rachel’s death) confirms that view. It also states that where moderate to severe depression in adolescents is unresponsive to combined therapies (including medication and psychological treatment) or where it is recurrent, sertraline (or other medication) may be used. In Rachel’s case serious consideration was given to the possible risks of sertraline as they were known at the time and the Consultant Psychiatrist consulted other specialists and guidelines on its use before commencing the treatment. While it is important that practitioners and particularly prescribers keep abreast of research in relation to prescribing it is expected that they will follow the NICE guidance. Rachel was being monitored for any sign of adverse side-effects after the prescription of sertraline. A systems question is: how parents and carers are taught to know what to look for with regard to any changes and risks on a day to day basis between contacts with CAMHS and how to respond to these and when to seek earlier contact with the treatment team. 5.26. Hiding medication Another learning point from Rachel’s case which may be common with other adolescents is the reliability of a young person taking prescribed medications. Rachel wanted to be better and was reported to be keen to try medication, while other members of her family were more sceptical about it or worried about the risk of negative side-effects. However, it is known that Rachel, at times, secreted her medication which she later used to overdose. 5.27. Several family members told the Independent Reviewer that they either discovered Rachel seeking to fake taking her medication or that they found a stash of medication which she had hidden. It is also known that Rachel stopped taking her mirtazapine as she thought that it made her gain weight. She also described that she was not good at taking her melatonin in the school holidays as she did not have a routine. Rachel’s mother could not remember this issue being specifically addressed in discussions with CAMHS staff nor as part of the Treatment or Safety Plans; although she did seek advice about Rachel vomiting medication 28 Dr Andrea Cipriani et al; 2016: Comparative efficacy and tolerability of anti-depressants for major disorder in children and adolescents: a network meta-analysis; The Lancet Vol 388 August 2016 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30385-3/abstract 29 Royal College of Psychiatrists: Depression in young people - helping children to cope: information for parents, carers and anyone who works with young people; March 2017 https://www.rcpsych.ac.uk/healthadvice/parentsandyouthinfo/parentscarers/depression.aspx 30 Depression in children and young people: identification and management; NICE; Clinical guideline (CG28); 2005, 2015 and 2017 https://www.nice.org.uk/guidance/cg28 50 while purging, shortly after Rachel was discharged from the Adolescent Unit in Spring 2016, questioning whether this would reduce its efficacy. 5.28. Family ‘usually’ supervised Rachel taking medication, but this did not include seeking to check that she had swallowed rather than secreted it. Rachel’s mother has stated that she did seek advice about this from the Treatment Team. Similarly, the effect of bingeing and vomiting could have had an impact on the efficacy of doses. It does raise a question about how much medication she was actually taking and whether she had had enough medication for any positive effects or any negative side effects to take place. Practitioners at the Focus Group reported that such behaviour is not uncommon in teenagers in treatment. While parents and practitioners will want to trust young people and normalise them as young adults to take responsibility for their own treatment and managing their own oral medication – where such medication is a key component of the treatment plan it is important that the plan considers whether medication taking should be supervised; especially when there have been examples of secreting medicines and overdoses. 5.29. Should Rachel have been recommended to go into the adolescent psychiatric residential unit after the early January overdose? The issue of whether Rachel should have been admitted after the January 2017 overdose has been addressed in the SUI Report, summarised above. This review has been asked whether more could have been done to recommend to Rachel to accept voluntary admission as she trusted staff and would have agreed if they had strongly advised her to agree to admission. The SUI Review confirmed that the decision not to convert the section 136 into a section 2 or 3 of the Mental Health Act, 1983 was correct. Voluntary admission was discussed on at least two occasions with Rachel as she had told a nurse that she wanted to be admitted – although that is not what she told the assessing psychiatrist. The family’s view is that the possibility of voluntary admission to hospital as an option was not fully explored, as a decision had been made that it was not appropriate. Family care was the only option fully considered when it was decided that Rachel did not need to go to hospital. Rachel’s family has subsequently asked whether other fords of ‘wrap-around’ care or community support, including over weekends is available; but this was not considered at the time. This raises a more strategic question, as well as a practice question, about what other non-hospital resources may be available when it is decided that hospital is not appropriate and how families are assessed for their understanding of risks and what any increased care and supervision needs may be. (See also paragraph 5.37 below) 5.30. Care Programme Approach, Treatment Plans and Safety Plans Issues about diagnosis and treatment are covered in the Trusts’ SUI Report. Additional learning points here relate 51 to how these are recorded and shared with key stakeholders; e.g. family and other key agencies, such as the school. It is to be noted that the School Counsellor attended CPA Meetings which is good practice; both in terms of coordinating a school’s response to a student with mental ill-health and also increasing understanding about school or study/exams as possible stressors – not just for Rachel but for young people in general it is recognised that examinations can be a major factor in mental ill-health. 5.31. It seems that the record of the December 2016 CPA Meeting (the last CPA Meeting) was not shared with mother or the school. It is understood that the Trust was piloting a new recording system for the CPA. It is not known why the CPA record was not shared at this time; a time when the Care Coordinators were handing over. It can be argued that the key persons were present and so knew what was agreed and what the Treatment Plan was, but it is important that these agreed actions are noted and shared in a timely way, especially if more agencies are involved or are absent. In Rachel’s case this was only the school and GP (in the background) but in other cases, especially where CSC, YOS or other services are involved this could be a key issue. 5.32. Rachel’s mother has shared with this review a print out that she was later given by CAMHS of the CPA Meeting in December 2016. This is an unhelpful ‘screengrab’ document of an inputting screen rather than a finished document as a record of a meeting. It is not clear to the Independent Reviewer that all the text in the text inputting boxes is shown or whether some additional text may be hidden in the paper version. A criticism in another Case Review31 of an adolescent suicide has been that the proforma used in the CPA Process are often adult focused not child or young person focussed. The questions on this form are such and have no specific space for risk assessments or for parents’ or carers’ issues as providing a safe and caring environment for the young person. Clearly the CPA process should not be a ‘tickbox’ exercise and there is no evidence that it was or that the form was used to direct the meeting; but as working tool to progress the assessment and plan after the meeting it is questionable, at best. The Mental Health Trust has stated that it is continuing to review the CPA and recording process, including trialling the written plans which are provided to parents, to improve them. 5.33. Safety Plans Rachel was assessed as being a high risk to herself on several occasions. The Safety Plans seen as part of this review are simple typed or hand-written bullet point documents. At different crises, Rachel was assessed, and it was agreed that Rachel should return home. The revised Safety Plans had to be produced quickly, there is a question, 31 SCR Child J; Lambeth Safeguarding Children Board, 2016 52 however, as to whether they have enough detail to be meaningful to anyone who was not present in the discussion. It is not clear if they supersede previous Plans or complement them or how they relate to the identified risks which are not spelled out. Some are signed, and others are not signed or dated and do not have contact numbers for emergencies. It is clear from evidence to the Inquest that the school was confused about the status of some of the Safety Plans that they had been sent, which they had not been party to discussing. Clearly, they are for use in emergencies, but the evidence seen suggests that CAMHS practice differs across practitioners. The Trust introduced a new template for Safety Plans with effect from early 2018; service users were involved in its introduction. 5.34. Changes in the Treatment Team Organisational systems issue can have an impact on the way services are delivered to service users. It has been noted that for Rachel changes in key practitioners may have impacted on her responses, or on decisions made. In the early stages Rachel commented to one psychiatrist that she had already met several people and would prefer not to have more changes. An additional issue to be considered for Rachel and other young people who move between services such as Community CAMHS, In-Patient CAMHS or need psychological medicine or psychiatric assessments services through an Emergency Department because of crises is that they will be seen by different practitioners or change whole Treatment Teams as their levels of need or risk change. Continuity and transfer should be carefully managed as it was in the longer parallel handover between Care Coordinators – which was good practice. The summary SUI Report draws attention to the differences in diagnosis and in treatment options between the Day/In-Patient Unit and Community CAMHS and the impact that this had on Rachel’s management in the longer term, but it is not clear if this is a cultural difference between the two services. Learning from the wider context of research about adolescent self-harm and suicide 5.35. A review into one young person’s death can give a picture of how local services may be operating and whether any improvements may be required. Lessons from Rachel’s death will be considered locally alongside the reviews into the deaths of two other young people. However, the CHSCB and its partners must also seek to learn from the wider picture and research into adolescent self-harm and suicide to consider prevention and treatment options in the commissioning and provision of local services; as well as ensuring up-to-date knowledge and skills for practitioners at the front line. Section 9 of this report summarises some key research and data on Suicide by Children and Young People published in July 201732 and the NCISH Annual Report for 201833 which provides additional data. 32 Suicide by children and young people. National Confidential Inquiry into Suicide and Homicide by People with Mental 53 5.36. The 2017 report sets out a number of key factors which can influence suicide in young people, alone or in combination. The report refers to ten common themes previously found in the previous study of suicide by children and young people up to 20 years of age. These are family factors, e.g. mental illness; abuse and neglect; bereavement and previous experience of suicide; bullying; suicide-related internet use; academic pressures especially related to exams; social isolation or withdrawal; physical health conditions that may have a social impact; alcohol and illicit drugs and mental ill health; self-harm and suicidal ideas. Of the suicides studied 51% of the young people were in education (school or college) and of those 43% were experiencing academic pressures (32% exam pressures). Another important factor in suicide was prior self-harm, 52% had a history of self-harm; cutting or overdose were the most common. 58% had previously expressed suicidal thoughts or hopelessness. 7% had had an episode of self-harm in the week prior to the suicide. 41% had a diagnosis of a mental disorder – most commonly an affective disorder such as bipolar or depression. 16% of the young people were receiving anti-depressants – usually SSRI or SNRI34 drugs. The presence of one of these factors is not an indication that a young person will take their life but that they may be in need of support and intervention. It will be seen that some of the indicators assessed in Rachel over the twelve months of her care are not uncommon. The national data serves to signpost indicators for risk assessment, treatment and commissioning options which should be considered in service planning and delivery. 5.37. In October 2018, Young Minds commented on the incidence of young people’s attendance at A&E Departments, where the young person has a psychiatric condition, noting an increase in numbers over five years35. From 2010-11 to 2017-18 the increase was from 9,372 to 27,487 for Diagnosis of Psychiatric Conditions and for Intentional Self-Harm a smaller increase from 18,291 to 21,904. The questions raised are whether A&E is the right environment for responding to young people’s mental health crises. Young Minds says that there is a need for community based alternative venues (‘havens’) for young people experiencing mental health crises and the need for dedicated mental health liaison and referral support to prevent young people being caught up in a cycle of returning to A&E. Illness (NCISH) Manchester: University of Manchester 2017 See section 9 of this report 33 The National Confidential Inquiry into Suicide and Safety in Mental Health. Annual Report. October 2018 University of Manchester See section 9 of this learning review for a summary of key issues 34 SSRI - selective serotonin reuptake inhibitors; and SNRI - Serotonin–norepinephrine reuptake inhibitors 35 Young Minds is a charity which promotes awareness and provides advice mental health for young people, parents and professionals: Press Release, 25 October 2018: https://youngminds.org.uk/about-us/media-centre/press-releases/ae-attendances-by-young-people-with-psychiatric-conditions-almost-doubled-in-five-years-new-figures/ 54 Key Line of Enquiry 2 Supporting young people with mental health problems in a community school setting – the challenge for schools 5.38. There is no doubt that Rachel’s school was caring and supportive of Rachel. Her suicide has raised some questions for the school about her care and its multi-agency management which were discussed above in the context of the Joint SUI report to which the school contributed. Key lessons that may be applicable to other schools where there are young people with serious mental health issues, including self-harm and suicidal thinking or behaviour are noted here. 5.39. It is important to see adolescent mental health in schools, the major universal service for this age group, in a wider public health and social context rather than a single school. Recent reports have noted the increase in young people having mental health problems and requiring services. The Children’s Society’s recent report on children’s mental well-being raises concern about the number of young people needing services and the prevalence of self-harm .36 37 The Government’s Green Paper: Transforming Children and Young People’s Mental Health Provision, 2017 38, a proposal and consultation document; and the Government’s response in 201839 show increasing numbers of young people with adverse mental health, ‘one in ten children and young people has some form of clinically diagnosable mental health disorder’, and the need to develop a strategic response nationally and locally, not just child by child. 5.40. There are wider systems issues than a single school. Although each school has a part to play in how it supports the well-being of its adolescent students who are going through a physical and psychological developmental life-stage into adulthood; while also learning and preparing for further education or employment. Schools are primarily education not welfare institutions. Schools can be a stressor as well as a safe place if a young person is worried and becomes unwell because of general academic stress or overwhelming anxiety about exams. This raises questions about how young people as groups are advised, encouraged and supported about exams, and where a single young person who has anxiety fits into 36 https://www.childrenssociety.org.uk/news-and-blogs/press-releases/one-in-four-14-year-old-girls-self-harm 37 The Children’s Society: The Good Childhood Report 2018 https://www.childrenssociety.org.uk/sites/default/files/good_childhood_summary_2018.pdf 38 Transforming Children and Young People’s Mental Health Provision: a Green Paper; December 2017. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/664855/Transforming_children_and_young_people_s_mental_health_provision.pdf 39 Government Response to the Consultation on Transforming Children and Young People’s Mental Health Provision: a Green Paper and Next Steps; July 2018 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/728892/government-response-to-consultation-on-transforming-children-and-young-peoples-mental-health.pdf 55 this. Media responses to GCSE and A Level success, toughness and league tables can feed into this anxiety. 5.41. Teachers may not have had training in young people’s mental health, especially acute mental ill-health and its management. The Government Green Paper commented on the value of Mental Health First Aid Training for schools40 and the need to increase mental health awareness of school staff. 5.42. In Rachel’s school, there was good liaison and communication with CAMHS, including attendance at the CPA Meetings by the School Counsellor. However, a school may not have the in-house expertise to deal with high risk cases. Rachel’s school did not fully understand the level of risk for Rachel and trusted CAMHS to make the decision about whether Rachel was well enough to return to school after an absence because of exam stress – when Rachel had fallen further behind and had exhibited worrying suicidal behaviour. For schools to be able to manage high risk behaviour in a potentially self-harming or suicidal student they must be a full partner to the risk assessment and Safety Plan to understand the risky behaviours and what actions the school can take to mitigate them or prevent harm. This means that schools must be proactive in seeking to be in key meetings (including remotely) with the assessing and treating health professionals and parents, or able to ask questions about and challenge the likely or probable risks and to consider how and if the student can be managed safely in the school. 5.43. School based Safety Plans should consider who will step in when key named persons are likely to be absent so that the student, family and others are aware of contingencies; including who to contact. If a student is to have time-out from class because of stress there needs to be a process for checking with that student how they are, over time, and whether it is right for them to continue to be in the school or whether they need more support and when a parent should be called. 5.44. After the deaths of Rachel and another student (two months previously) in Rachel’s school the Clinical Commissioning Group arranged that CAMHS would support local secondary schools with specialist mental health workers, part-time to provide advice, but not clinical work, as part of a pilot programme to develop approaches in schools. The WAMHS Project was seen by Rachel’s school as very helpful.41 A similarity can be seen in the proposals in 40 See also the Institute of Education’s evaluation of the Mental Health First Aid training in schools. An Evaluation of Phase One of the Youth Mental Health First Aid (MHFA) in Schools programme: “The training has given us a vocabulary to use.” Report October 2018 41 The WAMHS (Wellbeing and Mental Health in Schools) Pilot had two key strands. A Wellbeing Audit tool to be 56 the Green Paper for Mental Health Support Teams to work with clusters of schools to provide expertise and up to date knowledge to the school staff. This review notes that Hackney Local Authority and Clinical Commissioning Group have made a bid to be one of the ‘trailblazer’ authorities to test the proposals in the Government’s Green Paper for improving mental health responses in schools. As well as the mental health support teams these will also include encouragement for every school to have a Designated Senior Lead for Mental Health; and shorter waiting times for children who need to be assessed by NHS mental health services. 5.45. Rachel’s schools own lessons since the two tragic deaths have included introducing quiet rooms and spaces for students (a quiet garden space has been provided by a charity set up by the parents of Rachel and the other young person, with the support of fundraising by students and others), work with parents, and work with students about how to get help if they feel anxious. The school’s communication protocols in relation to students with a known mental health problem have been strengthened, with weekly meetings for identified students about whom there is concern; and a protocol has been established for students who are returning to school after a period of absence for mental health problems. A help group for parents of students with mental health problems has been established. Staff and students have had mental health first aid training. Peer listeners have been trained. Mental health has been included in assembly topics and the counselling capacity within the school has been increased. An important question for this review is: How are these lessons being learned in other schools which have not had the tragedy of a death such as Rachel’s? 5.46. A further learning point from the school is the need for schools to consider the possibility of suicide and its impact on students, staff and a school in critical incident plans or Bereavement Plans to ensure that something is in place in case if it is needed. That includes where to access counselling for peers and staff in schools after a tragedy. This review was informed that borough-wide guidance for schools on critical incidents was available but such guidance could not be found – raising the question about how easily schools would find it, when needed. completed by all 40 schools in the pilot, supported by Wellbeing Framework Partners (Leadership and Management Advisers from Hackney Learning Trust). Areas for development would be agreed from this and an Action Plan devised. This was supported by a CAMHS worker allocated to work strategically in the school for between one day per month and one day per week, depending on school size. The CAMHS worker’s role and activity will be defined by the Action Plan; they will not hold a caseload or do ongoing, direct clinical work with children. The aim of the pilot was to promote Academic Resilience and grow capacity within the school, as well as establishing excellent working relationships and communication across schools and CAMHS. 57 5.47. Preliminary evaluation research by the Institute of Education into the Mental Health First Aid Training Programme for Schools notes increased confidence for school-based champions who have had the training with greater understanding of mental health issues and how to respond and support whole school approaches42. It is not clear how much the free Mental Health First Aid Training for Schools43 has been taken up by other schools in City and Hackney. The CHSCB may wish to explore this further. 5.48. The DfE Research Report: Mental health and wellbeing provision in schools; Review of published policies and information; October 201844 was commissioned, as a limited, desk-based study, to see the extent and availability of schools’ published policies; how these were set within a whole school approach; how they differed by type or region of school; and in particular how such policies describe a school’s approach to promoting and supporting pupils’ mental health and wellbeing. It is noted that there is no legal duty for schools to publish online policies on children’s mental health, per se. Of the sample schools (90) 4% of primary and 1% of secondary schools had published a mental health policy online. The research explores the existence of other published policies which impact on pupils’ mental health and how these have been embedded. 56% of primary schools and 44% of secondary schools were providing some form of mental health support, including targetted support to pupils with emotional and behavioural difficulties or universal support to promote self-esteem and resilience. Targetted support included counselling, anger management classes, and interventions to raise self-esteem. These were provided mostly through the Pupil Premium strategies, where pupils had been identified as needing additional support. A small number of primary schools were using mental health screening tools to identify pupils with additional support needs. Some primary and secondary schools were providing universal or preventative activities to promote mental health and wellbeing; including wellbeing centres, school nurture approaches, school pastoral teams and home liaison workers and embedding mental health education and resilience building within the curriculum. Although there were limitations with the methodology the research review proposes that schools would benefit from further awareness, advice and resources to enable interventions to support mental health to be further embedded within whole school strategies and not just within behaviour policies aimed at managing difficult behaviour. Assistance may be needed to help schools see the close links between mental health and behaviour more holistically; including assisting schools to be more aware of risk factors relating to mental illness where pupils are not overtly disruptive but are showing symptoms 42 https://mhfaengland.org/mhfa-centre/news/ucl-report-schools-programme/ 43 Mental Health First Aid Training in Schools https://www.gov.uk/government/news/pm-mental-health-training-for-teachers-will-make-a-real-difference-to-childrens-lives 44 Department for Education: Mental health provision and wellbeing provision in schools; Review of published policies and information; Research Report; Rebecca Brown; October 2018 58 such as anxiety, depression, self-harm or suicidal thoughts. 5.49. Additional findings The main purpose of this review has been to seek to learn preventive lessons applicable in the wider field of child and adolescent mental health in cases where young people have self-harming and/or suicidal behaviour. Three findings arise from the period after Rachel’s death relating to investigation and support. 5.50. Investigation and safeguarding – use of digital media When a child or young person takes their life and the police have ascertained that a crime has not been committed, the investigation may not have the same resources as if the death had been as the result of harm or incitement by someone else. This can mean that the investigation does not fully consider the young person’s use of the internet or social media. However, it is an intelligence source to identify wider safeguarding risks to other, possibly identifiable, young people that might arise, for example, as a consequence of suicide or self-harm contagion. Attempting to investigate someone’s digital footprint as soon as possible after their suicide should be an immediate task, led by police, as this may help identify other young people who could be affected. Rachel was in an online group with other vulnerable young people and was also friends with young people known through mental health services. Accessing her computer and phone quickly would have alerted professionals to any specific actions which might have been required to safeguard or support them. 5.51. The Government Guidance, issued by Public Health England in 2015, Identifying and responding to suicide clusters and contagion; A practice resource 45 notes that identifying suicide clusters can be difficult and sets out indicators to be considered at the early planning stages. It suggests responses including identification of individuals and groups who may be particularly vulnerable and practical interventions to reduce the risk of a spread of suicidal (or self-harming) behaviour. There is a stronger potential for spread in mental health services and schools. With social media it should be noted that a cluster could be geographically dispersed. 5.52. Increasing understanding of the impact of social media on young people’s decision-making and actions It has become known that Rachel used and was impacted in different ways by social media, and the media, generally. She was reported to have used the internet to seek information about the amount of medication required to cause harm or death. She was also thought to have been affected by messages in a social media group of 45 Public Health England, 2015, Identifying and responding to suicide clusters and contagion; A practice resource https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/459303/Identifying_and_responding_to_suicide_clusters_and_contagion.pdf 59 which she was a member – which was not fully known at the time. Internet use and social media use can be a useful indicator of a young person’s state of mind in the period up to self-harm or suicide. As well as giving a view of the state of mind of a young person after the event to assist an understanding what led up to a critical incident or death it is important to consider how young people can be assisted to evaluate the information that they are accessing or that is being pushed to them. Rachel’s family have become aware that Rachel posted a message saying that she did not know whether she wanted to live or die. This raises a further question about how peers of young people experiencing emotional or mental health problems are advised on ways to respond to worrying messages, including seeking further help. 5.53. From a public health perspective, it is important to seek to measure how such use impacts young people’s decision-making and impulsivity when they are vulnerable from mental ill-health. To build up a picture over time and across a population of such young people it is important to consider whether a more forensic approach could be taken with regard to the use of the internet and social media by young people who self-harm or take their life. Over time this would allow preventative measures, including education, to be taken and could influence public health awareness and practitioner awareness. This may also inform risk assessments of particular young people to consider more fully how they are using social media and of its likely impact on them. 5.54. Peer support after suicide No school, or other institution, wishes to consider that a young person in their care may take their life and of the impact it may have for other young people, staff and the overall service. A young person’s death by suicide will require a different approach to other forms of Emergency or Generic Critical Incident Plans. Guidance which can be activated at immediate notice – given that in parallel social media information can travel faster than a school can seek to manage messages to students and families. Rachel’s school had to adapt a generic approach to respond to the emotional impact on the whole school system following the prior death of another student, in the term before Rachel’s death. The school has also learned subsequently that this is the case in other schools. At a time of great shock when actions need to be put in place quickly to inform and support the school population it would be important to have a well-designed template which sets out the steps and signposts resources. 60 6. Recommendations 6.1. The City and Hackney Safeguarding Children Board should consider the recommendations made to this review by Rachel’s Family at 3.57 above. In addition: 6.2. The Health and Wellbeing Board should expedite the completion and publication of a Local Strategy for Prevention of Suicide by Young People and consider whether this should be a Strategy to prevent self-harm and suicide by young people. The Board should set a timescale for completion and set out how the strategy will be implemented, monitored and reviewed; what key indicators should be collected regularly about young people’s mental health, self-harm, attempted suicide and suicide; and what the local resources are. A Head Teacher representative should be co-opted to the Steering Group. 6.3. The Clinical Commissioning Group, Local Authority (including the Director of Public Health and Director of Education) and the East London Foundation Trust Child and Adolescent Mental Health Service with local Head Teachers and Chairs of Governing Bodies (or their equivalents) should build on the positive links between schools and CAMHS started in the WAHMS project. A strategy and action plan should be devised to set out steps for this and be presented to the CHSCB and the Health and Wellbeing Board. (See Paragraphs 5.39 - 5.44 and also the summary of research and guidance from 5.47.) It is noted that the Hackney CCG has made a bid to be a pilot trailblazing Local Authority in the trialling of the national actions to be taken as part of implementing the Green Paper: ‘Transforming children and young people’s mental health provision: a green paper’46. 6.4. The CHSCB should consider convening a conference for Head Teachers and Chairs of Governors (and their equivalents) or working with their local representative bodies to promote the lessons from this review and the parallel reviews of young people’s deaths by suicide. The purpose of such a conference / liaison would be to raise awareness and 46 https://www.gov.uk/government/consultations/transforming-children-and-young-peoples-mental-health-provision-a-green-paper 61 learning between schools about children’s mental health and risk. This should include the national picture with regard to increasing understanding about children’s mental health in schools and the local lessons from this and other reviews; including study and exam stress, bullying, impact of social media and peer pressure. Such an event would build strong links to the WAHMS project. It could promote a review of whole school mental health approaches or policies, including a specimen approach. It could also provide guidance and develop mentors on Immediate School Recovery and Support Programmes in relation to child deaths, by suicide. The CHSCB should consider inviting the charity created by Rachel’s mother and the mother of another young person to assist with such a conference or wider liaison in order to promote the lessons from one school more widely. (See Paragraph 5.48, and the revised guidance Mental health and behaviour in schools, November 2018 published by the Department for Education47.) 6.5. The CHSCB should ask the Director of Education to review the take up of Mental Health First Aid Training in schools and promote this actively across Hackney, possibly including commissioning local delivery from the Mental Health First Aid charity across a cohort of local schools to build a network of informed and skilled staff from schools who can support each other. (See Paragraph 5.47) 6.6. The ELF Trust CAMHS should review its guidance for and management of the Care Programme Approach (CPA), agreement of Treatment Plans and guidance about creation and write up of Safety Plans for children and adolescents; including how patients, parents (carers) and key partner agencies can contribute to risk assessments, monitoring, and safety in an informed, holistic, realistic and achievable way. The Trust should reassure the CHSCB of the outcome of the review, actions taken and how the process will be quality assured, going forward. 6.7. The ELF Trust CAMHS should review how assessments consider the impact of stress on carers and wider family as part of ongoing assessment of a family’s ability to protect and care for a young person who has self-harming or suicidal behaviour. This should include providing information about Carers Assessments and when to refer to Children's Social Care for a Carers Assessment. The Trust may wish to review a number of current cases to consider if referring for a Carers Assessment would be appropriate and to understand what may be the barriers to this process. (See Paragraphs 5.18 – 5.20) 47 https://www.gov.uk/government/publications/mental-health-and-behaviour-in-schools--2 62 6.8. The CHSCB should seek reassurance from partners that there is in place, a robust and coordinated response to suicide by a young person, in the context of identifying and mitigating the impact on other children and young people. This is likely to be as part of the revised Rapid Review process following a critical incident, as set out in Working Together to Safeguard Children 2018, chapter 4. This should include if and how a young person’s digital footprint will be assessed to see if there are indications that others may be at risk of harm. (See Paragraphs 5.50 – 5.51) 6.9. The CHSCB should ask the Director of Education to review the generic guidance to schools on responding to critical incidents and its accessibility to ensure that it covers child deaths and support to peers and schools, including where a student takes their life. (See paragraphs 5.46 and 5.54) 6.10. The CHSCB or successor Child Death Review Partners48 (when they come into place) with the Child Death Overview Panel should consult with the Metropolitan Police and the Local Coroner about the investigation of child deaths by suicide in relation to access to electronic equipment used by the young person which may give a greater understanding of influences on the young person and their state of mind, over time. This will enable the Child Death Review Process to build up a clearer public health picture of the possible use of specialist websites, online advice services, social media and other important influencers on young people’s decision-making and impulsivity. (See Paragraph 5.53) 6.11. The CHSCB should provide an anonymised summary report of the key lessons from this review for frontline practitioners and first line managers across the multi-agency network. The CHSCB should also consider providing bespoke briefings and materials for key designated and named leads in local services to enable them to cascade the lessons from this report and the parallel reports to frontline practitioners. 48 Working Together to Safeguard Children 2018; Chapter 4: Improving child protection and safeguarding practice; & Chapter 5: Child death reviews 63 7. Appendix 1 The City & Hackney Safeguarding Children Board Response (CHSCB) and Partner Agencies’ Response to Rachel’s death 7.1 Following Rachel’s death, a Rapid Response meeting was convened by the City & Hackney Safeguarding Children Board under multi-agency guidance for responding to unexpected child deaths 49 . The Independent Chair of the CHSCB endorsed a recommendation that Rachel’s death did not meet the criteria for a Serious Case Review (SCR)50. The National Panel of Independent Experts in SCRs agreed with this decision. There was no evidence noted that abuse or neglect were factors in Rachel’s death. 7.2 The Independent Chair agreed that a multi-agency Local Case Review should be undertaken to analyse what happened, why, and to identify any practice improvements that should be made by organisations to safeguard and promote the welfare of children and young people. The Terms of Reference are in Appendix 1. A Panel of senior managers from the agencies involved, who had not been personally involved in the work with Rachel and her family, or in its management, was convened and the CHSCB appointed an Independent Lead Reviewer to advise and to author the final report. 7.3 Rachel’s parents were invited to comment on the Terms of Reference and to contribute to the review. Members of Rachel’s family have done so. Articles that Rachel’s mother had written about Rachel’s death and a TV programme were reviewed. 7.4 The Mental Health Trust and the Hospital Acute Trust undertook a joint independent Serious Untoward Incident Review, led by the Mental Health Trust. That review was made available to this review by the CHSCB. 7.5 Those agencies which had been involved with Rachel and her family provided reports for the Panel to analyse. Practitioners and managers who had been directly involved with Rachel and her family were invited to meet with the Panel to share their experience and reflections on and learning from the case. 7.6 An inquest was concluded in July 2017. The oral evidence to the Inquest and the 49 Working Together to Safeguard Children 2015, Chapter 5 50 Working Together to Safeguard Children 2015, Chapter 4 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/592101/Working_Together_to_Safeguard_Children_20170213.pdf 64 Coroner’s judgement was considered as part of this review. 8. Relevant findings from research into suicide by children and young people 8.1. Understanding that there may be other young people like Rachel gives impetus to learning and improvement, to seek to develop local preventive responses and public health approaches when there may be earlier signs in a young person’s life. There are two relevant research studies led by The National Confidential Inquiry into Suicide and Homicide by People with a Mental Illness. The first is a review of suicide by young people under 25. The second is the Annual Report 2018, covering a wider field and age range but with additional relevant findings to this review. Not all the antecedents and themes identified in the cohort studied were applicable to Rachel, but some similarities can be seen. The full analysis from the research is too detailed to be included here but should be examined when considering local suicide prevention strategies for young people. 8.2. Findings from Research Report: Suicide by Children and Young People; The National Confidential Inquiry into Suicide and Homicide by People with a Mental Illness: July 201751. The research report gives a view of suicide by children and young people under 25 in England and Wales in 2014 and 2015. 8.3. The Key Messages from the 2017 Research are: Suicide in children and young people is rarely caused by one thing; it usually follows a combination of previous vulnerability and recent events. The stresses that we (the research) have identified in young people before suicide are common in young people; most come through them without harm. Important themes for suicide prevention are support for or management of family factors (e.g. mental illness, physical illness, or substance misuse), childhood abuse, bullying, physical health, social isolation, mental ill-health, and alcohol or drug use. Specific actions are needed on groups (we have) highlighted: (1) support for young people who are bereaved, especially by suicide (2) greater priority for mental health in colleges and universities (3) housing and mental health for looked after children (4) mental health support for LGBT young people. 51 Suicide by children and young people. National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH). Manchester: University of Manchester, 2017. https://www.hqip.org.uk/wp-content/uploads/2018/02/8iQSvI.pdf 65 Further efforts are needed to remove information on suicide methods from the internet; and to encourage online safety; especially for under 20s. Suicide prevention in children and young people is a role shared front-line agencies; they need to improve access, collaboration and risk management skills. A later, more flexible transition to adult services would be more consistent with our findings of antecedents across the age range. Services which respond to self-harm are key to suicide prevention in children and young people and should work with services for alcohol and drug misuse, factors that are linked to subsequent suicide. 8.4. Common themes identified in the research were: Family factors (such as mental illness) Abuse and neglect Bereavement and experience of suicide (by others) Bullying Suicide-related internet use Academic pressures, especially related to exams Social isolation or withdrawal Physical health conditions that may have social impact Alcohol and illicit drugs Mental ill health, self-harm and suicidal ideas 8.5. The research sought to identify common antecedents for the young people in the cohort who were aged below 20, by gender. The common antecedents were: Previous contact with social care/local authority services (at any time) A history of self-harm Contact with CAMHS (at any time) Self-harm by cutting Psychiatric diagnosis (Being or having been) a looked after child Bereaved Experienced abuse Bullied Self-harm by self-poisoning Contact with youth justice/police (at any time) Excessive alcohol use All of these antecedents were found to have been more prevalent for females – but were also present for males. Illicit drug use No prior contact with services These two antecedents were more prevalent in males under 20 – but were also present 66 for females. 8.6. What the research findings say about prevention: “The circumstances that lead to suicide in young people often appear to follow a pattern of cumulative risk, with traumatic experiences in early life, a build-up of adversity and high-risk behaviours in adolescence and early adulthood, and a ‘final straw’ event.” The significant event may not seem severe to others and thus risk may be hard to recognise by family or professionals unless the history of past and present problems is also taken into account. 8.7. A model for prevention is suggested for use at different ages and stages (see Figure 12 in the study for more detail of the model). The possible interventions include: supporting vulnerable young children and their families promoting mental health in schools to address bullying and online safety services for self-harm and alcohol and drug misuse in young people healthy workplace and campus initiatives, and crisis services. 8.8. Other dynamics to be noted in considering support and preventive services for particularly vulnerable young people are: Bereavement services, especially when young people have been impacted by suicide of another person Internet safety (particularly for under 20s) in relation to websites which give information about suicide methods Greater staff awareness in front line services of suicide awareness and better multi-agency co-operation Self-harm should be seen as a crucial indicator of risk suicide and should be taken seriously – even if it appears minor. This may be the most important area for local development with regard to suicide prevention for young people; including psycho-social assessment, prompt access to psychological therapies and services for co-occurring problems such as alcohol or drug misuse. Additional Findings from the NCISH Annual Report October 201852 8.9. For children and young people under 20 who took their lives: 41% had been in contact with services (mainly CAMHS – 34%) in the previous three months. Mental illness was reported in 40%. The most common primary diagnoses were affective disorders, especially depression. Academic pressures overall were noted in 63%; with exam pressures being 27%. Previous self-harm was found in 49% and suicidal ideas (at any time) was 59%. 52 National Confidential Inquiry into Suicide and Safety in Mental Health, Annual Report: England, Northern Ireland, Scotland, Wales. October 2018. University of Manchester https://www.hqip.org.uk/resource/national-confidential-inquiry-into-suicide-and-safety-annual-report-2018/#.W8CTcvZFyUk 67 8.10. In 29% of all cases (any age) there had been a recent history of self-harm in the preceding three months. For under 25s this was 39%, with a higher proportion for females (51%). Patients with a history of self-harm more often had a diagnosis of personality disorder compared to other patients. 8.11. For patients who died as a result of suicide who had a recent history of self-harm (within three months) immediate risk of suicide at the professional last contact was judged to be low or not present in 76% (all ages) – lower than the risk for patients with no recent history of self-harm. Risk was also assessed as lower in this group when seen a week prior to death; or in the longer-term risk assessments. Author note: The research does not seek to explain this lower scoring in risk assessments for those with a recent history of self-harm. It would appear to be a dynamic to be considered in depth when undertaking such risk assessments where self-harm has been present. 8.12. What could have reduced the risk (all ages)? Clinicians views were: Closer supervision, closer contact with the patient’s family, improved compliance with treatment, a decrease in caseloads and access to psychological treatment. (See paragraph 170 of the report.) 68 9. Reading National Confidential Inquiry into Suicide and Safety in Mental Health, Annual Report: England, Northern Ireland, Scotland, Wales. October 2018. University of Manchester https://www.hqip.org.uk/resource/national-confidential-inquiry-into-suicide-and-safety-annual-report-2018/#.W8CTcvZFyUk Suicide by children and young people. National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH). Manchester: University of Manchester, 2017. https://www.hqip.org.uk/wp-content/uploads/2018/02/8iQSvI.pdf Transforming children and young people’s mental health provision, December 2017 A Green Paper https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/664855/Transforming_children_and_young_people_s_mental_health_provision.pdf Government Response to the Consultation on Transforming Children and Young People’s Mental Health Provision: A Green Paper and Next Steps, July 2018 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/728892/government-response-to-consultation-on-transforming-children-and-young-peoples-mental-health.pdf An Evaluation of Phase One of the Youth Mental Health First Aid (MHFA) in Schools programme: “The training has given us a vocabulary to use.” Roberts-Holmes, G., Mayer, S., Jones, P. & Lee, S.F. (2018) Institute of Education, University College London, October 2018 Retrieved from MHFA England website: https://mhfaengland.org/mhfa-centre/research-and-evaluation/ The Good Childhood Report 2018: Summary; The Children’s Society, 2018 https://www.childrenssociety.org.uk/sites/default/files/good_childhood_summary_2018.pdf Mental health and wellbeing provision in schools; Review of published policies and information Research report; October 2018 Rebecca Brown; Department for Education https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/747709/Mental_health_and_wellbeing_provision_in_schools.pdf Young Minds Report on: A&E Attendance by young people with psychiatric conditions almost doubled in five years – new figures October 2018 https://youngminds.org.uk/about-us/media-centre/press-releases/ae-attendances-by-young-people-with-psychiatric-conditions-almost-doubled-in-five-years-new-figures/ Royal College of Psychiatrists Network for Community CAMHS: Our Standards https://www.rcpsych.ac.uk/quality/qualityandaccreditation/childandadolescent/communitycamhsqncc/ourstandards.aspx Mental health and behaviour in schools – revised guidance November 2018, Department for Education 69 https://www.gov.uk/government/publications/mental-health-and-behaviour-in-schools--2 10. Useful Organisations / Resources ChildLine https://www.childline.org.uk/ Mental Health First Aid Training – Schools Training Programme https://mhfaengland.org/mhfa-centre/programmes/national-schools-programme/ Papyrus https://papyrus-uk.org/ Charity/campaigning organisation to promote awareness and research to prevent suicide by young people Papyrus-Hopeline UK https://papyrus-uk.org/hopelineuk/ Helpline and website for young people – and others who are worried about them Royal College of Psychiatrists https://www.rcpsych.ac.uk/usefulresources.aspx Samaritans https://www.samaritans.org/ Young Minds https://youngminds.org.uk/resources/ |
NC043702 | Death of a 5-month-old baby boy in June 2012 as the result of florid rickets caused by severe vitamin D deficiency. Following Baby F's death parents reported that he had been unwell for three days and not feeding. Both parents pleaded guilty to manslaughter. Following his birth, parents initially refused consent to medical treatment for Baby F, leading to children's services involvement. It is assumed that the parents' spiritual beliefs informed their refusal to treatment however this was denied by both parents at the time. Issues identified include: mother's late booking and declining of screening during pregnancy; failure to address the impact on the health of Baby F of mother's vegan diet and increased risk of vitamin D deficiency as a black African woman; and lack of professional curiosity in relation to parents' extreme spiritual beliefs. Identifies learning from the case, including: the need for all agencies to consider the tension between remaining sensitive to equality and diversity issues and safeguarding children. Makes various single agency and multi-agency recommendations.
| Title: Serious case review: Baby F: D.O.B. 01/01/2012: D.O.D. 14/06/2012: independent overview report. LSCB: Bexley Safeguarding Children Board Author: Oena Windibank Date of publication: 2014 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 BEXLEY SAFEGUARDING CHILDREN BOARD SERIOUS CASE REVIEW - BABY F D.O.B: 01/01/2012 D.O.D: 14/06/2012 Independent Overview Report. Author: Oena Windibank Post: Independent Consultant Date: July 2013 2 CONTENTS 1. Introduction 2. Methodology 3. Terms of Reference for the SCR 4. Context of Report/Sequence of events 5. Analysis of events 6. Learning from the events 7. Recommendations 8. Background reading/References 3 1 INTRODUCTION 1.1 This Overview report summarises the findings of the Serious Case R review undertaken into the death of Baby F. In accordance with Working Together 2010 * and Working Together 2013* the report seeks to analyse the events that occurred and to identify lessons that can be learnt by the LSCB and the agencies involved. 1.2 The SCR panel has undertaken a robust process of reviewing the involvement of all the agencies involved in the life of Baby F including in the antenatal period. In accordance with Working Together 2010/13 the SCR panel was chaired by an Independent Chair and this Overview Report is authored by a separate Independent Author. 1.3 Baby F died unexpectedly aged five months in June 2012. The cause of his death was determined at the post mortem to be due to Florid Rickets caused by severe vitamin D deficiency and this deficiency was also identified as the causation for severe growth failure. Rickets is an unusual and rare preventable illness 1.4 The skeletal survey revealed severe metabolic bone disease, multiple healing rib fractures, a spiral fracture of the left humerus and possible fractures of the metatarsal and metacarpal bones. These were consistent with florid rickets and severe skeletal hypo mineralisation, there were no signs of non-accidental injury. 1.5 Baby F was born in Hospital on the 1.1.12 to Mr and Mrs F, both parents are of African origin and have strongly held religious beliefs. Mrs F is a housewife and Mr F was an adult respiratory nurse at the time of these events. Baby F was their only child. 1.6 Mrs F booked for antenatal care late at 28 weeks at the GP practice during a GP new patient booking appointment. During the antenatal period Mrs F had refused an ultra sound scan and nutritional supplements advised due to mother’s strict vegan diet and ethnicity. Specific advice on the need for Vitamin D supplements was not given when nutritional supplements were discussed. Mrs F did however accept HIV testing on the advice of a relative. 1.7 At Birth Baby F was generally well although small for his gestational age (presenting with Inter Uterine Growth retardation, IUGR) however shortly after birth Baby F was admitted to SCBU where he was treated for jaundice, respiratory problems, hypoglycaemia and bleeding in the brain. 1.8 During this period his parents initially refused medical treatment for him which had been advised by his paediatric consultant, their continuing refusal led to the hospital making a referral of child protection concern to children's social care. Consent was given to treatment; it is believed that Mr and Mrs F's strongly held religious beliefs led to their initial refusal for treatment. 4 1.9 Following Baby F’s discharge from hospital there was a joint home visit by the social worker and health visitor and subsequently he was seen by the health visiting service, however his parents did not take him to two follow up hospital appointments, his 8 week check or commence his immunisations. He was not seen again by any agency from the 29th of February 2012 until his death on 14.06.12. 1.10 Baby F's parents reported to police after his death that he had had a cough since April, he had been unwell for a few days and was not feeding properly. His parents did not seek any medical assistance or advice with regard to his deteriorating symptoms, they reported that they were aware he was ill but were awaiting 'a sign from God' with regard to seeking help or treatment. 1.11 The police were called to the family home on the 14th June by the parents stating that their son 'had no sign of life' and he was sadly subsequently pronounced dead in hospital at 19.12 pm. 1.12 Mr and Mrs F were charged by the police with manslaughter and neglect on 7th March 2013. They both pleaded guilty to manslaughter in January 2014 and are due to be sentenced on 28 February 2014. 2.0 Methodology 2.1 The CDOP recommended to the SCR panel on 6th September 2012 that a serious case review be actioned in this case. The Independent Chair of the Safeguarding Children Board took the decision to undertake a serious case Review on the 28.12.2012. 2.2 An independent chair was appointed on 02.01.2013. 2.3 An Independent author was appointed on 02.01.2013. 2.4 The SCR panel comprised of representation from all agencies across the area and has reviewed all agency IMRs, requesting additional information/clarity as required. 2.5 IMR reports have been completed by all agencies involved in the care of Baby F, this includes; Children's social care. Primary care, Community Health services. Secondary care including midwifery services. these are noted in the report as Acute Trust 1 ( Antenatal and post natal care)and Acute trust 2. ( post death care) The local Clinical Commissioning Group (CCG). Police. Faith organisation. 5 The Ambulance service did not complete an IMR but were interviewed as part of the Health Overview report. 2.6 Annexed to the report is the action plan which includes recommendations from this review and the individual recommendations made by each agency. The agencies involved have reviewed all the actions as part of the Serious case review panel to ensure they meet the lessons learnt contained within the report. 2.7 Baby F’s parents were informed by the Independent chair of the SCR including its purpose to identify lessons learnt in relation to the services provided. They were invited to participate in the process however their legal representatives have declined the offer on their behalf due to impending legal proceedings. 2.8 The SCR was commissioned late December 2012 and four formal panels meetings took place with a number of clarification sessions in between. The final overview report is to be agreed by the LSCB core panel in July 2013 and presented to the LSCB in November 2013. Publication of the review will be dictated by the legal proceedings. 2.9 The review has considered research, local and national guidance and Policy and recent SCRs within the area to inform its analysis. 3. Terms of reference 3.1 To establish the facts of the case in relation to what was known to each agency in respect of ‘Baby F’ and his parents within the period between January 2011 and 1st January 2013. (Additional relevant information about the mother and father of ‘Baby F’ outside of this time frame should also be considered); 3.2 Consider the events that occurred, the decisions made, and the actions taken or not taken. Where judgements were made, or actions taken, which indicate that practice or management could improve, try to get an understanding not only of what happened but why. 3.3 Were Baby F’s needs appropriately identified, assessed and responded to? Were any risks to him appropriately identified? To what extent did agencies identify safeguarding concerns in relation to Baby F, in particular in relation to neglect? 3.4 Did assessments and services provided to the family take sufficient account of their race, culture, language, and religious needs, and any disability needs and how were these needs met? Did they examine the voice of the child and in what ways this was considered? 3.5 What was life like for Baby F? It is essential that his daily life experiences and an understanding of his welfare are at the centre of the SCR (Working Together, 2010, 8.1); 3.6 To what extent were the concerns for Baby F by different professionals given weight and acted on? 6 3.7 To what extent, if any, was professional optimism a factor? 3.8 How did inter agency communication and working together impact on the provision of services and the welfare of Baby F? 3.9 Was practice consistent with organisational and London Safeguarding Children Board procedures, BSCB Protocols and Policies and wider professional standards including the LADO and child death review process. 4. Context of report / Sequence of events. 4.1 For the purpose of reflection and clarity the sequence of events, analysis and learning have been identified into episodes of care with a final summary of overarching themes for learning. The Antenatal period; 10.10.2011 to 1.1.2012. 4.2 Mr and Mrs F were previously unknown to health services in the area until Mrs F registered at her new GP surgery, she was then seen seven times by health services until the birth of Baby F for routine or booking contacts. 4.3 10.10.2011: when Mrs F registered with her GP for a new patient check, she was seen by a health care assistant (HCA) who took a brief medical history which showed no particular issues, noting minor illness and immunisations only. 4.4 Mrs F advised that she is 28 weeks pregnant and follows a vegan diet, the HCA referred her for a GP consultation and Mrs F was seen that day by a locum GP who subsequently referred her into secondary/midwifery care. Mrs F was not seen again within primary care during her antenatal period. 4.5 1.11.2011; Mrs F was seen for the first time by the community midwife following a self-referral to the service at 30 weeks pregnant. At this contact the baby was recorded as small for dates, routine screening tests (NHS Antenatal Screening Programme) were offered but declined and no advice was given re Vitamin D supplements. 4.6 The next contact was on 1.12.2011; where formal routine booking was completed, Mrs F was by now 34 weeks pregnant. A risk assessment was undertaken taking into account Mrs F's medical, social, obstetric history including the late booking, the declining of routine screening, noting family history of diabetes and small for dates presentation. A referral was made to the consultant obstetrician. 4.7 2.12.2011; The GP practice received notification via the electronic booking form which advised that Mrs F was 34 weeks pregnant, a vegan, has had rubella vaccination and has consented to some tests but refused others on 'religious' grounds. 7 4.8 Following the referral by the midwife Mrs F was seen on the 7.12.2011; by the Consultant Obstetrician, during which time she expressed her unwillingness to seek care for either herself or her new born baby in the event of illness. This additional information prompted the obstetrician to request a referral to children's social care, this was however not completed. 4.9 20.12.2011; at a routine appointment with the community midwife, tests for diabetes screening and an ultrasound were declined and the baby was noted as still being small for dates. 4.10 28.12.2011; A week later Mrs F was noted as having painful and irregular contractions, but declined a labour assessment. The Ambulance service was called to the home address on 30.12 and transferred Mrs. K to hospital in established labour. Post natal period in hospital.1.1.12 until 6.1.12 4.11 Baby F was born in hospital at 01.07 hours on the 1st of January 2012 with a routine labour and appeared well although he was a low birth weight and noted to have intrauterine growth retardation (IUGR). 4.12 A detailed discussion was had regarding the value of maternal screening and Mrs F gave consent for maternal blood screening. 4.13 Soon after birth the paediatrician discussed the value of administering vitamin K but the parents declined this treatment. Mrs F informed the paediatric registrar that her religious beliefs did not allow her baby to have tests and stated she did not want her baby to have any tests. She also stated that the family were strict vegans and wanted to exclusively breastfeed but would accept soya milk top ups. 4.14 Discussions continued with the parents throughout this first day and then over the following two days in relation to the test required and the importance of the administration of Vitamin K. 4.15 During the first 12 hours of life Baby F developed concerns in relation to his blood sugar level and following review he was moved into the SCBU. 4.16 Over the following two days concerns continued to grow around the Baby F’s health and on 3.1.11; An initial meeting and discussion was had with his parents to explain the complications of his low birth weight. This included the need for phototherapy, adequate hydration, regular food and antibiotics. Over the course of a number of discussions the parents agreed incrementally to intravenous fluids and phototherapy but not the Vitamin K treatment. 4.17 The paediatrician expressed to the family that social care would need to be involved if their child's care was compromised. 8 4.18 During the course of the day Baby F’s condition continued to deteriorate despite active treatment and his worsening jaundice, respiratory distress and suspected infection led the paediatric team to have a further debate with the parents, strongly advising on treatment. During the day this concern led to the involvement of the safeguarding nurse and further communications with the parents advising them on the urgency of the treatment, however despite the collaborative approach the parents continued to refuse to consent to the treatment required (Vitamin K administration). 4.19 This lack of consent led to a social care referral being completed and faxed to children's social care after a telephone discussion by the safeguarding nurse late that afternoon. 4.20 Mr F consented to administration of the Vitamin K to Baby F a few hours later that evening. 4.21 The following day, 4.1.2011, further conversations continued with the parents and Mrs F advised the safeguarding nurse that her sister works as a midwife and her husband, Mr F was an adult respiratory nurse. She expressed that her religious beliefs were a contributory factor to not having antenatal care but Mr F noted that the refusal for the Vitamin K treatment was due to his belief that it was purely for government statistics. 4.22 The parents both stated that they would not object to further treatment and would bring the baby back to hospital if he became unwell. 4.23 The safeguarding nurse advised children's social care that the parents were now accepting treatment and requested that a senior manager consider a strategy meeting prior to discharge of the baby. Later references suggest that the safeguarding nurse indicated that this was no longer necessary. 4.24 Following the referral children's social care (CSC) sought legal advice in relation to this scenario, this was prior to being informed that the parents had given consent. 4.25 5.1.2011; Children's social care held a strategy discussion in response to the concerns raised, which included the police, the social worker and it appears that the safeguarding nurse provided information via the referral. The result of this discussion was that a single agency (social care led) enquiry was required under section 47 of the Children Act 1989. 4.26 Baby F’s condition improved considerably over the next three days, he was back to his birth weight and he was subsequently discharged from hospital on 7.1.2012. 4.27 No discharge planning meeting took place. 4.28 An agreement was made for a joint post discharge visit between the health visitor and the social worker, a discharge summary noting all the events was sent to the GP and a follow up hospital appointment was made for 6-8 weeks later. 9 4.29 The health visitor was informed by the paediatric liaison health visitor at the hospital of Baby F’s imminent discharge and brief details of his birth history, his family and the sequence of events. Post discharge until Baby F’s death, 7.1.2012 to 14.06.2012 4.30 The community midwife telephoned (rather than visited) on the first day post discharge at the family's request and then visited Baby F twice at home until 13.1.2012 when they discharged him from their care. 4.31 12.1.2012; The health visitor and the social worker undertook a joint visit to the family home. The health visitor undertook a new birth visit and the social worker undertook the core assessment. 4.32 There were no concerns regarding Baby F noted on the visit, the house was warm, interactions with his parents were good and he was feeding well. The father’s employment as an adult nurse was noted as was the support the parents were receiving from other family members who were medically trained and also their church. 4.33 The parents discussed the refusal of the Vitamin K stating that it was due to lack of information rather than based on their religious beliefs and that the hospital had not been clear about their level of concern. 4.34 Mrs F spoke about her faith in God stating ' he would make everything well'. She noted that she had had blood tests herself due to pressures from the hospital staff. The parents both cited professionals as being rude and judgemental of their beliefs but stated that their spiritual beliefs made them refrain from formally complaining. They reiterated that they were both vegans and that they did not take supplements due to their beliefs. They advised that they had yet to decide if they would have their baby vaccinated. 4.35 The social worker concluded that the parents were working well with health and were meeting their child's needs and made a decision to close the case. 4.36 This decision was supported by the social worker's manager who signed off the assessment noting that there may have been 'crossed wires' at the time of the baby's birth and that there were no ongoing concerns evident. 4.37 Baby F was seen once more at home by his health visitor, 20.1.2012 where he had gained weight and Mrs F appeared relaxed. A discussion was had re giving Baby F his immunisations and it was noted that the parents had not yet made a decision. A reminder was given to book his eight week check and confirmed that Mrs F's six week check was booked. No concerns were raised. 4.38 The next time Baby F was seen was in clinic by another Health Visitor, 9.1.2012; although he had gained weight he had dropped below the 0.4 centile. No follow up action was taken. 10 4.39 15.2.2012; Mrs F attended her six week post natal check, it was recorded that she continued to breast feed, no comment was made re giving dietary/vitamin supplements. 4.40 17.2.2012; Baby F missed his hospital follow up appointment. 4.41 29.2.2012; Baby F attended the Health Visitor clinic where he was found to have had a reasonable weight gain. The health visitor noted that he was still being breast-fed and discussed supplements with the parents. They also discussed the immunisations, the parents stated that they did not want either of these. They did agree to attend the eight week developmental check the following week however they subsequently did not attend for this appointment. 4.42 This was the last time that any professionals saw Baby F alive. 4.43 He also did not attend his second follow up appointment at the hospital on the 15.5.2012, following this the hospital wrote to the GP asking for Baby F to be reviewed and particularly with regard to his weight. The letter states that no further follow-ups would be sent but that the paediatrician would happily review the baby if the GP had concerns. 4.44 14.6.2012; Mr F called the police to the family home saying that their 'son had no sign of life'. The police report that he had been in cardiac arrest for 10 minutes prior to their arrival and that CPR had not been attempted by the family. The parents later reported that Baby F had had a cough since April and been unwell for about three days; he had not been feeding properly and had swelling around his eyes and arms. 4.45 An ambulance was called and Baby F was transferred to hospital where despite attempts to resuscitate him he was pronounced dead at 19. 12pm. Post Baby F’s death. 4.46 Children's social care duty team were informed of Baby F’s death by the police on 14.06.2012 and the health visitor and GP were informed the following day by the hospital. On the same day the health visitor became aware that Baby F had not attended either of his hospital follow up appointments, the reasons for this delay were not apparent. 4.47 25.6.2012; A Multi agency rapid response meeting took place attended by the designated paediatrician, the police, children's social care and representation of the health visitor via the named nurse. The meeting considered the events of Baby F’s birth and issues regarding lack of consent, the referral to children's social care, the history of his ill health from April, including the deterioration in the final few days and the lack of seeking any medical attention. The outcome was for there to be feedback to the CDOP although this is not reflected in the minutes. 11 4.48 The health visitor visited the family to offer support and condolences. The parents described that Mr F had tried to resuscitate Baby F but his skills were not good and he was too distressed. 4.49 They stated that they had not taken Baby F to his developmental check as it had seemed like a waste of time and would expose him to germs. Mrs F stated that they had not taken him to the hospital appointments as he was gaining weight and being seen by the health visitor so they saw no need. They also stopped attending the clinics as he was doing well and she didn't want him to get upset or exposed to germs. Mrs F stated that she had learned from her mistakes regarding the vitamin D deficiency and that in future she would ensure that her levels were not low and therefore not putting a baby at risk. She noted that they were probably low at that time. 4.50 On the 13.8.2012 Mrs F was started on iron and vitamin D following a blood test, it was unclear who had initiated this request. Mrs F was seen on 12.12 2012 and she reported that she was pregnant. The GP contacted the designated nurse for advice re contacting social care and they decided to await the scan results before making a referral. 4.51 18.12.12: Mrs F's GP was informed that she has had a miscarriage. 4.52 5.9.2012: The CDOP met and considered the findings of the post mortem, information from the agencies involved and the Rapid Response meeting. 4.53 The outcomes of the CDOP were to refer to the Local Authority Designated Officer (LADO) to refer Baby F’s father for investigation regarding his role and his possible neglect of Baby F’s medical needs and to request the LSCB chair for consideration of the case by the SCR panel. The police also contacted the Nursing and Midwifery council in reference to the conduct of the father and his capability/suitability as a registered nurse. 5. Analysis of Involvement. 5.1 Over the period of the events surrounding Baby F’s short life there are a number of common themes in relation to agencies' practice, these include some evidence of good practice and compliance with procedures. There are also however a number of occasions where practice feel short of expectations and opportunities were missed and the following narrative cites those specific examples. 5.2 Across all the agencies there are examples of; A lack of ownership and accountability in practice Newly qualified and/or inexperienced practitioners with poor senior management oversight of the case, Poor quality of assessments, influenced by a lack of depth and rigour of analysis and interpretation of information that ensures effective analysis of risk, 12 Poor ongoing assessment of risk with little evidence of considering the totality of events and behaviours. Poor compliance and in some cases lack of knowledge of policies and procedures. Poor inter and intra agency communication, including inconsistent and at times lack of documentation. Little challenge of parental views and in particular a passive acceptance of the parents description of the constraints on their health behaviours prescribed by their faith. Limited evidence of the voice of the child in professional decision making. A sense of relief once the parents had consented to treatment that minimised the level of existing risk for the child. An apparent lack of evidence of awareness/knowledge of the impact of maternal nutritional status on the health of either the unborn or new born infant. An apparent lack of understanding/knowledge of the role of the LADO and reporting requirements across agencies. 5.3 These examples were common themes that resulted in a lack of recognition of concern/risk and subsequent lack of response. Antenatal period. 5.4 Mrs F's first contact with her GP was when she registered at a new patient check where it was identified that she was 28 weeks pregnant. It may have been reasonable to assume that she had only recently moved into the area however further investigation could have provided an insight into why she was booking so late in her pregnancy which would be seen as unusual especially for a first baby. 5.5 The actions of the HCA in referring her immediately for GP consultation was good practice as was her recording of the late booking and her adherence to a vegan diet. 5.6 However the reasons for this were not then explored by the GP and the fact that she was a high risk pregnancy was not identified or acknowledged in the practice. Whilst the GP made a referral to the hospital for antenatal care there is no available documentation to that effect and therefore any concerns and possible implications are unlikely to have been understood by health professionals subsequently involved in Mrs F's care. 5.7 The GP practice failed to address Mrs F's vegan diet and its impact on either her or her child's health. Women who follow a vegan diet in pregnancy are at risk of deficiency in iron and vitamin B12, pregnant and breastfeeding women are also at risk of inadequate Vitamin D uptake and as a black African Mrs F was further compromised by the risk of vitamin D deficiency. All these factors were known at the time of her first appointment and should have been discussed in detail with Mrs F by her GP. NICE guidance in 2008 noted the increasing prevalence of rickets and the need for vitamin D supplements in certain cases and recommends routine assessment within antenatal care for vitamin D supplements. The government issued guidance in relation to Vitamin D supplements in pregnancy in 2012 and it can only be assumed that this practice were unaware of this guidance. However this is a 13 common feature in this SCR as no other health practitioners appeared to proactively follow this guidance/recommendations. 5.8 This was also a missed opportunity to share information that should have informed both the midwife and her health visitor of the level of risk for Mrs F and her baby. 5.9 Mrs F self-referred to midwifery care at 30 weeks, this late booking plus an unborn infant showing small for dates and declining of routine tests including the ultra sound scan should have prompted an assessment and identification of a high risk pregnancy at this point. Delayed bookings are also supposed to be followed up within two weeks of first contact in accordance with the hospitals' procedures however formal booking was delayed by almost four weeks and no intervening actions were taken. This has been identified as a failing on the part of the appointment system however it is unclear why the midwife or manager did not identify this delay and advise a home booking or alternative venue. It may suggest that the level of risk was not recognised as significant. 5.10 At the formal booking a risk assessment was undertaken and a referral was made to the consultant obstetrician which is good practice, although a detailed discussion with Mrs F re her diet, the baby's weight and the family's declining of tests was not explored until she was seen a week later by the consultant. 5.11 At this appointment further concerns were noted and the consultant was the first professional to recognise that the expressed views of Mrs F posed risks for Baby F. He appropriately requested a referral to social care which is an example of good practice however this key action amounted to nothing as the referral was not actioned and the consultant did not follow up to ensure that the referral had been made. The midwifery and obstetric professionals work within a team approach and the clinics are very pressured for time. This results in the medical staff delegating their safeguarding responsibilities to the nursing staff, and whilst this may be acceptable in terms of practicalities in some instances, the process can also lead to professionals delegating their accountabilities, which is poor safeguarding practice. 5.12 To compound this the junior member of staff appeared not to have fully understood the request for a social services referral and instead completed a concern and vulnerability form. Within the hospital this form has been amalgamated with the CAF for ease of completion and to avoid duplication, in this instance it is unclear why this form was used and what happened to the form itself as it was not highlighted in subsequent interactions with the family or triggered the expected case presentation for high risk cases. This may have been a result of confusion in relation to the current hospital processes that had recently changed and a lack of knowledge of processes for flagging concerns to senior staff. Senior midwifery overview of practice appears to have been absent and if present is likely to have identified the confusion and flagged the need to escalate concerns. 5.13 It is unusual for mothers to decline screening test in pregnancy especially ultra sound scans as these are usually an eagerly anticipated event. Pregnant women do have the right to 14 decline treatments and screening during pregnancy and it is good practice to recognise individual choice and cultural diversity. This also applies to the decisions made in relation to diet however in this instance it would appear that the voice and rights of the parents outweighed the obvious risk that these choices could have on the child. The midwives respected the parents expressed religious beliefs which is good practice however there was no professional challenge in relation to the extreme nature of the facts that were presented by the parents of this particular belief system. 5.14 In addition to this the professionals should have been well aware of the NICE guidance (2008) relating to vitamin D supplements in pregnancy in particular for black African mothers, plus the fact that Mrs F was a vegan should have increased concerns for the baby's' wellbeing particularly in light of parental non compliance with proactive screening. 5.15 Despite the concerns noted at this appointment and continued presence of the same risk factors the concerns were not raised again during the antenatal period and no one questioned the lack of escalation of the consultants concerns. One could assume that as Mrs F had been seen by a number of professionals during this time, staff assumed that the risks were either being managed or that they did not indicate a significant concern, also as noted the rights of the mother were seen as prominent. There is no evidence of professional curiosity or challenge of practice in the face of a number of high risk factors Post natal period. 5.16 Mrs F's labour and birth of Baby F were appropriately managed and the involvement of the paediatrician at the birth was indicative of good practice recognising the possibility of complications in light of the lack of maternal history. This good practice continues over the following days as the paediatrician maintained consistent and active involvement with the baby and his parents as his condition deteriorated. There are good examples of working closely with the family recognising their religious beliefs and culture and providing guidance and information in relation to the required treatment. The team also articulated early in the process that the well being of the child would take precedence and this included the early involvement of the safeguarding nurse. 5.17 An appropriate referral was made to children's social care when the health staff felt that the Baby F was vulnerable and needed protection due to his parents’ lack of consent to treatment. This included an initial telephone consultation by the safeguarding nurse and a timely faxed referral. 5.18 It would appear however that there was no challenge of the parents representation of the religious sanctions despite these being quite extreme and likely to put Baby F at risk. This may have related to an assumption that the safeguarding nurse had experience in the culture and belief systems and therefore these were genuine practices. It also suggests that the focus of attention was on consideration of parental choice. The parental issues appear to have clouded the professionals’ ability to focus on the experience of the child. 15 5.19 There was also no exploration of the contradiction of the parents accessing preventative treatment for themselves yet denying the same for the child. The father’s professional role as an adult nurse was known at this point but it neither informed the risk assessment nor initiated a referral to the LADO. It would appear that staff did not recognise the implications of his role either on his own child, his behaviours or potentially on other vulnerable patients in his care. 5.20 If these issues had been explored they may well have led to increased concerns in relation to the personal behaviours of the parents which may have meant that the concerns did not dissipate once the parents had given consent but portrayed a different picture of risk in the longer term. However it would appear when on reflecting on the marked shift from acute preventative action to minimal concern that the concerns were one dimensional, focussing by this point solely on the lack of consent. 5.21 The children's social care team appropriately sought legal advice and responded to the referral in a timely manner. The strategy discussion was not undertaken within a face to face meeting, this is in itself not poor practice however given the level of concern and initial response by CSC it is unusual. Presumably this was because by this time the concerns had dissipated as the parents had given consent. The referral form also appears to have been focussed on the parental refusal for treatment once the baby deteriorated with minimal information provided on the antenatal history particularly the declining of key screening and uptake of supplements. It is unclear if this relates to the transference of detail from the original telephone consultation or from the faxed form. 5.22 A key concern is the omission of the paediatrician in the strategy discussion as it is likely that this would have both occurred face to face at the hospital and provided a comprehensive picture of the risks. It is assumed that the safeguarding nurse's contribution to the discussion was via the referral however there appears to have been confusion as to the role of this nurse with social care believing that this was a named nurse and thereby assuming a higher level of safeguarding expertise. It could also be suggested that the safeguarding nurse also felt that once the parents had complied with the treatment the risk had gone, this is reflected in the discharge summary to the GP. 5.23 The strategy discussion form is brief on detail and lacks analysis on the rationale for progressing to a Section 47 enquiry, this undermines effective risk assessment. In particular the information on the form should inform the investigating social worker of the background and actions required and subsequent assessments may well be compromised. In this case this lack of rigour and detail could have suggested that the concerns had been eradicated and may explain in part why the seriousness of the situation was minimised going forward. 5.24 This lack of ongoing concern may also be the reason why there was no discharge planning meeting although this is a requirement under the Policies and Procedures (see Kent and Medway safeguarding children procedures 2010 section 5.25) whenever a professional or agency has raised child protection concerns about a child admitted to hospital. 16 5.25 The final strategy meeting and discharge planning meeting could have been combined however the lack of the discharge planning is a key missed opportunity. It is at this meeting that the comprehensive picture of events could have been identified, professional questioning and a robust risk assessment should have arisen through the multi agency discussions and reporting. The lack of this meeting further illustrated a picture of minimal concern by professionals and potentially provided both the parents and other professionals with no sense of concern for their behaviours as there was no clear plan to monitor them and Baby F once home. Post discharge. 5.26 The midwifery service continued to support the family appropriately until the health visitor had taken on the care of the family and this is good practice although there is no evidence of earlier communication between the two services which would have been expected in a high risk family. This is presumably due to the lateness of the booking although this should have increased the need for communication between the two services. 5.27 The HV undertook the new birth visit with the social worker which as good practice afforded them both the opportunity to explore in depth the parental behaviours. However the visit was extraordinarily optimistic and the parents were seen to be very co-operative. The nature of a new birth visit may have distracted from the need to explore, challenge and analyse the situation and the information available from the history. The decision by the social worker to close the case appears to have been made on the basis of an assessment that contained little depth and rigour. As previously stated this may have been influenced by the considerably reduced concerns noted at discharge, the lack of a discharge meeting and the parents compliance at the home visit. 5.28 There was a lack of any agency checks, which if undertaken is likely to have provided a more complete picture of the risks. 5.29 The detail within the core assessment is suggested to be more in line with an initial assessment, lacking analysis and identification of risk. The assessment was also completed within a very short time frame and notably less than the requirement, this reflects the lack of concern felt by the social worker. 5.30 The social worker appears to have been reassured that the parents were engaging with health services and presumably felt therefore that if there were any concerns the health visitor would seek further advice from CSC. It was appropriate that health became the lead agency however this assessment of compliance was based on minimal evidence. Also whilst the management of the baby's weight was a health responsibility there appears to have been no challenge from the social worker in relation to recognising the impact of this on the baby's vulnerability or the lack of a plan to monitor appropriate weight gain. 5.31 Both the social worker and the HV accepted the parents’ assertions that they had not withheld treatment and although subsequent enquiries with the hospital advised that this 17 was not the case there was no challenge by either professional. The details of the protracted discussions with the parents were available on the referral form however this did not factor on the assessment. There was no consideration of the contradictions between care accepted for themselves and that provided to their child. The parents repeated their religious beliefs and approach to screening and supplements and it was noted that Mrs F had low haemoglobin and was a vegan who was breast feeding. None of this information appears to have informed the assessment by either professional. 5.32 The parents stated at the visit that they felt that the staff at the hospital had been rude and pressurised them, it may be that the HV and social worker felt that they did not want to be seen in the same light and potentially subject to a complaint or to be judgmental. 5.33 Baby F remained underweight at the visit however evidence of weight gain appeared to reassure both the social worker and HV. The vulnerability of the baby due to his IUGR was not identified indeed the interaction and co-operation of the parents appears to have held great weight in the assessment despite this being on limited experience and the parents ability to remain engage was untested. 5.34 The social worker involved in the case was newly qualified although known to the team, this may explain her optimism however the supervising manager should have provided guidance around the level of assessment required and provided a greater degree of challenge to the assumptions made. 5.35 The health visitor made an appropriate decision to identify the family as one in need of 'targeted' intervention however the rationale for this decision and then the subsequent decision to reduce the level of need is not evident, nor are the corresponding levels of activities associated with these decisions. 5.36 It would appear that the HV was not provided with the Neonatal discharge summary, which would have informed her assessment of risk, however she had had a hand over by the liaison health visitor at discharge. 5.37 There is no evidence that the GP recognised the level of risk noted in the discharge summary or sought any advice or assurance from either the HV or the midwife following their interactions with Baby F on his wellbeing. It is unclear how effective the communication between the GP, HV and midwives are within the practice. 5.38 This lack of identification of risk and inter-professional communication was also highlighted when the GP was informed by the hospital of the missed out patient appointments. The paediatrician specifically requested that the GP reviewed the child, this should have raised an alert within the practice and a proactive response initiated. The GP advises that this was passed to the HV although no evidence for this is available, however even if the responsibility was delegated the accountability remains the GP responsibility and this should have been followed up. This was a significant missed opportunity and it is difficult to ascertain the reason for this lack of response by any of the health professionals. Failure to 18 attend clinic appointments is a clear potential for concern as noted by CEMACH 2008 noting it as a possible indicator of a family and child's vulnerability. GP practices were issued with a suggested process for ensuring the follow up of these families in 2009 following a local SCR, (this has also been reviewed and reissued in January 2013). In this case the process was clearly not followed. 5.39 This may be another indication of the lack of risk assessment and awareness by professionals in this case. In this instance the consultant letter also advised that there was no intention to follow up the baby at the hospital so the GP may have perceived this as a low level concern. This may explain why he did not follow up the lack of feedback from the HV possibly making the assumption that she would have contacted him if she had any concerns. 5.40 The hospital also failed to recognise the significance of the missed appointments particularly in light of the previous history of non-compliance, this should have promoted direct communication with the GP, HV and children's social care given their previous involvement. Discussion with the named nurse is likely to have escalated this and initiated the appropriate communications. It is likely that given the previous involvement if CSC were notified of the missed appointments this would have triggered a review. 5.41 The actions undertaken would suggest that the consultant believed that he had delegated his responsibility when asking the GP to follow up Baby F, as noted previously accountability however must not be delegated. This also appears to repeat the theme relating to the lack of assessment and comprehension of the level of risk for Baby F. This case reflects the concerns noted in a previous SCR in 2009 in relation to the importance of a full consultant review and the previous recommendations appear not to have been followed in this case. It is unclear from the evidence how well informed with these recommendations the medical staff are within the hospital, but this SCR would suggest that they are not embedded into practice. 5.42 The HV would appear to have been reassured by the attendance of Mrs F and her baby at the clinic, the weight gain noted at the second home visit and the clinic visit on the 29.2.2012 however the previous clinic visit had shown poor weight gain with Baby F being below the 0.4 centile. This concern does not appear to have been identified, if it had been then the HV may have considered checking on the baby when he did not attend further clinics rather than relying on the most recent weight. The post mortem found Baby F to be considerably underweight at the time of his death and the sequence of events would show that there was a gap in overview of his weight. It is not clear if there was a threshold of desired weight gain and close monitoring of progress which seems to be an oversight given Baby F’s birth history of IUGR and subsequent low positioning on the centile chart. This lack of a plan would suggest that the vulnerability of Baby F in relation to adequate nutritional intake was not recognised and in particular little regard appears to have been given to the impact of Mrs F's nutritional intake on Baby F. 5.43 The mother’s six week check also provided an opportunity for the GP to review the mother’s dietary intake. The GP should have been aware of the importance of breastfeeding mothers to take vitamin D supplements and this would have been even more relevant in Mrs F's case 19 due to her ethnicity. The GP would have had access to the antenatal and birth history and this would have enabled him to make a more thorough assessment of both the mother and babies needs and it would have been appropriate for him to have advised or prescribed vitamin drops for the baby. This is good practice even in the absence of the concerns that surrounded Baby F. 5.44 Another lost opportunity was the lack of follow up of the family when they missed the 8 week check, given that the family had informed the HV that they did not intend to give the baby his immunisations a follow up appointment at home would have been appropriate in this instance. It is unclear why this lack of engagement did not escalate concerns from the HV or GP it can only be assumed that the previous reassurance that the HV had received meant that she did not recognise the level of risk and presumably the GP was unaware. 5.45 This missed appointment alongside the missed hospital appointments should have triggered significant concerns on their own but particularly in light of the antenatal and postnatal history a further urgent discussion with CSC was required. The basis of co-operation and engagement upon which the core assessment was founded was no longer present but it does not appear that these collective factors were recognised therefore no further action or escalation was taken. This lack of concern continued when the family did not attend any further clinic appointments, given the vulnerability of the baby it would seem appropriate that this family had a low threshold for proactive contact. The HV does not appear to have reassessed the baby’s needs or vulnerability at any time in the process in particular when contact dropped off. Baby F had not been seen by any professionals for three and a half months by the time of his death. This is not unusual for well babies although one would expect to see mothers and babies fairly regularly in the first six months of life. In Baby F’s case the assessment had been closed on the basis that the HV would continue to have contact and engagement, there is no evidence to suggest that the level of vulnerability for this baby had reduced. It is unlikely that this case was discussed at the HV safeguarding supervision, as he was not on a child protection plan. It would appear that there is a lack of robust oversight in the management of cases such as this. Discussion with the safeguarding nurse during supervision would have raised the awareness of the growing vulnerability of this baby. 5.46 Baby F's father was working as an adult respiratory nurse at this time, this was known to agencies over the period of their involvement however no agency referred to the LADO. There were three separate occasions when concerns should have been raised this included the rapid response meeting. However it was not recognised as a safeguarding issue until the CDOP in September 2012, at this point a referral was made. It is unclear why there was a break down in multi agency working in this respect, evidence suggests that whilst agencies reference that they recognise and understand the role of the LADO there is little evidence of engagement. 5.47 The LADO made an appropriate request for a strategy meeting in September 2012 following the local policy, however this never took place. It is unclear why this was the case, however. 20 There appeared to be little oversight by the LADO of this case and it may simply have been missed. 5.48 At the time the LADO role was described as busy and difficult to manage competing demands, The LADO role and process is currently being reviewed by CSC as part of the Improvement Plan. 5.49 A rapid response meeting was held in a timely manner however it does not appear to have recognised the potential for neglect in this case; this appears to reflect the theme throughout the case of a lack of analysis and understanding of the presenting factors. The impact of the parents cultural and religious views hampered the assessments and decision making during Baby F’s life and these would appear to have also impacted on the findings of the meeting. Given that the rapid response meeting has the power of hindsight and a full picture of all the information it is of concern that the assessment and decisions continued to be weak. There may have been more of a focus on the parental behaviours and determining the rationale behind them rather than considering if neglect contributed to Baby F’s death. There also appears to have been little challenge within the meeting of the decision to defer the case to the CDOP. This may have been due to the professionals awaiting the results of the post mortem and police investigation before committing an opinion. 5.50 There is evidence of good practice at the hospital, Acute Trust 2,following Baby F's death as there was recognition of what life must have been like for him leading up to his death. 6. Learning from the case. 6.1 There are a number of common themes running through the case and these and the specific points have formed the basis of the recommendations made by this review. The specific points have been noted within the chronological order in which they occurred. Specific points Ante-natal period 6.2 When Mrs F registered with her GP practice it was evident that she had not received any antenatal care and was at an advanced stage in her pregnancy, she also refused some screening tests and noted her diet/nutritional intake. These factors should have alerted the GP to the vulnerability of both her and her unborn child. If the significance of these were not clear there was clearly enough cause for direct discussion with other professionals such as the midwife or health visitor. Effective communication would have raised the level of awareness at an early stage and if it had not indicated the need for a risk assessment at this point it would have contributed valuable intelligence that built a picture of risk over the coming weeks. 21 6.3 GPs note that changes to maternity care have resulted in little engagement with the midwifery service or with pregnant mothers and it may be that this distance contributed to the lack of recognition of the vulnerability of the unborn child. However these changes to the pathway do not detract from the accountability of all professionals who come into contact with vulnerable families and systems need to be in place to address any communication or knowledge gaps that this process creates. 6.4 Antenatal visits by Health Visitors to vulnerable families, such as Mrs F assist in effective communication and ongoing postnatal care. This visit would have informed subsequent antenatal and postnatal care and maintained a level of continuity of information that was lacking in this case. 6.5 Throughout the antenatal period there was a lack of recognition of the potential impact of the mother’s diet on Baby F despite recognising that he was small for dates. It is important that professionals recognise the implications of maternal health on their unborn infants including the mother’s diet. Recognition of this could have alerted the professionals to the need for close observation of Baby F’s development at an early stage and informed subsequent risk assessment. 6.6 Late bookings are recognised as an indicator of risk and in this instance were another contributory factor to the baby's vulnerability. Whilst this was recognised in the booking as a risk factor it did not precipitate any action and there was then a delay in follow up. Senior oversight of processes could have identified both the delay and the risk and ensured that this was addressed quickly. 6.7 Despite the appropriate action by the Obstetrician requesting a social care referral in light of the presenting risks the systems and processes in place appeared to be have been muddled and roles and responsibilities do not appear to have been clear or fully understood. Senior oversight of the processes should have noted the confusion and lack of follow up of the expressed concerns. This includes the consultant who should have followed up on his request to determine the outcome. 6.8 Junior staff do not appear to have understood the differences between a social care referral, the concern and vulnerability form and a CAF. Support to this staff group could have both identified the mistake and supported the staff member to understand the level of concern related to each of these interventions. Clarity and appropriate referral at this stage would have resulted in a risk assessment and whilst direct action may not have been taken Baby F's vulnerability would have been recognised and this would have contributed to subsequent assessments, especially when the parents later refused treatment. 6.9 This was a key point at which the lack of professional curiosity impacted on Baby F’s outcome. The nature of the spiritual beliefs and sanctions articulated by his mother were extreme and should have raised both concern and questioning. Simple exploration of these beliefs would have illustrated that these were personal views/behaviours as opposed to those of the church and would have informed the level of risk for the baby. Use of services 22 such as the hospital chaplaincy would have been appropriate and sensitive. However even if the faith organisation had supported the mother’s statements this behaviour would still have caused concern for the baby's well being and should have been addressed. It is likely that anxiety relating to ensuring that the mother’s needs are recognised and that the diversity of the parents was not compromised hindered a proactive approach. Professional efforts not to be judgemental are recognised as influencing the ability to apply safeguarding thresholds (Brandon et al 2005). This directly impacts on the recognition of the risk of significant harm for the child. 6.10 Litigation and or complaints against staff in relation to recognising the legal rights of the mother and the ethnic, cultural, religious rights of parents are likely to be influencing professionals’ behaviour and in turn losing the voice of the child. The need to stay Baby Focussed is paramount and reflected in many safeguarding reviews including the Munro Review (2011). Post natal period 6.11 During the immediate post natal period there continued to be a number of opportunities for staff to investigate and challenge the parents’ representation of their faith’s beliefs. This investigation would have alerted professionals to the risk that the baby faced from parents who failed to make their child's needs and wellbeing their priority. Whilst there was an appropriate escalation of concern the focus remained on consent for treatment and a deeper understanding of the parents’ motives and behaviours was not sought out. This lack of adequate assessment and challenge would suggest therefore that when consent was finally given the concerns abated as no underlying concerns had been recognised. 6.12 The de-escalation of concerns post consent and subsequent actions reflect the lack of robust assessment and analysis. 6.13 Senior management and/or safeguarding oversight into the events could have brought insight and challenge to the events. This particularly relates to the 'named nurse' role. The expertise, influence and specialist knowledge of a named nurse whose responsibilities are defined within Working Together would have provided this function. 6.14 To compound this gap CSC believed that the interactions were with a 'named nurse' which is likely to have led in part to their lack of urgency assuming that the risk had been assessed effectively. 6.15 It is also apparent that the responsibility for this case was passed to the safeguarding nurse with the assumption that this post had the expertise and knowledge to effectively oversee the process. 6.16 The importance of the senior expertise and oversight of a named nurse cannot be underestimated in terms of understanding risk, interpreting behaviours and providing 23 challenge. There needs to be recognition of this role and adequate capacity provided to fulfil its responsibilities and to provide assurance at both individual and organisational level. 6.17 Throughout the case there are good examples of practice and compliance with policy and procedures however there are a number of occasions where these were not complied with. It is important to ensure that agencies and staff within them recognise the importance and value of procedures and policies in safeguarding children and embed them into practice with confidence. There is also a lack of senior oversight evident that should have provided internal quality and compliance assurance. 6.18 This is particularly pertinent in relation to the absence of a discharge planning meeting which was a significant missed opportunity and breach of the procedures. Whilst it is the responsibility of health to initiate, CSC should have challenged the hospital and ensured that this was undertaken. The co-operation by the parents at this point is likely to have deflected the level of risk however the procedures provide a framework that ensures a proactive multi agency approach to recognising and managing risk that are effective in cases where risk is both obvious and hidden. 6.19 Whilst a strategy discussion did take place it was not face to face and only included the Police and CSC with information provided by the safeguarding nurse. Given the level of concern previously expressed and the seriousness of actions this should have precipitated a full strategy meeting in particular including the paediatrician. This would have provided more detail and an opportunity to challenge it is also likely to have agreed a discharge meeting or plan. 6.20 During the strategy discussion none of the agencies involved questioned the lack of a full strategy meeting and whilst this may be due to an apparent absence of concerns following the consent no professional queried if there were any remaining concerns. There was also no query as to the lack of the paediatrician in the discussions or query as to whether there may be further information required for the purpose of the discussion. It appears that the strategy discussion was taken on face value and no individual members saw any cause or role for them to raise any queries. 6.21 The multi agency role of strategy meetings and its purpose in facilitating a questioning and analytical environment upon which to make informed decisions is vital in ensuring that effective decisions and plans are made that adequately protect vulnerable children. All agencies need to recognise their broader safeguarding responsibilities within that context. Post Discharge 6.22 The core assessment lacked depth and rigour that will have directly impacted on the ability to effectively identify risk and subsequently led to poor decision making. It is likely that this was influenced by the reducing level of concern both implicit and expressed within actions leading up to the joint visit. However if a robust process of enquiry and analysis, as required 24 in an effective core assessment had been followed unresolved issues, contradictions in behaviour, parenting concerns and the baby's vulnerability would have been explored. 6.23 The overly optimistic and seemingly empathetic approach taken towards the parents is likely to have dominated decision making if all the available information had been thoroughly reviewed. The process of assessment within child protection should be undertaken over a period of time that enables a full review and analysis of available intelligence and engages all agencies involved in the Childs care. Following the procedures would have allowed that investigation and analysis in Baby F’s case and would have provided a different assessment of risk. 6.24 Joint visiting between agencies and in particular health and social care for newborn babies is good practice, informing effective assessment and decision making. However the combining of the new birth visit with the initial assessment is likely to have detracted from the need to determine the level of vulnerability of Baby F. The purpose and focus of these visits is clearly different and it would appear that the more supportive, relationship building nature of the new birth visit took precedent. 6.25 This visit and the subsequent interactions continued to evidence the lack of professional curiosity and challenge. Both the social worker and health visitor had information relating to Baby F’s history however did not question the discrepancies between the professionals and the parents’ accounts of events. There was also no challenge on the contradictory approach that the parents took towards their baby's health care and their own. Whilst this may have been related to a desire to maintain a good relationship and cooperation with the parents during the visit, this could have been followed up as part of the assessment. 6.26 It is unclear if the parent’s ethnicity or professional background served to divert the social worker and Health Visitor from raising any questions or challenge either to the parents or each other. The parents articulated their unhappiness with the hospital staff referencing feeling harassed and considering complaining. This may have intimidated the professionals and the anxiety at being the subject of a complaint particularly by a health professional and/or in relation to equality and diversity may have clouded their judgement. Supporting staff to be able to challenge parents regardless of their professional status and without compromising their equality and diversity responsibilities will ensure that care between respecting individual rights is balanced with protecting vulnerable children and adults. 6.27 There appears to have been no system in place to ensure communication between the hospital safeguarding nurse and the HV or named nurse within the community in cases where child protection concerns have been raised which would have informed the assessment. The process relies on the hospital liaison health visitor having adequate information available to recognise the vulnerability of the baby. 6.28 Baby F was known to have IUGR, however this did not feature in either professionals’ assessment and the risk that this history plus the mothers nutritional status created was not factored into his subsequent management. A weight management plan would have been 25 good practice and should be implemented in cases where a baby has growth concerns even when families are cooperative. 6.29 Monitoring of adequate weight gain is clearly a health responsibility, however a comprehensive core assessment incorporates the health and well being of children and this should have featured in the core care plan with assurance being sought by the social worker. 6.30 Whilst the Health visitor identified the family for targeted interventions it was unclear what this would entail and what triggers would be monitored to ensure the baby's well being. Clarity behind decision-making is essential to recognise the risk factors to be managed and to inform the management plan. Staff need to understand and appropriately use levels of intervention and the frameworks that are in place in order for them to be effective and meaningful. A clear identification of the management plan associated with the 'targeted' intervention would have provided a framework for managing risk and recognising Baby F’s increasing vulnerability. 6.31 During this period communications between professionals does not appear to have been effective in particular between the hospital, the GP and the HV. Baby F’s vulnerability appears to have neither been recognised or articulated in communications so when the hospital advised the GP of the DNA's the significance of this was missed by both parties and therefore not followed up. The process for communication with the HV was not robust and therefore the request to follow up Baby F failed to protect him. Whilst there was clearly a lack of recognition of the baby's vulnerability, effective communication processes would have contained vital information to professionals involved and provided another opportunity to recognise the risk. 6.32 The lack of professional accountability by key individuals is highlighted during this time and identifies the need for all professionals to follow up on their actions and concerns. This is particularly important when care is passed on or picked up by other services as it is at these points that essential information and intelligence is lost and the baby's vulnerability increases. This is evident in the follow up of the DNAs by the both the Paediatrician and GP, the follow up between the two HVs, the communication passed by the GP to the HV and the follow up of the missed 8 week check. 6.33 The lack of action when Baby F failed to attend either of his hospital appointments or the subsequent 8 week check is likely to be have been a result of the lack of recognition of risk. However there is clear guidance issued by CEMACH relating to the follow up of DNA’s, this is a common feature in the Victoria Climbie report findings and was significantly a finding in a local SCR in 2009. This would suggest that staff are not complying with the available guidance and recommendations and this therefore creates a weakness in the system to adequately protect vulnerable children. Systems and processes need to be robust, regularly reviewed and quality assured to ensure that they are embedded in practice. 6.34 Within this period effective senior oversight would have challenged the actions in place and are likely to have ensured a heightened level of response. This is particularly pertinent in 26 relation to the management response to the social workers assessment and the lack of safeguarding supervision in relation to this case for the Health Visitor. In both cases the role of the manager/supervisor would have been to challenge and reflect on the case and associated interventions. This role is vital within a quality assurance process and provides an essential safety mechanism for vulnerable children. In this case there was little analysis and challenge of the social care assessment and the HV did not choose to bring this case to supervision. Processes and systems need to ensure that the framework for senior and/or specialist oversight is effective and that staff recognise its role and importance. Post Death 6.35 A rapid response meeting was held in accordance with the Child Death Procedures however it would appear that this process also lacked rigour and analysis. The lack of senior representation and understanding of roles within the meeting will have contributed to the poor outcome. This level of expertise would also not have needed to have had the post mortem and police investigation results before committing an opinion. In some instances a strategy meeting is also called following an unexpected death of a child and this would have investigated the possibility of neglect however if a rapid response meeting is effective then it would fulfil this function. 6.36 The LSCB rapid Response template was not used and the documentation was poor. The minutes of the meeting were incomplete and of a poor standard, there was no reflection of any discussion in relation to neglect in this case.. This may have been due to the lack of debate in the meeting however this is not clear and therefore the information available in the notes would not have provided adequate information to inform any subsequent decision making. Common learning themes 6.37 There are a number of common themes noted throughout the case review, these run like a golden thread through the agencies involvement with Baby F and his family. These apply specifically to CSC, acute trust 1, the GP practice and the community service (HV) due to their involvement in Baby F’s care. However they cannot be seen to be exclusive to those agencies as the evidence is not available to demonstrate with confidence that all agencies would have managed these issues differently. 6.38 This was a preventable death and a number of opportunities to protect Baby F were missed. The nature and number of these themes would suggest that generally safeguarding practice was poor in this case. The recognised ' safety nets' within practice did not kick in so there was a cumulative picture of low risk that developed and this was not challenged. The quality of assessments was poor with little recognition or analysis of risk and therefore decision-making was flawed. 27 Professional practice focussed on maternal /parental needs over the needs of the child. There was no evidence of challenge of the parents’ views/representations or of their contradictory behaviours with a resulting loss of focus on the child. The ethnicity, diversity and possibly professional status of the family distracted professionals from challenging them. Supporting the equality and diversity rights of the family appeared to take precedence over the voice of the child. There was a lack of ownership and accountability by professionals, delegation to junior staff or other professionals was evident and there was no follow up or review of concerns. This contributed to the lack of identification of risk and increasing vulnerability was not picked up. There was a lack of senior management oversight, this includes directly to support junior staff and organisationally. Roles were often confused and not understood. The quality assurance function of management oversight was missing and led to continued poor assessment and decisions. The role and function of named nurse in acute trust 1 was not utilised as set out in Working Together and led to confusion for other agencies. Policies/procedures and guidance were not complied with in particular Discharge planning, DNA management, Core Assessment, rapid response meetings, managing allegations, the LADO role and nutritional guidance. This contributed to the lack of effective risk assessment and planning. There was poor Inter and Intra professional communication, leading to gaps in knowledge, misleading risk assessment and awareness of vulnerability. The lack of understanding of the impact of maternal nutrition/health on the unborn infant/baby resulted in no identification of risk or management plan. There was a consistent lack of professional curiosity and challenge to both parents and other professionals, this contributed to poor assessment, lack of recognition of risk/vulnerability and subsequently poor ineffective management. The role of Named senior officers within agencies and the LADO role and process was not used and does not appear to be understood. There are familiar learning points identified within this case to a previous local SCR in 2009 which suggest that previous learning has not been embedded into practice. The repeated lack of recognition of risk was not recognised as there was no professional who considered the whole picture or challenged previous decisions or lack of them. This 28 lack of identification of increasing vulnerability also appears to have conversely provided reassurance and served to reduce the risk observed by professionals as care unfolded. 7.0 Recommendations: There are a number of recommendations made within this report some of which build on individual agencies recommendations. As previously noted the main issues relate to learning within CSC and some Health agencies due to their involvement. Other agencies had little contact with this family either antenatal/ post natal or post discharge. The recommendations in a number of cases relate specifically to the agencies who had the contact related to that learning point. However within the principles of safeguarding children all agencies should reflect on the lessons to be learnt and the recommendations and consider what measures or assurances they need to review within their own area of professional practice. Whilst the Police and acute trust 2 had very little contact with this family and therefore a number of the specific recommendations do not apply to them they are advised to consider which of the recommendations would benefit their practice. A key learning point that should be considered across all agencies is the need for considering the tension that arises from the sensitivities and requirements of meeting the equality and diversity agenda whilst actively safeguarding children. These two issues can be conflicting and staff need support and training to both recognise and mange this tension, ensuring the child is adequately protected. Communication is addressed within agencies action plans relating to the specific instances where this failed Baby F, however poor communication is a common theme and is noted repeatedly in SCRs. All agencies and the BSCB should reflect on the need to continually promote good inter and intra agency communication. The report suggests that there were a number of missed opportunities to protect Baby F and that practice was poor across a number of areas. BSCB will need to be assured that the systems and processes in place to provide it with assurance are effective. At the time of this report CSC are under improvement measures and a number of the issues raised within this report are reflected in the improvement plan in particular the quality of assessments. BSCB will clearly be monitoring the improvement plan as part of their business. A number of concerns have been noted across health agencies and the report advises that the CCG's assure themselves that the services they are commissioning are effective with regard to safeguarding. 29 1. BSCB (and Kent LSCB) need to review its assurance processes in relation to the section 11 audit. Outcome: BSCB (and Kent LSCB) section 11 audit process robustly provides assurance of adequate safeguarding practice across member agencies. 2. Health and CSC need to assure BSCB that staff are undertaking effective safeguarding assessments. Outcome: Professional assessments are robust, holistic, informed and analytical and able to effectively identify the level of risk for the vulnerable child. 3. Agencies need to demonstrate to BSCB that they have internal quality assurance processes including regular audit in place with regard to safeguarding. Outcome: Safeguarding processes within organisations are effective and robust. 4. BSCB will audit practice to ensure the embedding of the SCR learning into practice. Outcome: The learning from this SCR has improved safeguarding practice. 5. All agencies will ensure that staff are equipped and able to challenge and question other professionals and parents within their safeguarding practice. Outcome: Staff will appropriately challenge and question parents and other professionals to protect vulnerable children. 6. Health and CSC will ensure staff are equipped to balance the equality/diversity rights and/or professional position of parents with the needs of safeguarding children. Outcome: Staff have the confidence and support to challenge and seek out advice in relation to the cultural/religious/professional status of parents in order to safeguard vulnerable children. 7. Acute Trust 1 and Primary care need to assure the BSCB that the professionals within their organisations are aware of and undertaking their child protection accountabilities effectively. Outcome: professionals recognise and fulfil their safeguarding responsibilities effectively. 8. BSCB needs to audit that the appropriate Named Senior Officers roles are in place across agencies and utilised appropriately including consideration of the protection of vulnerable adults. Outcome: Professionals utilise and inform the Designated Officers of cases where professionals working within statutory agencies are involved in child protection investigations 9. Acute Trust 1, community services and CSC need to assure BSCB that management oversight and expertise of safeguarding is in place within their organisation and is monitored to ensure it is effective. Outcome: Child protection concerns and safeguarding practice is quality assured by senior management oversight. 30 10. Acute trust 1 to demonstrate that child protection competency frameworks/processes/levels are in place for staff. Outcome: Staff are appropriately undertaking child protection interventions/actions in accordance with their level of skill and responsibility. 11. The CCG’s need to review the named nurse capacity and function within the Acute Trust (1) in line with the responsibilities as outlined within Working Together 2013. Outcome: The named nurse role will be able to adequately fulfil the expectations and responsibilities outlined within Working Together 2013. 12. The CCGs need to assure themselves of the efficacy of safeguarding arrangements within their providers in particular senior oversight of safeguarding practice. Outcome: Effective safeguarding practice is in place to adequately protect vulnerable CYP. 13. The CCGs need to assure compliance with the DNA policies across the health provider agencies. Outcome: Vulnerable CYP who DNA health appointments are appropriately identified and managed. 14. Acute Trust 1 needs to ensure that staff are compliant with the safeguarding procedures in respect of Discharge Planning. Outcome: All CYP who have child protection concerns have a discharge plan in place before leaving hospital. 15. All agencies to ensure that appropriate senior representation attends strategy meetings/discussions and adequate information is provided to ensure informed debate. Outcome: Strategy meetings make effective decisions based on enquiry, challenge and adequate information 16. Bexley CCG needs to ensure that the actions relating to acute Trust 2 are transferred to the legacy bodies. Outcome: Learning from this SCR continues to be actioned and embedded into practice within this geographical area. 17. BSCB need to review its monitoring process in relation to actions and recommendations from SCR's. Outcome: Lessons from SCRs are embedded into practice. 8.0 Background reading/References Bexley Local safeguarding Children Board: Serious case Review, Executive summary; Child A 2010 31 Brandon M, et al (2009); Understanding Serious case Reviews and their impact: A biennial Analysis of serious Case reviews 2005-07 DCSF. Brandon M et al (2011); A study of recommendations Arising from Serious Case Reviews 2009-210 DoE. Brandon M et al (2012); New Learning from Serious Case Reviews; a two year report for 2009-11 DoE. CEMACH: Confidential Enquiry into Maternal and Child Health; May 2008 Why Children Die: A pilot study 2006. DoH: Chief Medical Officer's Letter. Vitamin D -Advice on supplements for at risk groups. London: DoH 2012 Gambril, Ed (2005) ; Decision making in Child Welfare: errors and their context. Children and Youth Service review. Vol 27. Great Ormond Street Hospital 2012: Post Mortem Report for Baby F June 2012. HM Gov ; Working Together to Safeguard Children 2012. HM Gov ; Working Together to Safeguard Children 2013. Laming Inquiry ( 2003): Victoria Climbie Inquiry; report by Lord Laming . HM Gov LSCB Safeguarding Procedures ( specifically Discharge planning, DNA processes, Section 47 procedure, Rapid response and Chid Death Procedures): Bexley LSCB ( 2009) London LSCB (2010) Kent and Medway LSCB ( 2007) Munro, E ( 2011); The Munro review of Child protection: Final Report, A Child Centred System. DoE. National Institute for Health and Clinical Excellence : march 2008 Antenatal care Routine care for the healthy pregnant woman. NICE clinical guidance 62. National Institute for Health and Clinical Excellence : march 2008 Improving the nutrition of pregnant and breastfeeding mothers and children in low-income households. 32 NICE public health guidance 11 NHS Commissioning Board (2012) Arrangements to secure children's and adults safeguarding in the future NHS: the new accountability and assurance framework-interim advice. Rickets: medicinenet.com/rickets/article RCPCH 10: Safeguarding Children and Young People: Roles and Competencies for Healthcare Staff: Intercollegiate Document. UK WHO Growth Chart for Boys 0-4 years. |
NC51216 | Death of a 2-year-old boy in December 2017. Child Ak was taken to hospital on life support but died of cardiac arrest. Was found to have several drugs in his body and multiple unexplained injuries and bruises. Father was arrested, charged and convicted of Child Ak's murder. Father was known to services and had prior convictions involving drugs and a history of domestic violence. Child Ak's paternity only established in late September 2017. Agencies agreed pre-birth that Child Ak would be subject of a child protection plan for emotional abuse. In October 2017 police found Child Ak in father's care with drugs present and an understanding that Child Ak was left alone in the premises for periods of time. Ethnicity and nationality not stated. Learning includes: develop organisational culture that enables professional curiosity and that is child centred and child focused, ensuring that the child/young person is 'seen' or considered, when working with parents, even if absent; ensure that the child's 'voice' is heard; ensure that expectations regarding multi-agency information sharing are clearly understood across all levels of involvement. Recommendations include: develop procedures for effective work with young people who are parents where safeguarding is required for both a young parent and their child; identify and promote approaches to engagement and effective work with fathers or partners of parents; develop strategies to enhance practitioners' capacity to work effectively where there may be complex parenting arrangements, for example involving different parents - especially fathers/father figures - for several children within a single household.
| Title: Serious case review report: Child Ak. LSCB: Northamptonshire Safeguarding Children Board Author: Phil Heasman Date of publication: 2019 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Northamptonshire Safeguarding Children Board Serious Case Review Report Child Ak Phil Heasman Associate, In-Trac Training and Consultancy Child Ak: Serious Case Review Report 2 Contents 1) Introduction, background and rationale for the review – terms of reference p.3 2) Background information and key events p.4 3) Practice, its organisation and management – terms of reference: questions, issues, and themes p.7 4) Learning lessons; developing practice, its organisation and management; recommendations p.12 5) Conclusion p.22 Child Ak: Serious Case Review Report 3 1) Introduction, background and rationale for the review – terms of reference 1.1 A Serious Case1 Review (SCR) is one of several reviews and audits undertaken within the learning and improvement framework established by a Local Safeguarding Children Board (LSCB)2. A review provides an opportunity to open a ‘window on the system’ especially at a multi-agency/service level. Any learning, perhaps especially from a situation with the most tragic of outcomes, needs to continue to strengthen the development of the various strands of a ‘safety net’ (individual practice, its organisation and management, governance and quality assurance arrangements between and within each partner agency) comprising the response with, and for all children, young people and families. 1.2 Child Ak died in December 2017 just after his second birthday. Following a 999 call, ambulance crew conveyed Child Ak to the local General Hospital. Basic life support was undertaken throughout but sadly Child Ak died as a result of cardiac arrest. Child Ak was also found to have high levels of several drugs in his body and multiple injuries, bruises and other unexplained injuries of concern. Subsequently, his father was arrested, charged with and convicted of his murder. 1.3 The review concentrated in detail on a relatively brief period from 1st October 2017 – 31st December 2017. 1st October 2017 is the approximate time from which Child Ak’s parents, who lived separately, established informal care arrangements for Child Ak. The end date for the review included a period following Child Ak’s death, included to assist an understanding of initial steps taken to ensure that Child Ak’s siblings were safeguarded. 1.4 A panel was appointed to plan and manage the review comprising named and designated representatives from the local authority children’s services, appropriate health services, the police and the LSCB. The panel was chaired by Malcolm Ross and a lead review report author, Phil Heasman (a qualified social worker; previously a Principal Lecturer in Social Worker; an independent training, learning and development consultant) was appointed. Both the chair and report author are independent of the case under review and of the organisations involved. Individual agencies completed Internal Management Reviews (IMR reports) and a comprehensive integrated chronology was compiled from information provided by relevant agencies and services. An event was held for relevant practitioners to identify learning and encourage reflection on their involvement, to examine the actions and decisions taken and to understand their context. 1.5 For the purpose of the report, the child who is the primary focus will be known as Child Ak. The report refers additionally to other family members and other significant people identified by their relationship to Child Ak where possible, although in some places the relationship is described in terms of the link to Child Ak’s mother and father where this assists clarity. 1 Throughout this report the word ‘case’ is not used to define or describe an individual child but to represent the whole of a situation, people and services or agencies involved with a particular child and her or his family or families, people known to the child and the wider context of the child’s life and experience. 2 NB: Local Safeguarding Children Board (LSCB) is the term used to describe the past and current relevant multi-agency organisation; the term Local Safeguarding Partnership is used, especially in relation to the recommendations, to indicate the prospective successor body. Child Ak: Serious Case Review Report 4 A genogram of key members of Child Ak’s immediate families only: 2) Background information and key events 2.1 Whilst this report concentrates primarily on a relatively brief period in late 2017, many services and agencies had contact and worked with Child Ak’s mother and father (and members of their extended families) separately in preceding years including ‘universal’ services and agencies (e.g: health, education, police) as well as more specialist services (such as: Children’s Services, Family Nurse Partnership, Youth Offending Service). 2.2 When Mother became pregnant with Child Ak, a pre-birth child protection conference was held. It was decided that Child Ak would be made the subject of a child protection plan under the category of emotional abuse. From the pre-birth conference through to October 2017, involvement with Child Ak, his mother and other family members was based on decreasing or sequentially ‘stepped down’ levels of formal and organised involvement, as defined in the ‘levels’ of response within the Children Act 1989, the statutory guidance (Working Together 2015) and associated guidance of the LSCB. 2.3 Child Ak’s father was known in his own right to a variety of services including the police, probation and Children’s Services. Consent was not given for access to Father’s medical records for this review, however the police IMR report cites involvement by the police service with various members of Father’s family, both as victims and offenders. Father first came to the attention of the police in 1999 with sporadic contact over the subsequent few years for offences of damage and assault until 2005 where the offences apparently became more frequent and serious. There is a record of having multiple arrests, being charged with offences (with many involving drugs) and having related convictions. The police IMR report notes a history of domestic incidents (from verbal arguments to serious assaults) involving Father, his partners and with his brother. Child Ak: Serious Case Review Report 5 2.4 Children’s Services were involved separately, respectively, and to differing degrees of formal involvement, with Child Ak’s paternal siblings and families. 2.5 In the information available for this review, Child Ak’s paternity was only definitively established in late September 2017 when Mother contacted him and informal arrangements were made to share Child Ak’s care, spending half of each week with each parent. 2.6 It was not until October 2017 that services and practitioners made a link between Mother and Father and information established about the informal shared care arrangements. In mid-October Child Ak was found in Father’s care during the police execution of a Crown Court warrant. Drugs were present in the property and apparently accessible to Child Ak. There was also reason to understand that Child Ak was left on his own in the flat for periods of time. Father told officers that he was looking after his son for two days. The police made a referral and information was shared with the MASH and Children’s Services. 2.7 Two days after the incident, a multi-professional Strategy Discussion meeting was held. Substantial ‘case history’ background information was available to the meeting: in relation to Child Ak’s health and development; regarding both Child Ak’s parents including historic information and involvement with Children’s Services and with the police in their own right, respectively; information about Father including the suggestion that he was dealing drugs; information about the current nature of contact between Father and his other children. A summary of the information and consideration of risks and vulnerabilities at the Strategy Discussion meeting included: the respective age difference between Child Ak’s parents the potential risk to Child Ak when with Father, if Father is in possession of illicit substances; the fact that Father only has supervised contact with his other children; that Father is sharing Child Ak’s care even though his paternity had only recently been established; the degree of knowledge that Mother had of Father’s criminal history and domestic abuse history. 2.8 It was decided at the meeting that the threshold was not met for a section 47 enquiry (to ascertain whether a child is ‘suffering or likely to suffer significant harm’) as: a lot of the concerns relating to Mother were not recent; that Child Ak had potentially been exposed to harm with Father but had not suffered harm; that no concerns were raised by his nursery setting; and that health visiting services were seeing the children as part of the ‘universal service’ provision. The recorded concerns identified particularly related to Child Ak’s ‘mother’s capacity to risk assess and protect her children and ensure that contact is safe.’ 2.9 The outcome of the meeting was that referral/allocation to the Children’s Services First Response Team (FRT) would be made, with action to include: Child Ak: Serious Case Review Report 6 children to be seen in their home environment and observed (in order to ascertain their wishes and feelings) social worker to interview both parents and/or caregivers and determine the wider social and environmental factors that might impact on them and Child Ak; a single assessment to be undertaken with the family as part of the current enquiry and management oversight to be completed at appropriate checkpoints; all professionals involved with the child/family to contribute to the assessment and provide information about the child/family; genogram (diagram of family details) to be updated; chronology to be updated It was not a recommendation of the Strategy Discussion meeting that Child Ak should have a paediatric check or health assessment. An initial letter was sent to both parents following the Strategy Discussion meeting to inform them of the proposed assessment. 2.10 Following the allocation for assessment, information that Child Ak was in contact/staying with his Father was shared with the Multi Agency Safeguarding Hub (MASH) provided by practitioners involved in separate family proceedings that Father was a party to. 2.11 During the review process additional information was provided that concerns about Father and his (unsupervised) contact/care of Child Ak (and continuing after the incident in mid-October, the Strategy Discussion and allocation for assessment) had been reported to several Children’s Services practitioners on, it would seem, up to eight occasions by three different members of the extended maternal family of paternal sibling (a) (including one report from before the incident in mid-October) - and some were reported further within MASH and Children’s Services by the practitioners involved with this child. . 2.12 In early December, the social worker allocated to undertake the assessment attempted to contact Mother by telephone but was unsuccessful. 2.13 Two days before the incident in mid-December that led to this review being undertaken, further information was sent directly by an independent reviewing officer (IRO) - involved in the separate family legal proceedings unconnected with Child Ak - to the allocated social worker and manager reporting that it appeared that Child Ak was being cared for still by Father. It was also reported that the court had requested a parenting assessment of Father relating to concerns about potential emotional or physical harm linked to incidents of domestic violence and potential harm due to his apparent lifestyle, drug use and dealing. The IRO noted that no observations were recorded on Child Ak’s file since October. 2.14 The following day the allocated social worker succeeded in speaking on the phone to Mother who said that her son did not need a social worker and put the phone down on the worker. Following the call, the social worker planned to send Child Ak’s mother a letter explaining the social care concerns, the possible outcome of non-engagement, and proposed actions to be taken by social care if she continued to decline to discuss the situation. Child Ak: Serious Case Review Report 7 2.15 The next day the emergency services were contacted by Father. A paramedic crew attended, and Child Ak was taken to the local hospital where, sadly, his death was confirmed. Child Ak had experienced traumatic cardiac arrest and apparently had unexplained injuries, multiple bruises and other injuries of concern inconsistent with the account given. Father was arrested on suspicion of murder. 3) Practice, its organisation and management – terms of reference: questions, issues, and themes 3.1 The review sought to develop an holistic and systemic perspective in understanding Child Ak’s life and the circumstances of his life and death; in considering the impact of his parents and carers, his wider family and those associated with them on his development and wellbeing; and in understanding the work with Child Ak and his family by practitioners and their services and organisations, individually and together, focussing especially on a number of themes 3.2 Child Ak: what was like life for him; was his ‘voice’ heard, listened to and understood. Following the concerns that led to the Strategy Discussion meeting and the subsequent information about Child Ak’s continuing care by Father, the formal assessment (including an expectation that Child Ak’s wishes and feelings would be ascertained) and the recommended interview with both Child Ak’s parents may have provided a picture of what life was like for Child Ak. However, the Children’s Services IMR report suggests that there was a significant missed opportunity: ‘(Child Ak) was never seen from the period (of the incident leading to the strategy meeting) up to the time of his death… and therefore his voice was not heard. Consequently, Child Ak’s safety was seriously undermined with lost opportunities to place him at the centre of any analysis of risk.’ Additional Children’s Services information concludes that ‘Through the history of the case…’ there was ‘insufficient focus on the actual day to day experience of the children.’ 3.3 Child Ak’s care by Mother and wider maternal family. The assessment proposed at the Strategy Discussion meeting in October 2017 was essentially to establish potential levels of support (for a ‘child in need’, as opposed to a child in need of protection) and focused primarily on Mother’s capacity to appreciate and manage the potential risk to Child Ak given that ‘(Child Ak) has potentially been exposed to harm with dad but has not suffered harm… The concern is around mother’s capacity to risk assess and protect her children and ensure the contact is safe.’ 3.4 It is hoped that, but not known whether, the assessment would have: addressed Mother’s understanding of and response to the potential risk to her son in light of the incident in mid-October, especially in relation to her attitude towards contact and shared care between Child Ak and Father (and whether contact or shared care had continued or was planned); reviewed and analysed Mother’s history and the potential impact on her current parenting capacity or general level of vulnerability, resilience, capacity to protect, and sense of agency - or how her own experiences may have affected her capacity to recognise and manage risk and manage the relationship with Father that led to agreeing or allowing the shared care arrangement to continue. Child Ak: Serious Case Review Report 8 Although there was no formal involvement with the family by October 2017, there may have been an over-optimism on the part of practitioners at the Strategy Discussion meeting about Mother’s capacity, and those of others involved in his care, to recognise and manage risk even if they were not seen as a direct source of risk or vulnerability at that time. 3.5 Despite the fact that there was extensive information in the chronology and IMR reports about Child Ak’s maternal family and their extended involvement with many services, and Children’s Services identified ‘aspects of the family’ as a contributory factor, it is important to note that the level of formal involvement by practitioners and services in Child Ak life was ‘stepped down’ or decreased over Child Ak’s life up until October 2017. Information available to the review suggests that the injuries that led to Child Ak’s death did not apparently occur while he was in the care of his mother or maternal grandparents or in their home, but in the care and home of his father. 3.6 Father and involvement with fathers. Some information was known by some agencies about Father’s own background and family; about police involvement, offences and criminal convictions including for drug offences; and his parenting capacity in relation to his other children. There is a record of various expectations that parenting assessments would be carried out (including linked to concerns and decisions about contact or other arrangements and in family proceedings matters), reference to work relating to anger management and in relation to perpetrating domestic abuse. 3.7 The recommendations at the Strategy Discussion meeting in mid-October 2017 included that both Child Ak’s parents should be interviewed and that a single assessment should be undertaken with the family (but not families) and it is hoped that relatively recent information about concerns regarding drug use and contact in relation to the paternal siblings would have been considered further. It is suggested in the Children’s Services IMR report that the Strategy Discussion meeting in mid-October ‘failed to fully appreciate the significance of (Father’s) chronic history of domestic abuse and extensive history with the police for drug related offences.’ 3.8 Following allocation (after the Strategy Discussion meeting), the fact that direct contact was not made with Father to undertake the assessment meant that information was not obtained or analysed in relation to: Child Ak’s experience in Father’s care; questions about the quality of care (especially care that involved Child Ak staying with him for several days at a time); Child Ak’s health, development and wellbeing when with Father; what his needs were – both generic and specific (what Child Ak needed from his Father) and whether those needs were being met - and if so, how?; whether those needs were not being met – and if not, why not? 3.9 Finally, it seems deeply significant that despite all the information and analysis in the IMR review reports, the combined chronology or as a result of the criminal trial following Child Ak’s death, it has not been possible to establish a clear picture of the circumstances that caused or can explain Child Ak: Serious Case Review Report 9 the assault/s that resulted in the number, nature and great severity of the injuries leading to Child Ak’s death or the type and magnitude of the levels of drugs found in Child Ak’s body, post-mortem. 3.10 Working with interconnected families and related children and young people. The issue of working with interconnected families and the children and young people within them is highlighted by this review given the many individuals, households and extended families connected to Child Ak. Many people across the families that Child Ak was considered to be part of at different times of his life were actively involved with statutory services including Children’s Services where there was work within the requirements and provisions of statutory guidance (e.g: where children were considered ‘in need’ or in need of protection or where there were legal proceedings). 3.11 Agency practice, processes, organisation and management. The review considered the involvement of the individual agencies and their practitioners who had contact with or responsibilities in respect of Child Ak and his respective parents during the period of the review, primarily October to December 2017. 3.12 Health services. Child Ak and his maternal family were the subject of regular ‘multi-disciplinary’ safeguarding meetings at the GP practice and perhaps this raises an issue about one agency or service designating concerns as ‘safeguarding’ when there is no formal involvement as defined by the Working Together 2015/2018 ‘levels’ of ‘early help’, ‘child in need’ and ‘child protection’. It is not known how formally managed these meetings were and the way that information was shared - or how discussions and any proposed action was recorded and then made available to other practitioners who may have contact with members of the families on the practice’s register. It is not known whether families were informed of the fact that they are discussed at these meetings. 3.13 Also consideration might be given to what constitutes a ‘single agency’ when, under the umbrella term ‘health’, there may be many practitioners, from several professional groups with different contractual arrangements, perhaps working in different teams, certainly located in various places and with different organisational, support and administrative arrangements (including IT systems) – all of which could perhaps be construed as multi-organisation/-agency working. This may be important given the expectations in Working Together 2015/2018 about the requirements for formal management of multi-agency ‘early help’ (where ‘early help’ is a term used to describe the level of concern rather than a description of a ‘targeted’ service) and the associated expectations of an inter-agency assessment undertaken by a ‘lead professional who should provide support to the child and family, act as an advocate on their behalf and coordinate the delivery of support services.’ 3.14 Police service. The police IMR report provides several key learning points and emerging issues including the importance of maintaining a ‘safeguarding’ focus whatever the task or incident attended to. The recommendation in the police IMR report that: ‘Planned operations to identify an officer responsible for any safeguarding action needed’ is welcome and this may enhance the consistency and quality of information shared with other services when required. Similarly, the recommendation to undertake ‘a process of ‘dip sampling’ of engagement of officers attending Child Ak: Serious Case Review Report 10 DVs (domestic violence) with children present. To ensure that the voice of the child is heard’ is also welcome. 3.15 Multi/inter-agency practice, process, organisation and management including the Multi-Agency Safeguarding Hub (MASH) The main focus of multi-professional/multi-agency work during the period October to December 2017 relates to the response to the incident when Child Ak was found in Father’s care when concerns were raised about drugs in the flat and the level of supervision that Child Ak was given, especially in relation to the Strategy Discussion meeting held two days after – and the related decision making. The Children’s Services IMR report highlighted ‘a lack of a systematic and consistent approach in the threshold decision making’, suggesting that the ‘application of the Children’s Services Threshold pathway was at best ineffectual and at worst obscure in the decision making process’. Of note in the Children’s Services’ IMR report is the apparent emphasis on ‘imminence’ with additional Children’s Services information concluding that making threshold decisions in respect of section 47 enquiries based on the premise of ‘imminent danger’ is not an accurate reflection of how judgements should be made within the framework of risk, significant harm and likelihood of harm as set out in the Children Act 1989 and Working Together. 3.16 In the Children’s Services IMR report and in views expressed by panel members it is acknowledged that, on further reflection and with hindsight, the decision at the Strategy Discussion meeting should have been made to proceed to a ‘single 473 and ICPC (Initial Child Protection Conference) with legal advice; …there were certainly more risk factors than protective factors.’ 3.17 A further issue relates to the management of information within the MASH service – especially in respect of any information received and then further shared regarding Child Ak’s contact and continuing contact with, and care by, his Father. 3.18 Children’s Services. Child Ak was allocated to a social worker in the First Response Team for assessment on the same day as the Strategy Discussion meeting, with notification letters sent to both parents. The review panel heard of continuing work to develop the response to parents or carers following referral and it is hoped that this might include setting out clearly the rationale (including the details of cause for concern and related statutory basis for the work) and process for an assessment; the timescale; the areas to be addressed in the assessment; any expectations (for example in relation to contact, etc); the details of the lead practitioner who will be undertaking the assessment – and the opportunities for support and service pathways that may follow. This immediate allocation and sending a letter would appear to be good practice - not least given the fact that, even during the time that the review was being undertaken Children’s Services were seeking to manage a situation where there were many unallocated cases (Ofsted Inspection Report October 2018). 3 Section 47 Children Act 1989: the duty to investigate whether a child is suffering or likely to suffer significant harm - where a local authority have reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm, the authority shall make, or cause to be made, such enquiries as they consider necessary to enable them to decide whether they should take any action to safeguard or promote the child’s welfare. Child Ak: Serious Case Review Report 11 3.19 It is important to understand more about the circumstances affecting the practice and management of Child Ak’s ‘case’ in the period from October to December 2017 3.20 Problematic contributory factors are highlighted from information available to the review panel, including: delay insufficient consideration and follow up on the ‘high risks which had been identified for Child Ak from his father’ ineffective communication between and within professionals in Children’s Services concerns were not escalated. Secondly, ‘local strategic level factors’ are identified - potentially impacting on the effectiveness of work at the time: high turnover of staff large numbers of agency staff significant levels of management sick leave ineffective case management and priority monitoring systems which compounded problems and resulted in a lack of accuracy in identifying high risks or the need for urgency high caseloads a focus on ‘imminent danger’ lack of appropriate escalation 3.21 According to the Children’s Services IMR report, active steps were apparently being taken to address the issue of high workloads with a ‘recovery plan’ in place and discussions held about creating opportunities for staff to complete outstanding work, including work over the weekend. 3.22 There does not seem to have been an effective process for management oversight or a process to review the decision of the Strategy Discussion meeting in the event of additional information - or continued risk being identified. It is not entirely clear how notice of new or additional information is actually given once there is an allocated worker. If this is via email or telephone message, then ‘notice’ may be given or information ‘passed on’ but the information may well not have been meaningfully ‘shared’ or obviously received by the person with allocated responsibility. In information from Children’s Services it was concluded that: ‘The case management and priority monitoring systems do not seem to have worked well enough in this case. The impact of this was a lack of appropriate escalation… during October 2017 and resultant delay in taking the appropriate action at the right time to ensure (Child Ak’s) safety and protection.’ 3.23 There were also apparently issues about the IT systems and their reliability at a crucial point in early December 2017. It was agreed that the allocation of all cases should be reviewed by the Service Managers. This would have included his case - where the information and concerns about continuing contact between Child Ak and Father ‘would have been seen and should have led to an escalation to a higher level of action to safeguard him. However, IT systems issues prevented this from taking place and this further delay in being identified and responded to occurred during the emerging crisis of (Child Ak) being cared for by (Father) who was known to be a very risky adult.’ Child Ak: Serious Case Review Report 12 3.24 A question could be asked about the messages that may have been unwittingly given to or received by Child Ak’s respective parents about the level of concern or perceived risk to Child Ak as a result of the delayed follow up to the letter following the Strategy Discussion meeting informing them that an assessment would be undertaken. 4) Learning lessons; developing practice, its organisation and management; recommendations 4.1 Most of the IMR reports included sections on ‘lessons learnt’ and areas for development or recommendations of relevance to the specific practice, teams and service arrangements within the relevant agency itself. 4.2 The following, taken from the IMR reports, seem of particular note and of wider, multi-agency relevance: developing an organisational culture that is child centred and child focused; that ensures that the child/young person is ‘seen’ (or considered, when working with parents, even if absent – and referrals made if parents’ presentation gives cause for concern); that ensures that the child or young person’s ‘voice’ is heard; that safeguarding is considered in all circumstances including identifying an officer responsible for any safeguarding action needed in all police operations; clarifying, understanding and applying thresholds across frontline teams, within the MASH and for statutory intervention; ensuring effective systems to assist management accessibility and oversight, workload management (individuals and teams) and reflective, direct and recorded supervision of ‘cases’; ensuring that ‘high-risk’ cases are identified and prioritised; ensuring that assessments are child focused, follow a consistent framework to promote analysis and include a ‘Think Family’ perspective, ensuring that information about relations between adults and children in their care (including parental responsibility) is clear and accurate; developing an organisational culture that enables professional curiosity, professional judgement and professional challenge; ensure that expectations regarding multi-agency information sharing is clearly understood across all levels of involvement and that information and updates (e.g: records and minutes of meetings) are available and shared appropriately within each service or agency, that MASH Strategy Discussion minutes and decisions are available on the police information system; ensure that practitioners are trained to be able to fulfil their safeguarding roles and responsibilities at all levels of practice; ensure that procedures and protocols are understood and followed (e.g: record keeping, the ‘voice’ of the child). Child Ak: Serious Case Review Report 13 4.3 The 2018 LSCB Annual Report (2018) expects that each agency will track and audit the implementation of lessons and recommendations from agency reports and from SCR reports respectively. It is also expected that the appropriate LSCB/Local Safeguarding Partnership sub-group will review and evaluate information on action plans, progress and outcomes. 4.4 In addition to the learning points and recommendations in the individual IMR reports, the review considered several specific relevant themes. Some contextual commentary is followed by recommendations. Many of the themes that have been identified seem linked - with a degree of interactive dynamic overlap or common elements. They may also resonate with themes in other serious case reviews published by the LSCB and in national reports. 4.5 Seeing and hearing children. 4.5.1 This is definitely a theme that has been identified in many previous SCRs, overview analyses (the DfE biennial and triennial publications) and other reviews (e.g: Ofsted thematic review The voice of the child 2011) and was referred to across all the IMR reports, the practitioner event and the panel discussions. Pathways to harm; pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final Report (2016), notes that an active effort must be made to actually see children in their families – a lesson ‘so important that it must be re-emphasised and potentially re-learnt as people, organisations and culture change.’ 4.5.2 In the Ofsted review The voice of the child (2011) several aspects of practice that may inhibit children being heard and seen are identified – the first two perhaps being of direct relevance in this situation: ‘In too many cases... 1) the child/young person was not seen frequently enough by the professionals involved, or was not asked about their views and feelings 2) agencies did not listen to adults who tried to speak on behalf of the child/young person and who had important information to contribute 3) parents and carers prevented professionals from seeing and listening to the child/young person 4) practitioners focused too much on the needs of parents, especially on vulnerable parents, and overlooked the implications for the child 5) agencies did not interpret their findings well enough to protect the child.’ 4.5.3 The following messages or lessons from this review relating to seeing and hearing children seem of particular significance: seeing and recognising a child and their experience in all situations and in all relationships, families and home/household or care settings that he or she may be part of; seeing the child within the information (the ‘data’) in increasingly IT systems driven processes; recognising the risk of a child becoming ‘virtual’, an identifying name linked to a process or task; recognising the value of imagining the ‘voice’ of the child (one panel discussion included reflection on the question of what a child or young person might want from an SCR process and related recommendations); thinking about a child’s experience, beyond the immediate presentation; Child Ak: Serious Case Review Report 14 listening and responding effectively (including rigorous recording and timely and appropriate sharing of information with other practitioners) to people (including other extended family members and practitioners involved with other children) who may raise concerns and who may have important information about potential risks posed to a child; consider the message that a child or young person might take about the regard for their safety or welfare from the response of practitioners and managers. Recommendation 1: That: each agency is required to review guidance, procedures and training for practitioners and managers and ensure that: a) the fundamental message to ‘think child or young person’ is understood; b) any duty and expectation is fulfilled that a child/young person will be seen and that her/his views, wishes and feelings will be ascertained, taken into account and given due regard; c) the expectation is met that anyone who may contribute to an understanding of the child or young person’s experience is heard and their views (and especially any reports of concerns) are recorded and shared with other practitioners as necessary and taken into account in assessments and responses; the Local Safeguarding Partnership requires evidence from each agency that they are meeting this recommendation and that the effectiveness of direct work with children and young people and the ability to understand the experience of a child/young person (informed by all available sources of information) is measured as part of key performance indicators. 4.6 Young people in need of protection who may also be parents 4.6.1 Whilst this review has focused primarily on a short period of time (October to December 2017), the IMR reports and the combined chronology covered a period when Mother and significant others were young and legally considered children in their own right. 4.6.2 Perhaps the dominant language and ideas about effective safeguarding of children does not translate sufficiently when working with young people. A publication in 2018 Safeguarding during adolescence – the relationship between Contextual Safeguarding, Complex Safeguarding and Transitional Safeguarding (Firmin et al, Research in Practice) is helpful. However, additional consideration may be required when working with young people/adolescents in need of protection but who are also parents - ensuring that their need for protection or services in their own right is not lost. Additional consideration might also be given to young people in this situation where they are ostensibly being supported or are living with their parents – perhaps in whose care the young parent’s protection needs had arisen. Recommendation 2: a) That the Local Safeguarding Partnership and all partner agencies develop or review existing guidance and procedures for effective work with young people who are parents where safeguarding or the provision of services is required for both a young parent and her/his child - including the need for separate plans and appropriately differentiated services, resources and allocation of practitioners. Child Ak: Serious Case Review Report 15 b) That the guidance and procedures also consider the need for the careful assessment of the protective and parenting capacity of the parents of young parents especially where there are, or have been, concerns relating to the young parent’s own experience in their care; where a household is shared; where the parents of young parents may be considered part of the caring, support or protective arrangements for a baby/child and her/his young parent. 4.7 Parents and the potential impact of abuse including exploitation and domestic abuse 4.7.1 It seems of note that considerable information was available to the review about the experiences of several parents (but especially mothers) in both the immediate and extended families related to Child Ak – in relation to the potential legacy and impact of abuse, particularly domestic abuse. This may have relevance to an understanding of a parent’s vulnerability and potential capacity to recognise risk, to have a sense of agency and capacity for assertion and a degree of control within relationships to appropriately safeguard a child. This is not to seek to excuse attitudes or actions that could or should have been more protective, but it may form part of an explanation – and therefore contribute to practitioners’ analysis of risk and capacity to protect, especially including in relation to contact between a child and his/her father. Recommendation 3: That practitioners working with a parent who may have experienced abuse (especially including domestic abuse and/or exploitation) analyse and take into account the potential impact of those experiences on a parent’s own understanding of risk and any assessment of her or his protective capacity. 4.8 Fathers, partners, secondary and other carers and their families, connected families and networks. 4.8.1 This is another theme of other SCRs and an area highlighted for further research in a Department for Education evidence review (Wilkinson. J and Bowyer. S, 2017). It is acknowledged that there was only a relatively short period of time from Father being identified to the incidents that led to this review – but further development of work with fathers, partners and secondary carers would be beneficial, especially when assessing and analysing potential risks to a child. Recommendation 4: That where there is statutory involvement, all practitioners are expected and required: to establish and update information (sharing with other practitioners and agencies where appropriate) about a child’s or young person’s parents and carers, wider family/families’ members, associates and people of significance to the child (using genograms and ecomaps in all cases) - especially in relation to anyone who has parental responsibility and/or who is playing a part in caring for the child (formal, informal, regular, occasional – for shorter or longer periods of time, but especially where there is ‘staying care’); to establish information relating to the level of care or contact that a parent or carer has with a child (including any restrictions on, or conditions regarding, care or contact with any other children of that parent/carer); Child Ak: Serious Case Review Report 16 to include fathers or partners (including those who have contact) actively in all processes (especially in parenting assessments, meetings and plans). That the Local Safeguarding Partnership and partner agencies identify and promote approaches and resources relating to engagement and effective work with fathers or partners of parents. Recommendation 5: That the Local Safeguarding Partnership and all partner agencies actively develop strategies, procedures, guidance and systems (including in relation to information management and recording) to enhance practitioners’ and agencies’ capacity to work effectively where there may be: complex parenting arrangements, for example involving different parents – especially fathers/father figures - for several children within a single household; parents, perhaps especially fathers, who have several children but where the children live primarily in several different households – but where there may be unsupervised, supervised or even staying contact; several connected individuals or families (including those who may share a household) involved with statutory services and known to many different practitioners and services and who may have different allocated lead practitioners. 4.9 Engagement and compliance and the impact on children. 4.9.1 There was evidence of persistent engagement with Child Ak and his maternal family over an extended period: by the Family Nurse partnership practitioners, health visitors, social workers and others and the value of work within the context of relationships has been identified in SCR reports and other research. In a 2011 review Munro notes: ‘A recent overview of the evidence about effective interventions for complex families… showed the importance of providing ‘a dependable professional relationship’ for parents and children, in particular with those families who conceal or minimise their difficulties. …it was the quality of the therapeutic bond established between the social worker and client that was the basis for what was conceived of as a positive intervention.’ 4.9.2 However, the question of the capacity to influence and help effect lasting and sustained change was raised in some of the IMR reports with sporadic engagement in meetings and formal decision processes and with missed appointments at times. The theme of ‘disguised’ or ‘false’ compliance’ is mentioned in some of the IMR report information and has been referred to in previous analyses of SCRs. However, it may be important to recognise that a lack of engagement or compliance may not be deliberate, planned or part of a strategy but possibly a reflection of an individual’s organisation and functioning, her/his stage of life (especially perhaps with young parents), priorities, capacity or recognition of responsibilities. Again, it may be very important for practitioners also to recognise factors that could impact on parents’ and carers’ capacity and a personal sense of agency more generally – especially the possibility of coercion and control in domestically abusive relations and in family functioning, or where there may have been experience of exploitation. Child Ak: Serious Case Review Report 17 4.9.3 An emerging key message from discussions of compliance/non-compliance seems to be the importance of a primary and unrelenting focus on the child/young person and the impact of care arrangements (across the full range of carers who may be involved in her/his life) and outcomes for her or him in terms of health, development and wellbeing - rather than on parental activity per se. Learning from reviews analysed by the NSPCC4 highlights that ‘professionals need to establish the facts and gather evidence about what is actually happening, rather than accepting parent’s presenting behaviour and assertions. By focusing on outcomes (for the child/young person) rather than processes, professionals can keep the focus of their work on the child.’ 4.9.4 Parents may choose not to engage but it is important that practitioners consider carefully the point at which this choice denies a child or young person access to an assessment or service to protect or meet her/his needs - and follow the local multi-agency guidance: Resistant Families – Working with Refusal to Consent or Engage, where appropriate. Recommendation 6: That practitioners, supervisors and managers are guided and required through advice, procedures, practice supervision and related training to: maintain a clear focus on the impact on the child/young person (measured in terms of health, development and wellbeing) of parents’ or carers’ willingness and capacity to engage – both in assessments and in plans for work; to ‘Recognise that noncompliance may be a parent’s choice, but that does not mean it is the child’s choice.’ (Pathways to harm, pathways to protection 2016 p.143); to be aware that ‘Where child welfare concerns are identified, poor engagement by families should heighten concern and should not prompt case closure unless there has been a thorough risk appraisal.’ (p.147); to follow established single and multi-agency safeguarding arrangements and procedures to address any harm or risk of harm where required and escalate continuing concerns – including where services cannot be provided. This recommendation links to learning identified in another current SCR (Ref 070). 4.10 Assessments, thresholds and pathways including formalising multi-agency work (especially ‘non-targeted’ early help) 4.10.1 Working Together 2018 (p.16) expects that ‘safeguarding partners should publish a threshold document, which sets out the local criteria for action…’ including in relation to local arrangements agreeing ‘the levels for the different types of assessment and services to be commissioned and delivered. This should include services for children who have suffered or are likely to suffer abuse and neglect whether from within the family of from external threats’ (what Working Together 2018 newly refers to as ‘contextual safeguarding’ p.23). Information from Children’s Services suggests that there was ‘difficulty in being able to evidence a systematic and consistent approach in the threshold decision-making in relation to Child Ak and his half-sibling’ – and – that ‘inconsistent application of the thresholds to determine the right level of intervention led to incoherent management of the case.’ 4 (https://www.nspcc.org.uk/preventing-abuse/child-protection-system/case-reviews/learning/disguised-compliance/ Child Ak: Serious Case Review Report 18 4.10.2 The formal arrangements for multi-agency work may be clearly understood at ‘child in need’ and ‘child protection’ levels, for work with ‘looked after children’ (where the local authority identify a social worker as the ‘lead practitioner’) and ‘targeted early help’ (especially where this essentially involves a local authority provided or commissioned service). However, there may be less clarity about the statutory expectations (in Working Together 2015/2018) for the management of multi-agency work across the whole undifferentiated spectrum of ‘early help’ (where ‘early help’ is considered a status – of concern about a child’s wellbeing and potential unmet need - rather than a service). Recommendation 7: That: the Local Safeguarding Partnership completes the current work to review and revise the multi-agency Thresholds and Pathways guidance (referred to as ‘local protocols for assessment’ in Working Together 2018) for work with children, young people and families at all levels – including, especially, at the locally-defined ‘non-targeted early help level’ and in relation to the role of the lead practitioner and related co-ordination of a single, shared assessment; a co-ordinated plan; and the promotion of child/young person and family engagement; the Local Safeguarding Partnership updates guidance to reflect any future changes in operational arrangements and related processes – at the time that any changes are made; that partner agencies similarly revise and update their own related agency-/service-specific guidance – at the time that any changes are made; that promotion and compliance with the guidance is evidenced through training and supervision; that the application of the guidance and its impact is monitored, especially in relation to: the appropriateness and quality of referrals; decisions relating to section 47 enquiries made at Strategy Discussion meetings; the start and completion of assessments (including within statutory required timescales and in relation to the principles and parameters of effective and ‘high-quality’ assessments as set out in Working Together 2018); on plans, pathways and outcomes of service provision - so that children, young people and families receive the right help at the right time. 4.10.3 The incident that led to the Strategy Discussion in mid-October in relation to Child Ak included concerns that Child Ak had been found in the proximity of drugs, therefore it is also recommended: Recommendation 8: That where there is a concern that a child may have been in a situation where drugs were accessible to them, there must be a comprehensive risk assessment which will consider information or evidence of the accessibility of drugs within the household, and supervision of the child. A paediatric assessment should always be considered as part of an initial response or as part of all further enquiries or assessments. Child Ak: Serious Case Review Report 19 4.11 Practitioner and manager roles and responsibilities 4.11.1 Working Together (2015/2018) and related statutory guidance sets out the legislative context and related responsibilities, duties, powers and rights - for practice and its management. For social workers, the expectations are published in the Department for Education’s (DfE) Post-qualifying standard: knowledge and skills statement for child and family practitioners (May 2018). 4.11.2 Issues relating to management oversight and supervision of workers’ practice were reported in some of the IMR reports, significantly in relation to Children’s Services. The DfE’s expectations for Children’s Services/social work managers at the time of work with Child Ak were outlined in the Knowledge and Skills Statements for Practice Leaders and Practice Supervisors (2015)5 . Areas of competence in the current guidance for practice supervisors include: promoting and governing excellent practice; confident analysis and decision-making; practice supervision; shaping and influencing the practice system; and performance management and improvement. The recommendations reported to the panel from Children’s Services address several areas of practice and management: ‘to develop’, ‘to make clear’, ‘to ensure’ etc., but there are no apparent explicit recommendations about training and development for managers, supervisors and practice leaders to help achieve the proposed developments and then support and maintain the associated anticipated improvements for children and young people. Thus: Recommendation 9: That the Local Safeguarding Partnership requires assurance: from Children’s Services about the arrangements for managers’, supervisors’ and practice leaders’ training and support in the First Response (or equivalent) teams; and in relation to arrangements for management and quality assurance within the MASH service. It is expected that this will be monitored through reports to the Local Safeguarding Partnership and, within the local authority, as part of the Improvement Plan. 4.11.3 A further area relating to practitioner roles and responsibilities has been highlighted in this review: the importance of recognising that practitioners from all agencies have responsibilities across the safeguarding spectrum in relation to information sharing, raising concerns, challenging and escalating matters where concerns are not shared by others, or when new concerns arise. It is important that ‘professional challenge’ is seen as a positive step to present confidently an assessment and analysis relating to the wellbeing of a child and potential action, rather than as a way of gatekeeping and managing finite and potentially stretched resources. 4.11.4 Thus a substantial learning point is that practitioners from all agencies recognise that they have a responsibility to identify, raise and continue to raise safeguarding concerns that they have about children and young people’s wellbeing using the appropriate procedures (including the processes to manage differences of opinion, disagreements and conflict) and to escalate concerns (again using the established processes and procedures) where necessary. 5 Now republished as: Post-qualifying standard knowledge and skills statement for child and family practice supervisors (May 2018) and Post-qualifying standard knowledge and skills statement for practice leaders (March 2018) Child Ak: Serious Case Review Report 20 4.11.5 Similar may be suggested in relation to managers where they may have concerns about organisational arrangements, resource management and related practices that could impact on the effectiveness of response to children and young people, parents and carers. Panel members reported that the current culture in the local authority is now one where managers and supervisors are enabled and encouraged to identify and raise concerns when workload exceeds capacity and may, therefore, impact on the capacity to respond effectively to child in need or at risk - and if there is a risk that decisions may be resource-led and not children’s/young people’s needs-led. This is to be welcomed but will need monitoring in line with recommendation 11 (below). 4.12 Information sharing, information management and related systems 4.12.1 Information sharing and management has been a consistent theme of SCRs, public inquires and similar reports for decades (see Galilee 2010, report for the Scottish Parliament – a review of such reports dating back to the 1940s). In the IMR reports and at the practitioner event for this review, matters relating to information sharing, information management and related systems were similarly highlighted including, specifically: ‘systems that do not speak to each other’; the sharing of strategy meeting minutes and decisions to the police NICHE system; different IT systems across health services; the absence of a national ‘ContactPoint’-style or local ‘one-stop’ record of children or young people who are, or have been, the subject of child protection plans; or are identified as children ‘in need’ (CA’89 sn.17); or where there is involvement because of a child or young person’s legal status (e.g: accommodated under CA’89 sn. 20, subject of a Supervision or Care Order, CA’89 sn.31); where there may be specific contact arrangements as a result of past, present or prospective risk of harm, etc.; the accuracy of information gathered and shared; the potential challenge of having to ‘effectively navigate multiple domains and sources of information held both internally and across partner agencies’ (from the Children’s Services IMR report); the management of information coming in to and out of the MASH, for example: additional information, and what it means to notify or share information with an allocated worker or team; the absence of a co-ordinated system for tracking and monitoring cases. 4.12.2 Undoubtedly, information technology has a considerable potential: for assisting with the identification of risk of harm, and associated need and provision of services and support; for laterally linking information about children and their families when new connections are identified (a newly-identified father, for example, or a father who may be the parent of several children in different households); for ensuring that information is available to all relevant practitioners (e.g: in a GP surgery following a multi-disciplinary team safeguarding meeting); for assisting processes and management oversight such as ‘flagging’ timescales and the completion of tasks (e.g: appropriate allocation, seeing a child within three days of a decision to assess, completing an assessment within 45 days, etc). Child Ak: Serious Case Review Report 21 4.12.3 It is also recognised that practitioner uncertainty about appropriate information sharing can potentially hinder the process, perhaps especially with the new General Data Protection Regulation requirements. Recommendation 10: That the Local Safeguarding Partnership: review the all-agency guidance on information sharing to ensure that it is compliant with GDPR requirements, and promotes the principles for sharing information in safeguarding work set out in Working Together 2018 (especially the guide on p.20); evidence awareness of, and compliance with, the guidance across teams and services, in supervision and in training; ensure that minutes from multi-agency meetings are shared with all relevant partner agencies, especially MASH Strategy Discussion minutes with health agencies and the police; monitor instances when information sharing and management may have hindered or, equally, assisted effective responses to children and families. That all partner agencies review their own related guidance on sharing information both internally and with other agencies. 4.12.4 It is recognised that the challenge of communication between agencies’ and services’ separate information systems is a national issue but it is a learning point from this review that the Local Safeguarding Partnership should continue its work to promote and enhance the integration (where possible and appropriate) of local information systems and their capacity and functionality to enhance safeguarding practice and its management with children and families within and across services - and within and across work with individuals and families where necessary and appropriate. 4.13 Resources, services’ configuration and quality assurance. 4.13.1 The strategic work of partner agencies to develop and appropriately configure effective services, to manage the operational and practice implications and to assure the effectiveness and quality of services for children, young people and families, continues (especially for the local authority and Children’s Services within it). Thus, it is recommended Recommendation 11: That the Local Safeguarding Partnership will: monitor and evaluate the impact of strategic, operational, organisational and practice developments – including multi-agency arrangements and those of key safeguarding partners (particularly the local authority) - through a clear, open and transparent audit process identifying key indicators and relevant qualitative information and data to assist in the assurance of safe practice; and champion appropriate resource allocation. This should be monitored through reports to the Local Safeguarding Partnership and the Social Care Improvement Board. Child Ak: Serious Case Review Report 22 Recommendation 12: That the Local Safeguarding Partnership (through the Quality Assurance Sub Group or equivalent, as appropriate) monitors and tracks the implementation and impact of all the specific agency recommendations from the IMR (Individual Management Review) reports and related action plans, as well as the recommendations and action plan relating to this overview report. 5) Conclusion 5.1 Many people have contributed to this review and their time and expertise is appreciated greatly, especially as this helped in the development of an understanding of agencies’ and practitioners’ involvement with Child Ak, his families, significant other people in his life and the issues identified following his tragic death. 5.2 Two quotations from reports separated by nearly thirty years perhaps have relevance for this review: The inquiry report following the death of Liam Johnson London Borough of Islington (1989) included the following: ‘It was said to us before we started hearing evidence that if we could suggest ways in which families like this… could somehow be identified before the tragedy occurs it would be an enormous help. It will be clear from the pages that follow that although we suggest ways in which practice might be improved, we have been unable to suggest any infallible method of spotting potential child killers.’ Although, significantly, the reference at the time was not to the man identified in September 2017 as Child Ak’s actual biological father, a terribly tragic irony in this situation is that before his birth, at the pre-birth child protection conference, a key reason recorded for the need for Child Ak to be made the subject of a child protection plan was the ‘unknown risk his/her father poses.’ Secondly, the triennial analysis of serious case reviews (2016) embraces the idea of ‘pathways’ to harm and protection recognising that: ‘children are harmed within contexts of risk and vulnerability and that there are many opportunities for prevention and protection, even without being able to predict which children may be harmed, when or in what manner. It affirms the very positive work being done by professionals working with families to support and challenge, and acknowledges the need for an authoritative approach, combining authority, empathy and humility… …and taking hold of the opportunities to learn and improve.’ 5.3 It is perhaps impossible to say whether the developments identified in practice and its organisation and management that have been implemented already; that comprise the recommendations for individual services and agencies; or that may follow in line with the recommendations of this report – could have had an impact on the outcome for Child Ak, who was tragically killed by his father and in relation to whom it has not been possible to establish a clear picture of the circumstances that caused or can explain the assault/s that resulted in the Child Ak: Serious Case Review Report 23 number, nature and great severity of the injuries leading to Child Ak’s death or the type and magnitude of the levels of drugs found in Child Ak’s body, post-mortem. 5.4 It is hoped sincerely that the lessons and recommendations from this review (along with learning from audits of practice where positive outcomes may be highlighted for the children, young people and families with whom agencies work day in and day out) will enhance the vital ongoing work to further strengthen and develop practice, its organisation and management, quality assurance and governance - and strengthen the provision of effective services and responses to all children, young people and families. May 2019 |
NC52263 | Ingestion of a potentially fatal amount of methadone by a 20-month-old boy in 2018. Both parents were arrested on suspicion of child neglect. Liam is the youngest of 3 children to the same mother and father. Prior to Liam's birth parents had only been known to universal services and substance misuse services, as both parents were known to have misused heroin. Liam was in the care of the local authority, placed with his mother. Enquiries subsequently revealed that Liam's father had been staying at the family home, without the local authority's agreement, and that, despite suspecting that Liam had consumed methadone, parents had delayed seeking medical help for him. Ethnicity or nationality not stated. Learning and recommendations focus on the following: professionals having a better understanding of the impact of substance misuse (including methadone); placement with parent's procedure needs to be reviewed; professionals must balance optimism with objective evidence; fathers should be included be included in relevant assessments.
| Title: Serious case review: executive summary report: Liam. LSCB: Wirral Safeguarding Children Partnership Author: Wirral Safeguarding Children Partnership Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review Executive Summary Report _____________________________ LIAM In order to preserve the anonymity of the children in this family, Wirral Safeguarding Partnership has taken steps to disguise the children’s identities and circumstances. It has: • represented the children by names chosen at random and which do not necessarily reflect the children’s true gender; • used initials for key family members, indicating their relationship with the child; • avoided the use of exact dates; and, • removed details about local services which could lead to the recognition of the children and family. 1 Wirral Safeguarding Children Partnership February 2020 Summary of Case Liam was admitted to hospital in the autumn of 2018, at the age of 20 months, having ingested a potentially fatal amount of methadone. At the time Liam was in the care of the local authority, placed with his mother. Enquiries subsequently revealed that Liam’s father had been staying at the family home, without the local authority’s agreement, and that, despite suspecting that Liam had consumed methadone, parents had delayed seeking medical help for him. Both parents were later arrested on suspicion of child neglect. This was the second time that Liam had come to the attention of services. Whilst in hospital just after his birth, Liam was found to have suffered two skull fractures, with no explanation as to how they could have occurred. Care proceedings were initiated by the local authority, and during the course of those proceedings, mother revealed that she had dropped Liam. Within a month of the second event, Wirral Safeguarding Children Board (WSCB) undertook a rapid review of the information readily available to agencies, in accordance with the still current requirements of Working Together to Safeguard Children 2015, and concluded that the criteria had been met for a Serious Case Review. This decision was endorsed by the national Child Safeguarding Practice Review Panel. Family History Liam is the youngest of 3 children to the same mother and father. He has 2 older brothers, George and Alexander. Prior to Liam’s birth his parents had only been known to universal services and substance misuse services, as both parents were known to have misused heroin. During the pregnancy and after Liam was born, professionals understood that his mother and father had ended their relationship. Fathers living arrangements were not known to professionals. Whilst still in hospital, Liam was found to have swellings on his head. A CT scan revealed fractures of the skull with underlying bleeding. With no explanation for Liam’s injuries and his mother denying having dropped the baby, child protection procedures were initiated. A week later, before Liam was discharged from hospital, Liam and his brothers were made subject to interim care orders. Twelve weeks into care proceedings, their mother admitted to professionals that she had accidentally dropped Liam while they were in hospital. Childrens Social Care and the Children’s Guardian accepted that Liam’s injuries were the result of an accident and so supervision arrangements were lifted. It was agreed that the children could return to mother’s care prior to the final hearing. There was still uncertainty about Liam’s father’s role in the children’s lives and he was not recognised during the care proceedings. Throughout this time, specifically on three separate occasions in three months; Liam was seen to have either a fading bruise or a cut to his head which his mother explained as having resulted from a fall against a glass TV cabinet. 2 Wirral Safeguarding Children Partnership February 2020 The following month, Liam’s mother and the children moved out of area to the rehabilitation facility for 12 weeks. At the end of the 12 week period, his mother was drug-free. During this period his father’s engagement with the substance misuse service had been poor: he had not attended planned medicals. In the same month, Liam’s mother spoke to CSC about a plan for both parents to take the children on holiday. This suggested that there was a change in family dynamics and that his parents may have been back in a relationship, but this was not explored. A week after the last looked after child review Liam was taken by ambulance to hospital following a 999 call from house. Ambulance staff found him to be unresponsive, grey and not breathing on his own. On admission to hospital, Liam was very close to death and it was identified there had been some delay before an ambulance had been called. Key Learning For the review, a combined chronology of significant events was completed and a learning review for practitioners and managers was held in September 2019. The principal lessons and recommendations focused on the following practice issues: Professionals having a better understanding of the impact of substance misuse (including methadone) The review identified that there should have been a much more effective multi-agency approach to recognising and responding to the risks of parental drugs misuse. The practitioner learning event revealed that most practitioners had significant gaps in their knowledge about both the potential effects of opioid use on parents’ capacity to provide care for their children, and how their impact would be measured in any individual case. Liam’s mother was recognised to be the children’s primary carer, and yet no comprehensive assessment was ever completed of her substance use or its impact on her care of the children. Also, it was generally understood by professionals that the children were having some contact with their father although this had never been formally agreed. Their fathers inconsistent engagement with the substance misuse service, meant that there was only a partial understanding of his drugs use. There were clear misunderstandings of the purpose and effectiveness of routine drugs testing as an indicator of illicit drugs use, and non-specialist practitioners were overly reassured by negative results. Due to the combined work by the service and by CSC, ‘the case wasn’t viewed as high risk’. As the substance misuse learning summary indicates: ‘It is reasonable to believe that father spent more time at mothers house than the service or children’s social care were aware of at the time. Because the service wasn’t aware of fathers methadone being in the children’s home environment, the risk could not be adequately, or safely managed’. 3 Wirral Safeguarding Children Partnership February 2020 Placement with parent’s procedure needs to be reviewed After the incident in the hospital practitioners suspected that his mother had hurt Liam accidentally but that she did not want to say so. Her insistence on not being responsible caused more doubt amongst practitioners. There seems to be no evidence that there was any discussion as to whether there were avoidable factors on his mothers part which could have contributed Liam’s fall. Instead at the point that care proceedings began, all parties had agreed that this was a ‘single issue case’ focussing on determining the cause of Liam’s injuries, rather than the implications of his mothers drug use. The CSC learning summary indicated there was little information on file in respect of the decision to return the children to their mother’s care. It appears the NSPCC framework for reunification was not followed meaning the decision taken was ‘overly optimistic’ of their mothers ability to care for Liam and his brothers. The CSC learning summary also showed no record of formal supervision being provided to the allocated social worker from the start of care proceedings until after the children had returned home. This absence of supervision and management oversight would clearly impede and effective risk analysis and case planning. Professionals must balance optimism with objective evidence. Liam’s mother admitted to her drugs worker that during the care proceedings she had been able to evade urine testing reviews by attributing opioid positive results to co-codamol. She also admitted that she had stored surplus methadone while she was pregnant and taken this into hospital to reduce heroin withdrawal symptoms. Practitioners at the learning event considered the significance of the likely impact of taking this whilst taking what she was also being prescribed and acknowledged it could have had an impact on her ability to care for Liam, as it would have likely caused drowsiness. However, it seems practitioners were not aware of his mothers illegal use and hadn’t questioned it. Participants at the learning event talked about how well his mother presented at all times. She had been described by some as ‘middle class’. This combined with professionals considering his mother as ‘a protective factor’ after leaving rehabilitation, led to an over-optimism in her parenting ability. Father’s should be included be included in relevant assessments During the pregnancy and after Liam was born, professionals understood that Liam’s mother and father had ended their relationship. His fathers living arrangements were not known and the nature and frequency of the children’s contact with their father was unclear. Liam’s health visitor had worked with the family since Liam’s older brother, George, was six weeks old. Their father was never seen during this time and his details were not recorded on the health visitor file. Police and CSC held information about their fathers history of domestic violence in a previous relationship which included an incident in which two of his children were directly harmed. Within CSC, however, no link had been made between the children of Liam’s fathers first family, and Liam and his brothers. Police also had details of a violent incident some years ago where their father had been implicated in a case where a man had died. 4 Wirral Safeguarding Children Partnership February 2020 During care proceedings, Liam’s father stated that he did not want to be considered as an alternative carer and so he was not the subject of a parenting assessment. There was little consideration of the role that he played in their mothers life, and any future contact with the children did not form part of the final analysis of risk. This suggests that standard agency checks, including with police records, were not undertaken. 8 recommendations were made for the Partnership focusing on ensuring a shared understanding of processes and protocols with regards to substance misuse, understanding the implications of placements with parents and increased staff confidence working with substance users. This case raises the following key questions for agencies: • Do staff fully understand the impact of substance misuse on the children in the family, and the risks this presents? • Are staff able to challenge parents use of substances and confidently question the resolve of any parents who are reducing/abstaining? • Do staff monitor family dynamics, particularly where relationships between parents are unstable and change frequently, and does any assessment take into account the role of the father in the family? |
NC046631 | Death of an 11-month-old boy of Irish-traveller descent from a brain injury, after being found submerged in water whilst unsupervised in a bath. Baby F and his two half-siblings were subject to child protection plans under the category of neglect. Baby F's mother was sentenced to a six-year custodial sentence after pleading guilty to manslaughter. Mother had a history of: substance misuse, self-harm, domestic abuse, a lack of engagement with services, regular changes of address and periods of homelessness. Little information is known about the father. Issues identified include: a failure by midwifery services to identify and refer pre-birth safeguarding concerns to children's social care; difficulties in contacting and assessing the family because of mother's transient lifestyle; a misunderstanding within children's social care about the use of an Emergency Protection Order as opposed to reliance on Police Powers of Protection; a repeated lack of investigation by children's services following referrals from members of the public; and insufficient involvement of the father and wider family in assessments. Uses a systems approach to identify areas of learning. Recommendations to the local safeguarding children's board (LSCB) include to consider how to: encourage cultural change so that professional practice fully values the involvement of the public in safeguarding children; change cultural practice so practitioners routinely access and consider families' histories of agency involvement; and raise staff awareness of the difference between Police Powers of Protection and Emergency Protection Orders and between police welfare checks and the role of children's social care.
| Title: Baby F: serious case review: overview report. LSCB: Harrow Safeguarding Children Board Author: Edi Carmi Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Baby F Serious Case Review Author: Edi Carmi 11.10.15 CONTENTS EXECUTIVE SUMMARY I 1 INTRODUCTION 1 1.1 Initiation of Serious Case Review 1 1.2 Methodology 1 1.3 Structure of the report 3 2 CONTEXT 4 2.1 Family composition 4 2.2 Background culture of maternal family 5 2.3 History of family prior to period under review 5 3 APPRAISAL OF PROFESSIONAL PRACTICE 7 3.1 Introduction 7 3.2 Missed opportunities by midwifery to identify risks: April - June 2013 7 3.3 July - August 2013: late pregnancy, homeless, not attending antenatal care and first anonymous call 8 3.4 First few days in September 2013: birth of baby F 9 3.5 Buckinghamshire Refuge: September - October 2013 10 3.6 Inadequate investigation of anonymous referrals in Harrow: November 2013 - January 2014 11 3.7 Further referrals in Harrow with Mother avoiding professionals: February - March 2014 13 3.8 Child protection process initiated and children become subject to plans: Harrow April 2014 15 3.9 Implementation of child protection plan: May - July 2014 (Family in Ealing and then Harrow) 16 3.10 Immediate Harrow case management following review conference: mid July 20 3.11 Mother thought to be engaging better: late July - 10.08.14 21 3.12 Circumstances deteriorate rapidly from 11.08.14 23 4 THEMATIC ANALYSIS 26 4.1 Introduction 26 4.2 Midwifery failure to recognise need for pre-birth safeguarding referral 26 4.3 Professional difficulty in dealing with avoidant parents leaves children at risk of significant harm over a long period with their circumstances not being assessed 28 4.4 Repeated inadequate response to referrals by Harrow children's social care between August 2013 to February 2014 suggest threshold may be too high at this point in the system and /or that there are critical flaws in the understanding of responsibilities when families are mobile 29 4.5 Homeless and mobile families 30 4.6 Role of police welfare checks and of Police Powers of Protection 33 4.7 Response to referrals from members of the public 35 4.8 Management oversight and supervision 36 4.9 Understanding a family's history 37 4.10 Barriers to improving practice around neglect (in the context of previous focus by the LSCB on neglect) 38 4.11 Lack of involvement of Father and wider family in attempts to understand and assess the needs of the children 38 4.12 Voice of the child? 40 4.13 Where can we identify good practice in this case? 40 5 FINDINGS & RECOMMENDATIONS 42 5.1 Introduction 42 5.2 Findings 42 1. Systemic weaknesses in ante-natal midwifery services contributed to the failure to identify and refer pre-birth safeguarding concerns to children's social care 42 2. The belief that mother was a 'traveller' together with her effective avoidant behaviour contributed to a lack of effective follow up of concerns; this highlights the vulnerability of children in mobile families and the risk that children can become invisible 43 3. The case demonstrated a misunderstanding about the use of Police Powers of Protection instead of an Emergency Protection Order 44 4. There was repeated misunderstanding within children's social care of the function of police welfare checks as opposed to the children's social care responsibility to investigate allegations and concerns 44 5. The repeated lack of investigation by children's social care of the referrals from members of the public may reflect underlying cultural attitudes and suspicions to non professional referrals; such an attitude is a serious weakness in a safe service 45 6. The lack of individual supervision for social workers is likely to impact on cases that require a great deal of reflection and management oversight 45 7. There was little indication within midwifery services and children's social care 'front door' of practitioners understanding the need to take account of the family's known history 46 8. The father and wider family members were insufficiently involved in the assessments undertaken 46 9. During the period of this review mother and children were homeless and moved many times, including eight different bed and breakfast placement: the constant moves and type of accommodation provided is likely to be detrimental to the children's welfare 47 10. There were examples of good practice by individual practitioners, despite an overall service characterised by 'too little, too late' 48 GLOSSARY OF TERMS & ABBREVIATIONS 49 APPENDIX 1: PANEL MEMBERS 50 APPENDIX 2: AGENCIES INVOLVED WITH THE FAMILY 51 APPENDIX 3: PRACTITIONERS WHO CONTRIBUTED 52 i EXECUTIVE SUMMARY Context On 22.08.14 Baby F, aged 11 months, was found by his mother submerged in the bath, after she left him unsupervised. He was taken to hospital, but died in September 2014. Baby F and his two siblings had been subject to child protection plans under the category of neglect since the end of April 2014. Baby F's mother pleaded guilty to manslaughter in March 2015 and received a six year custodial sentence. Summary of Case Baby F's mother was well known to agencies in Harrow because of historic concerns about the neglect of her children due to her own lifestyle, which involved substance misuse, domestic violence and lack of engagement with services. Her eldest child (Sibling 1) moved to a relative when young and her next two children were the subject of child protection plans between 2010 and 2011. It was understood that these children are half siblings to each other and to Baby F. The period under review began with the start of her pregnancy with Baby F in early 2013. Prior to the birth the midwifery service did not identify the risks of a vulnerable pregnant woman who had not booked in for antenatal care, did not attend appointments offered and was neglecting her own health needs and in consequence the needs of her unborn baby. Children's social care were unaware of the pregnancy so no pre-birth assessment was undertaken. Baby F was born early, at a friend's home, delivered by the man understood to be his father. The paramedics thought they could smell alcohol on the mother's breath when they took mother and new born baby to hospital. Baby F remained in hospital (first in Brent and then in Buckinghamshire) until he was 23 days old, before joining his mother and two siblings in a refuge in Buckinghamshire; mother had moved there just before his birth. Despite intentions to hold a pre-discharge meeting at both hospitals baby F was discharged without such a meeting or any social work involvement. During baby F's first five months of life, from the time he was discharged from hospital, he was seen twice by health visitors and once in a clinic. No social worker saw him or his siblings despite concerns around the circumstances of his birth, mother's current circumstances, the context of the family history and several referrals from members of the public. These referrals mentioned that Baby F's parents were smoking heroin in front of the children, whose health and nutritional needs were being neglected. ii Despite initiating a child protection enquiry, Harrow children's social care did not see baby F and siblings or investigate the allegations that were made. This was due to confusion around the children's whereabouts, with Mother claiming to be travelling to different places. There was initially a mistaken assumption that Buckinghamshire would investigate concerns, even though the family had returned to Harrow, or an acceptance that it was not possible to locate the family and that the mother did not want help. This ignored both the fact that this was clearly a Harrow family and the alleged risks to the children that needed to be investigated. From February 2014 onwards there was a great deal of effort and tenacity displayed by the newly allocated social worker in constant attempts to locate the family and try to see the children. The health visitor at the time also put in a great deal of effort to support the family and ensure the children received the health resources they needed. However, despite this major individual and collaborative effort by the professionals, there was no progress made and the children did not receive the health and dental care they needed. Moreover, there was increasing suspicion that the mother had returned to misusing alcohol and drugs. Whilst it took too long for the management in children's social care to progress the case firstly to child protection and then to legal intervention, by the end of June the need for such was identified and legal planning meetings were held in July and August 2014, with the mother advised of the imminent use of legal intervention unless she complied with the child protection plan. A new social worker took over the case in July and initially there appeared to be some improvements made by the mother in response to the warning of legal intervention, but just before August Bank Holiday the social worker learnt from the Bed & Breakfast manager that a man was visiting the family every day, that the mother was borrowing money from the manager and other residents, and was overheard asking for heroin in a telephone conversation. Also Baby F's siblings were rescued by staff after they ran across the road unsupervised, dressed just in nappies. The next day the management of children's social care took legal advice and agreed that proceedings would be initiated, with an application for an Interim Care Order to be made after the Bank Holiday. Whilst consideration was given to the immediate removal of the children, a joint home visit by police and social worker that evening did not give grounds for the police to remove the children under Police Powers of Protection1, as there was no immediate risk: mother did not appear to be under the influence of substances and the children appeared well. 1 The Police have powers under s. 46 of the Children Act 1989 to protect children. If a police officer believes that a child is at risk of immediate danger and there is insufficient time to seek an Emergency Protection Order, then s/he may exercise powers under this Act to remove the child to suitable accommodation or if the child is iii The next day consideration was given to the immediate removal of the children that day through the taking of an Emergency Protection Order2 by children's social care. However, the understanding of legal advice was that there were insufficient grounds for such emergency action. Instead plans were made to provide support to the family over the Bank Holiday, with two visits daily. Legal intervention was planned to take place on the Tuesday with an application for an Interim Care Order. Tragically, between the support worker’s visits on the Saturday, the mother left Baby F unsupervised in the bath and he suffered brain injury which led to his death some weeks later. Findings and recommendations 1) Systemic weaknesses in ante-natal midwifery services contributed to the failure to identify and refer pre-birth safeguarding concerns to children's social care The provision of midwifery services demonstrated fundamental flaws in safeguarding practice involving the: inability to access historical records of patients who are not 'booked in' for services repeated lack of recognition of /or response to the vulnerability of a pregnant woman lack of fulfilment of the basic midwifery duty to ensure patients are 'booked' in (especially those who are vulnerable) Recommendation 1 The LSCB to ask the CCG and the LNWHT to report to the LSCB how midwifery will be able to provide a safe service which: provides access to historical patient records for all midwives, regardless of which team is providing the current service and whether or not the patient is 'booked-in' ensures that all midwives are able to identify and work with vulnerable patients, recognise safeguarding risks and make child protection referrals when required does not apply a DNA policy of withdrawing services following 3 DNAs, without reference to the fact that such behaviour is likely to denote greater need and risk provides a safety net which ensures the 'booking in' process is not avoided by staff due to time constraints and which addresses the risk to baby and patient of women who have not in hospital or in a place of safety, take steps to keep the child there. A child cannot be kept in police protection for more than 72 hours. 2 An emergency protection order or EPO is a court order granted under Section 44 of the Children Act 1989 on the grounds that a child will suffer immediate significant harm unless they are removed to council accommodation or moved from where they a current place of safety. Separation is only to be contemplated if immediate separation is essential to secure the child’s safety: ‘imminent danger’ must be established (X Council v B (Emergency Protection Orders){2004}. iv made use of antenatal provision 2) The belief that mother was a 'traveller' together with her effective avoidant behaviour contributed to a lack of effective follow up of concerns; this highlights the vulnerability of children in mobile families and the risk that children can become invisible Mother was understood to come from a travelling family, so when she missed appointments but explained she was staying in different places outside of London, practitioners accepted this as part of her culture, without further checking. There was inadequate consideration given to the need for follow up of concerns (in the case of children's social care) or of checking the children's health and development (in the case of health visitors) when mother claimed to be elsewhere. On one occasion children's social care assumed that another authority would undertake the required assessment (despite having not agreed this with them) and at other times no contact was made with the 'host' authority where Mother claimed to be, even when there was a s.47 (child protection) enquiry in progress. Even when Mother seemed to be staying in the B&B accommodation provided, she was skilful in avoiding professional contact, despite the tenacity of a social worker spending considerable time in trying to locate her. In such circumstances it is vital that intervention is taken at earlier points in order for practitioners to be able to see the children and assess their needs. Whilst in this case practitioners were threatening to take such action, this took too long. Mother explained to the author that the repeated warnings made to her, without immediate action, reassured her that no action would happen. Recommendation 2 a. The LSCB to consider how to develop practice so that: children within mobile families do not become 'invisible' and that they receive continuity of health and social care involvement, and when necessary intervention, even when the family moves around practitioners challenge avoidant parental behaviour and do not accept at face value explanations of the family travelling managers recognise the immense time involved in such challenge, but that this is required whenever there are safeguarding concerns no child protection case is ever closed because a parent claims to be living elsewhere, without an agreement by the next local authority to take over enquiries b. The LSCB to ask children's social care to report on quality assurance processes on the 'front door' of the service; in particular that children's needs within mobile v families are met (including cases not being closed without assurance of them being picked up in other areas) and that decisions for no further action are consistent with the safety of children. 3) The case demonstrated a misunderstanding about the use of Police Powers of Protection instead of an Emergency Protection Order The senior manager within children's social care identified the risk to the children the need for their urgent removal following the information received from the manager of the B&B. However, subsequent decision making reflected a misunderstanding within children's social care about the use of an Emergency Protection Order as opposed to a reliance on Police Powers of Protection, which should only be used if there is evidence if immediate risk. This case also demonstrated the need for social workers and managers to take account of legal advice, but when they feel that the risk is too high to leave children within the family whilst an Interim Care Order application is made, an EPO should be progressed and the matter put to the Court for a decision. Recommendation 3 Children's social care to hold facilitated workshops for managers to explore the differing use of Police Powers of Protection and Emergency Protection Orders. This should also cover the role of lawyers to provide advice as opposed to social work managers in making the decisions 4) There was repeated misunderstanding within children's social care of the function of police welfare checks as opposed to the children's social care responsibility to investigate allegations and concerns Within children's social care in Harrow there was an assumption that when police visited a home and concluded that the children were safe and well, there was no need for further investigation of referrals. This demonstrated a basic misunderstanding of the police role to establish if the children were at immediate risk of harm at that point in time, as opposed to the role of children's social care to undertake the wider and in depth assessment of the allegations. Recommendation 4 Children's social care to consider how best to disseminate to staff the distinction between police welfare checks and the role of children's social care, and how to establish if this is successful in changing practice. The LSCB to request a report from children's social care on the implementation and progress of this recommendation. vi 5) The repeated lack of investigation by children's social care of the referrals from members of the public may reflect underlying cultural attitudes and suspicions to non professional referrals; such an attitude is a serious weakness in a safe service Safeguarding is everybody's responsibility and referrals from members of the public need to be fully investigated. This needs to involve referrers being provided with the opportunity to meet with a social worker so as to provide more detail and evidence of concerns. This has been part of the London child protection procedures since the first edition in 2003. Recommendation 5 a. The LSCB to consider how best to promote cultural change so that professional practice fully values the involvement of members of the public in safeguarding children - such a cultural shift would see changes in practice which includes routine interviews of members of the public as part of follow up to referrals and assessment practice b. The LSCB to request agencies include the involvement of members of the public, friends and wider family in audits of response to referrals and of assessment practice - the results of such aspects of the audit to be provided to the LSCB and published as part of the promotion activities of the LSCB 6) The lack of individual supervision for social workers is likely to impact on cases that require a great deal of reflection and management oversight The allocated social workers in this case were part of the 'pods' within the children in need service. Staff within a pod are managed by a pod manager but do not necessarily receive individual supervision as this model of organisation predominantly uses group supervision for staff. Whilst group supervision can be a very helpful tool, it does not address the individual needs for reflection and management decision making that is typically needed in chronic neglect cases, especially in relation to avoiding delay in moving into child protection and legal proceedings. The social workers within this pod were concerned that their concerns about this case were not being adequately 'heard' by management at the time. It is important that whatever structure is in place, senior managers are assured that systems are in place for practitioners to have their concerns heard and addressed by managers beyond the individual pods. vii Recommendation 6 a. Children's social care to review the use [or not] of individual reflective supervision within pods, and report to the LSCB on how the needs for reflective case supervision are met in complex cases, and particularly where there is chronic neglect. b. Children's social care to provide systems for social workers to be able to articulate concerns about case management or to seek consultation, outside of the individual pods; children's social care to report to the LSCB how this will be accomplished and review its effectiveness 7) There was little indication within midwifery services and children's social care 'front door' of practitioners understanding the need to take account of the family's known history A common finding in serious case reviews is the lack of practitioner understanding of the need to access and understand previous agency history of the family, in order to evaluate the risk to children. In this case the practice weakness was evident in both midwifery services and the children's social care teams involved between August 2013 and January 2014. Recommendation 7 The LSCB to consider how to change cultural practice across all agencies so that practitioners routinely access the known agency history of families (including all carers), and that the history is taken into consideration in any responses 8) The father and wider family members were insufficiently involved in the assessments undertaken In common with findings from other serious case reviews nationally, there was insufficient involvement of the father in the assessments undertaken, although one social worker did initially try to engage him. Most critically the previous history of father was not accessed, although he was known to be the father of another child who had been adopted. The assessments also did not involve other family members, despite it being known that both paternal grandparents, maternal grandfather, and other members of the extended family were involved in supporting the family. viii Recommendation 8 The LSCB to consider how to change professional practice in all agencies, but especially within children's social care, so that all carers and involved family members are routinely involved in assessments of children subject to child protection plans and that their history is accessed as part of the assessment. 9) During the period of this review mother and children were homeless and moved many times, including eight different bed and breakfast placement: the constant moves and type of accommodation provided is likely to be detrimental to the children's welfare Whilst the reason for the frequent moves are not totally understood and were in part due to Mother's actions and inactions, such constant moves must have been disruptive and distressing for the children. The use of B&B accommodation for families is recognised as being unsuitable, only to be used when there is no alternative provision available and that the family should not remain there in excess of six weeks. This family were in B&B accommodation for longer than six weeks. Recommendation 9 a) The LSCB to establish the use of B&B accommodation by Housing for Harrow families, the frequency of moves between B&B per family and the total amount of time families spend in such accommodation before being offered more suitable temporary accommodation such as a flat or house. b) When the LSCB have this information, consideration to be given if there are systemic problems in the available provision and if further action is needed locally or in collaboration with other London boroughs. ix 10) There were examples of good practice by individual practitioners, despite an overall service characterised by 'too little, too late' The first Harrow health visitor who persevered in trying to see mother and tried to get children's social care in both Buckinghamshire and Harrow to investigate the concerns; had she escalated the failure of both children's social care services to do so, her involvement would have been even more effective The team manager of the child in need service for ensuring in February 2014 that the case was allocated and that this time the mother and children must be assessed The persistence and tenacity of both allocated social workers after February 2014 enabled the risks to be identified, recognised by management and begin to be addressed The persistence of the Ealing health visitor to try to facilitate the health and development needs of the children and her continuing involvement after the children moved out of Ealing The escalation of concerns by the Ealing health visitor, leading to the safeguarding advisor communicating concerns to Harrow children's social care The willingness of police to do welfare checks in response to referrals from members of the public The good communication and partnership working between the two allocated social workers and their colleagues in health and in the police, involving a number of joint visits The attempts by staff in the refuge to find mother, identify the whereabouts of the children and maintain the placement whilst trying to facilitate the family's return This case demonstrated some very good examples of safeguarding being everyone's business, with the last B&B manager and staff involved in trying to help the family, as well as reporting to the social worker the concerns about the children's care and mother's behaviour. This manager also contributed to this serious case review which has enhanced our learning. Members of the public also tried to contribute to the children's welfare by expressing their concerns at the time to police and children's social care. Such responsibility towards children in our community is to be greatly commended. What will the LSCB do in response to this? At the end of each finding in section 6 recommendations have been made for the LSCB. The LSCB has prepared a separate document which describes the actions that are planned to strengthen practice in response to the findings and recommendations of this serious case review. 1 1 INTRODUCTION 1.1 Initiation of Serious Case Review 1.1.1 On 22.08.14 Baby F, aged 11 months, was found by his mother submerged in the bath, after she left him unsupervised. Baby F was taken to hospital, but died in September 2014. Baby F and his half siblings (hereupon described as siblings) had been subject to child protection plans under the category of neglect since the end of April 2014. Baby F's mother pleaded guilty to manslaughter in March 2015 and received a six year custodial sentence. 1.1.2 The LSCB Chair at the time, Deborah Lightfoot, decided on 04.09.14 that a Serious Case Review should be held in respect of Child F. 1.2 Methodology 1.2.1 Statutory guidance3 requires SCRs to be conducted in such in a way which: recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings 1.2.2 Harrow Safeguarding Children Board (referred to as the LSCB) adopted a systems approach for this case to meet the above requirements. The systems principles and data collection process in the Social Care Institute for Excellence Learning Together systems guidance4 was used in developing this local approach. Period under review 1.2.3 The period under review is from 01.01.13 to 31.08.14. This covers the pregnancy of mother with Baby F until the tragedy that led to his death. Information that was held by agencies about the family prior to this period was provided in summary form to help understand the historical context of professional interventions. Learning from review 1.2.4 The LSCB identified particular areas of learning to be considered as part of this serious case review. These are the strengths and weaknesses of the multi-agency safeguarding system with regard to: Homeless and mobile families 3 Working Together to Safeguard Children, 2015 Chapter 4 4 Learning Together, Fish, Munro & Bairstow SCIE 2008 2 Substance misuse by parents Barriers to improving practice around neglect (in the context of previous focus by the LSCB on neglect) Where can we identify good practice in this case and what aspects of the multi-agency system support such practice? Process 1.2.5 The process used involved: Appointment of two independent lead reviewers, Edi Carmi, to chair the review and Ghislaine Miller, to lead on data collection and to produce the report. A review panel of senior managers to oversee the process (see appendix 1 for details) The lead reviewers to work collaboratively with the review panel, lead the analysis and write the review report Identification of agencies involved with the children in the family and their mother (see appendix 2 for details) Collation of a detailed chronology of professional activity Obtaining information from other areas where the family had lived or frequently visited: 19 LSCBs were contacted for information, those who confirmed knowledge of the family and contributed to the review were Buckinghamshire County Council and the London Borough of Ealing The review was undertaken from a multi-agency perspective from the outset: consequently individual management reviews from agencies were not requested Lead reviewers and Panel members’ involvement in speaking to practitioners so as to understand what happened and why- the rationale for actions, inactions and decisions Direct involvement of practitioners and managers through individual and two group meetings to provide information and participate in the findings; (see appendix 3 for details) Consideration of a variety of written records and reports undertaken as part of the ongoing work of practitioners Timescales and necessary delays 1.2.6 In order to be able to include all relevant staff and family members, the process was delayed until after the criminal proceedings on the advice of the Metropolitan Police Service (MPS). 1.2.7 Subsequent delay also occurred due to change in the authorship of the report in August 2014, when the review chair took over writing the report. Family participation 1.2.8 Mother participated in the review process, meeting with the lead reviewers following the completion of the criminal process. 1.2.9 Father and grandparents were also invited to participate but did not respond to the requests. 3 Limitations 1.2.10 Whilst Buckinghamshire contributed a chronology, none of their staff from children's social care or from health met individually with the lead reviewers, due to long term sick leave. Consequently the rationale for their decisions is not understood. 1.2.11 The Harrow children's social care pod unit manager and the first Harrow health visitor had both left Harrow and were not included in the review process. The locum solicitor who provided the legal advice was also not available. 1.2.12 The lack of response by grandparents and Father has limited our learning in this case. Maternal grandfather and paternal grandparents were very involved at times with Mother and the children. The role of Father at the time was never understood or explored; unfortunately this serious case review has not been able to overcome this omission and was unable to access historical data about him as a parent. 1.3 Structure of the report 1.3.1 The report is structured as follows: Section 3 provides the context in which to understand what happened during the period under review: o family composition o historical information of professional involvement prior to the period under review Section 4 explains what happened from the perspective of those involved at the time, including both professionals and family members Section 5 provides an analysis of the themes emerging from the practice in this case Section 6 provides the overall findings and recommendations A glossary of terms is provided at the end of the report The three appendices give the serious case review panel composition; the details of the agencies identified as providing services to the family in the review period and the practitioners who participated in the review process 4 2 CONTEXT 2.1 Family composition 2.1.1 Baby F lived with his mother, sibling 2 and sibling 3 in Harrow at the time of the incident. They were living in bed and breakfast accommodation. Term used in report Relationship to child F Age in August 2014 Residence in August 2014 Baby F Subject of the review 11 months Harrow B&B with mother Sibling 3 Elder half sibling of child F Nearly 3 years old Harrow B&B with mother Sibling 2 Elder half sibling of child F 4 years old Harrow B&B with mother 'Mother' Child F's mother 31 Harrow B&B 'Father' Understood to be the father of baby F Not known, but thought to be in Harrow with his parents (paternal grandparents) Maternal grandmother Baby F's mother's mother Harrow - but not with maternal grandfather. She died in December 2013 Maternal grandfather Baby F's mother's father Harrow, but not with maternal grandmother Paternal grandparents Baby F's 'Father's' parents Harrow Sibling 1 Mother's eldest child and baby F's half sibling 11 years old Has lived with a relative elsewhere in London for most of his life and has no contact with Harrow services during the period under review 5 2.2 Background culture of maternal family 2.2.1 Mother comes from an Irish travelling family background and was known to local services as a child. She has 7 siblings (4 sisters and 3 brothers). Mother explained to the lead reviewers that her parents settled in Harrow following one of her siblings need for regular specialist health support from a London hospital. However, she explained that her father (maternal grandfather) still has his caravan which he uses. 2.2.2 Mother still identifies herself as a traveller and throughout the period under review she told practitioners she was in various locations in England and Ireland, visiting relatives. It is not clear to what extent these trips were real or used as excuses at times that she wished to avoid contact, or to explain non attendance at appointments. 2.2.3 One of Mother's relatives had previously stayed at the refuge in Buckinghamshire, where mother was in September 2013: this relative also identified herself as a traveller. 2.3 History of family prior to period under review Maternal history 2.3.1 Mother has an elder son born in 2003. He lives with another relative in another London borough due to concerns about Mother's 'chaotic lifestyle' and ability to parent him. 2.3.2 Maternal grandparents lived at different addresses in Harrow prior to maternal grandmother’s death in December 2013. Mother and siblings 2 and 3 lived with paternal grandfather in 2011 and a family group conference5 was held at that time. 2.3.3 There was knowledge of mother's drug use in previous periods of intervention with Harrow children's social care and also information that a close relative of mother was a known drug user. 2.3.4 Mother describes herself as dyslexic, with difficulty reading and writing due to travelling around and missing school, but has subsequently learned to read. 5 A family group conference (FGC) is a voluntary process led by family members and assisted by an independent FGC facilitator. The aim is to plan and make decisions for a child who is at risk of harm. At the first part of the meeting, social workers and other professionals set out their concerns and what support could be made available. In the second part of the meeting family members make a plan for the child. The family is supported to carry out the plan, unless it is judged not to be safe 6 2.3.5 During Mother's pregnancy with sibling 2, there were serious concerns relating to her then partner's violence towards her when she was pregnant. Child protection concerns culminated in a child protection plan for the unborn baby in 2010 on the grounds of neglect. The concerns centred on paternal violence, maternal past disengagement from drug and alcohol services (she used heroin and diazepam), previous post natal depression, lack of engagement with antenatal services and discharging herself prematurely from hospital when recovering from a severe assault and before the outcome of checks on the unborn baby. 2.3.6 The child protection plan continued during the pregnancy with sibling 3, and the unborn baby was also made subject to a plan in August 2011, when there remained concern of violence from sibling 2's father, who was due out of prison. There was also reference to Mother's deliberate self harm. 2.3.7 The children were removed from the child protection plans in January 2012 and became subject to child in need plans6. This followed an independent parenting assessment and support provision to reduce the risk of domestic violence and a return to substance misuse, along with educative parenting work and input to promote Mother's mental health. 2.3.8 Mother and children then moved to Brent and Harrow children's social care transferred the case. Following this there were a number of moves as accommodation was provided in different boroughs. At the start of the review period Mother's accommodation was provided through Enfield housing. Paternal history 2.3.9 The review has found it difficult to obtain information about Father's history, due partly to the lack of practitioners doing so at the time, but also because this is contained in the file of another child (his daughter) who was subsequently adopted and the file therefore closed and not linked to Father. See 4.11 for further discussion about the lack of knowledge about the father. 2.3.10 There were also various comments of his to professionals which suggest he may have other children with different partner/s, but the London Borough of Harrow does not have any information on these. 6 A child in need plan is drawn up following an assessment which identifies the child as having complex needs and where a coordinated response is needed in order that the child's needs can be met. Children who have been subject to a child protection plan are and who receive child in need services for a further 6 month period after the child protection plan has ended. 7 3 APPRAISAL OF PROFESSIONAL PRACTICE 3.1 Introduction 3.1.1 Section 3 provides a commentary on professional practice during the period under review. 3.1.2 To understand the rationale for professional practice, what happened is described from the perspective of those involved at the time, professional staff and Mother. The information is derived from agency records at the time, individual interviews and group meetings with those involved in the period under review. 3.1.3 The details of what happened are broken into time periods. The commentary within the shaded boxes at the end of each time period is an appraisal of professional practice in that period. Where such appraisal and explanation reflects a recurrent theme regarding the service provided there is a cross reference to subsequent analysis in section 4. 3.2 Missed opportunities by midwifery to identify risks: April - June 2013 3.2.1 The first time local professionals learn about Mother's pregnancy, with Baby F, is in April 2013, when she was admitted to Northwick Park Hospital Maternity Unit with abdominal pain. She was 18 weeks pregnant and living in a refuge because of alleged domestic violence. She had not received any antenatal care to date, was not ‘booked in’ despite a history of significant health conditions. These health conditions required ongoing treatment and monitoring and placed Mother and unborn baby at a high health risk. Mother was aware of this having received treatment in a previous pregnancy. 3.2.2 Mother was discharged without being ‘booked in’ and returned four days later when the results of her blood tests unsurprisingly showed a health risk. Further tests were undertaken but she was still not 'booked in'. Over the next few weeks Mother failed to attend four antenatal appointments; the Acting Community Matron was informed and the case discussed with the Safeguarding Midwife, who advised that home booking be done by the community midwife. The booking administrator was informed, but still no home booking took place. Comment: The history of the family was known to the Jade team 7 who were involved in Mother's previous pregnancy. Their records would have shown both the health risk factors for Mother in pregnancy and also the background of her children being subject to child protection plans. The latter knowledge on its own should have resulted in an immediate referral to children's social care for a pre-birth assessment. These notes were never accessed in this pregnancy because Mother was never booked in. 7 The Jade Team are a specialist group of midwives who support women who are pregnant and have significant and high risk social vulnerability. The team case work directly with a small number of women risk assessed as highest need and provide a consultation service or shared care with community midwives to many others 8 Mother's self reported account of being in a refuge because of domestic violence, her late attendance and her non attendance at hospital, identified additional risks that were known by midwifery and should have in themselves triggered a referral to children's social care. The contributory reasons behind such a poor response by midwifery are discussed in section 4.2 3.3 July - August 2013: late pregnancy, homeless, not attending antenatal care and first anonymous call 3.3.1 In this period Mother did not attend ante-natal care and did not answer her telephone. In consequence, a decision was made that she would have to contact her GP and have a new referral if she wanted to be booked at Northwick Park Hospital. 3.3.2 In August, police received an anonymous telephone call expressing concern about siblings 2 and 3 (then aged two and three) being looked after by adults who were drunk. Police attended the address, spoke to Mother, who was not drunk, and saw both children. This was the first of a number of anonymous calls about the children's welfare received by agencies during the review period. 3.3.3 During July and August Mother remained unsettled, requesting assistance from Harrow Housing in July and again at the end of August, on basis that the father of sibling 2, was a perpetrator of domestic violence and had discovered her whereabouts. On both occasions she was referred to a neighbouring London borough who were then providing her with accommodation. 3.3.4 In August Mother was also in contact with Harrow children's social care and a refuge in Buckinghamshire. The latter offered her a place and Harrow children's social care provided funding for a night at a bed and breakfast unit [first B&B in the review period] and transport to a refuge in Buckinghamshire the next day(Friday). The case was then closed by Harrow children's social care. 3.3.5 The mother arrived at the refuge the next day (Friday, 30.08.13) and informed the staff of her pregnancy and due date, which was some three weeks later. Comment: At this stage Mother is in the last weeks of her pregnancy and has not been receiving antenatal care, despite concerns for her own health, that of the baby and historical concerns about her parenting. Instead of recognising the risks to Mother and baby and need for referral to children's social care, midwifery decide to terminate service to Mother without a re-referral from the GP. Given historical knowledge of Mother's parenting skills, and the knowledge of the imminent birth of another child, Harrow children's social care needed to undertake a pre-birth assessment, or ensure that this task was taken on by another authority. Most worrying is the lack of evidence at this stage of any contact with Buckinghamshire, or any checks about arrangements for ante-natal care and the imminent birth of the baby. 9 3.4 First few days in September 2013: birth of baby F 3.4.1 When staff arrived at the refuge on the Monday, Mother and children were missing. In fact the previous day (Sunday, 01.09.13) at 8.35am Mother was picked up by ambulance from an address in Brent, having given birth to Baby F in the toilet of a friend's home, apparently with Father's help. She had attended a party there the previous evening. Baby F was born at 37 weeks gestation. Paramedics smelt alcohol on Mother’s breath and took her and Baby F to Northwick Park Hospital. 3.4.2 Father visited along with maternal grandparents, saying this was his seventh child. The midwives smelt alcohol on his breath. Mother said her other children were with a friend. 3.4.3 The day after the birth Maternity made a referral to the multi-agency safeguarding hub (MASH)8 in Harrow. MASH advised Midwifery first to make a referral to Brent as Mother was homeless and the hospital was located in Brent and subsequently to Buckinghamshire, when it was learnt that mother had already been discharged when Baby F was two days old and had returned to the refuge. Baby F remained at Northwick Park Hospital in an incubator in the special care baby unit before being transferred to a hospital in Buckinghamshire when six days old as he had contracted pneumonia. 3.4.4 A psychosocial meeting was held (baby F aged 5 days old on 06.09.13) at Northwick Park Hospital, and a decision was made that baby F was not to be discharged until a strategy meeting was held. However, after discussion with a manager it was decided the baby could be transferred once a referral was made to children's social care. A doctor at the hospital first tried to make a referral to Brent children's social care, which was not accepted, and then to Buckinghamshire, appropriately marking this as urgent and requesting confirmation of receipt. Comment: The hospital acted appropriately in making referrals to Harrow, Brent and Buckinghamshire children's social care. The named nurse was though not informed of the concern; this could have provided another system to promote the safeguarding of Baby F. The lack of the initiation of child protection processes at this point was a major omission, given the history and the circumstances of the pregnancy and birth. Harrow MASH should either have initiated this themselves, with a strategy meeting at the hospital prior to baby F being transferred, or ensured that this happened in Buckinghamshire. Instead, Harrow left it to the hospital to liaise with children's social care in Buckinghamshire and made no direct contact at this point to provide a full understanding of the history and the risks to the children, although there was subsequent contact initiated by Buckinghamshire. See 4.4 for further discussion. 8 MASH The Multi Agency Safeguarding Hub is a team of practitioners from social care, health, education and police who access and consider multiple sources of information relating to a child or family in a timely and proportionate way, to ascertain level of risk following a referral or incident. 10 3.5 Buckinghamshire Refuge: September - October 2013 3.5.1 Baby F remained in hospital in Buckinghamshire for 17 days, having been transferred there when he was 6 days old. Mother and siblings 2 and 3 were at the refuge and staff there describe Mother as 'quite chaotic' and always needing something 'now'. Involvement with staff was around crisis which effectively prevented any chance to probe her background. 3.5.2 The children tended to run around 'all over the place' and lacked concentration but were happy and not aggressive. The children attended the play room, but only went to the induction session at the nursery. One of the children had 'very bad teeth' so staff made calls to a dentist, but Mother did not follow this through. 3.5.3 When baby F was aged nine days old, Buckinghamshire children's social care manager telephoned Harrow MASH, asking if the case was open and requested information. This was followed later in September with a written request for history. It is not clear what information was provided. 3.5.4 Records indicate that the child protection concerns were understood in Buckinghamshire: health visitor records refer to children's social care consideration for a legal planning meeting and an anticipated discharge planning meeting. Also the refuge were told by the social worker that there was concern about a lack of bonding between mother and baby. 3.5.5 However, the information from Buckinghamshire does not explain the change in plans and lack of discharge planning meeting, before Baby F's discharge from hospital aged 22 days (23.09.13). The health visitor saw Baby F at the refuge the next day, before Mother and her three children left the refuge three days later (Baby F aged 25 days old), saying she was at her brother's home and planned to return. 3.5.6 The workers from the Refuge were concerned as Mother missed the appointment to register baby F's birth and a visit from the Buckinghamshire health visitor. The staff at the Refuge kept in touch with her to keep her place open. 3.5.7 Mother was admitted to Northwick Park Hospital for 6 days in October via ambulance in relation to her ongoing health conditions. She told the staff at the refuge she had pneumonia. Whilst at hospital the whereabouts of her children were unknown, but she absented herself from the ward several times, which was explained by her as being to make arrangements about their care. 3.5.8 When Mother was discharged from hospital she did not make contact with the refuge, or return for her belongings. By the end of the month the refuge had ended her tenancy. Comment The original plan in Buckinghamshire for a discharge planning meeting was the appropriate response. The reason for not following this through is not known due to the inability of the Buckinghamshire staff to participate in the review, but does appear to be after a conversation with Harrow MASH. When Mother disappeared again from the refuge, with three such small children, a referral to children's social care was warranted, given the history and the vulnerability of such young children. 11 Meanwhile despite the concerns from the past, the lack of antenatal care and the worrying circumstances of baby F's birth, the children had not yet been seen by a social worker and only seen by one professional outside of the hospital (health visitor in Buckinghamshire); this was immediately following his discharge from hospital. Mother missed all other appointments and baby F had not had his 6 week check, which would have been due in mid October. 3.6 Inadequate investigation of anonymous referrals in Harrow: November 2013 - January 2014 3.6.1 This period starts in early November with an anonymous caller on 04.11.14 to both Harrow children's social care and the Metropolitan Police Service (MPS)). The caller alleged parental use of heroin smoked in front of the children who coughed up 'black stuff'. Baby F was reported as suffering with breathing problems and sibling 2 was always falling over; neither were receiving medical attention. The caller also referred to the parents’ lifestyle, lack of adequate food for the children, concerns around the circumstances of the birth of Baby F and earlier child protection plans for the siblings. 3.6.2 In response to these concerns the Police immediately attended the address (paternal grandparents in Harrow), saw Baby F sleeping in his cot and appropriate toys and food in the home. Mother was out with the siblings at the time. 3.6.3 The response of Harrow children's social care involved communication with Buckinghamshire children's social care (which established the case was still open, although no social worker had ever seen the family) and the previous Harrow health visitor (Harrow health visitor1) from 2010/2011. A s.47 enquiry9 was initiated, but the case was closed three days later without any further investigation being undertaken. 3.6.4 Meanwhile Harrow health visitor1 called at paternal grandparents; Father said Mother and children had left and he did not know where they were. When the health visitor reported this to Harrow children's social care she was told the case was closed as the family were living in Buckinghamshire. However, the Buckinghamshire social worker told her that the family were moving to Harrow and case closed there too. 3.6.5 Harrow health visitor1 persevered to try to see baby F, liaising with professionals: The Harrow GP told her of the lack of antenatal care and that baby F was not registered with the GP practice The Buckinghamshire health visitor said the family's records were sent to the Child Health Department [never received in Harrow, despite internal investigation] Harrow health visitor1 liaised with Buckinghamshire and Harrow children's social care: both reported the case was closed and the other area was responsible. 9 Where there is reasonable cause to suspect that a child is suffering, or likely to suffer, significant harm, the local authority is required under s47 of the Children Act 1989 to make enquiries, to enable it to decide whether it should take any action to safeguard and promote the welfare of the child. 12 Harrow health visitor1 spoke with Mother on the 'phone; she said she was at her brother's home in Peterborough, planning to return to Harrow the next week and confirmed that baby F (at that point aged 10 weeks old) had not had his 6 week check or immunisations Harrow health visitor1 persevered and contacted the Harrow children's social care team manager1, explained the lack of contact with baby F, mother's plans and that Buckinghamshire had closed the case, but was told that case responsibility was not accepted by Harrow 3.6.6 Harrow health visitor1 managed to see baby F (aged 11 weeks), his siblings and Mother in mid November at the home of a relative: Baby F had a cold, severe nappy rash and looked pale. The assessment of siblings was difficult due to the high level of noise and activity in the room. Harrow health visitor1 concluded that Mother was looking after her children in difficult circumstances, was determined to return to Harrow and could still be at risk of domestic violence by sibling 2's father. 3.6.7 Harrow health visitor1 followed up by checking with Mother she had sought advice at A&E regarding the nappy rash and arranged for Baby F to be registered and have his 6 week check at the GP surgery in late November. Mother instead took him for a 6 week developmental check at Alexandra clinic two weeks later (when he was aged 3 months) and made an appointment for his immunisations, but there is no evidence that the appointment was kept. 3.6.8 Harrow health visitor1 completed a CAF referral to Harrow children's social care, highlighting the history of child protection plans, substance misuse and domestic violence; Baby F's health needs not being met and that the family were homeless, moving on a weekly basis. 3.6.9 Harrow children's social care decided to undertake a Child in Need assessment, as opposed to the earlier s.47 enquiry. The team manager (Harrow team manager2) allocated this to a social worker (Harrow social worker1) in early December. Harrow team manager2 tried to see the family over the next month, but Mother variously reported herself to be in Kent, in Peterborough and in Manchester. She also informed Harrow social worker1 that her own mother (maternal grandmother) had died just before Christmas and that she was not planning to return to Harrow imminently. Following discussion with Harrow team manager2 the case was closed at the end of January 2014, without referral to Manchester, on the basis she was not in Harrow and not wanting social work support. 3.6.10 Harrow health visitor1 had also been speaking to Mother and learnt she was in Manchester and the plan was to transfer the health visiting notes, but there is no evidence that this occurred. 13 COMMENT The Harrow children's social care practice during these three months has significant shortcomings. The lack of professional contact with baby F and of further investigation into the concerns identified in the anonymous referral left the children at suspected risk of significant harm . The initial plan to undertake a s.47 enquiry was correct and its abandonment on the basis of the case being open in Buckinghamshire was wrong - whether or not the family returned to Buckinghamshire, the allegations concerned care of the children in Harrow and was Harrow's responsibility (see 4.5 for further discussion about mobile families).No local authority should close s.47 enquiries without being confident that the concerns are being investigated elsewhere. This did not happen. When the case was re-opened, the decision for it to be a child in need assessment and not a s.47 enquiry was flawed given the level of concern, but was based on the lack of supporting evidence from the police welfare check. This is a misunderstanding of the function of such a check which is a limited assessment of immediate risk, as opposed to a multi-agency investigation into chronic neglect (see 4.6). The subsequent closure of the case (without referral to another local authority) was based on Mother's absence from Harrow and her lack of wanting social work support. This ignored the reason for the assessment, which was about child protection concern. It also ignored the potential impact of bereavement and/or post natal depression on Mother's parenting. However, the manager recalls that because Mother often made up stories for avoiding contact, the account of her mother's death was at the time thought to be untrue. The Harrow health visitor, Harrow health visitor1, is to be commended during this period, as the only pro-active practitioner who did see the children, albeit only once, and liaised with colleagues in Harrow and Buckinghamshire, as well as escalating concerns to the team manager in children's social care in order to get Harrow children's social care to undertake an assessment. However, it seems when Mother then said she was going to be in Manchester for some time, the lack of referral to colleagues there, meant that the children's health and development needs continued not to be addressed. 3.7 Further referrals in Harrow with Mother avoiding professionals: February - March 2014 3.7.1 In the first week in February, a third anonymous referral expressed child protection concerns to police and Harrow children's social care about neglect and the parents using drugs in front of the children at paternal grandmother's home in Harrow. Allegations included children being hit with a spatula, children kept in the back room of the house, in a travel cot, and the room smelling of urine. Baby F was said to be given Calpol© to make him sleep so the parents could take heroin. 3.7.2 The police again undertook a welfare check and found no evidence of substance misuse or lack of food. MASH returned the case to the children's social care child in need team for an assessment and Harrow team manager2 allocated the case to a social worker (Harrow social worker2). 14 3.7.3 The MASH health practitioner informed Harrow health visitor1 of the concerns and advised a home visit. Harrow health visitor1 called Mother the next day to be told she was moving to Manchester and agreed to provide an address when she got there. Harrow team manager2 made it absolutely clear that the family needed to be found, that Mother had evaded contact by saying she was elsewhere and that other local authorities must be informed should Mother say she was staying elsewhere. 3.7.4 Over the next seven weeks Harrow social worker2 made 11 telephone calls or texts to Mother and 4 unannounced visits to paternal grandparents' home without success in seeing the children. Harrow health visitor1 and social worker2 liaised and both tried to locate Mother. 3.7.5 Mother gave information initially (second week of February) that she was in Manchester with aunt, was planning to stay 2/3 months and would text the address. In the third week of February, information provided by Mother was that she was going / was in Ireland. Also that week another different anonymous referral (from a different source) reported to a (different) social worker that Mother and Father were together, using heroin and crack cocaine, and that Father had previously had a child removed due to his drug use. Also at this point there was information about the substance misuse relating to Mother's close relative. 3.7.6 In the third week of March, Harrow social worker2 found Father and his mother at home on an unannounced visit and was told Mother and children stay at that address when in Harrow and was last there two weeks previously. Mother agreed by telephone conversation that she would attend an appointment with Harrow social worker2 at the end of March, on her return from Ireland. 3.7.7 Harrow social worker2 completed a social work assessment the last week of March recommending child in need plan, or a s.47 enquiry if mother failed to attend the appointment at the end of March. Comment These third and fourth anonymous referrals should have triggered a child protection threshold, and the urgent need to see the children. The team manager this time was clear in her instructions about what had to happen, and the social worker was right to point out the need for a child protection response given Mother's continuing evasion of professional contact in the face of the same concerns. By the end of March, baby F was aged 7 months and had been seen by 2 health visitors and one clinic since being discharged from hospital in September 2013. Siblings 2 and 3 similarly were not being seen by professionals, and not attending any pre-school or nursery, other than one attendance in Buckinghamshire in September. 15 3.8 Child protection process initiated and children become subject to plans: Harrow April 2014 3.8.1 The child protection process was initiated on 03.04.14 in response to Mother not attending the appointment agreed with Harrow social worker2. A strategy discussion with the police agreed a s.47 enquiry as well as an initial child protection conference. 3.8.2 Mother did not respond to texts and telephone calls, so Harrow social worker2 visited paternal grandparents address and saw clear signs of the family's presence. Mother denied this saying (in a 'phone call) she was on her way to London and would come to the office that day. She did not do so. Harrow social worker2 returned to the paternal grandparents' home that day in the late afternoon and saw Mother and three children. This was the first time a social worker had managed to see Baby F and his siblings since the birth of Baby F. 3.8.3 Mother acknowledged living at 8 different addresses since October, because of her travelling culture. She denied being in a relationship with Father or using drugs. Harrow social worker2 discussed sibling 2’s speech delay, which Mother queried as autism, and the lack of immunisations since 2012. 3.8.4 A written agreement was signed by Mother including attendance the next day at children's social care and housing, not to use alcohol or drugs, to take children to health appointments, to take telephone calls and give 72 hours notice of travel arrangements. 3.8.5 The next day Mother failed to keep her appointment with Harrow social worker2. An initial child protection conference was arranged for 25.04.14 and Harrow health visitor1 informed of events. Over the next 10 days Mother continued to miss appointments with the social worker and at health clinic, but did take the children to the GP surgery for immunisations and finally saw Harrow health visitor1 at the clinic on 17.04.14. She was in a rush en route to Housing, looked pale and thin, and did not have enough time to complete health assessments of the children. Mother obtained B&B accommodation in Barnet that day (second B&B in review period), having approached the Harrow Emergency Duty Team out of hours. 3.8.6 She subsequently attended Harrow Housing Services on 23.04.14 accompanied by Harrow social worker2 and provided an unspecific address history which included London, Peterborough, Manchester and Northampton, and an application in Watford. The decision was made to house Mother and three children under an interim homeless housing duty in a B&B Ealing (third B&B in review period). Harrow social worker2 visited the next day and the children appeared 'healthy and happy'. Mother complained of mice, bedbugs and a broken washing machine. 16 3.8.7 The initial child protection conference on 25.04.14 made all 3 children subject to a child protection plan under the category of neglect because of concerns about Mother's lifestyle and avoidance of professionals and parental substance misuse. The children's immunisations were now up to date and baby F (aged nearly eight months) was meeting his developmental milestones. Sibling 3's tooth decay was noted and that he needed a Speech and Language assessment. There were no health / developmental concerns in relation to sibling 2. The conference also learnt that Mother had difficulty reading and had dyslexia. 3.8.8 On the 28.04.14, the police were called to a shop by a member of the public, where sibling 3 (aged 2 years 8 months) had been found, having run off when Mother was visiting a friend. This was reported to children's social care. 3.8.9 The same day health visiting responsibility was transferred to Ealing. The children's records were still in Brent as Harrow had not managed to obtain them. The family had lived there from 2011 to 2013. Comment The concerns about the children start to be addressed at this point and the social worker provided the much needed perseverance to see Father as well as Mother and the children. In this instance, with Mother's evasive tactics challenged by a social worker, the children were finally seen and accommodation provided. It is one of the occasions when professionals did follow through with Mother on the consequences of her non compliance. However, there was no challenge to her regarding her neglect of sibling 1, which enabled him to run away without her noticing on 28.04.14. The conference child protection plan focused mainly on the many services the children required to meet their health needs (dental and optician appointments, developmental needs (Children's Centre and nursery) and the drug testing of the parents. Contingency measures included earlier core group or legal planning meeting and missing person's alerts should the children disappear again. What was missing was further assessment of both parents and their parenting capacity. Father had not attended the conference despite having agreed to do so. 3.9 Implementation of child protection plan: May - July 2014 (Family in Ealing and then Harrow) 3.9.1 Between the child protection conference convened by Harrow children's social care in April and the first review conference in mid July there was very little progress in terms of the implementation of the child protection plan. Overall Mother did not engage with services, albeit occasionally was seen with the children (often through unannounced visits) but with little follow through by her of the steps required to meet her children's needs as identified in that plan. Contacts with professionals demonstrated a pattern of missing appointments, not answering 'phone calls or messages and being out at visits. 17 3.9.2 Most critically neither Mother nor Father attended either of the two Core Group meetings held in this period. This is the multi-agency forum to make the plan more specific and monitor its progress, and where explicit parental agreement is sought. May 2014: family in Bed & Breakfast in Ealing 3.9.3 A new Ealing health visitor (Ealing health visitor2) made a number of appointments and visits in May and saw Mother twice in the first half of the month. Sibling 3 was home the first time and was observed to be eating chocolate despite his tooth decay. On the second occasion all the children were asleep and mother had just woken (afternoon visit). 3.9.4 Mother agreed to a clinic appointment, to register at a local GP, to register the children at a dentist, co-operate with referrals for Speech and Language therapy and Audiology for sibling 3. However, Mother did not attend the health clinic to complete the forms required for the referrals, and did not register with a GP or dentist. 3.9.5 Harrow social worker2 repeatedly tried to contact Mother during May, but she did not answer the telephone or respond to messages. In mid May Harrow social worker2 found only Mother and sibling 3 at home when he visited unannounced: the other children had been left asleep at a friend's. No-one answered the door when Harrow social worker2 visited unannounced on 28.05.14 and 30.05.14. On the latter occasion the caretaker said the family had not been seen for 5 days. 3.9.6 Mother also failed to attend her appointment with Housing on 30.05.14. June 2014: family in Bed & Breakfast in Ealing 3.9.7 Harrow social worker2 found the family, including Father at the Ealing B&B early on 02.06.14, despite Mother's assertions that the relationship was over. The place was cluttered and dirty, with 5 cigarette lighters lying around in the room. Sibling 3 was noted to have a dirty face and unwashed clothes. Mother claimed that registration with GP, dentist and nursery were all in progress. Father agreed to be assessed, but not immediately. 3.9.8 At a 'pod'10 supervision in Harrow children's social care the next day, further assessments and actions were decided, such as a parenting course and risk assessment of Father as well as a re-iteration of the actions already being pursued without success. 3.9.9 Mother attended Housing on 03.06.14 with some of the required documents and registered with a GP on 05.06.14. She missed her first appointment at the substance misuse service (RISE) on 09.06.14, saying she had a death in the family: it was noted that she was under the impression she was to undertake a drug test. 10 A 'pod' in Harrow children in need service provides a framework for supervisory arrangements and management oversight of case work. Weekly case discussions allow managers to provide greater scrutiny and challenge 18 3.9.10 On 11.06.14 Harrow social worker2 made an unannounced visit to the Ealing B&B. The caretaker told him that Mother left over the weekend with her 'boyfriend'. The social worker then went to Father’s parents’ house, where there was no reply there and neither of the parents answered their phones. 3.9.11 Harrow social worker 2 found Mother at the Ealing B&B the next morning, with the children. There was an unidentified 'older person' asleep. The social worker advised Mother that the children should not have contact with Father until he had been assessed. There had been no progress in accessing dentist, or addressing the children's health needs. The room was cluttered, and the children’s feet dirty. Mother was planning to visit a close relative the next week who was known to be a drug user. 3.9.12 Following this visit the case was discussed within a 'pod' supervision session on 13.06.14 with a decision to start the paperwork for a legal planning meeting. 3.9.13 The second Core Group Meeting was on 19.06.14: Mother failed to attend despite having been reminded of the meeting 2 days earlier by Ealing health visitor2 (when Mother had forgotten an appointment with her). Mother spoke to Harrow social worker2 on the phone several times saying she was on her way, but never arrived. 3.9.14 Ealing health visitor2 reported that she had only been successful in seeing the children on one occasion, and that Mother failed to attend three clinic appointments and one ‘home’ visit. In consequence there had been no progress made on the actions on the Child Protection Plan. The decision to hold a Legal Planning Meeting was shared. Mother attended the office later that afternoon and was updated on the Core Group Meeting. 3.9.15 When Harrow social worker2 and Ealing health visitor2 did a joint visit to the Ealing B&B the next week, the children had just woken up at lunch time, the room was cluttered with clothing, cigarette butts and lighters. Sibling 2 put a butt in his mouth, pretending to smoke. Mother said sibling 3 was registered with a dentist and waiting for an appointment. 3.9.16 Mother was told to register the children at Nursery by the end of the week. A further appointment was made with Ealing health visitor2 for a weight review at the clinic on 01.07.14 and Mother was reminded of her appointment with Ealing RISE (substance misuse service). She was told that there was grave professional concern for the children's safety. 3.9.17 Ealing health visitor2 accompanied the substance misuse worker to the home on 26.06.14. Mother was encouraged to access a Children's Centre for Baby F, aged nearly 10 months. First half of July 2014: Plans for legal intervention progress, family move to Harrow and change of social worker 3.9.18 The Mother failed to attend her appointment at Ealing RISE on 30.06.14 and also did not take the children to the clinic for their weight check on 01.07.14. On 03.07.14 the housing officer emailed Harrow social worker2 about Mother's lack of co-operation in attending appointments and providing documentary evidence. She had previously been warned she 19 would lose her accommodation and the case was then closed due to this lack of co-operation, despite the children being subject to a child protection plan. 3.9.19 Harrow children's social care agreed to house the family and that afternoon another social worker (Harrow social worker3) arranged B&B accommodation in Harrow (fourth B&B placement in the review period). 3.9.20 Harrow social worker 2 had been on sick leave, so the plans for the legal planning meeting had not progressed until the pod manager requested a Legal Planning Meeting on 04.07.14, because of parental alcohol and substance misuse, parental lack of engagement and neglect of the children's needs. 3.9.21 The case was re-allocated to Harrow social worker3 on 07.07.14 because of social worker 2's ill health. The new social worker met the family the next day when Mother attended a housing appointment. A new B&B placement was provided in Hounslow (fifth 5th B&B placement) on 08.07.14. In approving the finance for the B&B the Harrow children's social care service manager expressed concern about what work had been done to date and asked for an update. 3.9.22 A Legal Planning Meeting took place the next day when it was agreed that the threshold for initiating proceedings was met, and that the PLO11 route would be taken. 3.9.23 Harrow social worker2's had written the report for the child protection conference and provided his successor with an email summary of the case. The report cites the difficulties seeing Mother, her lack of registering for services for the children, sibling 3's tooth decay and toothache, Baby F's weight loss, concerns about the children's diet and the overall lack of progress on the protection plan. 3.9.24 Ealing health visitor2 did not provide a report, but attended the conference and reported that the children were up to date with immunisations, but she had been unable to carry out their developmental checks. The two older children were registered with a dentist and had their teeth examined. The referral was made for Speech and language therapy for sibling 3, but the children had not been registered at a nursery. 3.9.25 The decisions of the conference were similar to the previous plan, but with the added recommendation of a further legal planning meeting with a view to initiate care proceedings 'forthwith' and putting a police alert on the current address and the family to be reported officially missing if professionals were unable to access them. 11 The Public Law Outline [referred to as the PLO], is a revision of the 2003 Judicial Protocol, which was itself an attempt to reduce unwarranted delays in family court cases. The PLO emphasises the importance of strong judicial case management throughout a case; of narrowing the issues in dispute and seeking to resolve these at a much earlier stage; of reducing the amount of written material and oral evidence so that practitioners can focus on the big issues in a case; and of introducing a pre-proceedings gate-keeping regime to ensure local authority cases are better assessed prior to an application to court being made. 20 Comment This two and a half month period is the first time that professionals consistently tried to see the children and Mother. Unusually given the past, the family appear to have remained in the locality and with a great deal of perseverance both Harrow social worker2 and Ealing health visitor 1 do manage to see the children, albeit with great effort and somewhat infrequently. This was a case that understandably caused the social worker great anxiety (as he explained the review process), being unable to make any real progress with the child protection plan. Despite the fact the children were subject to a child protection plan, Housing ceased to finance their B&B and closed the case without notice to the social worker; this suggested working in isolation, and should have been addressed via co-ordinated activity between housing and children's social care. There was a slow professional response in terms of implementing the contingency arrangements defined in the protection plan, in particular legal proceedings. The lack of individual supervision sessions for the social worker would have been a major contributory factor to this slow decision making. See 4.8 for discussion of management issues. 3.10 Immediate Harrow case management following review conference: mid July 3.10.1 On 14 July a discussion took place between Harrow social worker3, two 'pod' managers and Harrow team manager2 about whether to initiate proceedings immediately rather than follow the Public Law Outline (PLO) route. They agreed daily visits to the family, a strategy discussion with the police and a further discussion with the Service Manager for a decision to be made. 3.10.2 Harrow social worker3 got no response to his home visit the next day and emailed his concerns to the service manager, Harrow team manager2 and the pod manager. The service manager, Harrow team manager2 and the pod manager met and agreed to ask the B&B to log Mother's whereabouts and her visitors. Through liaison with the caretaker it was anticipated visits would be more successful. 3.10.3 The police child abuse investigation (CAIT) team queried the need for a strategy discussion, and declined a joint investigation and the request for uniformed police to visit after only one failed visit. Harrow team manager2 advised the pod manager that another legal planning meeting be convened and for uniformed police to be called if the social worker remains unsuccessful in seeing the family. 3.10.4 Harrow social worker 3 made a referral to the Harrow substance misuse service, Compass Hidden Harm that day. The co-ordinator came out with him on a joint visit immediately, knowing Mother from an earlier successful period of intervention. The family were home and no concerns were noted about their physical and emotional presentation, nor about the home conditions. Sibling 3 had a bite mark said to be caused by sibling 2. The caretaker reported a man visiting every day, but Mother stated she had no visitors. The Compass co-ordinator planned to undertake an immediate drug test, but Mother refused, denying any drug use. 21 3.10.5 Also on 15.07.14, the audiologist discharged sibling 3 as a partial booking letter was returned as address was not correct. 3.10.6 On 17.07.14 the family moved to Harrow in their sixth B&B placement. Harrow social worker3 visited Mother, provided the pre proceedings letter and noted positive interaction between her and her children. The second legal planning meeting was held that day and decided to continue follow the pre-proceedings route following the positive visit and to give Mother the opportunity to be able to demonstrate if she had the capacity and motivation to change. Comment In the week following the review conference, the case was high profile involving three managers within Harrow children's social care after the family was not home when the social worker called. The review recommendation of involving the police if the family weren't home when visited was shown not to be feasible, as the police understandably did not see the need for their involvement on the basis of the family being out when an unannounced visit was undertaken. The impact of being homeless and constantly moving was evident with the 6th B&B placement for the family in the period under review, before the health visitor allocated in Hounslow had had the time to visit them. The Compass co-ordinator demonstrated very good practice by responding instantly to the referral and undertaking an immediate joint visit. 3.11 Mother thought to be engaging better: late July - 10.08.14 3.11.1 Mother was more co-operative once she knew of the initiation of the legal process. She started by attending an appointment at housing and providing requested documents on 21.07.14. However, she deferred drug testing for 11 days, having missed an appointment with the Compass Co-ordinator on 17.07.14, and asked instead to be seen on 28.07.14 (which was not possible for Compass). 3.11.2 A pre-proceedings meeting took place with Mother on 23.07.14. Father was not included in this action. The pod manager felt that Mother engaged in the meeting and a written agreement was signed (albeit this has not been located in the records). 3.11.3 The pod manager drew up an immediate plan of action on 25.07.14 for a Family Group Conference (FGC) referral and nursery placements identified by 30.07.14; a parenting assessment and a hair strand test to be completed by 06.09.14; an updated social work report by 08.08.14 and a review pre-proceedings meeting on 02.09.14. The manager also informed the police of the case going in the right direction following the pre-proceedings meeting. This view was communicated to the service manager and discussed in pod supervision on 04.08.14. 22 3.11.4 When Harrow social worker3 visited on 28.07.14 he discovered that Mother had dyed her hair, although she denied this. Harrow social worker3 concluded this was to avoid a hair strand test for substance misuse. Mother said that sibling 3 had seen the dentist and was to have 5 teeth removed. Harrow social worker3 checked the position with the dentist on 30.07.14 who confirmed the procedure would be undertaken at hospital. 3.11.5 The new health visitor (Harrow health visitor3) was allocated the family on 30.07.14 and immediately liaised with the social worker, the dental surgery and arranged a visit with Mother the next day. 3.11.6 The family was home for the appointment, with children dressed only in nappies. 11 month old Baby F was lifted from his soiled sheet and his nappy needed changing. The two older siblings kept opening the door, running outside, hitting and biting others, including Baby F. 3.11.7 Mother agreed to attend the clinic on 01.08.14. However, Mother then cancelled the appointment due to baby F having a sickness and diarrhoea bug, but said she wanted to see Harrow health visitor3. She did turn up at the clinic three days later, when Harrow health visitor3 observed the children to be clean and tidy, but was unable to assess the children because they were still poorly. 3.11.8 Mother attended a core group meeting for the first time on 05.08.14, meeting with Harrow social worker 3 and Harrow health visitor 3, leaving her children with maternal grandfather. Plans included progressing a referral for a Paediatric Assessment of both siblings, a speech and language referral for sibling 3 and encouraging Mother to register at the local Children’s Centre for playgroup for the children. The same day the local centre confirmed that Mother had requested two free-funded places. 3.11.9 Harrow social worker 3 made a referral to Early Intervention Support12 (EIS) for Mother on 06.08.14 and discussed this with her on his announced visit the next day. The only concern noted was the smell of smoke in the room. Harrow social worker 3 was positive about mother's recent engagement. Comment The Ealing health visitor (Ealing health visitor2) commendably attended Harrow on 29.07.14 for the core group meeting, despite case responsibility having moved first to Hounslow and then to Harrow. Unfortunately she had not been informed the meeting had been postponed. She then telephoned her colleague in Harrow to give her the history. This demonstrated a recognition of the need for continuity in the face of the family's constant moves. It was positive for the pod manager to take responsibility to identify actions required with dates. There appears to have been a very long time frame allowed for the hair strand test for substance misuse. 12 Early Intervention Teams provide integrated support to children, young people and families 0-24 (LDD). The key objective of the service is to provide evidence based early intervention, advice, support and direct case work to prevent issues escalating and requiring statutory intervention. 23 The positive view of Mother's engagement discussed at the pod supervision on 04.08.14 does appear to have some basis. The focus on tasks to be completed is necessary, but does not address the underlying assessments needed of parenting capacity and motivation to change. It is not at all clear how this can be undertaken during home visits with three children, who are all needing a great deal of attention. There appears to be no reference to Father and his current role in the family, although sibling 2 mentions 'daddy' and Mother states this refers to maternal grandfather. The social worker and manager begin to start the process of understanding the family by requesting information from another borough (where Mother had previously lived and where her eldest child (Sibling 1) was living) and asking Mother for family details to progress the FGC. 3.12 Circumstances deteriorate rapidly from 11.08.14 3.12.1 The situation deteriorated from this point, with the family being asked to leave the B&B on 11.08.14, due to Mother smoking and knocking on doors to borrow money. Mother signed an agreement with Harrow social worker 3 about rules when living in a B&B and was moved that day to a seventh B&B placement. This was also in Harrow. 3 days later they were moved to another B&B in Harrow, the eighth placement, with the same complaints about her behaviour emerging. 3.12.2 The Compass co-ordinator arranged an assessment appointment for 26.08.14, when it was planned Mother would attend the office. 3.12.3 On 19.08.14 Harrow health visitor3 visited the B&B, but the family was out. Harrow social worker3 visited the next evening and saw the children. The B&B Manager told the social worker that he believed Mother used drugs being delivered to her by men. He explained that a male knocked on the door aggressively every morning and she let him in. Another male had also been seen in the room. She had borrowed £50 from the B&B manager and asked another member of staff for a small amount of foil. He had overheard her asking for “one B’s” (slang for heroin) when speaking on the telephone. The two older children had ran across the road unsupervised in their nappies and members of staff had to bring them back. The Manager agreed to put his concerns in writing. 3.12.4 Mother appeared pale and dishevelled, but denied having visitors, and explained the children were playing. She provided names and contact details of family members for a family group conference. Harrow social worker3 communicated this information to Compass and managers at children's social care stating his concern that 'Mother's behaviour mirrors past behaviour and feels the children are at risk of significant harm'. 3.12.5 The next day the service manager convened a legal planning meeting in the afternoon attended by the service manager, Harrow team manager 2, Harrow social worker3, Harrow legal advisor and the Compass co-ordinator. 24 3.12.6 The legal advice was that the threshold had been met for legal proceedings and the meeting considered options 'to manage risks' until an interim care order (ICO)13 hearing could take place in court after the Bank Holiday. By this time it was out of hours and the decision was to ask police for assistance in a joint visit that evening. 3.12.7 Harrow team manager2 had a telephone strategy discussion with the Police and a joint s47 enquiry with a joint home visit agreed for that evening at the B&B. The Police were told by Harrow team manager2 that legal advice was that the threshold had already been met to issue proceedings. 3.12.8 At 8.30pm that Thursday evening Harrow social worker3 made a home visit with two police CAIT Officers. The room was untidy and an asthma inhaler was found, with foil inside, considered likely to be used for smoking heroin. This was removed for testing, with Mother denying that it was hers. No heroin was found during the police search of the room and the police were clear that the threshold to remove the children under Police Powers of Protection (PPoP)14 was not met. The social worker knew Mother would not agree to the children being accommodated under s.20 Children Act 1989 and then suggested the family stay with relatives, contacted a family member to discuss this. This proved to be not possible for the relative. 3.12.9 The next day a case discussion took place between a second legal advisor, service manager and Harrow team manager2. The social worker and pod manager were on leave. The decision was taken to proceed with an application for an Interim Care Order (ICO) after the Bank Holiday, as the grounds for an Emergency Protection Order (EPO15) were not met. If there were any further concerns over the weekend, an EPO should be sought. 3.12.10 Harrow team manager2 planned to visit Mother with the Compass co-ordinator, but Mother left the B&B before this was accomplished. Arrangements were made for Mother and the children to be visited regularly over the Bank Holiday by a sessional EIS worker, who would also contact the Compass co-ordinator to attend for a drug testing. 13At the start of care proceedings, the council asks the family court to make a temporary court order, called an ‘interim care order’ or ICO under s.38 of the Children Act 1989. If the court agrees, the council can take the child into care on a temporary basis. This can be for up to 8 weeks at first. After that, it can be renewed every 28 days. 14 The Police have powers under s. 46 of the Children Act 1989 to protect children. If a police officer believes that a child is at risk of suffering significant harm in a particular situation then s/he may exercise powers under this Act to remove the child to suitable accommodation or if the child is in hospital or in a place of safety, take steps to keep the child there. A child cannot be kept in police protection for more than 72 hours. 15 An emergency protection order or EPO is a court order granted under Section 44 of the Children Act 1989 on the grounds that a child will suffer significant harm unless they are removed to council accommodation or moved from where they are currently living. 25 3.12.11 The EIS worker planned to visit the family on the evening of Friday 22.08.14, but the Manager of the B&B told her that Mother and the children were out that evening. She telephoned Harrow team manager2 for advice and agreed to go twice on the Saturday: morning and early evening. The B&B manager was advised to call police if any concerns arose over the week-end. 3.12.12 The EIS worker went to the B&B at about 09:10 on Saturday 23.08.14 and saw the family. There were no evident signs of drug taking. The EIS worker arranged to return about 17:00 when they would go to the park; this would enable her to better assess the children out of the confines of the B&B. 3.12.13 At 16:18 that day an ambulance was called to the B&B where baby F was reported as not breathing. Mother explained to the Fast Response Unit when they arrived that she had left baby F in the bath unattended whilst she got his bottle. When she returned he was in the bath not breathing. Oxygen was administered and CPR commenced, before baby F was transferred to hospital. 3.12.14 PPoP were taken on the siblings that evening and they were placed with foster carers. Comment The social worker correctly identified the risk to the children, having received the information from the B&B manager on the evening of 20.08.14 and he recalls emailing his manager immediately, copying in more senior managers. The lead reviewers have been provided with different understandings of the decision making the next day ( 21.08.14) and what was anticipated would be the outcome of the joint visit that evening. It was entirely appropriate to consider the available options to intervene that day, as well as the plan to initiate care proceedings after the Bank Holiday. However, the misunderstandings around the use of PPoP are discussed in 4.6 26 4 THEMATIC ANALYSIS 4.1 Introduction 4.1.1 Section 5 considers professional practice themes that emerged from this case exploring what helps and hinders good safeguarding practice. Section 6 provides the concluding systemic findings and recommendations arising from this analysis. 4.1.2 The LSCB identified particular areas of learning to be considered as part of this serious case review. These are the strengths and weaknesses of the multi-agency safeguarding system with regard to: Homeless and mobile families Substance misuse by parents Barriers to improving practice around neglect (in the context of previous focus by the LSCB on neglect) Where can we identify good practice in this case and what aspects of the multi-agency system support such practice? 4.1.3 Discussion of these is included in this analysis. 4.2 Midwifery failure to recognise need for pre-birth safeguarding referral 4.2.1 This was Mother’s fourth pregnancy and there was a history of previous risk factors relating to what was defined as her 'chaotic life', substance misuse, domestic violence, post natal depression and self harm and general neglect of her children's needs. This led to siblings 2 and 3 being subject to child protection plans between 2010 and 2012, and sibling 1 living with a family member. 4.2.2 This history should have been well known to maternity services at Northwick Park Hospital as they had been involved during Mother's previous pregnancy, when there was a pre-birth conference and a child protection plan for the unborn baby. Also from the last pregnancy there was knowledge of Mother's serious health conditions which required additional monitoring during pregnancy. 4.2.3 Maternity services repeatedly missed the need for an urgent referral for a pre-birth assessment. This was due to not: Accessing Mother's notes (containing her history) as she was not booked-in and Identifying her current circumstances (domestic violence, in a refuge, lack of ante-natal care and attendance at appointments, neglect of own health needs) as being a risk, requiring accessing her history and a referral to children's social care 27 4.2.4 Mother's previous history was on the records of the Jade team, who provided the service on Mother's previous ante-natal care. This is a specialist team for vulnerable Mothers. The Jade team was set up with the philosophy that vulnerable women have individualised care, continuity and ongoing support during and post maternity service involvement. Staff were aware that the Jade team had prior involvement, but did not access the history. Whilst there was an attempt to liaise with the Jade team, with one message left, this was not followed up. 4.2.5 The fact of previous involvement of the Jade team should have triggered the need to access the records. The author is advised that when patients are not 'booked-in' for midwifery services, staff are not able to access their historical records. The lack of routine access to a patient's records is a systemic failing, and should not be dependent on whether the patient has 'booked-in' or if the staff 'booked-her in'. 4.2.6 Moreover, this inability to access the records given the risk factors associated around the two inpatient episodes, poor general health, concerns about non attendance at appointments and domestic violence, should have triggered the need to urgently 'book-in' the Mother for antenatal services, which would have given access to the history. The reasons behind this failure in the basic duty of a midwife, has been attributed by practitioners to the length of time the booking process takes (around an hour). The lack of attendance at appointments contributed to the failure to book Mother in for antenatal services and at one point this was referred to the safeguarding midwife. However there is no evidence of her advice being followed to undertake a home 'booking-in. 4.2.7 A further worrying aspect to the midwifery service was the response when Mother missed a 3rd appointment due to GP advice (she had contact with chicken pox) was to inform Mother to return to the GP if she wanted a referral to Northwick Park Hospital, or attend her nearest hospital. Such a response to hard-to-reach patients has long been recognised as flawed, especially in the Mother's circumstances of needing to be monitored. 4.2.8 There has been discussion within the review whether Mother should or should not have received services from the Jade team. Given her vulnerability, this should have happened in the current configuration of service delivery. However, there is also debate about whether it is helpful to have such a separate team, given the need for all midwives to be able to identify and support vulnerable parents, as opposed to seeing this as the remit of a specialist team. This risk has been highlighted in a previous case review undertaken involving this midwifery service and been recognised within the internal subsequent service review: 'The principles of establishing specialist midwifery team to provide expertise in managing and supporting women with particularly complex and challenging child protection concerns is commendable. ....... The difficulty then arises ......, subsequent midwifery colleagues become deskilled in this challenging area of health care, delegation of recognising, responding and 28 reporting becomes a specialist role when all midwives have a statutory responsibility for safeguarding children'16 4.2.9 The major concerns about the failure of midwifery to identify risk, book-in the Mother for services and make a pre-birth referral to children's social care are addressed in the first finding and recommendation in section 6. 4.3 Professional difficulty in dealing with avoidant parents leaves children at risk of significant harm over a long period with their circumstances not being assessed 4.3.1 Mother was considered to have a 'chaotic lifestyle'. This may or may not have been true, but it tended to be accepted easily as an excuse for her not attending appointments. In fact her behaviour was largely predictable when seen over time, not answering her phone or responding to messages and not keeping appointments, even when the children were subject to child protection plans and written agreements. 4.3.2 Mother's apparent mobile lifestyle may or may not have been real, but it acted as a very successful way to avoid professional contact, constantly telling practitioners she was out of Harrow for that week, or for several weeks. 4.3.3 This behaviour of not answering her phone or claiming to be out of the locality was from Mother's perspective an extremely successful way of avoiding professional assessment of the risks to her children, so delaying and hindering the ability of practitioners to be able to obtain information to justify child protection and then legal proceedings. Mother managed to successfully divert the investigation into concerns about her children expressed in anonymous referrals through avoiding contact, and saying she was away. Consequently, despite significant concerns and allegations about the children's welfare, children's social care repeatedly did not assess the children's safety at all (see 5.5), closing the case, without seeing the children. 4.3.4 Once the case was finally allocated for assessment at the beginning of February 2014, following the third anonymous allegation, there was a determination that this time the family needed to be found. The social worker showed great persistence and determination over the next two months, but never managed to see mother or children. Neither did the health visitor. This did appropriately lead to a child protection enquiry and an initial conference, but her avoidant behaviour continued. 4.3.5 The impact of such avoidant behaviour was that before February 2014 Harrow children's social care would close the case, and from February it prevented adequate assessments of the parenting or of the children's health and development so delaying any decision making about the safety of the children. 16 Review of Maternity Safeguarding Services at Northwest London Maternity Unit (internal report December 2013) 29 4.3.6 In some instances within health, the lack of attendance at appointments led to the service being withdrawn, as opposed to raising concerns. This happened when Mother did not attend 3 midwifery appointments. 4.4 Repeated inadequate response to referrals by Harrow children's social care between August 2013 to February 2014 suggest threshold may be too high at this point in the system and /or that there are critical flaws in the understanding of responsibilities when families are mobile 4.4.1 Between August and the end of January, Harrow children's social care repeatedly either refused to accept the referral or closed the case without investigation, either on the basis that a police 'welfare' check had been done and not identified concerns, or because the family did not live in Harrow. In all these instances the priority appears to have been 'gatekeeping' by children's social care to prevent access to services as opposed to a focus on the safety of the children. 4.4.2 In August 2013 an anonymous phone call that the children were looked after by adults who were drunk led to police welfare check which established Mother was not drunk at that point. No further assessment by children's social care of the possibility that Mother and other unknown adults might be drunk at other times. Given what was known about her earlier parenting, this would not have been out of character. 4.4.3 When just after this, in August 2013, Mother was homeless and eight months pregnant and allegedly escaping threat of domestic violence by sibling 2's father, assistance was provided in terms of B&B accommodation and travel expenses to a refuge in Buckinghamshire. Given the pregnancy, the known family history, as well as the anonymous referral, it should have been clear that Mother was struggling and there needed to be an assessment of the children's needs. Because the refuge was outside of Harrow the case was closed without consideration of the need to refer to Buckinghamshire. The circumstances of Baby F's birth were referred by Northwick Park Hospital, with references to questions about the possible withdrawal from drugs of Mother and baby (later this concern is discounted). Harrow children's social care did not accept the referrals: initially on the basis that the hospital was located in Brent, so the referral should go there and subsequently as the refuge was in Buckinghamshire. On neither occasion was there any acceptance of responsibility to ensure Mother and children received help by a children's social care which was in possession of the history (see also 4.7 response to referrals from members of the public).Evidence from other agency contributions to the review indicate that Buckinghamshire children's social care originally intended to hold a strategy discussion and pre-discharge meeting prior to Baby F joining his family in the refuge, especially in the light of concerns about Mother's lack of bonding being observed: Baby F was discharged without this. 30 4.4.4 Further anonymous referrals in November 2013 about parental substance misuse and neglect of the children were not investigated other than police welfare checks (see discussion of these in 5.5 below). Whilst a s.47 was briefly initiated, the case was closed on the totally mistaken insistence that Buckinghamshire would be responsible, even though the family were no longer there. 4.4.5 During these six months when Mother was very pregnant and the first 5 months of baby F's life it is very difficult to understand the lack of any social work assessment or s.47 enquiry in November, given the very high level of risks in this family on the current concerns in the context of Mother's history. The priority appears to have been in for Harrow children’s social care to not get involved at all, despite the fact that the family were self evidently a Harrow family, and mother's moves (if they did occur) were temporary and short. 4.4.6 The outcome of the avoidance of involvement in both authorities was that Mother and children, including a new born baby continued to live a nomadic lifestyle without there being any investigation of the considerable concerns that were being reported. 4.5 Homeless and mobile families Mobility and/or avoidance? 4.5.1 It is well recognized that children can be particularly vulnerable when families move between local authorities, especially because of the lack of continuity of services and changes. For this reason the London Child Protection procedures17 have, since the initial edition in 2002, included a chapter covering the arrangements between agencies in different authorities, so as to minimize risk to children. 4.5.2 Mother stated she was constantly moving around, going to visit family in Ireland or elsewhere in the UK. It would be difficult to speculate how much of this moving around is because she is a Traveller and how truthful she was about travelling as opposed to saying she was elsewhere so as to avoid professional contact. Her own parents, also Travellers, are now settled in Harrow, but Mother was clear when interviewed for this review, that her life experience has been moving around, which contributed to her lack of consistent education and learning to read. 4.5.3 The impact of her apparent high mobility was that professionals were often unaware of her whereabouts, so could not assess the needs of the family or the risks to the children. Moreover this mobility prevented the children being able to attend Children's Centres and pre-school. 17 London Child Protection Procedures 2002 edition 1; 2003 edition 2; edition 3 2007; edition 4 2011, edition 5 2015 31 4.5.4 Even more disturbingly was the impact such reported mobility had on the ability of professionals to undertake assessments, even when there were child protection allegations that needed investigating. The response in Harrow was for children's social care to close the case as opposed to either continue with the investigation or ensure this was being done elsewhere. At one point both Harrow and Buckinghamshire closed the case based on the false assumption that it was open to the other area. 4.5.5 Once the children were subject to child protection plans, the travelling around the UK became less of a feature as opposed to Mother's avoidant behaviour (see 5.2). However, Mother's homelessness, her inability to comply with the requirements to produce evidence for housing and latterly her own behaviour led to constant moves between B&Bs. Some moves were in Harrow but she was also placed in Ealing and in Hounslow. This led to enormous obstacles in providing for the children's health needs as moves between boroughs led to changes of health visitors and the loss of appointments at dentists and audiology (in the case of sibling 3). Accommodation provided to the family 4.5.6 During the 20 month period under review the family were provided with eight different B&B placements by Harrow Council. They were also known to have had a placement in a refuge in Buckinghamshire. For much of the time it was not known where and in what circumstances the family were staying and what implications this had on the welfare of the children. 4.5.7 The reason for the constant moves was not always apparent, but involved being asked to leave because of the behaviour of mother (asking others for money), mother choosing to give up the accommodation, decision by the housing authority as well caused on one occasion because mother did not produce the written evidence that had been requested - in that case the family were evicted, despite being subject to a child protection plan, and children's social care had to step in with a new B&B. 4.5.8 The use of B&B accommodation is not good practice for families, although in recent years the shortage of properties available has led to an increase in its use, especially in London. Shelter18 gives the following advice on their web-site: 'The law says that councils should only place families and pregnant women in bed and breakfast hotels when no other accommodation is available. If you are placed in a B&B, this should not be for more than 6 weeks'. 4.5.9 Amelia Gentleman in The Guardian19 in 2013 points out that the number of families placed in B&B had been increasing over the previous decade and quotes Shelter research: 18 http://england.shelter.org.uk/get_advice/homelessness/emergency_accommodation_if_homeless/emergency_housing_from_the_council 19 http://www.theguardian.com/society/2013/nov/04/homeless-families-b-and-b-highest-decade 32 'based on interviews with 25 families who were, or had recently been, living in B&Bs, found that most felt unsafe. Almost half said their children had witnessed disturbing incidents, including threats of violence, sexual offences and drug use and dealing.... Most of the families lived in one room, and half said their children were sharing beds with their parents or siblings. Twenty-two said it was very difficult to find a safe place for their children to play, 12 had to share kitchen facilities, and three had no cooking facilities. One family reported sharing a cooker and a fridge with 22 other people. Two-thirds of the families interviewed said their children had no table to eat on, more than half had to share a bathroom or toilet with strangers, and 10 families shared with seven or more other people...'. 4.5.10 In this case the professional observations all appeared to be around the family having one room. In one place mother complained about vermin in the premises and in another it was observed the children were able to open the door and get out of the room, and were constantly getting out of the room. Additionally, the family were in B&B accommodation well in excess of six weeks. Impact on practitioners 4.5.11 Mother’s high mobility, combined with her active avoidance of professionals and appointments, made this family a real challenge to professionals, who carried the responsibility and duty of care to the three children. 4.5.12 Individual discussions with those involved confirmed that it was very frustrating, stressful and tiring trying to work with Mother and safeguard the children. Many of the professionals involved showed great tenacity, and this is to be applauded. Especially of note here are social workers involved with the family in 2014 and the Ealing health visitor who took on responsibility after the family moved out of Ealing to liaise with her counterparts in Hounslow and Harrow and even to try to attend a core group meeting. 33 4.6 Role of police welfare checks and of Police Powers of Protection Welfare checks by police 4.6.1 There was a repeated theme that when police undertook welfare checks in response to concerns, their conclusion that the children were safe and well was misunderstood as there being no basis for the referrals. 4.6.2 To the credit of the police these visits always done promptly and in full liaison with children's social care. They were useful in so far as establishing if there was any immediate risk to the children (at the point of time of the visit). Such a check though provides a snapshot at a moment in time and whilst of immediate use, cannot replace an investigation of the allegations or concerns, as is the responsibility of children's social care. 4.6.3 Within children's social care in Harrow there was an assumption of 'malicious' referrals on the basis that police found no evidence to support the allegation, as opposed to an understanding of the limitations of such police welfare checks. Police Powers of Protection (PPoP) 4.6.4 On 21.08.14, there was high level concern about the immediate risk of harm to the children and whether action should be taken immediately, prior to the Bank Holiday, to remove the children. 4.6.5 In this decision making a misunderstanding of the role of Police Powers of Protection (PPoP) occurred, along with an apparent misunderstanding of the legal advice provided to the local authority by their legal advisors. 4.6.6 The service manager described in the review process that on hearing of the increased concerns about Mother's suspected use of heroin and lack of adequate supervision of her young children, she immediately convened a legal planning meeting to obtain advice. This meeting was attended by the team manager, social worker and the substance misuse co-ordinator. 4.6.7 Discussions were held about the possibility of removing the children that night, which was what the service manager considered was needed (according to her contribution to the review). Various options were explored, including PPoP, applying for an Emergency Protection Order (EPO), the use of s.20 voluntary agreement (which mother was thought unlikely to agree) and the family staying with a relative. The latter was thought to be risky as Mother could change her mind. 34 4.6.8 There are different understandings of the legal advice provided that day, but all agree that the view was that the grounds had been met to issue care proceedings and that this would be implemented after the Bank Holiday. The legal advisor to the serious case review panel reports that the grounds for an EPO were not however met, as the concerns were ongoing and the risks had not substantially changed. This is though different to the understanding of the social worker and managers who attended the meeting and considered that the taking of an EPO that day was an option, and the grounds for such action were met. 4.6.9 The service manager explained that the decision agreed at the end of the meeting was for a joint visit by police and social worker that evening, with a request to police for the children to be removed under PPoP. The use of an EPO was decided against due to the fact that by this time it was after office hours (this does not prevent the use of an EPO, but does make it a longer more complex process). 4.6.10 This expectation within children's social care that the police would use PPoP that evening has been reported by both social work and police participants to this review, and caused misunderstanding between those involved at the time about the appropriateness of such an expectation. PPoP can only be used if there is evidence of immediate harm to the children. That was not the case, so it was not an option for the police officers concerned. The lack of removal of the children that night came as a disappointment to the children's social care service manager. 4.6.11 The next day the service manager considered what other options were available to get the children out before the week-end and a further legal planning meeting was held. The understanding of the legal advice provided as explained by those involved that day, was that the grounds for an EPO were weakened because the police had not found evidence the previous evening for a PPoP. The serious case review panel is advised that this would not necessarily be the case, but that the grounds for an EPO were weak as described in 4.6.8 above. 4.6.12 Whatever the advice provided, the decision for legal intervention lies with children's social care and not with legal advisors: if the view was that the risk to the children was too great to leave them over the week-end, this could and arguably should have been put to the Court. The new information provided by the manager of the B&B had changed the evaluation of risk for the social workers. 4.6.13 In conclusion there was a misunderstanding by staff within children's social care of the use of the PPOP as opposed to an EPO. Also if the managers were convinced that the children needed to be out of mother's care, as has been communicated to the lead reviewers, this should have been tried, even if the legal advice was there were insufficient grounds. 35 4.6.14 This is not the first time that the use of PPoP instead of an EPO has arisen in case reviews in Harrow. In a learning review in 2012, a recommendation was made that 'Police Powers of Protection should only be used in an emergency and not as a replacement for an Emergency Protection Order'. 4.6.15 In discussion with practitioners as part of this serious case review, police officers confirmed this misunderstanding by children’s social care of the police role, which has on occasion caused tension between the two services. 4.7 Response to referrals from members of the public 4.7.1 A feature of this case was the number of 'anonymous' referrals during the period under review, sometimes with the same referral being made to both police and children's social care. Although anonymous in terms of not wanting her/his identity disclosed or on records, it is understood that the identity of two of the referrers was in fact known. The referrals were made in three different time periods and on each occasion the police visited the family home and found no evidence of immediate harm. However, these visits were either not followed up by children's social care (August 2013) or not followed up effectively due to Mother and children not being seen due to Mother's claims she was travelling. 4.7.2 What is also notable in this case was the final trigger to initiate legal proceedings and to consider emergency removal of the children came from information supplied by staff at the bed and breakfast accommodation, as opposed to professional contacts and assessments. Unfortunately baby F died in the week-end prior to the implementation of the resulting plan to initiate care proceedings after the Bank Holiday. 4.7.3 Other than the manager of the bed and breakfast accommodation there is no evidence that the various referrers were offered the opportunity to meet with and fully discuss their concerns with a social worker. In one instance there is evidence from records that because of the lack of any evidence from the police visit, assumptions were made that the referral was 'malicious'. 4.7.4 When the London child protection procedures were first written in 200220 the author (also the author of this report) provided the instruction that when members of the public make a referral they should 'be offered the opportunity of an interview'. This has remained part of every edition of the London child protection procedures since that time. The reason for this instruction was partly in recognition of a cultural bias towards professional referrals and wariness of anonymous referrals, but also an appreciation of the limitations of telephone and written communications. These are likely to only form a small part of the information that is available and follow up interviews provide the opportunity to explore and obtain fuller understanding of the basis of concerns and information. 20 London child protection procedures edition 2002 and edition 2 2003. 36 4.7.5 Interviews with concerned members of the public will usually provide relevant additional knowledge such as suggestions of alternative sources of evidence, including other individuals who may be able to contribute to any assessment of the concerns, as well as how best to do undertake any resulting investigation. The author though is aware from other case reviews and case audits over the country, that face-to-face interviews of referrals from members of the public do not form part of usual professional practice. 4.7.6 The serious case review process has been able to identify and speak with one of the individuals who tried to make a referral. This has highlighted the inadequacies of the earlier responses, as it is evident that s/he would have been able to have provided further evidence about the children's care and of other concerned individuals who may have been a source of further evidence. 4.7.7 In conclusion our multi-agency safeguarding system relies on an understanding that safeguarding is everybody's responsibility and that means not just social workers, not just professionals, but also members of the community. When that duty is exercised by members of the public, their concerns need to be heard and investigated fully, as these referrals come from those who may (and in this case evidently did) know most about the family's circumstances. 4.8 Management oversight and supervision 4.8.1 The role of both management and critical reflection is especially important in cases of neglect, as a there is a risk of becoming desensitised to the conditions of individual families living in chronic neglect circumstances. Moreover, because of its nature, intervention in neglect cases often involves building up evidence over time, and the need for management oversight to identify when 'enough is enough'. With avoidant parents where it becomes impossible to get information and make assessments, due to lack of direct contact, it is very much a management decision about the need for more assertive intervention. 4.8.2 Working Together 2015 emphasises the important role of critical reflection in supervision: “No system can fully eliminate risk. Understanding risk involves judgement and balance. To manage risks, social workers and other professionals should make decisions with the best interests of the child in mind, informed by the evidence available and underpinned by knowledge of child development. Critical reflection through supervision should strengthen the analysis in each assessment.”21 21 Working Together 2015, DfE, paragraph 46-48 37 4.8.3 There is evidence that within health, health visitors were discussing this family in their safeguarding supervision and that by July concerns were being raised with Harrow children's social care by the Safeguarding Children Advisor in Ealing Community Services 4.8.4 The allocated Harrow social workers were in the Child in Need team, which is split into 'pods', each with a 'pod' manager, who provided weekly group discussion on cases of concern for all the staff in the 'pod'. However, this case was never discussed in individual supervision with a line manager. This is a major weakness with such a case and this omission will have been a major cause of the delay in moving from child in need to child in need of protection, and the subsequent delay in holding a legal planning meeting and moving into initiating the PLO. 4.8.5 Also in this case, evidence from the practitioners involved at the time indicates that the allocated social workers were themselves extremely worried about the circumstances of these children and felt insufficiently heard and supported about the need for more assertive intervention at an earlier stage. One practitioner spoke of his view at an earlier stage of the need for legal intervention, and his strategy of copying in more senior managers to emails to highlight his concerns. Within children's social care management there is now a view that management at the time had been too 'process' driven, which led to the concerns of practitioners being insufficiently heard. 4.9 Understanding a family's history 4.9.1 The understanding of a family’s history with an agency is a fundamental basis for any assessment from deciding how to respond to a referral, to decisions about threshold and types of intervention further along the ‘child’s journey’ with professionals. The rationale for this is, as noted by Munro22 : ‘The best predictor of future behaviour is past behaviour...’. 4.9.2 This is particularly important in cases of chronic neglect, which is typified by improvements and deteriorations in parenting capacity, often in line with the levels of support provided. Brandon et al23 refers to the 'start again syndrome' in neglect cases when the history is either not known or largely ignored: 'In families where children suffered long term neglect, children’s social care often failed to take account of past history and adopted the ‘start again syndrome’. 22 Eileen Munro 'Effective Child Protection' 2nd edition, Sage Publications 2008.ISBN 978-1-4129-4695-7 (pbk) 23 Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003–2005 Marian Brandon, Pippa Belderson, Catherine Warren, David Howe, Ruth Gardner, Jane Dodsworth, Jane Black (DCSF 2008) 38 4.9.3 The practice in this case highlights both systemic and practice weaknesses in accessing and understanding the history of the family. 4.9.4 Within midwifery, there appears to be systemic obstacles in accessing the history when women are not 'booked in' for a service as discussed in 4.2 above. However, over and above the systemic problems was evidence of a lack of understanding the importance of accessing the history in the context of knowledge that the Mother had been previously identified vulnerable (received services by the Jade team), reported herself as fleeing domestic violence and had neglected her own health care and consequently that of the unborn baby. 4.9.5 In children's social care the practice between August 2013 and January 2014 took no discernible account of the known history of the family and consequent risks to the children in the light of the current circumstances and repetition of earlier concerns. 4.10 Barriers to improving practice around neglect (in the context of previous focus by the LSCB on neglect) 4.10.1 There have been several previous case reviews in Harrow involving children living in situations of chronic neglect, as well as the LSCB devoting its annual conference in 2013 to the subject. The fact that there continue to be case reviews in Harrow around practice in neglect cases, is not surprising given that neglect continues, both locally and nationally, to be the category of child protection plan used most frequently. In the year 2013/14, the DfE statistics24 44.4% of the children who became subject to child protection plans in England were on one for neglect, with 32.8% for emotional abuse, 9.9% for physical abuse, 4.6% for sexual abuse and 9.3% for multiple categories. Within Harrow that year, the DfE statistics demonstrate a similar pattern, with 91 children subject to a child protection plan for neglect, 67 for emotional abuse, 18 for physical abuse and fewer than five children for either sexual abuse or multiple categories. 4.10.2 The practice obstacles for improving practice around neglect are those mentioned in other themes, in particular understanding the history of a family and the role of management and supervision (see 4.8 and 4.9 above). 4.11 Lack of involvement of Father and wider family in attempts to understand and assess the needs of the children 4.11.1 A common finding in serious case reviews nationally is the absence of fathers in professional assessments. Brandon et al 25 refer to this: 24 Characteristics of children in need: 2013 to 2014, https://www.gov.uk/government/statistics/characteristics-of-children-in-need-2013-to-2014 25 Understanding Serious Case Reviews and their Impact A Biennial Analysis of Serious Case Reviews 2005-07, Marian Brandon, Sue Bailey, Pippa Belderson, Ruth Gardner, Peter Sidebotham, Jane Dodsworth, Catherine Warren and Jane Black (DCSF 2009) 39 'Fathers and men: A number of issues emerged including the dearth of information about men in most serious case reviews; failure to take fathers and other men connected to the families into account in assessments; rigid thinking about father figures as all good or all bad; and the perceived threat posed by men to workers' (p.3) 'There was, yet again, scanty information about men in most reviews, particularly in relation to an understanding about past history. This pattern reflects the wider problem of the lack of information about and lack of engagement with men in child health and welfare more broadly (Haskett et al 261996). The information that was available sometimes highlighted the tentative engagement by and with men and fathers...' (p.52). 4.11.2 In this case whilst there were some attempts to involve the father in assessments, meetings and conferences the father did not co-operate. In the absence of father's involvement with professionals an unrealistic expectation was made with the mother that she should not have contact with the father unless he was assessed. This was ineffective and by the time of the initiation of the Public Law Outline had been abandoned. 4.11.3 Even more critically, the risk or not to the children of the father's involvement in their lives remained unknown in part due to a failure to undertake any basic research into his history, which involved another child of his being adopted. He also variously mentioned having other children, to his GP and within the hospital following baby F's birth. This was not known to the social workers and never consequently investigated. Wider family 4.11.4 Another weakness in this case was the lack of involvement of extended family on both sides in assessments, despite the family staying often with paternal grandparents and the known high historical involvement of maternal grandfather and siblings. 4.11.5 When wider family, and where relevant friends, are involved in assessments it becomes possible to triangulate self reported information. Moreover it provides opportunities to obtain wider information and also provide family and friends with possible ways to express concerns without having to make specific referrals. 26 Haskett M, Marziano B, Dover E. (1996) Absence of males in maltreatment research: a survey of recent literature. Child Abuse & Neglect, 20:1175-82 quoted in Brandon et al, Understanding Serious Case Reviews and their Impact A Biennial Analysis of Serious Case Reviews 2005-07 40 4.12 Voice of the child? 4.12.1 There is relatively little understanding by professionals about the wishes or feelings, or the experiences of the children, as there was little actual contact directly with them. When practitioners did manage to see the family, the descriptions are of a mother struggling to manage her three children aged under 5 years. The two siblings appear to be out of control, racing around and escaping, whilst baby F is largely on the bed or by the end of his life crawling. All the children are described usually as being just in a nappy, or vest and nappy, and often also looking dirty at times. Clearly within the surroundings of the visits, in one room, it would have been difficult for practitioners to have engaged any of the children directly on a one-to-one basis. 4.12.2 There are though some glimmers into the experiences of the children, especially in the description provided by practitioners in their interviews as part of this review. The manager of the B&B in August 2014 described baby F as smelling of stale urine and 'poo' when they arrived, that he was full of life and responded to attention, that Mother did not show much affection and left the children unsupervised whilst trying to get money from other residents 4.12.3 Overall the children lived their lives constantly moving around, usually staying in one room all together in somewhat unhygienic conditions. They did not attend any nurseries or pre-schools, so were not having the benefit of consistent relationships with other children and adults in a more formal setting, which would have assisted their development in preparation for school. 4.12.4 Sibling 3 in particular appears to have suffered through lack of his health needs being addressed, which must have left him in discomfort and possible pain. He was suffering with tooth decay and required the extraction of 5 teeth. This was not done during the period under review, despite records referring to him being in pain and the concerted efforts of a health visitor and social worker. There are also concerns about his speech and development, but the planned assessment by the speech and language therapist and paediatrician never occurred due to Mother's neglect. 4.13 Where can we identify good practice in this case? 4.13.1 Overall this case was characterised by 'too little, too late' especially in regard to the lack of midwifery identification of concerns in the antenatal period, children's social care lack of intervention prior to February 2014 and then the slowness in which the case moved to a child protection plan, legal planning meetings and initiation of care proceedings. 4.13.2 However, there were also examples of good practice in this case: The first Harrow health visitor who persevered in trying to see mother and tried to get children's social care in both Buckinghamshire and Harrow to investigate the concerns; had she escalated the failure of both children's social care services to do so, her involvement would have been even more effective 41 The team manager of the child in need service for ensuring in February 2014 that the case was allocated and that this time the mother and children must be assessed The persistence and tenacity of both allocated social workers after February 2014 enabled the risks to be identified, recognised by management and begin to be addressed The persistence of the Ealing health visitor to try to facilitate the health and development needs of the children and her continuing involvement after the children moved out of Ealing The escalation of concerns by the Ealing health visitor, leading to the safeguarding advisor communicating concerns to Harrow children's social care The willingness of police to do welfare checks in response to referrals from members of the public The good communication and partnership working between the two allocated social workers and their colleagues in health and in the police, involving a number of joint visits The attempts by staff in the refuge to find mother, identify the whereabouts of the children and maintain the placement whilst trying to facilitate the family's return 4.13.3 This case demonstrated some very good examples of safeguarding being everyone's business, with the last B&B manager and staff involved in trying to help the family, as well as reporting to the social worker the concerns about the children's care and mother's behaviour. This manager also contributed to this serious case review which has enhanced our learning. 4.13.4 Members of the public also tried to contribute to the children's welfare by expressing their concerns at the time to police and children's social care. Such responsibility towards children in our community is to be greatly commended. 42 5 FINDINGS & RECOMMENDATIONS 5.1 Introduction 5.1.1 This section contains the overall findings of this serious case review, with the associated recommendations for the LSCB. The findings relate to what we have learnt about the strengths and weaknesses in multi-agency safeguarding systems through examining what happened to baby F. 5.1.2 The LSCB has prepared a separate document with their responses to these findings and the plans to address the recommendations. 5.2 Findings 1. Systemic weaknesses in ante-natal midwifery services contributed to the failure to identify and refer pre-birth safeguarding concerns to children's social care 5.2.1 The provision of midwifery services demonstrated fundamental flaws in safeguarding practice involving the: inability to access historical records of patients who are not 'booked in' for services repeated lack of recognition of /or response to the vulnerability of a pregnant woman lack of fulfilment of the basic midwifery duty to ensure patients are 'booked' in (especially those who are vulnerable) Recommendation 1 The LSCB to ask the CCG and the NWLHT to report to the LSCB how midwifery will be able to provide a safe service which: provides access to historical patient records for all midwives, regardless of which team is providing the current service and whether or not the patient is 'booked-in' ensures that all midwives are able to identify and work with vulnerable patients, recognise safeguarding risks and make child protection referrals when required does not apply a DNA policy of withdrawing services following 3 DNAs, without reference to the fact that such behaviour is likely to denote greater need and risk provides a safety net which ensures the 'booking in' process is not avoided by staff due to time constraints and which addresses the risk to baby and patient of women who have not made use of antenatal provision 43 2. The belief that mother was a 'traveller' together with her effective avoidant behaviour contributed to a lack of effective follow up of concerns; this highlights the vulnerability of children in mobile families and the risk that children can become invisible 5.2.2 Mother was understood to come from a travelling family, so when she missed appointments but explained she was staying in different places outside of London, practitioners accepted this as part of her culture, without further checking. 5.2.3 There was inadequate consideration given to the need for follow up of concerns (in the case of children's social care) or of checking the children's health and development (in the case of health visitors) when mother claimed to be elsewhere. On one occasion children's social care assumed that another authority would undertake the required assessment (despite having not agreed this with them) and at other times no contact was made with the 'host' authority where Mother claimed to be, even when there was a s.47 (child protection) enquiry in progress. 5.2.4 Even when Mother seemed to be staying in the B&B accommodation provided, she was skilful in avoiding professional contact, despite the tenacity of a social worker spending considerable time in trying to locate her. In such circumstances it is vital that intervention is taken at earlier points in order for practitioners to be able to see the children and assess their needs. Whilst in this case practitioners were threatening to take such action, this took too long. Mother explained to the author that the repeated warnings made to her, without immediate action, reassured her that no action would happen. Recommendation 2 a) The LSCB to consider how to develop practice so that: children within mobile families do not become 'invisible' and that they receive continuity of health and social care involvement, and when necessary intervention, even when the family moves around practitioners challenge avoidant parental behaviour and do not accept at face value explanations of the family travelling managers recognise the immense time involved in such challenge, but that this is required whenever there are safeguarding concerns no child protection case is ever closed because a parent claims to be living elsewhere, without an agreement by the next local authority to take over enquiries b) The LSCB to ask children's social care to report on quality assurance processes on the 'front door' of the service; in particular that children's needs within mobile families are met (including cases not being closed without assurance of them being picked up in other areas) and that decisions for no further action are consistent with the safety of children. 44 3. The case demonstrated a misunderstanding about the use of Police Powers of Protection instead of an Emergency Protection Order 5.2.5 The senior manager within children's social care identified the risk to the children the need for their urgent removal following the information received from the manager of the B&B. However, subsequent decision making reflected a misunderstanding within children's social care about the use of an Emergency Protection Order as opposed to a reliance on Police Powers of Protection, which should only be used if there is evidence if immediate risk. 5.2.6 This case also demonstrated the need for social workers and managers to take account of legal advice, but when they feel that the risk is too high to leave children within the family whilst an Interim Care Order application is made, an EPO should be progressed and the matter put to the Court for a decision. Recommendation 3 Children's social care to hold facilitated workshops for managers to explore the differing use of Police Powers of Protection and Emergency Protection Orders. This should also cover the role of lawyers to provide advice as opposed to social work managers in making the decisions 4. There was repeated misunderstanding within children's social care of the function of police welfare checks as opposed to the children's social care responsibility to investigate allegations and concerns 5.2.7 Within children's social care in Harrow there was an assumption that when police visited a home and concluded that the children were safe and well, there was no need for further investigation of referrals. This demonstrated a basic misunderstanding of the police role to establish if the children were at immediate risk of harm at that point in time, as opposed to the role of children's social care to undertake the wider and in depth assessment of the allegations. Recommendation 4 Children's social care to consider how best to disseminate to staff the distinction between police welfare checks and the role of children's social care, and how to establish if this is successful in changing practice. The LSCB to request a report from children's social care on the implementation and progress of this recommendation. 45 5. The repeated lack of investigation by children's social care of the referrals from members of the public may reflect underlying cultural attitudes and suspicions to non professional referrals; such an attitude is a serious weakness in a safe service 5.2.8 Safeguarding is everybody's responsibility and referrals from members of the public need to be fully investigated. This needs to involve referrers being provided with the opportunity to meet with a social worker so as to provide more detail and evidence of concerns. This has been part of the London child protection procedures since the first edition in 2003. Recommendation 5 a) The LSCB to consider how best to promote cultural change so that professional practice fully values the involvement of members of the public in safeguarding children - such a cultural shift would see changes in practice which includes routine interviews of members of the public as part of follow up to referrals and assessment practice b) The LSCB to request agencies include the involvement of members of the public, friends and wider family in audits of response to referrals and of assessment practice - the results of such aspects of the audit to be provided to the LSCB and published as part of the promotion activities of the LSCB 6. The lack of individual supervision for social workers is likely to impact on cases that require a great deal of reflection and management oversight 5.2.9 The allocated social workers in this case were part of the 'pods' within the children in need service. Staff within a pod are managed by a pod manager but do not necessarily receive individual supervision as this model of organisation predominantly uses group supervision for staff. Whilst group supervision can be a very helpful tool, it does not address the individual needs for reflection and management decision making that is typically needed in chronic neglect cases, especially in relation to avoiding delay in moving into child protection and legal proceedings. 5.2.10 The social workers within this pod were concerned that their concerns about this case were not being adequately 'heard' by management at the time. It is important that whatever structure is in place, senior managers are assured that systems are in place for practitioners to have their concerns heard and addressed by managers beyond the individual pods. Recommendation 6 a) Children's social care to review the use [or not] of individual reflective supervision within pods, and report to the LSCB on how the needs for reflective case supervision are met in complex cases, and particularly where there is chronic neglect. b) Children's social care to provide systems for social workers to be able to articulate concerns about case management or to seek consultation, outside of the individual pods; children's social care to report to the LSCB how this will be accomplished and review its effectiveness 46 7. There was little indication within midwifery services and children's social care 'front door' of practitioners understanding the need to take account of the family's known history 5.2.11 A common finding in serious case reviews is the lack of practitioner understanding of the need to access and understand previous agency history of the family, in order to evaluate the risk to children. In this case the practice weakness was evident in both midwifery services and the children's social care teams involved between August 2013 and January 2014. Recommendation 7: The LSCB to consider how to change cultural practice across all agencies so that practitioners routinely access the known agency history of families (including all carers), and that the history is taken into consideration in any responses 8. The father and wider family members were insufficiently involved in the assessments undertaken 5.2.12 In common with findings from other serious case reviews nationally, there was insufficient involvement of the father in the assessments undertaken, although one social worker did initially try to engage him. Most critically the previous history of father was not accessed, although he was known to be the father of another child who had been adopted. 5.2.13 The assessments also did not involve other family members, despite it being known that paternal grandparents, maternal grandfather, and other members of the extended family were involved in supporting the family. Recommendation 8 The LSCB to consider how to change professional practice in all agencies, but especially within children's social care, so that all carers and involved family members are routinely involved in assessments of children subject to child protection plans and that their history is accessed as part of the assessment. 47 9. During the period of this review mother and children were homeless and moved many times, including eight different bed and breakfast placement: the constant moves and type of accommodation provided is likely to be detrimental to the children's welfare 5.2.14 Whilst the reason for the frequent moves are not totally understood and were in part due to Mother's actions and inactions, such constant moves must have been disruptive and distressing for the children. 5.2.15 The use of B&B accommodation for families is recognised as being unsuitable, only to be used when there is no alternative provision available and that the family should not remain there in excess of six weeks. This family were in B&B accommodation for longer than six weeks. Recommendation 9 a) The LSCB to establish the use of B&B accommodation by Housing for Harrow families, the frequency of moves between B&B per family and the total amount of time families spend in such accommodation before being offered more suitable temporary accommodation such as a flat or house. b) When the LSCB have this information, consideration to be given if there are systemic problems in the available provision and if further action is needed locally or in collaboration with other London boroughs. 48 10. There were examples of good practice by individual practitioners, despite an overall service characterised by 'too little, too late' The first Harrow health visitor who persevered in trying to see mother and tried to get children's social care in both Buckinghamshire and Harrow to investigate the concerns; had she escalated the failure of both children's social care services to do so, her involvement would have been even more effective The team manager of the child in need service for ensuring in February 2014 that the case was allocated and that this time the mother and children must be assessed The persistence and tenacity of both allocated social workers after February 2014 enabled the risks to be identified, recognised by management and begin to be addressed The persistence of the Ealing health visitor to try to facilitate the health and development needs of the children and her continuing involvement after the children moved out of Ealing The escalation of concerns by the Ealing health visitor, leading to the safeguarding advisor communicating concerns to Harrow children's social care The willingness of police to do welfare checks in response to referrals from members of the public The good communication and partnership working between the two allocated social workers and their colleagues in health and in the police, involving a number of joint visits The attempts by staff in the refuge to find mother, identify the whereabouts of the children and maintain the placement whilst trying to facilitate the family's return 5.2.16 This case demonstrated some very good examples of safeguarding being everyone's business, with the last B&B manager and staff involved in trying to help the family, as well as reporting to the social worker the concerns about the children's care and mother's behaviour. This manager also contributed to this serious case review which has enhanced our learning. 5.2.17 Members of the public also tried to contribute to the children's welfare by expressing their concerns at the time to police and children's social care. Such responsibility towards children in our community is to be greatly commended. 5.2.18 Members of the public also tried to contribute to the children's welfare by expressing their concerns at the time to police and children's social care. Such responsibility towards children in our community is to be greatly commended. 49 GLOSSARY OF TERMS & ABBREVIATIONS Term used in report B&B Bed and Breakfast accommodation CAF Common Assessment Framework CCG Clinical Commissioning Group CIN Child in Need under s.17 Children Act 1989 DfE Department for Education DNA Did not attend (a pre-booked appointment) EIS Early Intervention Service EPO An emergency protection order or EPO is a court order granted under Section 44 of the Children Act 1989 on the grounds that a child will suffer significant harm unless they are removed to council accommodation or moved from where they are currently living. FGC Family Group Conference Front Door GP General Practitioner ICO Interim Care Order: At the start of care proceedings, the council asks the family court to make a temporary court order, called an ‘interim care order’ under s.38 of the Children Act 1989. If the court agrees, the council can take the child into care on a temporary basis. LNWHT London North West Healthcare Trust LSCB Local Safeguarding Children Board MASH Multi-agency safeguarding hub MPS Metropolitan Police Service PLO The Public Law Outline [referred to as the PLO], is a revision of the 2003 Judicial Protocol, which attempts to reduce unwarranted delays in family court cases. Pod A framework for supervisory arrangements and management oversight of case work. PPoP Police Powers of Protection: Under s. 46 of the Children Act 1989if a police constable believes that a child is at risk of suffering significant harm then he/she may exercise powers under this Act to remove the child to suitable accommodation or if the child is in hospital or in a place of safety, take steps to keep the child there. A child cannot be kept in police protection for more than 72 hours. RISE A substance misuse service based in Ealing s.47 Section 47 of the Children Act 1989, which provides the legal basis for a child protection enquiry SCR Serious Case Review 50 APPENDIX 1: PANEL MEMBERS The review panel consisted of the following members: Agency: Lead Reviewer HSCB Chair HSCB Business Manager Central North West London NHS Foundation Trust Harrow CCG Designated Nurse Harrow CCG Designated Doctor Metropolitan Police Compass Drug & Alcohol Service Children’s Services, Harrow Council HB Public Law 51 APPENDIX 2: AGENCIES CONTRIBUTING TO THE REVIEW Brent Children’s Services Buckinghamshire Health Care NHS Trust Central North West London NHS Foundation Trust Ealing Community Services GP Surgery, Ealing Ealing RISE Enfield Community Services Enfield Social Care Harrow Community Services Harrow Children’s Services Harrow Housing Services Hounslow & Richmond Community Health Trust London Ambulance Service London North West Health Care Trust Wycombe District Council 52 APPENDIX 3: PRACTITIONERS WHO CONTRIBUTED Family Support Worker, Harrow Council Social Workers x 2, Harrow Council Team Manager, Harrow Council MASH Team Manager, Harrow Council Service Manager, Harrow Council Health Visitor, Harrow Community Health Services Lead Midwife, Harrow Community Health Services Parental Substance Misuse Worker, Compass Manager, Bed & Breakfast accommodation Refuge workers x 4, Refuge Centre Social Care Lawyer, HB Public Law Safeguarding Midwife, London North West Healthcare NHS Trust Housing Adviser, Harrow Council CP Named Nurse, Buckinghamshire Health Care NHS Trust CP Lead Professional, Buckinghamshire Health Care NHS Trust Metropolitan Police Officers x 2 |
NC049171 | Concerns about serious harm to three siblings due to suspected fabricated or induced illness (FII). Child F, Child G and Child H lived with their parents and a number of siblings. The children had extensive medical histories, including invasive surgical interventions, and had been seen by a large number of health practitioners in a number of hospitals. Two of the children were seen by more than 30 doctors. Their perceived medical needs had an impact on their educational, social and emotional development. Health and education staff had expressed concerns about the possibility of FII for a number of years, but a referral was not made until 2013. The Significant Learning Incident Process methodology was used to conduct the review. Key learning points include: GPs should take a coordinating role when a child is attending a variety of clinics and hospitals for treatment; practitioners should be wary of relying solely on information provided by parents and ensure that the child's views are sought and listened to; practitioners should be alert to signs of disguised compliance by parents; early concerns about FII should be recorded and discussed with Safeguarding Leads; practitioners need to maintain professional curiosity in cases where concerns emerge over a period of time. Recommendations for the LSCB include: request a review of the national Child Protection Procedures regarding FII to ensure that learning from this review and NSPCC research are reflected in the procedures; share learning from this review with NHS England; request that the Department for Education updates guidance on safeguarding and FII.
| Serious Case Review No: 2018/C6975 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. 1 LOCAL SAFEGUARDING CHILDREN BOARD EXECUTIVE SUMMARY REPORT SERIOUS CASE REVIEW Children F, G and H Author: Adrienne Plunkett 2 1. Background to Serious Case Reviews 1.1. The Local Safeguarding Children Boards Regulations 2006 outline that LSCBs should undertake reviews in specified circumstances. 5 (1)(e) Undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. 5 (2) For the purposes of paragraph (1) (e) a serious case is one where: (a) abuse or neglect of a child is known or suspected; and (b) either (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 1.2. Given the timeframe for this Serious Case Review, it was commenced under the guidance contained in Working Together to Safeguard Children 2013, Chapter 4,1 but completed with reference to the guidance in Working Together 2015.2 This emphasises the importance of LSCBs developing a Learning and Improvement Framework and outlines that reviews should be completed in a way which: Recognises the complex circumstances in which professionals work together to safeguard children; Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time, rather than using hindsight; Is transparent about the way data is collected and analysed; Makes use of relevant research and case evidence to inform the findings. 1.3. Working Together 2015 encourages LSCBs to use a variety of models for undertaking SCRs, including the systems approach. The Significant Incident Learning Process (SILP) is one such model. 2. Introduction to the Significant Learning Incident Process (SILP) 2.1. The SILP methodology reflects on multi-agency work systemically. It engages frontline staff and their managers in the review, focussing on why those involved acted in a certain way at that time. Importantly it recognises good practice. 2.2. The SILP methodology adheres to the principles of; Proportionality Learning from good practice Active engagement with practitioners 1 Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children, HMG, March 2013. 2 Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children, Department for Children, HM Government 2015. 3 Involvement of families 2.3. SILPs are characterised by practitioners, managers and Agency Report Authors coming together for a Learning Event. Agency Reports are shared in advance and the perspectives of all those involved are discussed and valued. The same group then comes together to consider the draft Overview Report at a Recall Event. 3. Process for this Serious Case Review: 3.1. In March 2014, the Chair of the Local Safeguarding Children Board made the decision to undertake a SCR in respect of the children. It was agreed that the criteria had been met under Paragraph 8.5., Working Together to Safeguard Children 2013. 3 There was concern that the children in the family had been seriously harmed due to suspected fabricated and induced illness and there was cause for concern as to the way in which the Local Authority, Board partners and other relevant persons had worked together to safeguard the children. 3.2. Furthermore, a decision was taken that the SCR would be undertaken using the SILP methodology and a Scoping Meeting to discuss the Terms of Reference was held in July 2014. 3.3. The Lead Reviewer was Ms Ohdedar, and the Independent Report Author Ms Plunkett. Ms Ohdedar is a former Head of Law with a background in child and adult protection law and advocacy. She is involved in undertaking case reviews and training on the SILP methodology. Ms Plunkett is a qualified social worker, with a MA in Child Studies. She has substantial experience in Children’s Social Care, including as a senior manager. 4. Introduction to the case under review: 4.1. This Serious Case Review relates to a large family where concerns about fabricated and induced illness came to the fore in 2013. 4.2. Several of the children in the family have extensive medical histories, including invasive surgical interventions. Their perceived medical needs impacted on their educational, social and emotional development. Over a significant period, a large number of hospitals and health practitioners were involved with the children; different hospitals treating different children and at times different hospitals treating the same child. 4.3. It is known that two of the children presented at Hospital 3 with ’high levels of symptoms’ of asthma, and ‘the level of treatments they received escalated and included ‘beyond guidelines treatments to manage their conditions’. This was not unusual for a tertiary centre and although their treatments were extensive, they were not extraordinary and did not raise concern. Two of the children received treatment at five hospitals and were seen by more than 30 doctors. It appears that no one health practitioner had an overview of the children’s medical treatment or co-ordinated this. 4.4. During the SILP Scoping Period Children’s Social Care provided a service to the family as Children in Need and Direct Payments were funded. The Mother declined all other support services offered, e.g. social activities for the children, 3 HMG, March 2013. 4 respite care. It appears that practitioners, in health and education, had growing concerns about the possibility of fabricated and induced illness over some years. 5. Family Engagement: 5.1. Both parents were approached to participate in the Serious Case Review and both initially declined to do so. Mother subsequently agreed to meet with the LSCB Manager and Overview Report Author to hear about the outcome of the review. The children’s Grandmother, Grandfather and Uncle met with the LSCB Manager and Overview Report Author. 5.2. The children were approached to ascertain if they wished to contribute to the SCR and meetings have been held with them. The purpose of this contact was to gain their views about the services offered to their family to ascertain if there were any lessons to prevent something similar happening to another child. 5.3. Overall, the children’s view was that their Mother should not take the full responsibility for what happened to them and that the doctors should accept some responsibility, as they need to agree to any treatment a child receives. Doctors have many years of training, so why did they not suspect what was happening sooner? 5.4. All the children said they did not form a relationship with any of the doctors or nurses involved in their treatment. At appointments, it was generally their Mother talking and doctors seemed to be very reliant on what she was saying. Whilst doctors were talking to their Mother, the children would be playing or sitting on the bed. One child commented that they were not ‘an important person in the conversation’. All children believe that doctors should engage more directly with children and allow them to have more say in their treatment. One of the children did not understand why they were being tube fed, but this became a normal part of life, another knew they were having unnecessary treatment, but did not have the opportunity to tell anyone. One child spoke of not wanting the treatment and being scared, but thought it was okay because Mother was present. 5.5. The children had the following messages for practitioners: Involve the child more – talk to them on their own, get to know about their life and explain what is happening and why, so that they understand their treatment. Go with their ‘gut feeling’ – follow up on any suspicions. Don’t do nothing. It is not enough to base a diagnosis and treatment solely on what a parent is saying – doctors need more evidence. 6. Scoping Period: 6.1. Child H attended two hospitals, the local district general hospital and Hospital 4, due to concerns about failure to thrive. Hospital 4 diagnosed coeliac disease and a gluten free diet was introduced, which led to Child H thriving and steadily gaining weight. However, Mother reported a very different picture of Child H’s health to the two hospitals, with the district general hospital being presented with a child who had recurrent viral infections, which resulted in 5 missed schooling. Further tests were undertaken based on Mother’s reported concerns, the results of which were normal. The Pharmacy Team identified ordering of high quantities of nutritional supplements, but were reassured by the GP and Dietician and the fact that the child’s medical care was being managed by a tertiary centre. 6.2. Child G was seriously ill as a young child and tube feeding was introduced at the district general hospital. There was uncertainty about the exact nature of Child G’s health difficulties, the GP identified Mother’s extreme anxiety and CAMHS noted discrepancies between Mother’s accounts and their observations. A referral was made to Hospital 4 and a gastrostomy was performed. Over a number of years, Mother failed to comply with the requirements of Child G’s treatment; Mother did not engage in work with CAMHS and with the Feeding Clinic, which was aimed at reducing the dependency on tube feeding, and failed to change the feeds when required. Despite Child G presenting as well and gaining weight, continued health concerns were reported by Mother which led to a number of tests being undertaken, the results of which were normal. Child G had a gastrostomy in place for many years. Initially there were some medical indications for this, but these resolved and Mother consistently blocked attempts over several years to move away from tube feeling, which hence became normalised for Child G. 6.3. Child F has a complicated medical history. Child F was initially treated at Hospital 3 for asthma and Hospital 3 made a referral to Hospital 2 for treatment for gastro-oesophageal reflux. Mother was anxious for Child F to have a gastrostomy inserted and, despite some concern about the medical need for this, the procedure was undertaken. The plan was that oral feeding should still be encouraged, minimising the dependency on tube feeding. For the next two years Child F was seen routinely at the Outpatients Clinic, but Mother failed to engage with the Feeding Clinic and the Speech and Language Therapist, whose focus was on encouraging oral feeding. In order to gain a fuller picture of Child F’s health needs, admission to hospital for observation was recommended twice, but Mother declined this. 6.4. Agencies Involvement: 6.4.1. During the Scoping Period for the SCR, a number of referrals were made by agencies to Children’s Social Care (CSC). In 2003 a referral was made by the district general hospital due to Mother’s extreme anxiety about Child G’s health needs and concerns about the impact this was having on the family. In response CSC completed an Initial Assessment and Child in Need plans were put in place. 6.4.2. When Child G commenced at nursery, a multi-agency meeting was held to discuss medical provision and support. Mother refused to commit to the plan and withdrew the child from nursery. 6 6.4.3. The school made a referral in 2007 as Mother was having difficulty coping. The school requested an assessment of the underlying causes of the children’s medical difficulties. Mother withdrew consent to the referral and, as no concerns were raised about the care of the children, no further action was taken. 6.4.4. During 2010 the concerns of the Consultant Paediatrician at the district general hospital increased. Letters were sent to Hospitals 2, 3 and 4 raising concerns about the children being over-investigated and over-treated due to the symptoms presented by their Mother. The Gastroenterologist at Hospital 4 suggested that Child G should be admitted to hospital locally to be weaned off the gastrostomy and planned to discuss with the Perplexing Presentation Multi-Disciplinary Team. The Consultant Paediatrician was to refer to Children’s Social Care and the possibility of a Professionals’ Meeting was to be considered. There is no evidence that these actions took place. 6.4.5. The Consultant Paediatrician also wrote to the GP outlining concerns about Mother’s anxiety outweighing her ability to meet Child G’s treatment needs, i.e. not supporting Child G to take food orally or to be admitted to hospital for observation. There is no evidence of follow up by the Paediatrician or the GP. 6.4.6. Later in the year the Consultant Paediatrician prepared a comprehensive written referral, raising clear concerns about fabricated and induced illness, for submission to CSC. However, this was not submitted as Child G was due to be admitted to Hospital 4 to be weaned from the gastrostomy, but this did not take place. 6.4.7. Agencies’ concerns continued during 2011. The Consultant Paediatrician again wrote to the GP. There had been no success in arranging a multi-agency meeting and the plan was to refer the family to CSC, but there is no evidence this was progressed. The Consultant Clinical Psychologist, Hospital 3, wrote to the Consultant Paediatrician, copying in the GP, raising concerns about Mother’s wellbeing and made a referral to CSC. Mother withdrew her consent to the referral and no further action was taken. Shortly afterwards the Consultant in Paediatric Respiratory Medicine, Hospital 3, made a referral to CSC for practical help, but again Mother withdrew her consent. 6.4.8. The Carers’ Information Service (CIS) made a referral to the Children with Disabilities Team for support for the family. A Core Assessment was undertaken which noted that the house was very cluttered with crates of medicines, feeds, nappies and equipment. Mother presented as very anxious, stating that the children’s father provided irregular support and should not be contacted. A network meeting was arranged involving the Respiratory Nurse, Hospital 3, CIS Manager, Social Worker and Mother. The focus of this was practical support needs and funding. The Children with Disabilities Panel agreed direct payments for household help. Mother declined any support services, e.g. befriending service, respite care. Following the assessment there were 6 monthly reviews of 7 the direct payments, but no active social work involvement and no direct contact with the children. 6.4.9. The School were increasingly concerned about their observations that the children were not displaying symptoms of their diagnosed health conditions and discussed this with the School Nurse. The children were seen eating normally in school. This led to the School Nurse and Children’s Hospital at Home Team meeting with the Consultant Paediatrician, who agreed Mother was in a high state of anxiety, but did not consider there was sufficient evidence to make a referral to CSC in respect of fabricated and induced illness. The School Nurse went on to seek advice from the Named Nurse and raised concerns about the need for Child F to be tube fed with Hospital 2. 6.4.10. CSC undertook the review of the Child in Need plan in 2012. Mother declined additional support, i.e. short break activities. The children were not seen, nor was their father. The CWD Panel increased the direct payments. The Consultant Paediatrician wrote to the GP regarding the lack of support being offered to Mother. There is no evidence of any further action being taken. 6.4.11. In 2013 an assessment being undertaken by Hospital 3 identified a disparity between accounts given by Child F and Mother. The Specialist Paediatric Respiratory Nurse undertook a home visit and concerns identified were shared with the multi-agency team leading to a referral regarding FII by the Children’s Hospital at Home Team to CSC’s Children with Disabilities Team. 7. Emerging Themes: 7.1. Voices of the children: 7.1.1. All professionals work in partnership with parents and when making assessments of a child’s health and development they are dependent on information provided by the parents. The picture gained from the discussions with the children during the SCR is of doctors predominantly talking to their Mother, whilst they played or sat on the bed. The children did not feel that they built up a relationship with any of the medical practitioners and the doctors agreed this had not been possible. Partly this was due to the spasmodic contact with the children, which would have made it difficult for the children to gain trust and confidence, but also Mother created barriers. The children recognise that their Mother would have made this difficult and would have tried to prevent Doctors talking to them directly. However, their firm view is that doctors need to try and find ways of talking to children directly and not base their diagnoses totally on what is reported by a parent. 7.1.2. From the Agency Reports, it is clear that Mother’s voice very much dominated with practitioners and there was an almost total reliance on her accounts of the children’s symptoms, leading to health professionals undertaking procedures which were not medically indicated. The children’s views were not consistently sought and used to inform decision-making about treatment. Their voice was silent. 8 7.1.3. The risks to children from FII are not only physical, but also emotional and psychological. The extent of involvement in FII by children themselves varies on a continuum, from unawareness through passive acceptance to actual participation. The London Safeguarding Children Board Child Protection Procedures highlight that children living with FII can become confused about their state of health and many become preoccupied with anxieties about their health and survival.4 In this case Mother’s extreme anxiety regarding the risks to the children was expressed in front of them; she repeatedly stated that they would become seriously ill or die if they did not receive certain treatments. This undoubtedly led to the children having a distorted view of their medical conditions and prognosis. 7.1.4. Overall, the Review has identified that there were limited efforts to communicate directly with the children and too great a dependence on Mother’s reports by all practitioners. There needs to be a greater awareness of the importance of engaging directly with children and young people; intervention needs to be child centred. If a parent tries to block these attempts, then this should raise agencies’ concern. This has been a strong message coming from the children, and practitioners at the Learning Event considered that the importance of remaining child-focused and listening to the child was one of the key learning points for them. This highlights that when there are concerns about FII, medical practitioners need to make additional efforts to speak to the child on their own, without the parent being present. 7.2. Policies and Procedures and knowledge regarding FII: 7.2.1. There is a need for all practitioners working with families, particularly those with children with complex health needs and/or disabilities, to have an understanding of the key elements of fabricated and induced illness (FII); how to recognise the warning signs and what action to take. This includes an awareness of the possibility of FII being a factor when children have genuine underlying medical problems. The NSPCC Research Briefing5 notes that although FII is relatively rare ‘this should not undermine or minimise its serious nature or the need for practitioners to be able to identify when parents or carers are fabricating or inducing illness in children.’ 7.2.2. Many of the agencies contributing to the SCR have identified that practitioners’ level of knowledge and understanding of FII was extremely limited. There was no evidence that practitioners had accessed, consulted or implemented the multi-agency national guidance 6. In addition, the guidance was not available on all the health trusts’ intranets. This lack of awareness of the FII guidance is extremely concerning given that many of the practitioners were working with children with complex needs. It could be argued that if staff had had a working knowledge of the guidance they would have been more able to recognise the indicators of FII at an earlier stage and known, or sought advice about, what action to take. 4 LSCB London Child Protection Procedures, 2013. 5 Lazenbatt and Taylor, Fabricated or induced illness in children: a rare form of child abuse? NSPCC Research Briefing, July 2011. 6 Safeguarding children in whom illness is fabricated or induced: Supplementary guidance to Working Together to Safeguard Children, Department for Children, Schools and Families, 2008. 9 7.2.3. The DSCF Guidance provides practitioners with a helpful framework for managing these highly complex cases. Significantly, if the procedures for FII had been triggered, a multi-agency professionals’ meeting would have been held and a Responsible Paediatric Consultant identified. The Royal College of Paediatrics and Child Health guidance7 highlights that the consultant responsible for the child’s health is the clinical lead for the case and should take responsibility for all decisions about the child’s healthcare, i.e. tests and treatment. This is a key step in dealing with cases of suspected FII, as there is then a clinician who can draw up a chronology and co-ordinate the involvement of health agencies and practitioners. This would have led to a joined-up approach and more robust consideration of whether further medical procedures were indicated for the children. 7.3. Early Recognition: 7.3.1. One of the key findings in the NSPCC Research Briefing is that ‘Recognition of FII depends, in the first instance, on medical or paediatric clarification of the objective state of the child’s health, followed by detailed and painstaking enquiry involving collection of information from many different sources and discussion with different agencies.’ 8 It is clear in this case that there was considerable information available, but it was not pulled together, or analysed, to provide an objective overview. As early as 2005 the GP was becoming concerned about the number of hospital attendances. There is evidence that Mother had a knowledge of medical procedures and was keen for the children to undergo tests and surgical procedures for which doctors did not see the need. 7.3.2. During the review, the factors below were identified which are likely to have contributed to why the early warning signs of FII were not identified and acted upon in a timely way. It is not unusual in cases of FII for the child to have a medical condition and this can present challenges for practitioners in assessing what are genuine symptoms and what are fabricated or induced. Concerns build up gradually and it can be a challenge for doctors to work out what is real and what is not real, and when concerns trigger the threshold for intervention. The large number of hospitals and doctors involved in the children’s treatment mitigated against a comprehensive overview being gained of the children’s medical conditions and treatment, and of Mother’s presentation. No single health care provider had a full picture of the children’s medical needs and treatment, or of the family functioning. The children were receiving tertiary care, i.e. highly specialised consultant care, in regional or national centres of excellence, which may have led to practitioners in community health and education relying on the 7 Fabricated or Induced Illness by Carers (FII) A Practical Guide for Paediatricians, Royal College of Paediatricians and Child health, 2009. 8 Lazenbatt and Taylor, NSPCC 2011. 10 professional expertise of these paediatric specialists in diagnosing, monitoring and managing the children’s chronic conditions. Concern about FII was not raised by secondary or tertiary care specialists. The issue of hierarchy and power. The Consultant Paediatrician was reluctant to pursue a referral to CSC without the support of Hospitals 2 and 3. There was a perceived power differential between the district general hospital and the specialist centres. Similarly, the School felt that their concerns would carry less weight. Medical practitioners work in partnership with parents and their starting point is that parents know their children well and want the best for them. It is, therefore, a significant step to think that parents may have harmful intentions. Practitioners can have difficulty in re-evaluating their views about a family and can get stuck in a particular way of thinking. Supervision provides an opportunity for practitioners to review their understanding of situations. This is important as new information may become available which needs to be rigorously assessed, particularly if this appears to be at odds with the prevailing understanding of the case. In this case practitioners held the view that the family required support, as Mother was struggling to meet the demands of her children’s complex medical needs. Practitioners were slow to reconsider this perception, despite the increasing body of evidence that there were inconsistencies in Mother’s account of the children’s medical conditions and a reluctance on her part to accept services which would help to normalise their lives. In view of the controversies relating to Doctors Meadows and Southall,9 Paediatricians appear to be cautious about raising, and recording, concerns about FII and of being publicly criticised if found to have made unsubstantiated child protection allegations. A survey by the Royal College of Paediatrics and Child Health (RCPCH) in 2003 found that paediatricians were reluctant to take on the role of Designated Doctor and that one in six had been the subject of a serious complaint. The President of the RCPCH noted that paediatricians were ‘demoralised by the GMC case against Professor Meadow’ and there was ‘a need to restore confidence in the profession. 10 Professionals need to feel very confident when referring a case of FII to Children’s Social Care of meeting the threshold for intervention. Difficulty for a lone practitioner to raise the issue of FII, as this can lead to the worker becoming alienated from the team. The fear that the concern about FII is unfounded and the child may be seriously ill. 9 David Southall ‘I will not apologise for what I did’. The Guardian, 5 May 2010. 10 Doctors reluctant to work on child protection committees, survey shows. British Medical Journal, 5 February 2004 (328). 11 Iatrogenic harm, i.e. harm caused to the child by medical treatment. For medical practitioners, who had been treating a child over a considerable period of time, there will be emotional challenges in coming to terms with the fact that the illnesses could have been fabricated or induced and hence the medical interventions unnecessary. 7.3.3. The above is helpful in understanding why action was not taken much sooner in relation to concerns about FII. However, it is concerning that the practitioners did not access the support and advice that would have been available to them through Safeguarding Leads or consult the Guidance, which provides a helpful framework for managing cases when there are concerns about FII. 7.4. Communication between agencies: 7.4.1. There is considerable evidence that Consultants and Hospitals operated in silos, without considering the need to communicate with colleagues in the same hospital/other hospitals who were also treating children in the family. In addition, there was very limited direct communication between the hospitals and community health services, notably with the GP. 7.4.2. There were points when letters were sent evidencing serious safeguarding concerns which should have prompted an urgent response and an agreed plan of action. However, this did not happen. There was a pattern of letters to the GP being uploaded onto records, with little consideration of the contents. 7.4.3. There are examples of the School Nurse and the Children’s Hospital at Home Team, despite having key roles with the family, not being included in communications and meetings. This meant that the views of the school were not promoted. 7.4.5. The GP Practice was well placed to gain an overview of the children’s medical conditions and treatments. The Practice received letters from the routine clinic attendances, as well as the letters of concern from the Consultant Paediatrician. However, the GP did not take a central, co-ordinating role, maybe because this was a single-handed practice and given the number of hospitals and clinics involved it would have been a time-consuming task to do so. There was a tendency in the GP records for letters from hospitals to be logged onto the children’s notes without any comments or actions documented. This meant that the GP failed to identify the pattern of concerns being raised. 7.4.6. The children’s medical care was fragmented across primary, secondary, tertiary and specialist services with no one professional taking overall responsibility and, given the weaknesses in inter-agency communication, Mother was able to exploit the situation to fulfil her own needs. 7.5. Role of the parents: 7.5.1. Research indicates that in the majority of cases of FII the child’s mother is responsible for the abuse. The behaviour of the mother is likely to be highly manipulative and controlling and will have a powerful impact on professionals, individually and collectively, i.e. on the effectiveness of multi-agency working. 12 Managing this behaviour, therefore, presents a real challenge to individual professionals, as well as to the functioning of the multi-agency network. 7.5.2. In this case Mother appears to have been extremely persuasive, with a good medical knowledge, enabling her to convince medical teams to undertake investigations/procedures for which there were not always medical indications, or to delay procedures which were believed to be in the children’s best interest. Some of the invasive tests undertaken most parents would only agree to if they were convinced that they were necessary. Mother is described as being ‘very believable’ and what she reported over time became fact, without any evidence to support this. She is also described as being difficult to challenge, she tended to always have an answer to any queries raised and could become confrontational. 7.5.3. Mother had an ability to play professionals against each other, as was apparent between health and education, where Mother conveyed to health practitioners that the school was not making appropriate adjustments for the children’s health difficulties. She blocked attempts to convene multi-agency meetings, telling school staff that it would be impossible for health staff to attend meetings. 7.5.4. Mother displayed disguised compliance. On the surface, she appeared to be co-operative, but actually she did not co-operate and was highly avoidant. There was a discernible pattern of her blocking offers of support services, particularly those that would enable practitioners to get close to the family and gain a fuller picture of the children’s lived experiences. Mother co-operated selectively and on her own terms. There was a disconnect between Mother’s presentation as being under considerable emotional and physical strain, but repeatedly not accepting services which would help to relieve some of the strain. 7.5.5. It is apparent that Mother’s approach and behaviour had an emotional impact on practitioners. Presenting as the single parent of a number of children with complex health need, she could be very demanding emotionally. This may have affected practitioners’ ability to maintain professional objectivity and to stand back and reflect. The longer the deception continued, the more Mother had to lose, including financially. Therefore, she had to work hard to maintain the picture that she had created, making her even more difficult for practitioners to challenge. 7.5.6. Dealing with the behaviour of parents is one of the real challenges in cases of FII and highlights the importance of practitioners seeking advice and consulting the national guidance at an early stage. This helps to minimise the sense of being overwhelmed and the risk of manipulation by parents. 7.6.6. Little information was available to the review in respect of the role of the children’s father in the family. Mother portrayed him at different times to practitioners as being ‘a friend and landlord’, providing irregular support and being deceased. Mother minimised his role in the family and he was not engaged in the initial or core assessments undertaken by Children’s Social Care. 13 8. Developments since Scoping Period: The outcome for the children has had an impact on all the health agencies involved in the SCR: Health Service 1 holds monthly Clinical Governance Meetings, when specific cases are discussed. Hospital 2 holds weekly multi-disciplinary meetings where complex families are discussed, and safeguarding issues addressed. Hospital 3’s safeguarding practice has developed, with increased engagement with safeguarding professionals and supervision. Hospital 4 had reviewed all relevant cases and provided training in FII for Consultants. A FII Aide Memoire and flow chart have been produced for GPs. Multi Agency Safeguarding Hub (MASH) established January 2014. Hub consists of staff from Children’s Social Care, Police, Health, Education, Youth Offending Service, Early Intervention, Youth Service and Probation. It provides the capacity, skills and practical arrangements to collect analyse and securely store information held by all partners about children and families that is relevant to an assessment of safeguarding risk. A common set of risk indicators is used to ensure a consistent approach to identifying and categorising the level of risk. Greater scrutiny in respect of direct payments, with quarterly financial returns and six -monthly reviews. LSCB Fabricated and Induced Illness Training: Further Learning Events for dealing with cases of FII for key multiagency staff are planned. LSCB is developing training in working with challenging and uncooperative parents. LSCB Escalation Policy was developed and launched 9. Key Learning Points: GPs should take on a co-ordination role when a child is attending a variety of clinics/hospitals for treatment, review incoming communications thoroughly and respond to any concerns raised. GPs are well placed to identify patterns, e.g. appointments not attended/cancelled. Other agencies retain responsibility for communicating directly with the GP and highlighting any concerns. All practitioners should guard against relying solely on information provided by parents and ensure that the child’s views are sought and listened to. If a parent is obstructive this should be highlighted as a cause of concern. 14 Children should be fully engaged in their care and treatment and should be supported to gain an age appropriate understanding of the treatment they are receiving and the reasons why. Practitioners should be alert to signs of disguised compliance by parents and assess the impact of this on agencies’ ability to safeguard and meet the needs of children and young people. Early concerns about Fabricated and Induced Illness should be recorded and discussed with Safeguarding Leads/Designated Doctors and Nurses. Government Guidance provides a sound framework to manage such concerns, including holding a Strategy Meeting where concerns can be shared, a multi-agency plan put in place and a Responsible Paediatric Consultant identified. The role of the Responsible Paediatric Consultant is crucial in pulling together a medical chronology, overseeing and co-ordinating children’s treatment and preventing unnecessary medical interventions. Practitioners should not delay in making a referral to Children’s Social Care on the basis that it will not be accepted. Better to make the referral and have the discussion, rather than not do so. Responsibility rests with the agency to submit a good quality referral, which provides sufficient information to evidence the concerns raised and assists CSC with decision-making. Practitioners need to be mindful of the impact on them of children being treated at a specialist unit or at a ‘centre of excellence’ and not allow this to prevent them raising valid concerns. Need for improved communication between Tertiary Hospitals and community health services, including District General Hospitals and GPs. Direct communication between professionals, e.g. telephone conversations, meetings, is the most effective way of sharing concerns and agreeing a way forward. Sending a letter raising a concern is not sufficient, this needs to be followed-up by direct communication in order to agree a way forward. The role of the School Nurse is important in providing a conduit between the school and health professionals. Reflective supervision and support is essential for practitioners working with families where there are concerns about FII, given the complexity and challenges of working with the parents. 15 Practitioners need to maintain ‘respectful uncertainty’ and professional curiosity in cases where concerns emerge over a period of time. 10. Conclusion: 10.1. Cases of fabricated and induced illness are amongst the most complex, and professionally challenging, that practitioners working in child protection deal with. There can often be diverging views amongst medical practitioners and concerns, if proved wrong, about the consequences of not treating a seriously ill child. Parents are likely to be knowledgeable, plausible and difficult to challenge. Whilst such cases are not uncommon, practitioners are unlikely to have the opportunity to develop their skills and knowledge in this area. For these reasons knowledge of, and adherence to, the available guidance is essential to safeguard children and young people. 10.2. This Serious Case Review has identified the long standing physical and emotional abuse of the children due to Fabricated and Induced Illness. They received unnecessary and invasive medical procedures over a significant period of time, including after tests had shown that any medical symptoms had resolved. It is very clear that a number of practitioners had suspicions about fabricated and induced illness as early as 2005, but certainly by 2009. It is therefore of concern that it was not until some years later that multi-agency action was taken to safeguard the children. Until then child protection procedures had not been initiated, i.e. Strategy Meeting, Section 47 enquiries, Initial Child Protection Conference. The various guidance in respect of FII, both for health practitioners and for multi-agency working, had not been consulted. 10.3. Several factors have been identified which contributed to this delay; practitioners lack of knowledge of the FII guidance, lack of effective communication between health practitioners and with community services, Mother’s disguised compliance and manipulative behaviour and practitioners’ lack of engagement with the children, so that their voice was not heard. 10.4. The number of hospitals that the children attended made communication between medical practitioners more challenging, but also more essential. The GP should have assumed a co-ordination role but, as a single-handed Practice, did not do so. The fact that the children were receiving treatment from specialist clinics at ‘centres of excellence’ gave validation to their diagnosis and treatment, and led to other agencies, e.g. schools, feeling less able to challenge. There was a culture of letters between agencies and a pattern of these not being responded to, or followed up, even when they raised significant safeguarding concerns. Practitioners did not demonstrate professional curiosity. Mother could take advantage of this. There is particular learning here for hospital staff. 10.5. What has come through during the Serious Case Review from the medical practitioners is almost a fear of raising concerns about FII, due to worries about ‘getting it wrong’ when a child is seriously ill, but also about attracting unwanted criticism or media coverage for themselves and the hospital. A survey by the 16 Royal College of Paediatrics and Child Health 11 indicates that this has been a national issue, which could be preventing doctors from taking safeguarding action and, if so, needs to be addressed. 10.6. It is important to listen to, and learn from, the children’s views. Whilst it is recognised that Mother would have made it difficult, the children’s firm view is that doctors should never rely solely on what a parent is telling them. Children need to be spoken to and helped to understand their medical condition and any proposed treatment. They should be given a voice. As one of the children has said, doctors should act on their ‘gut feelings’, ‘one child is too many’. Practitioners should think the unthinkable. 10.7. This was a complex case for practitioners to deal with. Sadly, the lack of a robust, co-ordinated, response allowed the fabricated and induced illness to continue for many years. The longer it continued the more difficult it was to unpick what was fact and was not, and the greater Mother’s commitment to maintaining the status quo. 10.8. There are many lessons for individual agencies and for multi-agency working from this Serious Case Review. These should be shared widely by the Local Safeguarding Children Board to reduce the likelihood of children experiencing similar abuse. 11. Recommendations for Local Safeguarding Children Board (Contained in Interim Report): 1. LSCB should promote the voice of the child and ensure that the importance of communicating with children and young people, including non-verbal communication, so that an understanding of their lived day to day experiences can be gained, is embedded in all procedures and training provided. This should be routinely audited through single and multi-agency case file audits. 2. Any practitioner who has concerns about possible fabricated and induced illness should, at an early stage, consult their Safeguarding Lead, e.g. Named GP, Named Doctors and Designated Professionals, and consider the need to initiate the FII Guidance, e.g. Strategy Meeting, Lead Professional. 3. LSCB should have a clear, accessible, escalation policy in place so that practitioners are informed about what action they should take if they have concerns about a child which they consider are not being responded to appropriately. Following an appropriate period there should be an audit of practitioners’ knowledge and use of this policy. 4. LSCB should request a review of the national Child Protection Procedures in respect of dealing with cases of FII to ensure that learning from this SCR and NSPCC Research are reflected in the procedures. This should include: 11 BMJ, February 2004. 17 Highlighting the important role that can be played by GPs in identifying concerns about FII in a family. Consideration of how to promote communication between tertiary, specialist and external agencies, including community and secondary health services, Children’s Social Care and education. The challenges for individual practitioners and the multi-agency network of working with parents in such cases, and the emotional impact this can have. Single and multi-agency supervision training should highlight the key role of supervisors in providing reflection and challenge in potential cases of FII, which can present difficulties for practitioners in terms of dealing with parental behaviours and maintaining a focus on the needs of the child. 5. LSCB should share the learning from this SCR with NHS England, as there is significance nationally for tertiary hospitals, centres of excellence, District General Hospitals and community services in working effectively together to safeguard children and young people. 6. LSCB’s Independent Chair should write to the Department of Education to request that the supplementary guidance to Working Together, Safeguarding Children in whom illness is fabricated or induced, be updated to reflect the learning from this and other SCRs in relation to FII. 7. LSCB’s Independent Chair should alert the Association of Independent Chairs of LSCBs to the findings of the SCR and to the need for updated guidance. 8. LSCB should request a report regarding the capacity of School Health/Nursing resources and the impact of this on services. |
NC50882 | Neglect and possible sexual abuse of a 6-year-old child. Child was made the subject of a care order in January 2016 and is now in foster care. Mother had longstanding substance misuse problems and the child was exposed to criminal activity and domestic abuse. Three child protection referrals between 2009 and 2012 which were investigated but identified no further concerns. An initial assessment was completed in December 2013 and enquiries to the child's school revealed there were concerns about attendance, presentation, dental health and communication. A section 47 enquiry was undertaken and completed in May 2014 which identified significant concerns around neglect and parental substance misuse. Child disclosed sexual abuse by mother's partner to mother's aunt and made further disclosures when interviewed by police. Crown Prosecution Service decided not to initiate criminal proceedings. Child was placed in foster care in August 2015 due to mother's imprisonment for shoplifting. Throughout the period under review, mother did not co-operate with professionals and refused consent to share information. Ethnicity or nationality not stated. Learning includes: little evidence that the child's views were gathered and supported; child protection conferences became focused on helping mother rather than the child; and delayed decisions can mean that children experience lengthy exposure to abuse and neglect. Recommendations include: update protocol on working with families who are not cooperating; ensure training on information sharing for safeguarding children is available to staff in partner agencies; and ensure that there is meaningful engagement from schools across the region.
| 1 Child Practice Review Report Cardiff and Vale of Glamorgan Regional Safeguarding Children Board Extended Child Practice Review Re: CPR 03/2016 Brief outline of circumstances resulting in the Review Legal context from guidance in relation to which review is being undertaken An Extended Child Practice Review was commissioned by Cardiff and Vale of Glamorgan Regional Safeguarding Children Board (CVRSCB) on the recommendation of the Child & Adult Practice Review Sub-group in accordance with Social Services and Well-Being Wales Act 2014 Part 7, Volume 2 Child Practice Reviews guidance. The criteria for this Review were met under section 3.12 of the above guidance namely: A Board must undertake an extended child practice review in any of the following cases where, within the area of the Board, abuse or neglect of a child is known or suspected and the child has died; or sustained potentially life threatening injury; or sustained serious and permanent impairment of health or development; and, the child was on the child protection register and/or was a looked after child (including a care leaver under the age of 18) on any date during the 6 months preceding the date of the event referred to above; or the date on which a local authority or relevant partner identifies that a child has sustained serious and permanent impairment of health and development. The terms of Reference for this review are at Appendix 1. Background information The child who is the subject of this Extended Child Practice Review is now the subject of a Care Order to the Local Authority. The timeline of this review covers events between 1st January 2014 and 10th January 2016 when the Care Order was granted. The child was born in 2009 and was the only child of a single mother who was living with her own parents at the time of the child’s birth. The mother had longstanding substance misuse problems during her pregnancy and the first 6 years of her child’s life. The child suffered exposure to the mother’s substance misuse, her criminal activity and to domestic abuse. The child did not have a stable home, and suffered neglect of their health and developmental needs and of their education. The mother’s boyfriend had a history of convictions for violence and substance misuse and he is alleged to have sexually abused the child. Services were involved with the family from the time of the child’s birth and the child’s name was on the child protection register from June 2014 to September 2015. The mother consistently refused to share the child’s paternity with professionals and the father’s identity was only ascertained during the care proceedings. The child had no knowledge of their father during the timeframe for this review. The child is now in foster care and responding well to an improved and supported family environment however the decision to proceed with an extended child practice review was made on the basis of the impact of the sexual abuse the child had suffered and because of the likely consequences of the long term neglect and emotional abuse. 2 In January 2016, some five months after the child was removed from the mother’s care, the grandfather died in a house fire. Mother was accused of murder but this was reduced to manslaughter and was ultimately found not guilty by reason of insanity. Despite the mother’s mental state being a crucial evidential factor in the court case concerning the grandfather’s death, throughout the timeline of this review there is no reference to mother having or having had a mental illness. A Domestic Homicide Review into the grandfather’s death has been conducted in parallel with this review. Significant Events Prior to the Period Under Review There were 3 child protection referrals prior to the period covered by this review. The first was from the neonatal unit, where the child was admitted following birth for observation due to mother’s substance misuse during the pregnancy and her agitation and threats to leave the unit with the baby, and also because of the aggression displayed by the grandfather on the ward. The second referral occurred in September 2010 and came from the Community Addictions Unit (CAU) because of concerns about domestic abuse involving the grandparents and occurring in the mother and child’s presence. There was also an acknowledgement that the mother’s engagement with CAU and other services was poor. Within the referral by CAU it was noted that home visits were regularly refused by the mother and that the Health Visitor reported that she was not being allowed access to the property to see the child. The third referral by a neighbour in August 2012 was because of concerns about poor home conditions, substance misuse and frequent callers to the address. The child was said to be often left alone in the front garden with only bags of crisps to eat. Initial assessments were undertaken in response to the first two referrals and a core assessment was undertaken on the third occasion. Mother’s explanation was that the first incident was due to mother’s perception that ward staff were discriminating against her because of her addiction problems, that the concerns in the second referral were exaggerated and that the third referral was malicious. All three referrals detailed above were investigated by Children’s Services but no further concerns were identified and the child protection process was not progressed. In 2013 a referral was received by Adult Services which alleged financial abuse by the mother and grandfather towards the grandmother. No further safeguarding action was taken as the grandmother did not wish to proceed with the matter. Mother continued to be known to CAU, and homelessness was identified as a matter of concern due to the mother, the grandfather and the child having vacated the grandmother’s property. The grandfather was known to have resided with the mother and child for the duration of the period of the review although it was noted by professionals that he refused to engage in any assessment or discussion concerning his grandchild. Significant Events During the Period Under Review The Initial Assessment, completed at the beginning of the period under review, was initiated as a result of two PPD1 notifications received by social services from the police in December 2013; mother had been shoplifting whilst the child was in her care. The assessment was hampered by mother’s lack of cooperation and refusal to consent to the social worker contacting other agencies to seek information about the child and family. Enquiries made by social services with the child’s school in December 2013 had identified concerns about the child’s attendance, punctuality, presentation and poor dental health. The child’s poor attendance was reflected in poor developmental and educational progress. The child’s milk teeth were decayed and it was subsequently necessary for 10 of them to be extracted. The child also had a turn in the eye but wearing of prescribed spectacles was intermittent. The child had failed hearing and vision screening tests by the school nurse and was assessed as having mild/moderate difficulty in understanding spoken language. The mother did not acknowledge the concerns raised by social workers at the time and her engagement with 3 them remained unchanged and was considered to be poor. She was consistently confrontational and obstructive. The outcome of the Initial Assessment was a recommendation to proceed to S.47 enquiries because of concerns about parental substance misuse, neglect of the child’s basic care needs and instability of housing. The Core Assessment took 12 weeks to complete (according to the All Wales Child Protection Procedures (AWCPP) it should be completed in less than 35 working days) and between the referral that generated the Initial Assessment and the subsequent Initial Child Protection Conference almost 6 months elapsed. The social workers involved at the time were not available to attend the learning event, and the practitioners who did attend were unable to explain this delay as the reason was not recorded formally within the case notes. In March 2014 police were called to a landlord tenant dispute. The mother had been served with an eviction notice from her private landlord for the two bedroomed flat she shared with the grandfather and the child. On attending the property police repeatedly asked mother, and grandmother who was present at the time, to remove the child from the room due to concern that the child had witnessed all parties shouting, was clearly distressed by events and was crying, but the mother refused to take the child out of the situation. A Police Protection Document or PPD1 (now known as a Public Protection Notification or PPN) was submitted at the time due to concerns about the child’s distress and the police officer’s view that the mother was not acting in the best interests of the child. In May 2014 the S.47 assessment was completed and identified significant concerns around emotional harm, neglect, parental substance misuse and the mother’s criminal activities. In June 2014 the child was placed on the Child Protection Register under the categories of neglect and emotional abuse. School’s attendance at subsequent core groups was inconsistent. During this period the mother had poor engagement with CAU and regularly missed drugs tests. She often failed to attend appointments for her own health needs and for those of her child, and appeared unable to accept the impact this would have on her child’s health and well-being. In early October 2014 the grandmother mother contacted the police and expressed concern for her grandchild who was at home with the mother and her boyfriend who had allegedly caused damage to a door. Police attended and identified no concerns for the child and no damage to the property. The boyfriend was present and the police submitted a PPD1 (now a PPN) containing his details which was shared with partner agencies. Two days later the mother contacted police to make a Claire’s Law disclosure request. The boyfriend had a history of domestic abuse. Attempts were made to contact the mother to advise her of this fact. Contact was not made until the following month, by which time the mother advised the police that she had changed her mind and did not want the disclosure. She gave no reasons as to why she had taken this decision. It was noted during the review that no PPD1 was submitted concerning this Claire’s Law application and the boyfriend’s history of domestic abuse. In January 2015 at a Review Child Protection Conference there was mention of a short relationship with a man, and the mother informed conference that she had ended the relationship having been made aware of her boyfriend’s background, which had included charges of battery, domestic violence and the possession of drugs. The conference report noted as an action that the child should only be introduced to new friends and partners of the mother once relationships were established and appropriate checks completed. The review panel questioned the appropriateness of the recommendation given that it was an unrealistic and unenforceable request. In March 2015 the mother contacted South Wales Police to make a Claire’s Law request about a new boyfriend of five months. She stated that she wanted to find out his history because of her 5 year old child. The boyfriend had 16 separate warning markers which included self-harm, violence, mental health issues, domestic abuse aggressor, the subject of restraining orders, and possession of weapons (bladed article). An occurrence was created and tasked in error to a dormant police inbox that was no longer monitored. When this mistake was discovered the mother was contacted by police, but declined the information being offered regarding the boyfriend. The Claire’s Law application was not progressed and, whilst intelligence 4 was captured on police information systems concerning the association, no PPD1 (now a PPN) was created and the information was not shared with multi-agency partners. In April 2015 on a statutory CP visit the social worker noticed that mother was wearing a wig to conceal the fact that clumps of her hair were missing, she also had a scald on her thigh and a burn on her arm. Mother gave implausible explanations for these injuries and the child subsequently disclosed having witnessed the boyfriend hurting the child’s mother. It seems likely therefore that the injuries seen in April 2015 were inflicted by the boyfriend. In March 2016 The National Training Framework on Violence against women, domestic abuse and sexual violence (VAWDASV) was launched. Within this framework Group 2 training describes the group of professionals who will “Ask and Act”. Ask and Act is defined as a process of targeted enquiry across the Welsh Public Service in relation to VAWDASV. As a result of this training participants will be skilled, able and confident to “Ask and Act”, proactively identifying and offering support to victims of VAWDASV. Also during April 2015 mother was taken to court for a shoplifting offence and was given a 12 month community order. She was allocated a Community Resource Centre worker and given an appointment for the 15th of April 2015 which she failed to attend, citing having to care for her elderly parents. At a Review Child Protection Conference held in July 2015 mother advised that she had ended the relationship a few days previously, adding that the boyfriend had never been physical towards her. However the Social Worker had recorded in July 2015 that the child had witnessed an argument between the mother and the boyfriend and the child said that they were frightened that he would hurt the mother. It is of concern that despite agencies being aware of mother’s relationship with this man no action was taken to ascertain his role in the child’s life. The day after conference the social worker received a telephone call from grandmother informing her that the child had made a disclosure that mother’s boyfriend had come into the child’s bedroom with a knife and run it along the child’s arm. This contradicted mother’s assertion the day previously that the relationship was over. He had threatened that he would get rid of the child so that his own two children could live in the house instead. The boyfriend kept a knife in his sock and also on the bedside cabinet and the child had tried to hide it due to being scared for mother’s safety. Police response officers attended and the child was removed from the address and placed with the maternal grandmother. When the child was interviewed, the child repeated the disclosures and also reported having been placed in a shed for misbehaving and having witnessed several domestic violence incidents and the mother’s self-harming behaviour. Disclosures of a sexual nature were later made to mother’s aunt about the boyfriend, and the child was interviewed by police at the Cardiff Sexual Assault Referral Centre (SARC) where further disclosures of sexual touching and indecent exposure were made. The relationship between the child and mother’s boyfriend was clearly having a considerable impact on the child. During this time a viability assessment of the maternal grandmother and grandfather was commenced, and this appears to be the first time throughout agencies’ involvement with the child that the grandfather’s background and relationship with the child had been formally explored. By August 2015 the child was placed into foster care by the local authority, due to mother’s imprisonment for shoplifting and breach of her probation order, and negative viability assessments in respect of both maternal grandparents. A full care order was granted by the family court in January 2016 and the child remains looked after. Throughout the period in foster care the child has continued to make more detailed disclosures of further sexual abuse which the boyfriend has denied to police. Following full investigation and consultation with the crown prosecution service the decision was made not to initiate criminal proceedings. 5 Practice and organisational learning Identify each individual learning point arising in case (including highlighting effective practice) accompanied by a brief outline of the relevant circumstances As part of this Child Practice Review a Learning Event was held for practitioners involved with this child. The Reviewers would like to thank all those who attended the learning event for their contribution to the learning from this Review. Much of the practice and organisational learning considered below was raised at the Learning Event. The Child Practice Review process The panel expressed concern about the delay in initiating the child practice review process in this case. The referral was made by the police as a result of their involvement in the domestic homicide review; if there had been no death this child may never have come to the attention of the Safeguarding Board. The referral proved challenging for the child practice review sub group of the Cardiff and Vale Regional Safeguarding Children Board as the “sustained serious and permanent impairment of health or development” aspect of the case was debatable given that by the time of the referral the child was in foster care and responding well to an improved and supported family environment. The decision to proceed with the child practice review was made however, not only on the basis of the impact of the sexual abuse the child had suffered but also because of the impact of the long term neglect and emotional abuse. It was noted that the case would potentially highlight wider learning for multi-agency partners and proceeding to a CPR was agreed. The delay in initiating the review resulted in challenges for the process, in particular none of the social workers directly involved in the care of the child at the time were still in post and available to attend the learning event. Case notes for the child lack clarity and detail in some parts, and this has resulted in poor history and chronology. This means that some of the questions which arose from the discussion of the 2 year timeline remain unanswered. At the Learning Event practitioners commented that the general practitioner for the child was not present and the GP was thought to have known the family well. Despite this, there was no record of the child having been seen by the GP during the period of the review. The GP’s involvement may have been with the adult family members, which is where practitioner’s focus too often lay and the child was often unseen. The Learning Event Practitioners also suggested that it would have been helpful to have representation from Legal Services at the Learning Event to aid understanding of the legal advice given in this case, whilst at the same time acknowledging that they are not the decision makers. The Voice of the Child It is accepted that in order that any child is fully supported then professionals must engage with the parents and wider family members. However, this must always be balanced with the need to ensure that all services involved have a clear line of sight to the child. Throughout the timeline of this review there was very little recorded about direct contact and discussion with the child. There is little evidence that the child’s views, wishes and feelings were actively gathered and supported. Mother’s behaviour meant that many professionals concentrated on her needs as opposed to those of the child. Throughout core group meetings, reviews and home visits, it was noted that much of the dialogue revolved around mother as opposed to her child, for example concerns about her wanting support for her housing situation and lengthy discussions about mother’s relationship breaking down. The Signs of Safety model which has now been introduced in Cardiff Council supports professionals to ensure that children are seen and interviewed. The three houses exercise is undertaken which ensures that children are allowed to explore and demonstrate, either verbally, in writing or via drawings and play, what is working well, what they are worried about and what they want to see happen. This process expects workers to evidence that they have spoken to the child alone and in an appropriate environment to ascertain their true views, wishes, and feelings. It is pertinent that only when the child subject of this review felt safe and supported were they able to disclose the abuse which occurred in the home prior to them being placed in foster care. 6 Practitioners’ Response to Mother and her Disruption of the Child Protection Process The mother was variously described by practitioners as aggressive, confrontational and obstructive. Her behaviour was often manipulative and deflective in nature to ensure that professionals did not have open access to the child. At the Learning Event practitioners shared that child protection conferences and core groups and even some child protection statutory visits were ‘all about mother’, her concerns, her substance misuse and her relationships. They became diverted from their primary purpose by ‘helping’ mother in the belief that they were thereby promoting her engagement, even although this did not result in any sustained or meaningful progress. If challenged about her failure to engage with professionals and services or comply with the child protection plan, and when escalation was suggested, mother became upset and angry. The Learning Event participants observed that, when on occasion mother walked out of meetings, they believed that they then had to suspend any further discussion in her absence. She thus effectively disrupted the child protection process. The one Core Group at which there was effective information sharing and analysis, a clear action plan and an explicit statement of the consequences which would result if the plan was not adhered to, was the one Core Group which mother chose not to attend. Mother’s response to this more assertive practice was to comply with services and the plan, just enough and for just long enough, to avert the planned consequences of her noncompliance i.e. she employed disguised compliance. Practitioners should ensure that when parents’ behaviours or actions prevent or compromise necessary safeguarding discussions and planning, the discussion or the meeting should continue in the parents’ absence. Professionals can hold a meeting to share concerns, information and strategies and to draw up a plan without the parents being present, albeit there must always be a plan made to share what has been discussed with the family after the meeting. The RSCB has a multi-agency protocol in place for working with families who are not co-operating with safeguarding issues which aims to advise staff in understanding and responding to such issues. The protocol is now out of date (October 2011) and requires review and updating urgently. Consent to Information Sharing As noted above, the Initial Assessment at the beginning of the period under review was hampered by mother’s lack of cooperation and refusal to consent to the social worker contacting other agencies to seek information about the child and family. Given the history of prior concerns and three previous child protection referrals in this case, consideration should have been given to over-riding mother’s refusal to consent to information sharing for the purposes of the Initial Assessment, on the grounds that the child was at risk of significant harm. Many previous reviews have identified that the failure by practitioners and agencies to share information appropriately about children and their families may have serious consequences for the children, through leaving them at risk of significant harm. In his review following an inquiry into abuse in children’s homes in North Wales in 2002 Lord Carlile stated: ‘There is nothing within the Caldicott Report, the Data Protection Act 1998 or the Human Rights Act 1998, which should prevent the justifiable and lawful exchange of information for the protection of children or prevention of serious crime.’ In Lord Laming’s report on ‘The Victoria Climbie Inquiry’ Recommendation 13 includes ‘ …it must make clear in cases that fall short of an immediately identifiable section 47 label that the seeking or refusal of parental permission must not restrict the initial information gathering and sharing. This should, if necessary, include talking to the child’. Similarly the All Wales Child Protection Procedures 2008 state under section 1.4 ‘Sharing Information among Professionals’ that ‘effective sharing and exchange of relevant information between professionals is essential in order to safeguard children. The law is rarely a barrier to disclosure of information. There is no restriction in the Data Protection Act or any other legislation that prevents concerns regarding individuals being highlighted and shared between agencies for the purpose of protecting children. The Bichard and Carlile reports both confirm the need to be aware that concerns from a number of sources, which individually may not be of significance, can build up a picture which may suggest a child is suffering or is at 7 risk of suffering significant harm and therefore requires professionals to act to protect them. Whenever possible, consent should be obtained before sharing personal information with third parties, but the public interest in child protection always overrides the public interest in maintaining confidentiality or obtaining consent from families. A child’s safety is the paramount consideration in weighing these interests’. The Code of Practice on the exercise of social services functions in relation to Part 3 (Assessing the needs of individuals) of the Social Services and Well-being (Wales) Act 2014 states that; ‘The willingness and ability to share appropriate and relevant personal information between practitioners and service providers is inherent to the delivery of effective integrated health and social care services’ and that ‘when a child or adult is identified as being at risk of abuse or neglect the presumption should be that all information is shared among relevant partners’ at an early stage provided it is lawful to do so….’ and that ‘If anyone with parental responsibility for a child under 16 refuses an assessment for that child ……. The refusal of a parent must be overridden…where the local authority suspects the child is experiencing or is at risk of abuse, neglect or other kinds of harm.’ Interface with Adult Services As noted previously mother had involvement with the CAU throughout the child’s life. It has also been acknowledged that practitioners allowed mother to prevent them having an open dialogue with the child and they did not always ensure that the child was at the centre of their interventions. It was evident to the reviewers on reading the timeline that whilst there was some communication with, and attendance at core group meetings by, the CAU service social worker this was often sporadic and limited. The inference throughout was that as CAU involvement was with the mother, then without her consent, much of the information they held could not be shared. It was clearly highlighted within the timeline that the interface between adult and children’s services could be strengthened. Decision-Making Within a Child’s Timeframe The mother in this case had, by her own admission in 2014, spent 7 years in and out of treatment for her drug addiction and during all that time she had not engaged positively or consistently with the CAU and had not made any sustained positive progress towards giving up or even stabilising her drug use. These 7 years included her pregnancy and the first six years of her child’s life. During the first six years the child suffered exposure to the mother’s substance misuse, to domestic abuse and to criminal activity. The child did not have a stable home, and suffered neglect of their health needs (notably including their dental health) and their education, whereby the child’s school attendance and punctuality were poor, and neglected presentation at times isolated the child from their peers. The child was exposed to their mother’s extended family members, associates and partners at least one of whom had a history of convictions for violence and substance misuse and who is alleged to have sexually abused the child. According to Brown and Ward in their 2013 report ‘Decision-making within a child’s timeframe’ children who remain with parents who have not made substantial progress in overcoming adverse behaviour patterns and providing a nurturing home within a few months of their birth may continue to experience maltreatment for lengthy periods. The principle that children are best brought up by their own families is enshrined in policy and legislation. Identifying the few children whose parents will not be able to meet their needs within an appropriate timeframe requires professionals to set these principles aside. Delayed decisions mean that children experience lengthy exposure to abuse and neglect, disruption of attachments with carers, unstable placements and prolonged uncertainty about their futures. International research has shown that such adverse (foetal and) childhood experiences or ACEs can lead to physical and chemical disruptions in the brain that can last a lifetime. The biological changes associated with these experiences can affect multiple organ systems and increase the risk, not only for impairments in future learning capacity and behaviour, but also for poor physical and mental health outcomes. This has been corroborated by recent studies of the Welsh population1. Adults in Wales who were physically or sexually abused as children or brought up in households where there was domestic violence, alcohol or drug abuse are more likely to adopt health- 1Welsh Adverse Childhood Experiences (ACE) Study, Public Health Wales NHS Trust 2015/16 8 harming and anti-social behaviours in adult life. They are also more likely to experience poor mental health and to be diagnosed with a chronic disease in later life. Practitioners at the Learning Event recognised that this case had ‘drifted’ and suggested that it would be good practice for there to be mandated senior management review when children’s names remain on the child protection register at the second review conference. Re-victimisation, Poly-Victimisation and Disclosure Children who have been abused or neglected in the past are more likely to experience further abuse than children who have never been abused or neglected (re-victimisation) and children who are being abused or neglected are also likely to be experiencing another form of abuse at the same time (poly-victimisation). 2 The child subject of this review suffered many forms of abuse some of which the child was only able to disclose in stages once they were removed from the care of the abusers. The child’s experience of suffering multiple forms of abuse and the pattern of disclosure is not untypical and practitioners need to be aware of this in order that they may be alert to the increased vulnerability of the abused children they encounter, and take this into account giving it due weight when assessing risk. Dental Neglect One of the concerns identified during the S47 enquiries about this child at the beginning of the period under review was the pre-existing extensive dental decay which subsequently resulted in the child having ten teeth extracted under general anaesthetic. Poor oral health negatively impacts on the daily activities and quality of life of children. Untreated dental decay may cause pain, sleep deprivation, reduced nutrition, functional limitations, higher school absenteeism and reduced school performance.3 This negative impact may include the need for general anaesthesia for dental extractions sometimes on more than one occasion. A representative from the C&V UHB Dental service attended the learning event and highlighted strongly for attendees the long term impact of poor dental health on an individual. Dental neglect is defined as ‘the persistent failure to meet a child’s basic oral health needs, likely to result in the serious impairment of a child’s oral or general health and development and includes a failure or delay in seeking treatment for significant dental caries or trauma, failure to complete a recommended course of treatment, or allowing a child’s oral health to deteriorate avoidably’.4 It is rarely present in isola-tion, but instead forms part of the more general neglect of a child or may co-exist with other forms of abuse. Early identification of dental neglect by healthcare professionals and appropriate action, if necessary making a child protection referral, may help prevent children from experiencing further harm. Record Keeping and Multi-agency Communication In common with many other reviews, some issues with record keeping were identified during this review. In particular there was an incident in April 2015 when a social worker visited the home to find mother under the influence of substances and in sole charge of the child. The social worker was unable to find a safe person to leave the child with and, according to her records; she attempted to enlist the support of the police in dealing with this incident and also took advice from an emergency duty team social worker. However neither police nor EDT could find a corresponding record and the social worker did not record the names of the professionals she spoke to. This made it impossible to fully clarify the events of that evening. When it was discussed by the practitioners at the learning event it became apparent that there was a lack of understanding amongst some of those present about other professionals’ roles, their powers and the limitations of their powers, which may have led to a breakdown in effective communication on the evening in question. Practitioners at the learning event commented on the utility of the multi-agency timeline in helping them to see the whole picture and understand what had been happening for the child, as they had not been aware of all the multi-agency information at the time of their involvement. In particular the child’s school were unaware of much of the multi-agency information, particularly about the agencies who were working to support mother. The learning event participants thought that it would be useful for the core group to have a 2 Child Abuse & Neglect 31 (2007) 479–502 3 BRITISH DENTAL JOURNAL VOLUME 220 NO. 9 MAY 13 2016 4 j o u r n a l o f d e n t i s t r y 4 2 ( 2 0 1 4 ) 2 2 9 – 2 3 9 9 shared multi-agency timeline which they could keep updated in order to monitor the progress made against the child protection plan. Such a timeline should include analysis, not merely record events, and could potentially be a good source of evidence for legal processes helping to minimise delays. The involvement of Education in the Child Protection process is critical. School staff are the practitioners to whom school aged children are most likely to make a disclosure of abuse and who have more hours of contact with children than any other professional in most instances. However there is a challenge for schools around meaningful representation at core group meetings and child protection conferences which occur during school holidays. Where possible core groups and child protection conferences should be held during term time. When this is not possible the arrangements should be made so that the school’s safeguarding lead can attend even outside of term time. Public Protection Notices (PPN) Process It was evident within the review that communication between the police and children’s services could have been strengthened. There were occasions when PPNs (formerly PPD1s) were not completed when they could have been, or failed to identify potential risks to the child within the events reported, in particular on the numerous occasions when mother was arrested. Whilst this information was fully shared for consideration in the police report for the Review Child Protection Conference best practice would have been for it to have been shared at the time. In respect of those PPNs (formerly PPD1s) that were completed there was little follow up by children’s services. When a child on the child protection register is identified by a warning marker within police intelligence systems, those children will be linked by association to their parents. If researched effectively by officers they should be able to identify when those arrested have responsibility for a child on the child protection register and undertake the necessary welfare checks, albeit this review has identified that this area needs to be strengthened. Improving Systems and Practice In order to promote the learning from this case the review identified the following actions for the SCB and its member agencies and anticipated improvement outcomes:- The reviewers have identified that many of the learning points in this case are far from unique and have been evidenced in other child practice reviews that have been undertaken here and elsewhere. As a result of these learning points being repeatedly identified, the C&V Regional Safeguarding Board has tasked its CPR/APR Sub-Group to develop and lead on regular learning workshops for all statutory and partner agencies across Cardiff and the Vale. The initial themes for the learning workshops have been identified as follows; the voice of the child, disguised compliance, difficult conversations with family members, sharing information, meeting attendance, and holistic approaches. Recommendations: 1. When a care order is granted for a child or at the earliest opportunity in a case, the decision will be made and recorded by a relevant member of the multi-agency team as to whether or not a referral to the Safeguarding Board for consideration of a child practice review is indicated. This will mitigate against delays to the CPR process. 2. When Legal Services have given advice regarding a child who subsequently becomes the subject of a Child Practice Review they will be represented on the panel, provide a timeline of their involvement and be invited to attend the Learning Event if deemed appropriate by the panel. This will aid practitioners’ understanding of their respective roles, evidential requirements and the legal advice given in the case. 3. Cardiff and Vale Safeguarding Children Board (C&VSCB) must be satisfied that a) at every statutory child protection visit practitioners have recorded that they have spoken to the child alone and in an appropriate environment, to ascertain their true views wishes and feelings, and to provide an opportunity for potential disclosures to be made, so that the voice of the child may be heard 10 b) internal case file audits should evidence that the process of senior managers in Children’s Services recording their approval of the progress achieved against the child protection plan, before the second and any subsequent child protection review conference is undertaken, to ensure that decisions are made within the child’s timeframe 4. C&VSCB will update and relaunch their ‘Multi-Agency Protocol on Working with Families who are not Cooperating with Safeguarding Issues’ and ensure that practitioners are aware of its contents. Managers and independent conference chairs should promote its use where appropriate, to help practitioners make an authoritative response to the resistant family, so that children are effectively safeguarded. This policy must clearly state that when parents’ behaviour prevents or compromises necessary safeguarding discussions and planning, it is permissible to continue or hold a meeting of the professionals involved without the parents being present, albeit there must always be a plan made to inform the family after the meeting. 5. C&VSCB will be satisfied that training, support and advice around the need for effective inter and intra agency information sharing for the purposes of safeguarding children, including when parental consent is and is not required as well as enquiries and checks on wider family members, is available to staff working with children and families in all partner agencies. All agencies will ensure parents are informed at the start of their involvement that the welfare of the child is paramount, and that all relevant information will be shared and all necessary action will be taken. 6. C&VSCB will be assured that practitioners understand the relevance of ACEs and are aware of their potential long term impact and understand the concepts of poly-victimisation and re-victimisation. This knowledge should be applied and given due weight when assessing the risk to children and making decisions about their future care. 7. C&VSCB will require that all partner agencies ensure that members of their staff attend Group 2 training under the National Training Framework so that they are skilled, confident and able to ‘ Ask and Act’ proactively identifying and offering support to victims of domestic abuse. 8. a) C&VSCB will ensure that all practitioners who work with children and families are aware of the concept of dental neglect. It is rarely present in isolation, may form part of the more general neglect of a child and may co-exist with other forms of abuse. Early identification and that taking appropriate action may help prevent children from experiencing further harm b) C&VUHB will ensure that all general dental practitioners know how to access appropriate safeguarding children training and advice, so that practitioners are confident in acting appropriately when they see dental neglect in a child. 9. C&VSCB will provide multi-agency training on a rolling basis to inform practitioners about their own and other professionals’ roles and powers in the child protection process. This will enable better understanding and multi-agency communication. 10. C&VSCB will introduce a consistent standardised multi-agency timeline template that becomes the responsibility of each agency to complete when attending the initial child protection conference. The multi-agency timeline will be maintained and updated at each core group meeting and presented as part of the report to the review child protection conference. This will ensure effective information sharing between agencies. 11. C&VSCB will challenge and hold to account partner agencies whose practitioners consistently fail to prioritise attendance and participation at Child Protection Conferences and core group meetings. 12. C&VSCB will be satisfied that Education Departments across the region ensure that there is meaningful engagement from the child’s school and attendance at child protection conferences and core group meetings, even when these have to be arranged during school holidays. 11 13. South Wales Police will review their procedure for linking parents with children on the child protection register in order to strengthen the process. All relevant agencies will review their arrangements regarding the action to be taken on receipt of a PPN (formerly PPD1) and ensure that practitioners are aware of the expected response to ensure appropriate actions are taken to safeguard children. Statement by Reviewer(s) REVIEWER 1 Dr Lorna Price Designated Doctor National Safeguarding Team (NHS Wales) REVIEWER 2 (as appropriate) Alys Jones Operational Manager, Safeguarding, Cardiff Council Statement of independence from the case Quality Assurance statement of qualification Statement of independence from the case Quality Assurance statement of qualification I make the following statement that prior to my involvement with this learning review:- I have not been directly concerned with the child or family, or have given professional advice on the case I have had no immediate line management of the practitioner(s) involved. I have the appropriate recognised qualifications, knowledge and experience and training to undertake the review The review was conducted appropriately and was rigorous in its analysis and evaluation of the issues as set out in the Terms of Reference I make the following statement that prior to my involvement with this learning review:- I have not been directly concerned with the child or family, or have given professional advice on the case I have had no immediate line management of the practitioner(s) involved. I have the appropriate recognised qualifications, knowledge and experience and training to undertake the review The review was conducted appropriately and was rigorous in its analysis and evaluation of the issues as set out in the Terms of Reference Reviewer 1 (Signature) Reviewer 2 (Signature) Name (Print) LORNA PRICE Name (Print) ALYS JONES Date 11th October 2018 Date 11th October 2018 Chair of Review Panel (Signature) Name (Print) DAVID DAVIES Date 11th October 2018 Appendix 1: Terms of reference Appendix 2: Summary timeline 12 Child Practice Review process To include here in brief: The process followed by the SCB and the services represented on the Review Panel A learning event was held and the services that attended Family members had been informed, their views sought and represented throughout the learning event and feedback had been provided to them. The Cardiff and Vale Regional Safeguarding Children Board (CVRSCB) Chair notified Welsh Government in November 2016 that it was commissioning a Child Practice review in respect of Case CPR 03/2016. External Reviewer: Dr Lorna Price Designated Doctor National Safeguarding Team (NHS Wales) Internal Reviewer: Alys Jones Operational Manager Safeguarding Social Services, Cardiff Council Chair of Panel: David Davies Head of Achievement for All Learning and Skills, Vale of Glamorgan Council The services represented on the panel consisted of: Education, Vale of Glamorgan Council (Chairperson) South Wales Police Social Services Cardiff Children’s Services (Reviewer) National Safeguarding Team, NHS Wales (Reviewer) Education, Cardiff Council Housing, Cardiff Council Cardiff & Vale University Health Board Community Rehabilitation Company, Wales Social Services Cardiff Adult Services Welsh Ambulance Service, NHS Trust Cardiff & Vale Integrated Family Support Team (IFST) The Panel met between the period March 2017 and December 2017 in order to review the multi-agency information and provide analysis to support the development of the report. A learning event was held on the 28th of September 2017 and was attended by representatives from the following agencies: South Wales Police – Detective Constables and Police Constable C&V University Health Board – Consultant Paediatric Dentist, School Nurse, Health Visitor Social Services Cardiff Children’s Services – Team Manager, Social Worker, Operational Manager, IFST Worker Education, Cardiff Council – Head Teacher Social Services Cardiff Adult Services - Team Manager, Cardiff Alcohol and Drug Team, Cardiff and Vale UHB – Community Addictions Unit and Social Worker Welsh Ambulance Service, NHS Trust - Nurse Adviser, Call Handler Coordinator NHS Direct Wales, Call Handler NHS Direct Wales, Senior Nurse Adviser Family declined involvement 13 For Welsh Government use only Date information received ……………………….. Date acknowledgment letter sent to SCB Chair ………………………… Date circulated to relevant inspectorates/Policy Leads …………………………. Agencies Yes No Reason CSSIW Estyn HIW HMI Constabulary HMI Probation 14 Appendix 1: Terms of reference C&V RSCB Child Practice Review 03/2016 Extended Review Terms of Reference Background Children Services raised concerns in January 2014 that the child’s basic care needs were not being met - the school has reported that the child appeared unkempt and their attendance was very poor. Concerns were also raised regarding the child’s dental hygiene, progress and development. Professionals also raised concerns of the mother’s engagement with agencies (CAU and missed tests). The child was placed on the Child Protection Register (Neglect and Emotional Abuse). There were concerns surrounding a relationship with the mother and a new male. The mother made a Claire’s Law request for a male, the mother was contacted by police and declined the information being offered regarding the male and no Claire’s Law disclosure report was prepared as a result. The child had made disclosures about the male of a physical and sexual nature. The child was removed from the address. The child was placed into foster care. There was a fire in the home address of the mother and grandfather. It was later established that the grandfather had been found passed away in the upstairs bathroom of the property and his death was being treated as suspicious. The mother was linked to the investigation as a murder suspect. Timeframe for Review: 1st January 2014 – 10th January 2016 The review panel have decided that the incidents subsequent to the child being removed from the home did not need to be included in the timeframe however; the reviewers will still consider any significant events outside of the timeframe as party of the context. Criteria for an extended review The criteria for extended reviews are laid down in the Social Services and Well-being (Wales) Act 2014; Working Together to Safeguard People Vol. 2 – Child Practice Reviews are: 3.12 A Board must undertake an extended child practice review in any of the following cases where, within the area of the Board, abuse or neglect of a child is known or suspected and the child has: died; or sustained potentially life threatening injury; or sustained serious and permanent impairment of health or development; and the child was on the child protection register and/or a looked after child (including a person who has turned 18 but was a looked after child) on any date during the 6 months preceding – the date of the event referred to above; or the date which a local authority or relevant partner identifies that a child has sustained serious and permanent impairment of health and development. Core tasks Determine whether decisions and actions in the case comply with the policy and procedures of named services and Board. 15 Examine inter-agency working and service provision for the child and family. Determine the extent to which decisions and actions were individual focused. Seek contributions to the review from appropriate family members and keep them informed of key aspects of progress. Take account of any parallel investigations or proceedings related to the case. Hold a learning event for practitioners and identify required resources. In addition to the review process, to have particular regard to the following: Whether previous relevant information or history about the child and/or family members was known and taken into account in professionals' assessment, planning and decision-making in respect of the child the family and their circumstances. How did that knowledge contribute to the outcome for the child? Whether the child protection plan (and/or the looked after child plan or pathway plan) was robust, and appropriate for that child, the family and their circumstances. Whether the plan was effectively implemented, monitored and reviewed. Did all agencies contribute appropriately to the development and delivery of the multi-agency plan? What aspects of the plan worked well, what did not work well and why? The degree to which agencies challenged each other regarding the effectiveness of the plan, including progress against agreed outcomes for the child. Whether the protocol for professional disagreement was invoked. Whether the respective statutory duties of agencies working with the child and family were fulfilled. Whether there were obstacles or difficulties in this case that prevented agencies from fulfilling their duties (this should include consideration of both organisational issues and other contextual issues). There are ongoing criminal investigations however; these are unlikely to interfere as the trial date is 22nd March 2017. The Specific Tasks of the Review Panel Agree the timeframe for the review including any necessary reference to any significant background information or previous incident. Identify agencies, relevant services and professionals to contribute to the review not already requested by the Child Practice Review Sub Group, produce a timeline and an initial case summary and identify any immediate action already taken. The Panel has determined that the appropriate agencies to be engaged in this review and therefore participate as members of the review panel are: Health: Cardiff and Vale University Health Board Children Services: Cardiff Local Authority Education Services: Cardiff Local Authority South Wales Police Housing, Cardiff Local Authority Welsh Ambulance Service Team Wales Community Rehabilitation Company 16 Adult Services, Cardiff Local Authority Produce a merged timeline, initial analysis and hypotheses. Plan with the reviewer/s a learning event for practitioners, to include identifying attendees and arrangements for preparing and supporting them pre and post event, and arrangements for feedback. Based upon the timeframe within which the Panel will conclude the review the learning event will be scheduled for the 28th of September 2017. Plan with the reviewers contact arrangements with the child and family members prior to the event. Advice will be sought about how to engage with the family/birth family subject to the review and any relevant family members. Receive and consider the draft child practice review report to ensure that the terms of reference have been met, the initial hypotheses addressed and any additional learning is identified and included in the final report. Agree conclusions from the review and an outline action plan, and make arrangements for presentation to the Child Practice Review Sub Group and the RSCB for consideration and agreement. It is proposed that the report will be shared with the Child Practice Review Sub Group at its meeting scheduled for the 20th of March 2018 and at the RSCB meeting scheduled for the 17th of April 2018. It is proposed that the final report will be signed off by the end of April 2018 and submitted to Welsh Government by May 2018. Plan arrangements to give feedback to family members and share the contents of the report following the conclusion of the review and before ratification at RSCB. The Panel Chair and Reviewer will provide feedback to the family in advance of the RSCB meeting scheduled for 17th of April 2018. Identify and commission a reviewer/s to work with the review panel in accordance with guidance for extended reviews. Agree the timeframe. Identify agencies, relevant services and professionals to contribute to the review, produce a timeline and an initial case summary and identify any immediate action already taken. Produce a merged timeline, initial analysis and hypotheses. Plan with the reviewer/s a learning event for practitioners, to include identifying attendees and arrangements for preparing and supporting them pre and post event, and arrangements for feedback. Plan with the reviewer/s contact arrangements with the individual and family members prior to the event. Receive and consider the draft child practice review report to ensure that the terms of reference have been met, the initial hypotheses addressed and any additional learning is identified and included in the final report. Agree conclusions from the review and an outline action plan, and make arrangements for presentation to the Board for consideration and agreement. Plan arrangements to give feedback to family members and share the contents of the report following the conclusion of the review and before publication. 17 Confidentiality Statement Signature: Date: Name (Print): Position/Role: Contact No : Parent Organisation: Witness Signature: Date: Name(Print): Rank/Status: Sharing Information There is also a DHR (Domestic Homicide Review) being undertaken by Cardiff Council into the death of the grandfather and it was agreed by both the CPR Panel and DHR Panel that because there will be many similarities and individuals involved in both cases, that the CPR Reviewers will meet with the family members on behalf of both the CPR and DHR. It has been agreed by the Panel that information/findings from this CPR may be shared with the DHR. Tasks of the Safeguarding Children Board Consider and agree any Board learning points to be incorporated into the final report or the action plan. Review Panel complete the report and action plan. Board sends to relevant agencies for final comment before sign-off and submission to Welsh Government. Confirm arrangements for the management of the multi-agency action plan by the Review Sub-Group, including how anticipated service improvements will be identified, monitored and reviewed. Plan publication on Board website. Agree dissemination to agencies, relevant services and professionals. The Chair of the Board will be responsible for making all public comment and responses to media interest concerning the review until the process is completed. Confidentiality Closure Statement To be completed if there are any changes to the information provided since completion of the review. 1. I have been told and I agree that under no circumstances (unless otherwise instructed by the panel Chair) will I discuss any aspect of the Practice Review with any person not directly involved in or appointed to the review. 2. I have been instructed and I agree, that should any person not appointed to the review enquire or otherwise attempt to discuss the review, I will provide no information whatsoever to them. 3. I agree to report any such attempted enquiry to the review Chair. 18 Name: Position/Role: Parent Organisation: Signature: Date: Part 3: Agreement for persons leaving or ceasing activity with review. 1. I am aware of the confidentiality of the review and that this confidentiality is essential to its existence. I am also aware that any breach of this confidentiality could directly affect the responsibilities and capabilities of the review. 2. I agree that I will not discuss or otherwise divulge any information whatsoever relating to the review to any person or organisation without the express and written permission of the review Chair. 3. I agree that I will make no further enquiries on behalf of the review, and should any person or organisation contact me in the belief that I am still directly involved in the review; I will decline the communication and direct the person or organisation to the review Chair. 4. I agree that I will not discuss the review with any person, including any present or past member of the review, and that I will notify the review Chair of any such attempt at communication of information. I undertake not to record or retain in my possession any material, whether written or otherwise recorded, which relates to the review, and that I will not, under any circumstances, publish or otherwise make public any aspect of the review or reveal the identity of persons subject of the review. Date: Signature: Witnessed by (Print): Signature: 19 APPENDIX 2 Cardiff and Vale of Glamorgan Regional Safeguarding Children Board Summary Timeline Re: C&V RSCB CPR 03/2016 Type of activity 2014 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec University Health Board Child admitted as a day case to the Dental Hospital. Extensive dental extractions under general anaesthetic for dental caries. Core Group meeting. It was explained that continuation of poor engagement with Community Addictions Unit would result in a reduction of her medication and discharge from treatment. Police Strategy discussion between police and Children’s Services. Decision to proceed to an Initial Child Protection Case Conference. 20 Type of activity 2014 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Social Services Initial Assessment completed by Children’s Services. Concerns around parental substance misuse, evidence of neglect of child’s basic care needs, instability of housing. S47 enquiries/Core assessment started. S.47 enquiries/core assessment concluded. Significant concerns around emotional harm, neglect, parental substance misuse, criminal activities of mother. Family due to be evicted due to rent arrears. Initial Child Protection Conference held. Child registered under the categories of Neglect and Emotional Abuse. Core Group identified. Outline Child Protection Plan formulated. Case transferred to long-term social work team. Core Group held. Improvements noted to home conditions and child’s general care, but concerns expressed re poor school attendance and punctuality and very poor engagement by mother with Community Addictions Unit. First Review Child Protection Conference; Child’s name retained on register under categories of Neglect & Emotional Abuse. Further concerns regarding care of child and mother’s poor engagement with Community Addictions Unit. Core Group meeting held. Mother did not attend. The Chair recommended that a new Written Agreement be drawn up to include engagement with services, particularly Community Addictions Unit. The Written Agreement should be in place for three months and if broken Public Law Outline Core Group held. Mother reported that she had been in relationship for several months. The Social Worker had completed checks; there was information held by the police in relation to previous convictions for battery, charges of domestic violence and possession of drugs. Mother informed the core group that since being made aware of this information she had ended the relationship. Core Group held. Mother has attended CAU and provided supervised urine samples which were positive for illicit substances. Mother is now on Methadone which she collects daily. 21 Type of activity 2014 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec proceedings should begin due to the lengthy history of non-engagement. Detailed timelines were produced by the relevant services for the purposes of the review to assist the understanding of the complex interactions between events and services in this case. This summary and partial timeline contains limited and anonymised details and is provided to supplement the outline of circumstances in the Child Practice Review report. Type of activity 2015 2016 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan University Health Board Core Group Meeting. Mother’s engagement with Community Addictions Unit noted to be barely acceptable. Mother was attending CAU for dispensing with a man. She stated they were not in a relationship and that he was just a friend. Police SWP received a telephone call from Mother, wishing to make a Clare’s Law application in respect of her new boyfriend of five months. Mother received a prison sentence for shoplifting offences and breaching her bail conditions. The child continued to make disclosures of abuse including sexual abuse and was interviewed by the police. Further police interview completed and record closed. 22 Type of activity 2015 2016 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan CRC Court Sentence for shoplifting offences. Mother received a 12 month Community Order. Probation officer was allocated. Mother failed to attend the initial appointment with Wales Community Rehabilitation Company. Mother committed several shoplifting offences that same day and the child was with her. Mother attended Community Rehabilitation Company for initial appointment under the influence of substances. Offender Manager 23 Type of activity 2015 2016 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan contacted social services and relayed her concerns that Mother was not fit to care for child that day. Arrangements were made for the child to be taken from school to grandmother’s address. Social Services Second Review Child Protection Conference. Positive improvements were noted but needed to be maintained. Child’s name remained on the Child Protection Register under the categories of Emotional Abuse & Neglect Statutory Child Protection visit to family home. Mother and child present. Boyfriend also arrived at the home whilst social worker was visiting. She had concerns about the presentation and behaviour of mother; that mother was misusing substances which were impacting on her self-care and the child was being exposed to Legal Planning meeting held. Agreed PLO pre-proceedings. During a home visit the child informed the Social Worker that the boyfriend hurts mummy and that the child is scared of him. The child was removed to the care of grandmother. Third Review Child Protection conference. The outcome of the conference was that the child’s name remained on the Child Interim Care Order Granted. Child placed in foster care. Once in foster care the child made disclosures about domestic violence perpetrated by the boyfriend on the child’s mother and the dog. The child described witnessing drug use by the mother and the boyfriend. Fourth review child protection conference. The child’s name was removed from the register as the child was looked after by the local authority. The child made further disclosures of sexual abuse to the foster carer. Care order granted. 24 Type of activity 2015 2016 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan parental substance misuse. CP statutory visit by social worker. Mother was under the influence of substances and the child was present at the home in her sole care. The social worker had significant concerns for mother’s wellbeing and her capacity to care for the child. Other family members were not contactable. Mother refused consent for section 20 accommodation. The social worker phoned the police for assistance but they refused to attend the home. She then contacted Protection Register under the categories of ‘Neglect’ and ‘Emotional Abuse’. Grandmother reported to the social worker that the child had disclosed that mother’s boyfriend threatens the child and the mother with a knife, he comes in to the child’s room at night and they are scared of him. Legal Planning Meeting held. Viability assessment of extended family members was negative. Mother was not engaging with a parenting assessment or written 25 Type of activity 2015 2016 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan the Emergency Duty Team to seek guidance and report her concerns. It is unclear from the records how safeguards were put in place. agreement and is still in a relationship with the boyfriend. Threshold met to initiate care proceedings. Housing Anti-Social Behaviour Unit receives a complaint from Mother’s neighbours regarding many visitors to and around the property at all hours. ASBU open an investigation. |
NC044361 | Executive summary of the review into the death of a 4 year old girl in September 2011 who was subject to a child protection plan. Mother pleaded guilty to manslaughter on the grounds of diminished responsibility and was detained in a secure mental health facility. Previous incidents of physical abuse. Concerns had been noted about the mother's inappropriate sexual behaviour towards her daughter. Issues around mother's hostility, cultural sensitivities and the focus of professional intervention on trying to get a mental health diagnosis for the mother, rather than assessing the impact of the mother's behaviour on the child's safety and welfare. Learning focuses on: the need to listen to children; the importance of comprehensive and robust assessments; greater recognition of key risk factors; greater awareness of the indicators of sexual harm; professional confidence in challenging medical assessments and outcomes. Makes interagency and various single agency recommendations covering children's social care, police, GP and NHS Trusts (including mental health) and housing.
| Title: Executive summary of the serious case review in respect of Child U. LSCB: Manchester Safeguarding Children Board Author: Colleen Murphy Date of publication: 2013 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Executive Summary of the Serious Case Review in respect of Child U This report has been commissioned and prepared on behalf of Manchester Safeguarding Children Board and is available for publication on the 28th February 2013. Until publication this report remains confidential and must not be shared with non-relevant parties in keeping with the MSCB Data Sharing Protocol. Manchester Safeguarding Children Board Chair: Mr I Rush Review Panel Chair: Mr D Hunter Author: Ms C Murphy 2 1. Introduction 1.1 On the evening of 22nd September 2011, MU (mother of Child U) presented at the accident and emergency department of her local hospital with self inflicted injuries to her wrist and neck. MU was assessed at risk of further self harm, and was seen by an Emergency Medicine Registrar for assessment. MU informed medical staff that she had cut her wrists and ankle with a knife as she wanted to end her life; also that she had taken approximately ten paracetamol the previous night and drunk half a bottle of rum that day. MU went on to say that she ‘did what she did because it needed to be done’, and that ‘the system was corrupt; social workers were treating her badly and had taken her daughter’. When asked where her daughter was, MU informed medical staff that she was dead at home because she had suffocated her on Tuesday evening. The medical report noted that when disclosing her actions, MU showed no signs of regret and was very calm in her demeanour. 1.2 The police were contacted immediately and told of the information given by MU. The police attended the home address of Child U and MU urgently, and discovered the deceased body of a child, later confirmed to be Child U. Child U was four years and 9 months when she died. 1.3 Child U had been the subject of a multi agency Child Protection Plan at the point of her death. 1.4 MU was formally charged with the murder of Child U. She was detained in a secure mental health facility awaiting trial. 1.5 The Post mortem examination and investigations did not identify any natural conditions that could account for Child U’s death; and it was noted that the circumstances described by MU provided a plausible account of how death occurred. 1.6 At Crown Court in November 2012, MU was deemed fit to enter a plea following a period of psychiatric treatment. MU pleaded not guilty to the murder of Child U, but guilty to manslaughter on the grounds of diminished responsibility. Both defence and prosecution Doctors were satisfied that MU was suffering from paranoid schizophrenia and had been at the time of the killing. MU was sentenced to a Hospital Order which is made when a person is convicted for a crime punishable by imprisonment and the Court is satisfied that the person is suffering from a mental disorder and, it is appropriate for them to be detained for medical treatment. In addition a Restriction Order was made for an indeterminate period of time which means that MU can only be released upon application to the Independent Mental Health Tribunal and application/ recommendation to the Ministry of Justice. 3 2. Methodology 2.1 A Serious Case Review Panel was established which comprised of the following people: Independent SCR Chair, Mr David Hunter Detective Sergeant, GMP Safeguarding Vulnerable Person Unit Service Lead for Safeguarding, Manchester Children’s Social Care (CSC) Designated Nurse, NHS Manchester Designated Doctor, NHS Manchester Acting Business and Performance Manager, MSCB Associate Director, Manchester Mental Health & Social Care Trust (MMHSCT) Head of Operations, Sure Start and Early Years Regional Director, Family Action Group Chief Executive, Adactus Housing Association. The Serious Case Review Panel met on nine occasions between January and October 2012. 2.2 An Independent Author Ms Colleen Murphy was appointed to write an Overview Report on the process and findings of the Serious Case Review. 2.3 The key lines of enquiry for the Serious Case Review were as follows: The timeframe for the period of review is 3rd July 2008 and 22nd September 2011. This represents the period of time that statutory agencies became aware of a concern for Child U until the date of death. 1. How did agencies recognise and respond to sexually harmful behaviours and the potential impact on Child U and other children? Analysis to include adult & child’s behaviour, comments, language & thoughts. 2. To what extent did assessment of mother’s parenting take account of her behaviour towards Child U, other children, other adults, professionals and staff? 3. How did agencies concerns regarding mother’s reported mental health issues inform the planning and safeguarding of Child U. 4. How holistic were agencies assessment of Child U’s needs in relation to wider family and social isolation? 5. To what extent did agencies and services take account of issues such as: race and culture, language, age, disability, faith, gender, sexuality and economic status and how did this impact upon agencies assessment and service delivery? 6. What factors influenced the police decision to take Child U into police protection on 5th July 2009 and 13th October 2010? 7. To what extent were Child U’s voice, wishes, feelings, behaviours and needs explored, understood and taken account of when making 4 decisions about the provision of services? Was this information recorded? 8. To what extent did agencies communicate effectively and work together to safeguard and promote the continued wellbeing of Child U? 2.4 The following agencies provided Individual Management Reports for consideration: • Manchester Children’s Social Care • Manchester Early Years and Sure Start • Greater Manchester Police • Adactus Housing • NHS Manchester • Manchester Mental Health and Social Care Trust • Central Manchester Foundation Trust. Each IMR contained a chronology of agency contacts which was amalgamated to create a multi-agency chronology. 2.5 Alongside the SCR, there are two parallel processes that have occurred. Manchester Mental Health and Social Care Trust have conducted a Serious Untoward Incident Enquiry, the report from which was made available to the SCR panel. Additionally, the death of Child U has resulted in a murder charge against her mother, which was taken into account by the Serious Case Review Panel. 2.6 Each contributing agency has completed an Individual Management Review (IMR) with an understanding of the need to maximise independence and a desire to identify any learning opportunities. Authors engaged in the IMR process with rigour and critical honesty and for the purposes of the Serious Case Review this produced a good standard of draft reports. All IMR Authors attended a panel meeting to present their reports and the Serious Case Review Panel undertook constructive challenge of each IMR, in order to assist authors to reflect critically on the work undertaken by their agency and, where necessary, IMR authors redrafted their reports and recommendations. No panel members were involved in the writing of IMRs. This enabled an objective and challenging approach by the SCR panel. The individual agency recommendations are attached as section six of this report. 2.7 Once all information was received, the SCR Panel considered that there was a need for specialist opinion from an Independent Psychiatrist to provide an informed and objective view of the possible contributory factors and mental health responses in relation to MU. The panel posed the following questions for consideration and received a helpful and informative response. 5 • Review medical intervention and comment on whether the outcome of assessments were appropriate to the patient’s history and presenting behaviours as reported by herself and others at that time? • To what extent is it possible for a patient to mislead an assessment in this patient’s circumstance? • When the patient had a diagnosis in 2005: (1) what was the potential impact of her not receiving an ongoing service, (2) what was the likelihood of re-occurrence? (3) Should she have been reviewed during her period of medication? • Given the patient’s presentation, how can this behaviour be explained without the presence of mental illness? Can you give an indication whether cannabis use would offer explanation? • What are the effects of ongoing cannabis use on mental health? • Are there any indicators of the patient’s behaviour that should have been seen as a risk to her child? 2.8 The Serious Case Review Panel (SCRP) gave careful consideration as to who should be consulted as part of the review from Child U’s family. The SCRP was mindful that criminal charges were pending and the Acting MSCB Business and Performance Manager contacted the police in order to ascertain a view from the investigation officers and Crown Prosecution Service about the appropriateness of speaking with family members who could also be trial witnesses. The Panel was advised that it would not be appropriate to speak directly with trial witnesses, but that there were no objections to other family members. The Serious Case Review Panel had very limited information about the father of Child U (FU) and the Chair of the Panel made telephone contact with Child U’s father who was living abroad. Child U’s father considered that someone should have contacted him when Child U’s mother needed help and he would have come to England and stated he did not know that there were problems which needed help. The panel intended if possible to speak with Child U’s mother before any other family members, however, once the trial date was put back, and as she was a key witness, the SCR panel had to review the original intention to seek contribution from Child U’s mother prior to any other family member. It was clear that there were significant gaps in understanding Child U’s mother’s personal life and relationships which would inhibit the analysis of trying to understand why she acted as she did. A decision was made to approach family members, who then helpfully contributed to the knowledge and understanding about Child U and her mother to assist the review. 6 3. Summary of Events 2008 3.1 Child U lived alone with her mother in a first floor flat. Up until the age of 18 months, Child U was known only to routine universal services. MU gave the impression that she was fairly isolated from her family. It is also known that she experienced some disharmony with her neighbours, and often reported incidents to Housing which she believed had been caused by a neighbour. Investigation of the incidents found no cause for concern. 3.2 In July 2008, a concerned member of MU’s personal support network made contact with a community police officer to discuss concerns in relation to MU, and her view that she needed support. The concerns related to comments made by MU that her 18 month old daughter (Child U) wanted to have a sexual relationship with and that she (MU) was hearing voices. 3.3 The police made a referral to Children’s Social Care. A strategy meeting and joint visit concluded that a mental health assessment should be arranged for MU. The pathway to achieving such an assessment proved problematic for the social worker to achieve, and ultimately MU was seen by an out of hours GP and assessed as not in need of an immediate mental health assessment, and that further medical input should be done through the routine GP. The social worker completed an Initial Assessment which recommended no further action, and the only subsequent medical follow up was by a health visitor. MU said she was more embarrassed than annoyed by the referral, stating that Child U was everything to her and she felt professional support groups had nothing to offer. 2009 3.4 In February MU began attending a local Sure Start Children’s Centre. Records of her visits to the Centre indicate that she spoke a lot about God, and how God does not judge or punish. The Children’s Centre contacted the Health Visitor as they were concerned about MU’s behaviour to other parents which was experienced as rude, aggressive and on occasion prejudiced. The Health Visitor discussed the information with the GP and established that MU had not recently seen the GP but it was agreed that MU would be invited into the surgery to discuss a referral to psychiatry. When MU attended the surgery, Child U was reported as looking and interacting well with her mother. MU declined a referral to psychiatry but accepted that she had said inappropriate things to other mothers and would curb her tongue in future. 3.5 MU had expressed a desire to move home, and the Health Visitor wrote to her housing provider to support this. MU also asked the GP to send a letter to support this, but was recorded as abusive by the GP when discussing this 7 during a telephone conversation. However, when the Housing Association sent a medical assessment questionnaire to MU regarding application for medical priority, this was not completed and the application for medical priority was cancelled. 3.6 In July a maintenance operative undertaking routine housing repairs reported that MU had been aggressive towards him and that he was concerned about the way Child U was treated. This information was referred to Children’s Social Care, stating concern for MU’s mental state and a concern for how Child U was handled. There is no record of how this referral was responded to. Shortly after, MU attended a police station with Child U and said she was having arguments with her partner and no longer wanted to live with him. She told the officers that ‘she began to hear the television laughing at her … FU became frustrated … and told her she was mad…’ The Police Officers became concerned that MU said to Child U ‘it’s just me and you now; we will have to take each day as it comes and see how long we last. At least we know there is a place for us up there... .’ The Police took MU to the hospital Emergency Department, and provided the history from the current and their previous involvement. MU was assessed by a Mental Health Liaison Nurse, it was concluded that there were no signs of mental illness, denial of auditory hallucinations or thoughts of suicide or self harm. During the episode police officers were concerned about aspects of MU’s behaviour towards Child U, which was perceived as sexualised. Child U was placed in emergency foster care as the police exercised their powers of protection. During a joint visit between police and Children’s Social Care the following day, MU denied saying ‘there is a place up there for us’ and it was agreed that Child U would return home whilst the Social Worker would conduct a core assessment. When Child U did return home, MU was concerned that she may have been sexually abused in foster care. A subsequent assessment by a Mental Health Social Worker and a Community Psychiatric Nurse (CPN) concluded that there was evidence of symptoms of mental disorder with overvalued ideation, delusions of reference and hypersensitivity to environmental dangers, however, that MU was not responding to hallucinations, thought blocking or formal thought disorder. MU declined any input from mental health services and it was agreed that as MU was not appropriate for services, therefore the referral was closed to mental health services. The Core Assessment was completed in August 2009, it did not fully explore family relationships, analyse need and risk yet on this basis the case was closed to Children’s Social Care. 2010 3.7 Between May and July, the Children’s Centre made three referrals to Children’s Social Care (CSC). They each outlined similar concerns about MU’s behaviour In April 2001; the Children’s Centre were concerned by MU’s presenting behaviour and comments she had made such as ‘this is what people do they try to control you’. In May, a parent wrote a letter of 8 complaint to the Children’s Centre outlining concerns about MU’s behaviour towards her child. A referral was made to CSC which outlined the incidents and stating concerns for MU’s mental health. Following consultation with the Health Visitor, no further action was taken. The Children’s Centre made a further referral a week later following a meeting with MU. A decision was then made to allocate a Social Worker to undertake an Initial Assessment. The Initial Assessment was completed by early June, it lacked any detail about Child U’s parenting and no further action was the agreed outcome. MU was resistant to the Children’s Centre staff discussing any outstanding support needs. 3.8 In late July, the Children’s Centre made a referral to Children’s Social Care raising concerns on behalf of the management team who considered that a further assessment was needed. A decision was made to ask the Mental Health Team to further assess MU’s mental health to establish whether her health was impacting upon her ability to parent. Consultation took place with MU’s GP who advised that it was not thought that MU had mental health problems; however, the Mental Health Manager advised that MU had been assessed by a psychiatrist in 2005 and diagnosed with schizoid personality; significantly, this information had not been made available at previous assessment points. A plan was agreed that the GP would invite MU into the surgery for assessment. GP records indicated that MU was invited to attend the GP, but there was no follow up when she did not do so. No further action as taken by Children’s Social Care or mental health services. 3.9 During September MU had several interactions with her Housing Association. On one occasion, an officer told her he would have to put the phone down because she was aggressive, and whilst visiting the home and hearing loud music she was told that enforcement action would have to be taken if it did not stop. In late September, two maintenance workers went to MU’s home to complete repairs in the bathroom and kitchen. After the visit, the workers completed ‘Concern Cards’, raising concerns about what they experienced and saw. The workers reported that MU was abusive to them and used abusive language to Child U; they reported concerns about the welfare of Child U and state of mind of MU. 3.10 In October, the police responded to a call from a member of the public who witnessed MU hitting Child U hard. Child U was observed to have a bleeding scratch to the bottom of her neck, and when asked how this had happened, she said mummy had done it in an accident. The police invoked Police Protection Powers and MU was seen by a police surgeon who stated that she was fit to be detained. Child U was placed in emergency foster care. She told a Social Worker that MU slaps her when she doesn’t listen. Following a strategy meeting, it was agreed that MU would receive a caution and Child U would return home. An agreement was made to convene an Initial Child Protection Conference which took place late November. 9 3.11 The Child Protection Conference was attended by key agencies, apart from the Children’s Centre who had not been invited. Child U was made the subject of a Child Protection Plan under the grounds of neglect. The reason for neglect has no explainable rationale, when the focus of the Conference was risk in relation to physical and emotional abuse. 3.12 In December, a Housing Officer and Manager visited MU to discuss complaints from local residents. MU stated that she was being harassed but couldn't say who by or why. When asked what made her feel that she was being harassed she said that mud had been placed deliberately in her gutter to scare her and her daughter and that there was no grass growing on her lawn. MU was described as aggressive throughout the interview, shouting at both officers and not allowing them to speak. During this, Child U became more and more animated, and also shouted derogatory abuse at the officers. 2011 3.13 In January, two Housing Maintenance Workers attended MU’s home. During the visit MU asked the men to marry her, but was also verbally abusive to them whilst they were cleaning up. As a result of this, MU was sent a written warning about her behaviour towards staff. 3.14 MU and Child U continued to attend a second Children’s Centre, however, a number of incidents led other parents to be upset and offended by MU and they began to leave the sessions to avoid the situation. Parents reported that they felt intimidated by MU and unable to challenge her. The Children’s Centre completed a referral form however, it would appear that they were not aware that Child U was the subject of a Child Protection Plan, but were aware of the concerns raised by the previous Centre. 3.15 The first Review Child Protection Conference was held in February 2011. The meeting was not attended by Police and the Children’s Centre was invited but sent apologies. This meeting did not record any real progression of the issues of concern, there was no systematic evaluation of what had been achieved during the review period and no timescales were allocated to achieve further progress. Child U remained subject to a Child Protection Plan for neglect. The summary of the Conference is clearly at odds with the reality of the situation as it indicates that MU was now taking on board advice. The meeting confirmed the need for mental health assessment and a parenting approach. 3.16 In March, MU was referred to the Children and Parents Service (CAPS) for a parenting course; however, when she was contacted by the service she refused the parenting course. 3.17 In April, the Social Worker contacted MU’s GP and requested an urgent assessment. The Social Worker was advised to ring back the following week as the GP would invite MU into surgery. The GP discussed the situation with a 10 Consultant Psychiatrist who felt that mental health assessment was advisable. The GP thought it would be difficult to make this referral as MU hadn’t been seen since 2009, and agreed to discuss further with the Social Worker who was felt to be best placed to make the referral. The Social Worker contacted the GP again and was advised to send a referral to the Psychiatrist which was done that day. Once received by the Manchester Mental Health and Social Care Trust, the referral was quickly allocated and a plan was made for a Mental Health Social Worker to visit MU in May to conduct the assessment. 3.18 A Mental Health Social Worker conducted the assessment. Some abnormalities of mental state were noted but no symptoms of psychosis. The assessment could not be completed in full because Child U’s presence was too disruptive, but MU had agreed to attend any outpatient psychiatry appointment. There are many recorded attempts by the Mental Health Social Worker to consult with the child’s Social Worker prior to making arrangements directly with MU but no contact was established. An arrangement was made with MU for an appointment in July. MU was subsequently assessed at the outpatient clinic. The assessment concluded no abnormal findings, but notably did not have access to the records from 2005 which were handwritten on a different system to the one in operation. 3.19 The third Review Conference was in July. The Conference was not attended by the Police, or MU. Child U remained subject to a Child Protection Plan for neglect. MU was unhappy with the continued plan when she could see nothing wrong. 3.20 A Core Group meeting was held in August, attended by Social Worker, Health Visitor and MU. The focus of discussion was MU’s decision to home educate Child U. The Health Visitor remained very concerned about the impact of MU’s decision on Child U and discussed this issue with the Named Nurse who in turn raised the issue of concern with the Deputy District Manager (DDM) from Children’s Social Care who agreed to review the case and perhaps seek legal advice. In September an Education Case Worker visited MU to discuss the issues relating to home schooling. MU advised she had researched home schooling on the internet and intended to pursue this. Child U was due to start school in January 2012, and the worker arranged to visit again in the New Year. 3.21 Throughout August and September, there are more positive recordings of Child U’s behaviour and MU’s interactions with her from the Children’s Centre. A Core Group took place on 14th September where the focus was assessing home education, progressing the CAPS work and accessing activities that would promote social development for Child U. An appointment was made for CAPS on 23rd September; however, MU was still expressing reluctance to engage in parenting work. This was the last contact with MU and Child U prior to the death of Child U. 11 4. Lessons Learnt Whilst the review identified individual failings across the system, this did not equate to systemic failings within the system. There were however a number of significant factors which impacted on the effectiveness of the operation of the child protection system and these are the areas from which key learning was drawn. 4.1 The challenge of working with parents who are hostile or difficult to engage MU was perceived as having a difficult personality by all professionals who worked with her, she responded badly to any criticism or request for change, and this may be one reason why the Child Protection Plan and Core Group did not sufficiently focus on issues where change was required, and remained too occupied in attempting to achieving a partnership with MU, consequently lacking focus on Child U. There is a place for professionals only meetings, in particular this should be considered as necessary in situations where professionals may feel stuck with intractable problems. 4.2 The need to listen to Children Children, however young or old, must be at the heart of a child protection process. This does not mean simply focussing on them as an object of concern, but allowing children to be heard through whatever means they can communicate and express themselves. This may be verbal, through behaviour and by observation. Child U was not afforded this opportunity. 4.3 The Insufficiency of Assessments of Child U No sufficient assessment was achieved of Child U. Her father was unaware that she was the subject of a Child Protection Plan, and all information was taken from MU without corroboration. The insufficiency of Core Assessments is a central issue which results in a lack of recognition of risk. For Child U, the lack of understanding of the risks to which she was exposed resulted in a wrong categorisation of risk and this had detrimental consequences for the ongoing case management. 4.4 The need for greater recognition of Key Risk Factors MU was known to have used cannabis from being a young teenager, yet the questions about usage, dependency and impact were never asked. MU alleged that she needed to leave her home when FU was present, citing domestic dispute as the reason, yet the facts were never asked or established. The majority of professionals working with MU believed she experienced mental health problems, and whilst specialist assessment was sought, aspects of her behaviour remained problematic and not understood in the context of her health or personality. National research confirms that domestic violence, mental health issues and substance misuse are common factors in parents whose children become the subject of SCRs and this is reflected in those conducted in Manchester. This 12 combination of factors should therefore been regarded as highly significant when assessing risk to children. 4.5 The need for greater awareness of indicators of sexual harm There was continued evidence to suggest that MU was pre-occupied with sexualised behaviour and risk of sexual abuse to Child U. Despite this being a significant concern for the review and the Serious Case Review Group, this issue was only tacitly recognised within the contacts that MU and Child U had with professionals, and was not a feature of the Child Protection Plan. 4.6 Professional Confidence to challenge medical assessments and outcomes The medical assessments of MU’s mental health did not provide the answers that professionals were looking for to understand her presenting behaviour. The medical focus when assessing MU appeared to be to make a decision about eligibility for service rather than to undertake a more thorough assessment of mental health need. The lack of any challenge to the medical professions is often a combination of professional deference as well as a lack of technical knowledge from which to question the judgement of a medical practitioner. In this case the outcome of medical assessments served to create a diversion to health and social care services working together to better understand MU, rather than create a pathway to the joint approach that was even more necessary in the light of the not understanding why MU acted and thought as she did. 4.7 Cutting time at key points of the Child Protection Process is false economy in achieving both good outcomes and effective use of resources All agencies and practitioners face high demand on their time, and can be tempted to focus on task rather than strategy. Trading time for competing demands is often given as a reason for not holding strategy meetings but the absence of one strategy meeting, as evidenced immediately following the assault on Child U, can have a profound impact upon the multi-agency response to child abuse and, therefore, on how well children are ultimately protected. Maximising both the protection of children and the criminal accountability of those who harm children, is best achieved through the practice of Strategy Meetings. This is written into procedure and statutory guidance and a failure to comply will compromise the welfare of children. 4.8 The Child Protection system needs skilled professional judgement The Child Protection Conference is the epicentre of the child protection system, the significance and demands placed on Conference Chairs should not be underestimated. If the Child Protection Conference does not identify weaknesses in assessment, gaps in planning and hazards to good outcomes, practitioners will be falsely reassured that risk is reducing. Professional judgement is central to safeguarding work in all agencies. For staff to perform optimally, a degree of professional challenge is necessary as without this, any deficits in reasoning will go without notice. Generally a culture of challenge is a feature of all safe systems, and for staff with safeguarding responsibilities 13 this needs to be ever present as a method of professional support. This case highlights the autonomy of the Child Protection Conference Chair and how the lack of other sources of challenge such as safeguarding partners and robust line management can come together to create less safe systems. 4.9 The review identified that all agencies have safeguarding training and have the skills to identify causes for concern. However, it is less evident that staff have enough awareness and knowledge of mental health issues to work from a position of confidence. 4.10 Two issues that feature in this learning are present in so many Serious Case Reviews, that being the need for good assessment to underpin work with families and the need to listen to children. This suggests a need for greater guidance and challenge to staff from first line managers who are accountable for the quality of assessments completed within their span of management. 4.11 Although with the benefit of hindsight it is possible to reach a hypothesis about why MU acted as she did with some confidence, this should not imply that such a judgement was possible prior to the incident occurring. Based on what was known leading up to the death of Child U, her death could not have been predicted. By virtue of what was known to agencies the SCR Panel believed that MU, through her misguided actions, genuinely believed she was saving Child U from future harm. 5. Multi Agency Recommendations Recommendation 1 That consideration is given to how multi agency services can draw upon an ongoing mental health input to assessment and case planning when a person is assessed as having no diagnosable mental illness, yet continues to present with what appears to be mental ill health. Recommendation 2 The current multi agency escalation policy is amended to extend beyond disagreement and include those cases were professional(s) have concerns that a case is either ‘stuck’ or proving very difficult to progress. Recommendation 3 That all agencies take responsibility for strict adherence to the requirement for Strategy discussions/meetings and that the MSCB requires evidence of expeditious progress with this. 14 Recommendation 4 That the findings of this Serious Case Review are used as an instructive case scenario against which to test out the developing guidance for single assessment. This should include the significance of building in: • points of multi agency peer challenge; • management oversight of multi agency child protection plans; • the place for purposeful professionals only meeting. Recommendation 5 That MSCB commission a deeper analysis of the reasons why Child Protection Plans focussing on risk of sexual abuse are lower than the national average and develop and action plan. Recommendation 6 That the MSCB request an audit from the Safeguarding Improvement Unit that reports on the robustness of the child protection planning arrangements to include: • Appropriate categorisation criteria; • Robust child protection plan; • Effective core group activity. 6. Individual Agency Recommendations 6.1 Manchester Children’s Social Care The report draws together what can be learnt and improved upon as a consequence of this review and makes the following recommendations: 1. Strengthen the existing quality assurance framework to improve the quality and consistency of assessments. 2. Embed the updated Quality Audit Framework and reporting to Senior Management. 3. Invitations to Initial Child Protection Conferences should reflect those Agencies with historical as well as current involvement. 4. Strengthen existing quality assurance work and management oversight in relation to S47 processes. 6.2 Manchester Early Years and Sure Start The recommendation for action by Manchester Early Years and Sure Start are as follows: 15 1. Develop current policy and practice to ensure that managers escalate concerns when a parent is unwilling to engage in the Common Assessment Framework process. 2. Develop quality assurance practice within supervision to ensure that all recording is in line with standards outlined by MSCB and introduce guidance on recording timescales. 3. Introduce quality assurance practice in relation to the completion of a Safeguarding Children Referral. 4. Develop supervision practice and support for all staff dealing with complex needs including mental health issues to ensure that all staff including volunteers assess and sign post or refer as appropriate. 6.3 Greater Manchester Police The recommendations by GMP are as follows: 1. That the Public Protection Division (PPD) produce an induction pack for all PPIU staff, including supervisors, specific to child protection. This pack should include guidance on role requirement, inter-agency working, strategy meetings and the completion of PPIU logs, drawing from the guidance in both WTSC 2010 and GMP’s Safeguarding Children Policy and Manual of Guidance 2010. 2. That the PPD considers (and monitors) the provision of IT equipment to the PPIU on this division, to ensure that staff have sufficient computers to support them to complete their operational duties. It is the Author’s view that GMP should extend the learning from this review to ensure that all divisions, across other Local Authority areas have in place, and comply with, standardised procedures to accurately reflect the issues and decisions from strategy meetings. 6.4 Adactus Housing The recommendations for actions are: 1. Disseminate good practice from this case and establish annual training programme for frontline maintenance staff to recognize signs of abuse and how to report any suspicion that abuse may be occurring. 2. In order to make it easier for staff to report concerns introduce use of pre-paid and addressed envelopes for onward transmission of “Concern Card” by maintenance operatives to the Tenancy Enforcement and Support Team. 3. All new starters to be made aware of the Group Safeguarding Policy as part of the Group induction programme. 4. When appropriate use this case as a case study to reinforce to staff in briefing sessions that where they are victims of abuse and inappropriate 16 behaviour by customers, any such incidents should be referred to the Tenancy Enforcement and Support Team for investigation, followed by appropriate action to challenge such behaviour. When appropriate use this case as a case study to show how significant their role in safeguarding is. 5. Introduce a system for auditing concern cards to ensure a record is kept of all Concern Cards completed and action taken. This should enable an analysis to be undertaken of the source and type of concern’s being raised, which in turn may highlight areas for improvement or further training. 6.5 NHS Manchester The recommendations for action by NHS Manchester are as follows: 1. There should be consolidation of the work begun on increasing GP contribution to Child Protection Case Conferences. 2. Flagging of children subject to a Child Protection Plan and their families should continue to be promoted with the aim that every child placed on a plan since March 2011 is correctly flagged on their GP record. 3. The GP Safeguarding Children Steering Group should consider a wider application of the use of Read Codes to flag vulnerable children and families and make recommendations on this to the LMC. 6.6 Manchester Mental Health and Social Care Trust The recommendations for action from Manchester Mental Health and Social Care Trust are: 1. To ensure that the Trust’s plans for a reorganisation of community services during the first half of 2012 result in clarity about eligibility for services, an appropriate allocation of patients to the right service, and training of staff in the operational policies of the service teams. 2. To ensure that decisions made in team meetings will be recorded in the patient’s records and the referrer is informed of the outcome. 3. To establish a recognised procedure is developed for escalating referrals when there have been several referrals or significant events causing concern, and to ensure that a senior clinician undertake the assessment. 4. To ensure that where a joint assessment is undertaken then an integrated assessment is prepared with Children’s Services. 5. To ensure that all significant paper record that would not be otherwise available are scanned into the AMIGOS record. 17 6. To develop a process for the review in supervision of decisions to discharge patients who are difficult to engage. The finding that a patient is difficult to engage with should prompt an assessment of what action could be taken to achieve engagement and lead to an exploration of access to alternative services. 7. There should be training in the identification and management of emergent psychotic symptoms so that in the management of younger people with possible symptoms of psychosis the EIP service should always be considered as a possible support. 8. There should be a summary opinion in the AMIGOS record following all outpatient clinic assessments which will be available to all MDT members prior to the typed letter being added to the records. 9. Clinicians undertake longitudinal history - taking as an integral part of all assessments and pay attention to the nature as the degree of presenting difficulties. They undertake a holistic assessment considering all needs of the service user, rather than focusing on eligibility criteria. 10. Clinicians comply with the Safeguarding Children Policy by sending discharge letters and letters following assessments to all agencies involved in the care of a parent. 6.7 Central Manchester Foundation Trust The recommendations for action by CMFT are as follows: 1. CMFT will reinforce the existing safeguarding children basic awareness training package to include adult behaviours in the recognition of sexual abuse of children. 2. Health Visitor corporate case load practice standards are audited to ensure compliance and improved practice standards. 3. CMFT to develop an information pathway for adult A+E staff. To ensure information related to vulnerable adults seen in the department and who have child care responsibilities is shared with the appropriate health visitor or school nurse. All of the above recommendations have been actioned. 6.8 NHS Manchester Commissioning Overview Report The recommendations arising from this report are as follows: 1. Central Manchester Foundation Trust (CMFT) to ensure Health Visitors (HV) make contact directly with mental health staff who are involved with the family, so they can assess together, the impact of a parent’s mental health needs on the child and that that HV’s know how and when to make a direct referral. 18 2. CMFT to ensure that staff are contacting named nurses, who specialise in child protection, appropriately when there are child protection concerns and that significant event chronologies are being suitably analysed. 3. The primary care commissioning team and the 3 Clinical Commissioning Groups in Manchester to support the work to improve GPs participation in child protection processes. 4. NHS Manchester commissioners of health visiting services to ensure that the current review considers the findings in this case around: corporate caseload management and accountability, communication with adult services, case planning, training and escalation. 5. MMHSCT to assure commissioners that clinical supervision includes the impact on the child of mental health problems and that the audit programme includes analyzing a sample of case notes to ensure that the impact on a child has been assessed and appropriately managed. 6. MMHSCT to ensure a robust pathway to transfer care to another area is in place and quality assured. 7. NHS Manchester’s mental health commissioners to seek assurance that all available historical information is now being accessed to inform clinical decision making. 8. NHS and LA commissioners to ensure that MMHSCT allow appropriate access to services where there are wider determinants of mental health including social circumstances; and that eligibility criteria are consistent with the section 75 partnership agreements re assessing parents who have dependent children. 9. Mental health commissioners to ensure the Early Intervention Service and referral criteria is reinforced to and understood by MMHSCT staff and service providers outside of mental health. 10. MMHSCT to revise its assessment tool and risk assessment protocols to include asking questions about any termination of pregnancy as well as feelings about a pregnancy and birth. 11. MMHSCT to add a risk flag to AMIGOS to highlight a woman with children who has had previous contact with mental health services. 12. The findings in this case to be shared with sexual health commissioners to inform a review of the assessment and support offered to women before and after a termination. 13. Manchester City Council and NHS Manchester commissioners to ensure the Dual Diagnosis Service and referral criteria is reinforced to and understood by service providers outside of mental health. 14. CMFT and MMHSCT to ensure that safeguarding supervision and training of HV’s focuses on the voice and perspective of the child particularly when the toxic trio are present (mental health, substance misuse and domestic abuse). 15. Primary care commissioners to ensure safeguarding training to GPs is strengthened further to ensure that maintaining a focus on the child is a key message. Appendix 1 - Multi Agency Action Plan Child U SCR - Multi-agency Action Plan Working Together to Safeguard Children in Manchester 19 No. Recommendation Lead Key Actions Evidence Key Outcome Date 1. That consideration is given to how multi agency services can draw upon an ongoing mental health input to assessment and case planning when a person is assessed as having no diagnosable mental illness, yet continues to present with what appears to be mental ill health. Safeguarding Practice and Improvement Group 1. Head of Safeguarding, CSC, and Head of Patient Safety, MMHSCT, design and undertake an audit of cases including mental health needs and Children’s Social Care involvement, with the aim of producing a good practice guide. 2. Good practice guide is presented to and signed off by MSCB. 1. Audit tool. 2. Good practice guide. 3. Evidence of dissemination, implementation and use of guidance. When there are concerns about mental health needs (with or without diagnosis), the focus on parenting capacity and the impact on children is maintained. End of March 2013 2. The current multi agency escalation policy is amended to extend beyond disagreement and include those cases where professional(s) have concerns that a case is either ‘stuck’ or proving very difficult to progress. Policy and Procedures Subgroup 1. Convene a Task & Finish Group led by a manager from CSC and including representation from: Health, MMHSCT, Education, Police, Sure Start and Early Years. 2. Amended escalation policy is presented to 1. Terms of reference of the task and finish group. 2. Minutes or action notes from the meetings. 3. Evidence of dissemination, implementation and use. Increased staff confidence by providing access to an area based network of professional expertise in supporting children’s needs. End of March 2013 Appendix 1 - Multi Agency Action Plan Child U SCR - Multi-agency Action Plan Working Together to Safeguard Children in Manchester 20 No. Recommendation Lead Key Actions Evidence Key Outcome Date and signed off by MSCB. 3. That all agencies take responsibility for strict adherence to the requirement for Strategy discussions/meetings and that MSCB requires evidence of expeditious progress with this. MSCB Executive 1. MSCB to request a collective progress report from CSC (Area Safeguarding Manager) and GMP (DCI from PPD and DI nominated by the DCI from PPD) on the S47 process in Manchester to cover: a) Is sufficient priority and time being invested in S47 meetings? b) Are the right people invited? c) Do those who need to know receive the plan? E.g. GP, Examining Paediatrician, School, Health Visitor? d) Is every child Reports to MSCB via Executive. MSCB is assured that there is a consistent approach across the City to the convening and process of S47 strategy discussions in accordance with existing statutory guidance. End of January 2013 & end of July 2013 Appendix 1 - Multi Agency Action Plan Child U SCR - Multi-agency Action Plan Working Together to Safeguard Children in Manchester 21 No. Recommendation Lead Key Actions Evidence Key Outcome Date considered for an ‘Achieving Best Evidence’ Interview and the rationale for a decision recorded? 2. Initial report provided from the group to MSCB by the end of January 2013. 3. Group continue to monitor the situation and provide an update report to MSCB by the end of July 2013. 4. That the findings of this Serious Case Review are used as an instructive case scenario against which to test out the developing guidance for single assessment. This should include the significance of building in: • points of multi agency peer challenge; MSCB Executive 1. The convening of a Task and Finish Group led by an Area Safeguarding Manager, CSC involving a Social Work Consultant and representatives from the Child in Need Service, MCAF team, Education/Schools and 1. ToR for Task and Finish group. 2. Minutes or action notes from meetings. 3. Revised guidance and framework in relation to assessment and integrated working. Single high quality assessment process supported by peer challenge and clear management oversight. End of March 2013 Appendix 1 - Multi Agency Action Plan Child U SCR - Multi-agency Action Plan Working Together to Safeguard Children in Manchester 22 No. Recommendation Lead Key Actions Evidence Key Outcome Date • management oversight of multi agency child protection plans; • the place for purposeful professionals only meeting. Health. 2. The group should develop multi agency guidance and a framework relating to holistic single assessments. This should include decision making points in line with revised Working Together guidance and any proposals to integrate the First Response service. 5. That MSCB commission a deeper analysis of the reasons why Child Protection Plans focussing on risk of sexual abuse are lower than the national average and develop and action plan. MSCB Chair & MSCB Business Manager 1. MSCB Chair, Business Manager and Head of Safeguarding, CSC meets in order to identify the most appropriate resource to undertake this piece of work. 2. The meeting should establish the Terms of 1. Document showing scope and terms of reference. 2. Report containing analysis, recommendations and actions. MSCB are satisfied that children at risk of sexual abuse are being recognised and effectively protected. End of March 2013 Appendix 1 - Multi Agency Action Plan Child U SCR - Multi-agency Action Plan Working Together to Safeguard Children in Manchester 23 No. Recommendation Lead Key Actions Evidence Key Outcome Date Reference and scope of the research. 3. Upon conclusion a report containing analysis, recommendations and an action plan should be produced to MSCB. 6. That MSCB request an audit from the Safeguarding Improvement Unit that reports on the robustness of the child protection planning arrangements to include: • Appropriate categorisation criteria; • Robust child protection plan; • Effective core group activity. MSCB Executive via the Head of Safeguarding, CSC 1. Head of Safeguarding, CSC coordinates a case audit of a dip sample of cases over the last six months in relation to cases subject to CPP. 2. At the conclusion of the audit a report and action plan is presented to the MSCB Executive. 1. Audit tool. 2. Audit report. MSCB are assured that the chairing of the case conference in this case was a deviation from standard practice. End of March 2013 |
NC50900 | Death of a 2-years-5-months-old girl in March 2015. Child B was found unresponsive by her biological mother; taken to hospital by ambulance, where she was pronounced dead. Child B showed no signs of obvious trauma but was filthy with severe head lice infestation, underweight with evidence of severe neglect, dental decay and severe nutritional deficiency. Toxicology tests found evidence of alcohol, diazepam and paracetamol. Home described as uninhabitable by Police on the day of her death. Mother, her female partner and Child B and her two sisters lived in a privately rented flat. Services believed mother was a single parent. Known to universal services only; no concerns reported by nursery or school until issues of hygiene raised with school nurse in 2012. In 2014, school raised further concerns about head lice and hygiene with health visitor. Unannounced visits were made to the home by school nurse, health visitor and Social Work Services; some did not gain access. Child B was not seen by any professionals for 8 months before her death. Ethnicity or nationality not stated. Key issues include: thresholds for intervention were high; insufficient professional challenge. Learning points include: need for shared understanding of the decision-making processes in relation to thresholds; assumptions about what is good enough in the care of children needs to be challenged; need for comprehensive assessment, addressing the impact on the welfare of all children in the family. Review reported in February 2016 but publication delayed for criminal proceedings to conclude.
| Executive Summary Significant Case Review Undertaken on behalf of Glasgow CPC On Child B February 2016 1 CONTENT Introduction ........................................................................................................................... 3 Terms of Reference .............................................................................................................. 3 Agencies Requested to Provide Reports and Chronologies .................................................. 3 Membership of Review Team ................................................................................................ 4 Process ................................................................................................................................. 4 The Facts .............................................................................................................................. 6 Analysis ................................................................................................................................ 7 Family Background ............................................................................................................... 7 Information from the composite chronology ........................................................................... 8 Key Issues .......................................................................................................................... 10 Conclusion .......................................................................................................................... 13 Unanswered Questions ....................................................................................................... 14 Learning Points ................................................................................................................... 14 GLOSSARY of TERMS ....................................................................................................... 16 2 Introduction This Significant Case Review (SCR) was commissioned by the Glasgow Child Protection Committee (CPC) in the context of the National Guidance for Child Protection Committees on Conducting a Significant Case Review March 2015, Scottish Government. A SCR is intended to discover whether lessons can be learned about the way local practitioners and agencies work together, following the death of a child in the community or where the child has not died but experienced significant harm or is at risk of significant harm. A SCR Panel was convened on 16 June 2015 and agreed the initial Terms of Reference, which were subsequently amended and agreed by the Review Team and Panel. Terms of Reference • To provide an overview of the family context prior to Child B’s birth. • To consider the visibility of the child and family in the community, particularly health and education services. • To review information about the contact the family had with agencies from 2012 until 2014. • To review information, from the time of mother’s pregnancy with Child B, with a particular focus from July 2014 until March 2015. • To consider what assessments were made when Child B had lice and what actions were taken as a result of these assessments. • To review communication between partner agencies. • To consider how effective the assessment process was in identifying risks and in decision making. Agencies Requested to Provide Reports and Chronologies In order to undertake the SCR, each agency that had direct involvement with the child and family was requested to instigate a single agency review and submit a report with a chronology to the review panel. There had been no Scottish Children’s Reporter Administration (SCRA) involvement until after the child’s death and so it was agreed that there was no need for assistance from SCRA in the Significant Case Review. The Review Team and Review Panel met during the period June – December 2015. Single Agency Reports were received from the following: • NHS Greater Glasgow &Clyde • Education Services • Social Work Services • Police Scotland 3 Membership of Review Team Independent Chair Lead Officer Glasgow CPC Interim Director NHSGG&C Professional Nurse Advisor NHSGG&C Quality Improvement Officer Education Services Senior Officer Social Work Services Service Manager Social Work Services Detective Inspector Police Scotland Process Information for the SCR was collected from the respective agencies using individual interviews and access to case record files. The Review Team members then completed a Single Agency Report and chronology. These documents were submitted to the Review Team and Review Panel for consideration and discussion of the findings. The chair drafted a composite chronology and report of findings which were discussed with the Review Team and Review Panel. A verbal update of progress with the SCR was given to Glasgow CPC on 2 November 2015 with a written summary of progress given to David Williams, Executive Director Social Care Services/Chief Officer Designate Glasgow City HSCP. The final report was due to be submitted to the Chief Officers in December 2015 but in the light of further information being submitted in December 2015, a request for an extension until the end of February 2016 was made and granted. The report was completed in February 2016 but, on instruction from the Crown Office and Procurator Fiscal Service, publication was delayed to allow for criminal proceedings to conclude. Notes on redaction of this Report This document contains the conclusions and recommendations of the Significant Case Review relating to B. In the interests of transparency, every effort has been made to disclose as much of the SCR as is lawfully possible. The only editing prior to disclosure is the redaction of personal data, disclosure of which cannot be justified under the General Data Protection Regulation and Data Protection Act 2018. Although there has been a criminal trial and extensive media coverage of this case, and a certain amount of both personal data and special category personal data is, as a result of this, publicly available, disclosure of the personal data contained in this report must still comply with data protection law. This means that even though some of the redacted information may already be publicly available, or it may be considered to be in the public interest to disclose, it cannot automatically be disclosed, as data protection law contains certain conditions which must first be met. The process of redacting the SCR has involved careful consideration of:- • The need for transparency and the overall purpose of the SCR in the identification of any lessons learned. • The public interest in disclosure. • Considering whether information is sensitive personal data, (for example, because it is information about a person’s physical or mental health or condition, his/her sexual 4 life, or the commission or alleged commission of an offence) and whether its inclusion in the SCR complies with data protection legislation. • Balancing interests in terms of the right to respect for private and family life in terms of Article 8 of the European Convention on Human Rights, meaning that any information contained in the report relating to B herself and other people whose history was closely linked to B can only be released if it is lawful, necessary and proportionate to do so. The executive summary of the SCR follows but with certain text (generally containing biographical details) redacted for the reasons set out above. Any redactions are clearly marked with the word “[Redacted]”. Some minor grammatical changes have been made (unflagged) to maintain consistency of language following some redactions. 5 The Facts On the morning of 20 March 2015, Child B, aged 2 years 5 months, was found to be unresponsive on the couch within her home. An ambulance was called. While waiting for the ambulance, her Biological Mother was given advice on how to administer CPR which was then commenced in the home by her Biological Mother on the advice of the ambulance crew. Child B was taken to the Royal Hospital for Sick Children (RHSC), Yorkhill where she was pronounced dead at 8.07am. An initial post mortem examination was undertaken on 23/24 March 2015 and findings were consistent with the preliminary examination i.e. Child B showed no signs of obvious trauma or injury but was filthy with severe head lice infestation and was extremely thin and underweight with evidence of severe neglect. A further double doctor post mortem examination undertaken on 2 April 2015. There was no evidence of serious underlying natural disease or abnormality. Child B was very thin, 80% of the expected weight for her age, with her ribs, shoulders and backbone very visible through her skin. Her hair was heavy and matted appearing to have been unbrushed for a substantial period with areas of the scalp being thickened and leathery (usually seen as a result of chronic irritation) and some areas of baldness. Multiple ulcers and crusted scabs were also in evidence. Massive numbers of head lice were present in her scalp, face and chest. The infestation period was estimated by the Pathologist to be for at least 6 months but possibly up to 17 months or longer. The palms of her hands showed black dirt in the creases. Her finger nails were dirty with black dirt beneath them. The soles of her feet and toenails were filthy and blackened. There were multiple small brown scabs on her right shin, both wrists and forearms and on the upper, mid and lower back, with multiple small healed scars on the mid back. Toxicology was positive for alcohol, diazepam and paracetamol. Alcohol was present at low levels consistent with exposure or possible contamination as a result of the post mortem examination. There was evidence of ingestion of diazepam between September 2014 and March 2015. Paracetamol was present at low levels within prescribed limits. In addition there were changes in keeping with dehydration, evidence suggestive of dental decay in the two upper first teeth, evidence suggestive of anaemia and probable Vitamin B deficiency. These findings are consistent with severe nutritional deficiency/starvation and investigations were undertaken in order to establish definitively whether this led to Child B’s death. Prior to her death, Child B must have suffered deterioration in her general health, nutrition and overall wellbeing, indicative of severe neglect. On the day of Child B’s death, the house was described as uninhabitable by the Investigating Police Officer. Specifically, the house was filthy with head lice apparent on the outside door frame. The conditions within the house were poor with rubbish strewn throughout. It was impossible to gain entry to the kitchen area due to it being packed full of rubbish bags which were waist high. The rubbish bags consisted of food and rubbish dating back to 2013. The couch which the Child B had slept on was so badly infested with head lice that it had a large hole and had disintegrated, and could only be described as being in a terrible condition. Child B’s siblings and parents were taken to the police office on 20 March 2015 and it was very apparent that they had extensive head lice. Officers reported that the head lice were visible, walking over the children. The children were dirty and had a strong body odour. The rooms in the police office and the vehicle in which the family had been transported had to be treated by Rentokil. The ambulance crew who took Child B from the house to the hospital had to remove their uniforms due to lice infestation and the ambulance required to be cleaned. 6 In March 2015, the family lived in a privately rented multi-story block of flats in an area of multiple deprivation within the city. Female Partner, Biological Mother’s partner worked as a cleaner. The family was largely dependent on state benefits. Police Scotland referred the case to the Child Protection Committee (CPC) requesting that consideration be given to a Significant Case Review (SCR) being undertaken. In June 2015, the CPC Review Panel discussed the case and all agreed that this case warranted a full SCR. There was an ongoing police investigation into the circumstances surrounding Child B’s death, and of the living circumstances of the children in the family unit. Given this, the family/carers were not involved in the SCR. Analysis When the Review Team had undertaken their investigations and discussed their findings it became apparent that agencies did not have an accurate, shared understanding of the family’s circumstances and that many aspects of the case remained unclear. The police investigation following Child B’s death provided hitherto unknown information to the SCR and prompted further examination of agency records and supplementary interviews with staff in Health and Education Services. In addition, the provisional post mortem report was not made available to the SCR until 12 November 2015 and contained information relevant to the SCR findings. The following provides a summary of information available to the SCR and addresses the terms of reference. Where the term “family” is used in the report, this refers to Biological Mother, Female Partner, Sister 1, Sister 2 and Child B. Family Background In March 2015, the family consisted of Biological Mother, aged 34 years, Female Partner aged 33 years, Sister 1 [redacted – of primary school age], Sister 2 aged [redacted – also of primary school age but younger than Sister 1] and Child B who was 2 years and 5 months. The family attended universal health services. The two older children, Sister 1 and Sister 2, attended nursery prior to starting school. There were no concerns reported by the nursery or school until issues related to hygiene were raised by the school with the School Nurse in November 2012, just after Child B was born on 8 October 2012. The family was not known to Police Scotland until Child B’s death in March 2015. At the beginning of the SCR process, Health, Education and Social Work Services understood that Biological Mother was a single mother, perceived as a caring parent who loved her children but was struggling to cope. The Police investigation following Child B’s death on 20 March 2015 shed light on the reality of the home and family circumstances when it emerged that the biological mother, Biological Mother was not a single parent but that Biological Mother and Female Partner had cohabited as a couple in a same sex relationship for approximately fourteen years, therefore from before the birth of Sister 1, Sister 2 and Child B. Without exception, all health staff were of the impression that Biological Mother was a single parent and had no awareness of Female Partner being in a same sex relationship with Biological Mother. While Biological Mother may have found it difficult to share the fact that 7 she was in a relationship with Female Partner, it remains the case that the motivation for withholding this information is unknown. The family are known to have occupied three tenancies since 2000, either abandoning or being evicted from the first two, and with issues being noted regarding rent arrears and the condition of the second property. The second property required a major clear out after the family vacated, with repairs and replacement of items also necessary. No referral was made to SWS to alert them to the housing situation in 2011 when there were two children in the household. The family moved to a different tenancy in [Redacted] and Child B was born on 8 October 2012. The family remained there until Child B’s death on 20 March 2015. As has been indicated in the Facts section of the report, the police reported that the house was uninhabitable in March 2015. It is the view of the investigating police officer that it is not possible that these conditions had suddenly happened. The description of the house and hygiene of all family members indicate that the family had been experiencing unacceptable living conditions over a considerable period which had not been addressed by either Biological Mother or Female Partner. Information from the composite chronology Child B was primarily known to Health Services. Education Services had no direct responsibility in relation to Child B. All Health contact for child B was as part of the universal service for children and she was seen 13 times by the Health Children and Families Team from when she was 11 days old until she was 1 year 9 months. There were eight home visits, six in the first six weeks. During routine health visits, Child B appeared well and gained weight, and it was reported that she was meeting her developmental milestones and that her immunisations were up to date. Biological Mother declined the offer of the Childsmile Programme to assist with oral health and general dental care. Child B was not registered with a dentist though she had dental caries at the time of her death. In November 2012, the Head Teacher (HT) of the school attended by Sisters 1 and 2 expressed concerns about Sisters 1 and 2 in relation to hygiene, head lice and inappropriate clothing to the School Nurse and raised the concerns with Biological Mother. This information was also passed to the Health Visitor who conducted a series of home visits, following which improvement was noted by the Health Visitor in the children’s presentation. Child B was assessed by health in accordance with the national guidance contained in “A New Look at HALL 4- the Early Years- Good Health for Every Child”. In February 2013, a Single Agency Assessment was completed by the Health Visitor and Child B was described as achieving developmental milestones. The house was noted as being reasonably clean though scantily furnished with some household items in a poor state of repair. In March 2013, when Child B was 5 months old, the Health Plan Indicator (HPI) was formally recorded as “Core”, meaning that Child B was not seen as at risk, that her needs could be met through the universal child health programme and that she did not need additional support. Unless there was a change in circumstances, the next planned review (in line with the universal pathway) was due in April 2015, when Child B was 30 months. Child B died when she was 29 months old. 8 Over a period of 25 months, Biological Mother sought support from the Community Pharmacy Minor Ailments Scheme (MAS) in relation to Child B on 17 occasions from two months old until two months before her death. Child B was not seen by the pharmacist on every occasion and although the attendance at MAS may seem very high as listed in the health chronology, there was sufficient time between visits for there to be no alert to the General Practitioner (GP). In addition Child B attended the GP on two occasions for upper respiratory infections, when she was physically examined at an emergency appointment. The SCR found no evidence of any assessment having been made of Child B having head lice. Biological Mother had been given sufficient treatment for all four known family members but reported to the School Nurse that she had treated Sister 1 and Sister 2 for head lice but had not treated either herself or Child B. The School Nurse had advised Biological Mother to treat all of the family and had offered to go to the house to do this. Biological Mother declined these offers. In February 2014, the Depute Head Teacher (DHT) raised further concerns regarding head lice and hygiene with the School Nurse about Sisters 1 and 2, who subsequently contacted the Health Visitor. It was agreed that a joint visit to the family home would be undertaken but there is no record of a visit taking place at that time. In May 2014, the DHT again contacted the School Nurse in relation to persistent head lice infestation and poor hygiene about Sisters 1 and 2. The School Nurse and Health Visitor attempted to arrange a home visit but this was cancelled by Biological Mother, so the School Nurse made an unannounced home visit in June 2014. Additional concerns noted during this visit prompted the School Nurse to make a referral to Social Work Services (SWS). There had been no SWS contact with the family prior to this. SWS made an unannounced visit to the home but did not gain access. The Health Visitor visited separately and did gain access to the family home. She had serious concerns about the living conditions, describing the home as unsafe for a child, and arranged a joint visit with SWS. Significant improvement in the condition of the home was noted at the joint visit and it was deemed appropriate that health staff would manage the treatment of head lice whilst school staff would monitor Sister 1 and Sister 2. The School Nurse had three further contacts with Biological Mother regarding head lice and reports that Sister1 and Sister 2 had sickness and diarrhoea, advising that the children should be taken to the GP. There is no record of an appointment with the GP for this. Child B was not seen by a Health Visitor after 4 July 2014. Child B attended the Emergency Department at Glasgow Royal Infirmary (GRI) on one occasion in July 2014. Biological Mother advised the hospital that Child B had been running in the living room, tripped and hit her forehead on the edge of the table. Child B was seen by an Emergency Nurse Practitioner (ENP). Her weight was documented and there was no mention of head lice in the notes. There was no suspicion of non-accidental injury and Child B was discharged home. As a matter of routine, a letter advising of this attendance was sent electronically to the GP. This was not shared with the Health Visitor and therefore could not be followed up by the Health Visiting Service. Four requests were made by Biological Mother to MAS following this attendance at hospital, the last time being 6 January 2015. There is no evidence that Child B was seen by the Pharmacist at MAS on these occasions. There is very limited information for the period July 2014 until March 2015. 9 From the information gathered by the SCR team, there is no evidence that anyone outside the family saw Child B after 9 July 2014 until 20 March 2015. At the time of her death, Child B was noted to have suffered signs of extreme neglect. Her general condition in the months leading up to her death included severe head lice infestation, being physically emaciated and malnourished, listless and lacking energy typical of a normal two year old. Although Child B was not seen by any professionals during the 8 months prior to her death her poor general state would have been evident to all who came in contact with her. Whilst Child B was not visible to agencies, she was visible to her care givers and to her family who would have seen her every day. Key Issues Lack of basic information Staff in health and education believed that Biological Mother was a single parent and that the children’s father had no involvement. There was no knowledge of Female Partner as Biological Mother’s partner until after Child B’s death and therefore no understanding of the shared parenting arrangement at home. The ongoing unhygienic condition of the family home was unknown. Thresholds The view was taken that this was a mother doing her best in difficult circumstances. The SCR found that this family was compared to other families in an area of multiple deprivation, rather than the individual needs of the children being addressed. The SCR found that, as a consequence, thresholds for intervention were high in this case. Biological Mother appeared to be cooperative, but declined offers of counselling to address her anxiety, Triple P, Childsmile and help with head lice treatment all of which would have afforded the opportunity to make an impact on parenting skills. Health accepted Biological Mother’s word that Sister 1 and Sister 2 were clear of head lice. This should have been checked in the light of the reported recurrent infestations over time. Assessment and Professional Challenge Although there were a number of indicators of neglect, observed over a period of time, there was a lack of focus on the children’s needs and no clear assessment of needs, particularly in relation to Child B and no effective intervention made. The child was not at the centre of the assessment process 10 Professional staff dealt with each incident in isolation and did not take a holistic approach to working with this family. The SCR found that there were general ongoing hygiene issues and recurrent head lice infestation, noted for Biological Mother, Sister 1 and Sister 2, and in the home. There was no evidence that the professionals involved considered the impact on Child B, though the school did mention to both School Nurse and Health Visitor that there was a baby in the family. There is evidence that hygiene issues were present from the time of Child B’s birth, and indeed probably before. However, there was no recognition that the children were suffering neglect. The school worked closely with the school nurse around their concerns about hygiene and head lice. They had regular discussions with the school nurse and collaborated with her and Biological Mother on attempting to tackle the issue of head lice in particular. Biological Mother always appeared to be responsive to the school’s concerns but with no sustained improvement. Although hygiene and head lice were the focus of their concerns, the school should have considered the impact of neglect on the family and made this known to Social Work Services by submitting a Notification of Concern for the family. There was a low level of the use of formal assessment tools. The education chronologies for the two older siblings provide an account of the school’s discussions with the school nurse. It is not clear that these chronologies were used to assess that, over a protracted period, the girls were suffering neglect. The use of chronologies as an assessment tool is crucial. At no time did health assess Child B for head lice, in spite of the school mentioning to the school nurse that there was a baby in the house. The school nurse and health visitor did discuss the concerns and agreed to make a home visit on 19 June 2014, but this was cancelled by Biological Mother. They did make unannounced home visits separately the following week but no re-assessment was done. Following the individual home visits and the joint home visit in July 2014, there was no formal reassessment of the Health Plan Indicator although there was evidence that the home circumstances had changed. The Health Plan Indicator should have been changed to “additional” to reflect the need for additional support until such times as the professional staff were confident that the observed improvement in the physical home environment had been sustained. Health and education staff recognised that there were parenting concerns but there was no recorded professional challenge of Biological Mother when she declined or made no response to offers of assistance. Similarly, there appears to have been no professional challenge when Childsmile was declined or when offers to assist with the treatment of head lice were turned down. There was a failure by professionals to identify non-engagement. Consideration was not given to the impact of Biological Mother’s [Redacted] problems on the care of her children, nor was there communication between the GP and Health Visiting Service. There appears to have been a “wait and see” approach in spite of the GP recognising sufficient concern to note a possible referral to SWS in April 2014, but there was no such referral to SWS. Following the joint social work and health home visit in July 2014, there was no further involvement by SWS. The key factor in determining the response from SWS lies in the acceptance of the professional assessment and autonomy of the health visitor which then shaped the approach with regard to roles and responsibilities, allowing the Health Visitor to be the lead professional. The briefing of the Social Worker by the Team Leader as to the purpose of the visit and the conversation between the Social Worker and Health Visitor 11 resulted in the focus being on the home conditions rather than the health and hygiene issues pertaining to all the children as per the initial referral by the School Nurse. SWS should have reviewed the referral information and made a broader assessment of the home circumstances than was made on 4 July 2014. Although SWS had the expectation that health and education would monitor the situation and re-refer if necessary, SWS could have made a follow up visit to see whether the improved home conditions had been sustained. SW records from July 2014 indicate that there were no issues requiring follow up. There was no re-referral to SWS by health or education. There was a lack of attention on agreeing outcomes for children. Communication The lack of good interagency information sharing and effective joint decision making is key to the failure to address Child B’s needs. It is essential that professionals communicate both within their agency and across agencies to ensure appropriate sharing of information, joint assessment and planning in line with key components of the Getting it Right for Every Child framework (GIRFEC). There was too great a focus on pre-arranged home visits and there was an over-reliance on telephone contacts to discuss important issues and share information. Unannounced home visits would have provided an opportunity to gain insight into home circumstances and would have supported a more robust assessment of need and care planning. Whilst there is an alert to the GP should requests to MAS be deemed too high, there is no expectation of a link between MAS and the Health Visiting Service which would have given the Health Visitor the opportunity to review Child B’s use of medication to manage minor childhood conditions including teething. Clarity of follow up arrangements and respective roles and responsibilities should have been addressed. There was a reliance on colleagues and assumptions made in relation to following up issues with the family. Liaison between Housing and SWS where a family with children has been living in adverse housing conditions would have led to sharing of information and subsequent assessment of need. Administrative / Practice Issues There were separate written records of the outcomes of the joint home visit in July 2014. The absence of a shared agreement/understanding of the outcome meant that there was no clarity about the action to be taken. Administrative tasks should be undertaken timeously with case notes recording all relevant detail. For example, it is important to identify the adults living in the home, who is present on each visit and their relationship to the child. There is a need to use, build and review chronologies within Education and Health. Consideration should be given to supervision arrangements for staff and whether they are sufficient. 12 Conclusion It is the view of the SCR team that, after the allocation of a Core HPI and, particularly, from July 2014 until her death in March 2015, this child was seen as planned in line with the core pathway in place at that time. Despite a change in circumstances, the HPI was unaltered from Core. While services identified that this was a vulnerable family in need of support, the signs of neglect were underestimated for Sister 1 and Sister 2 and were unrecognised for Child B, leading to an insufficient assessment of the needs of all of the children in the family. Attention was not paid to a young child living in a highly vulnerable situation. The focus of attention was either on Biological Mother or siblings Sister 1 and Sister 2. The assessment process by Health Visiting Services in the first year of Child B’s life allocated her to a Core level of support i.e. assessed Child B as being able to be supported by universal services, and therefore not requiring ongoing involvement. This assessment influenced subsequent involvement and decision making by agencies. While education highlighted that there was a baby in the household, there is no evidence that the case was formally reviewed by Health Visiting Services. In addition, the home visits which highlighted adverse living conditions did not lead to a reassessment by the health visiting service of the allocation to Core support to Child B. It is the view of the SCR that the lack of reassessment of Child B in June and July 2014 when she was 20/21 months old is key to the missed opportunity to provide the additional support required for this family. A reassessment would have put the focus on Child B for the first time since her assessment at 22 weeks old and would have, at the very least, provided the possibility of recognising and tackling Child B’s severe neglect. Education staff talked to Biological Mother about hygiene and head lice of Sister 1 and Sister 2, their pupils, and raised concerns repeatedly with Health, pointing out that there was also a baby in the household. The school did not seek advice from others (health, social work, education) apart from the school nurse. The school did not consider completing a Notification of Concern to Social Work Services in respect of the family, on the grounds of “a culmination of minor concerns over a period of time” (MC57) focussing on the hygiene issues of the older girls. This would have led to a closer look at the family circumstances. Health sought to tackle the concerns about hygiene and head lice but this was confined to short term interventions. Input was triggered by individual incidents and there was no assessment of the overall family circumstances over time. The SCR team concluded that while Biological Mother appeared to engage with services when prompted, in fact there was evidence of non- engagement and of keeping services at a distance. Despite the large number of professionals involved and in contact with the family the communication and information sharing between professionals was inadequate to enable a comprehensive overview and assessment of the family. There is a fundamental issue in relation to the thresholds used to determine what is acceptable in the care of children. In this case it is clear that the thresholds were high. There was insufficient professional challenge within and across agencies about the standard of care. 13 Unanswered Questions Despite extensive investigation, a number of questions remain. The SCR concluded that there were signs of neglect for all the children in the family. The evidence indicates that Child B was neglected to a differing degree from her sisters. The SCR could find no explanation for this and no reason to explain why the extent of the neglect worsened in the last eight months of Child B’s life. Whilst Child B was not visible out with the home, Child B was seen every day by her care givers and other family members. The information contained in the post mortem report indicated that prior to her death, Child B must have suffered deterioration in her general health, nutrition and overall wellbeing, indicative of severe neglect. The SCR could find no explanation for why there was no effective action taken by family members to improve Child B’s health and wellbeing. The role of the extended family and their level of involvement with the family is unknown, but it is hard to accept that the extended family did not recognise that the family’s living circumstances were at an unacceptably poor standard for all the children, and, that all of the children, and Child B in particular, were suffering severe neglect. The motivation for Biological Mother to present to professionals as a single parent is unknown, when in reality this was a two parent family. Biological Mother actively denied that there was another adult living in the home. None of the services involved were aware that Female Partner lived in the family home and was also the children’s parent, until after Child B’s death. Female Partner’s motivation for remaining in the background is not known, nor is it clear how much involvement Female Partner had in day to day parenting. Biological Mother was perceived to be a concerned parent though evidence indicates that action about the children was often taken when prompted by professionals about particular concerns. Biological Mother was given much advice about head lice treatment and demonstrated that she was able to treat Sister 1 and Sister 2 successfully at least in the short term, though the improvement was not sustained. It appears that Biological Mother did not treat herself or Child B and so re-infestation was inevitable. We have no understanding of why Biological Mother did not treat herself or Child B for head lice. While the shared parenting arrangement, paternity of the children, role of the extended family and housing history was not known, this in itself makes no substantive difference to the overall assessment by the SCR that this was a vulnerable family requiring additional support. Better, fuller assessment of the children and family circumstances would have given greater weight to the consideration of multiagency working which would have put a focus on addressing the needs of the children in this family. Learning Points Interagency Issues • Within and between Health, Education and Social Work Services, there needs to be a shared understanding of the decision making processes in relation to thresholds, bringing clarity to providing interventions for children in areas of multiple deprivation who have the same right to protection as all other children. Assumptions about what is good enough in the care of children require to be challenged. 14 • There needs to be ongoing training within and across Health, Education and Social Work Services in the identification of signs of neglect, leading to informed use of the notification of concern process. • Consideration should be given to the greater use, at an early stage, of formal assessment tools such as the Glasgow Neglect Toolkit, formerly the Graded Care Profile. • There is a need for comprehensive assessment, addressing the impact on the welfare of all children in the family. Where a parenting need is identified for a particular child within a family the impact of that need should be considered for all children within the family. • Where there are concerns regarding a child, there should be a specific focus on developing and using a chronology to assist those professionals involved in gaining a more comprehensive understanding of the family situation and potential impact on the health and well-being of the child. Chronologies should be reviewed and used as part of the assessment process to ensure that the accumulation of concerns is recognised and next steps taken. • There should be appropriate professional challenge within and across each agency with regard to decision making and accountability. • Workers need to access all relevant information prior to conducting a home visit. • When undertaking joint visits, workers should remain mindful of their professional role, responsibility and accountability, ensuring that it is reflected in the joint assessment that results. • Follow up arrangements should be clarified between agencies at the time of joint visits and a written record of outcomes agreed. • Case recording must be completed timeously, with a clear account of the nature of the visit, what took place, who was present and their relationship to the family. It must also provide an analysis and a clear recommendation regarding whether further action is required or not. This is particularly important because there can be a series of staff involved throughout interventions. • There should be greater use of constructive challenge. Professionals need to challenge parental decisions that do not reflect the best interests of the child. Professionals must be confident and skilled when they are required to deploy their skills in holding difficult conversations with a parent/carer. For example, parents should be challenged in relation to their own hygiene. • Consideration should be given to follow up when self- reported assessment tools are inconsistent with observed circumstances. Agencies should not accept a parent’s self-reporting of an issue being addressed without clear evidence to support the self- report. Single Agency - Health • There is a need to improve communication pathways within and across health services to ensure that professionals working in different parts of the system are fully informed. GPs and General Dental Practitioners should routinely share relevant 15 information with Health Visitors particularly where there is likely to be an impact on the child e.g. mental health issues. • Consideration should be given to review the existing protocol between GPs & Community Pharmacy and consideration given to the development of a protocol between Community Pharmacy & Health Visiting when parents present frequently requesting medication for minor ailments, particularly teething. • Agreed pathways should be followed and an explanation for any deviation from standard protocols should be recorded e.g. the Edinburgh Postnatal Depression Scale should have been repeated at 12 weeks. • Health Visitors should formally reassess the Health Plan Indicator when there is a change in circumstances. • Where there are ongoing concerns in relation to infestation of head lice, Health Visitors should ensure that all children are assessed and appropriate information is shared with parents and carers on prevention, treatment and follow up. • School Nurses should fully assess wider health needs, using appropriate assessment tools, when receiving repeated referrals related to hygiene. • The Triple P parenting programme needs to address their process for engaging parents who fail to attend. Consideration should be given to alternative parenting support if a parent fails to engage in the Triple P programme. Single Agency – Education • The school should have made their concerns known to Social Work Services by submitting a Notification of Concern (Management Circular 57) for the family. Single Agency – Social Work • Administrative tasks relating to screening forms should be completed timeously Single Agency – Housing/Social Landlords • The systems and processes between Housing/ Social Landlords and SWS need to be developed and strengthened leading to improved reporting 16 APPENDIX 1 GLOSSARY of TERMS CPC Child Protection Committee CPR Cardiopulmonary Resuscitation DHT Depute Head Teacher ENP Emergency Nurse Practitioner GIRFEC Getting it Right for Every Child GP General Practitioner GRI Glasgow Royal Infirmary HT Head Teacher HPI Health Plan Indicator HSCP Health and Social Care Partnership MAS Minor Ailments Scheme MC57 Management Circular 57 NHS National Health Service RHSC Royal Hospital for Sick Children SCRA Scottish Children’s Reporter Administration SCR Significant Case Review SWS Social Work Services Triple P Positive Parenting Programme 17 |
NC045615 | Death of a 14-week-old girl in March 2012. Post-mortem examination jointly conducted by two pathologists resulted in the recording of two different probable causes of death: Sudden Infant Death Syndrome and unascertainable. Child Y lived with mother, father and five older siblings in a three bedroom property at the time of the incident. Family had been known to children's services since 2003 and children were subject to Child in Need and Child Protection plans at different times before and after Child Y's death. Professionals' concerns primarily related to home conditions, children's personal hygiene and school attendance. Issues identified include: father's dominance, his occasional threatening behaviour towards professionals and his resistance to professional intervention; poor assessments, not carried out in a timely manner contributing to 'drift'; and lack of appreciation of the long-term impact of neglect and belief that better outcomes would be achieved by maintaining parents' cooperation. Makes various recommendations focusing on conflict resolution, multi-agency working and training. Undertaken using a systems model.
| Title: Serious case review: concerning Child Y: overview report. LSCB: Leeds Safeguarding Children Board Author: Peter Ward Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Leeds Safeguarding Children Board Serious Case Review Concerning Child Y Overview Report Published 27 January 2015 Child Y Overview Report 27 January 2015 2 Table of Contents Page 1. Introduction 3 2. Circumstances leading to decision to carry out a Serious Case Review 3 3. Scope and Terms of Reference of the Review 4 4. Contributors to the Review and Methodology 5 5. Summary of Family Circumstances 7 6. Summary of Agency Involvement and Key Events 7 7. Analysis 23 8. Views of the Family 49 9. Conclusions 49 10. Recommendations 52 Appendices Appendix 1 Abbreviations Appendix 2 References Appendix 3 Integrated Action Plan Child Y Overview Report 27 January 2015 3 1. Introduction 1.1 This Serious Case Review (SCR) was commissioned following the death of Child Y who died at 14 weeks of age. 1.2 The review was commissioned in compliance with regulation 5(1) (e) and 5(2) (a) & (b) (ii) of The Local Safeguarding Children Boards (LSCBs) Regulations 2006 which came into effect on 1 April 2006. Regulation 5 sets out the functions of LSCBs including the requirement for them to undertake reviews of serious cases in specified circumstances. 1.3 Working Together to Safeguard Children 2013 states that an SCR must be undertaken when abuse or neglect of a child is known or suspected and either (i) the child has died or (ii) the child has been seriously injured. In the case of (ii) an SCR has to be undertaken unless it is clear that there are no concerns about inter-agency working. 1.4 In accordance with Chapter 4 of Working Together to Safeguard Children 2013, the purpose of this SCR is: To look at what happened in this case, why, and what action will be taken to learn from the SCR findings? For such action to result in lasting improvements to the services which safeguard and promote the welfare of children and help protect them from harm. To ensure that there is transparency about the issues arising from the SCR and the actions that LSCB partner agencies are taking in response to them, including sharing the final Report of the SCR with the public. Consequently this report is not intended to be a judicial opinion or to apportion blame but to consider, with the benefit of hindsight, the above three points. 2. Circumstances leading to decision to carry out a Serious Case Review 2.1 Child Y was born in November 2011 and died in March 2012 having lived with both parents and five older siblings. Child Y’s mother woke one morning to find the child apparently dead; Child Y was taken to hospital by ambulance and formally pronounced ‘life extinct’. According to the parents Child Y had appeared fit and well the previous night and had last been seen alive at 05:00 hours when the mother had fed the child. 2.2 The cause of Child Y’s death will be determined by an inquest, which has yet to take place. A post mortem examination was carried out jointly by two pathologists the after the death and they wrote separate reports. One pathologist considered the probable cause of death to be Sudden Infant Death Syndrome whilst the second considered the cause of death to be unascertained. Both reports refer to there being several recognised risk factors for sudden infant death in this case. These include co-sleeping, Child Y being small for their age, maternal smoking and alcohol misuse, poor social circumstances and the time of year (winter). Child Y Overview Report 27 January 2015 4 2.3 Although no evidence has been found to indicate that abuse or neglect was a direct factor in the death of Child Y, several agencies had been involved with the family over a lengthy period of time and had, at times, raised concerns about the care of the children. In addition, following death, Child Y was found to have been malnourished and to have had severe vitamin D deficiency. As a result of these factors, the Chair of the Leeds Safeguarding Children Board decided, on 16 August 2013, to commission an SCR. 2.4 Following a detailed investigation by West Yorkshire Police a decision has been taken by the Crown Prosecution Service that FY and MY will not face any criminal charges relating to Child Y’s death or neglect of the children. 3. Scope and Terms of Reference of the Review 3.1 The timeframe of this SCR is from 1 January 2010 to 1 July 2013 although organisations were also asked to provide brief relevant background information which pre-dated this time period. The SCR considers Child Y and all the siblings, including Sib6Y who was born after Child Y died. 3.2 In considering organisational involvement, organisations were asked to specifically consider the following key issues: 1. What evidence did agencies have that Child Y and the siblings were being neglected and how did they respond to this evidence, in ensuring the wellbeing of the children? Were the risks to the children properly identified, evaluated, and appropriately responded to? Were the right services provided to meet the needs identified? 2. How did professionals take this information into account in relation to Child Y before and after birth and what weight did they give to it? 3. To what degree did agencies engage directly with the children to hear their account of home life prior to and following Child Y’s birth? 4. Did the professionals involved with and in contact with the children and their family members exercise respectful disbelief, active curiosity and build constructive and assertive relationships with the family and if not, why not? 5. What opportunities were there for agencies to intervene more robustly and provide assertive family support with clear plans and clear reviews of those plans and which set out the nature of the concerns the plans were designed to address? 6. When was consideration given to the potential need for a pre-birth Initial Child Protection Conference and to the impact on the family of another child? 7. How did agencies deal with disagreements between one another and what was the impact of this on the service provided to the children? 8. How were issues of non-engagement, including the parents’ failure to Child Y Overview Report 27 January 2015 5 register Child Y with a GP, addressed and what was the impact of this on the service provided to the children? 9. How did agencies respond to father’s intimidatory behaviour and what was the impact of this on the service provided to the children? 10. How have agencies responded differently to the family since Child Y’s death and what has been the impact of this on the children? 11. How well supervised and supported were the frontline staff in contact with the family and were they given the opportunity to reflect on what they were seeing and doing as regards the family? 12. Were there any barriers identified that impacted on how staff exercised their professional practice? 4. Contributors to the Review and Methodology 4.1 The Lead Reviewer for this SCR is Peter Ward who has a background in social care and has worked in management and front line social work. Mr Ward is qualified to degree level in social work and has a post-graduate diploma in management studies. He is now the Director of Arrow Social Care Consultancy Limited and, as such, undertakes investigations and other consultancy work on an independent basis. Since 2005 he has been involved in 15 Serious Case Reviews as an Independent Overview Report Author, Individual Management Review Author or Panel Chair. 4.2 The Panel Chair for this SCR is Sheila Sutherland who has been a qualified social worker since 1972. Mrs Sutherland has over thirty years experience in working within or managing social care services for children; including a total of fourteen years as Head of Services for Children and Families in Cumbria and Blackpool. Since September 2009 she has worked as a self employed consultant to Children’s Social Care Services. In addition she worked throughout the last three years with the Centre of Educational Leadership, (CEL) Manchester University as Social Care Learning Development Consultant on the development and delivery of Children’s Social Care Leadership Programmes. 4.3 As a Consultant Mrs Sutherland has worked with Blackburn, Blackpool, Bury, Bradford, Cumbria, Leeds and Rochdale on both Serious Case Reviews and as investigating officer in case and staff conduct enquires. She works as an Associate of CEL Leadership and Change, contributing to the design and leading on the coordination and delivery of Social Care Leadership Development programmes. 4.4 In accordance with the guidance issued in Chapter 4 of ‘Working Together to Safeguard Children’ (HM Government 2013), both the Lead Reviewer and the Panel Chair are independent of Leeds Safeguarding Children Board and the organisations involved in the review. 4.5 This SCR has been undertaken using a ‘systems’ model in order to reach a deeper understanding not only of what happened but why. The initial terms of reference were agreed based on information which was provided to the SCR Child Y Overview Report 27 January 2015 6 standing sub-Committee of Leeds Safeguarding Children Board. Organisations which had been involved with the family during the relevant time period were then asked to provide a detailed chronology of their involvement and an analytical report which considered their involvement alongside the key issues identified in the Terms of Reference. The individual chronologies were subsequently integrated into one integrated chronology which has been used in writing this Overview Report. 4.6 Reports were provided by the following organisations: Leeds City Council – Children’s Social Work Service (CSWS) Leeds City Council – Education Service Leeds City Council – Housing Leeds NHS England – GP Services Leeds Community Healthcare NHS Trust (LCH) Leeds and York partnership NHS Foundation Trust (LYPFT) Leeds Teaching Hospitals NHS Trust (LTHT) West Yorkshire Police 4.7 Two facilitated learning events have been held using Root Cause Analysis, to analyse Key Practice Episodes (KPEs) identified from the chronology and reports. In total 10 KPEs were identified and these are listed below. Each was considered by a group of approximately five participants. For each of the KPEs, participants were asked to consider: a. what happened, b. what should have happened, c. the reasons for any discrepancy between a & b d. what has been learnt as a result 4.8 The concept of using KPEs in SCRs was introduced by Fish et al in the Social Care Institute for Excellence document Learning together to safeguard children: developing a multi-agency systems approach for case reviews (SCIE guide 24). Fish et al write that “‘key practice episodes’ describe episodes from the case that require further analysis. These are episodes that are judged to be significant to understanding the way that the case developed and was handled. They are not restricted to specific actions or inactions but can extend over longer periods. The term ‘key’ emphasises that they do not form a complete history of the case but are a selection. It is intentionally neutral so can be used to incorporate good and problematic aspects.” 4.9 Every organisation that provided a report was represented at the Learning Events, which were attended by a mixture of management and front line staff in order to achieve a wider knowledge base and understanding of the working environment. The events were led by the Panel Chair, the Lead Reviewer and the assistant manager, Leeds Safeguarding Children Board. Administrative and Clerical Support was provided by Leeds Safeguarding Children Board. 4.10 Key Practice Episodes considered at the Learning Events 1. Timing of the decision by the Primary School to refer to the Children’s Social Work Service in April 2010 2. Response to a referral from the primary school to the Children’s Social Work Service in April 2010 alleging neglect Child Y Overview Report 27 January 2015 7 3. Reported ‘drift’ in Summer and Autumn 2010 4. What were the opportunities for better joined up agency working in May 2011? 5. The decision by the Children’s Social Work Service to end their involvement with the family after the Child In Need meeting in July 2011 6. The response to concerns expressed by the Leeds Addiction Unit Midwife in October & November 2011 7. The response to concerns raised by the school in February 2012 8. Agencies’ response to the pregnancy of MY with Sib6Y compared to her pregnancy with Child Y 9. Why was there such a superficial response to the Neglect of the Children? 10. What were the barriers, between and within health agencies, to information sharing regarding the children? 4.11 Child Y’s parents and older siblings were all invited to contribute to this SCR and chose to do so. The Lead Reviewer met with MY alone and Sibs 2Y & 3Y together whilst the Panel Chair met with FY alone and Sibs 4Y & 5Y together. The Lead Reviewer and Panel Chair together met with Sib1Y. A brief summary of those discussions is provided in section 9 of this report. 5. Summary of Family Circumstances 5.1 The whole of Child Y’s short life was lived with both parents, who are married to one another, and five older siblings. The family lived in a rented three bedroom property. 5.2 Other significant family members were an aunt and uncle of Child Y’s father. Child Y’s siblings lived with this great aunt and uncle for a few weeks following their sister’s death. 5.3 Since Child Y died, but during the period covered by this review, Child Y’s parents have had another child, referred to in this report as Sib6Y. The family have also moved to a larger house. 5.4 The family are white, British and both parents grew up in West Yorkshire. No specific needs have been identified in relation to the family’s race, language, ethnicity or religion. There are no issues relating to disability. 5.5 A genogram was produced to assist in undertaking this review. 6. Summary of Agency Involvement and Key Events 6.1 Introduction 6.1.1 This section of the Overview Report provides factual information regarding agencies involvement with Child Y and the family during the period from 1 January 2010 to 1 July 2013. It is divided into two parts, the first of these is a brief description of each of the agencies that has contributed to this SCR along with a brief outline of the services they provided to the family during the period covered by it. The second part is a chronological summary of the key events that occurred during the period in question. As part of the SCR, each agency produced a detailed chronology showing their contacts with and about Child Y Child Y Overview Report 27 January 2015 8 and the family over the period covered by this SCR. These individual chronologies were integrated into one composite chronology which has been used throughout the SCR. The chronological summary in this section of the report has been produced from the composite chronology. The analysis of this factual information will follow in section 8 of this Overview Report. 6.2 Organisations Involved Leeds City Council – Children’s Social Work Service (CSWS) 6.2.1 CSWS has been involved, from time to time, with the family since 2003. During the period covered by this SCR, CSWS involvement has primarily been due to poor home conditions, the children’s personal hygiene, school attendance and punctuality. 6.2.2 During the period covered by this SCR CSWS had involvement with the family during the following time periods: April 2010 – July 2011 October 2011 – January 2012 March 2012 – end of review (case closed briefly in November 2012) 6.2.3 From April 2010 to February 2011 a Family Resource Centre worker undertook some work with the family. The children were subject to a Child in Need plan from September 2010 to July 2011, and July 2012 to October 2012 and a Child Protection Plan from February 2013 to the end of the period covered by the review. Following the death of Child Y a ‘bridging plan’ was in place. Leeds City Council – Education Service 6,2.4 The Education Service has been involved with the family since January 2002 when Sib1Y entered statutory school provision. Records suggest that the Education Service had safeguarding concerns for the children, specifically in relation to neglect, from approximately 2005. 6.2.5 Although Child Y never reached school age the five older siblings were all of school age throughout the period covered by this review. Between them they received education at one primary school and two high schools and one was home educated for part of the time. 6.2.6 Information from the Education Service shows that throughout the period covered by the review, school staff had concerns about the welfare of some of the children and shared these concerns with other relevant agencies. 6.2.7 On two occasions (one of which was prior to the period covered by this review) FY chose to home educate one of the children. On both occasions, the elective home education officer determined that the standard of education being provided was ineffective and recommended a return to school. During the periods when this child was on the roll of High School 2 attendance was poor; recorded at various times from March 2011 to July 2012 as being between 17.6% and 24.3%. 6.2.8 In November 2011 one child was referred to the Educational Psychology Team and eventually issued with a statutory statement for Special Educational Needs. Child Y Overview Report 27 January 2015 9 Records show that the primary school had considered a referral to be appropriate as early as February 2010 but the parents had been unwilling to consent. Leeds City Council – Housing Leeds 6.2.9 The family were tenants of Leeds City Council throughout the period covered by the review; living in a three bedroom property from December 2003 to July 2013 when they moved into a four bedroom property. Local housing office staff visited the property to carry out annual tenancy visits and made additional visits as required in relation to reports of anti-social behaviour and when other organisations raised concerns about the condition of the property. NHS England – GP Services 6.2.10 Child Y’s parents and older siblings were all registered with the same GP practice throughout the period of the review and they each visited the GP between two and five times during that time period. 6.2.11 Child Y herself was never registered with a GP. Leeds Community Healthcare NHS Trust (LCH) 6.2.12 LCH is a Community Health Service Provider which provides many services to the residents of Leeds. During the period covered by this review LCH provided health visiting and school nursing services to the Y family. LCH also provided the Sudden Unexpected Death in Infants and Children (SUDIC) rapid response team that investigated the death of Child Y Leeds and York Partnership NHS Foundation Trust (LYPFT) 6.2.13 LYPFT provides specialist mental health and learning disability services to people within Leeds, York, Selby, Tadcaster, Easingwold and parts of North Yorkshire. Leeds Addiction Unit (LAU) sits within LYPFT and provides assessment, treatment and aftercare for people who misuse alcohol and other drugs and who have complex needs. The pregnancy and parenting team of LAU were involved with the family from April to November 2011 when MY was pregnant with Child Y and again in 2013 when MY was pregnant with Sib6Y. The involvement of LAU in 2011 ceased 16 days before the birth of Child Y, when FY said he was unwilling to allow the midwife to visit the family home again. Leeds Teaching Hospitals NHS Trust (LTHT) 6.2.14 LTHT provides specialist and general hospital services across the city of Leeds and incorporates Leeds General Infirmary, St James’s Hospital, Chapel Allerton Hospital, Seacroft Hospital and Wharfedale Hospital. 6.2.15 Child Y was born in an LTHT hospital and Sib6Y was taken to hospital immediately after being born at home. Although the majority of antenatal care to MY was provided by LYPFT (see above), a community midwife from LTHT was involved towards the end of the pregnancy with Child Y after FY refused to allow Child Y Overview Report 27 January 2015 10 the LYPFT midwife to visit the family home. Community midwives also provided post natal care following the births of Child Y and Sib6Y. 6.2.16 Four of Child Y’s five older siblings visited the Emergency Department on at least one occasion during the period covered by this SCR. In total the siblings attended the Emergency Department as a result of 10 separate incidents; it appears that two were sports related injuries, four were understood to be other accidental injuries, and three were self-inflicted as the result of deliberate acts. The remaining attendance is described as a ‘left knee injury’ with no indication as to the cause. Some of these attendances were at Leeds General Infirmary whilst others were at St James’s Hospital. 6.2.17 One sibling attended a clinic due to enuresis and was admitted overnight, from the Emergency Department, on one occasion due to blood being seen in the child’s stools. 6.2.18 MY attended the Emergency Department twice during the period covered by the review; once with a lacerated finger and once with chest pains. 6.2.19 FY did not receive any services from LTHT during the period covered by the review. 6.2.20 Child Y was taken to the Emergency Department at Leeds General Infirmary on the morning of her death and pronounced life extinct at the hospital. West Yorkshire Police 6.2.21 West Yorkshire Police had their first contact with the family in 1999, in respect of a domestic incident. Full details of this incident are no longer available. Other contacts prior to the period covered by this review occurred in 2005, 2006 and twice in 2007. 6.2.22 In 2010 and 2011 West Yorkshire Police had brief contact with the family in relation to issues that have no bearing on this SCR. None of these contacts resulted in any family member being charged with an offence. In October 2011 a Police Officer attended a multi-agency meeting to discuss the family. 6.2.23 The Police were contacted by hospital staff when Child Y died and an investigation into the death was carried out. Subsequently the Police have been involved with the family in respect of child welfare issues. 6.2.24 The Police have also carried out an investigation into the death of Child Y in order to establish whether there may be grounds to charge anyone in connection with her death. As stated at paragraph 2.4 of this report, the Crown Prosecution Service have now decided that charges will not be brought. 6.3 Chronological Summary of Key Events Start of period covered by SCR – Notification of MY being pregnant with Child Y (January 2010 – April 2011) Child Y Overview Report 27 January 2015 11 6.3.1 In April 2010 the learning mentor from the Primary School made a referral to CSWS regarding concerns about neglect. It was recorded that the children attended school in dirty clothing; one child had reported eating nuts from the hamster cage due to hunger and another was exhibiting self-harm type behaviour. The learning mentor then phoned FY who was reportedly cross about this, said he would move the children from the school and denied being aware of the school’s ongoing concern regarding the children. 6.3.2 Prior to the referral being made, staff from the primary school had had concerns for at least four months and had discussed these concerns with Housing Services. During this same period, school staff had offered to support the family through a Common Assessment Framework (CAF)1 on four occasions but FY had always declined these offers of support. This included two occasions when a staff member from the school visited FY and MY at home to discuss concerns. FY and MY had also refused to visit the GP regarding one child’s behaviour or to agree to a referral to the educational psychologist. On 21 January 2010 one child received a ‘year 6 school health surveillance’ check from the school nurse and the outcome was recorded as satisfactory. Five days later, in a telephone call, the special educational needs co-ordinator from the Primary School informed the school nurse that the school may commence a CAF in respect of the three youngest children. The special educational needs co-ordinator agreed to keep the school nurse informed but subsequent records do not indicate that the school nurse was made aware of the parents’ refusal to engage with a CAF. 6.3.3 Following receipt of the referral CSWS liaised with the school nurse and a social worker and family resource worker visited the family at home, seeing both parents and all five children and carrying out an Initial Assessment. Concerns were documented about hygiene, the children’s presentation and school attendance. As a result of this assessment it was agreed that the family resource worker would offer support in the short term. 6.3.4 In May 2010 the social worker made a follow up visit to MY, FY and one child, who was not in school, to discuss the outcome of the assessment. The social worker expressed concern to the school nurse that the children were thin and their hygiene poor and asked for treatment for enuresis which two of the children were experiencing. It was agreed that the social worker would give the school nurse’s contact details to FY and MY so they could make an appointment. The parents did not contact the school nurse so the social worker contacted the school nurse again to ask that MY and FY be contacted regarding enuresis. The school nurse made contact with the parents and both the children received appointments to attend the clinic in June 2010. They did not attend the first appointments but by the end of the month they had attended appointments and been prescribed medication. The concerns about hygiene and the children being thin were not picked up by the school nurse at this stage and there is no evidence of the school nurse sharing concerns about the family with the GP practice. 6.3.5 Also during May 2010, one child was taken to hospital with a tooth lodged in the bottom lip after reportedly falling over a barrier. The child was admitted to a ward 1 The Common Assessment Framework is a national assessment tool which can be used to assist agencies in supporting families where children have additional needs that are not being met by their current service provision. Child Y Overview Report 27 January 2015 12 for surgery. Hospital staff were concerned that all the family were unkempt and contacted CSWS who informed that a plan was in place. 6.3.6 The same month, one child disclosed, at school, being hurt by an older sibling. The learning mentor undertook to discuss this matter with MY although there is no evidence in the records that this was ever done. Four days later the children were all late for school and when they arrived, MY reported that there had been trouble at home. Following further discussion MY disclosed that she and her husband had had an altercation which had resulted in FY leaving the family home. There are no subsequent records concerning this but the social worker made a record of a home visit to the whole family shortly after. 6.3.7 Around the same time, it was agreed in supervision between the social worker and CSWS team manager that the social worker, family link worker and school would continue to support the family. 6.3.8 In June 2010, the elective home education officer determined that the family home was not suitable for one child to be home educated. Attempts to get the child back into High School continued throughout the period covered by review, with limited success. 6.3.9 6½ weeks after the initial assessment had been carried out, the social worker visited the whole family at home to check on progress and recorded that the family were positive about continuing to work with the Family Resource Centre. A few days later it was recorded in the social worker’s supervision that there were no concerns regarding family dynamics and that school attendance had improved but that concerns remained regarding home conditions and presentation. 6.3.10 Concerns about the children’s hygiene continued in July 2010 with High School 1 reporting that in July 2010 that one child was extremely dirty, smelt unclean, had no socks on and had fallen asleep in class. One week later another child was seen by the GP having carved their own initials into their forearm with a dart. It is recorded that the child had scratched the arm but not drawn blood and did not need medical attention. The child reported doing this “to be cool” and the GP accepted this. The GP did not identify any behavioural problems and deemed this not to be in the category of a self-inflicted injury. The GP confirmed this view to the social worker. 6.3.11 A CAF was recommended in June 2010 and again in August 2010 but these were not undertaken. In August 2010 the family resource worker informed the social worker that the family as they had not been in when a visit had been attempted and therefore they had not been seen. On the same day the social work team manager recorded a concern that the case had been low priority compared to some of the social worker’s other cases and had “drifted”. It was recorded that the case would be transferred to a different social worker and was to close in the next six weeks. The new social worker discussed the family with the family resource worker that same month and agreed that the best option would be to proceed to a CAF; the reason given being that the core assessment had not been completed because the family are wary of agencies. 6.3.12 Despite the request to transfer to a CAF, a Child In Need meeting was held eight days later with a review date set for three months later. It was agreed that the Child Y Overview Report 27 January 2015 13 family would be transferred to a long term social work team but this transfer was delayed as the manager of the long-term team had left. As a result of this delay it was agreed, in the social worker’s supervision in October 2010, that the current social worker would carry out the Core Assessment within a month. However, records suggest that, in the event, the family were transferred to a social worker in the long term team before the end of October 2010 but this social worker did not manage to meet the family until December 2010 after two planned visits in October 2010 were cancelled by the social worker and a planned visit in November 2010 did not go ahead because the family were out. 6.3.13 There is no record as to when the Core Assessment was completed because the ‘assessment started’ and ‘assessment completed’ dates have not been recorded; however, it is clear from the content of the assessment that it was completed after the end of 2010. In addition, the Core Assessment is not signed off by a team manager, as it should be. It is signed, but not dated, by a social worker; but this is believed to be a different social worker to the one who undertook the assessment. 6.3.14 Also in October 2010 one child was taken to the GP by MY complaining of intermittent abdominal pain and not eating much. The GP took a urine sample and noted that the child’s hygiene was poor. 6.3.15 In November 2010 FY reported that one child was still wet at night despite the treatment received for enuresis. The child was referred to hospital regarding the enuresis and given an appointment in January 2011 which was not attended. Also in November 2010, one child was offered a place at High School 2. 6.3.16 The Child in Need meeting scheduled for December 2010 actually took place in January 2011; there was no representation from the school nursing service. Records indicate some disagreements between professionals about the level of support required but concerns remained and it was agreed that the Family Link Worker would give extra support. 6.3.17 On the day of the Child in Need meeting one child was observed at school to be tired and unclean with a strong odour. The child reported going to bed around 1.00 a.m. and been woken by a sibling at 6.30 a.m. It was recorded that this was not the first time this child had appeared tired in lessons and these concerns were raised at the Child in Need meeting. 6.3.18 Also during January 2011, one child attended hospital having had a finger bitten by a hamster and, later in the month the same child attended with an injured knee. A different child, meanwhile, fractured two fingers having reportedly caught them in the garden fence. 6.3.19 In February 2011 the Primary School asked the school nurse to carry out health checks on the three youngest children. Parental consent was obtained and the checks were duly carried out. The school nurse found that all three children were on track with regards to their growth and noted that they were wearing clean clothes but their hair was not brushed. 6.3.20 One day in February 2011 one child arrived at school late (approximately 10:30 hours) with MY and it is recorded that the child smelt of urine, was dirty and had Child Y Overview Report 27 January 2015 14 a smudge on their face. The safeguarding support worker at the High School sent an email to the social worker listing the concerns that the school had about the child. Two days later the social worker phoned the learning mentor at the Primary School to ask whether there were any concerns about the younger siblings. The learning mentor outlined concerns about the children being poorly dressed and having poor hygiene and recorded that the social worker said the case was going to be “stepped up as the parents are not improving” and that there would probably be a Child Protection Plan due to long-term neglect. CSWS do not have a record of this conversation. 6.3.21 Also in February 2011, the social worker informed High School 1 of a plan to have a meeting with the family that week. Records indicate that the meeting did not take place until a month later; however it is also recorded that the social worker was on annual leave on the date that the meeting is recorded as having been held. Therefore the Lead Reviewer wonders if the meeting with the family was actually in February 2011 but has been incorrectly dated. 6.3.22 In March 2011, a child did attend the enuresis clinic with the mother and medication was prescribed. It was recorded that the child appeared unkempt and had a bruised left arm, but claimed not to know the cause. It was also recorded that the family was receiving input from CSWS. 6.3.23 In April 2011, the same child was taken to hospital after MY saw blood in the child’s stools. It was recorded that the child had a history of eating bolts and screws and had eaten sharp plastic and crayons the previous day. The child was seen in the Emergency Department, referred to paediatric surgeons and admitted to a ward. Investigations were undertaken and the bleeding resolved itself; LTHT records state that the child was discharged with follow up from the GP, GP records show that the only correspondence received regarding this was a discharge advice note from the hospital. 6.3.24 Also in April 2011, the social worker had supervision with the team manager and it was recorded that the social worker would refer to Family Support as the family resource worker had been taken off the case and that there would be a Family Support meeting in May “to pull it all together”. Records show that the family resource worker’s involvement with the family had ceased in February 2011. Notification of MY being pregnant with Child Y – Birth of Child Y (April 2011 – November 2011) 6.3.25 In April 2011, MY attended the first antenatal appointment of her pregnancy with Child Y, at approximately 12 – 14 weeks gestation. It was decided that the antenatal care should be provided by LAU because MY disclosed that she was drinking four cans of lager each evening and the community midwife dully made this referral. Two weeks later, MY failed to attend an antenatal clinic appointment at the GP practice. 6.3.26 In May 2011, the Primary School contacted the social worker to express concerns about the children’s poor attendance at school. The social worker explained that the family resource worker was no longer working with the family and the social worker did not have time to provide the continuous support needed by the family. The social worker agreed to discuss the case with the Child Y Overview Report 27 January 2015 15 manager and did so that same day. The manager recorded that the children were fed and wore appropriate clothing and there was lots of emotional warmth but that school attendance was declining. The manager also recorded that a Family Support Meeting was required and that the case would be transferred to a new social worker or social work assistant in early July 2011. 6.3.27 Also in May 2011 midwife 1 and an addiction nurse from LAU had their first meeting with MY, visiting her at home and carrying out a comprehensive assessment. The LAU staff noted that the house was very dirty and unkempt due to there being multiple animals in the house. It was also recorded that there was a social worker involved with the family. The author of the IMR from LYPFT has noted that the assessment was only partially completed and that there was neither information about FY nor a needs analysis of the other children. 6.3.28 Following the assessment, the midwife contacted the RSPCA to try to arrange for in excess of 15 hamsters to be re-housed; it is not recorded whether this was achieved. The midwife also completed a communication form to alert the obstetric service to LAU involvement and the maternal alcohol issues but this form did not mention the concerns around hygiene. The day after the home visit from LAU staff, MY missed another ante natal clinic appointment but the day after that, she attended a booking appointment. 6.3.29 That same month, a Child in Need Meeting was held in relation to the family. This was the first such meeting since January 2011. MY’s pregnancy was noted but LAU staff were not present at the meeting. An overall improvement in the family was noted with future targets set for the children to improve their punctuality and attendance at school. It was stated that CSWS may cease their involvement if these targets were reached. 6.3.30 Later in the month, MY attended an antenatal clinic at hospital with the midwife and addiction nurse from LAU, her alcohol consumption was reviewed, and the effects of alcohol on an unborn child was discussed. An alcohol reduction regime was planned and a referral made to a cardiologist at LGI regarding MY’s Supra Ventricular Tachycardia (SVT). 6.3.31 MY continued to receive antenatal care through June 2011 and reported that she was still drinking four cans of lager each evening. The LAU midwife expressed concern about the presence of birds and bird faeces in the house. 6.3.32 In July 2011 another Child In Need meeting was held and it was reported that there was to be a change of social worker. The current social worker was unhappy with the lack of progress and suggested more intensive family support was required. FY became angry about this and was reportedly abusive to the social worker. After the meeting the CSWS team manager decided to close the case because FY did not want social work involvement. The following month CSWS sent a letter to MY and FY to inform them that CSWS was to close its active involvement due to the parents’ “reluctance to engage with social care in last Children in Need meeting” but that CSWS would become involved again if there were any more referrals to CSWS. This letter was copied to the other agencies involved. Despite this letter and the social worker writing a closing summary, the case was not formally closed until January 2012; however CSWS had no more direct contact with the family until November 2011. For three Child Y Overview Report 27 January 2015 16 months between July 2011 and October 2011, the service’s involvement appears to have been limited to phone contact with other professionals, including the elective home education officer, the addiction therapist and the head teacher at the Primary School. 6.3.33 In August 2011, the midwife and addiction nurse from LAU carried out another home visit, seeing MY, FY and some of the children. The midwife recorded that MY appeared ‘vacant’ when her husband was talking and the midwife was unable to talk to MY on her own because some of the children were present. The midwife also recorded that the house appeared unkempt and all the children appeared dirty and markedly dishevelled, however well nourished. 6.3.34 LYPFT records state that in September 2011, the addiction nurse discussed the case with the social worker who reported having only recently taken over the case and not knowing about MY’s alcohol intake. Also that there had been a Child in Need plan but FY was not willing to engage with services so the case was to be closed the following week. 6.3.35 A few days later, the elective home education officer visited the family home regarding one child’s education and subsequently contacted CSWS to express concern about the condition of the home, especially with a baby due. This included a report that the house contained a pigeon, hamsters, a rat and two dogs. The following day the social worker passed these concerns on to the addiction nurse and subsequently the midwife and addiction nurse carried out a home visit. At this visit the midwife told the parents that there had been liaison with CSWS; FY is reported to have become verbally abusive and aggressive and stated that the LAU staff were no longer welcome in his home. This was the last time staff from LAU visited the family home in connection with MY’s pregnancy with Child Y. 6.3.36 Following on from this home visit the case was discussed within LYPFT at clinical supervision and a team meeting. It was agreed to contact CSWS and also to contact Public Health if needed for further action and/or advice. The addiction nurse phoned CSWS and was told that staff familiar with the case were on leave but information would be sent to them by email. Public Health and Infection Control within NHS Leeds were also contacted. In October 2011 the addiction nurse spoke to CSWS again and expressed concerns. 6.3.37 As a result of the concerns from LAU, CSWS requested assistance from Housing Services, who visited the property and reported that the condition was fair but that rubbish needed to be cleared in order for surveyors to undertake a full inspection. Later in the month it was recorded that that FY and MY had been provided with a garage and the house condition had improved. Surveyors had identified various repairs that were needed but FY and MY had declined any other support apart from assistance in applying for a larger property. 6.3.38 CSWS also arranged a meeting which took place in October 2011. The meeting was attended by social worker 1, the LAU midwife and representatives from the Primary School, High School1, Housing Services and the Police. It is recorded that the social worker and midwife were to carry out a joint visit to the family and the social worker was going to check whether there should be a pre-birth Initial Child Protection Conference regarding the unborn baby or an Initial Child Child Y Overview Report 27 January 2015 17 Protection Conference for all the children. The following day, the social worker informed other professionals involved that there was not going to be a Child Protection Conference and the planned joint visit was not going ahead because the CSWS service delivery manager thought it might seem oppressive to the parents. 6.3.39 Also in October 2011, a ‘32 week’ meeting was held at LAU, which was attended by the midwife, addiction nurse and health visitor all of whom were from LAU. The ’32 week’ meeting has routinely been held by LAU in the 32nd week of a service user’s pregnancy. It constitutes a multi-agency review of the service users’ care and treatment and the level of risk to the unborn and existing children. Housing Services and the schools were not invited whilst the social worker, community based health visitor and neonatal abstinence specialist nurse were invited but not in attendance. In addition MY was invited to the meeting but did not attend and she also missed an ante natal appointment, leading to concerns that she was not engaging following her husband telling the midwife and addiction nurse to leave the house. Concern was expressed about the lack of involvement from CSWS and it was agreed that the midwife would co-ordinate a referral to CSWS from the various agencies with concerns. This action was taken and a referral was made on eight days later. 6.3.40 Three days after the midwife made the referral; the health visitor from Leeds Community Healthcare made their first visit to the home and was concerned about the state of property, including the number of animals. The health visitor considered it to be unsuitable for a new born baby and contacted the midwife and CSWS, who told responded that the family was not an open case to CSWS. 6.3.41 Also in October 2011 the social worker told the midwife that the social worker wanted them to carry out a joint visit to the family home a few days later. However, the following day the social worker left a message for the midwife to cancel this visit and instead the CSWS team manager and a social work assistant visited; apparently because FY said that he would not allow the midwife to come to his house. It was agreed with FY and MY that CSWS would keep the case open until the baby was born and for four weeks afterwards but the rationale for this decision is not recorded. 6.3.42 In November 2011, the social worker, health visitor and community midwife from LTHT all carried out visits to the home and found the property to be in a much better condition than had previously been the case. The community midwife had taken over from the LAU midwife as a result of FY’s refusal to allow the community midwife to visit his home. Also in November 2011 Child Y was born in hospital; mother and child were discharged home two days later. Child Y’s lifetime (November 2011 – March 2012) 6.3.43 The social worker visited the family at home a few days after Child Y was born, seeing all the children including Child Y. It was noted that the home was warm and the lounge acceptable. A smell of urine was noted in one bedroom but the bedding was clean and the baby was recorded as eating and sleeping well. 6.3.44 The community midwife visited Child Y and MY at home on six days after Child Y was born and again five days later; before handing care over to the health visiting Child Y Overview Report 27 January 2015 18 service. The health visitor tried to visit but got no reply but visited again six days later and did gain access. The health visitor recorded that the house was a little cluttered but generally clean; although it is unclear how many rooms were seen. 6.3.45 The day before the health visitor’s visit, the social work assistant tried to visit the home. FY would not allow the social worker into the property but they spoke through a window. The social work assistant informed FY that this might be the last visit as the concerns ‘had been addressed’. The case was closed by CSWS in January 2012; it appears that the social work assistant never saw Child Y and had not been in the house, or seen any family members except for FY since nearly seven weeks before. 6.3.46 Twice in January 2012, the Primary School noted that one child was very tired. The child reported being kept awake by the baby. Also in January 2012, another child was taken to the Emergency Department after punching a wall due to being angry with a teacher. 6.3.47 Also in January 2012, the health visitor visited to complete the 6 – 16 week contact. The health visitor told MY that there would be a change of health visitor due to services being ‘realigned’. The health visitor had no concerns about the house or Child Y. MY told the health visitor that she had not had an appointment from the GP for the 6 – 8 week medical (Child Y was 7½ weeks old) or contact from the Children’s Centre. After this visit the health visitor requested a visit from an Outreach Worker from the Children’s Centre and contacted the GP practice who said that Child Y was not registered with a GP. The health visitor phoned MY to recommend that Child Y be registered with a GP as soon as possible. This was the last occasion when anyone from an agency involved with this SCR saw inside the family home prior to Child Y’s death. 6.3.48 The day after the health visitor had visited the family home, the Primary School phoned CSWS to express concerns that one child had reported being kept awake because Child Y was persistently crying. The member of staff from the school was informed that social worker 1 was not in work and that the case was closed to CSWS so, if school were concerned they needed to re-refer. The member of staff from school spoke to the health visitor and explained that two of Child Y’s siblings had said Child Y cried a great deal. The health visitor reported having no further concerns, having seen Child Y the previous day, but said the service would be visiting more frequently than the ‘core offer’ requires, due to the recent involvement with CSWS. The health visitor also said that if school continued to have concerns they should contact CSWS. 6.3.49 One week later two of the children informed school staff that their mother had been taken in an ambulance that morning. Records from LTHT show that MY attended ED at 06:06 hours with right sided chest pain when breathing in or moving. She declined pain relief; chest X-ray and blood tests showed no abnormalities. Child Y remained with MY due to being eight weeks of age and breast feeding; one of the other children was also in attendance. MY was discharged at 08:10 hours with no follow up required. 6.3.50 The following day, the learning mentor from the Primary School phoned social worker 1 again to explain that school staff still had concerns and were unhappy that CSWS had ended their involvement with the family. The social worker Child Y Overview Report 27 January 2015 19 responded by saying that if any additional concerns came to light school staff could re-refer. The social worker also recommended that the learning mentor should phone the health visitor regarding concerns that the other children were being kept awake by Child Y. 6.3.51 That same day, health visitor 1, phoned the GP surgery again and was informed that Child Y had still not been registered with the GP. Health visitor 1 also contacted CSWS, having been informed that they had ceased their involvement. Health visitor 1 expressed concerns about this due to Child Y not being registered with a GP and already being late for the first immunisations and medical check. Finally, the health visitor tried to phone FY and MY about GP registration but did not receive an answer to the call and therefore left a message asking them to phone back. The family did not phone back but a few days later the health visitor managed to speak to FY who said that he would register Child Y with the GP the following day. However he did not do so. 6.3.52 In January 2012 the child who had reportedly eaten hard plastic met with the educational psychologist. 6.3.53 In February 2012 FY & MY attended a meeting at High School 1. School staff were concerned that the parents and Child Y were very dirty. The school teacher initially spoke to the social worker about this concern and was told that the case was closed to CSWS and that contact should be made with the health visitor. The school did phone the health visitor whose response was that concerns must be referred to CSWS as they have a statutory duty to investigate concerns about neglect. The health visitor then spoke to the manager about concerns that CSWS had asked the school to contact the health visiting service; the manager advised the health visitor to complete an incident form to highlight these concerns and this was done two days later. Also that day the health visitor and social worker spoke to each other about the case. Following the phone call, the social worker recorded that the health visitor would visit the family and the health visitor recorded that records would be transferred to the new health visiting team to facilitate an early visit to the family. 6.3.54 Child Y’s care was transferred to a new health visitor, as health visitor 1 had previously said would happen, and the new health visitor wrote to MY and FY on to arrange a visit 18 days later. six days before this visit, the learning mentor at the Primary School contacted the Health Visiting Service with concerns about two of the children and to report that a member of staff had seen Child Y and thought the child looked very underweight. The learning mentor was informed of the planned visit. When the health visitor visited the house there was no answer; the health visitor spoke to MY by phone and arranged to visit again with an outreach worker two days later but again there was no response and a further date was set to meet seven days later. 6.3.55 On the day of the attempted visit by the health visitor and outreach worker, the head teacher from the Primary School again expressed concerns to the health visitor about Child Y and was told that the health visitor intended to make a referral to the health visiting safeguarding team if Child Y was not seen the following week. Child Y Overview Report 27 January 2015 20 Child Y’s death – Notification of MY’s pregnancy with Sib6Y (March 2012 –January 2013) 6.3.56 The following morning MY stated that she woke to find Child Y lifeless. Despite attempts at resuscitation by FY and health staff Child Y was pronounced dead at hospital. The Sudden Unexpected Death In Infants and Children (SUDIC) process commenced and consequently the Named Nurse, Consultant Paediatrician and police visited the family home. Following the visit, the Named Nurse reported the home conditions as appalling, and one of the worst environments the Named Nurse had witnessed. Records and verbal reports suggest that the improvements made before Child Y was born had not been maintained and that items that had been moved out of the house and into a garage had since been moved back in. 6.3.57 CSWS reopened the case, held a strategy meeting and initiated Section 47 enquiries to consider issues of possible neglect. All five children and their parents went to stay with FY’s aunt and uncle. An Initial Child Protection Conference was arranged for the following week but was adjourned, by the Conference Chair, in consideration of the family’s mourning of the loss of Child Y. Instead the professionals held a meeting without FY and MY present and a Child Protection Bridging Plan was put in place. 6.3.58 The family remained with FY’s aunt and uncle through April 2012 but confirmed to the social worker in late April 2012 that they intended to move back to their home whilst they waited to be re-housed, this move happened in late May 2012. In late April 2012 the social worker’s manager recorded in supervision that core assessments still needed to be completed in respect of all the children. 6.3.59 During May 2012 the school nurse completed health assessments of three of the children and it was reported that the hygiene of all the children was better whilst they were living with their great aunt. The educational psychologist met with the same child as before, MY and FY’s aunt and allegations were made that this child was being bullied at school. CSWS completed the core assessments and decided that the family should be supported under a Child in Need Plan as they believed that Child Protection could be seen as a punitive measure that could further alienate the family. 6.3.60 In June 2012 one child was excluded from High School 1 due to behaviour and FY was reported to be verbally abusive to the school about this. There were further reports that the child who had seen the educational psychologist was being bullied at school and this was having an impact on attendance. 6.3.61 Plans were made for a Child In Need meeting and a Family Group Conference to be held. The Child in Need meeting went ahead in July 2012 and it was agreed that the current plan would continue but the Family Group Conference did not go ahead as, having met the family, the Conference Co-ordinator considered that the time was not right as they were still grieving and distressed. 6.3.62 In August 2012, concern was expressed that whilst one child’s appearance had improved whilst living with the father’s aunt it had deteriorated again since the family had moved back into their own home. Child Y Overview Report 27 January 2015 21 6.3.63 Also in August 2012 a child attended hospital having punched a wall when angry with a teacher; there had been a similar incident with the same child in January 2012. It was recorded by school that counselling was being sought for this child and a referral was made by CSWS to the Specialist Therapeutic Team (STT) who questioned the relevance of the referral given the parents’ resistance to help. Therapeutic services expect consent and co-operation from parents and it appears that this was not forthcoming. Consequently, the Specialist Therapeutic Team did not become involved with the family. At the end of September 2012 it was reported that this child’s behaviour in school had stabilised. Another child’s school attendance was reported as being 33.3%. 6.3.64 In October 2012 High School 1 raised concerns about the children being late for school and their unkempt appearance whilst the Primary School expressed concern to CSWS about the appearance of one child. Later in the month three of the children were suspected of causing criminal damage to vehicles. The Police expressed concerns about their hygiene. 6.3.65 FY’s aunt and uncle were continuing to support the family and liaise with CSWS and at a Child in Need meeting in October 2012 CSWS decided to close the case. They were asked by the Primary School to keep it open until after the inquest into the death of Child Y but the Primary School was told to re-refer if they had further concerns and the case was closed the following week. It was, however, reopened shortly after when CSWS became aware that the SUDIC process had not yet been completed. 6.3.66 The final SUDIC meeting took place in November 2012 and, following this, reminders were placed on the GP records for both parents and all five children to refer to CSWS if they had any concerns. 6.3.67 Also during November 2012 High School 1 and the school nurse referred the family to CSWS due to concerns that their situation was deteriorating again and reports that FY’s aunt was no longer seeing the children. The Named Nurse for Safeguarding Children from LCH spoke to the CSWS team leader regarding concerns and the team leader confirmed CSWS’s view that the case could be managed with a CAF but that there were concerns if FY’s aunt was not seeing the children. 6.3.68 Education Officers visited the family home on 12 occasions between October 2012 and November 2012 regarding one child’s non school attendance. On the majority of occasions there was no response. In 1 November 2012 the elective home education officer visited with a police officer. FY opened a window but would not open the door or let the officers in. He did however allow them to see the child through a window. FY was angry with the enquiries made by the Police Officer to ascertain the location and welfare of the child and rang the Divisional Control Room, wanting to make a complaint. FY spoke to the Divisional Control Room Supervisor who advised him of the Police Powers of Entry under Section 17 of PACE. FY did not wish to pursue a complaint but requested that the attending Police Officer be spoken to. FY also stopped sending the other children to school and told High School 1 that he intended to home educate all the children. Child Y Overview Report 27 January 2015 22 6.3.69 In December 2012 concerns continued to grow and CSWS decided to re-open the case with a view to holding a Child Protection Conference and Family Group Conference. FY visited the GP in December 2012 and said that he had been feeling down for months. GP notes refer to him arguing with one child and striking out but it is unclear whether he struck the child, or which child he was referring to. A follow up appointment was arranged for 28 December 2012 but FY did not attend. Despite the alert in FY’s GP record, the GP did not refer to CSWS. Notification of MY’s pregnancy with Sib6Y – Birth of Sib6Y (January 2013 –April 2013) 6.3.70 In January 2013, MY was seen by the GP and found to be 25 weeks pregnant; she was referred to the GP and the addiction unit. Also in January 2013, a Special Educational Needs (SEN) support worker met the child who had seen the educational psychologist and completed an assessment. 6.3.71 In February 2013, an Initial Child Protection Conference was held and all the children were made subject to Child Protection Plans. At the first Core Group meeting later in the month FY expressed a wish to transfer all the children to High School 2 but said the school did not want them because of attendance issues with one child. 6.3.72 Also in February 2013 the GP practice was asked to screen all the children for vitamin D deficiency. This was because the post mortem of Child Y had shown vitamin D deficiency. When the children were screened they were all found to have vitamin D deficiency and were prescribed supplements. 6.3.73 In March 2013 it was decided that when the baby was born, MY and the baby would go to a mother and baby unit together for three months. Also in March 2013 the statutory educational assessment of one child began and a referral was made for a Family Group Conference. 6.3.74 In April 2013, the LAU midwife, social worker and health visitor carried out a joint home visit. Both parents were present, along with three of the children; the condition of the house was deemed to be ‘acceptable’ and it was recorded that MY was on an alcohol reduction programme. 6.3.75 A core group meeting was held in April 2013 and three days later Sib6Y was born at home at 35 weeks gestation. Birth of Sib6Y – End of Review Period (April 2013 –July 2013) 6.3.76 Following Sib6Y’s birth at home the baby and mother were taken to hospital. 10 days later an Interim Care Order was made for Sib6Y with Interim Supervision Orders for the other five children, who were in their father’s care. MY and Sib6Y remained in hospital for 12 days more and were then discharged together to a foster placement. The following week a Review Child Protection Conference was held and it was decided that the children would remain subject to Child Protection Plans. Six days later, a Family Group Conference was held and a Family Plan was agreed. Child Y Overview Report 27 January 2015 23 6.3.77 In June 2013 the family were offered a tenancy of a four bedroom home near to FY’s aunt and uncle. They accepted this and MY and Sib6Y were reunited with the other family members in July 2013 when they moved into this house. 7. Analysis Introduction Analysis is provided for each of the individual terms of reference (ToRs), based on information gathered from the individual agency reports, consideration of the Key Practice Episodes which were explored during the two Learning Events, discussions within the SCR Panel Meetings and wider reading undertaken by the Lead Reviewer. There is considerable overlap between some of the ToRs so, in order to avoid unnecessary duplication of information the report cross references where appropriate. 7.1 Term of Reference (ToR) 1. What evidence did agencies have that Child Y and the siblings were being neglected and how did they respond to this evidence, in ensuring the wellbeing of the children? Were the risks to the children properly identified, evaluated, and appropriately responded to? Were the right services provided to meet the needs identified? 7.1.1 Working Together to Safeguard Children 2013 provides the following definition of neglect: “The persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to: provide adequate food, clothing and shelter (including exclusion from home or abandonment); protect a child from physical and emotional harm or danger; ensure adequate supervision (including the use of inadequate care-givers); or ensure access to appropriate medical care or treatment. “It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs” (page 86, appendix A) 7.1.2 Throughout the period covered by this review there was evidence of neglect within the family, which at various times included the following: the children’s poor hygiene and presentation, including unpleasant smell, dirty clothes, unwashed and unbrushed hair and persistent head lice; the children being hungry; the children being late for, or absent from, school; inconsistent attention to the treatment of enuresis in two of the children, including not collecting prescriptions and not attending appointments at the enuresis clinic Child Y Overview Report 27 January 2015 24 the condition of the home, including overcrowding, animal faeces, absence of food and cleaning materials, no bedding and urine soaked mattresses. 7.1.3 The children’s attendance at school in a tired, hungry, dirty, unkempt and smelly condition created problems for them with other pupils. One of the children was particularly affected by bullying; as a result spending playtimes and lunch breaks playing alone in the classroom on the computer, to avoid this. This child ate sharp metal objects and at seven years of age reportedly expressed a wish to die when talking to school staff. 7.1.4 Historic records show that many of these issues had been present for several years. LCH identified that basic indicators of neglect had been present for at least twelve years requiring intermittent episodes of statutory intervention. Agency knowledge of neglect in this case 7.1.5 Throughout the period covered by this review the Primary School had concerns that the children were being neglected as a result of the way the children presented at school. School staff monitored this and referred to CSWS on several occasions. Concerns were also raised by staff from High School 1 and by the elective home education officer who attended the family home with regard to one of the children. 7.1.6 The school nurse, from LCH, was aware that the children displayed indications of being neglected; in addition to the school nurse’s own observations information was received from school, CSWS, Emergency Department attendance slips and hospital consultant letters. The school nurse offered support to the family with the enuresis being experienced by two of the children and showed persistence when MY and FY did not collect prescriptions or take the children for appointments. The school nurse also referred one of these children on to the enuresis clinic in hospital when the child’s enuresis persisted. 7.1.7 The health visitor, also from LCH, became involved with the family in October 2011 as a result of MY’s pregnancy. LCH have identified that liaison between the school nurse and health visitor did not happen early enough in this case and that historical health records should have been accessed due to the presence of safeguarding concerns. 7.1.8 CSWS had had periods of involvement with the family prior to the period covered by this SCR. During the period covered by the SCR they were aware of features of neglect within the family from April 2010 when the Primary School made a referral and were involved in providing support to the family during the majority of the period covered by the review. It appears that at times this was proportionate and led to improvements in the overall care of the children but there was a lack of clear assessment and planning, and periods when the case was allowed to drift. These issues are explored in detail elsewhere in this analysis 7.1.9 Child Y’s five older siblings each visited the GP surgery between two and five times during the 3½ year period covered by this SCR. Therefore none of the children could be described as frequent visitors to the GP. On one occasion a GP recorded that the hygiene of one of the children was poor but no action was Child Y Overview Report 27 January 2015 25 taken. The author of the Primary Care IMR explains that the GP practice was aware that CSWS and addiction services were involved with the family and speculates that the GP may not have pursued the hygiene issue because the family were already receiving additional support. Records suggest that whilst the school nurse was aware that the children were experiencing neglect, the nurse had little communication with the GP practice about the family and did not make them aware of the concerns. Child Y was never registered with a GP. 7.1.10 LTHT’s contacts were with the children individually rather than as a family and were in respect of specific incidents and ailments. There is no sense that staff from paediatrics in LTHT were aware that the children were from a family where neglect was a concern. Of 20 contacts that paediatrics in LTHT had with the various children there were two occasions where concerns were noted about the appearance of the family. Firstly, in May 2010 one of the children attended the Emergency Department following an accident at home; the family was noted to be unkempt and staff in the Emergency Department contacted CSWS via the emergency duty team (EDT). It is written on a social care communication sheet within the child’s hospital record that CSWS staff contacted the ward to which the child had been transferred for surgery and provided information that the child was subject to a child protection plan which should continue. In actual fact this information is incorrect; CSWS were involved with the family in May 2010 but they were receiving Family Support and were not subject to Child Protection Plans. It is not known whether CSWS provided incorrect information or if it was incorrectly recorded by LTHT staff. On another occasion one of the children was described as unkempt at the enuresis clinic appointment; CSWS were contacted and informed hospital staff that the family was known to them. This was confirmed by the school nurse. 7.1.11 LYPFT first became involved with the family in April 2011 when MY was referred to LAU due to her pregnancy and known alcohol misuse. Records show that the LAU midwife and addiction nurse had concerns about the condition of the property from the time of their first visit. These concerns were in the context of MY expecting a baby, not concerns about the children who already lived in the property. 7.1.12 Housing Services were contacted by the Primary School in December 2009 and by CSWS in September 2011. On both occasions contact was made because of concerns about the property and Housing Services’ involvement was correctly focussed on the condition of the property. Practical solutions were put in place and Housing Services’ reported back to the school and CSWS as appropriate. Although Housing Services’ focus was on the property, staff have received safeguarding training and, following the visit in December 2009 reported that the children appeared happy and did not present as unwell or dirty. 7.1.13 The Police were unaware about the concerns of possible neglect in the family until October 2011 when they were asked to attend the meeting called by CSWS. Prior to Child Y’s death there is no indication that agencies ever considered whether the neglect reached the level where a criminal act may have been committed. Since Child Y’s death the Police have collated and investigated all the child neglect concerns in order for a decision to be made as to whether there are grounds for a prosecution. Child Y Overview Report 27 January 2015 26 Referral from Primary School to CSWS April 2010 7.1.14 Paragraphs 6.3.3 and 6.3.4 summarise the initial action taken as a result of the referral from the Primary School in April 2010. Although CSWS undertook an Initial Assessment, the case was not progressed to a Core Assessment and a Child in Need plan was not put in place until five months later, in September 2010. It is the view of the CSWS Head of Service (Social Work) involved in this SCR that the initial assessment and previous history downplayed the significance of neglect. At the Learning Lessons Event, it was considered that continued CSWS involvement should have resulted in a Core Assessment being undertaken to identify the children’s needs. 7.1.15 CSWS appear not to have considered the referral in the context of the long history of concerns relating to neglect within this family but instead the referral was treated in isolation. The statement that there were no concerns about family dynamics ignores the concerns about some of the behaviour and suggests that the possible significance of self harming, particularly in young children, was not considered or understood. Equally there was no consideration of what the parents’ apparent unwillingness to recognise there was a problem and their refusal to agree to it being investigated further, indicated about their commitment to the welfare of the child. Instead, because professionals observed what appeared to be positive relationships within the family, it was assumed that the family dynamics were fine and input focussed on school attendance and hygiene. 7.1.16 There is no evidence of the school nurse addressing the concerns about the children being thin or making the GP practice aware of the concerns about the family. Family Support 7.1.17 The principal outcome, from the initial assessment, appears to have been the introduction of a family resource worker to support the family. The family resource worker commenced work with the family in May 2010 and is believed to have worked with them until February 2011. However this review has found significant problems with this provision of family support. 7.1.18 At the time the case was referred to the Family Resource Centre it was expected that a social worker would request support from the centre using a referral form which the centre manager would then process. It appears that, in this case, the family resource worker bypassed this system and carried out the work without the manager’s knowledge. This did not come to light until approximately nine months later in February 2011 at which point action was taken which meant the family resource worker could no longer work with the family. 7.1.19 Given this situation it is evident that the manager of the Family Resource Centre did not provide any supervision or management in respect of this case. The family’s social worker was aware that the family resource worker was working with the family and it may be that the social worker did provide some oversight of the work that was carried out but no records of such work have been found. Equally, there is no plan as to what work the family resource worker was asked to undertake. Child Y Overview Report 27 January 2015 27 7.1.20 MY and FY have both contributed to this SCR by meeting with the Lead Reviewer and Panel Chair respectively. MY told the Lead Reviewer that CSWS was “in and out of the house a few times and offered to help get the children ready for school in the morning”. She added that she was not bothered about CSWS coming in and helping but her husband was set against having any help. 7.1.21 Given the above information, it is impossible to know how much support was provided to the family or whether this had any benefit for the children. It seems to be the case that this problem was created by one member of staff acting independently but it is a matter of great concern that it took so long to come to light. It is believed that the social worker did not know that the family resource worker was working without the manager’s knowledge. Nevertheless the absence of a clear plan for the family resource worker or records of ongoing communication between the social worker and family resource worker are a further concern. Summer 2010 to early 2011 7.1.22 Paragraphs 7.3.17 to 7.3.19 summarise the action taken in the summer and autumn of 2010. 7.1.23 Two weeks before the first Child in Need meeting, which was held in September 2010, a record had been made that the case would be closed in six weeks. However, at the meeting it was agreed that a Core Assessment would be undertaken and the family transferred to a long term social work team. The SCR Panel has not received any information as to why the plan changed in this way. 7.1.24 A core assessment should have been carried out much sooner. This would have facilitated a decision as to whether the children should be supported through a Child in Need plan or if concerns were sufficiently serious to warrant an Initial Child Protection Conference. Either way, a clear multi-agency plan was required, which clarified the roles of different agencies and stated what needed to be achieved. Regular meetings, involving the key parties were required to monitor progress. 7.1.25 Despite the Child in Need meeting in September 2010 and the decision to carry out a core assessment the drift in the case was not arrested. The core assessment was still not carried out in a timely manner and the introduction of the new social worker from the long term team was delayed significantly. 7.1.26 Over this period the family was given low priority by CSWS; the SCR Panel has been told that CSWS in Leeds had assessment teams with high caseloads and long term teams would not accept cases without the proper assessments having taken place. Therefore cases drifted due to being “stuck” between assessment and long term teams. CAF was wrongly promoted or understood to be a gatekeeping process with the result that a family would not be taken on by CSWS unless a CAF had been tried first. Consequently, agencies faced difficulties referring to CSWS in cases where the family would not agree to a CAF being undertaken. It is reported that the team working with Child Y’s family were very stretched with low morale and agency staff filling several vacancies. Social workers previously had up to 30 children on their case loads whereas the current target is 15 to 20. At the present time average caseloads are about 22 with Child Y Overview Report 27 January 2015 28 some teams having achieved the target of 15 to 20 and all other teams heading in that direction. 7.1.27 Records from the Child in Need meeting held in January 2011, nine months after CSWS became involved, indicate some improvements for the children but also that significant concerns remained. It was recorded that the family resource worker was to give extra support but, as is explained above, the following month the family resource worker actually stopped working with the family and the social worker reportedly told the Primary School that there was likely to be an Initial Child Protection Conference (see paragraph 6.3.20). 7.1.28 Contrary to the suggestion that an Initial Child Protection Conference would be held, the records provided to this SCR suggest that CSWS did not have any significant involvement with the family until the next Child in Need meeting which was in May 2011. By this time MY was pregnant with Child Y and the analysis is contained within ToR2 below. 7.1.29 In summary, during the period from January 2010 to May 2011 agencies were involved with the family due to concerns about neglect. The main intervention appears to have been the introduction of a family resource worker but this was not managed properly, there are no records to show what work was done and little if any indication of positive change. 7.2 ToR 2. How did professionals take this information into account in relation to Child Y before and after the birth and what weight did they give to it? 7.2.1 In May 2011 LAU became involved with MY as a result of her pregnancy. The midwife and addiction therapist from LAU had concerns about the condition of the family home when they carried out their first visit and the midwife took some action to try to improve matters. However, despite taking some positive action to try to improve the home situation, the midwife did not liaise with other organisations involved with the family. The midwife knew that CSWS were involved but did not discuss the concerns with CSWS until three months later. 7.2.2 No explanation has been provided as to why the midwife did not contact CSWS regarding these concerns in May 2011. As a result of this, action has been taken to tighten up LAU’s process of seeking background checks from CSWS when referrals are first received. 7.2.3 At the Child in Need meeting in May 2011 MY and FY informed people of MY’s pregnancy. The only agencies in attendance at this meeting were CSWS and the schools. Records do not indicate what consideration these agencies gave to the arrival of another baby into the family, either in respect of the impact on the baby of coming into a family where neglect was a feature or the impact on the other children of the arrival of a sixth child. In fact, CSWS suggested that they may end their involvement with the family. 7.2.4 Following the news that MY was pregnant it would have been appropriate for the social worker to contact the midwife to ensure that the midwife was aware of CSWS involvement, co-ordinate the work being undertaken with the family and invite the midwife to the next Child in Need meeting. However, none of this was Child Y Overview Report 27 January 2015 29 done and by the time of the next Child in Need meeting in July 2011, there had still not been any contact between the LAU midwife and CSWS. Therefore they were unaware of one another’s concerns. 7.2.5 The next Child in Need meeting was held in July 2011 and was attended by FY and MY as well as staff from the Primary School, High School 1, CSWS and Housing Services. No health staff were present even though the school nurse was involved in respect of the children. This was the fourth Child in Need meeting to be held over period of 10 months but the school nurse had not attended any of them. The school nurse was an important resource who was actively involved in addressing the enuresis experienced by two of the children. The school nurse’s presence at Child in Need meetings could have enhanced the care planning. Barriers to the school nurses attendance are considered in ToR 12. 7.2.6 By the time of the July 2011 Child in Need meeting the midwife and addiction nurse from LAU had still not had contact with the other agencies working with the family and were still unaware of the CSWS involvement despite their involvement with MY due to her pregnancy and continued drinking. Once again, there is no evidence that the potential impact of MY’s pregnancy and the arrival of a sixth child into an already overcrowded house was considered at all. 7.2.7 The decision of the CSWS team manager, after the Child in Need meeting, to close the case was contrary to the view expressed by the social worker that more intensive support was required. Records suggest that this decision was made on the basis of what FY wanted rather than what was considered to be in the best interests of the children, which suggests that the work was not child focussed in the way that it should have been. It appears that throughout the period covered by the review FY was the dominant person within the family. Not only was there a lack of child focus but professionals did not take time to seek the views of MY. It is also clear and that the family were still hard to engage. Given FY’s unwillingness to work with CSWS at this time, the SCR panel are of the view that CSWS should have considered whether there were grounds for an Initial Child Protection Conference to put social work involvement onto a more formalised footing. There is no evidence that this was considered (see paragraph 6.3.32). 7.2.8 The elective home education officer and addiction nurse acted appropriately in raising concerns about the condition of the property in September 2011, although, as has already been explained the addiction nurse and midwife from LAU should have made CSWS aware of these concerns several months earlier. When the concerns were raised with CSWS they appropriately liaised with Housing Services who supported the family with improving the condition of the house. This included carrying out repairs and providing a garage so that the family could move items out of the third bedroom. (see paragraphs 6.3.34 – 6.3.37) 7.2.9 The meeting arranged by CSWS, which was held in October 2011 (see paragraph 6.3.38), resulted in a shared view that an Initial Child Protection Conference should be held due to the concerns that were in place. However, this did not go ahead because the service delivery manager in CSWS was of the view that working with the family on a child in need basis was more likely to secure parental co-operation than child protection measures would. Child Y Overview Report 27 January 2015 30 7.2.10 Whilst acknowledging that improvements were made to the condition of the home over the next few weeks, and recognising the danger of hindsight bias, the SCR panel are of the view that there were grounds for convening an Initial Child Protection Conference following the meeting in 5 October 2011. There were significant concerns about the suitability of the property which were long standing and the imminent arrival of a new born baby increased these concerns. However, the condition of the home should not have been the only concern. A primary focus of organisations should have been on the welfare of the children and the condition of the home should have been seen as an indicator that the parents were either uncommitted or unable to adequately care for their children. Concerns remained about the children’s personal hygiene, their punctuality at school, the mental health of one child, lack of schooling of another and MY’s drinking. Furthermore, there was no reason to believe that the improvements relating to the house would be maintained as no significant improvement had been achieved in the 18 months since the Primary School referred to CSWS in April 2010. Agencies did not really question why FY and MY had allowed the property to deteriorate to such a state, what this said about their motivation to provide a suitable environment for their children or their motivation to sustain any improvements. In addition, the imminent arrival of a baby would add a new dynamic to the family and this should have been considered. 7.2.11 It is, of course, impossible at this stage know how the family would have reacted if CSWS had gone down the route of an Initial Child Protection Conference or what the outcome would have been for the children. 32 week meeting 7.2.12 The ‘32 week’ meeting, held in October 2011, should have provided an opportunity to plan for Child Y’s birth. In the event it was only attended by staff from LAU, none of whom had any further contact with MY, FY or any of the children because FY refused to allow them into the house after he had been verbally abusive to the LAU midwife in September and MY had not attended antenatal appointments. The community midwife did not attend the ‘32 week’ meeting because at the time it was held, there was no plan to transfer antenatal care from LAU to LTHT. Records do not show why the health visitor and social worker did not attend the ‘32 week’ meeting although it was held around the times described above when the Primary School and health visitor were told that the case was not open to CSWS. 7.2.13 LAU have now changed their procedure and brought this meeting forward to 26 weeks to ensure interventions are made in a more timely way. Further work is underway in LAU to improve the involvement of key professionals in these meetings and to consider how risk and vulnerability are assessed. Communication between LAU and maternity services at LTHT has also been improved to ensure that relevant information from this meeting is shared with staff on the delivery suite at hospital. Discharge home for Child Y 7.2.14 Although there was no Initial Child Protection Conference, the concerns expressed by the midwife, and subsequently by the health visitor whilst MY was Child Y Overview Report 27 January 2015 31 pregnant with Child Y led to a multi-agency response that resulted in an improvement to the condition of the house. This improvement was such that agencies felt comfortable with Child Y being discharged home after birth. Closure of case by CSWS 7.2.15 As with some of the earlier interventions it appears that there was a lack of planning and joined up working in CSWS’s decision to end their involvement with the family in January 2012. In November 2011, CSWS recorded that they would remain involved until four weeks after the baby was born. Any CSWS involvement should be based on a process of assessment, planning, intervention and review and therefore it is not practical, at the outset, to determine the length of intervention as this will need to be dependent on the outcomes. Instead of deciding in advance that the case would be kept open until four weeks after the baby was born, CSWS should have set a date to review their involvement. 7.2.16 The history of this case should have led to concern that the family were unlikely to sustain the improvements in their home conditions without continued intervention. The fact that they had a new baby in an already overcrowded household should have made agencies even more wary that improvements would not be maintained. Working Together to Safeguard Children 2013 states that: “The plan should be reviewed regularly to analyse whether sufficient progress has been made to meet the child’s needs and on the level of risk faced by the child. This will be important for neglect cases where parents and carers can make small improvements. The test should be whether any improvements in adult behaviour are sufficient and sustained.” (pages 22-23, paragraph 52) 7.2.17 In the event CSWS closed the case in January 2012, but the last time anyone from CSWS had seen Child Y was seven weeks earlier and the last contact with the family had been on over three weeks earlier when the social work assistant spoke to FY through a window after he refused entry to the house (see paragraph 6.3.45). It is difficult to imagine a situation where it is appropriate to close a case when access to the house and the children has been refused at the last visit. Instead the refusal to allow access should have been viewed as an additional concern. The decision to close the case indicates that CSWS may have used the rule of optimism, believing that real change had been made despite the behaviour of FY, the family history and there being no evidence that the improvement would be sustained. 7.2.18 ‘Doing the Simple Things Better’ describes the ‘de-escalation’ process that should be followed when a case needs decrease in complexity or severity and a family requires a different level of response. The following principles should be followed: “There should always be an interim arrangement, with a mutually agreed handover date, whereby the current Lead Professional or key worker re-assigns lead responsibility to the new key worker but continues to be available to provide information, advice and guidance about the case “Any relevant information gathered before the escalation or de-escalation of need should be made available to the services who will henceforth be providing support; practitioners should build on existing assessments where possible, rather than carrying out new assessments Child Y Overview Report 27 January 2015 32 “A written care plan should support the re-assignment of lead responsibility, to ensure that the agreements made are recorded” (Doing the Simple Things Better, p10) 7.2.19 When CSWS closed this case the health visitor became the Lead Professional involved with the family. However there is no indication that any planning took place of the nature described above, although the de-escalation process has been in place since 2010. The Health Visiting Service had determined that Child Y should receive a service in line with the Universal Plus category of the Healthy Child Programme. This requires the health visitor to visit “as appropriate”. In this case, health visitor 2’s first visit was planned to take place six weeks after health visitor 1’s last visit. In the absence of a written care plan, there is no indication as to how an appropriate frequency of visits was determined. School concerns January & February 2012 7.2.20 During the second half of January and early part of February 2012 both the Primary School and High School 1 expressed concerns about the welfare of Child Y to the social worker and health visitor both of whom appear to have been of the opinion that the other should address the concerns (see paragraphs 6.3.46 – 7.3.50 and 7.3.53). The case was closed to CSWS at this time and the health visitor was the lead professional. 7.2.21 It is unclear from the Education Services record whether the Primary School’s concern in January 2012 was about the impact on one of the children of being kept awake or the welfare of Child Y but the LCH record suggests that the school’s concern was for the welfare of Child Y. Given that the school’s concern was based on a report from a child that the baby cried a lot and the fact that the health visitor had visited the family and seen Child Y the previous day, the health visitor’s response, of having no concerns, appears reasonable. However, the Lead Reviewer considers that it would have been appropriate for the health visitor to have suggested that the school phone again if they continued to have concerns, rather than suggesting that future contact should be with CSWS. 7.2.22 The concern raised by High School 1 in February 2012 amounted to a concern about neglect as Child Y and the parents were reported to be very dirty (see paragraph 7.3.53). The records from that time show that the social worker considered that the High School’s concerns should be addressed by the Health Visiting Service whilst the health visitor considered that they should be addressed by CSWS. That difference of opinion has been repeated in this SCR with CSWS considering that the social worker’s request that the school phone the health visitor was “proportionate and in line with policy” because the health visitor was lead professional and LCH explaining that the health visitor considered it to be CSWS’s duty to investigate the School’s concerns about possible neglect. This difference of opinion illustrates the complicated nature of work with children and families and demonstrates the need for decisions to be made on a case by case basis following a conversation about the individual characteristics and history of the specific case. 7.2.23 In this case the social worker and health visitor did have a conversation about the case but their records suggest that there was a misunderstanding between them about what action was going to be taken following the conversation. The social Child Y Overview Report 27 January 2015 33 worker appears to have incorrectly believed that the health visitor intended to visit the family whilst the health visitor in fact went through with the earlier plan to transfer the family to a different health visiting team with a request for an early visit. It is important for professionals to be clear with one another about exactly what action is going to be taken following such a conversation. Furthermore if agreement cannot be reached, practitioners should escalate their concerns to their manager. 7.2.24 An additional factor was that the school contacted a specific social worker who had been involved with the family but had closed the case some weeks before. A request for service in respect of a closed case would need to be made through the Duty and Advice Service rather than being made to an individual social worker. 7.2.25 The situation with the Health Visiting Service was also complicated as the case was being transferred from one team to another due to a service reconfiguration. The health visitor who had been involved up to that point had carried out what was planned to be the final visit in January 2012. Health visitor 1 then delayed transferring the case whilst trying to chase up Child Y’s registration with the GP. When the school contacted health visitor 1 with their concerns in February 2012 the case was about to be transferred. 7.2.26 A number of different actions could have been taken at this stage; the school or health visitor could have contacted the Duty and Advice Service and made a referral regarding their concerns. Alternatively the health visitor could have carried out an opportunistic visit to the family before transferring the case or the new health visitor could have done so as soon as it was allocated. The school could also have sought advice from the education safeguarding advisors, something which they did do November 2012. However, although these actions were available, it is not possible to know whether any of them would have resulted in a different outcome for Child Y. Summary 7.2.27 Key messages from a recent study of Neglect and Serious Case Reviews included the following: “neglect can be life threatening and needs to be treated with as much urgency as other categories of maltreatment “neglect with the most serious outcomes is not confined to the youngest children, and occurs across all ages “the possibility that in a very small minority of cases neglect will be fatal, or cause grave harm, should be part of a practitioner's mindset. Practitioners, managers, policy makers and decision makers should be discouraged from minimising or downgrading the harm that can come from neglect and discouraged from allowing neglect cases to drift “the key aim for the practitioner working with neglect is to ensure a healthy living environment and healthy relationships for children.” (Brandon et al, Neglect and Serious Case Reviews, University of East Anglia/NSPCC, March 2013) 7.2.28 The indication in this case is that the neglect was never considered to be particularly serious or potentially life threatening and it is important to note that, at Child Y Overview Report 27 January 2015 34 the time of writing, there has been no finding as to the cause of death of Child Y, as the inquest has not been held. However, considering the whole period covered by this review, there is a picture of chronic, ongoing neglect. Improvements were made in the short term when agencies made a concerted effort to work together with the family but these improvements were not sustained when agencies, particularly CSWS reduced their involvement. This is not untypical of neglect cases, and is highlighted in Working Together to Safeguard Children 2013 (page 24, paragraph 59) where it is also stated that “professionals should be wary of being too optimistic”. Also in common with many cases of neglect, until the death of Child Y, there was no single serious incident that warranted child protection enquiries. Instead there were ongoing concerns at a lower level. 7.2.29 Child Y’s imminent arrival provided a catalyst for a more robust response which focused almost entirely on the condition of the property rather than the care of the children. However within weeks of Child Y’s birth, work with the family had almost ended; CSWS ended their involvement and there was no clear plan as to what support and monitoring other agencies were going to provide. The Health Visiting Service had determined that the family would receive the Universal Plus service but a minimum visiting frequency had not been determined. At the time of Child Y’s death at three months of age, no one from any agency had been inside the house for six weeks and the property was found to be in a very poor state again; cluttered with no food, washing materials or bedding and Child Y’s Moses basket unusable. 7.2.30 In January 2012, Action For Children in partnership with the University of Stirling carried out a review of Child Neglect in the UK. This found that teachers, health workers and nursery staff were increasingly aware of child neglect but unsure what to do. They also found that 42% of social workers questioned felt that the point at which they could intervene in cases of child neglect was too high. Many social workers also said that there was a lack of support services or resources to refer families to. A follow up report in 2013 found that nine out of ten teachers, social workers and police officers were regularly coming into contact with children they suspect are suffering from neglect but as many as 40% feel powerless to intervene. These findings reflect some of the features of this case with agencies being aware of the neglect but feeling unable to take action that would significantly improve the situation. 7.3 ToR 3. To what degree did agencies engage directly with the children to hear their account of home life prior to and following Child Y’s birth? 7.3.1 Many of the concerns about the children were raised by the schools, which did have an opportunity to engage with them directly. The Primary School report that one of the children did share information about home life and sometimes presented as quite unhappy to the extent that at seven years of age, the child had expressed a wish to die. By contrast the schools found that the other siblings were reluctant to engage in talking about home life. One child spent very little time in school so there were limited opportunities for schools to engage with the child. Child Y Overview Report 27 January 2015 35 7.3.2 CSWS reports that the children’s views were gathered during regular home visits across the period covered by this report and records are full and thorough in this respect on most occasions. These records include references to the children being seen alone at school but they were not recorded as being seen alone in the home which would be the usual expected practice. 7.3.3 CSWS staff considered the children to be contented and they are often described as “chatty”, “playing” and “settled” with good relationships between them and their parents, who are described as loving. However CSWS acknowledged in the SCR that FY was a dominant and difficult personality and this may have impacted on what the children said. The Lead Reviewer believes there to be evidence that relationships were not as good as CSWS believed but, even if they were good, this is insufficient if the quality of physical care is likely to lead to significant harm. It is important that professionals do not allow apparent warm relationships to blind them to negative features of neglect. 7.3.4 The author of the CSWS IMR considers that it would have been pertinent for CSWS to give more weight to the information being shared by school. In reality there is no indication that CSWS ever explored the school’s concerns about how the child referred to in paragraph 7.3.1 presented. 7.3.5 There were a small number of occasions when health practitioners had an opportunity to engage with individual children. Prominent among these was when a child was taken to hospital on 1 April 2010 with blood in their stools, having reportedly eaten hard plastic and crayons and it appears that the matter was dealt with purely as a physical health issue with no questioning as to why the child had done this. There was no follow up from the GP and CSWS were not informed of the incident. This SCR has not established why hospital staff appear not to have been curious or concerned about the child’s behaviour. 7.3.6 Similarly one of the other children was taken to hospital twice in 2012 having injured their own hand by punching a wall at school reportedly due to being angry with a teacher. On both occasions the child was discharged with no follow up and no investigation as to the underlying causes of the behaviour. The guideline for the management of repeated attendance at the Emergency Department by Children and Young People makes specific reference to the response required when a young person attends ED following an incident of self-harm. Further enquiries suggest that the injuries sustained by the child were very minor; amounting to nothing more than grazing of the hands and it seems probable that the incidents were considered to be an immediate response by the child to a frustrating situation rather than a deliberate attempt at self harm. The Lead Reviewer accepts that these were not clear incidents of self harm but is of the view that staff at ED should have explored the reasons for the behaviour with the child in order to consider whether referral to another agency would have been appropriate. 7.3.7 The GP review identified that the surgery had a chance to proactively engage with the family when the children had their vitamin D levels checked. It concludes that the GPs and other staff should have exercised a respectful disbelief, activity curiosity and a more assertive approach in their engagement with the family. Child Y Overview Report 27 January 2015 36 7.4 ToR 4. Did the professionals involved with and in contact with the children and their family members exercise respectful disbelief, active curiosity and build constructive and assertive relationships with the family and if not, why not? 7.4.1 As explained in the analysis of ToR 3, CSWS staff appear to have disregarded the Primary School’s concerns about one of the children, instead concluding that the children were all happy at home. Records show that CSWS staff mainly dealt with FY who was sometimes “eloquent, convincing and rational” and at other times was “abusive and obstructive”. However, although staff found FY’s behaviour to be unpredictable and difficult there is little evidence of them considering the children’s experience of living with him 7.4.2 Statements contained within the Core Assessment suggest that CSWS’s focus was on working in co-operation with the parents and avoiding, at almost any cost, the risk of using child protection procedures or commencing legal proceedings. The Lead Reviewer believes that this approach prevented staff from developing appropriate assertive relationships with FY and allowed him to dictate the agenda. Based on the information within the core assessment, it appears that the reason for this approach was the aforementioned view that there was love and emotional warmth within the family. 7.4.3 Staff from most of the agencies involved in this SCR had concerns about the condition of the family home at some time during their involvement and much of the interventions focused on trying to improve this. By contrast there appears to have been no assessment of parental motivation to maintain better standards or the apparent contradiction between the perceived emotional warmth and the inadequate living conditions. 7.4.4 The agency report provided by LYPFT considered that there was a possibility that the addictions work was too task focussed and the holistic picture not taken into account but found it difficult for good practice to be identified in some areas due to a lack of robust record keeping. 7.4.5 Also, as explained in the analysis of ToR3, on some occasions medical problems were considered as purely medical without consideration of the triggers or emotional impact of the issue. Where medical problems are considered in this way practitioners are less likely to liaise with other agencies to gain a wider understanding of the child’s situation. It is not known why hospital staff were not more curious as to why the children had behaved in these ways. 7.4.6 In many cases where neglect is a feature, there is no single incident that requires an immediate response from agencies but a series of smaller incidents which, on their own can seem innocuous but taken together cause concern. In this case there was a perception at the Learning Events that the children had attended the Emergency Department at the hospital on a large number of occasions and it was questioned whether staff on the Emergency Department should have recognised this and been curious about it. The Lead Reviewer has established that over the period of 3½ years that this review covers, Child Y’s five older siblings attended the Emergency Department (ED) in respect of a total of 10 Child Y Overview Report 27 January 2015 37 injuries, including two which were sports related. One of the children sustained five of these, including both the sports related injuries. 7.4.7 On 1 November 2011, part way through the period covered by this review, LTHT introduced a guideline for the management of repeated attendance at the Emergency Department by Children and Young People. This guideline defines regular attendance as “attending more than three times at the Emergency Department within a period of six months” although it points out that discretion needs to be exercised with regard to children attending for appropriate management of long term medical/psychological conditions. Three attendances at the Emergency Department by the child who sustained five injuries were between January and June 2011. Therefore, if this policy had been in place at that time the child would have just met the criteria of being a frequent attendee on this occasion. 7.4.8 Overall, the Lead Reviewer concludes that the children’s attendance was not sufficiently frequent that it should have been recognised by Emergency Department staff. Nevertheless, in considering this issue it became clear that there are barriers to Emergency Department staff identifying families where there are repeated and frequent attendances and these will be addressed in the analysis of ToR12. 7.5 ToR 5. What opportunities were there for agencies to intervene more robustly and provide assertive family support with clear plans and clear reviews of those plans and which set out the nature of the concerns the plans were designed to address? 7.5.1 The introduction of Family Support following the referral to CSWS in April 2010 was an appropriate response. However, as has been explained in the analysis of ToR1, the introduction of Family Support was not handled appropriately and it is impossible to know what input the family resource worker had. In addition, there were no clear plans and no Child in Need meeting until nearly five months later. Therefore it is unknown what impact the Family Support had. 7.5.2 In the following months there were several opportunities for CSWS to intervene more robustly but instead the case was allowed to drift, with CSWS seeming to vacillate between planning more intensive support and considering closing the case. In October 2010 there was a decision to carry out a Core Assessment, which could have led to a more robust response with a clear plan but this was not carried out (see ToR1). In July 2011 the social worker advocated more intensive support but a decision was then taken to close the case because FY withdrew his co-operation (see ToR 2). In October 2011 professionals involved with the family considered that there should be an Initial Child Protection Conference but the Service Delivery Manager considered that this would be counterproductive and in January and February 2012 the schools expressed further concerns (see ToR2). 7.5.3 One child missed a considerable amount of schooling and, for two periods, was home educated by FY until assessments deemed that this was not of sufficient standard. The Education IMR found substantial problems with the manner in which High School 2 dealt with this child’s non attendance and a recommendation has been made to address this. The Education IMR also points Child Y Overview Report 27 January 2015 38 out that where vulnerable children and young people are being home educated, they do not benefit from the protective factors associated with school attendance. The author of the Education report explains that from January 2014, the Integrated Safeguarding Unit has established a ‘risk management’ panel to consider complex cases in relation to electively home educated pupils and other vulnerable groups such as children identified as missing education. 7.5.4 During the period covered by this review, CSWS records report one attempt to engage with the Special Therapeutic Social Work Team. This was in August 2012 and appears to be in relation to the behaviour of the child who had twice punched a wall. Therapeutic services expect consent and co-operation from parents and it appears that this was not forthcoming, consequently no service was provided. Efforts to secure support should have been made much earlier in relation to the concerns about the behaviour of the child who ate hard plastic but this was not addressed. A lack of co-operation from the parents should have been a consideration in the care planning and may have led to an Initial Child Protection Conference which would have the rigour of a child protection plan or action under public law outline. This therefore is another occasion when the parents’ resistance to support resulted in services ‘backing off’ when a more robust response would have been appropriate. 7.5.5 ToR 8 of this report analyses how issues of non-engagement were addressed. Many of these provided opportunities for agencies to intervene more robustly. 7.6 ToR 6. When was consideration given to the potential need for a pre-birth Initial Child Protection Conference and to the impact on the family of another child? 7.6.1 There was one occasion when consideration was given to holding a pre-birth Initial Child Protection Conference whilst MY was pregnant with Child Y. This was in October 2011 and is addressed in the analysis of ToR2. The analysis of ToR2 also details the consideration given to the impact on the family of another child. 7.6.2 Within days of Child Y’s death an Initial Child Protection Conference was arranged in respect of the other children. This is addressed in the analysis of ToR 10. 7.6.3 When FY was found to be pregnant with Sib6Y a pre birth Initial Child Protection Conference was held which resulted in all the children being made subject to Child Protection Plans. This is also addressed in the analysis of ToR 10. 7.7 ToR 7. How did agencies deal with disagreements between one another and what was the impact of this on the service provided to the children? 7.7.1 Agencies involved with the family were unhappy with the decision of CSWS to end their involvement in July 2011 but did not challenge the decision or voice their dissatisfaction formally. In 2011 there was no protocol regarding disagreements between agencies and it is believed that the professionals involved were unaware how to challenge the decision to close the case. Since Child Y Overview Report 27 January 2015 39 then a ‘conflict resolution process’ has been introduced regarding disagreements between agencies with provision for issues to be escalated where staff cannot agree. This protocol is included within ‘Doing the Simple Things Better’ a handbook issued by Children Leeds in May 2012 to support joint working for people working with children. Some participants at the learning Events suggested that this protocol is not well known about by staff. 7.7.2 Staff from LAU were unhappy about the response from CSWS in September 2011 and the addiction nurse escalated concerns within LYPFT. This was an appropriate response which resulted in action from CSWS. 7.7.3 The decision taken by CSWS not to hold a pre birth Initial Child Protection Conference in October 2011 was counter to the views expressed by agencies present at the meeting on 5 October 2011. However this review has not been provided with any information to suggest that agencies formally challenged the decision. 7.7.4 At the beginning of February 2012 the social worker and health visitor had a difference of opinion as to who should respond to the High School’s concerns regarding Child Y. They had a phone conversation on 3 February 2012 to try to resolve the issue but records suggest that the call ended with them having a misunderstanding as to what was going to happen next. This is addressed in the analysis of ToR2. 7.7.5 In October 2012, at a child in need meeting, CSWS stated that they were going to close the case. The learning mentor from the Primary School requested that the case be kept open until after the inquest as the school still had concerns regarding hygiene, dirty and unsuitable clothing and MY and FY not providing sufficient food for the children. The learning mentor was advised to re-refer, if there were any further concerns and the learning mentor’s opinion was recorded in the minutes of the meeting at their request. The author of the Education IMR considers that this decision should have been challenged more robustly by the learning mentor. 7.7.6 In November 2012 High School 1 and the School Nursing Service both raised concerns with CSWS that the family situation was deteriorating. Initially CSWS were unwilling to become involved with the family again and the school and School Nursing Service both sought guidance within their own organisations which resulted in CSWS being formally challenged over the decision not to re-open the case. Subsequently CSWS did re-open the case and a Child in Need meeting was held on 14 December 2012. It is considered that both the school and the School Nursing Service acted appropriately in seeking advice and challenging CSWS at this time. 7.7.7 Whilst the SCR was being carried out a view was expressed by several Panel Members that the disagreements that arose in respect of this case were largely the result of CSWS applying a higher threshold to their intervention than is applied by other agencies. Particular incidents which reinforced this view were when CSWS decided to close the case after the July 2011 Child in Need meeting, the decision not to hold an Initial Child Protection Conference in October 2011 and the response to the concerns raised by the schools in January and February 2012. Child Y Overview Report 27 January 2015 40 7.7.8 SCR panel members considered there to be a need for clear thresholds to allow organisations to challenge one another with confidence. Panel members noted that at present Leeds does not use an explicit threshold document to determine eligibility for service and it was explained that Leeds Safeguarding Children Board is committed to pursuing a non-thresholds model where decisions result from conversations between professionals based on assessments of the individual needs of the children concerned. Concern was expressed that this non-thresholds model may make it more difficult for practitioners to identify and refer cases where children are at risk of significant harm, especially where the concerns are around neglect. 7.7.9 Despite the perception that CSWS applied a higher threshold to intervention in this case, there is no evidence of any agencies referring to thresholds whilst they were working with the family. The Lead Reviewer is of the opinion that the disagreements between CSWS and other agencies were not principally the result of CSWS applying a higher threshold for intervention but were driven by a lack of appreciation of the long term impact of the neglect in this family and a belief that better outcomes would be achieved by maintaining the cooperation of the parents. Nevertheless, the introduction of a non-thresholds approach is clearly a source of anxiety for some agencies and will be explored in the final section of this analysis. 7.8 ToR 8. How were issues of non-engagement, including the parents’ failure to register Child Y with a GP, addressed and what was the impact of this on the service provided to the children? 7.8.1 During the early part of 2010 the Primary School suggested to FY and MY, on four occasions, that it would be beneficial to undertake a CAF. However FY and MY would not agree to this and they also refused to consent to a referral to the educational psychologist in respect of one of the children. They also refused to take this child to the GP. 7.8.2 Without parental consent school staff were unable to carry out a CAF or to refer to the educational psychologist and therefore they were limited in the action they could take to address their concerns. Nevertheless any agency could have made a referral to CSWS before April 2010 if they had considered their concerns as to the welfare of the children to be sufficiently serious. Education records show that the Primary School thought that Housing Services had made a referral to CSWS in January 2010 and that CSWS had declined to get involved. Records from Housing Services do not support this version of events and it therefore appears that there was a misunderstanding between the Primary School and Housing Services. However, the Primary School’s belief that a referral had been made to CSWS, may well have acted as a disincentive to make a referral themselves. 7.8.3 Schools cannot ask school nurses to see children without the parents’ consent. However, the school could have consulted more with the school nurse about their concerns. A finding in many SCRs is that professionals have not shared important information with colleagues from other agencies. Caution is required when sharing sensitive, personal information, particularly if consent has not been given. Nevertheless, where there are concerns about the welfare of children it is Child Y Overview Report 27 January 2015 41 reasonable for professionals to share concerns in a proportionate manner, in accordance with national guidance. The aforementioned handbook, ‘Doing the Simple Things Better’ includes the seven golden rules for information sharing taken from Department for Education Guidance ‘Information Sharing: Guidance for Practitioners and Managers’. The SCR was informed that the LSCB and Human Resources within Education Services now offer training on working with hard to engage parents and recognising and addressing disguised compliance. 7.8.4 The analysis of ToR 1 includes an explanation of why the family resource worker stopped working with the family in February 2011. At the Child in Need meeting in May 2011 it was stated that the family resource worker initially visited the house seven days a week to support the family and help put some boundaries in place but was now on a leave of absence and both parents did not wish for another worker to take over. Due to the lack of records it is impossible to know how CSWS responded to FY and MY’s refusal to accept a different family resource worker or what difference this made to the children. 7.8.5 It is also explained in the analysis of ToR 1 that the decision made by CSWS to end their involvement with the family was the result of FY withdrawing his co-operation to work under a Child in Need Plan during the Child in Need meeting in July 2013. This decision ran counter to the expressed view of the social worker, at that meeting, that more intensive support was required. It is difficult to understand why the CSWS team manager made the decision to act in line with FY’s wishes although it is reported that, at that time, there was a culture, within CSWS, of closing cases due to parental non-engagement. 7.8.6 In September 2011, FY reportedly became verbally abusive and said that staff from LAU were no longer welcome in his house (see paragraph 6.3.35). As a result of this MY missed antenatal appointments and she also failed to attend the 32 week meeting at LAU, although it is not known whether she would have attended if the incident with FY had not occurred. Ultimately the LAU midwife handed care over to the LTHT community midwife prior to Child Y being born as a direct result of FY and MY ceasing to engage. This therefore is an occasion when FY determined what services another family member received. 7.8.7 In December 2011 FY refused to allow the social work assistant into the house (see paragraph 6.3.45). CSWS’s response to this was to end their involvement with the family, so again there was no challenge to FY’s lack of engagement and no assessment of the welfare of the children. 7.8.8 Twice in the space of three days no-one answered the door when the health visitor tried to carry out planned visits to the family home (see paragraph 6.3.54). The second of these dates was the day before Child Y died. It is impossible to know what action would have been taken if either of these visits had gone ahead but, given the situation that faced the SUDIC team on the day of Child Y’s death, it seems almost certain that the health visitor would have found a house that was once again in a poor condition. 7.8.9 In 1993 Reder et al coined the term ‘disguised compliance’, which they used to refer to situations where a parent or carer appears to co-operate with agencies in order to reduce the professional concerns so that professional intervention is reduced or ended. In this case the parents demonstrated disguised compliance Child Y Overview Report 27 January 2015 42 by working with agencies to tidy and clean the house prior to the birth of Child Y but allowing it to deteriorate again as soon as agencies withdrew their involvement. 7.8.10 Similarly, the parents stated on three occasions that they were going to register Child Y with a GP the following day when, in reality, they had not even registered Child Y’s birth and therefore Child Y could not be registered with a GP (see paragraphs 6.3.47 and 6.3.51). The first health visitor showed persistence in chasing up this issue of non-registration but there is no indication that the new health visitor addressed the issue after taking over. Despite showing persistence the health visitor did not speak directly to any of the GPs within the practice, instead checking with the receptionist whether registration had taken place. The report provided to this review by NHS England states that the surgery does not assume responsibility for registering a new born baby, considering that it is the responsibility of the health visitor to encourage the parents to register their child. Nevertheless, the lead Reviewer considers that where the health visitor is having difficulty acquiring the parents’ co-operation contact with the GP would be appropriate to consider what other action could be taken. 7.8.11 Parents have 42 days in which to register the birth and after this time the Registrar on occasion will contact the health visitor. Child Y was 96 days old at the time of death but the registrar had not made contact with the health visitor. 7.8.12 On three occasions one of the children did not attend appointments at the enuresis clinic. The child was eight years of age at the time of the first appointment and nine at the times of the others. At this age the child could not be expected to go to the clinic alone and was dependent on being taken by MY or FY. Indeed it is the view of the Lead Reviewer that the use of the phrase ‘did not attend’ for children is misleading; ‘was not brought’ would be more accurate. 7.8.13 After the first failure to attend, the clinic wrote to the school nurse, who re-referred. After the later ones the child was discharged from the clinic and the GP was informed. In such circumstances a failure to attend could, in itself, be viewed as a sign of neglect but there is no evidence that it was viewed in this way in this case. In November 2013 LTHT approved a revised version of the ‘Elective Treatment Access Policy’. This is the Trust’s policy for dealing with missed appointments. Appendix 4 of this policy provides guidance for the follow up of vulnerable children and vulnerable adults. This specifies that if a vulnerable child or adult does not attend a clinic appointment, notes must be reviewed, at the time, by the consultant or senior doctor who must consider certain specified factors in order to consider whether there is a safeguarding risk in the non-attendance and then act accordingly. Appendix 4 further states that a letter detailing the DNA (did not attend) appointment should be sent to the referring GP or Health Professional with a copy to the health visitor or school nurse (if applicable) and that this letter should clearly state what action the GP is expected to take in response. 7.8.14 Brandon et al have identified the risk of ending a service because a child misses appointment writing that: “Missed appointments should be followed up and not considered a reason to withdraw a service. Children and young people who disappear from view may be at risk of severe or life-threatening harm from neglect. To be Child Y Overview Report 27 January 2015 43 safe, children need to be seen and importantly, to be known.” (Neglect and Serious Case Reviews, 2013, p15) 7.9 ToR 9. How did agencies respond to father’s intimidatory behaviour and what was the impact of this on the service provided to the children? 7.9.1 With the exception of LTHT and Primary Care, all the agencies involved in this SCR had some experience of FY behaving in a way that was perceived as threatening and/or intimidatory. In the case of Primary Care, although there is no record of him being threatening or intimidating, there is a record of him being difficult to engage and, on one occasion, verbally abusive. On occasion, agencies asked staff to visit in pairs as a result of concerns about how FY might behave. 7.9.2 Education Services have provided the SCR with evidence of occasions when school staff persevered with action they believed to be in the best interest of the children, despite FY responding in a threatening manner. One example given is an occasion when FY was “extremely upset and argumentative” in a telephone conversation with the director of safeguarding at High School 1 and said he was going to home educate his children due to alleged victimisation, lack of education and being assaulted. The director of safeguarding contacted FY’s aunt and explained his concerns about the impact that this course of action would have on the children. The outcome was that the children returned to school. Another example was when the learning mentor at the Primary School phoned home to request a change of clothing for one of the children due to the fact that they smelled and FY reportedly became verbally abusive. Later that same day the learning mentor visited the house and found FY’s attitude to be much improved. 7.9.3 LYPFT consider that the addiction midwife was not intimidated by FY but that his constant presence and hostility did hinder conversation around domestic violence with MY and potentially also with the older children, particularly one who was present at many of the appointments. 7.9.4 LCH found that neither the health visitors nor the school nurses felt personally threatened by FY’s behaviour and, despite his behaviour health visitor 1 made a referral to CSWS and informed FY that this had been done. 7.9.5 CSWS report that their response to FY’s alleged intimidatory behaviour was to persist. The example given is that the team manager urged FY to discontinue this behaviour for a period up to the impending birth of Child Y and for four weeks beyond. In addition, CSWS also report that there does not appear to be a sense of intimidation towards social workers that was at an uncomfortable or unmanageable level on most occasions but also that there is little evidence recorded of direct confrontation with FY. It is evident from parts of the Core Assessment that CSWS took great care to avoid direct confrontation with FY as it was considered that this would have an adverse affect on his willingness to engage which would ultimately be counterproductive. 7.9.6 Although agencies have generally found that staff did not allow FY’s behaviour to adversely affect their actions it is evident that he was the dominant family member who controlled agency interaction with the rest of the family. Child Y Overview Report 27 January 2015 44 Furthermore, as described in the analysis of ToR 8; his failure to engage reduced agency contact with the family and on some occasions his behaviour directly prevented professionals from seeing the children. In addition, the Lead Reviewer believes it possible that FY’s threatening behaviour at the Child in Need meeting in July 2011 was a factor in the decision of CSWS to end their involvement with the family and as explained in the response to ToR4, the Lead Reviewer considers that CSWS should have been more challenging of FY’s behaviour at a much earlier stage. 7.10 ToR 10. How have agencies responded differently to the family since Child Y’s death and what has been the impact of this on the children? 7.10.1 Paragraph 6.3.57 of this report describes the action taken by CSWS immediately after Child Y’s death. This was the first time that the family had been dealt with under Child Protection measures and was appropriate in the circumstances. 7.10.2 The decision to postpone the Initial Child Protection Conference was taken based on the Chair’s assessment of the situation at the time and as such it would be inappropriate to second guess whether this was the correct decision. The Lead Reviewer has seen the bridging plan that was agreed in place of holding a Conference. This consists of 10 actions all with the desired outcome of supporting the children in relation to their emotional health. The actions comprise a mixture of support to be provided to the family and information that is required for the reconvened conference. None of the actions require the parents’ cooperation and although this review has been told that the family went to stay with FY’s aunt and uncle this is not mentioned in the ‘Bridging Plan’. Therefore it appears to have been an informal arrangement with the family free to return home at any time. 7.10.3 Although there was an intention that the Conference should be reconvened this was not done as the children’s presentation improved whilst they were living with their great aunt and uncle and a decision was taken to manage the case via what was described as a robust child in need plan. 7.10.4 Through the second half of 2012, after the family had returned to their own home and were no longer living with FY’s aunt and uncle, a number of concerns were raised, particularly by the schools. Notwithstanding these concerns, CSWS ended their involvement again. In December 2012, CSWS attended a meeting at High School 1 and, according to education records, it was agreed that an Initial Child Protection Conference would be held in the New Year. In the event the Conference did not take place until February 2013, after it was found that MY was pregnant. It is not known whether or not the Conference would have gone ahead if MY had not been found to be pregnant. (see paragraphs 6.3.58 – 6.3.69) 7.10.5 The above history suggests that despite a relatively robust response immediately after Child Y died, CSWS continued to view the family as needing short term support rather than long term intervention. This is despite indications that nothing had really changed for the children. However one positive change was the involvement of FY’s aunt and uncle in supporting the family. FY had reportedly spent significant parts of his childhood living with this aunt and records Child Y Overview Report 27 January 2015 45 suggest that she was a positive influence on the family. During the time they lived with her the children’s presentation improved during this time and the child whose behaviour and demeanour had caused the primary school most concern, in particular, appeared happier than had previously been the case. Quality assessment should consider the support available within the extended family and, where appropriate, agencies should work with members of the extended family to support families. There is no evidence to suggest that this was done prior to Child Y’s death but it was done afterwards. 7.10.6 In November 2012 High School 1 and the School Nursing Service challenged CSWS in a way they had not done when they had concerns prior to the death of Child Y. 7.10.7 Following the completion of the SUDIC process, in November 2012, the GP practice put an alert on the records of FY, MY and all the children, to the effect that CSWS should be informed if practitioners had any concerns regarding Child Neglect. However, when FY visited the GP in December 2012 the GP missed the alert and did not make CSWS aware of concerns. The author of the Primary Care IMR believes that this was the result of human error on the part of the GP as opposed to a problem with the system that is in place for alerts. Consequently there is no recommendation that this system should be changed. 7.10.8 Agencies did not know about MY’s pregnancy with Sib6Y until January 2013 when she was approximately 25 weeks pregnant. She was again referred to LAU for antenatal care due to her continued drinking and an alcohol reduction programme was commenced. She was also offered, and accepted, the Care of the Next Infant (CONI) programme, which is a national programme led by health visitors for parents who have lost a child previously. The GP referred MY’s pregnancy to CSWS which was appropriate in light of the previous history and was consistent with the alert that had been placed on the GP record for MY and the other family members. An initial Child Protection Conference was held at which all the children were made subject to Child Protection Plans and subsequently arrangements were made for MY and Sib6Y to go to a foster placement for a limited time following Sib6Y’s birth. The LAU midwife, social worker and health visitor carried out a joint visit to the family home where both parents and three of the older children were seen. An Interim Care Order was made by the court in respect of Sib6Y following birth, along with Interim Supervision Orders for the other children. MY and Sib6Y remained in the foster placement until the family were re-housed to a bigger house near to FY’s aunt, at which point they moved back together as a family. The Family Group Conference held in May 2013 provided a more formalised opportunity to involve FY’s aunt and uncle in working with professional agencies to support the family. 7.10.9 MY’s pregnancy with Sib6Y received a much more robust and co-ordinated response than the pregnancy with Child Y which was, in part at least, a direct consequence of Child Y having died. Records suggest that MY and FY largely cooperated with this more robust response. However it is not known whether, having lost a child, they were more willing to co-operate with agencies than they had been previously or if a robust response earlier in CSWS’s involvement would have paid dividends. Child Y Overview Report 27 January 2015 46 7.11 ToR 11. How well supervised and supported were the frontline staff in contact with the family and were they given the opportunity to reflect on what they were seeing and doing as regards the family? 7.11.1 The SCR Panel has been provided with little information about the level of supervision received by front line staff in contact with family although there are several records which refer to the social worker receiving supervision. 7.11.2 Staff from LAU, in September 2011 and the High School and School Nursing, in November 2012 sought safeguarding advice from within their agencies regarding concerns they had about the welfare of the children and the CSWS response to these concerns. 7.12 ToR 12. Were there any barriers identified that impacted on how staff exercised their professional practice? 7.12.1 The school nurse did not attend any of the four Child in Need meetings that were held prior to Child Y’s birth, including the one in May 2011 when the school nurse, reportedly, did not receive an invitation. The SCR panel questioned whether the School Nursing Service gave this case a lower priority than Child Protection Cases would be given and if this was the reason for non-attendance. It was also questioned whether this was a resource issue and whether the agency’s commitment to attend such meetings needed to be reviewed. It was noted that the School Nursing Service does have difficulty meeting the expectation that it will attend all Child Protection Conferences, Core Group meetings and Child In Need meetings involving school age children and, understandably prioritises Child Protection meetings ahead of Child in Need meetings. It was also noted that since this time, a citywide, electronic diary has been introduced within the School Nursing Service which assists managers in prioritising the attendance of school nurses at meetings. 7.12.2 The analysis of ToR5 describes the impact on CSWS staff in late 2010 of large caseloads and staff absences. 7.12.3 During the period covered by this SCR the family had contact with four different health care providers; the GP practice, LCH, LTHT and LYPFT. Within LCH they had involvement with Health Visiting and School Nursing Services and within LTHT with Maternity Services and Paediatric Services. The level and range of involvement of these various health care providers is outlined in section 7 of this report and their awareness of neglect within the family is addressed in the analysis of ToR1. 7.12.4 The individual agency reports and the integrated chronology suggest that there were significant gaps in information sharing between and within health agencies. For example, the GPs appeared unaware of the extent of neglect in the family despite the School Nursing Service being aware of this and staff in different parts of LTHT were not fully aware of each other’s involvement. 7.12.5 One practical barrier to information sharing is that different services, even within individual organisations, use different IT systems and these systems are not Child Y Overview Report 27 January 2015 47 compatible with one another. Other information is still recorded in paper systems which are not always shared. This appears to have been a particular problem at LTHT. 7.12.6 As stated in the analysis of ToR4, there are barriers to staff in the Emergency Department at LTHT identifying families where there are repeated and frequent attendances. Historically two hospital sites within the Trust had Emergency Department provision for children and staff on one site would not have been immediately aware if the child had previously attended the other one. This problem has now been overcome as provision for children is now concentrated onto one hospital site with one IT system. A remaining issue is that children are treated as individuals and systems do not make links between different children from the same family attending the Emergency Department. Whilst it is correct to treat children individually the Lead Reviewer is concerned that the Emergency Department may miss an important link if the children from one household had frequent attendances to the Emergency Department but these were spread out between several siblings. 7.13. Recent Changes in Leeds 7.13.1 In carrying out this review, the SCR Panel have been made aware of the substantial and significant structural changes being introduced in Leeds to support families. 7.13.2 Services for children have been reorganised across 25 local clusters with a Targeted Services Leader in post in each cluster. The aim behind cluster working is to “ensure that families are offered the right intervention at the right time, as early as possible in the life of a problem, to prevent issues escalating which may result in poor outcomes for the family.” (One minute Guide number 13). If this arrangement had been in place in early 2010, staff from the Primary School could have discussed this case at a guidance and support meeting in order to help to find a way forward. 7.13.3 Working Together to Safeguard Children 2013, in line with a recommendation from the Munro Review of Child Protection, has removed the distinction between initial and core assessments, replacing this with a set of conditions that should be met by local assessment protocols (Working Together to Safeguard Children 2013, p24, paragraphs 62-63). 7.13.4 CSWS in Leeds have responded to this by introducing the Child and Family Assessment which has been in use since November 2013 for all children’s assessments. This is an assessment tool also used by several other Local Authorities. The assessment tool is being introduced alongside Frameworki, a new computerised information management system and CSWS state that this will have the following benefits compared with the initial and core assessments used previously: A dynamic assessment One single assessment Less prescriptive format Emphasis on direct work Focus on analysis and action (One Minute Guide 12) Child Y Overview Report 27 January 2015 48 7.13.5 CSWS also report that the service is now more responsive, with social workers typically having smaller caseloads and the introduction of Clusters enabling agencies improve the way they work together. Whilst these changes are viewed positively, it is vital that the outcomes are monitored carefully to ensure that they result in improved outcomes for the most vulnerable children in Leeds. 7.13.6 A Duty and Advice team has been established to act as the front door for referrals into Children’s Social Care and to provide advice to professionals and practitioners. This team is primarily comprised of qualified social workers and an advanced practitioner from CSWS and also has representation from the Police and Community Health. Therefore, any practitioner who has a concern about a child has an opportunity to speak to a qualified social worker. 7.13.7 The ‘Early Help Approach’ is a framework that is being developed with the aim of helping to ensure that children are provided with the right support at the right time. Instead of using specific ‘thresholds’ to help practitioners decide whether or not a child or family qualifies for a particular type of support this model encourages ‘conversations’ between practitioners to consider the individual circumstances of a particular family with the aim of reaching a decision as to what help or support is required. The Deputy Director, safeguarding, Specialist and Targeted describes the advantages of this approach as follows: “Founded on collaboration and conversation “Promotes shared responsibility and flexibility “Recognises complexity of unique needs of each individual child and family “Reduces bias of individual professional and agency decisions through debate.” (Beyond Thresholds: A framework for better decision making for vulnerable children in Leeds, p5) 7.13.8 The Deputy Director, safeguarding, Specialist and Targeted also acknowledges that work is required with “all local agencies and professionals” regarding this new approach and a programme of “consultation and engagement events” are planned throughout Spring 2014. (Beyond Thresholds: A framework for better decision making for vulnerable children in Leeds, p6) 7.13.9 This is an ambitious set of changes and there is a danger that the absence of thresholds may be perceived by some as an attempt to ration scarce services at a time of significant budgetary constraints and that practitioners will feel disempowered when referring to CSWS. However, it should be noted that, in this case, the availability of thresholds did not prevent a situation whereby agencies disagreed about the level of intervention required and who should provide such intervention. The proposed consultation and engagement events are key to getting practitioners on board with the changes but the Lead Reviewer suggests that there will also be the need for clear guidance for all agencies and robust systems to enable decisions to be challenged and professionals’ disagreements to be resolved. 7.13.10 Considering these changes in the context of this case, some panel members expressed an anxiety that the potential serious harm, particularly emotional harm, caused by neglect was not always fully recognised or understood by some staff. This deficit in understanding could undermine the success of the case ’conversations’ which are to be central to the ‘Beyond Thresholds’ framework. In this SCR it has been established that there was a failure over some years to fully Child Y Overview Report 27 January 2015 49 appreciate the extent of the neglect by the parents, FY and MY, in not properly caring for their children. The Panel were concerned that the long term emotional harm which could result to the children from such prolonged neglect was not fully understood by the staff involved with the parents. Panel members spoke of the need for a conference or regular training which addresses not only the indicators of neglect but crucially the long term effects of parental neglect upon children. 8. Views of the Family 8.1 All family members, except for Sib6Y who is a baby, engaged with this process and shared their views of some agencies. Their comments reinforced the picture of a close family who want to be left to get on with their life together. 8.2 From the information provided FY presented as the dominant adult; he believes that professionals became over involved with the family and exaggerated issues, such as the risk of his wife drinking whilst pregnant and the children arriving at school late. He said that he previously held positive view of social workers has been destroyed by his family’s involvement with them. FY appears reluctant to accept agencies becoming involved in his family’s life; even during a period when he acknowledged that the family had difficulty managing the house he is unsure if he would have accepted help if it had been offered. 8.3 MY presented as more amenable to help but said she has always been quiet and appears to have readily accepted her husband’s refusal of help. 8.4 MY and FY provide contrasting information about whether there were concerns about Child Y’s weight in the weeks leading up to the death. MY stated that she asked the health visitor if she should take Child Y to the doctor because she (MY) was concerned that Child Y was underweight. This is interesting as the health visitor was actively trying to persuade the family to register the baby with a GP. 8.5 A common theme from the discussions with the children was that they did not think their mother and Sib6Y should have had to go into foster care when they came out of hospital following Sib6Y’s birth. Instead they believe that the whole family should have been able to live together. 8.6 Various family members acknowledged that their old house was over crowded and in poor condition and that the new property is much better but there was no acknowledgement that the children were being brought up in an unacceptable environment. 8.7 It was acknowledged that some professionals had worked well with the family but one child expressed the view that social workers do not take any notice of what is said unless it is what they want to hear and also that whenever relationships between the family and workers becomes good the workers are replaced. 9. Conclusions 9.1 This SCR was commissioned as a result of the tragic death of Child Y. The cause of Child Y’s death is unascertained as the inquest has not yet taken place and it has not yet been established whether neglect was a factor. It follows that this review is unable to conclude that different actions from any of the agencies Child Y Overview Report 27 January 2015 50 involved may have led to a different outcome for Child Y. Nevertheless, this review has produced learning which will result in changes being made to improve practice for the future. The key learning is summarised below. 9.2 Within the period covered by the review, Primary School staff showed great perseverance in trying to work with the family. However, in early 2010 they were unsure what action to take in the face of FY’s reluctance to accept help and, with hindsight, should have referred to CSWS sooner than they did in. The introduction of Cluster working should make it easier for schools, and other agencies in such situations to share concerns, thereby allowing a quicker response. 9.3 Following the referral from the school, CSWS became involved but there was an absence of an appropriate assessment or a clear plan with the result that the situation was allowed to drift. Involvement focussed on the outward, physical signs of neglect without addressing the underlying causes, questioning the parents’ motivation and/or ability to care adequately for their children or considering the psychological well being of the children. The referral was treated in isolation rather than in the context of there being a long history of concerns relating to neglect within the family. 9.4 Assessments were not carried out in a timely manner and there were no clear, consistent plans to support the family, with clear statements of what improvements needed to be achieved. Until February 2011, the main input to address the neglect was family support via a family resource worker but this was not properly set up or managed and it is not possible to know what support was provided or what impact this had. After this support ended, CSWS vacillated between wanting to provide additional support and planning to cease their involvement. 9.5 When MY became pregnant with Child Y there was insufficient consideration of the potential impact of another child on the family. Antenatal services from LAU and CSWS should have engaged with one another much sooner once it was known that MY was pregnant with Child Y and there should have been better representation at Child in Need meetings. Four Child in Need meetings were held between September 2010 and July 2011 but the school nurse did not attend any of these. Midwifery staff should have been invited after it was known that MY was pregnant but this was not done. 9.6 For a period of almost two years immediately prior to Child Y’s death, work was attempted with this family to address the unsuitable home conditions and the neglect that the children were experiencing. When agencies intervened the family made improvements to the home conditions but these were not sustained when intervention was stepped down. Agencies should have been particularly alert to the risk that the family would not sustain the improvements in the condition of the property following the birth of Child Y. 9.7 FY is the dominant person within the family; he was often unwilling to accept help and support and at times was intimidating and threatening to professional staff providing services to the family. As a result, insufficient attention was paid to the views of the children and MY, and services were withdrawn on FY’s request. The Lead Reviewer and SCR panel are of the view that FY was not challenged Child Y Overview Report 27 January 2015 51 sufficiently robustly and that in July 2011, CSWS should have considered initiating an Initial Child Protection Conference when FY was not prepared to work with them. In addition, the Lead Reviewer and SCR panel are of the view that there were grounds for an Initial Child Protection Conference in October 2012. 9.8 At times agencies disagreed with one another about the level of intervention required and there was a view amongst some agencies, most notably the schools, that CSWS had a higher threshold for intervention than they themselves had. The Lead Reviewer is of the opinion that the disagreements between CSWS and other agencies were not principally the result of CSWS applying a higher threshold for intervention but were driven by a lack of appreciation of the long term impact of the neglect in this family and a belief that better outcomes would be achieved by maintaining the cooperation of the parents. With neglect, unlike some other forms of abuse, there is usually no single incident that requires a response. The findings of this review suggest that professionals in Leeds working with children need training which addresses not only the indicators of neglect but crucially the long term effects, particularly the emotional harm, of sustained parental neglect upon their children. 9.9 On some of the occasions when front line staff disagreed with one another about the level of intervention required by the family they escalated their concerns to their managers. However, this was not consistently done and a view was expressed in the Learning Events that the ‘conflict resolution process’ was not well known about or understood by staff in some agencies. 9.10 There were occasions when GPs and practitioners at the hospital saw one of the children and should have questioned the underlying issues behind the presenting medical problem. It is important that medical practitioners listen to the voice of children and share concerns with other agencies. 9.11 There were also occasions when the parents did not take children for hospital appointments. LTHT have recently reviewed the ‘Elective Treatment Access Policy’ which details the actions that should be taken when a person does not attend a hospital appointment. The Lead Reviewer and SCR Panel believe that there is a need to recognise that, generally, children do not decide not to attend appointments. Instead they are not taken to appointments by their carers. In some cases this is, in itself, neglect and should be viewed as such by health professionals. 9.12 The response when MY was pregnant with Sib6Y was considerably more robust than during the pregnancy with Child Y. An Initial Child Protection Conference was held and legal proceedings were instigated. Although the children were understandably upset at being separated from their mother for a few months it is the view of the Lead Reviewer and SCR Panel that agencies finally put the needs of the children first and acted appropriately. It is vital that the agencies continue to provide a robust response to ensure that the needs of the children are met in the long term. The Family Group Conference has provided a formal opportunity to involve FY’s aunt and uncle in supporting the family. 9.13 Throughout the period covered by this SCR, one child’s attendance at school was poor. For part of the period covered by this SCR, the child was being home Child Y Overview Report 27 January 2015 52 educated. The review has found concerns when vulnerable children and young people are home educated as they are unable to benefit from the protective factors associated with school attendance. At other times, this child was on the role of High School 2 but attendance was very poor, often less than 20%. This was not well managed by the school. 9.14 Substantial changes are being made to the delivery of services to children and families in Leeds. This includes the development of locality cluster working, a multi-agency Children’s Services Duty and Advice Service, and an ‘Early Help Approach’ (the right service at the right time) which promotes multi-agency conversations to determine the best way to intervene in the lives of vulnerable children and young people rather than a reliance on a more traditional ‘thresholds for intervention’ framework. These changes provide opportunities for professionals to provide a more responsive and timely service. However, it is a new way of working and will need to be introduced carefully with a comprehensive package of training and guidance to ensure that staff in all affected agencies understand the changes. 10. Recommendations 10.1 Individual agency reports have identified changes that need to be made within their organisations and 27 separate recommendations have been made to address these. The Panel endorsed these recommendations, which have been progressed by the relevant agencies.. The SCR Panel and Lead Reviewer make the additional recommendations below: 1. The Chair of the LSCB should ensure that the conflict resolution process (also known as ‘dispute resolution process’ and ‘concerns resolution process’) is updated, published on the LSCB website and widely disseminated to staff in agencies working with Children and Families in Leeds. This process should be completed within six months of this Overview Report being approved by the LSCB. The Outcome sought is that children and young people receive early help to promote their wellbeing and safety 2. The Chair of the LSCB should ensure that a system is developed to monitor(i) the frequency with which the dispute resolution process is being used and (ii)the outcomes of the process. This system should be developed within six months of this Overview Report being approved by the LSCB. The Outcome sought is that children and young people receive early help to promote their wellbeing and safety 3. The Chair of the LSCB should ensure that a dissemination programme and comprehensive package of training and guidance is provided to ensure that staff in all affected agencies understand the changes being made to the delivery of services to children and families in Leeds. This should be consistent with the programme outlined on page 6 of ‘Beyond Thresholds’ (9 January 2014), a report from the Deputy Director, Specialist, Safeguarding and Targeted to Leeds Safeguarding Children Board. This should be achieved within six months of this Overview Report being approved by the LSCB. The Outcome sought is that children and young people receive early help to promote their wellbeing and safety Child Y Overview Report 27 January 2015 53 4. The Chair of the LSCB should ensure that the Learning and Development sub group develops and implements an initiative to address the training needs of staff in agencies working with Children and Families in Leeds in relation to working with families where chronic neglect is a feature. This should include guidance as to when the Police should be involved. This should be achieved within six months of this Overview Report being approved by the LSCB. The Outcome sought is that children and young people do not suffer neglect and receive early help to promote their wellbeing and safety. 5. The Deputy Director, Specialist, Safeguarding and Targeted should assure the Chair of the LSCB, through regular reporting to the LSCB, that the changes in practice reported by CSWS, as detailed in paragraphs 7.13.4 and 7.13.5 of this report are firmly embedded in practice and are leading to improved outcomes for children. This should be achieved within six months of this Overview Report being approved by the LSCB. The outcome sought is that the needs of children and young people are effectively assessed and met through the provision of appropriate services that lead to the promotion of their safety and wellbeing 6. The Head of Nursing for Children within LTHT should ensure that Appendix 4 of the LTHT Elective Treatment Access Policy is amended to include specific reference to the fact that children do not choose not to attend hospital appointments and where a parent or carer fails to ensure the child’s access to appropriate medical care or treatment this, in itself, can be neglect. This should be achieved within three months of this Overview Report being approved by the LSCB. The outcome sought is that vulnerable children receive appropriate and necessary medical care that promotes their health and wellbeing 7. The Head of Safeguarding within LTHT should explore whether records relating to different children from the same household can be linked so that Emergency Department staff are aware if there are frequent attendances. This should be achieved within six months of this Overview Report being approved by the LSCB.The outcome sought is that links are made with all children in a family where a particular child attends a hospital emergency department thus ensuring that all siblings are safeguarded Child Y Overview Report 27 January 2015 54 Appendix 1 – Abbreviations CAF Common Assessment Framework CSWS Children’s Social Work Service DNA Did Not Attend EDT Emergency Duty Team GP General Practitioner (Doctor) KPE Key Practice Episode LAU Leeds Addiction Unit LCH Leeds Community Healthcare LTHT Leeds Teaching Hospitals NHS Trust LYPFT Leeds and York Partnership NHS Foundation Trust NHS National Health Service SCIE Social Care Institute for Excellence SCR Serious Case Review ToR Term of Reference Child Y Overview Report 27 January 2015 55 Appendix 2 – References Brandon, M. et al (2013) Neglect and Serious Case Reviews, University of East Anglia/NSPCC Burgess, C. et al (2013); The State of Child Neglect in the UK, Action for Children & University of Stirling Children Leeds (May 2012): Doing the Simple Things Better – A handbook supporting joint working Department for Education (2008): Information Sharing: Guidance For Practitioners and Managers Faulkner, G. (undated): ‘The Front Door’- Journey to an Outstanding Service. Report to Leeds Safeguarding Children Board Fish et al (SCIE guide 24); Learning together to safeguard children: developing a multi-agency systems approach for case reviews, Social Care Institute for Excellence HM Government (2013): Working Together to Safeguard Children Leeds Early Start Service (September 2012): Early Start Service Handbook Leeds Safeguarding Children Board (12 March 2014): Right Conversations, Right People, Right Time, Early help and our approach to responding to the needs of children and families in Leeds 2014 -15 Leeds Safeguarding Children Board (November 2013): One Minutes Guide No. 12, Child and Family Assessment Leeds Safeguarding Children Board (November 2013): One Minutes Guide No. 13, Cluster Working Leeds Safeguarding Children Board (November 2013): One Minutes Guide No. 14, Frameworki Reder, et al (1993): Beyond Blame Child Abuse Tragedies Revisited. London: Routledge Walker, S. (9 January 2014): Beyond Thresholds: A framework for better decision making for vulnerable children in Leeds. Report to Leeds Safeguarding Children Board Wigley, L. (November 2013): Elective Treatment Access Policy. Leeds Teaching Hospitals NHS Trust |
NC50709 | Life threatening non-accidental injuries to a 4-month-old girl in August 2016 due to shaking. Mother and partner were arrested but not prosecuted. Child LI, her twin and older half-sibling made subject of care orders. Mother called an ambulance because Child LI was unresponsive and floppy. Hospital staff noticed bruises on abdomen and upper thigh and CT scans revealed sub-dural haemorrhages. Child was transferred to out of area hospital and a section 47 enquiry was initiated. Mother's partner had a history of coercive and controlling behaviour and was made the subject of a Non-Molestation Order following reports of domestic abuse by Mother's sister in 2014. Partner maintained contact with Child LI's older half-sibling. Family were known to services. Family is White British. Findings include: effective communication between domestic abuse services and police; tendency to see domestic abuse incidents as isolated events rather than part of a bigger picture of coercion and control by Partner; children were not on the 'radar' of children's social care and there were no records giving full context of children's experiences. Uses Welsh Model to review case. Learning includes: multi-agency policy and practice should manage risk assessment of children who experience domestic abuse in the context of coercive controlling behaviour; coercive control should be included in local multi-agency guidance and strategy planning. Recommendations include: family courts should be given the outcomes of court ordered actions to inform decisions about children in accordance with the paramountcy principle; and records should be placed on information platforms by Police in a timely manner.
| Title: Serious case review: overview report: Child LI LSCB: Lancashire Safeguarding Children Board Author: Paul Sharkey Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Serious Case Review Overview Report Child LI Author: Paul Sharkey (MPA) Date: April 2018 Publication Date: 31st July 2018 2 Page Part 1; Introduction 3 Part 2; Aims, Terms of Reference and SCR Process Issues 3 Terms of Reference 4 Scope of SCR 4 Methodology 4 The Panel 5 Confidentiality 5 Family Involvement 6 Race, Religion, Language and Culture 6 Parallel Proceedings 6 Dissemination of Learning 6 Part 3; Background and Overview 6 Part 4; Agency Involvement and Case Narrative 7 Part 5; Analysis of Practice with regard to the ToRs 16 ToR 1 16 ToR 2 25 ToRs 3 and 4 27 Tor 5 28 Tor 6 29 Part 6; Findings and Conclusions 29 Part 7; Key Learning Points and Improvements 31 Part 8; Glossary of Terms 32 References 33 3 Part 1 Introduction 1. The subject of this serious case review (hereafter, referred to as an SCR) is Child LI who was born in April 2016. LI was seriously injured in August 2016, aged four months, whilst in the care of their mother (MLI) and male partner (PMLI). Child LI has a twin (S2LI) and an older half-sibling (S1LI) who was born in June 2014 and is the child of MLI and PMLI. The latter is not the father of the twins. 2. Following admission to a local hospital at the end of August, LI was examined and found to have sustained life threatening injuries with lifelong consequences for their health and development. LI was transferred to an out of area hospital for specialist care and further tests. 3. The injuries were deemed by examining doctors to be non-accidental and a joint enquiry was undertaken by Lancashire Children’s Social Care and Lancashire Constabulary. Child LI and the two siblings were removed from the care of MLI and PMLI and became looked after by the local authority who started care proceedings. 4. Lancashire Constabulary arrested the two adults and started a criminal investigation into the circumstances of LI’s injuries. 5. The Lancashire Safeguarding Children Board considered the circumstances of LI’s injuries and decided on the 04.10.16 to hold a SCR. Part 2 Aims, Terms of Reference and SCR Process Issues Aims 6. The overall purpose of this SCR is set out in Government Guidance1, namely to undertake a rigorous, objective analysis that will; “Look at what happened in this case, and why, and what action needs to be taken to learn from the Review findings. Action results in the lasting improvements to services which safeguard and promote the welfare of children and help protect them from harm. There is transparency about the issues arising from this case and actions which the organisations are taking in response to them. Including sharing the overview report with the public” ( Working Together, 2015, 72) Terms of Reference (ToR) 7. This SCR and the overview report have been undertaken in relation to the following terms of reference, namely; 1. Critically examine and evaluate the effectiveness, or otherwise, of agency/multi-agency attempts to safeguard LI and her siblings in relation to the identification, assessment and management of the risk from harm and domestic abuse. 1 Working Together to Safeguard Children (2015): HM Government/Department for Education 4 2. Comment critically on the effectiveness, or otherwise, of agency and multi-agency interventions-including early help and support for the carers- regarding planning, implementation and review that sought to safeguard and protect LI and her siblings from harm, including domestic abuse. 3. Examine the effectiveness, or otherwise, of inter/intra-agency working, including information sharing and case handovers/transfers, both within and without Lancashire in relation to safeguarding LI and her siblings. 4. Examine the efficacy, or otherwise, of decisions made and actions taken to safeguard LI (including pre-birth) and her siblings. How child focused were they and did they comply with agencies’ policies and procedures and those of the Lancashire Safeguarding Children Board? 5. Examine the involvement of other significant wider family members in the life of Child LI and her siblings including a consideration of the potential for caring for the children. 6. Examine to what extent safe handling advice and support was provided to the carers. Scope of SCR 8. The time-frame under examination by this SCR was from September 2014 to the end of August 2016. This covers the period from the first Police Protection of Vulnerable Person (PVP) referral on MLI to when the local authority started care proceedings on LI and the two siblings following the discovery of non-accidental injury on the 26. 08.16. 9. The SCR was undertaken under the ‘ Working Together’ 2015 statutory guidance as it was commissioned by the Lancashire Safeguarding Children Board (LSCB) in October 2016. Methodology 10. At the behest of the Lancashire Safeguarding Children Board the ‘ Welsh Model’2 format was used to undertake this SCR3. 11. The following documents, meetings and events underpinned the SCR; Time-line of Significant Events/Analysis. Discussion and analysis at four panel meetings. Learning event involving front line practitioners and managers: February 2018 Conversations with family members ( to be done) Reference to the six ToRs Liaison with the Lancashire Police Senior Investigation Officer (SIO) and Crown Prosecution Service (CPS) Sight of all relevant documents A visit by the lead reviewer in June 2017 to the Multi-Agency Safeguarding Hub (MASH) and conversation with the Children’s Social Care MASH manager. 2 ‘ Protecting Children in Wales: Guidance for Arrangements for Multi-Agency Child Practice Reviews (2012); Welsh Government 3 Albeit, within the overall framework of Government guidance, ‘ Working Together’ 2015, Chapter 4. 5 The adoption of a broadly,’ Systemic’, approach to the understanding and analysis of the case within an organisational context of professionals’ actions and decision making at the time. A focus on learning and not blame 12. There was a delay in progressing the SCR because of the need to wait for permission from the Police SIO and CPS before holding the practitioner’s event in February 2018. A final decision was made by the CPS in March 2018 not to proceed with a prosecution of MLI and PMLI. Additional delays were caused by the need to wait until the care proceedings were concluded in August 2017. 13. Mindful of the delays and the need to identify learning and make changes to practice and policy in a timely manner, a draft report was provided to the panel in July 2017. This contained some early learning which was communicated to the panel and the LSCB and resulted in changes to the operation of the Lancashire Multi-Agency Safeguarding Hub (MASH). The Panel 14. The Panel comprised of senior representatives from the following agencies; SCR Panel Chair Mrs. Louise Burton, NHS Chorley and South Ribble, CCG, NHS Greater Preston CCG and NHS West Lancashire CCG Service Manager CAFCASS Named Nurse for Safeguarding Children and Adults Blackpool Teaching Hospitals Service Manager Fylde Coast Women’s Aid Deputy Designated Lead Nurse; Safeguarding Children NHS Fylde and Wyre CCG Fylde District Team Leader Lancashire Children and Family Well-being Service Detective Inspector Lancashire Constabulary Team Manager Lancashire Children’s Social Care Named Nurse for Safeguarding Lancashire Teaching Hospital Trust Business Support Officer LSCB ( non member) Business Co-ordinator LSCB ( non member) 15. The independent lead reviewer was Mr. Paul Sharkey (MPA)4. He had no previous connection with either the LSCB or any partner agencies, including those involved in the SCR. He has a professional background in statutory and third sector safeguarding of over thirty years at senior 4 Master’s in Public Administration (2007) from Warwick University Business School. 6 management level. He has authored/chaired more than fifteen SCRs since 2002 and has attended several DfE/NSPCC courses on improving the quality of SCRs over recent years. Confidentiality 16. In compliance with Government guidance this SCR has respected the right to anonymity of Child LI, their family and the professionals involved in the case. 17. Family Involvement MLI and PMLI declined to be interviewed by the lead reviewer for the purposes of this SCR. However, LI’s aunt ( ALI) did and her views are included here. She advised that the family were very supportive to MLI, particularly during the initial separation between her and PMLI. Following the separation MLI spent a lot of time with the family; this drifted when she reconciled back with PMLI. ALI cared for the children following the birth of the twins during MLI’s hospital stays and again following Child LI sustaining her injuries. ALI did not have significant contact with agencies/services involved with the family but what contact she had she reported to be good. ALI reported the PMLI stayed in the background at family events and following the birth of the twins MLI moved area closer to PMLI’s family and contact was limited. MLI did not share information with her family. ALI would like to be informed when the report is published. Race, Religion, Language and Culture 18. Child LI and family are English speakers of white British heritage. Parallel Proceedings 19. As mentioned previously, the care proceedings on LI and the two siblings finished in August 2017. The CPS decided in March 2018 not to proceed with a prosecution of MLI and PMLI. Dissemination of Learning 20. To be done by LSCB and Panel members Part 3 Background and Overview 21. PMLI had a history of coercive control5 of female partners prior to starting a relationship with MLI in early 2013. She soon started to experience coercive control from PMLI and left in early 2014 but returned to him shortly after. S1LI was born in June 2014. MLI left her partner again in the autumn of 2014 and went to live with her sister who supported her in finding accommodation. There were two incidents in late 2014 which involved the Police making Protection of Vulnerable Persons (PVP) referrals to the Lancashire MASH. 22. MLI applied for and obtained from the Family Court a one year non-molestation order6 against PMLI in September 20147 which, in October of that year was varied to a ten year order. MLI received support from the health visiting service and the Independent Domestic Violence Adviser (IDVA), consequent to two multi-agency risk assessment conferences (MARACs) in late 2014 and early 2015. Support from a local Children’ Centre was offered to MLI who declined. A third PVP was made by the Police in January 2015.The Family Court, following a recommendation from CAFCASS (Child 5 Defined by Evan Stark (2009) as, ‘A strategic course of self-interested behaviour designed to secure and expand gender-based privilege by establishing a regime of domination in personal life……….the oppression is ongoing rather than episodic (a course of conduct) and resulting harms cumulative, that is, multi-faceted, and that involves rational, instrumental behaviour’. ) 6 Under the Family Law Act 1996. 7 Heard before a District Law Judge. 7 and Family Court Advisory Service), made S1LI the subject of a child arrangement order in February 2015 with a provision for regular contact with PMLI. 23. MLI and S2LI remained living away from PMLI for most of 2015 but the couple resumed their relationship in early 2016. By this time MLI was pregnant with LI and the twin, S2LI. The children were born in April 2016. A referral was made by the local hospital staff to Lancashire MASH (Children’s Social Care) a few days after the births regarding concerns around domestic abuse. A DASH assessment was undertaken by the IDVA service. 24. Lancashire CSC, on the basis of information received from the IDVA and the health visitor -who in turn, based their assessments on what they had been told by MLI- concluded that the risk level did not meet the Continuum of Need (CoN) threshold for child protection or child in need intervention. 25. A fourth PVP, following an incident between MLI and PMLI, was made by the Police in late July 2016 and assessed as standard risk, thus not reaching the threshold for CSC intervention. It was later established by the Police enquiry that LI had sustained two bruises to their face on or around the 02.08.16 whilst in the care of their mother and PMLI. The evidence was captured on MLI’s phone which was seized by the police in the course of their enquiry. There was no reference made to the bruising (assuming it was visible)8 by the health visitor (HV2) who saw LI and the twin on the 04.08.16. 26. The twins received their immunisations at the GP surgery on the 25.08.16. That night, LI was taken by ambulance, with their mother, to the Accident and Emergency department of the local hospital. On examination, LI was found to have suffered serious injuries which were thought to be non-accidental in nature and transferred to the out of area hospital. 27. All three children were taken into the care of the local authority and a police investigation was started. The care proceedings finished in August 2017 with all three children being made the subject of care orders to Lancashire County Council. The family proceedings court found either one or both of the adults caring for her, were, on the balance of probabilities, responsible for LI’s injuries. It could not say who, in fact, had specifically caused the injuries. 28. On the 26.03.18, the SCR was informed by Lancashire Constabulary that a decision had been made by the CPS that there were insufficient grounds for a realistic prospect of a conviction of either MLI or PMLI. Part 4 Agency Involvement and Case Narrative 2013/14 29. Child LI’s mother (MLI) started a relationship in March 2013 with PMLI which led to her moving in with the partner and his mother later that year. MLI became pregnant with S1LI in late 2013 but left PMLI in early 2014 because of his controlling and coercive behaviour. The couple reunited in the Spring of 2014 and S1LI was born that summer. A health visitor (HV1) was allocated and proceeded with the ‘Universal’ offer.9 8 Although the picture of LI’s bruising was taken on the 02.08.16 its age was not known and could have originated before the date given. There was a possibility that the bruises had disappeared by the 04.08.16. The lead reviewer was not able to speak to the health visitor (HV2) to ascertain whether she noticed the bruising or not as this was beyond the control of the SCR. 9 This consists of every new mother and baby having access to a health visitor, receiving development checks at just after birth, 6-8 weeks, 9-12 months and 2-21/2 years; and being given good information about health start issues such as parenting and immunisation. 8 30. Following continuation of his controlling behaviour, MLI and S1LI left PMLI for the second time and went to live with her sister (S1) in the early autumn of 2014. The move resulted in the allocation of a new health visitor (HV2). 31. S1 reported domestic (mental) abuse of her sister by PMLI on the 10.09.14 to the Lancashire Police who made a Protection of a Vulnerable Person (PVP) referral, graded at ‘Medium’ to the MASH that day.The MASH assessed MLI as being in an emotionally abusive and controlling relationship with PMLI. Information was shared with the National Probation Service, health agencies and the Independent Domestic Violence Advisor (IDVA) service. The social work assessment within the MASH graded the PVP, against the Continuum of Need (CON) at Level 3 (not needing a referral to CSC) and recommended a step down to a Children’s Centre. 32. MLI was assigned an IDVA, advised to seek legal advice regarding child contact with S1LI’s father and offered family support from a local Children’s Centre (CC1). No criminal offence was identified. 33. A one year non-molestation order, under section 42 of the Family Law Act 1996, with conditions, was made in MLI’s favour on the 22.09.14. PMLI was served notice of the order on the 24.09.14 and a copy lodged on the same day at Blackpool Police Station. 34. A second PVP was made by the Police to the MASH on the 04.10.14 following a complaint made by MLI regarding a ‘Revenge porn’ incident initiated by PMLI. The MASH assessment of medium risk determined that the incident did not breach the conditions of the non-molestation order or give grounds for a harassment offence.10 35. MLI and her baby received support from HV2 and IDVA1during late 2014 but declined intervention from the Children’s Centre. The Family Court granted a ten-year non-molestation order on the 17.11.14, made a finding of fact on the issue of domestic abuse and ordered that CAFCASS provide a Section 7 report for a February 2015 hearing. It granted twice weekly daytime contact for S1LI’s father (PMLI). 36. MLI told IDVA1 that the abuse had started in September 2013, shortly before becoming pregnant with S1LI. She described a very controlling relationship with PMLI frequently checking her phone, not allowing her on Facebook, deleting all the numbers in her book, controlling what she wore, her money, access to her family and not allowing her out on her own. 37. IDVA1 undertook a CAADA-DASH11 risk assessment on the 20.11.14, scoring 14, thus indicating ‘High Risk’ ; and made a referral to the MARAC, in addition to placing a DV marker on the property with the Police. 38. CAFCASS received a request from the Family Court on the 10.12.14 for a section 712 report to be submitted by the 18.02.15. An updated safeguarding letter had been sent to the Court by a Family Court Adviser (FCA1) on the 20.11.14 confirming that enhanced information (from the Local authority and the Police) had not raised any additional safeguarding concerns or need for immediate action regarding S1LI.The case was re-allocated to FCA2 on the 15.12.14 who triaged it as ‘Low 10 (Arguably, it did; NB came before the legislation, section 33 of the Criminal Justice and Courts Act 2015 (which came into force in April 2015) which makes it an offence in England and Wales to disclose private sexual photographs and films without the consent of the individual depicted and with the intent to cause distress. There is a maximum sentence of two years imprisonment. 11 Co-ordinated action against domestic abuse-Domestic Abuse, Stalking and Honour based Violence risk assessment and management model (2009) 12 Of the Children Act, 1989. 9 risk’ based on the available information. A transcript of the Finding of Fact hearing of the 26.09.14 was requested on the 19.12.14 for FCA2 to assess any risks. 39. The MARAC held on the 18.12.14 deemed MLI to be at very High Risk and noted her to be engaging with services. It agreed; IDVA1 to advise MLI to carry non-molestation order to present when necessary. IDVA1 to request vulnerable marker when MLI moved. IDVA1, victim update. Police to re-check PNC with previous name provided, before it was changed by deed poll (this referred to PMLI). IDVA1, Children’s Centre and HV2 to refer to Children’s Social Care if any concerns about S1LI. 2015 40. Lancashire Police made a third domestic abuse PVP to the MASH on the 06.01.15, having done a DASH and classified the incident at Medium Risk, consequent to MLI’s complaint about feeling intimidated by PMLI at a handover of S1LI a few days earlier. MLI referred to the non-molestation order and attendant conditions but despite the recent MARAC (and the order having been lodged at Blackpool Police Station on the 24.09.14), these details were not on the PNC. She was advised to obtain it from her solicitor. 41. The PVP referral remained in the Police queue until the 16.01.15 and was reviewed on the 17.01.15 (a Saturday) as a single agency by the police sergeant who, because of the presence of S1LI, raised the referral to High risk and referred to the MASH. S1LI was identified at risk of being used as a tool between the parents. The MASH social worker considered the episode and concluded that it was Level 3 on the Continuum of Need , which indicated a, ‘ Step down’ , to a Children Centre, thus not getting onto CSC’s ‘ radar’. The PVP was finalised on the Monday 19.01.15. 42. PMLI was not arrested for breaching the terms of the non-molestation order despite a referral being made to the MARAC for breach of the order. PMLI was advised by the Police by telephone not to have any further unnecessary contact with MLI. 43. On the same day, FCA3 (CAFCASS) was contacted by MLI’s solicitor and told of the incident and PMLI ‘bombarding’ her with Facebook posts and texts. FCA3 sent a s16a13 e-mail update to the Court outlining recent events concerning PMLI’s behaviour and requested an urgent court review, which in the event, did not happen. It was noted by CAFCASS that the e mail did not address the risks to S1LI were he to have continuing contact with his father. 44. MLI and her baby moved into their own accommodation in January 2015. IDVA1, on the 14.01.15, asked the Police to place a DV marker on the new address as per the MARAC of the 18.12.14. 45. MLI was seen by FCA3 on the 11.02.15 and 16.02.15 regarding the forthcoming Child Assessment Order hearing in the family court scheduled for the 24.02.15. FCA3 noted that MLI was, ‘Still very much afraid of her ex-partner ‘, and felt intimated at hand-overs of S1LI. She 13 This is a risk assessment required of CAFCASS under section 16 of the Children Act 1989-see section 2 of the CAFCASS child protection policy 2014. 10 was DASH assessed by FCA3 as ‘High risk’, with reference to serious findings having been made against PMLI in the previous Finding of Fact hearing. PMLI was seen on the 16.02.15 and 18.02.15 by FCA3. 46. A second MARAC was held on the 12.02.15. Resulting actions were, Victim update by IDVA1. IDVA1, joint visit with Police. IDVA1 to speak to victim regarding non-molestation order conditions being varied. Police to re-check PNC information. Children’s Centre to check engagement with victim. BTHFT, CSC and Children’s Centre to check records for any additional children. 47. The S.7 report was filed with the Family Court on the 18.02.15. It recommended a child arrangement order to PMLI that included the existing contact arrangements. Any move to overnight contact should only occur following PMLI’s attendance on a Domestic Violence Perpetrators Programme (DVPP), a Separated Parents Information Programme (SPIP) and a GP referred ‘Anger management’ course. 48. A final order was made on the 24.02.15 by the Family Court that followed the recommendations of the S.7 CAFCASS (FCA3) report. No further mention was made of the DVPP/SPIP programmes and there was no court requirement for CAFCASS to monitor PMLI’s attendance at these. 49. IDVA1 and PC1 (Police officer) visited MLI in early March and discussed the MARAC plan. A copy of the ten year non-molestation order was e-mailed to the Police who agreed to update the Police National Computer (PNC). 50. PMLI, via his GP attended the first session of an ‘Anxiety’ workshop in March 2015 but had dropped out of the programme by April having attended only one meeting. The workshop did not cover anger management as recommended by FCA3 for the family court. 51. IDVA1, at MLI’s request finished her involvement and closed the case in early May. MLI and SLI continued to attend clinic in May/June for routine weighing. There were no further recorded incidents of intimidation or abuse between MLI and her ex-partner during 2015. 52. MLI attended her GP in late September when her pregnancy was confirmed. A twin birth LI and S2LI) with an expected delivery date of early May 2016 was established. She booked in with the local Trust midwifery service in early October and was duly seen by a community midwife (CMW2). MLI mentioned that she had been subject to domestic abuse by her previous partner, who was not the father of the twins. She continued to engage well with the midwifery service for the rest of the year with no safeguarding concerns identified. 2016 53. In early January, MLI was seen by a doctor at the local hospital for reduced foetal movements. On examination to MLI a small laceration was identified, in addition to foetal heart beats. She was asked to stay for further treatment but left without telling staff. A message was left on her phone requesting that she attend the next week for a scan. There was no documentation as to whether any questions about the lacerations had been followed up, which would have been expected practice. 11 54. MLI did attend for an ante-natal appointment on the 08.02.16 and arrangements were made to see her in four weeks. S1LI was admitted the next day, by ambulance, to the local hospital 2, Accident and Emergency with a prolonged seizure. MLI, along with the other parent (not documented, but thought to be PMLI) was present. 55. S1LI was admitted to the children’s ward where they received appropriate treatment and remained for two days. It was noted that the baby had some scarring due to a cannula to the right hand which was treated. There were no concerns recorded about the parental interaction whilst on the ward. 56. S1LI was again seen on the 13.02.16 in the local hospital 2 due to concerns that the scarring to the hand was not healing. There were no concerns from the plastic surgeon who deemed that the hand was healing well and S1LI was discharged home. 57. MLI attended ante-natal appointments and the early pregnancy unit in March with some anxieties about the growth of the unborn children. She was admitted overnight to the local hospital 1 on the 21.03.16 and transferred to an out of area hospital 2 because of threatened pre-term labour. It was noted that PMLI was at home caring for S1LI. This was the first documented reference that the couple were together despite the 10 year non-molestation order. MLI was unaccompanied and upset at having no family visitors whilst at out of area hospital 2. Following obstetric tests, she was assessed as fit to discharge and left the hospital on the 24.03.16 with an appointment to attend local hospital 1 on the 29.03.16. Treatment information was shared with local hospital 1. 58. MLI self-referred to local hospital 1 maternity triage on the 27.03.16 for severe itching, previously diagnosed as obstetric cholestasis. It was noted that her abdomen appeared to be bruised. There was no evidence of any routine enquiry regarding the bruising. She left the unit saying she could not stay as her ‘Husband’ (PMLI) needed to go to work. She attended the midwife delivery unit at the local hospital 2 on the 29.03.16 for ‘Bloods’. 59. The twins, LI and S2LI were born on the 14.04.16 at 35 weeks gestation. LI was transferred to the neonatal unit due to hypoglycaemia (low blood sugars). The birth notification was received by the health visitor (HV2) on the 15.04.16. 60. 32. MLI and PMLI were heard arguing by SCBU14 staff on the 16.04.16. PMLI was wanting MLI to self-discharge as she was ‘neglecting’ S1LI. Domestic abuse and appropriate services were discussed. Expected practice would have been for staff to have discussed comments made about S1LI by PMLI with the Paediatric Liaison Nurse (PLN). MLI was noted on the 17.04.16 to be attending to all of the twins’ needs and she also had a visit from her family. Neither PMLI nor S1LI visited. MLI told ward staff that PMLI was not the twins’ father which appeared to be the first time they became aware of this fact. 61. SCBU staff reported PMLI’s aggressive behaviour to themselves and MLI to the PLN1 on the 19.04.16. The health visitor team reported to PLN1 that there had been significant domestic abuse between the two resulting in a MARAC, police markers on the property and a ten year non-molestation order against PMLI. A referral was made by ward staff to the IDVA service and both safeguarding and the named midwife were informed of the situation by PLN1. 14 Special Care Baby Unit. 12 62. MLI was seen by IDVA1 on the 21.04.16 who carried out a DASH risk assessment which scored 6, based upon the information given. MLI said that she did not want any support from FCWA (IDVA service) but would contact if she needed any future support. IDVA1 said she was going to make a referral to CSC and also spoke with the health visitor about the situation. MLI and the twins were discharged home. The named midwife completed a referral to CSC. 63. CSC received the named midwife safeguarding referral on the 22.04.16 regarding the three children and was processed by SW1 on the 27.04.16. The referral reported a high risk of domestic abuse and reference was made to the February 2015 MARAC. 64. The current information from the health visitor HV2, who had discussed the situation with MLI was that there were no safeguarding concerns at that time. The MASH (police) was contacted by CSC who recorded that the last domestic abuse incident was in December 2014; this being a verbal argument over contact with S1LI. It was recorded that the PNC was checked regarding this incident and there was no order out against PMLI in relation to MLI. IDVA1 had seen MLI and had assessed the (DASH) risk as low. On this basis, CSC did not make a child protection referral and closed the case due to a lack of evidence that MLI was at current risk of being a victim of domestic abuse. It noted that the professionals involved with MLI and the children were aware of the situation and were monitoring and giving support. Any further concerns regarding S1LI would result in consideration ‘To be given re C and F at that time’. (Children and Family assessment). 65. MLI received two midwife visits on the 22 and 24 April with no documented enquiry into the relationship with PMLI or domestic abuse. HV2 made the first home visit on the 25.04.16 under the Universal service offer. MLI spoke about the previous domestic abuse from PMLI who was not present. She said that her children were her priority and understood the importance of keeping them safe. She did not show any indication of a low mood to HV2. Expected practice would have been to record any history of post-natal depression (PHQ9 tool) and enquire about the relationship with PMLI. 66. MLI was admitted to the medical ward at local hospital 1 on the 27.04.16 for itching (cholestasis) and other ailments and received appropriate treatment. She self-discharged three days later. 67. The health visitor (HV2) was contacted by a social worker (SW1) on the 27.04.16 regarding the referral from the SCBU concerning PMLI’s aggressive behaviour. HV2 saw LI on a home visit on the 28.04.16. She was seen again on the 04.05.16 in the care of MLI’s sister (the aunt to LI and S2LI) and PMLI. PMLI was said by maternal family members to have been an excellent support whilst MLI was in hospital. The midwife visited for the last time on the 05.05.16 when nothing of any significance was noted. MLI and the children were discharged into the care of the health visitor (HV2) and GP. 68. MLI was admitted to LOCAL HOSPITAL 1 with sepsis on the 06.05.16 when some bruising to her legs was noticed by the nurse. Enquiries were made regarding domestic abuse. MLI said that PMLI had been staying with her since the twins’ birth. She was discharged on the 09.05.16. 13 69. On the 09.05.16 S1LI (nearly two) was seen by the GP for a 1cm laceration to the roof of his mouth. ‘Dad’ had reportedly given the child calpol for the pain. Nothing abnormal was discovered; reassurance and advice were given. 70. HV2 visited MLI and the children on the 11.05.16 for routine baby checks. MLI had not heard from CSC. HV2 checked later and found that CSC had closed the case, MLI was informed of this by HV2. No routine enquiry was documented by the health visitor into MLI’s relationship with PMLI. 71. On the 16.05.16 the GP referred S1LI for a paediatric appointment regarding the reported change in the child’s behaviour (angry), waking in the night screaming and weight loss. The GP felt it might be ‘Night terrors’ but wanted a second opinion. 72. It was recorded that MLI did not turn up on the 23.05.16 for a surgical clinic appointment. She was normally good with attendance. 73. On the 05.06.16 MLI made allegations to the Lancashire Police that she and her new partner (thought to be PMLI) had been receiving malicious Facebook messages for the last two months from an ex-partner. A PVP domestic abuse referral was made to the MASH at standard risk and a crime report completed for a criminal offence of harassment. MLI said that the ex-partner was an alcoholic and she was happy for him to be given a warning in the first instance. The information was shared with HV2 on the 17.06.16. 74. The twins were seen by the GP and HV2 on 08.06.16 for the 6-8 week review. A routine visit by HV2 took place on the 20.06.16 when the PVP referral was discussed. Intervention was nominally at ‘Universal’ level but the frequency of contact was above this. MLI consented to investigations into her bilestones. 75. On the 22.06.16 the GP recorded that LI did not attend a hip ultrasound scheduled at LOCAL HOSPITAL 1. 76. On the afternoon of the 04.07.16, PMLI contacted NHS 111 regarding a laceration to S1LI’s lip; the second time he had sustained an injury. PMLI said that S1LI’s lip had got trapped in a DVD case. He was advised to see the GP. MLI then contacted the GP and was advised to attend the GP or primary care. There was no evidence that the parents and S1LI attended for medical attention. 77. The twins were notified by HV2 on the 25.07.16 as having received their first childhood immunisations. 78. On the 26.07.16 MLI contacted NHS 111 with concerns about S2LI having a fever, pain and inconsolable crying. A GP triage call was requested (FCMS) and a GP tried three times to contact with no answer. There was no follow up. 79. No access was reported by HV2 on a planned visit on the 29.07.16. 14 80. On the 30.07.16 (a key date) the Police attended a domestic incident at PMLI’s address involving MLI who said that the two had recently re-united despite the existence of a ten year non-molestation order. MLI said that there had been a ‘massive blowout’ that night over the twins. A finding of fact from the later care proceedings stated that on this date the three children were exposed to aggressive behaviours between MLI and PMLI that led to the Police being called. MLI had left the house with LI who had been grabbed with excessive force by PMLI. 15She returned to her own address but PMLI had S1LI and S2LI and was refusing to hand himS2LI over to her. 81. Consequent to the Police presence PMLI handed over the other twin but S1LI remained with him, despite the previous MARACs and the ten year non-molestation order. All three children were deemed to be ‘Safe and well’ by the officers who submitted a PVP domestic abuse referral to the MASH at standard risk. The information was shared with IDVA, CSC, Health and Probation. 82. The Court ( care proceedings on the three children) finding of fact based upon the findings of the Police investigation, found that on 02.08.16 LI had two bruises to her face, one on each cheek. 16The injuries were as a result of trauma and were inflicted by MLI and/or PMLI on or before the 02.08.16. Both adults failed to seek appropriate or any medical attention for LI’s injuries. 83. S1LI was seen on the 03.08.16 by a paediatrician following the GP referral. MLI reported that his behaviour had improved and he was less angry; eating and sleeping better. The doctor thought that the child’s behaviour might have been related to being ill and in hospital.The child was still complaining of a painful right hand where the cannula had tissued.The child was to be seen in six months if the parents felt that the behaviour had not improved. 84. HV2 was informed on the 04.08.16 of the recent domestic abuse incident. She visited MLI at her address who appeared to minimise the incident, despite the existence of the ten year non-molestation order. MLI said she was happy with PMLI; the incident was due to problems with his mother who had moved away. She described her emotional well-being as ‘Very happy, feels good’; good family support was noted. The twins were meeting their developmental milestones. 85. S1LI attended the Accident and Emergency department at the LOCAL HOSPITAL 1 on the 24.08.16 with a head injury (a 4cm haematoma). This was the third time the child had presented with an injury since 09.05.16 but the first time at A/E. Both parents were present and explained that the S1LI had tripped over the dog and hit their head on the bannister.The injuries matched the story given and the child was discharged home. 86. The twins attended GP surgery on the 25.08.16 at 5pm for their immunisations. Nothing untoward was noted. 87. On the same day at 20.47 hours, MLI made a 999 call regarding LI who was unresponsive, lifeless and floppy. The child was taken by ambulance to the LOCAL HOSPITAL 1, arriving at approximately 10pm, with their mother. Two bruises were noted above the umbilicus (abdomen) and the left upper thigh. A CT scan at LOCAL HOSPITAL 1 showed sub-dural 15 According to the Court Finding of Fact. 16 This was evidenced from the Police examination of MLI’s mobile phone during the later criminal enquiry. 15 haemorrhages (bleeding on the brain). Lancashire Emergency Duty Team (EDT) was contacted who liaised with the Lancashire Police. LI was transferred to the out of area hospital. No suitable explanation was given by MLI for the cause of the injuries. 88. An investigation was started by Lancashire Police into the non-accidental injuries sustained by LI. Both parents were arrested by Merseyside Police on suspicion of S.18 assault and child neglect and were subsequently given police bail, pending further enquiries. EDT and Lancashire Police did a home visit to find the other two siblings in the care of their maternal grandfather. The children became cared for by their maternal aunt. EDT noticed a bump on S1LI’s forehead which the grandfather said was caused by the child falling over a dog. There was no reference documented as to whether the family members had been considered as being possible perpetrators or the potential risk to the children. 89. A strategy meeting was held on the 26.08.16 at the out of area hospital with the Police, Health and CSC. A S.47 enquiry was started. LI had an MRI brain-scan on the 27.08.16, whilst in the PICU ( paediatric intensive care unit). This showed, acute-bilateral sub-dural haemorrhages, evidence of diffuse axonal injury (brain damage), and extensive retinal haemorrhages. The subsequent Court finding of fact (based on the later Police enquiry) found that the some of the injuries had most likely been sustained within fifteen days of the 26.08.16 and probably far less. Other injuries were up to seven and eleven days old respectively. 90. The finding of fact established that the injuries to LI’s head and eyes were inflicted by MLI or PMLI forcefully shaking LI, with or without an impact with a semi-yielding object, at or after 6p.m. on the 25.08.16. Furthermore, it would have been obvious to whoever shook LI that inappropriate force had been used and that urgent medical attention should have been sought for her. The adult who had witnessed the other shaking LI or was aware that the child had been shaken by or had been inappropriately handled by the other on the 25.08.16 had concealed the same from professionals and had failed to seek timely and appropriate medical attention for her. 91. The Court also established that LI had sustained bruising injuries to their abdomen and thigh, inflicted on more than one occasion, on the 23 and/or 24.08.16 by MLI and/or PMLI as a result of excessive rough handling. Depending on who was responsible for the injuries, the other adult had failed to protect LI and their siblings by permitting the assailant to remain in the same household. Moreover, both adults had failed to seek any medical attention for LI’s injuries. 92. Neither adult had as of the date of the final hearing ( 01.09.17), been open and honest about the circumstances in which the injuries were inflicted to LI by one or both of them, on or before the 02.08.16, on 23 or 24.08.16, or on the 25.08.16. 93. Care proceedings were started on the children on the 31.08.16 and completed on the 01.09.17 when all three children were made the subjects of care orders to the local authority. 94. The CPS decided in late March 2018 that there were insufficient grounds to mount a realistic prospect of a conviction of MLI and PMLI. 16 Part 5 Analysis of Practice with regard to the Terms of Reference 1. Critically examine and evaluate the effectiveness, or other wise, of single/multi-agency attempts to safeguard LI and siblings in relation to the identification, assessment and management of the risk from harm and domestic abuse. 95.There were ten occasions, during the time frame in question when professional considerations regarding potential harm and domestic abuse were given to the welfare and safety of LI and her two siblings. These were, The four PVPs of the 10.09.14, 04.10.14, 06.01.15 and 30.07.16 made to the MASH. The two MARAC’s held on the 18.12.14 and 12.02.15. The CAFCASS section 7 report provided for the Family Court hearing of the 24.02.15. The DASH assessment made by IDVA1 on the 21.04.16 The child protection referral made by the named midwife for safeguarding to the CSC received on the 22.04.16, a few days after the birth of LI and the twin. The s.47 joint investigation conducted by Lancashire CSC and Lancashire Police following the serious injuries to LI sustained on the 25.08.16. 96. S1LI was involved on all ten occasions, with LI and her brother being involved in the four episodes after their birth, namely the IDVA1 DASH assessment, the CSC assessment, the final PVP and the joint S.47 investigation. The Lancashire Multi-Agency Safeguarding Hub (MASH)17 The Lancashire County MASH18 was set up in April 2013 originally on the basis of Police only referrals. Its vision is, ‘ To identify and make safe all vulnerable people in our communities at the earliest opportunity by sharing information and making referrals into pathways across the safeguarding partnership.’ ( LSCB MASH-Diagnostic July 2016) 97. The MASH operating manual defines the MASH thus, ‘ The Lancashire MASH will allow participating agencies to share information in a timely and secure manner and enable agencies to decide on appropriate referral pathways into services for vulnerable people.’ (LSCB MASH-Diagnostic July 2016) 98. The MASH consists of the following agencies, 17 The Lancashire MASH has changed considerably in the last 12 months ( April 2018, at the time of writing). See Lancashire MASH Operational Manual ( Version 9, Update, February 2018) for an update on developments and current arrangements 18 Blackpool and Blackburn and Darwen have their own separate MASHs. 17 Local authority, Customer Access Service, Children’s Social Care, Adult Services, YOT, Education workers, Early Response Team, LADO. Police Health Probation; National Probation Service Fire and Rescue 99. Originally set up in Leyland, the MASH relocated to Accrington in June 2014. The LSCB completed a ‘Diagnostic ‘, in 2016 and made a number of recommendations. Since then a multi-agency strategic board and operational group have been established and a systems review of process has been completed. Closer links have been developed with the Police and social care localities.19 CSC merged the workers in the Contact and Referral Team (CART-the ‘Front Door’ team) and MASH together and managed both police referrals and referrals from other agencies such as, health and education. The Social Care team within the MASH manages all non-Police referrals but not Protection of Vulnerable People (PVP) referrals which include domestic abuse referrals. These are processed by the Police. Where children are involved levels of contact/intervention are assessed against the Lancashire ‘ Continuum of Need (CON) and Threshold Guidance’20 by a social worker within the team who will recommend the following outcomes, Close and No Further Action Step down to Early Help Step up (Child in Need or Section 47 child protection) to a district team for a statutory Child and Families assessment. The outcome will be ratified and decided upon by the CART manager. The Four PVP Referrals 100. Following a DASH assessment, all PVP domestic abuse referrals to the MASH are graded at three levels by the attending police officer, depending on the degree and likelihood of harm to the potential victim. These levels are, Standard Medium High 101. The first two PVPs of September and October 2014 (so called ‘Revenge Porn’) on MLI were both graded at Medium Risk by the attending police officer. The MASH, as per procedure, reassessed the risk assessment and on both occasions agreed with the original medium risk grade. Appropriate safeguarding measures were taken (see paragraphs 32/33 above) to protect MLI by way of mitigating future risk. 102. All medium and high risk PVPs were passed onto the CART who on both occasions, in relation to S1LI, identified the Level of Need, according to the Continuum of Need/ Threshold 19 The single site MASH (as of June 2017 when this section of the report was written) has since been devolved into localities which has improved local inter-agency links and contacts. ( See later section for more details) 20 This was refreshed in May 2016. 18 guidance framework, at Levels 3 and 2 respectively. At that time, this meant a ‘Step down’ to a children’s centre. There was no involvement with CSC as the Level of Need did not warrant this. Consequently, there were no entries made of these PVPs on the recording system (Liquid Logic). This meant that they did not show up in the later CSC assessment of the 22.04.16 following the birth of LI and her twin, consequent to the referral from the LOCAL HOSPITAL 1 staff who had concerns about domestic abuse towards MLI from PMLI. 103. By the time of the third PVP in early January 2015, MLI had obtained a ten year molestation order (with conditions) from the Family Court. She had also been subject to an IDVA DASH assessment and MARAC which had raised her situation to that of High Risk. 104. Given the previous IDVA1 DASH and MARAC high risk classification the MASH, on this occasion came to the same conclusion of High Risk. Despite the ten year non-molestation order having been granted in September 2014, and having been lodged at Blackpool Police Station on the 24 September, the details (conditions) were not on the PNC. This meant that the Police could not confirm if there was a power of arrest attached to it. In the event there was, as evidenced by the non-molestation order being noted (in the Police/MASH documentation of this PVP), on the 16.01.15, to be on the PNC with a conditional power of arrest. Arguably, it would have been a reasonable decision to have arrested PMLI for breach of the order, given that he had contravened the conditions of the Court. 105. It is not known why the full details of the non-molestation order, including the powers of arrest, were not entered in a timely way onto the PNC, especially as the order from the Family Court had been lodged at Blackpool Police Station in the previous September. This omission would have implications for later actions taken by CSC regarding the referrals made by the IDVA and the LOCAL HOSPITAL 1 staff on the 22.04.16. ( See below at paragraphs 145 to 148) 106. Notwithstanding the High Risk PVP grading, the Continuum of Need (CON) recommendation by the MASH social worker (MSW1) concluded that S1LI and his mother’s situation met Level Three, namely a step down to children’s centre services. Whilst recognising that there was a risk that S1LI was being used as a tool between the couple, SWM1’s recommendation was accepted by the MASH Police sergeant and ratified by the CSC MASH team leader. The actions were that a referral was made to the MARAC and children’s centre services were to ascertain that all necessary supports were in place for S1LI and mother. In fact, MLI had declined early support from the local children’s centre in the previous November. Comment 107. In all the circumstances of the time, it would seem that the MASH social worker (MSW1) made a defensible decision to designate the PVP referral at Level 3. However, this meant that the PVP referral did not go to CSC at -statutory intervention- Level 4 , namely Children in Need and/or Section 47 child protection services and was therefore not entered onto that agency’s electronic case recording system (Liquid Logic). A consequence of this was that the PVP incident did not show up at the later child protection referral to CSC of April 2016. 108. The final PVP referral made on the 30.07.16 was submitted by the attending police officer to the MASH at Standard Risk, which, at that time, were not passed onto CSC; and hence, was not recorded. Therefore concerns about the children were not passed to the social worker in the 19 MASH for assessment against the CON.The incident never registered on the CSC recording system and the referral was closed by the MASH. 109. Given the existing ten year non-molestation order, the circumstances of the incident, ‘ A massive blow out over the twins’, the previous three PVPs and the two MARACs at ‘High Risk’, there is a strong case for this PVP to have been submitted at the very least as a Medium Risk. It may have been that the attending officers were not in full possession of the relevant information, notwithstanding that the non-molestation order, should at that time, have been recorded on the PNC. 110. In any event, MASH Police staff could have challenged the Standard Risk grade and elevated it to medium or even high. Had this been done, the referral would have been considered by the MASH social worker, graded against the CON at Level 4 21and possibly resulted in a strategy discussion and/or further intervention from CSC. Comment 111. In summary, none of the first three PVPs warranted a referral to CSC as they did not meet the Level 4 statutory intervention/assessment threshold. The final PVP was not considered by the MASH social worker (MSW1) because of its, arguably incorrect, Standard Risk designation. Therefore, the existing MASH processes had resulted in a systemic outcome whereby any concerns for the children would need to reach Level Four of the CON in order to trigger a statutory response ( i.e a potential Child in Need/Child Protection intervention) from CSC and the opening of a case record. Consequently, at no time during the period in question were LI or the two siblings ever an open case to the CSC. Of significance, nor was there any record available that would give the bigger, historical picture of the children’s experiences whilst in the care of their mother and the attendant implications of potential risk from the two adults. In essence, the children were never on CSC’s radar. 112. A key lesson emerging from the above analysis would suggest that consideration should be given to entering a ‘Flag and Tag’ on CSC and Police electronic recording systems ( ‘ Liquid Logic’) of all-including ‘ Standard- PVPs involving children. This would enable the MASH social worker, CSC and the Police to have access to a fuller historical context of a referral involving a child and lead to a more informed and better understanding of potential risk to children, especially within the context ( as in this case) of perpetrator coercive and controlling behaviour. 113. ‘ Flag and tag’, of all PVPs by CSC and the Police would also alert CAFCASS to possible child protection concerns when doing early safeguarding checks in private law family proceedings ( see below in section dealing with the CAFCASS section 7 report). The Two MARACs 114. There was a social worker present at both of the MARACs in December 2014 and February 2015. MLI’s situation was deemed to be High Risk. It was noted at the second MARAC that an action for the Police was to re-check PNC information in regard to the10 year non-molestation order. Appropriate actions were taken to mitigate the risk to MLI and S1LI from PMLI, including the IDVA having sent an e-mail on the 06.03.15 to the Police regarding amending the PNC in relation to the 10 year non-molestation order. 21 At the time Level 4 was split into CoN 4A ( Child in Need) and CoN 4B ( Child Protection) 20 115. It is not known whether CSC had(s) facilities to cross reference electronic recording systems ( Liquid Logic) with MARAC meetings and minutes that could have informed social work assessments of need and risk for children. However, it is the case that the social worker at the MARAC would record any information onto the LCS (Liquid Logic recording system) if the case was already open to CSC. This did not happen with MLI and S1LI as CSC did not open a case subsequent to the two MARACs, presumably because the level of risk and need to the child did not meet the Level 4 (CON) statutory intervention threshold. The lead reviewer and panel took the view that this arrangement was not child focussed. 116. The learning from this would suggest that, in a similar way to PVPs ( see above), CSC should arrange for all MARACs involving children to be, ‘ Flagged and Tagged up’, on its electronic recording system, irrespective of the threshold level of need (CON). CAFCASS Section 7 Report 117. CAFCASS received MLI’s application for a Child Arrangements Order sometime shortly after the first Family Court hearing of the 26.09.14, through a ‘Work to First Hearing’, notification. The Family Court Adviser (FCA1) had previously recommended that consideration be given to a judge-led conciliation meeting and for the parties to attend a Separated Parenting Information Programme (SPIP) to assist them in understanding the impact of parental conflict on S1LI. 118. As per standard procedure, safeguarding checks were conducted with the Police and the Local Authority into the adults and any known risks to S1LI. It is not known whether the two PVPs logged by the Police were notified to FCA1 although both associated incidents were known to the Family Court hearing of the 17.11.14. A safeguarding letter was filed on the 20.11.14 notifying the Family Court that the enhanced information did not raise any concerns or require any immediate action. 119. However, FCA1 would not have been aware at that time of either the IDVA1 DASH High Risk assessment made on the 20.11.14 or the subsequent MARAC of the 18.12 14 ( High Risk) which came after the filing of the letter. The Court had ordered on the 17.1.14 that CAFCASS file a Section 7 Report by the 18.02.15 for the hearing scheduled for the 24.02.15. 120. The Family Court judge, on the basis of the evidence presented at the hearing of the 17.11.14, varied the non-molestation order from one to ten years in duration. This was done on the grounds of PMLI’s previous record of domestic abuse and his current behaviour towards MLI, especially in relation to his uploading of a video of sexual imagery of her onto the internet (the so called ‘Revenge Porn’ episode). Moreover, he instructed that a copy of the judgement transcript be placed upon the Children Act file for consideration by the judge at the hearing of the 24.02.15. 121. Of significance to this Review, the judge also indicated that the transcript evidence be used by CAFCASS to consider whether or not to undertake a risk assessment of PMLI in the light of the findings made regarding the issue of PMLI’s continued contact with S1LI. The court’s concerns were specifically in relation to the sexual imagery (of MLI) that he had distributed onto the internet and the implications for S1LI’s welfare. 122. The judge was also of the opinion that the uploading of the video of MLI constituted firstly, harassment under paragraph three of his previous order of the 22.09.14 and secondly, posting of a derogatory statement relating to the applicant ( MLI). He was happy for MLI to refer the matter to 21 the Police and CPS to consider whether to prosecute for breach of the order. There was no evidence that she did this. Comment 123. In summary, serious findings were made against PMLI by the Family Court. The significant extension of the non-molestation order reflected the seriousness of PMLI’s coercive control and abusive behaviour towards MLI and the concerns of the court in this regard. Moreover, the court had concerns about the safety and welfare of S1LI in relation to the matter of continued contact with his father and any potential risk emanating from the ‘Revenge Porn’ episode. 124. It is of some concern that FCA3 did not address the risks to S1LI, from continuing contact with his father, in the updated Section 16 (a) risk assessment of the 06.01.15. This states that, ‘ If … an officer of the Service … is given cause to suspect that the child concerned is at risk of harm, he must a) make a risk assessment in relation to that child and b) provide the risk assessment to the court.’ ( CAFCASS Child Protection Policy 2014, page1) Comment 125. By the time of the updating to the court, there had been an IDVA DASH assessment (made on the 20.11.14) graded as High Risk and a MARAC held on the 18.12.14 that deemed MLI to be at High Risk from PMLI. The Review questioned why there had been no communication between FCA3 and the IDVA or MARAC about their involvement, as, arguably, the information sharing could have made for a more informed and accurate risk assessment had this been done. 126. The Review learnt from CAFCASS that the reason why this was not done was because of the Family Proceedings Rule 2010 (FPR 2010)22 which prohibits the dissemination of information relating to family proceedings without leave of the court, save in exceptional circumstances. IDVAs by virtue of r.2.3 FPR 2010 are not included in the tightly defined category of professionals, ‘ Acting in furtherance of the protection of children’. Moreover, MARACs; understood as a diffuse collection of individuals and not a legal corporate entity, are not included in the category of professionals. 127. CAFCASS, therefore can not share information with professionals who fall outside the Rules without leave of the court. It can however, where there are legitimate safeguarding concerns, share information with an, ‘Officer of the local authority exercising child protection functions’. This, in essence, is what permits a CAFCASS officer to make a section 47 referral to the local authority. 128. In this case the CAFCASS officer ( FCA3) was unaware of the two MARACs and therefore did not make contact with the MARAC chair to request the sharing of information. Although there would have been a CSC representative at the two MARACs no information was entered onto that agencies’ electronic recording system because the case did not reach Level 4; the statutory intervention threshold. In short, the two PVPs and two MARACs did not provide grounds for CSC to open a case on S1LI. 129. However, the ongoing family proceedings were known to the IDVA so it could have been possible for her to have contacted- with MLI’s permission- the CAFCASS officer with a view to have shared information. Had this been done, it could possibly have triggered a section 16a 22 See the document , ‘MARACs and disclosure into court proceedings’, produced by the Working Party of the Family Justice Council ( Family Justice Council/CAADA); December 2011. Also, ‘ MARACs and Disclosure From Family Court Proceedings’, ( CAFCASS) 22 assessment coupled with a request for the court’s leave to disclose to the IDVA and members of the MARAC, relevant information from the family proceedings. 130. The Review learnt from the CAFCASS panel member that in some areas the local MARAC will ask a routine question where children are involved, whether there are court proceedings and CAFCASS involvement. This affords the opportunity for the MARAC chair to consider whether any relevant information should be shared with CAFCASS and passed onto the family court. 131. A key piece of learning indicates the need, in circumstances where children are involved in domestic abuse, for the IDVA service and the wider MARAC system- including CSC and the Police- to develop communication links with the family court and CAFCASS. 132. It is not known why FCA3 did not produce a risk assessment of S1LI’s situation or why this was not picked up by the manager. There appeared to be no management oversight and sign-off. Arguably, it would have been helpful if FCA3 had had sight of the transcript of the Hearing of the 17.11.14 and the finding of serious risk in relation to PMLI, although this was not requested until the 19.12.14 by FCA3. In this regard it is of some concern that CAFCASS did not receive the transcript until the 11.02.15. Ideally, the findings judgement should have been sent to CAFCASS at the time that the Section 7 hearing was ordered, namely on the 17.11.14. 133. The learning point from this practice episode suggests that the Family Court needs to send findings, judgements and transcripts in a timely way to CAFCASS in order for it to provide accurate and full reports; and appropriate recommendations to later hearings. 134. By the time of the completion of the S.7 report on the 18.02.15, the CAFCASS family court adviser had interviewed both parents and seen the transcript of the earlier hearing containing the findings and concerns of the judge regarding S1LI’s continuing contact with his father. The family court adviser undertook a DASH assessment and concluded the risk to be high. There was no evidence that he was aware of the High Risk DASH assessment of the IDVA and the actions of the two MARACs. It is not known whether MLI mentioned her ongoing involvement with IDVA1 and the MARAC. 135. The report made no mention of the 10 year non-molestation order but did note that PMLI did not accept the Court’s findings in full, in particular the ‘ Revenge porn’ finding and concluded that, ‘ The impact of this in relation to the request of the Court and the risks that PMLI poses to MLI and the impact upon S1LIin the long term is significant.’ 136. The family court officer (FCA2) identified that PMLI had a lack of understanding about the impact of his abusive behaviour towards MLI on his son regarding emotional harm and the longer term implications of domestic violence on children, being immense. 137. Notwithstanding the High Risk assessment and PMLI’s lack of insight of his behaviour on S1LI and his mother, the report recommended a Child Arrangements Order being made on S1LI, to include a plan for the child to spend time with their father. Whilst recognising the risks to S1LI, the plan could proceed to overnight stays, ‘ Following completion of the SPIP (Separated Parents Information Programme) course23 and referral to the DVPP (Domestic Violence Perpetrators Programme) course…….(and) PMLI to continue with seeking assistance from his GP re anger management.’ 23 To include MLI. 23 138. It was noted that a DVPP referral would be made on condition that PMLI was able to fully accept the findings of the Court, which needed to be, ‘ Fully explored by the Court. The Court needs to be assured that PMLI fully accepts and takes responsibility the findings made against him by the Court.’ 139. The report noted that attendance on the aforementioned programmes would alleviate, ‘ Some of the risks and fears that MLI has in respect of coming to terms with the contact moving forward and leading onto S1LI having overnight with his father.’ Comment 140. Clearly then, FCA2 was very aware of the significant risks to S1LI from his father and had recommended to the court that any progress on contact should be conditional on PMLI’s full acceptance of the court’s previous findings regarding his abusive and controlling behaviour and attendance on the SPIP and DVPP programmes. In this regard, FCA2’s Section 7 report and risk assessment was the only example of an agency seeking to safeguard both MLI and, in this case, S1LI. 141. It is not known how thoroughly the Court fully explored the analysis, conclusions and recommendations of FCA2’s section 7 report. In the event, the requirements for PMLI to attend the SPIP and DVPP programmes prior to increased contact with his son were not implemented, despite the risks set out by FCA2. It is not known why the court chose this course of action. Arguably, it would have been in S1LI’s interests for the court to have followed the recommendations of FCA2 and asked for a progress report at a later date, before considering whether to proceed to overnight contact. Given FCA2’s concerns about potential risk from PMLI it was open to the court to order the local authority to undertake a section 37 ( Children Act, 1989) assessment. 142. In any event, CAFCASS’s involvement with the family finished with the conclusion of the final hearing of the Family Court on the 24.02.15, albeit there was an unexplained delay in closing the case on the 06.05.15. The IDVA DASH Assessment of 21.04.16 143. IDVA1 assessed the risk as ‘Low’ giving a DASH/Safelives score of six based upon the replies from MLI. She told IDVA1 that she was not living with PMLI although this was challenged by the health visitor who had seen him. There is a suggestion that MLI tended to minimise her responses to IDVA1who in completing the DASH/Safelives assessment would have considered the implications of pregnancy, babies and young children in the family. ‘ The presence of children increases the risk of domestic violence for women ( Walby and Allen,2004)………..There is a significant association between risk and the number of children in the household, the greater the number the higher the risk………The presence of step children in particular increases the risk to both the child and the woman……Clearly, young children are extremely vulnerable in situations of domestic abuse and consideration must be given both to the risks that they face and the risks to the mother.’ (Safelives, 2014, 6-7) Comment 144. MLI declined any IDVA support and said that she was able to recognise any signs of controlling or abusive behaviour from PMLI and would contact the Police if necessary. Given the 24 information provided by her and the refusal of support it is difficult to see what else IDVA1 could have done to protect MLI and the three children. In the event she correctly ensured with the midwife that a safeguarding referral was made to CSC. The Safeguarding Referral to CSC of the 22.04.16 145. CSC’s decision of no further action was based upon, firstly, the information from the health visiting team that suggested the couple were not residing together, albeit that their relationship was unclear. No concerns were raised about MLI’s care of the children; she was aware of her responsibility to safeguard them. She said that they were her priority above that of PMLI. She also reportedly had support from her family who lived close by. Secondly, there had been no concerning incidents since December 2014 when MLI had contacted the Police to report PMLI. This had involved a verbal argument over contact with S1LI. Thirdly, checks with the MASH established that there was no outstanding order against PMLI, despite the ten year non-molestation order being extant an on the Police PNC. Fourthly, the IDVA had recently completed a DASH assessment which concluded that the risk to MLI was low at six points. 146. On the information provided by other agencies and MLI herself, the assessing social worker and the manager concluded that there was no evidence of any current safeguarding concerns regarding the children, or that MLI was the victim of any current domestic abuse or any risk of domestic abuse. The situation was being monitored and supported by the health visiting service who would refer back to CSC in the event of any further domestic abuse concerns. Comment 147. It would seem that the decision not to proceed to a Children and Family assessment was predicated upon incomplete information. Firstly, there had been three PVPs and two MARAC’s prior to the referral, which, with the exception of the December 2014 MARAC, were not evident to CSC, because of the CoN threshold issue and absence of an open case on the children, noted above. The December MARAC had actually resulted in a ‘High risk’ designation (partly due to the ‘ Revenge porn’ episode) which was not mentioned in the CSC assessment. Moreover, the third PVP in January 2015 had not been picked up, as had, very significantly, the matter of the ten year non-molestation order which should have been on the Police PNC since January 2015. In the opinion of the Review it would also have been good practice to have spoken directly with the IDVA regarding her assessment. Comment 148. Had the three PVPs and the two MARACs been flagged up on CSC’s Liquid Logic as mentioned above and the ten year molestation order been known about, in addition to a conversation with the IDVA, this may have resulted in the CSC undertaking a Child and Family assessment. This, in turn, may have provided a fuller and more accurate assessment of the needs of the children and the potential risks-particularly in the context of coercive control; albeit that the concept was not widely appreciated at the time- they faced whilst in the care of their mother and PMLI. That said, there could have been several possible CSC intervention outcomes, ranging from, no further action, through to children centre/early help, Children in Need and statutory child protection action. 25 The injuries to LI of the 02.08.16 and the health visitor’s 3-4 month maternal and infant health assessment of the 04.08.16 149. Regarding the bruising to LI’s cheeks identified by the Police investigation and established as a finding of fact in the later care proceedings on the three children. The lead reviewer was not able to speak to HV2 as this was outside of the control of the Serious Case Review. It was documented that on the 04.08.16, HV2 completed a health assessment on LI and the twin and concluded that they were, ‘ Meeting their developmental milestones’. Assuming that the bruising was visible, there was no evidence that any questions had been asked by HV2 about its causation and the implications for LI and her siblings. Alternatively, it may have been that the bruising had faded and was no longer visible to HV2 at her visit, as it was not known when the bruising was caused. Although it was photographed by MLI on the 02.08.16 it may have been sustained some time before. Comment 150. There are thus two possibilities, firstly, that the bruising was visible at HV2’s visit and she did not see them. Secondly, that they had faded and were no longer visible. The Child Protection Enquiry of the 25.08.16 151. From the evidence provided the multi-agency child protection enquiry into the injuries sustained by LI was well conducted and in accordance with LSCB policy and procedures. 152. It is not known how and why the decision was made to leave LI’s siblings in the care of family members without there having been a risk assessment into their safety and well-being. 153. Enquiries were made by the review of the North West Ambulance Service (NWAS) into why there was a 42 minute delay from the telephone call being made to the arrival of the ambulance. NWAS reported that the 999 call from MLI was graded as Red 2 which is classed as potentially life threatening and commands an 8 minute response ( 75% of the time), this being a national standard. The emergency medical dispatcher continually searched for a nearer resource to allocate to the call. The delay was caused by the high volume of 999 calls at that time and protracted handover times at the local hospital 1. ToR 2 Comment critically on the effectiveness, or otherwise, of agency and multi-agency interventions-including early help and support for the carers- regarding planning, implementation and review that sought to safeguard and protect LI and her siblings from harm, including domestic abuse. PVPs and MARACs 154. Following the two PVPs made in September and October 2014, MLI obtained a ten year non-molestation order, with conditions, against PLMI. The judge made the lengthy order because of the compromising video that had been made by PMLI who subsequently posted it on the internet. As previously noted, the order was lodged on the 24.09.14 at the local Police Station. 26 155. Based on the MASH assessments and the IDVA1’s ‘ High Risk’ DASH assessment made in November 2014 ( see paragraphs 32-35 above ) and the first MARAC of the 18.12.14, a protective plan as set out in paragraph 11 above, was initiated for MLI.This included her and S1LI being referred to a children’s centre. By this point she was living with a sister and awaiting her own accommodation. The second MARAC of mid-February (following the third PVP of 06.01.15) updated the original set of protective actions and included a joint visit from IDVA1 and a police officer (PC1) in early March. MLI choose not to engage with the children’s centre which precluded her from receiving any early help and support. She had taken appropriate action in leaving PMLI, obtaining the ten year non-molestation order and applying for her own accommodation, in addition to being supported by her own family. Comment 156. There was therefore effective intervention taken through the Family Court and MARAC process to protect MLI and S1LI from PMLI. Regarding formal child protection measures for S1LI, there were none taken because none of the three PVPs resulted in Children’s Services within the MASH deciding on statutory intervention by undertaking a Level 4 Child and Family assessment. As previously mentioned this was because MLI’s circumstances did not reach the prescribed threshold, as per the Continuum of Need ( CoN) operating at that time. The reasons for this are set out above at paragraphs 107 to 111. CAFCASS and the Child Arrangement Order 157.Despite FCA2 producing a very sound Section 7 report based upon an effective and comprehensive risk assessment the Family Court decided not to implement the underpinning recommendations to the child arrangement order ( see above at paragraph 141). Comment 158. Given the independence of the Family Court24 it has not been possible to ascertain why directions were not made in accordance with FCA2’s recommendations. As previously noted at paragraph 103, given the documented risks from PMLI to S1LI it was open to the court to have ordered the local authority to undertake a section 37 (Children Act, 1989) assessment. There was therefore no protection planning or review emanating from the child arrangement order. The IDVA DASH Assessment of 21.04.16 Comment 159. As previously mentioned and for reasons set out above (at paragraphs 143-144) the IDVA DASH assessment did not result in a referral to the MARAC and a resultant protection plan. 24 See, ‘ President’s guidance: Judicial Cooperation with Serious Case Reviews’, issued by Sir James Munby, President of the Family Division on 2 May 2017. 27 The Safeguarding Referral on the 22.04.16 to CSC from the Midwife Comment 160. As noted above the referral resulted in no further action and hence no resultant child protection plan. The reasons for this outcome are set out at paragraphs 145-147 above The Child Protection Enquiry of the 25.08.16 Comment 161. This was conducted in an effective manner resulting in a sound child protection plan. It was well implemented and subject to review which protected LI and her siblings from further abuse. There was good information sharing both between Lancashire agencies and also with the out of area police force and hospital. Decisions were made by the Lancashire local authority that were child focussed and promoted the safety and well-being of the children. Indeed, they became subjects of care orders in August 2017 and are now being well cared for as children looked after by Lancashire County Council. Decisions were compliant with the policies and procedures of the Lancashire Safeguarding Children Board. ToRs 3 and 4 Examine the effectiveness, or otherwise, of inter/intra-agency working, including information sharing and case handovers/transfers, both within and without Lancashire in relation to safeguarding LI and her siblings. Examine the efficacy, or otherwise, of decisions made and actions taken to safeguard LI (including pre-birth) and her siblings. How child focused were they and did they comply with agencies’ policies and procedures and those of the Lancashire Safeguarding Children Board? 163. There was effective information sharing and inter-agency working between the Police and the IDVA service regarding the first three PVPs in late January 2015 resulting in the MARAC considering the case and a sound plan that mitigated the risks to MLI and S1LI. The CSC at the MASH assessed the PVP at Level 3 and stepped down the referral to children’s centre support services which was the appropriate decision given the CoN framework of the time. As was noted above, MLI declined the offer of early support from the children’s centre. 164. The omission by the police to enter the ten year non-molestation order, with the conditions, on to the police national computer at the point of notification by the family court in September 2014, fell short of expected practice and was not compliant with procedure. It is not known why this was not done sooner that March 2015. Had this information been known at the time of the third PVP in January 2015, arguably, PMLI would have been arrested for breaching the conditions of the non-molestation order. 165. Communications issues between CAFCASS and the local MARAC (including the IDVA service) in respect of the Family Proceedings Rule 2010 have previously been addressed above in paragraphs 111-116. 28 Comment 166. This SCR has learnt that CAFCASS produced a, ‘Practice Pathway’, in May 2016 setting out a structured approach to risk assessment in domestic abuse. The guidance is mindful of the impact of domestic abuse on children in private law applications and makes reference to the need, where appropriate and with the Court’s leave, for a referral to be made to the local MARAC. A key piece of learning is the need for local MARACs to routinely enquire whether there is any CAFCASS involvement in domestic abuse cases involving children. 167. As was noted above, FCA2 produced a very good section 7 report for the child arrangement application which appropriately recommended several conditions including attendance by PMLI at a SPIP and a court referral for him take part in a DVPP. This was good practice by the FCA and it was unfortunate that the Court, for reasons unknown, did not agree to this as a court ordered activity (COA). Doing so would, self-evidently have been in accordance with the paramount , ‘ Welfare principle’, of the child as per section 1(1) of the Children Act 1989 and in the interests of S1LI. Comment 168. Notwithstanding the independence of the judiciary, a lesson from this episode suggests that, unless there are compelling reasons not to do so, the recommendations of the FCA should ordinarily be followed if they are demonstrably consistent with the paramount welfare of the child as per section 1 of the Children Act 1989. 169. Analysis of inter-agency practice and decision making in relation to the IDVA DASH assessment and midwifery safeguarding referral to CSC in April 2016 can be found above at paragraphs 143-147. 170. Analysis of inter-agency practice and decision making regarding the child protection enquiry and resulting child protection plan for the three children can be found above at paragraph 151-153. ToR 5 Examine the involvement of other significant wider family members in the life of Child LI and her siblings including a consideration of the potential for caring for the children. 171. There was significant wider family involvement with MLI and the children, especially in late 2014 and 2015 when MLI had separated from PMLI and received support from one of her sisters. MLI moved around her family network and at different times was supported by her father and other siblings. This may have caused difficulties for professionals to stay in contact. However, it seemed that professionals’ involvement with the wider family was limited, albeit adequate to the circumstances. 172. The ToR will be augmented following visits to the wider family. 29 ToR 6 Examine to what extent safe handling advice and support was provided to the carers. 173. The SCR learnt that within the Lancashire midwifery service all parents are offered the baby steps programme, which includes safe handling. However, in this case it was not documented whether the programme was offered to MLI and if it was, whether she took it up. The lead reviewer learnt that the health visitor (HV2) had covered safe handling with MLI. Part 6 Findings and Conclusions ToR 1 174. Effective actions were taken to protect MLI and S1LI from domestic abuse and harm following the three PVPs and two MARACs of 2014 and 2015. 175. The CAFCASS section 7 report provided a sound risk assessment for the Family Court’s consideration in regard to S1LI and the potential for harm from his father. Unfortunately, the Court choose to ignore the risk mitigating conditions set out by FCA2 prior to granting PMLI increased ( overnight) contact with S1LI and was not in the child’s best interests. 176. The IDVA DASH risk assessment of April 2016 was dependent on the information given by MLI which indicated a low risk, albeit there was a suggestion that she was minimising. Given the circumstances of the time, the low risk outcome was, in the opinion of the lead reviewer, a reasonable and defensible decision. 177. The CSC assessment of April 2016 was based upon incomplete and inaccurate information as set out in the above paragraphs (120-122). The result was a partial understanding of the situation which tended to minimise the potential risks to the children and their mother. There was a tendency to see the various episodes of domestic abuse as isolated events and not as part of a bigger picture of a pattern of control and coercion of MLI by PMLI. 178. In this sense, the CSC assessment was ineffective as it did not lead to a fuller Children and Family assessment. However, even if there had been such an assessment this would not necessarily have resulted in a formal child protection outcome, as arguably, the circumstances would not have met the threshold for Level 4 ( statutory) intervention. However, the family, including LI and her two siblings would have been an opened case and therefore entered on the CSC electronic recording system ( Liquid Logic); in short they would have been on CSC’s ‘radar’. 179.The fourth PVP at the end of July 2016 was sent in as, ‘Standard’, risk and therefore did not proceed to a MARAC or lead to a consideration by CART of the potential safeguarding issues for the three children. This should have been re-assessed by the MASH as, at least, ‘Medium’. Had this happened, MLI might have been protected by a MARAC and the children’s potential risk environment assessed. 180. None of the first three PVPs warranted a referral to CSC as they did not meet the Level 4 child protection threshold. The final PVP was not considered by the MASH social worker because of its, arguably incorrect, Standard Risk designation. Therefore, the existing MASH processes had 30 resulted in a systemic outcome whereby any concerns for the children would need to reach Level Four of the CON, to trigger a child protection response from the CSC and the opening of a case record. 181. Consequently, at no time during the period in question were LI or the two siblings ever an open case to the CSC. Of significance, this meant that there was never any record available that would give the bigger, historical picture of the children’s experiences whilst in the care of their mother and the attendant implications of potential risk from PMLI. In essence, the children were never on CSC’s radar. 182. A key issue for contemporary practice is the need to locate the domestic abuse suffered by MLI during the time-frame in question within the context of ‘ Coercive control’, albeit that the legislative framework and accompanying guidance25 (the Serious Crime Act 2015, section 76) was not implemented until December 2015. 183. It is suggested that MLI’s experiences of domestic abuse and the implications for the children of risk from PMLI would now better be understood by agencies within the context of coercive control. 184. Therefore a core piece of learning from this Review suggests that current and future multi-agency policy and practice should understand and locate the risk assessment and management of children who experience domestic abuse within the wider context of coercive control. It is noted that there is no reference to coercive control in the current (2009) Lancashire County Council/ Lancashire Constabulary, ‘Domestic Abuse Guidance and Protocol. It is suggested that this should be updated to include coercive control. ToR 2 185. Given that MLI and S1LI were not living with PMLI in early 2015, the existence of the ten year non-molestation order and the support she was getting from her own family, it can be concluded that the MARAC plan and IDVA intervention were effective in protecting MLI and S1LI from domestic abuse and harm from PMLI at that time. 186. There was also effective liaison and communication between the IDVA and the Police in implementing the MARAC multi-agency plan. 187. The decision to review and end her involvement with MLI by IDVA1 in May 2016 was appropriate given that the known circumstances and risk factors did not warrant any further intervention. Moreover, MLI was not requiring any continuing support. 188. The child arrangement order did not did not protect S1LI from potential abuse from his father because there was no mandated court ordered activities in relation to SPIPs and DVPPs. 25 See Home Office guidance , ‘ Controlling or Coercive Behaviour in an Intimate or Family Relationship’ ( December 2015) 31 ToRs 3 and 4 189. Information sharing and inter-agency working between the Police and the IDVA service was effective regarding the initial three PVPs in late 2014 and January 2015. The two MARACs provided for a sound plan that managed the risk from PMLI to MLI and S1LI. 190. There was sub-standard practice by the Police in not entering the ten year non-molestation order, with accompanying conditions, on to the PNC in October 2014 in compliance with the court’s expectation. Had this been done in a timely way it is likely that PMLI would have been arrested in January 2015 for breach of the order. 191. A key piece of learning indicates the need, in circumstances where children are involved in domestic abuse, for the IDVA service and the wider MARAC system- including CSC and the Police- to develop communication links with the family court and CAFCASS. Consideration should be given for local MARACs to routinely enquire whether there is any CAFCASS involvement in domestic abuse cases involving children. ToRs 5 and 6 192. MLI received good support from her wider family when asked for. 193. Safe handling was included the midwifery service, ‘ Offer’, and addressed by the health visitor with MLI. Part 7 Key Learning Points and Improvements 194. The Lancashire Safeguarding Children Board and its partners are challenged by this SCR to consider what actions are needed to translate and implement the following key learning points and suggested improvements. The need to consider, ‘Flagging and tagging’, all domestic abuse PVPs (including Standard) involving children onto CSC’s Liquid Logic and Police electronic recording systems in order to get the ‘Big picture’ of the historical extent of domestic abuse and whether coercive control is a factor. This should include all children irrespective of whether or not they are an open case to CSC. The need to consider ‘, Flagging and tagging’, all MARACs involving children onto CSC’s Liquid Logic and the Police case recording systems, irrespective of whether or not they are an open case to CSC. The need for the local MARAC to routinely enquire whether there is any CAFCASS involvement with a child where their carer is subject to a MARAC plan. The need for Lancashire Police to ensure that non-molestation orders and their accompanying conditions are placed, in a timely manner, on appropriate information platforms ( e.g. the PNC) The need for family courts to consider following the recommendations of CAFCASS FCAs in regard to mandating appropriate court ordered actions (CAO) such as SPIPs and DVPPs. The need for family courts to be given the outcomes of CAOs so as to inform decisions about children in accordance with the paramountcy principle. The need to raise awareness, understanding and the use of the legislation and practice around coercive control amongst professionals and agencies. 32 The need for coercive control to be included in local multi-agency guidance and strategic planning. Part 8: Glossary of Terms Family LI Subject Child MLI Mother of LI S1LI Older ( half) sibling to LI S2LI Twin to LI PMLI Partner to MLI and father to S1LI S1 Sister to MLI Professionals FCA1 Family Court Adviser 1 FCA2 Family Court Adviser 2 HV1 Health Visitor 1 HV2 Health Visitor 2 HV3 Health Visitor 3 IDVA 1 Independent Domestic Violence Advisor 1 MSW1 MASH social worker 1 PLN Paediatric Liaison Nurse PO1 Police Officer 1 Terms A and E Accident and Emergency Dept. CAADA-DASH Co-ordinated Action Against Domestic Abuse-Domestic Abuse, Stalking and Honour Based Violence risk assessment CAFCASS Child and Family Court Advisory Service CC1 Children’s Centre CMW Community Midwife COA Court Ordered Activity CoN Continuum of Need CSC Children’s Social Care CPS Crown Prosecution Service DfE Department of Education DVPP Domestic Violence Perpetrators Programme ( Lancashire) EDT Emergency Duty Team ( Lancashire Social Care) 33 FPR Family Proceedings Rule GP General Practitioner IDVA Independent Domestic Violence Adviser LADO Local Authority Designated Officer LSCB Lancashire Safeguarding Children Board MARAC Multi-Agency Risk Assessment Conference MASH Multi-Agency Safeguarding Hub NSPCC National Society for the Protection of Children NWAS North West Ambulance Service PNC Police National Computer PVP referral Protection of Vulnerable Person SIO Police Senior Investigation Officer PICU Paediatric Intensive Care Unit SCBU Special Care Baby Unit SCR Serious Case Review SPIP Separated Parents Information Programme ToRs Terms of Reference YOT Youth Offending Team References 1. CAFCASS Child Protection Policy; 2014 2. Evan Stark; 2009 3. Family Law Act;1996 4. Home Office Guidance, ‘ Controlling or Controlling Behaviour in and Intimate of Family Relationship’; December 2015 5. Lancashire MASH Operational Manual ( Version 9, Update) February 2018) 6. LSCB MASH-Diagnostic ; July 2016 7. Lancashire Continuum of Need and Threshold Guidance LSCB; Refreshed May 2016 8. Protecting Children in Wales; Guidance for Arrangements for Multi-Agency Child Practice Reviews, 2012: Welsh Government 34 9. President’s Guidance, Justice J Munby;President of the Family Division; 2 May 2017: ‘Judicial Cooperation with SCRs’ 10. Working Together to Safeguard Children 2015, HM Government/Department for Education 11. Working Party of the Family Justice Council, 2011; MARACS and Disclosure into Court Procedures; Family Justice Council/CAADA |
NC048193 | Death of an 8 week old girl, Child S, in October 2015 whilst sleeping with her mother on the sofa. Child S was taken to hospital following a cardiac arrest and life support was withdrawn after three days. The post mortem gave the cause of death as natural causes. At the time of writing this report the coroner's inquest had not taken place. Child S was subject to an interim supervision order and a child protection plan at the time of her death. The family was known to Swindon Borough Council Children, Families and Health, Great Western Hospitals NHS Foundation Trust, CAFCASS. Child S had three siblings who lived with the mother who also had child protection plans and children in need plans. The father was sentenced to a community order for common assault which prevented him from contacting the mother, the victim of the assault, since March 2014. There was evidence of parental misuse of drugs and alcohol and domestic abuse was witnessed by children who were also subject to child neglect. There were concerns that child S did not seem to be feeding well in the weeks leading up to her death. Issues identified include: the impact of neglect, the impact of time spent in hospital on ability to care for children, communication gaps between organisations, delays between health visits for a vulnerable baby when the health visitor was unavailable and the workload of safeguarding midwife. Recommendations include:minimum requirements of GPs involvement in child protection processes are agreed; make training available to Children and Families staff regarding the effects of long term drug use on the brain and to consider the impacts on patient's ability to care for their family after a discharge from intensive care.
| Title: Serious case review: Child S. LSCB: Swindon Local Safeguarding Children Board Author: Helen Davies Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review Child S November 2016 1 TABLE OF CONTENTS Page 1. Introduction 2 2. Arrangements for Serious Case Review 3 3. Methodology 5 4. Brief Chronology 6 5. The Family 9 6. The Agencies 11 6.1. Wiltshire Police 11 6.2. The General Practitioners 12 6.3. Great Western Hospitals NHS Foundation Trust 13 6.4. Swindon Borough Council Children, Families and Community Health 14 Health Visiting 14 Social work 15 6.5. Swindon Borough Council Law and Democratic Services 16 6.6. Cafcass 18 6.7. Wiltshire Probation Trust 19 6.8. Swindon Borough Council Education Service 19 6.9. Swindon Borough Council Housing Services 19 6.10. Coram Voice 20 6.11. NSPCC 20 7. Key Issues 21 7.1. Communication 21 7.2. Professional Standards 21 Assessment 21 Identification of Neglect 22 The Children’s Voices 23 Decision Making and Risk Analysis 23 Effective Professional Practice 24 7.3. Organisational Issue 24 7.4. Safe Sleeping 25 8. Conclusion and Lessons Learned 26 9. Recommendations 28 Appendix A Composition of Case Review Group 30 Appendix B Details of Independent Lead Reviewer 31 Appendix C Terms of Reference 32 Appendix D Principles Underpinning Review 33 Appendix E References 34 2 1. INTRODUCTION 1.1 In October 2015 child S, aged 8 weeks, was taken to hospital following a cardiac arrest. Her mother had fallen asleep on the sofa with child S and awoken to find that she was unresponsive. She was placed on life support in a specialist paediatric intensive care unit; following deterioration in her condition, life support was withdrawn three days later when she died. The post mortem report gave the cause of death as natural causes. At the time of writing this report, the coroner’s inquest has not taken place. Child S was subject to an interim supervision order and a child protection plan at the time of her death. 1.2 This matter was referred to the Local Safeguarding Children Board in Swindon where child S lived. On 5 November 2015, the Case Review Group (CRG) of the Swindon Local Safeguarding Children Board (SLSCB) met to consider whether the criteria for a serious case review were met. 1.3 There is a legal requirement, as defined in statutory Guidance, Working Together to Safeguard Children 2015, to undertake a serious case review when abuse or neglect of a child is known or suspected and - either a child has died, or - a child has been seriously harmed and there are concerns about how organisations or professionals worked together to safeguard the child. 1.4 At its November meeting, the CRG concluded that the criteria for a serious case review (SCR) were met, whilst recognising similar issues/potential overlap and learning with another current SCR. The Independent Chair undertook to discuss with the Lead Reviewer for the other SCR and undertake a peer challenge with another experienced LSCB Chair. Following these processes, she decided on 27 November 2015 that the SCR criteria were met, as the child was subject to a child protection plan and interim supervision order, and neglect was a factor in the decision to issue care proceedings, but that the SCR needed to be proportionate. 1.5 The purpose of a serious case review, as set out in statutory Guidance, Working Together 2015, is to identify improvements which are needed and to consolidate good practice in order to prevent similar deaths or serious harm. This report has been commissioned and published by: Swindon LSCB 3rd Floor Wat Tyler West Beckhampton Street Swindon SN1 2JG Tel: 01793 463803 Email: [email protected] Website: www.swindonlscb.org.uk 3 2. ARRANGEMENTS FOR THE SERIOUS CASE REVIEW 2.1 The SLSCB decided that its Case Review Group would be the reference group for this review. It was chaired by Alex Walters, the Independent Chair of the Board. Its function was to manage and oversee the conduct of the review. The membership of the CRG is set out at Appendix A. The Board appointed an independent reviewer, Helen Davies, to lead the review and to write this overview report. She was assisted by Lesley Boorman, SLSCB Business Manager, and Fiona Francis, Swindon Borough Council (SBC) Service Manager, Quality Assurance and Review (SCR Champion). Further details are at Appendix B 2.2 Seven Individual Management Reviews (IMRs) were requested from the following agencies which had substantial contact with child S and her family: - Great Western Hospitals NHS Foundation Trust - Local Clinical Commissioning Group (Swindon general practitioners) - Swindon Borough Council Children, Families and Community Health including Heath Visiting and Social Work - Wiltshire Police - Swindon Borough Council Legal Services - CAFCASS (Children and Family Court Advisory and Support Service) 2.3 In addition, background reports were requested from agencies with less significant or less recent information: - Swindon Borough Council Housing Services - NSPCC - Coram Voice - Wiltshire Probation Trust - Swindon Borough Council Education Service 2.4 This report was written in anticipation that it will be published. Consequently, the information in the report is limited so as to; 1) take reasonable precautions not to disclose the identity of the child or family 2) protect the right to an appropriate degree of privacy of family members 2.5 Terms of Reference for this SCR are at Appendix C. Child S was the main subject of the review and its principal focus was from 1 April 2015 (when her mother’s pregnancy with child S became known to agencies) until 15 October 2015 (when child S died). However, all agencies were asked to provide a summary of all significant events and relevant family history outside the specific timescale and to consider any safeguarding issues for child S’s older siblings. 2.6 All individual management reviews addressed the terms of reference. All the authors of the individual reviews were independent of the case management, 4 and all conducted interviews with staff involved with child S and her family. At least 17 members of staff were interviewed. 2.7 Following consideration of the combined chronology of events and the individual reviews, the independent reviewer and the SCR Champion met at a learning event with thirteen professionals who had worked with child S and/or her family. They included a midwife, health visitor, social worker and her manager, and staff from the nursery and school attended by child S’s siblings. This provided a valuable opportunity to gain their perspectives of their work with child S’s family and to consider lessons learned. 2.8 Immediately afterwards, a smaller meeting was held with a social worker and her manager, a SBC solicitor and the Children’s Guardian to consider legal processes relevant to child S and her siblings. 2.9 After the first draft of this report had been compiled, the independent reviewer and the SCR Champion met with IMR authors and key professionals in order to seek their views on preliminary findings and on recommendations. Five IMR authors attended this meeting along with eight of the professionals who had attended the earlier learning event. A GP also attended this meeting. 2.10 A letter was also sent to the District Family Judge requesting her to consider if the review raised any issues from the perspective of the family court. To date, no reply has been received 5 3. METHODOLOGY USED TO DRAW UP THIS REPORT 3.1 This overview report relies on: - the agency IMRs and background reports - subsequent discussions with the CRSG reference group - dialogue with the IMR authors - discussion at the learning event in April 2015 - discussion at the follow up meeting in June 2015 - the views of Child S’s parents and grandmother, discussed in section 5 3.2 This report consists of: - a factual context and chronology - commentary on the family’s input to the SCR - analysis of the part played by each agency - closer analysis of key issues arising from the review - conclusions and recommendations 3.3 The conduct of the review has not been determined by any particular theoretical model. However, the review has been carried out in keeping with the underlying principles of the statutory Guidance, set out in Working Together 2015. These are at Appendix D. 6 4. BRIEF CHRONOLOGY OF KEY EVENTS 4.1 This section of the report briefly describes key events from the birth of child S’s oldest sibling. Further detail is then provided at appropriate points throughout the report. 4.2 Child S lived with her mother and her three older siblings, all of whom are white British. The father of the children was not supposed to have any contact with the mother, but had some contact with the children (supervised by a family member). During her pregnancy, the mother told health professionals that child S had a different father, but after her birth it was confirmed that she had the same father as her three older siblings. The mother also has two other children, one of whom (now an adult) was brought up by her grandmother; the other is in foster care. As neither had been part of the household for many years, this report only refers to child S’s three siblings that lived with her. 4.3 The family had a considerable history of involvement with SBC Children and Families Service prior to the time frame of this review – for at least 20 years. The children spent several periods subject to child protection plans as well as children in need plans. The concerns were parental misuse of drugs and alcohol, domestic abuse witnessed by the children, and neglect of the children. 4.4 At the start of the time frame for this review, the Children and Families Service had no involvement with the family, the case having been closed at the end of January 2015 and stepped down to Team Around the Child (TAC). 4.5 In March 2015, the mother had her first contact with a midwife for her pregnancy with child S. The midwife rightly identified safeguarding concerns, given the past history, and notified these to the safeguarding midwife. 4.6 In April 2015 the mother was admitted to hospital suffering from a life threatening illness. Her three children were looked after by members of their extended family. During this period of hospitalisation, a grandmother and the children’s school made a referral to the Children and Families Service expressing concerns about the state of the family home and how the mother would cope after her discharge from hospital. 4.7 Later in April 2015 a strategy meeting was held attended by social work staff, the police and staff from the children’s school/nursery. The mother was due for discharge, but the meeting recommended that the children should remain with their grandmother until the family home had been cleaned up and that a safety agreement should be drawn up with the mother. If she did not comply, the children would be made subject to police protection. 4.8 By the end of April 2015, the condition of the family home had improved following input from friends of the mother. She signed an agreement in which she agreed to cooperate with a parenting assessment as well as maintain the house in a reasonable state, only allow the children to have supervised contact with their father (supervised by his mother) and to ensure that the children attended school/nursery. The children then returned home. 4.9 In May 2015, an initial child protection conference was convened, which concluded that the three children and the unborn child S should be made 7 subject to child protection plans under the category of neglect. A core group meeting was held 2 weeks later, when it was noted that the house was in a poor state again. 4.10 By June 2015 the state of the family home had deteriorated and the mother had failed appointments to progress the parenting assessment. Therefore, service manager approval was given for a legal planning meeting, which duly took place in early July 2015, when it was agreed to hold meetings under the Public Law Outline (PLO) with both parents. 4.11 In early July 2015, the first review child protection conference took place. All children, including unborn child S, remained subject to child protection plans under the category of neglect. Virtually, all concerns remained from the initial conference apart from improved school attendance, as a neighbour was taking the children to school. 4.12 The PLO meeting with both parents was held in mid July; the outcome was that the local authority would be applying for care orders on the children because the conditions in the home remained unacceptable and the social worker had been unable to progress the parenting assessment due the mother’s lack of cooperation. A few days later another core group meeting took place, which focused mainly on the arrangements when the mother went into hospital to have child S. 4.13 Child S was born in August 2015 and the hospital agreed that the mother and baby could remain in hospital until the outcome of the local authority’s application for interim care orders on child S and her siblings. The initial application for interim care orders/emergency protection orders before magistrates was referred to a judge later the same day. She agreed, as did the Children’s Guardian, with the extended family’s proposal to supervise the care of the children by the mother and made no orders. The mother and child S were duly discharged from hospital, subject to an extensive written agreement, which included the requirement that child S slept on her own. 4.14 Another court hearing took place before the same judge four days later. She did not consider that there was a trigger event (in the context of chronic neglect over an extended period) to justify interim care orders and the immediate removal of the four children from their mother. This was also the view of the Children’s Guardian. Interim supervision orders were made on the four children and assessments of the mother were commissioned. A contested interim care order hearing was scheduled for the end of October. 4.15 Another core group meeting was held early in September, when there were no particular concerns about child S. During September and early October, there was massive input from core group members to support the mother and children and improve the home conditions. This included an outreach support worker and visits at weekends. However, the cleanliness of the kitchen and bathroom continued to be of great concern. 4.16 The next core group meeting was held in the family home on 28 September 2015. There was considerable focus on sleeping arrangements, and the mother was reminded repeatedly about the risks of co sleeping, as it was unclear whether she was sleeping on the sofa in the lounge, close to child S who slept in a moses basket, or in her bedroom. During the meeting the health 8 visitor was concerned about child S who did not appear to be feeding well (she was breast fed) and seemed drowsy. After the meeting she weighed child S and was concerned about a drop in her weight. She made an appointment for the baby to be seen by a GP later that day. The GP was concerned about child S, but the baby was not dehydrated. He spoke with the health visitor by phone and understood that the family was having an assessment by their social worker later that day, so he did not refer for an immediate assessment; instead he referred her for a paediatric assessment. This had not taken place before her death. 4.17 On 12 October 2015, the mother woke early on the sofa to find child S lying beside her unresponsive. Child S was admitted to a children’s hospital and placed on life support. Sadly, her condition deteriorated and she died on 15 October after the support was withdrawn. Her mother explained that she must have fallen asleep while breast feeding her. No criminal charges were brought. 4.18 On 15 October 2015, child S’s three older siblings were made subject to interim care orders and placed in foster care. They were subsequently made subject to care orders and now live with a member of their extended family 9 5. THE FAMILY Child S’s mother 5.1 Child S’s mother agreed to speak with the author by phone. She was very positive about the health visitor, community midwife and all the staff at the specialist children’s hospital, all of whom she described as ‘amazing’. She felt that they all did their best to help her. She was also positive about the outreach support worker and the staff at the older children’s school. She was critical of the social workers as she considered that she did all they asked of her but it was never enough. She wished she had received more professional help (and help from her family) after her discharge from hospital in April 2015 when she was very weak. 5.2 Understandably, her main preoccupation was the loss of her three older children, which compounded the loss of child S. She did not believe that they should have been removed from her care, and she was unhappy with the current contact arrangements. In her view, the family member looking after them receives far more support than she did. Child S’s father 5.3 The father also agreed to speak with the author by phone. He did not feel able to comment on the agencies working with the mother and his children, as he was not involved with them. He took the same view as the mother that she needed more help after her serious illness, that she did everything that was asked of her by Children and Families, and the older children should not have been removed, and that the family member looking after them receives more support that the mother did. Child S’s grandmothers 5.4 The maternal and paternal grandmothers were also invited to contribute to the review. They both had considerable involvement with child S’s siblings and had, between them, looked after them on three occasions during the time frame of this review. The paternal grandmother agreed to speak with the author by phone. She praised the input from the nurses at the children’s hospital and from Wiltshire Police at the time of child S’s hospitalisation and death. The family was given contact details of five different bereavement services; she herself had benefited from contact with the Lullaby Trust, which had put her in touch with another bereaved grandmother. 5.5 The paternal grandmother also commented that the mother had valued her health visitor and appreciated the continuity, as she had known her for seven years. In her view the key issue was the state of the home and the mother would have benefitted from more help with cleaning. She also commented that the mother was very tired due to her recent illness and breast feeding; she was not getting enough sleep. 5.6 Her main criticism was the decision to move child S’s three siblings into foster care many miles from home on the day that child S died. In her view, this was not in their best interests and compounded the feelings of loss experienced by all family members. She felt that the process of securing the older children’s future should have been slowed down and options explored within the family. (They now live with a family member). In response, Children’s Services 10 explained the complexity of assessing family members and that placement so far away was in order to keep the three children together. 5.7 Despite several attempts to contact her, the author has not been able to speak with the maternal grandmother. 11 6. THE AGENCIES 6.1 Wiltshire Police 6.1.1 Wiltshire police had previous involvement with child S’s family recorded on their systems which relate to concerns around domestic abuse, child protection and drug/alcohol abuse. There was involvement with child S’s family on four occasions during the time frame of the review. The first was an investigation into child neglect in April 2015 following a referral from the siblings’ school about the state of the family home. The detective constable (DC), leading the investigation, worked closely with the allocated social worker. They advised that the family home was not in a fit state for the children to return following the mother’s discharge from hospital, and the DC advised that the children would be made subject to police protection if they returned before improvements had been made. On a later date, the DC and social worker checked the state of the house, which had improved dramatically following assistance from family and friends. A detective sergeant subsequently reviewed the evidence and decided that no further action was necessary. Her rationale was that, although the house had been in a very bad condition, the mother’s poor health meant that it was not proportionate to caution her. Following police and social work intervention, the situation had improved significantly; therefore, it was not in the public interest to seek a prosecution. Police involvement continued in the initial child protection conference. 6.1.2 The second involvement was in August 2015 when a strategy discussion was undertaken by the Multi Agency Safeguarding Hub (MASH) following a concern that the older siblings might be staying with someone who posed a risk to children while their mother was in hospital giving birth to child S. Social workers tracked the children’s whereabouts and it was established that they were safe. No further action was taken by the police. 6.1.3 The next involvement was the following day when further concerns were raised about the older children’s care while their mother was in hospital. The children’s services emergency duty service (EDS) requested that the police check on the children’s whereabouts as it was believed that their father was caring for them. Police officers visited the paternal grandmother, who confirmed that she was caring for the children. The officers saw the children. They then contacted the father, who confirmed that he had no contact with the children. No further action was necessary, apart from updating EDS. 6.1.4 The final involvement was on 12 October 2015 when the ambulance service notified police that child S was in cardiac arrest, and rapid response procedures were carried out. Two officers attended the family home, one of whom was the DS who had reviewed the child neglect investigation in April 2015 to allow continuity. This DS was in contact with children’s services and the specialist hospital during the next two days. She also took a statement from the mother and went to the hospital after she had heard about the baby’s death. 6.1.5 The IMR author concludes that the practice of the Wiltshire police officers and staff was entirely appropriate. While the decision not to caution the mother in April 2015 might be seen as controversial as there was sufficient 12 evidence to do so, the author is satisfied that the poor state of the house was part of a much bigger child protection concern in which the focus was intervention and support to rectify the problem. The lead reviewer agrees with her conclusion. 6.1.6 The IMR author also notes that the response officers went beyond the minimum requirements when checking on the children’s safety in August 2015. As well as seeing the children at the grandmother’s home, they additionally contacted the father independently, showing respectful uncertainty. She particularly commends the DS involved at time of child S’s hospitalisation and death for showing levels of compassion and support to the mother (and extended family) that went beyond what was expected of her in her role. 6.1.7 While the IMR author notes the generally good communication between Wiltshire police and children’s services in this case, she also notes learning in the circumstances when a child is critically ill but has not yet died, as it appears that, at times, the communication between the two agencies was disjointed. She, therefore, recommends that, in such circumstances, meetings/discussions should take place every 24 hours between the relevant DS and social worker to ensure that each is fully up to date with the other’s actions and intentions for that day. The lead reviewer endorses this recommendation 6.2 The General Practitioners 6.2.1 Two of child S’s older siblings, the mother and the father were all registered at the same GP practice, which has a very high caseload of vulnerable families. The third sibling had not been registered despite reminders, resulting in a delay in immunisations. However, both this sibling and child S had been registered by the time of her death. The practice was aware of the family background of domestic abuse and parental substance misuse, along with the mother’s history of significant medical issues as well as a history of depression. The practice was concerned about the welfare of the children in the family. Despite her history of several life threatening illnesses, the mother (and her three children) was an infrequent user of primary care services and frequently did not attend appointments in secondary and tertiary care. 6.2.2 During the timeframe of this review, the practice’s involvement was around the mother’s pregnancy. She was only seen once with child S on 28 September 2015 because of the health visitor’s concerns about child S’s weight. The GP who saw her was contacted by the health visitor by phone before the consultation; she updated him about her concerns about the baby’s weight loss and demeanour. He then rang the health visitor after the consultation to tell her that he did not think an immediate paediatric assessment was necessary that day. The GP believed that the family had a social work visit later that day; had this not been the case, he would have arranged for child S to be seen by the hospital paediatric team later that day. Although concerned about the baby’s weight, after examining the baby, he was content to make a referral to the community paediatric team. 13 6.2.3 The IMR author concludes that the GP’s involvement with child S was appropriate from a medical point of view. However, she notes that overall information sharing would have been much stronger if the practice had been more involved in the child protection process; for example, analysis of the risks to the children of incomplete immunisations and poor hygiene in the home, alongside the effects of the mother’s medical history and depression on her ability to parent may have enhanced the application for care proceedings. The practice had no record on file of invitations to child protection conferences or minutes of conferences during the timeframe of this review, and was not aware of the care proceedings application. (Subsequent enquiries revealed that the practice had been invited to some of the conferences and sent minutes). The practice works closely with both health visitors and midwives, and the health visitor is used as a conduit of information sharing with children’s services. Good practice suggests that GPs should be more involved themselves. While noting that this GP practice has been proactive in its take up of safeguarding training with almost all GPs trained to level 3 intercollegiate competencies, the IMR author makes suggestions about how they could be more involved in child protection processes. The lead reviewer endorses the recommendation that as a minimum the practice should provide a report to child protection conferences, providing holistic information about a family, as suggested in the GP Safeguarding Toolkit. 6.3 Great Western Hospitals NHS Foundation Trust 6.3.1 The community midwifery service provided by the local hospital was involved with child S’s mother during her pregnancy with her. The first involvement was in March 2015 when a community midwife booked her for pregnancy care and reviewed the past history. She recognised the safeguarding concerns and passed them onto the safeguarding midwife for review. The safeguarding midwife did not contact Children’s Services Family Contact Point (FCP) until 3 weeks later. A referral to children’s services was requested but this was not made for a further three weeks. The delays were due to workload issues and lack of cover of the safeguarding midwife’s responsibilities when she was on leave. 6.3.2 Early in April 2015, the mother contacted the GP surgery as she was unwell. The community midwife phoned her back and was so concerned that she decided to visit her between her morning and afternoon clinics. On arrival at the family home, it was clear that the mother was very unwell, so the midwife rang immediately for an ambulance to take her to hospital, where she spent eleven days in the intensive care unit (ICU) 6.3.3 Following her discharge home after nearly three weeks in hospital, the community midwife went out of her way to see the mother at home for her appointments (most appointments are held at GP surgery or hospital). She was very sensitive to the needs of the mother for support but also involved in child protection processes, working closely with the social workers to address the safeguarding concerns. She saw child S on several occasions after her birth and had no specific concerns about her health and wellbeing during this four weeks period. The IMR author commends the community midwife for her exceptional care of the mother, alongside her alertness to child protection 14 concerns, including her potentially lifesaving action to ensure that the mother received urgent medical treatment in April 2015. She was supported in her work by the safeguarding midwife, who, despite her limited capacity, persistently monitored the actions in relation to this family. 6.3.4 The IMR author helpfully includes in her report information from the Society of Critical Medicine about the effects of a stay in ICU. Specifically, recovery can be lengthy, and up to 50% of all patients who stay in ICU for a week or longer develop muscle weakness which makes the activities of daily living difficult and the patient may take more than a year to recover. The author rightly queries whether the agencies working with the mother appreciated the impact of her poor health on parenting. She identifies important learning that, following a stay in ICU, there should be greater consideration given to assessing the ability of a parent to be able to care for their children, particularly those that are lone parents or have limited support. 6.3.5 The author also identifies the lack of communication around ICU/hospital discharge to midwifery and obstetrics; the discharge letter was only sent to the mother’s GP. She makes a number of recommendations to improve sharing of information and the quality of records within the Trust. 6.4 Swindon Borough Children, Families and Community Health Health Visiting 6.4.1 The health visitor had worked with the family since 2007, so had delivered a service to child S’s three older siblings. In the past she had made a number of referrals to children’s social care because of her concerns for the health and emotional wellbeing of the children. She was particularly concerned about the mother’s persistent low mood and tried to encourage her to go to her GP to enable her mental health to be assessed. 6.4.2 During the time frame of the review, the health visitor conducted a developmental assessment of child S’s youngest sibling in April 2015 and visited again in July 2015 to review development and weight. She visited child S on four occasions during August and September, two of which coincided with core group meetings in the family home. She discussed sleeping arrangements for child S and gave the mother the leaflet from the Lullaby Trust about safer sleeping, pointing out the important aspects and mentioning sudden infant death. She also focussed on persuading the mother to register child S and her youngest sibling with the GP. 6.4.3 The health visitor had no serious concerns about child S until her last visit on 28 September 2015. Her weight had dropped by between 2 – 3 centiles. Her weight gain since birth was so small that this is deemed a significant loss in NICE guidance. The guidance to professionals is that they should action urgent follow up. The health visitor also observed how quiet child S was. She gave her a small amount of formula feed in a bottle but noted that the baby needed encouragement to be kept awake and to continue to feed. The health visitor rang the GP practice to organise an appointment for child S and her mother later that day. She spoke to the GP to explain her concern about the baby’s demeanour and the significance of the drop by 2 – 3 centiles. She also told him that she herself had fed the baby some formula during the morning 15 and that this would impact on the baby’s alertness at the time of the GP appointment. 6.4.4 Later, the GP rang the health visitor when the mother and baby were with him to inform her that, in his view, child S was well and was alert at the visit and he did not think immediate assessment by a paediatrician was required. The health visitor recalls checking that the GP remembered that she had fed child S some formula which would have influenced her presentation. She also recalls offering to contact the social worker to explain that an immediate referral to the hospital paediatrician should take precedence over the scheduled meeting with her to start the parenting assessment. She remembers the GP telling her that he would refer child S to the paediatrician as a matter of urgency. The health visitor did not challenge this decision but considers that her representations above constituted a professional challenge to the GP’s thinking. The health visitor was about to go on two weeks’ leave so made sure that the mother had contact details of her colleague health visitors and alerted them in case of contact during her absence. She assumed that the paediatric assessment would take place during her two weeks’ absence, so she did not ask her colleagues to weigh child S during her leave. She reflected that if she had thought the assessment was not going to happen quickly, she would herself have referred child S by ringing the consultant paediatrician on call, which is established health visitor practice. The health visitor acknowledges that this level of detail about the events of 28 September 2015 is not recorded in the case notes. 6.4.5 The IMR author concludes that the service offered to this family was in line with what is agreed good practice for families where babies and young children have safeguarding needs. There was evidence of good practice in ensuring that child S was seen quickly by a GP following the health visitor’s observed concerns. The health visitor herself, at the learning event, reflected whether she should have challenged the GP’s decision that an urgent referral to a paediatrician was not necessary, and possibly have escalated the matter. The lead reviewer, while commending the health visitor for her prompt action, queries why no arrangement was made for a health visitor colleague to check that the paediatric assessment had happened, and to weigh and monitor child S during her two weeks’ absence, given the significance of the small weight gain and the baby’s status subject to a child protection plan and interim supervision order. Social Work 6.4.6This service had considerable involvement with the mother and her children for many years because of concerns about parental alcohol and drug misuse, the unhygienic state of the home, domestic abuse witnessed by the children, and very poor school attendance by child S’s two oldest siblings. The children lived in a home that was chaotic, untidy and filthy, at times, and had been subject to child protection and children in need plans over several years. Nevertheless, at the start of the timeframe for this review, the case was closed to Children and Families due to an apparent improvement in the condition of the home by January 2015. 6.4.7 The brief chronology in section four outlines key details of Children and Families involvement between April – October 2015 so they will not be 16 repeated here. The IMR author concludes that during the period of the review, social work practice was good in relation to the work undertaken with the children and their parents. Social workers clearly explained their concerns to both parents and outlined what might happen if things did not improve. Attempts were made to involve the father and to get to know him. They made clear efforts to get to know the older children and build a relationship with them; they were seen both on their own and with their mother. Practical help was offered to clear up the house that was initially rejected, but then accepted once the care proceedings had commenced. Safeguarding procedures were used appropriately and timescales adhered to. The multi-agency group of professionals appeared to function well with good attendance at core group meetings and good information sharing in between. Care proceedings were initiated in a timely manner. The lead author endorses this conclusion. 6.4.8 The author highlights that the key issue in this case was difficulty in presenting evidence to the courts to justify immediate removal of children in cases of chronic neglect. She therefore recommends: - workshop between staff from Children and Families Service and Legal Team to consider research on neglect and form a shared view of the effects on children - training made available to staff about the effects of long term drug use on the brains of those who misuse drugs - further training in court work for social workers with particular emphasis on the PLO and writing of statements for court The lead reviewer endorses these recommendations. 6.5 Swindon Borough Council Law and Democratic Services Department 6.5.1 This case was open to the Legal Department from June 2015 to January 2016, when care proceedings were concluded on child S’s siblings. During the first period up to mid-August 2015, legal advice was provided on the grounds to proceed to a pre proceeding meeting and then to make an application to court. The IMR author concludes that the actions taken by the Legal Department and the legal advice provided were appropriate. The lead reviewer, based on her discussions with the assistant team manager and child care lawyer, at the learning event, concurs with this view. 6.5.2 The second period was in mid-August, covering the care proceedings application for Emergency Protection Order (EPO)/Interim/Care Orders in respect of the three older siblings, up to the initial hearing, which also included an application for an EPO in respect of child S. After discussions at court, the case was transferred on the same day from the magistrates court to a district judge to hear EPO applications on all four children. After further discussions and agreement between the parties, no order was made and the case was adjourned for an interim care order application three days later. The agreement was based on a temporary arrangement whereby the paternal grandmother would supervise the care of the children and the father signed an agreement not to go to the family home. The legal services IMR author explains that the case of X Council v B established that separation under an 17 EPO is only to be contemplated if immediate separation is essential to secure the child’s safety – i.e. imminent danger must actually be established. Given this case law, he concludes that the agreement reached by Children’s Services, with legal advice, for there to be no order appears to be reasonable. 6.5.3 The most significant event was the interim care order hearing before the same district judge. During pre-hearing discussions, the mother indicated that she would not agree to interim care orders. The Children’s Guardian did not feel that there was enough to justify interim removal without a fuller hearing or a contested case. When the parties went before the district judge she indicated that her view was that there was not enough evidence for her to separate the four children from their mother under an interim care order. The parties then had more discussions and an agreement was reached by all that there should be interim supervision orders on all four children supported by a tight written agreement which set out requirements as to the mother’s care of the children and also provided that the father’s contact must be supervised. Further assessments were ordered, including a viability assessment of a relative as possible carer for the children. A date was fixed for a contested hearing and case management at the end of October. If the mother breached the written agreement, there was court permission for the local authority to return to court for removal of the children. 6.5.4 The IMR author explains that relevant case law (Re L – A,2010) requires a judge, when deciding whether to make an interim care order, to test whether a child’s safety demands immediate separation, as well as considering the statutory grounds set out in Section 38(1) of the Children Act 1989. This means that cases of longer term neglect are difficult to prove at an interim stage. The author notes that the social worker’s statement for the hearing provides an analysis of harm and the impact on the children and an analysis of parenting capability, but the statement could have been clearer as to why the children’s safety demanded immediate separation at an interim stage, which would have assisted the judge. Having read the statement, the lead reviewer agrees. 6.5.5 The IMR author concludes that the child care lawyer’s practice was reasonable in advising the social worker and her manager not to pursue an application for interim care orders, as the judge had indicated her view, the Children’s Guardian had indicated his view that there was not enough evidence to justify immediate removal, and there was the possibility of an agreement with the mother and the father on key actions to reduce risks pending a final hearing. During discussion at the learning event, the social worker and her manager, child care lawyer and Children’s Guardian all accepted that, given that there was no specific event (apart from the birth of child S) to warrant immediate removal and the social worker’s statement focussed primarily on chronic neglect over many years, the actions were reasonable. 6.5.6 Finally, the IMR author notes that, following child S’s admission to hospital in October 2012, swift action was taken to secure the removal of the three surviving children on interim care orders, a key factor being the evidence that the mother had breached the written agreement by sleeping with child S. 18 6.5.7 There are two similar recommendations to those made by the author of the Children and Families IMR: - that the format for the first social worker statement is reviewed to include a section heading as to why the child’s safety demands immediate separation at an interim stage - that there is further training by the Legal Department of Children’s Services staff on the preparation of statements and the evidence needed to satisfy the grounds for an interim care order. At the learning event, relevant staff agreed that these were key learning points from this review. 6.6 Cafcass 6.6.1 An experienced Children’s Guardian was involved in the public law proceedings in relation to the three older siblings from mid-August 2015 and was involved with child S following her birth until her death on 15 October 2015. By the time of the first court hearing, he had not had time to read the application. At the learning event, he explained this was due to annual leave. However, he was involved in the negotiation of the safety plan to protect the children during the four day period until the adjourned hearing. On that morning, having read the initial papers, he visited the family home in order to meet the mother and all four children, and make an initial observation, and inform his views for the court hearing. He did not support immediate removal of the children, and the children’s solicitor advised that the threshold for immediate removal was not met. He recognised that there were serious concerns but was focussed on the longer term picture, informed by the proceedings. He next had contact with the family and key professionals when he attended the core group meeting on 28 September 2015. 6.6.2 Significantly, in this case, the initial Case Management Hearing (CMH) took place before the Children’s Guardian was ready to prepare an initial analysis report. The district judge set the second CMH (and a contested hearing) to start on 29 October 2015, because there was insufficient court time for her to hear it earlier. However, the late setting of this CMH influenced the work of the Children’s Guardian. It is usual for the Guardian to prepare an initial analysis report for the CMH. Its main purpose is to identify gaps in evidence and provide advice on behalf of the child about what might be needed and by when. In order to prepare such a report Children’s Guardians need to frontload their work and quickly understand the issues in the case. If the second CMH had been scheduled earlier, the Guardian would have prepared an initial analysis report, which would have facilitated a systematic analysis of the issues relating to each child at that point. At the learning event in April 2016, the Children’s Guardian explained that, while he did not consider that there was a specific event to justify immediate removal in August, his view might have been different if he had undertaken an initial analysis report shortly afterwards. He also noted that the local authority case was weakened by there being no social worker present in court who knew the family. The social worker that had written the statement had just left the country and was unavailable, and the new social worker had just taken over. 19 6.6.3 The IMR author notes some learning for the practitioner in this case. The broader learning relates to identifying and managing the risks associated with neglect. She highlights on line learning material available to CAFCASS Guardians which could assist them in being more systematic and bringing a child’s lived experience to the fore. She also helpfully notes that CAFCASS is currently working with the NSPCC who have been commissioned to develop a tool in Spring 2016 to support analysis in neglect cases. The Children’s Guardian’s manager is signed up to becoming a trainer for this tool and will deliver training to her team. She has also volunteered her team to participate in a six month follow up to provide feedback and contribute to any changes that may be required. Thus, local Children’s Guardians will be benefitting from a specific focus on neglect. 6.7 Wiltshire Probation Trust 6.7.1 The father was sentenced to a community order of twenty four months in March 2014 for common assault, which prevented contact with the victim, the mother of his children, unless approved by his supervising officer. During the time of the order, the probation officer had contact with Children’s Services in September 2014 when the father had sanctioned contact with his children in order to assist during the mother’s serious illness. 6.7.2 During the time frame of this review, the probation officer attended the initial child protection conference in May 2015 and had telephone contact with the children’s social workers sharing information and risk assessments. 6.8 Swindon Borough Council Education Service 6.8.1 Child S’s older siblings attended the same primary school/nursery. The school had many concerns and a considerable involvement with the family over many years. A family support worker had been involved as was the school nurse. During the time frame of this review, members of the school staff were appropriately involved in attending child protection conferences and core group meetings. It was clear from discussion at the learning event in April 2016 with the head teacher, school nurse and family support adviser that they were all committed to meeting the children’s needs both educational, and emotional and social. The children were provided with a range of support in school. 6.9 Swindon Borough Council Housing Services 6.9.1 The council was the mother’s landlord. Its only significant involvement during the period of this review was to arrange a property inspection following a report from the social worker that the home was in a very poor state of repair. The mother was not at home at the time of the pre-arranged property inspection and subsequently advised in a telephone call the she had no outstanding repairs. The author of the briefing report notes that, with the benefit of hindsight, it might have been appropriate for a follow up on the condition of the house despite the tenant cancelling the appointment. 20 6.10 Coram Voice 6.10.1 The children’s social worker arranged for the two oldest siblings to have their own advocate, which is good practice. They were seen by the advocate at school on five occasions, and their wishes and feelings were represented by the advocate at the review child protection conference and a core group meeting. 6.11 NSPCC 6.11.1 The NSPCC submitted a briefing report but their involvement with the family had ended in 2011 so was not relevant to this review. 21 7. KEY ISSUES 7.1 Communication 7.1.1 Generally, communication between agencies about this family was good. This is clear from the analysis in IMRs and from the discussion at the learning event. 7.1.2 Three significant gaps were identified. The first pertained to the mother’s admission to ICU in April 2015. Sharing of information between Health organisations was not adequate; the youngest child’s health visitor was not formally notified of the mother’s serious illness, while the discharge summary was only sent to the family GP. Even though the mother was pregnant, her midwife and obstetrician were not given copies. Most importantly, information about the time taken to recover from such serious illness and the ongoing debilitating effects was not made available to key professionals, including social workers, which was particularly relevant for a pregnant lone mother of three children, with limited support. 7.1.3 The second gap pertained to GP involvement in child protection processes. Although the family’s GP practice had good communication between GPs and community midwives and health visitors about many vulnerable families through minuted meetings, it appears that they expected health visitors to pass this information onto conferences and core group meetings, without this being explicitly agreed. The GP explained that this was due to limited capacity. In this case, the GP was not aware that care proceedings had been initiated. 7.1.4 The third was during the difficult time when child S was critically ill in hospital when communication between Children’s Services and the Police about their intentions was not always clear. 7.2 Professional Standards 7.2.1During the period of the review, there were generally good professional standards in relation to the quality of assessment, identification of neglect, and decision making. However, in previous years, it appeared that opportunities had been missed to take positive action to protect child S’s siblings from the impact of chronic neglect. A detailed analysis is beyond the scope of this review. Assessment 7.2.2 It is to the credit of the children’s social workers, and assistant team manager, supported by more senior managers, that they quickly assessed in the Spring of 2015 that the pattern of chronic neglect, interspersed with short lived improvements, was having an adverse effect on the older children and would be repeated with the expected baby. They acted quickly to assess the mother’s parenting capacity, and when she failed to cooperate, sought legal advice and initiated care proceedings. While the social worker’s statement for court could have been more specific about the immediate harm the children were likely to suffer, it is positive that the long term risks had been identified. 22 7.2.3 The community midwife immediately identified safeguarding concerns when she met the mother at her first ante natal appointment and passed them on appropriately. The head teacher and staff at the children’s school were attuned to possible indicators of a deteriorating situation and were involved in conveying to Children’s Services the grandmother’s concerns about the state of the family home in April 2015. 7.2.4 The police officer and social worker collaborated positively in assessing the state of the family home together in April 2015 and the police officer was assertive in threatening legal action in respect of the children if it did not improve. The health visitor identified rapidly that child S required urgent assessment by her GP on 28 September and ensured that it happened. However, it is a cause for concern that no paediatric assessment of whether the slow weight gain was due to neglect had taken place by the time the baby was admitted to hospital two weeks later. The Swindon Clinical Commissioning Group reports that action is now being taken to improve the Failure to Thrive pathway and address waiting times for community paediatric services. 7.2.5 Gaps in assessment were about the mother’s mental health and the possible impact on her functioning of long term drug use. These were due to her failure to attend GP appointments when encouraged to do, and until care proceedings were initiated, there was no legal mandate to compel her to cooperate. 7.2.6 Another gap was accuracy about the father’s involvement with the mother and the children. Despite efforts to engage him by the probation officer and the social worker, it is clear that he had more involvement than either he or the mother admitted. Identification of neglect 7.2.7 The nub of this case is timely identification of neglect and its pernicious effects on children. Despite possible failures to act assertively in the past to protect the children, in 2015 all agencies were collaborating effectively and were alert to the neglect suffered by the children. The key issue in 2015 was preparation of evidence to satisfy a judge that the risks from ongoing neglect were so serious that immediate removal of the children from their mother was justified. The assistant team manager considered that the birth of a fourth child increased the risk significantly. However, the case law with regard to interim care orders requires clear evidence of immediate harm to warrant immediate separation, and the judge, Children’s Guardian and the children’s solicitor did not consider that this threshold had been met. 7.2.8 There is learning for Children’s Services and legal services about the effective drafting of court statements when immediate removal of children is deemed necessary in the context of chronic neglect. Legal services report that changes have already been made to the social worker template for court reports. It is encouraging that the local CAFCASS team will be involved in piloting a new assessment toolkit around neglect. It could be helpful to take the debate to the local judges, as this is a notoriously difficult area. 23 The children’s voices 7.2.9 Child S was only eight weeks old when she died. She was seen on numerous occasions by the community midwife, health visitor, social worker and outreach support worker. Throughout the last four weeks of her life she was seen by a professional several times each week, as a massive package of support, coordinated by the core group, was in place to support her mother and monitor the children’s wellbeing. Overall, there were positive observations of her development and interaction with her mother. There was some concern about her grubby appearance and about her slow weight gain, which became more concerning on 28 September. 7.2.10 The older children had improved attendance at nursery and school so were observed and spoken with on each school day. The school nurse was supporting the oldest child with one to one sessions. 7.2.11 The children’s social workers made strenuous efforts to communicate with the two oldest children and regularly saw them on their own. These two also had an advocate from a voluntary organisation, who saw them several times. Their experiences, wishes and feelings were communicated to the core group and in the court statement. Decision making and risk analysis 7.2.12 From April 2015 onwards, safeguarding procedures worked effectively for the older children and subsequently for child S. She had been identified as a child at risk of neglect before her birth. There was a core group of professionals collaborating proactively to safeguard her and oversee the written agreement in place through the care proceedings. The only gap was the delay in obtaining a paediatric assessment of her slow weight gain and whether neglect was a factor. This was due to her GP assessing that an immediate referral to a paediatrician was not required when he examined her on 28 September 2015, and delays in securing an appointment with a community paediatrician. A further concern was the failure to weigh child S in the subsequent two weeks. Her health visitor was on annual leave, but no arrangement was made to weigh the baby in her absence. 7.2.13 All the professionals working with child S and her mother were well aware the risks of co sleeping. The mother had been given written information by the community midwife when she left hospital after child S’s birth. The health visitor had given her written and pictorial information and spoken with her about the risks during her new birth visit. The social worker had ensured that it was addressed in the written agreement. No one had any reason to believe that the mother had slept with any of the older children when they were babies, but some professionals believed that mother was sleeping on the sofa. All the literature and oral advice given to the mother addressed the specific risks of co sleeping on a sofa. Child S had a moses basket where she was to sleep at night; she often slept in a small pram in the living room during the day. At the learning event in April, all members of the core group were clear that they reminded the mother regularly of the risks of co sleeping, including sleeping on a sofa, especially the outreach support worker who saw her frequently. The Children’s Guardian confirmed that it was a topic for 24 discussion at the core group meeting on 28 September, when the mother was present. It was reported that the mother’s attitude was that this was her sixth baby and she knew the risks. Effective professional practice 7.2.14 There were many examples of effective professional practice, including staff, notably the community midwife and the detective sergeant, involved at the time of child S’s death, going beyond the call of duty to promote the mother’s health and wellbeing. 7.2.15 There were some very good examples of inter-agency communication, cooperation and coordination. The hospital allowed the mother and baby to remain there for a few days while court hearings took place; the police and social workers generally collaborated well together. There was a huge level of coordinated support to the mother and children from August 2015, with a clear focus on safeguarding the children. All staff involved with the family were committed to doing their best for the children. 7.2.16 The social workers engaged well with the older children and ensured that they had independent advocates. School staff ensured that the children received additional support. The health visitor ensured that child S was seen quickly by a GP. 7.3 Organisational Issues 7.3.1 Effective preparation of evidence for court, especially in complex cases of chronic neglect, has been addressed above. Both Children’s Services and Legal team would benefit from considering together ways to improve understanding of case law and practice before and during court hearings. Ideally, the judiciary should be involved. 7.3.2 The workload of the safeguarding midwife was highlighted in this case, given the significant delay in making a referral to Children’s Services. While it made no difference to the safeguarding of the children, it needs to be addressed. 7.3.3 The capacity of GPs to be involved appropriately in child protection processes, ensuring that all relevant information is shared with child protection conferences and core groups, was also an issue, which is not confined to this family’s GP. 7.3.4 It is concerning that no arrangements were put in place to check the progress of the paediatric assessment and monitor the weight of such a vulnerable baby during the health visitor’s absence. 7.3.5 There are lengthy delays for appointments with community paediatricians. It is concerning that there did not appear to be any means of expediting the assessment of this vulnerable baby, subject to a child protection plan and an interim supervision order. As indicated in paragraph 7.2.4, this matter is being addressed by the clinical commissioning group. 25 7.4 Safe sleeping 7.4.1 The professionals working with child S ensured that her mother was aware of latest NICE Guidance on co-sleeping and sudden infant death syndrome (SIDS). The public health message recommends that parents are informed that there is an association between co-sleeping (parents sleeping on a bed or sofa or chair with an infant) and SIDS. The association is likely to be greater when they or their partner smoke. The association may be greater with: - parental recent alcohol consumption, or - parental drug use 7.4.2 They regularly reinforced these messages. The mother said that she smoked outside the family home, and there was no evidence to the contrary. The mother had a longstanding pattern of alcohol and drug misuse, but all professionals working with her stated at the learning event that they saw no evidence of misuse during the period after child S’s birth. 7.4.3 The author reviewed eight SCRs from other LSCBs where co-sleeping had played a part in an infant’s death. The key themes were that co-sleeping occurred in the context of neglect and substance misuse. In most cases, the parent had consumed alcohol and/or drugs before sleeping with the infant. 7.4.4 One review noted that while health professionals had a good knowledge of the risks associated with co-sleeping, social workers did not. This was not the case with child S. 7.4.5 Recommendations relevant to co-sleeping included: - reviewing the information about safe sleeping given to parents; - health professionals to undertake a safe sleeping assessment to embed the information - safe sleeping to be built into child protection plans For child S, the information given was of a good standard, a safe sleeping assessment had taken place, and safe sleeping was built into the safety plan drawn up after the court hearings. 7.4.6 Research by Brandon et al into neglect and serious case reviews notes that, while maltreatment accounts for a very small proportion of SIDS, SIDS features in one in six of all death related SCRs. They also note that professionals can be falsely reassured about a baby’s safety, even when the infant is subject to a child protection plan for neglect, saying that a good relationship between a baby and parent cannot keep the infant safe; for example, when co-sleeping with a parent who has consumed drugs or alcohol. 26 8. CONCLUSIONS AND LESSONS LEARNED 8.1 At the time of her death, child S was only 8 weeks old. The potential risks of significant harm through neglect were recognised before her birth; therefore, she was made subject to a child protection plan before birth. The social workers involved with the family assessed that the birth of a fourth child into a household where the mother was struggling to ensure hygienic conditions and adequate levels of care would increase the levels of neglect for all the children. They, therefore, applied for an emergency protection order in respect of child S shortly after her birth in August 2015. The order was not granted because the judge did not consider that the grounds for immediate separation of the baby from her mother were met. This was because her grandmother agreed to supervise the care of the baby and her siblings, subject to a written safety plan, for a four day period. 8.2 The social workers persisted in their application to separate child S and her siblings from their mother at a hearing for interim care orders four days later. Again, the judge did not consider that there was sufficient evidence to meet the case law test of immediate harm, which would justify immediate separation of the children from their mother. They were all made subject to interim supervision orders and a detailed written agreement was signed by the mother, which included that child S must sleep in her moses basket. 8.3 Thereafter, child S was seen very regularly by a number of different professionals each week, who reminded the mother about the risks of co sleeping, including on a sofa. Although her weight gain was slow, there were no significant concerns about the care of child S until the end of September 2015, when her weight gain was so slow and her presentation so drowsy that her health visitor made sure that she was seen by a GP within hours. The GP, after examining her, did not consider that immediate assessment by a paediatrician was necessary. Therefore, she was referred to a community paediatrician, but had not been seen by the time of her death two weeks later. 8.4 Wiltshire police accepted the mother’s explanation that she had fallen asleep on the sofa with child S while breast feeding and concluded that her death was a tragic accident. No criminal charges have been brought. 8.5 All agencies working with child S and her family were alert to the risks of neglect and to the risks of co sleeping. It was considered that child S could only be protected from the chronic neglect suffered by her three older siblings if she were removed from her mother’s care. However, they were not able to provide sufficient evidence to the judge to meet the legal threshold for immediate separation. This is notoriously difficult in cases of neglect, where a ‘trigger’ event is often missing. In this case, the local authority statement could not identify a trigger, apart from the stress caused by a new baby. 8.6 During her short life, there was no opportunity to present further information to the court which might have justified removal. (The next court hearing within the care proceedings was scheduled for two weeks after child S’s death). It might have been helpful if child S had been weighed in the last two weeks of her life and if a paediatrician had assessed speedily whether her slow weight gain was due to neglect. Also, it might have been helpful if the contested interim care order hearing had been scheduled earlier in the proceedings, 27 thereby requiring the Children’s Guardian to analyse potential risks to all four children. Any of these options may have provided additional evidence to present to the judge, but, obviously, this is mere supposition. 8.7 This review has revealed much good practice by the professionals working with child S and her siblings. In particular, after many years of neglectful parenting, its impact on the children was recognised, and positive action was taken to improve the quality of the lives of child S’s siblings. The nub of this case is the difficulty in meeting the legal threshold for removal under an interim care order in cases of neglect. Swindon Children’s Services and Legal team have already identified lessons from this case, while CAFCASS, nationally and locally, is involved in a project to sharpen practice in cases of neglect. This case has already been discussed by the Chair of Swindon Safeguarding Children Board with the local senior judge, with a view to considering lessons learned. 8.8 Other learning from this case has been the need for greater understanding of the impact of very serious illness, notably time in intensive care, on parents’ subsequent functioning and their physical ability to provide day to day care for their children. 8.9 This review has also identified possible gaps in resources, notably workload of the safeguarding midwife in Swindon, GPs’ capacity to be involved in child protection processes, and significant wait for community paediatric assessment. 28 9. RECOMMENDATIONS FROM THIS SERIOUS CASE REVIEW 9.1 Introduction 9.1.1 These recommendations reflect the key issues arising from this review. Agencies have not awaited the completion of this review in order to address issues arising from this case. Some of these recommendations, or aspects of them, have been identified and addressed already. Individual agencies have made recommendations following their own reviews, not all of which are listed here. 9.2 Recommendations to the Swindon Safeguarding Children Board 9.2.1 The Board should ensure that expectations about minimum requirements of GPs’ involvement in child protection processes are agreed with the Clinical Commissioning Group and that their implementation is monitored 9.2.2 The Board should satisfy itself that there is sufficient capacity to fulfil the requirements of the safeguarding midwife role 9.2.3 The Board should clarify the processes for vulnerable children being assessed speedily by community paediatricians and consider whether any changes are necessary 9.2.4 The Board should engage with local Family Justice Board to consider any lessons learned from this SCR 9.2.5 The Board should make representations to the Department for Education and the Ministry of Justice, requesting that the judiciary be required to participate in serious case reviews when they have had recent involvement with the child and family 9.3 Recommendations to Swindon Borough Council 9.3.1 The health visiting service should review its procedures on escalation of concerns and on cover arrangements for vulnerable children in the absence of their health visitor 9.3.2 The Children and Families Service and Legal team should consider positively in which circumstances a statement from a GP might be helpful in care proceedings. 9.3.3 These recommendations from the individual reviews are endorsed: - the format of the first social worker statement is reviewed to include a section heading as to why the child’s safety demands immediate separation at an interim stage - there is further training by the legal department of children’s services staff on the preparation of statements and the evidence needed to satisfy the grounds for removal under an interim care order 29 - workshop to be held between staff from Children and Families Service and legal team, including Children’s Guardians, to consider research on neglect and form a shared view of the effects on children - training to be made available to Children and Families staff about the effects of long term drug use on the brains of those who misuse drugs 9.4 Recommendation to Swindon Borough Council and Wiltshire Police 9.4.1 This recommendation from the Police individual review is endorsed: - in periods of ‘limbo’ when a child is critically ill, meetings should be held every 24 hours, by phone or in person, between the detective sergeant and social worker to ensure that they are fully up to date with the agencies’ actions and intentions for that day 9.5 Recommendation to Great Western Hospitals NHS Foundation Trust 9.5.1The Trust should consider how individuals, their families and professionals working with them can develop a greater understanding of the impact on patients after discharge from intensive care, notably the impact on the ability of the patient to be able to care for their children effectively 9.5.2 The Trust should ensure that all relevant health professionals are notified of the discharge of vulnerable patients 9.6 Recommendation to CAFCASS 9.6.1 CAFCASS should consider how Children’s Guardians can be involved in workshop with social workers and local authority legal services to consider research on neglect 30 Appendix A Composition of Case Review Group Alex Walters, Independent Panel Chair Designated Doctor, Swindon Clinical Commissioning Group Head of Children, Families and Community Health, Swindon Borough Council Service Manager, Early Help, Children, Families and Community Health, Swindon Borough Council Service Manager, Quality Assurance and Review, Children, Families and Community Health, Swindon Borough Council (SCR Champion) Area Manager, Gloucestershire/Wiltshire Probation Trust Continuous Improvement and Strategic Support, Public Protection Unit, Wiltshire Police Service Manager, Swindon NSPCC LSCB Strategic Manager LSCB Quality Assurance and Training Manager Divisional Director of Nursing, Women and Children’s Division, Great Western Hospitals NHS Foundation Trust In attendance Helen Davies, Independent Lead Reviewer 31 Appendix B: Details of the independent lead reviewer/author of this report. Helen Davies trained in social work and worked in local government in a range of social work and management positions, including thirteen years as an assistant/deputy director of children’s services. Since 2011, she has worked as an independent consultant and been involved in a number of reviews in respect of children and adults. She has never worked in any of the agencies involved in this review. 32 Appendix C: Terms of Reference for this Serious Case Review The serious case review primarily considered events in the period from April 2015, when the mother’s pregnancy with child P became known to Children’s Services until mid October 2015 when child P died. However, all agencies were requested to include relevant background information about her three older siblings. Child P is the main subject of this review but the circumstances in relation to any safeguarding issues for her siblings needed to be fully considered. The agencies were asked to draw up their individual management reviews around the following issues: - Did agencies communicate effectively and work together to safeguard and promote the children’s welfare? - Was the level and extent of agency engagement and intervention with the family appropriate? Were assessments undertaken in a timely manner, was the quality adequate and did they include fathers, extended family and historical information? - Was any information known by any agency about parental mental health issues, domestic abuse, substance misuse or parental anti social behaviours or concerns re neglect? If so, was appropriate consideration given to how these impacted on parenting capacity and were appropriate referrals made? - Were the decisions and actions that followed assessments appropriate and were detailed plans recorded and reviewed? - Were the children’s views and wishes sought and taken account of in assessments and planning? Did this include the presentation of young non verbal children being fully considered? - Was race, religion, language, culture, ethnicity or disability a factor in this case and was it considered fully and acted on if required? How was the uniqueness of this particular family recognised? - Did events and the information available appropriately inform the application for care proceedings? - Was information on co-sleeping provided and were the risks understood? - Were there any organisational or resource factors which may have impacted on practice in this case? - Were appropriate management/clinical oversight(supervision) arrangements in place for professionals making judgments in this case? - The lead reviewer to consider national research and findings from other SCRs and make recommendations as appropriate 33 Appendix D: Principles Underlying this Serious Case Review The conduct of this review has not been determined by any particular theoretical model. It has been carried out in keeping with the underlying principles, set out in the statutory Guidance, Working Together to Safeguard Children 2015: - There should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works and promote good practice; - The approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined; - Reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed; - Professionals should be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith; - Families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring that the child is at the centre of the process; - Final reports of SCRs must be published, including the LSCB’s response to the review findings, in order to achieve transparency. The impact of SCRs and other reviews on improving services to children and families and on reducing the incidence of deaths or serious harm to children must also be described in LSCB annual reports and will inform inspections; - The review will recognise the complexity of safeguarding children and seek to understand not only what happened but why individuals and organisations acted as they did; 34 Appendix E: References This report has been generally informed by the following publications Working Together to Safeguard Children (Department for Education 2015) In the Child’s Time: professional responses to neglect (Ofsted 2014) Missed Opportunities: Indicators of Neglect – What is ignored, why, and what can be done Brandon et al (DfE Research Report 2014) Neglect and Serious Case Reviews, Brandon et al (University of East Anglia/NSPCC 2013) Repository of Serious Case Reviews, NSPCC National Institute for Health and Care Excellence (NICE) Guidance on co-sleeping and sudden infant death syndrome (updated 2014) |
NC049389 | Death of a 3-month-old girl in March 2015 as the result of Sudden Unexpected Death in Infancy (SUDI). Emily was a twin and lived with her brother, mother, and maternal uncle. She and her brother were born prematurely and kept in hospital for longer than medically necessary because of concerns about mother's ability to look after their basic needs, due to perceived learning difficulties and lack of support. Professionals had voiced concerns about the amount of care provided and the level of control Emily's aunt had over her mother, who had history of depression and self harm. Emily's aunt visited the home daily, and there were domestic abuse incidents in the home between her and her brother. Shortly after discharge from hospital professionals identified a number of concerns, including low weight gain, poor home conditions, and significant nappy rash. A Single Assessment Framework was started when the twins were discharged but was not completed. Learning includes: the risks associated with twins and prematurity are not routinely articulated across multi-agency partners; there may be a tolerance of sibling violence that would not be accepted for intimate partners, which does not acknowledge the risk for children; professionals' overreliance on diagnosis fails to recognise the continuum of needs of parents who have learning or mental health difficulties; the lack of a multi-agency neglect framework and toolkit inhibits a shared professional understanding of neglect. Makes a number of recommendations in the form of questions to the LSCB around the additional needs of premature and twin babies; sibling domestic abuse; and professionals' understanding of neglect.
| Serious Case Review No: 2018/C7100 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. 1 SCR: Emily Final Report Local Safeguarding Children Board Serious Case Review Emily Bridget Griffin and Local Authority Service Manager February 2018 2 SCR: Emily Final Report Contents 1. Introduction ..............................................................................................................................3 1.1. Why this case was chosen to be reviewed ............................................................................. 3 1.2. Methodology Organisational learning and improvement ...................................................... 3 1.3. Reviewing expertise and independence ................................................................................. 4 1.4. Review Team ........................................................................................................................... 4 1.5. Case Group .............................................................................................................................. 5 1.6. Involvement of family members ............................................................................................. 5 1.7. Documentation ....................................................................................................................... 5 1.8. Specialist advice ...................................................................................................................... 5 1.9. Methodological comment ....................................................................................................... 6 1.10. Terms of Reference – Timeframe ....................................................................................... 6 1.11. Research Questions............................................................................................................. 6 1.12. Family composition ............................................................................................................. 7 1.13. Summary of case ................................................................................................................. 7 2. Appraisal of practice ..................................................................................................................8 2.2. Birth of twins, discharge of Mother and referrals to Front Door. .......................................... 8 2.3. Discharge home and escalating concerns. ............................................................................ 10 2.4. Referral to Early Help and response. .................................................................................... 11 2.5. Extended community response and escalating concerns. .................................................... 12 2.6. Completing the Single Assessment (SAF) .............................................................................. 15 2.7. What makes learning from this case more widely applicable? ............................................ 16 3. The Findings ............................................................................................................................ 16 3.1. Summary of findings ............................................................................................................. 16 3.2. Finding 1 ................................................................................................................................ 17 3.3. Finding 2 ................................................................................................................................ 20 3.4. Finding 3 ................................................................................................................................ 24 3.5. Finding 4 ................................................................................................................................ 28 3.6. Additional Learning ............................................................................................................... 32 Appendix 1: References .................................................................................................................... 34 3 SCR: Emily Final Report 1. Introduction 1.1. Why this case was chosen to be reviewed 1.1.1. This Serious Case Review (SCR) was commissioned by the Independent Chair of a Local Safeguarding Children Board (LSCB) after a referral from the Regional Child Death Overview Panel (CDOP) requested that a serious case review should be considered. After consideration, the LSCB Serious Case Review Sub Group concluded that the circumstances surrounding the death of Emily1 met the criteria for a serious case review. 1.1.2. This Serious Case Review (SCR) is about the services provided to Emily and her family prior to her death in March 2015. Emily was a twin who was three months old when she died; the cause of death was described by the coroner as “unascertained” which comes under the category of “sudden unexplained death in infancy” (SUDI). 1.1.3. The findings of this serious case review do not indicate that inter-agency practice or the practice of any individual or organisation could have altered the outcome of this case. However, inevitably, in any review of the professional response to a child death there will be lessons to be learnt, and so it is here. 1.2. Methodology 1.2.1. Regulation 5 of the Local Safeguarding Children Boards (LSCB) Regulation 2006 sets out the functions for LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. How serious case reviews are undertaken is not set out within the regulations, however “Working Together to Safeguard Children” (2015, 4;7) helpfully clarifies that; “Reviews are not ends in themselves. The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children.” 1.2.2. Statutory guidance requires SCRs to be conducted in such a way which: recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and 1 All names of family members have been anonymised 4 SCR: Emily Final Report makes use of relevant research and case evidence to inform the findings (WT 2015, 4:11) To comply with these requirements, the LSCB has used the Social Care Institute of Excellence (SCIE) Learning Together2 systems methodology and used a ‘Small Learning Together’3 approach in this SCR. 1.3. Reviewing expertise and independence 1.3.1. This SCR has been led by two people both independent of the case under review. The Lead Reviewer is independent of the Local Authority Council and the second reviewer is training under supervision from the independent lead and is a senior manager at the Local Authority Council. Neither reviewer had any previous involvement with this case. Together, for the purposes of this report, they are known as the Lead Reviewers. 1.3.2. The Lead Reviewers received supervision from SCIE as is standard for Learning Together accredited reviews. This supports the rigour of the analytic process and reliability of the findings as rooted in the evidence. 1.3.3. Bridget Griffin is an experienced Lead Reviewer and is accredited to carry out SCIE reviews and to mentor training lead reviewers. 1.4. Review Team 1.4.1. A team of senior managers was formed from the relevant agencies; these professionals are referred to as the Review Team. The Review Team work alongside and with the Lead Reviewers to ensure direct relevance to local systems to maximise the learning and included the following members: Service Manager – Safeguarding and Quality Assurance Local Authority Children’s Services Policy & Projects Officer Local Authority Housing Services Detective Inspector Regional Police Force Area Manager Local Authority Early Help Services Designated Nurse for Safeguarding Children Local Clinical Commissioning Group Business Manager Local Children & Adults Safeguarding Board Project Support Officer Local Children & Adults Safeguarding Board 2 Fish, Munro & Bairstow 2010 3 The core principles of Learning Together are fixed but the process is flexible and this results in a review that is proportionate. It enables the creation of a tailored process and product to fit with each particular situation. 5 SCR: Emily Final Report 1.5. Case Group 1.5.1. The Review Team identified those professionals who had direct involvement with Emily and her family; these professionals are referred to as the Case Group. In line with a small Learning Together review a learning event was held with these practitioners facilitated by the Lead Reviewers. The purpose of this event was to understand the multi-agency perspectives about the services provided to Emily and her family, and to explore whether the learning in this case had wider significance to other children and families in the area. The workshop considered the research questions (see below) throughout the learning event and the information from this workshop supported the formulation of the findings reported within this review. 1.6. Involvement of family members 1.6.1. The involvement of family members is integral to any SCR. A member of the Review Team met with Emily’s mother to advise her of this SCR and to seek her views and participation. Unfortunately, Emily’s mother did not feel able to participate at this time and therefore her views are not reflected within this review. Emily’s father was not actively involved with the twins and so his views have not been sought. 1.7. Documentation 1.7.1. A range of documentation has been provided for the purposes of this SCR. These documents have been analysed by the Lead Reviewers and members of the Review Team and include, but are not exclusive to: An integrated multi-agency chronology Assessments completed by the Health Visiting Service, the Midwifery Service and Early Help Minutes of the TAF meeting Weight charts Correspondence (letters and emails) between various professionals Referrals to the local Front Door service for concerns about children (referred to as ‘Front Door’). LSCB website (including the annual report and the threshold document) Joint Strategic Needs Assessment Relevant guidance and protocols between services CDOP minutes Post Mortem Report, Coroners Verdict and associated toxicology report 1.8. Specialist advice 1.8.1. The cause of Emily’s death has been determined and recorded following post mortem as ‘Unascertained’. Within the child death overview process ‘unascertained’ is recorded as Sudden Unexpected Death in Infancy (SUDI). It has been noted that there was a close proximity between Emily’s first immunisations and her death; this has been considered and thoroughly scrutinised by expert medical professionals who have concluded there is 6 SCR: Emily Final Report no clinical link. The timing of these immunisations has been concluded as an unfortunate coincidence, with no causal link. Specialist medical advice has been reflected within this review. 1.9. Methodological comment 1.9.1. This SCR involved many multi-agency professionals and whilst every attempt has been made to include all the relevant professionals in the Case Group, this has not been possible. Where relevant, those professionals who have not attended case group meetings have been offered separate conversations. 1.9.2. As this SCR progressed, additional information was sought from newly identified professionals and as such this caused delay. Whilst this led to an extension of the timescale for completion, it has not impacted upon the findings. 1.10. Terms of Reference – Timeframe 1.10.1. The scope of the timeframe for this review was from 6th December 2014 to 12th March 2015. This timeframe was chosen as it covers the birth of the twins and the sad death of Emily. However, significant events relevant to the case prior to the start date of the timeframe were included in the chronology completed by each agency. 1.10.2. The agency chronologies were merged and used to produce an interagency timeline. This was carefully analysed by the Lead Reviewers and the Review Team and provided opportunity for Review Team members to raise questions and clarify their understanding of the circumstances of the case and the services provided. 1.10.3. These discussions informed the research questions and allowed key practitioners to be identified (who would be required to attend a learning event) and to enable the single and interagency practice in this case to be better understood. 1.11. Research Questions 1.11.1. Integral to the SCIE Learning Together methodology is the early formulation of ‘research questions’ to provide a framework for investigation and analysis. These questions were agreed at the initial review team meeting and identified the following aspects of multi-agency safeguarding work which the review team hoped to learn more about. 1.11.2. There were 3 broad areas of interest; Labelling, specifically when using the term ‘learning difficulty’. Question 1: How far do professionals have a shared understanding of the phrase ‘Learning Difficulty’ and how does this impact upon the multi-agency response? Think Family, how co-dependent support can be assessed. Question 2: When providing services to adults who care for children, how are their vulnerabilities and their impact in the caring role assessed 7 SCR: Emily Final Report and supported? Multi-agency practitioners as a source of safety Question 3: How do multi-agency practitioners secure effective intra and inter agency work? 1.11.3. In addition, at the request of the Child Death Overview Panel (CDOP), this SCR has considered the learning for the area in relation to safeguarding children from neglect. During this SCR information emerged that enabled these research questions to be explored and where appropriate these have been covered in the relevant findings. 1.12. Family composition Andrea Mother Emily Female twin Billy Male twin Charlotte Maternal Aunt Jake Maternal Uncle ‘Grandad’ Family Friend 1.13. Summary of case 1.13.1. Emily was a twin. She and her brother (Billy) were born on 6th December 2014, 6 weeks prematurely, to Andrea who was a single mother. Both twins were initially supported in the Neonatal Intensive Care Unit (NICU) and later on a ward prior to discharge home with Andrea. The twins had been kept in longer than they medically needed because the midwives were concerned about Andrea’s ability to look after the basic needs of the twins, and about the level of support available to help her over the holiday period. 1.13.2. Andrea had some known vulnerabilities including difficult childhood and a history of depression and self-harm. She had secured employment as a carer for the elderly and had a close relationship with a family friend that she called Grandad. She took an active role in caring for him and he offered emotional support to Andrea in the care of the twins, however, he had chronic health problems. Andrea, as a new and single mother, had limited access to additional support to help her meet the needs of premature twins as both her natural parents had died, and she was no longer in a relationship with the twins’ father. 1.13.3. Andrea lived with her brother Jake and her sister (Charlotte) visited daily. Charlotte spent a lot of time with Andrea and the twins and was often present when professionals visited. There were concerns about the amount (and quality) of care Charlotte was providing to Emily and the level of control Charlotte had in her relationship with Andrea. 8 SCR: Emily Final Report There were known domestic abuse incidents at Andrea’s address between Charlotte and Jake. 1.13.4. Shortly after the twins were discharged home, professionals identified cumulative concerns. Andrea was unable to establish routines for the twins and there were concerns about low weight gain, hunger, bleeding nappy rash, poor home conditions, lack of food or formula and the twins being inappropriately dressed. 1.13.5. Emily died at three months old. Her death was sudden, unexpected, and deeply distressing for all her family. 2. Appraisal of practice 2.1.1. The Appraisal of Practice forms an essential component of a SCIE Review. It considers the practice in this case, looking at multi-agency decision making, assessments and interventions from the time of Emily’s birth to her death. It aims to provide an explanation of ‘why’ things happened; outlining what got in the way of professionals being as effective as they wanted to be. Any issue identified that was common across more cases in the area is discussed in more detail in the findings, which are cross-referenced. 2.2. Birth of twins, discharge of Mother and referrals to Front Door 2.2.1. This period highlights the quality of referrals made to Front Door by Midwifery and the challenges of information sharing and risk assessment when working across multi-agency boundaries. 2.2.2. The twins were born prematurely at 34 weeks gestation. The close monitoring of midwives providing ante natal care to Andrea meant that Andrea’s vulnerabilities (including a history of overdose, long term depression and her responsibilities of providing care to her ‘grandad’) had been recognised and were clearly recorded; this was good practice. On the day the twins were born, senior midwives noted concerns about Andrea’s capacity to care for the twins, queried whether Andrea had a learning difficulty, and stated that urgent follow up was required. These observations were promptly recorded, which was good practice. At this point, the twins were on a ward and mother’s parenting was monitored. However, the use of the term ‘learning difficulty’, without adequate description of what this meant, and the very brief reference to Andrea’s ability to cope did not provide sufficient detail of the concerns that were observed. The added risk of caring for premature twins was not referenced and it was unclear what ‘urgent follow up’ meant. Articulating the risks associated with multiple births and prematurity is discussed in Finding 1 and responding appropriately to concerns about possible learning difficulties is discussed in Finding 4. 2.2.3. Three days later Andrea was discharged but the twins remained on the special care baby unit. Four days after her discharge a midwife visited Andrea at the home of ‘grandad’. This 9 SCR: Emily Final Report was an opportunity to observe Andrea, without the responsibility of caring for premature twins, so that an understanding of potential parenting capacity could be gained and to form a view about what support she required within the community. Although the midwife appropriately noted concern about Andrea’s capacity to provide care to the twins, no detail was recorded about the substance of these concerns and this was an important omission. Three days later, the twins’ care was transferred to the health visitor. No joint visit or joint handover took place (which is acknowledged ‘best practice’) as the volume of work within the area did not allow for this at that time. 2.2.4. On 18th of December, whilst the twins were still in the special care unit, a referral was made to Front Door by the specialist safeguarding midwife. This referral was made 12 days after the twins were born as this allowed the midwifery team to gather enough information to make an informed referral. 2.2.5. A previous referral had been made to Front Door in the antenatal period but there was no record of the outcome on file. Front Door had responded to this referral and sent a letter recommending that Andrea was referred to the local children’s centre to access support. However, this letter was not received. With no recorded outcome, an assumption was made that the needs of the twins did not meet a Children’s Services threshold and in the absence of further correspondence from Front Door a referral to the Children’s Centre had not been made. 2.2.6. Regardless, the midwifery team could have referred Andrea to a Children’s Centre at a much earlier point during the ante natal period. It was not possible to ascertain why this referral was not made but the lack of awareness in the area within the midwifery service about the services provided by Children’s Centres (that can be accessed by making a direct referral) was thought to be a contributory factor. 2.2.7. A second referral to Front Door, made by the specialist safeguarding midwife on the 18th December, appropriately contained information about Andrea’s vulnerabilities and shared information received from the GP that Andrea did not have a diagnosed learning difficulty. Although some concerns about Andrea’s lack of engagement with the twins and her parenting capacity were briefly referenced, there was no specific information about the risks associated with prematurity or the risks associated with multiple births. Midwifery services operating from a special care baby unit are well placed to understand these vulnerabilities and have a responsibility to be explicit about these risks and to share their expertise with multi-agency partners so that accurate decisions about risks and thresholds can be made; but this did not happen. It was understood that relevant local guidance does not specify the need to articulate these risks and there is an assumption that multi-agency partners will understand these risks (and therefore there is no need to do this). This is an unsafe assumption. The risks of multiple births and prematurity and the sharing of expertise is discussed further in Finding 1. 2.2.8. Over the next few days discussions took place between a manager in Front Door and the specialist safeguarding midwife. During these discussions Front Door was advised that a 10 SCR: Emily Final Report parenting assessment was ongoing and that this would continue as Andrea had been readmitted to the ward. Readmitting parents to support with preparation for discharge is usual for premature babies. Recorded in the referral form held in Front Door was that the specialist midwife stated that no concerns had been highlighted during this early part of the parenting assessment (although during this SCR the midwifery team have disputed this). Front Door concluded that the case did not reach a threshold for a safeguarding response and, based on the information recorded on the referral form, this was a proportionate decision. 2.2.9. The narrative nature of the correspondence by the midwifery team, the lack of clarity provided about the concerns (noted by three senior midwives), the lack of reference to the specific risks of prematurity and multiple births and the vague conclusion that Andrea required ‘support’ did not provide Front Door with the information they required to make an informed decision about risk. The quality of referrals received across agencies has been the subject of concern within the area and relevant issues are discussed further in Finding 1. 2.3. Discharge home and escalating concerns. 2.3.1. This period highlights the importance of discharge planning in providing an opportunity to share information, assess risk, co-ordinate care within the community and provide a timely response to vulnerable children. 2.3.2. On the 27th of December, Andrea, Emily and Billy were discharged home. The twins had been kept on the ward for an extended period because of the concerns and this was good practice. However, no discharge planning meeting took place and as there had been no previous visit to Andrea at home there was no information available to determine whether the home environment was safe for the twins, and no assessment of parenting capacity in the community. It was understood that according to the protocol available at this time4 discharge planning meetings only took place if Children’s Services were involved, even in circumstances such as these. That said, midwifery care continued until 40 days postnatal and this was good practice. 2.3.3. On the twins’ first night home, the twins were cared for separately; Andrea cared for Billy at the family home and Charlotte (maternal aunt) cared for Emily at her home. Care UK5 received 2 calls from Charlotte who reported that Emily had been crying non-stop for 4 ½ hours. At the same time, Billy was bought into A&E by Andrea. Separately both twins were noted to be in considerable distress and it was concluded that the likely cause of this distress was hunger. 4 The Expected Baby Protocol (2011) 5 Care UK is a British company providing health and social care. The company works with councils, Clinical Commissioning Groups and doctors to deliver care and support for older people and those with learning disabilities or mental health problems, as well as a range of healthcare services for NHS patients 11 SCR: Emily Final Report 2.3.4. Two days after the twins were discharged, the community midwife made an initial visit to Andrea and the twins at the family home. The information received from Care UK and the Children’s Hospital was recorded on the GP and health visitor records and Andrea told the midwife about her visit to hospital with Billy. However, this was not discussed with Andrea and no comment was made about parental capacity in light of these events. The midwife noted several concerns including; ‘filthy’ home conditions, exposure of the twins to extreme temperatures, Andrea’s lack of comprehension about the needs of the twins (including the need to feed the twins regularly) and ‘man-handling’ of the twins by Charlotte. The midwife appropriately discussed these concerns with her safeguarding lead and made a referral to Front Door the next day. 2.3.5. It was a timely referral that covered some relevant areas, but the involvement of Care UK and the Children’s Hospital was not mentioned. Most importantly, the referral did not articulate the importance of the midwives’ concerns in the context of multiple births and prematurity, and no professional analysis or judgement on present or future risks was provided. 2.3.6. Front Door responded by stating they remained unclear about the risks and referred the family to Early Help. Based on the information provided in this referral, this was a reasonable response. However, as no professional judgement had been provided, Front Door were not supported in their decision making about risk. Had this been provided, it is the view of the Lead Reviewers and Front Door that the threshold for a child protection response would have been met. The quality of referrals and importance of articulating risk is discussed further in Finding 1. 2.4. Referral to Early Help and response 2.4.1. This period highlights the importance of multi-agency work in understanding and responding to neglect. 2.4.2. Four days after the twins were discharged, the midwifery parenting assessment was sent to Front Door. The parenting assessment was a copy of day to day ward staff observations that were hand written and not easy to make sense of. However, the specialist safeguarding midwife helpfully summarized the concerns in an email to Front Door. Although the key areas of concern were indicative of potential neglect the terms risk, child protection, safeguarding or neglect were not articulated and there was no reference to the particular vulnerabilities of multiple births and prematurity, again, this did not support colleagues in Front Door to make an informed decision about risk. The importance of articulating professional expertise is explored further in Finding 1. 2.4.3. As the case had been passed to Early Help, Front Door sent the information directly to the Early Help Service. Whilst there was no professional judgement in the information sent by 12 SCR: Emily Final Report the midwifery team, it is the view of the Lead Reviewers and a manager in Front Door6 that this additional information should have prompted a review of the risks by Front Door to consider whether the threshold for a child protection assessment was now met. This did not happen and fell below expected practice7. 2.4.4. Twelve days later, an Early Help Social Worker visited the twins. The timing of this visit was in line with expected practice within the service, as the focus of the Early Help Services was on prevention and support, not on urgent child protection cases. There had been no management review of the available information, either in Front Door or in Early Help, and so there was no reason for the referral to be seen as anything other than a routine request for support. During the visit it was found that Emily was not at home as she was with Charlotte, and so a subsequent visit took place 2 days later when both Emily and Billy were present. These visits were an opportunity to form a view of parenting capacity and consider support needs, but this did not happen, and the focus of these visits was unclear. This was a missed opportunity to consider the experience of the twins and put in place a clear plan of service provision, including a timely multi-agency assessment, a child centred plan and reviewing mechanism. 2.4.5. At this time, some Early Help social workers had limited experience of under 5’s and the additional risks of multiple births/ prematurity. The service had been very recently restructured and some of the staff were new to the role and had limited recent experience of completing assessments (SAF’s8). The focus of the service was on prevention, and as a result practice was routinely focused on support needs, not on risk assessment. These issues had a detrimental impact on the services provided to this family and relevant issues are discussed in the Additional Learning. 2.5. Extended community response and escalating concerns. 2.5.1. This period examines the confusions caused by the absence of a multi-agency assessment and plan, minimisation of the impact of domestic abuse on children, and the delayed involvement of a Children’s Centre. 2.5.2. During a new birth visit to the twins, Andrea told the Health Visitor about a fight that had happened at home in front of the twins between her brother and her sister and she reported feeling bullied by her sister. The Health Visitor appropriately passed this information to Early Help. Early Help contacted the police who confirmed they had been involved in a domestic dispute at the home address. This information was recorded on the Health Visitor and Early Help files but nothing further was done. This information 6 Who was interviewed as part of this SCR and asked to reflect on the decisions made over this period. 7 Considerable changes have taken place in the services provided by Front Door and Early Help since this time, relevant issues are explored further in the Additional Learning 8 Single Assessment Framework 13 SCR: Emily Final Report suggested that the twins were exposed to domestic abuse and, despite frequent observations by professionals that the household regularly featured loud and aggressive behaviour, there was no consideration of how this violence and aggression may be impacting on the twins’ emotional world and development. The limitations of existing perceptions about domestic abuse and the impact on children, is discussed further in Finding 2. 2.5.3. When the twins had been at home for four weeks the Early Help Social Worker recognised that the family would benefit from the services offered by a children’s centre. Both the Health Visitor and Social Worker made referrals to different children’s centres to gain this support. They were aware that services provided by children’s centres in the area could provide appropriate support to this family, however, despite previous referrals to various children’s centres no such support had been secured. There was confusion about which children’s centre the family needed to be referred to and this resulted in significant delays. 2.5.4. Children’s centres use a postcode database to identify which families fall within their reach area. When referrals are received outside the reach area, it is usual practice to pass the referral to the correct children’s centre. It was not possible to understand why this did not happen, but the result of these various confusions was that Andrea did not receive the support she needed. 2.5.5. Over the following few weeks, the family were visited regularly by a health visitor and were seen at the GP practice. The Health Visitor and a Tenancy Support Officer made clear observations about the care the twins were receiving and appropriately shared these concerns with the Early Help Social Worker, including; bleeding nappy rash, poor weight gain, the twins being cold to the touch and hungry, rough handling, poor hygiene standards, health and safety concerns (including the out of control behaviour of a dog in the household, lack of parental understanding of the risks posed to the twins by household objects or unhygienic living conditions) and Charlotte’s aggressive behaviour. Andrea was noted to be in financial difficulties, she seemed ‘disassociated’ and there were concerns about the twins witnessing violence in the household. 2.5.6. These concerns were appropriately shared amongst the professionals and were indicative of neglect, but this term was not used by any of the professionals involved and no changes resulted for the children. For children to be adequately safeguarded, clear guidance needs to be available to inform and underpin the work of safeguarding practitioners in this complex area. In the area, there is no specific framework or tools to support an understanding of neglect and this was felt to be significant in explaining why neglect was not considered. This is explored further in Finding 3. 2.5.7. At the end of January, the twins were due for a routine GP appointment alongside their first immunisations. The Health Visitor shared her growing concerns, about possible failure to thrive, with the GP. Sharing concerns, taking time to analyse the concerns and agreeing next steps, was good practice. The GP subsequently wrote a letter of referral to the 14 SCR: Emily Final Report Community Paediatrician and the weight charts were included. However, the wider concerns did not form part of the letter of referral. 2.5.8. Based on the weights that had been plotted, the Community Paediatrician concluded there was no evidence of failure to thrive. The GP was informed, and the Community Paediatrician took no further action. At this point, although many of the professionals were very concerned, the multi-agency group appeared stuck as to the next steps. Whilst the referral to the Community Paediatrician was appropriate (and received a prompt response), the twins required a holistic assessment based on an informed understanding of neglect so that the full range of their needs/ experiences were considered alongside a judgement about parental capacity. The importance of understanding neglect is explored in Finding 3. 2.5.9. Twelve days later, a nursery nurse visited the family and made many detailed and astute observations about the care the twins were receiving and appropriately shared these concerns with Early Help. Concerns included; unsafe sleeping arrangements, Andrea’s lack of awareness of the risks presented to the twins by household hazards, significant nappy rash, the twins being naked and cold to the touch, Charlotte’s verbal aggression in front of the twins and her rough handling of them, feeding that was described as ‘functional’ (with no emotional warmth) and Andrea’s apparent fixation on a constricted feeding regime. The view of the Nursery Nurse was that the babies were exhausted from crying, due to hunger. Early Help advised that the twins should be seen by the GP for an urgent appointment. 2.5.10. The GP saw the twins promptly and noted they were low weight and, contrary to professional advice, Andrea confirmed she fed them water in between formula feeds. The GP fed this back to the health visitor who appropriately sought advice from their safeguarding lead and contacted Early Help to request that the case was escalated, this was good practice. 2.5.11. The clear and succinct concerns of the Nursery Nurse, the immediate report made to Early Help, the follow up appointment made by the GP, the swift report made to the Health Visitor by the GP, the supervision accessed by the Health Visitor and the immediate request for escalation, were all good practice. The focus of the health professionals was correctly focussed on assessing the risk, cross checking with each other and referring for step up. 2.5.12. Early Help agreed to ‘step up’ the case to Front Door, to elicit a child protection response. The Emergency Duty Team (EDT) was contacted to request that a visit was made over the weekend. EDT declined to visit the family on the basis that it was not an emergency. A follow up visit was booked by Early Help for the following Monday. As this was a case of chronic neglect, and not immediate risk, the decision by EDT was proportionate. However, no further attempt was made to step up the case to Front Door, either at the time or subsequently, and the professionals involved were left with a false impression that the referral to EDT constituted a failed attempt to ‘step up’ the case. It 15 SCR: Emily Final Report was not possible to fully understand this confused response by Early Help, although the issues explored previously and in the Additional Learning are relevant. 2.6. Completing the Single Assessment (SAF) 2.6.1. This period looks at the impact of an uncompleted SAF on multi-agency decision making and risk assessment. 2.6.2. The Early Help Social Worker visited the family on the following Monday. During this visit, concerns highlighted by five professionals (health visitor, nursery nurse, tenancy support officer, children’s centre manager and GP) were briefly raised and advice was provided. Following this visit, a multi-agency Team around the Family (TAF) meeting was arranged to take place 10 days later (although this wasn’t shared with Andrea at the time). Given the level of concerns around Andrea’s care for the twins, a prompt multi-agency meeting should have taken place sooner. This response was disproportionate to the risks in this case and left the professionals working with Emily without an assessment or plan. 2.6.3. By the 26th of February, the SAF, started by Early Help when the twins were discharged, remained incomplete (this was some 8 weeks after it had been started). As it stood, it was purely a narrative account of the information received at the original point of referral and by the time of the TAF (on the 26th of February) the information was out of date. As the SAF was never finalised, its contents were not shared with Andrea, her engagement with services was not discussed, and her views were not recorded. There was no information about the extent of professional concerns over the 8 weeks since the twins had been discharged, there was no analysis, no sense of the twins lived experiences, and no management oversight, this fell below expected practice. 2.6.4. At this time, there was little practice guidance policy/procedure in place to guide the work of the Early Help teams in relation to completion of the SAF and the TAF. There was scant management overview and guidance and the working relationships between Early Help and Children’s Social Care / Front Door were unclear. Since this time, there have been considerable changes within the Early Help service and as a result no finding has been made. However, relevant issues are discussed further in the additional learning. 2.6.5. The TAF meeting was the first opportunity for professionals to collectively share information, clarify the risks, and agree next steps. It was attended by Andrea, the Early Help Social Worker, children’s centre staff, the Health Visitor and the Tenancy Support Officer. There were no formal minutes of this meeting, however, the notes made by the Tenancy Support Officer indicate that whilst concerns were raised by professionals the overall focus of the meeting, and the plans that were made, focussed on Andrea’s needs and little reference was made to the needs of the twins. It was unclear what needed to change for the twins to be adequately parented and safeguarded from harm. The absence of formal notes and the focus of the TAF fell below expected practice. Importantly, whilst the meeting seemed focussed on Andrea’s support needs, despite frequent professional observations that Andrea may have learning difficulties, there was no consideration of the 16 SCR: Emily Final Report impact of any learning difficulties on Andrea’s ability to care for the twins or on the reasonable adjustments that should be made by services. Meeting the needs of adults with learning difficulties (diagnosed or otherwise) is discussed further in Finding 4. 2.6.6. Emily sadly died two weeks after the TAF meeting. 2.7. What makes learning from this case more widely applicable? 2.7.1. The ‘Learning Together’ methodology uses an individual case to provide a ‘window on the system’, identifying whether the learning that has been identified in one case is more systematic and widespread, thereby leading to a broader understanding about what supports and what hinders processes and practice locally. The Findings for the Board are identified out of the appraisal of practice, and those areas of learning that provide the most significant illumination for wider practice are then prioritised. 2.7.2. This case highlights elements of good practice by the professionals involved. However this case also shows that despite individual dedication and enhanced levels of inter-professional communication and home visits, the lack of an informed, structured, multi-agency response meant that the service response was confused, leaving both Andrea and the twins without the services they most needed. 3. The Findings 3.1. Summary of findings 3.1.1. This section contains findings that have emerged from the SCR. Each finding lays out the evidence identified by the review team that indicates that these are not one-off issues. Evidence is provided to show how each finding creates risks to other children and families in future cases because they undermine the reliability with which professionals can do their jobs, and therefore provides useful organisational learning to underpin improvement. 3.1.2. Four priority findings were chosen because they represented areas of practice which were significant in how this case was managed, but which also reflected wider patterns of practice and the systems which underpin that practice. They relate to one of the six categories of underlying patterns. Each finding is set out in a way that illustrates: How does the issue feature in this particular case? How do we know this issue is underlying and not unique to this case? What is known about how widespread this issue is? What are the implications for the reliability of the multi-agency child protection system? 3.1.3. The evidence for the different ‘layers’ of the findings comes from the knowledge and experience of the Review Team and the Case Group, from the records relating to this case, other relevant documentation and from relevant research evidence. 17 SCR: Emily Final Report 3.1.4. The remainder of this section explores the four Findings. FINDING Typology FINDING 1: The risks associated with twins and prematurity are not routinely articulated or understood across multi-agency partners resulting in a lack of clarity around the additional needs of these children and the services required. COMMUNICATION & COLLABORATION IN LONGER TERM WORK FINDING 2: Current service provision in England is largely predicated on a formulaic understanding of domestic abuse that inadvertently leads to a tolerance of sibling violence that would not be accepted for intimate partners, leaving the risk for children unassessed and not acknowledged. MANAGEMENT SYSTEMS FINDING 3: The lack of a multi-agency neglect framework and toolkit inhibits a shared professional understanding of neglect resulting in a reluctance to name the cause of harm to a child as neglect and leads to a confused multi-agency response. MANAGEMENT SYSTEMS FINDING 4: Professionals overreliance on diagnosis fails to recognise the continuum of needs of parents who have learning (or mental health) difficulties and the potential impact on children. COMMUNICATION & COLLABORATION IN LONGER TERM WORK Findings in detail 3.2. Finding 1 FINDING 1: The risks associated with twins and prematurity are not routinely articulated or understood across multi- agency partners resulting in a lack of clarity about the additional needs of these children and the services required. Introduction 3.2.1. Babies are entirely dependent on their immediate caregivers, and a parent’s capacity to respond appropriately to the emotions and needs of their babies has a profound impact. 18 SCR: Emily Final Report Becoming a new parent is a major transition; there are times when every parent feels under pressure and may struggle to cope with the stresses and responsibilities of their role. For parents of premature babies this can be a particularly challenging time, with additional challenges compounding this stress. “Premature birth is a significant stressor for parents and may adversely impact […] parenting behaviour” 9 3.2.2. Premature babies are defined by the World Health Organisation as those born before completing 37 weeks in the womb. This is an important issue as organ development over the last few months and weeks of pregnancy is vital. Premature babies can face particular physical and emotional challenges after discharge and if babies have been in a special care unit this may impact on quality of attachment between baby and parent. In addition, inevitably there will be a period of adjustment for babies after moving from an environment where they have been used to a fixed routine on the ward regarding feeding and sleeping, are familiar with an external environment that includes fixed light and temperature and where they are protected from common household dangers and infections. 3.2.3. Equally, there will be a period of parental adjustment. Evidence10 suggests that caring for premature babies can be stressful for any parent and as a result it can be harder to develop a good parent – child relationship. If compounded by the additional stress of multiple births and pre-existing parental vulnerabilities, it is imperative that the multi-agency network fully understands these complex needs and responds appropriately. This finding suggests that these vulnerabilities are not routinely articulated or understood, and this has a corresponding impact on the support that is provided. How did this finding manifest in this case? 3.2.4. The twins were born at 34 weeks, and spent their first few weeks of life in a special care unit. Andrea was discharged 3 days after their birth, whilst the twins remained in special care, and during this time Andrea had intermittent contact. After two weeks, in line with usual practice, Andrea was readmitted and discharged with the twins five days later (just prior to the twins reaching full term). That night, calls were made to the emergency services by Charlotte and Andrea attended A & E as the twins were in some considerable distress; it was concluded that the probable cause of their distress was hunger. The next day, a midwife visited and was very concerned about the filthy state of the family home (including a significant number of health and safety issues), the feeding regime in place and Andrea’s overall care of the twins. 9 Bilgin, A. and Wolke, Dieter. (2015) Maternal sensitivity in parenting preterm children: a meta-analysis. Pediatrics, 136 (1). e177-e193. ISSN 0031-4005 10 Cuthbert, et al (2011) All babies count: prevention and protection for vulnerable babies: a review of evidence (NSPCC) 19 SCR: Emily Final Report 3.2.5. In the various referrals, assessments and correspondence between health professionals (including specialist midwives, community midwives, safeguarding midwives and a health visitor) and with Children’s Services (including Front Door and Early Help) whilst concerns were raised about Andrea’s vulnerabilities and her care of the twins (including but not exclusive to her feeding and handling of the twins), there were no references to the specific risks posed by multiple births and prematurity and no impact analysis of these combined factors (actual or predicted). Overall, the information passed to Children’s Services Front Door Team was characterised by a narrative description. As a result, the risks were not fully understood and the service response was both confused and delayed. How do we know this issue is underlying and not unique to this case? 3.2.6. During the Case Group Meeting, members of staff from the intensive care unit were asked about whether it would be normal practice to articulate the specific risks associated with multiple births and prematurity when completing a parenting assessment or when referring to Children’s Services. It was confirmed that this is not routinely specified as there is an assumption that staff within Children’s Services would be conversant with these particular risks. It is understood that relevant local guidance available at the time) does not highlight these specific risks and this provides a partial explanation for why it is not common practice for these risks to be articulated. 3.2.7. In addition, staff were asked about discharge planning meetings and whether these were held in cases of multiple vulnerability (such as those identified in this case). Practitioners confirmed that unless Children’s Services are involved it is not routine practice to hold discharge planning meetings in these circumstances. What is known about how widespread this issue is? 3.2.8. It was understood that this issue has been previously recognised by Front Door and there has been some joint work with midwifery services to improve the quality of the referrals so that an accurate judgement on risk and service provision can be made. However, a recent Serious Case Review in the area has identified the quality of referrals to Front Door from multi-agency partners as an ongoing safeguarding issue. What are the implications for the reliability of the multi-agency child protection system? 3.2.9. Nearly 1 in 10 babies are born prematurely and many will spend time in a neonatal unit11. It is not known how many of these babies will have additional vulnerabilities because of their parents/family circumstances, or how many of these are multiple births, but research suggests that they are at increased risk of abuse and neglect. In a system that is working well, the expertise held by specialist staff within these units (and by staff based within the 11 According to the Office for National Statistics, 52,160 babies - 7.3% of live births – in England and Wales were born prematurely during 2012: http://www.ons.gov.uk/ons/rel/child-health/gestation-specific-infant-mortality-in-englandand-wales/2012/index.html 20 SCR: Emily Final Report community) will be used to its full advantage by incorporating this expert knowledge in assessments, referrals and in communication with multi-agency safeguarding colleagues. However, if assumptions are made about the knowledge of other professionals and an assessment of risk is regarded as the domain of others, the risks to children will not be understood and children will not receive the services they need. FINDING 1: The risks associated with twins and prematurity are not routinely articulated or understood across multi-agency partners resulting in a lack of clarity about the additional needs of these children and the services required. Summary Prematurity and multiple births are key factors to consider when assessing need. Staff within health services, including but not exclusive to midwifery services and neonatal staff, are well placed to provide multi-agency partners with expert advice about a baby’s needs and parental capacity to inform multi-agency decision making. In the absence of this, there is a danger that decisions about service provision will be ill-informed and the risks to children potentially unacknowledged. Questions for the Board How has recent work to improve the quality of referrals been evaluated? Is there a need for additional work to be completed to address the specific issues highlighted in this finding? Is there a need to reconsider the criteria for holding a discharge planning meeting? How will the Board evaluate required improvements? 3.3. Finding 2 Finding 2: Current service provision in England is largely predicated on a formulaic understanding of domestic abuse that inadvertently leads to a tolerance of sibling violence that would not be accepted for intimate partners, leaving the risk for children unassessed and not acknowledged. Introduction 3.3.1. The Government defines domestic abuse as: “any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged 16 or over who are, or have been, intimate partners or family members regardless of gender or sexuality.” The behaviour captured in this definition includes: “…a pattern of acts of 21 SCR: Emily Final Report assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim”12. 3.3.2. A growing body of research13 has demonstrated that domestic abuse is not a single phenomenon and that types of domestic violence can be differentiated with respect to the dynamics, context, and consequences, and suggests that four patterns of violence can be identified: coercive controlling violence where one person is violent and controlling violent resistance, usually a form of self-defence separation instigated violence, which occurs in the context of relationships ending; and situational couple violence, the most common form of domestic abuse, which is conducted by individuals of both genders nearly equally and is likelier to occur among younger couples, such as adolescents. 3.3.3. From a child’s perspective all types of domestic abuse present risks to their physical and emotional wellbeing; a child living within loud and chaotic homes where there are regular arguments between household members will, regardless of the relationship between these household members, perceive this as a threat and this will inevitably lead to triggering a stress response. If ongoing, this can have profound consequences for their development by affecting their brain neurons / pathways14 and research is increasingly suggesting that this can have a long-term impact on a child’s physical and mental health, and on their social relationships and learning. How did this finding manifest in this case? 3.3.4. When asked to describe the household within which the twins lived, all practitioners spoke about this being both loud and chaotic with frequent arguments occurring between all the siblings. They spoke of Charlotte’s aggressive and controlling behaviour towards Andrea, particularly concerning the care of the twins. 3.3.5. During the 3-month period under review there were several occasions when it was clear the twins had been exposed to violence, including an occasion when the police were called to the home after a fight occurred between Charlotte and Jake in front of the twins. There 12 https://www.gov.uk/domestic-violence-and-abuse 13 Working relationally with couples where there is situational violence’ A policy briefing paper from ‘The Tavistock Centre for Couple Relationships’ www.tavistockrelationships.ac.uk/policy. And: Johnson, M.P. (2008) A Typology of Domestic Violence: Intimate Terrorism, Violent Resistance, and Situational Couple Violence. The North-eastern series on gender, crime, and law. Lebanon, New Hampshire, US: UPNE 14 Such as: National Scientific Council on the Developing Child, 2005, 2007, 2010) Chaotic homes and school achievement: a twin study. Hanscombe KB, Haworth CM, Davis OS, Jaffee SR, Plomin R J Child Psychiatry. 2011. The role of chaos in poverty and children's socioemotional adjustment. Evans GW, Gonnella C, Marcynyszyn LA, Gentile L, Salpekar (1987). The physical environment and development of children. Handbook of environmental psychology (pp. 281–328). New York, NY: Plenum Press 22 SCR: Emily Final Report was additional information to suggest that Andrea was regularly bullied and controlled by her sister and was unable or unwilling, because of her reliance on her sister to provide care to Emily, to effect any change in this relationship. Charlotte was recorded as taking over, shouting and using derogatory comments, breaking the stair gate in a rage, and Charlotte was witnessed as being loud and aggressive in front of the twins – making them visibly flinch. Despite these known concerns, the impact on the twins was not adequately considered. How do we know this issue is underlying and not unique to this case? 3.3.6. Discussion within the Review Team and Case Group suggested that although they were clearly concerned about Charlotte’s behaviour towards both Andrea and the twins, they did not understand that this aggressive, controlling and violent behaviour could constitute domestic abuse, and struggled to articulate the impact of this behaviour on Andrea’s wellbeing or the children’s lived world. It seemed that this form of violence was not something that was considered when assessing risk. 3.3.7. Current training models and service provision for families experiencing domestic abuse can often be premised on a traditional assumption that domestic abuse is coercive and controlling violence (usually involving a male perpetrator and a female victim) and that this can only be construed as abuse if it involves an intimate relationship. What is known about how widespread this is? 3.3.8. There is considerable research and available data on domestic abuse perpetrated by men on women, and about children living in these environments.15 3.3.9. Eight million people in the UK (24.4% of people between the ages of 16 and 59) have been victims of domestic violence and abuse (6.1% in the year 2011/12), and 25% of young people have witnessed at least one episode of domestic violence and abuse by the age of 18.16 One in seven (14.2 per cent) children and young people under the age of 18 will have lived with domestic violence at some point in their childhood.17 3.3.10. However, these statistics do not provide sufficient evidence about the nature of the domestic abuse that is being recorded and there is little current UK research about the diverse types of domestic abuse or the numbers of children affected. 3.3.11. Research completed by the Centre for Justice18 highlights the limitations of current perceptions and service response to domestic abuse: 16 Early intervention in domestic violence and abuse Jonathon Guy with Leon Feinstein and Ann Griffiths 17 Early intervention foundation. Meeting the needs of children living with domestic violence in London Research Report Lorraine Radford, Ruth Aitken, Pam Miller, Jane Ellis, Jill Roberts and Ana Firkic Refuge/NSPCC (research project funded by the city bridge trust November 2011) 18 Domestic Violence, Breaking the Cycle a Report for the Centre for social Justice. Farmer and Callan 2012 23 SCR: Emily Final Report The logical response to the power and control approach (to DA) emphasises providing safety and resources for female victims fleeing abuse, a punitive response to male perpetrators via the criminal justice system, prevention campaigns aimed at challenging patriarchal attitudes and treatment programmes that challenge and confront male perpetrators about the controlling and sexist motivations behind their behaviour. 3.3.12. The report asserts that a far more complex view needs to be taken both to the perceptions of domestic abuse and services adapted accordingly. What are the implications for the reliability of the multi-agency child protection system? 3.3.13. A safe system considers the impact of any form of domestic abuse on victims and children, supports professionals to consider broader factors (that are not based on a gendered stereotype of this form of abuse), encourages a more nuanced understanding of what constitutes domestic abuse and ultimately invites different professional responses. 3.3.14. Current child protection systems are well established to consider risk when children are living in households where there is domestic abuse perpetrated within an intimate relationship, and commonly involving male on female violence. This is a well-known child protection concern; services are alert to the risks to children who are living in this environment and suitable services are available. However, holding a restricted view of what constitutes domestic abuse, and perceiving the impact on children as constrained within an established familiar construct fails to appreciate a child’s lived experiences and presents risks to the child’s immediate and long-term safety and development. FINDING 2: Current service provision in England is largely predicated on a formulaic understanding of domestic abuse that inadvertently leads to a tolerance of violence perpetrated by siblings that would not be accepted for intimate partners, leaving the risk for children unassessed and not acknowledged. Summary To effectively safeguard children, professionals working with children and families need to be aware of the differences in the nature of domestic abuse and first and foremost consider the perspective of the child who is growing up in an environment where domestic abuse is present. As it currently stands, a formulaic service response and understanding of domestic abuse seems to prevail and this has significant implications for multi-agency safeguarding practice. Questions for the Board How well does current training provision address the issues highlighted in this finding? Are any adjustments needed to ensure that services currently provided to victims and perpetrators of domestic abuse and to children reflect the latest research and the issues highlighted in this finding? 24 SCR: Emily Final Report 3.4. Finding 3 FINDING 3: The lack of a multi-agency neglect framework and toolkit inhibits a shared professional understanding of neglect resulting in a reluctance to name the cause of harm to a child as neglect and to a confused multi-agency response. Introduction 3.4.1. Emily’s sad death at 12 weeks old has been recorded as “unascertained” and therefore comes within the category of “Sudden Unexpected Death in Infancy” (SUDI). This is the term used to describe the sudden and unexpected death of a baby. Around 290 children under one die every year of SUDI in the UK. Most are babies under 6 months.19 Many of the known risk factors underpinning SUDI are consistent with and seen in cases of neglect. In this case, no link between the neglect experienced by Emily and her death was found. 3.4.2. While the causes of SUDI are not fully understood there are established risk factors and they include: Dwelling in an area of perceived high deprivation Smoking; Parental mental health; Domestic violence; Premature/low birth weight; Parental substance misuse; Co-sleeping; Parental alcohol consumption 3.4.3. The link between SUDI and neglect is reported in the 2012 biennial study of findings in Serious Case Reviews.20 3.4.4. Brandon highlights that neglect is a particularly difficult area of work for practitioners. Identifying multiple risks, naming concerns as potential neglect, working within the framework of support, monitoring and judging progress and finally determining whether the child protection framework is appropriate for intervention presents a challenge. 19 Sudden Infant Death Statistics, Office of National Statistics, 2015. 20 Brandon et al 2012. 25 SCR: Emily Final Report 3.4.5. Brandon emphasises the need to consider the importance of interacting risk factors, and states: “Our previous work 21 has emphasised the importance of an interacting risk perspective. This holds true for these cases of SUDI where interacting risk factors for example prematurity, parental smoking, alcohol misuse, deprivation and co-sleeping would have elevated the risk to the infants” and goes on to say: “…practitioner uncertainty regarding thresholds, criteria and what constitutes significant harm and neglect can lead to confused opinions. Unrealistic practitioner optimism may also result when small changes to a child’s circumstances are made which are given too much ‘weight’ when the overall risks remain unchanged. […] defining neglect in terms of the likelihood of significant harm or impairment to the child’s development rather than on whether the child has been harmed, may encourage practitioners to focus on whether a child’s needs are being met, regardless of parental intent.” 3.4.6. The use of tools is well recorded and noted in many SCR’s. Tools help measure and define risk, provide a framework to support practitioner assessment, increase the potential to bring objectivity and support multi-agency understanding of the family situation. In this case, it was found the neglect was not conceptualised by any of the professionals involved and the absence of framework and associated tools was found to play an important part in this. How did this finding manifest in this case? 3.4.7. Initial professional contact at the booking appointment identified that Andrea had past vulnerabilities which would indicate potential risk and correctly referred on to a specialist safeguarding midwife. Subsequent contacts with health and medical professionals also correctly identified and recorded multiple concerns, with significant consistencies as evidenced in case recording by different professionals. These included Andrea’s historical vulnerabilities including low mood, self-harm and depression, lack of support to assist with parenting and her own concerns on how she will cope, and the more immediate risks following the twins’ discharge of the filthy conditions of the home. 3.4.8. Professionals openly raised concerns that Andrea may have low levels of understanding and queried a learning difficulty, noted she appeared disengaged from meeting the basic needs of feeding and changing and was unable to control or influence her family support. They noted poor weight gain, the twins often appearing distressed through delayed feeding, bleeding nappy rash, rough handling, functional feeding, Andrea appearing 21 Brandon et al 2008 26 SCR: Emily Final Report disassociated and often in low mood, the twins visibly flinching in response to the loud and aggressive behaviour within the household, an unsecured dog, and a lack of awareness about hygiene and the safety of the twins. 3.4.9. In response to the level of concern felt by professionals, a high level of professional activity took place and there was frequent communication between them to make sure that someone would see or speak to Andrea daily. Andrea’s acceptance of this level of contact was seen as positive, with small successes such as attending a children’s centre group being accepted as an indication of progress. 3.4.10. The missing element seen in this case and one of most crucial importance was that of a shared understanding between professionals of the interacting risks, the compounding impact of these upon the lived experience and long-term development of the twins and an unwillingness to name the possibility of actual or likelihood of neglect. How do we know this issue is underlying and not unique to this case? 3.4.11. In this case it is notable that none of the tools available to help with an objective assessment of neglect or to address the numerous concerns were used. The lack of identification of neglect by all the professionals in this case, and a corresponding reluctance by the Review Team to name the harm the twins were suffering as neglect, suggest that the difficulties in conceptualising and naming neglect is not unique to this case. 3.4.12. In addition, during this SCR a review team member reviewed several cases held at early help level and found no evidence of neglect being named as part of a risk assessment, despite features being present. 3.4.13. The Lead Reviewers were told that the Signs of Safety (SOS)22 approach has been recently adopted in the area and that this approach discourages professionals using the term neglect, instead encouraging a descriptive account of parental behaviours and impact on a child (rather than use of a simple term such as neglect that in isolation is unhelpful to parents). The Lead Reviewers had some sympathy for this view and it is clear that the SOS approach is a very helpful way of articulating impact and balancing the risks and protective factors. However, in the absence of a specific neglect framework or tools (such as Graded Care Profile - GCP) 23 this may run the risk of dissipating professional concerns and may lead to confusions within the multi-agency network about how to frame the safeguarding risks and provide a timely response. What is known about how widespread this issue is? 22 A solution-focused, strengths- based approach to social work practice; Eileen Munro, Terry Murphy and Andrew Turnell 23 The GCP scale was developed by Dr Srivastava in the early 1990s, GCP has been deployed in over 60 local authorities to help identify and intervene in cases of child neglect. 27 SCR: Emily Final Report 3.4.14. Recent research and SCR’s demonstrate how multi- agency risk assessment and effective intervention in cases of neglect continues to present a challenge to safeguarding practitioners and services. 3.4.15. Neglect is the most common form of child maltreatment in England (Department for Education, 2013; Radford et al, 2011) and the USA (Sedlak et al., 2010). In England, almost half (43%) of child protection plans are made in response to neglect, and it features in 60% of serious case reviews (Brandon et al., 2012).24 A key and recurring theme throughout the previous biennial reviews has been the extent and significance of neglect in the children’s lives. This is evidenced yet again in this latest review for 2011-2014.25 3.4.16. Recent evaluation by the NSPCC26 of the use of a tool in the assessment of neglect (GCP) recognised that the use of this framework and associated tools enabled practitioners to identify risks and potential harm more effectively, particularly in cases of neglect, and assisted in either allaying concerns or effectively escalating concerns to secure an appropriate response. What are the implications for the reliability of the multi-agency child protection system? 3.4.17. If neglect is conceptualised within an informed framework, the causes of neglect are better understood, appropriate tools are used to understand the impact of neglect from a child’s perspective and services are more able to provide effective, timely, intervention. In a system that struggles to identify neglect, and as a consequence is unable to provide effective services, at best children will remain living in conditions that will have a detrimental long-term impact on their emotional, behavioural, physical and mental health, at worst the safety of children will be seriously compromised. FINDING 3: The lack of a multi-agency neglect framework and toolkit inhibits a shared professional understanding of neglect resulting in a reluctance to name the cause of harm to a child as neglect and leads to a confused multi-agency response. Summary Neglect presents complex challenges to practitioners and services. It continues to be a common feature of serious case reviews and researchers, policy makers and child protection services remain concerned 24 Missed opportunities: indicators of neglect – what is ignored, why, and what can be done? Research report November 2014 Marian Brandon, Danya Glaser, Sabine Maguire, Eamon McCrory, Clare Lushey & Harriet Ward – Childhood Wellbeing Research Centre 25 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final report May 2016 Peter Sidebotham, Marian Brandon, Sue Bailey, Pippa Belderson, Jane Dodsworth, Jo Garstang*, Elizabeth Harrison, Ameeta Retzer and Penny Sorensen University of Warwick University of East Anglia 26 National Evaluation of the Graded Care Profile Robyn Johnson and Richard Cotmore NSPCC Evaluation department, Oct 2015 28 SCR: Emily Final Report about the quality and consistency of service provision in tackling neglect. Equipping practitioners and services with an informed neglect framework and tools has shown to be effective in how neglect is understood, and how children are safeguarded. Questions for the Board Should the LSCB adopt a neglect framework and suitable tools to compliment use of the SOS approach across the multi-agency network? 3.5. Finding 4 FINDING 4: Professional overreliance on diagnosis fails to recognise the continuum of needs of parents who have learning (or mental health) difficulties and the potential impact on children. Introduction 3.5.1. The shared understanding and the use of terminology for people with learning difficulties or learning disability continues to cause much confusion between professionals, with agencies publishing differing definitions and guidelines according to their professional background, commonly with an emphasis and reliance on meeting thresholds to achieve diagnosis. 3.5.2. National statistics show that up to 1 in 5 of any population is likely to have a difficulty in learning, the extent to which this may impair daily life or learning as a child and can often lead to a diagnosis by a medical professional or through chartered psychologists. Such diagnoses are determined by multiple factors and can either follow a medical route expressed through NICE guidelines or a psychological route through the British or American Psychological Society. 3.5.3. Intellectual functioning is usually determined through comprehensive testing and is frequently reported in age equivalents, where chronological age and comparative intellectual functioning are used to support description of usual cognitive functioning. Adaptive and social functioning is a broad definition and relates to a person’s performance in coping on a day-to-day basis with the demands of their environment; in simple terms, “what they do”. In order to determine adaptive and social functioning it is usual to undertake assessment, using recognised scales and checklists and these are usually completed by professionals with the person in question and or family members/others. 3.5.4. This, in simple terms, sets out the familiar approach to any assessment, where accepted tools are used to determine whether diagnostic thresholds have been met. Receiving a diagnosis of a learning disability is important in medical and legal contexts and so, it follows, must be important within a safeguarding context, when parenting ability is being assessed. Consistent with any threshold, there will be some cases that do not meet the 29 SCR: Emily Final Report required threshold for a learning difficulty diagnosis as the level of need is not significant enough. But it is too simple and too big a jump therefore to assume therefore that no learning difficulty exists. This leads to the crux of the matter when trying to determine safe and effective parenting. Applying such a threshold potentially ignores significant numbers of the population because their levels of need are simply not “significant enough”. 3.5.5. Much time and energy could be spent on trying to determine a single, shared definition, however the reality is that this is likely to be unachievable and masks the questions of most importance here, which is how far does having a learning difficulty or disability, and to what level, impact upon a person’s ability to parent safely? Do professionals have a shared understanding of this and how do they take any such learning difficulty into account when assessing and identifying immediate or longer-term impact upon children? 3.5.6. This becomes even more complex as disability (which can include a learning difficulty) is a protected characteristic under the Equality Act 2010 (EA2010) and forms the legislative basis for the Public-Sector Equality Duty (PSED). Both the Equality Act and Public-Sector Duty are underpinned by the Human Rights Act (HRA). Under the HRA adults can self-declare a protected characteristic including where they have difficulties or impairments which may impact upon many areas of their life. 3.5.7. The Public-Sector Equality Duty (PSED) covers all public-sector employees and functions and is referenced in NICE guidelines. The PSED requires consideration of any protected characteristic and where this may apply for public sector employees to determine if they should apply any reasonable adjustments. Examples of reasonable adjustments include providing information in different formats or in different ways, offering services more flexibly and taking into account the protected characteristic in any assessment or allocation of service. Applying a reasonable adjustment does not require meeting a diagnostic threshold. How did this finding manifest in this case? 3.5.8. Andrea had contact with multiple professionals (community midwife, a specialist midwife, hospital midwives, a health visitor and nursery nurse, GP, practice nurses, early help social worker, tenancy support officer, children’s centre manager and children’s centre worker) and all of them queried whether Andrea had a learning difficulty. They recognised and described Andrea as seeming much younger than her age and identified the ideal support as one which is not available to her age group (e.g. Family Nurse Partnership). The GP recognised this could be important from previous experience and looked up Andrea’s personal records. She confirmed that Andrea did not have a diagnosis of any learning difficulty. Andrea never suggested to any professionals that she had a learning difficulty and no professional ever raised this with her, although it was accepted by all and was not challenged. 3.5.9. In the absence of a diagnosis the professionals were at a loss to clearly understand the impact of Andrea’s ability to consistently follow professional advice; they did not consider 30 SCR: Emily Final Report whether Andrea needed reasonable adjustments for advice and guidance different to that which they usually offer. It isn’t clear why Andrea never had a learning difficulty assessment, we can only presume that her needs were not considered “significant enough” to trigger such an assessment and so none was undertaken. 3.5.10. It is also relevant to consider the amount of caring that Charlotte was undertaking for the twins. Charlotte routinely cared for Emily, which one case team member estimated as taking place more than 50% of the time, and a significant number of case recordings show that Emily was not available as she was with Charlotte. Charlotte did have a diagnosis of a learning difficulty and indeed told health professionals that she had a mental age of 7 years. Despite these concerns, the impact on the twins was not considered and no reasonable adjustments were made by services. How do we know this issue is underlying and not unique to this case? 3.5.11. As a result of the commonality of this issue, the Review Team requested that the use of the term ‘learning difficulty’ and impact on service response was specifically explored during this SCR (Ref: Research Questions P.6). 3.5.12. The Lead Reviewers learnt that the use of the term learning difficulties was quite often seen within case recordings across the agencies, even when there had been no previous diagnosis. It was reported as being commonly used as a phrase that indicated professionals were concerned about parental levels of understanding but without a diagnosis, professionals struggled to identify how services needed to be adapted or what reasonable adjustments needed to be made. What is known about how widespread this issue is? 3.5.13. There are recent cases reported in Family Law courts where parents with diagnosed learning difficulties have launched defences based on the Equality Act, where they feel professionals have not taken into account reasonable adjustments. However, no research could be found on how reasonable adjustments, and the consideration of them, are used for those who do not meet diagnostic thresholds as applied for medical and legal purposes. 3.5.14. This issue is seen in a recent City and Hackney 2016 SCR27. In this SCR the reviewer concludes that whether or not the criteria for learning difficulties or mental health is met, existing risk factors (arising from the fact that some level of learning difficulty or mental health difficulties are identified) should be assessed and considered as such. It is suggested it may be helpful to produce a tool for assisting professionals to assess levels of learning difficulties, and the potential impact upon parenting, and that a greater level of understanding of adult learning difficulties should be promoted across all agencies. 27 Harrington, Kevin (2016). Serious case review: Child H: overview report. Hackney: City and Hackney Safeguarding Children Board. 31 SCR: Emily Final Report 3.5.15. This SCR reported that the relevance of a diagnosis for the parent was not the most important factor and indeed could mask the true focus of services which should be about identifying other risk factors potentially arising from a parent with some level of learning difficulty, including the potential impact of neglect on the baby and the ability of that parent to meet the basic needs of a baby. What are the implications for the reliability of the multi-agency child protection system? 3.5.16. Where there is a shared understanding of a parent’s needs, and a clear framework in place to address these needs, professionals are enabled to make an informed assessment of risk, assess parenting skills, and make a judgement on parental capacity to change. This approach results in effective multi- agency assessment and planning to address risks and the provision of effective support for parents where needed. 3.5.17. In the absence of a diagnosis or a shared understanding of parental needs, the impact of any learning difficulty (perceived or actual) on parental capacity will be unknown. Professionals may hold false expectations of parental capacity and overly rely upon parents to keep their children safe. Such false optimism can lead to the risks being missed, and a failure to identify what services a parent may need (or what adjustments should be made to services) to enable a child’s needs to be met. The consequences are that children may be left too long in situations of harm, or conversely, ill thought out services provided that fail to give parents sufficient opportunity to effectively care for their children. Finding 4: Professionals overreliance on diagnosis fails to recognise the continuum of needs of parents who have learning (or mental health) difficulties and the potential impact on children. Summary The use of the term learning difficulty is commonly seen in multi-agency case recordings but when there is no formal diagnosis, professionals struggle to understand the needs of parents and the impact on parental capacity. When safeguarding children, locally agreed thresholds and guidance can provide a level of support, but more importantly, recognising the needs of parents with a perceived learning difficulty and making suitable adjustments to the way services are provided is critical in preventing harm to children and giving parents the best possible opportunity to parent their children and protect them from harm. Questions for the Board How do professionals across all agencies understand the terminology of learning difficulties and consider how services will be provided to support those that have learning difficulties, with diagnosis or not? 32 SCR: Emily Final Report What changes in service provision may need to be made? 3.6. Additional Learning Early Help 3.6.1. In line with the area’s commitment to intervening early in a child’s life to prevent problems developing or escalating and to enable a child to reach their full potential, Early Help Services are provided across the city to children with additional or complex needs. These children are supported by Early Help teams who are responsible for assessing need using a Single Assessment Framework (SAF) and planning for a child’s needs through multi agency meetings known as a Team Around a Family (TAF). 3.6.2. These children meet the threshold for intervention by statutory services. This group includes those children who require an assessment undertaken by a social worker to determine whether or not they are ‘children in need’. This is defined under section 17 of the Children Act 1989 and includes those who have already been assessed as children in need, and those who have suffered or who are at risk of suffering significant harm as defined under section 47 of the Children Act 1989. 3.6.3. The local area Front Door Team is the first access point to these services, receiving referrals from other agencies or from members of the community and making threshold decisions about levels of need and passing referrals to the service that would best meet these needs. Using a definition of urgent need, children’s cases are passed to Children’s Services. Alternatively, if it is concluded that on the information available a child has emergent, complex or additional needs, referrals are passed to the Early Help Service. This approach both meets the needs of children and families in providing a service to children which is led by their needs, and ensures that Children’s services have the capacity to provide an immediate response to children at risk of harm. 3.6.4. For this to work well, there needs to be a clear and dynamic interface between the Early Help and Children’s services, suitably well-trained professionals employed in these services, consistency in how risk is understood, how assessments are completed, and how plans are made, delivered, reviewed and monitored. The local authority acknowledges that a child and family’s needs are dynamic and therefore supports a fluid approach to the question of need and risk, it is an approach that underpins the reality of children and families lives; need is not static and therefore the service response must be subject to review and change. 3.6.5. In this case, the nature of the services provided by Early Help and the absence of any meaningful interface with children’s social care teams seemed to contradict this approach. It was understood that the reason for this was due to several factors. A significant remodelling of social work and Early Help had taken place in November 2014, family 33 SCR: Emily Final Report intervention social work support had been moved into Early Help and Social Work Units were formed to work with child protection cases. Front Door focussed on determining immediate danger and providing a swift response, and Early Help on parenting support and longer-term work (with higher risk being stepped up to the new social work units). 3.6.6. The professionals within this case were unclear about how these changes (and the changes in services provided by children’s centres) interacted with service delivery. The response was therefore one of confusion, with significant delays and missed opportunities for a step up and the focus of intervention centred on support to Andrea, rather than on the lived experiences of the children. 3.6.7. No finding has been made about the Early Help Services, as it was understood that there have been some significant changes to the way Early Help and Front Door now operate. These changes include a far clearer and more robust interface between Early Help and the specialist teams, routine involvement of experienced social workers (who are more actively involved in decision making within both service areas), improved step up processes, strengthened policy and procedure in relation to the work of the teams and better management supervision oversight and review. Summary In light of further changes currently taking place within the Early Help Service, the Board is recommended to consider the learning that has emerged from this serious case review (and others) and consider what more may be needed, if anything, to improve service delivery going forward. Questions to the Board How is the Board reassured that actions identified from previous Serious Case Reviews are evident in ongoing service delivery? 34 SCR: Emily Final Report Appendix 1: References Bilgin, A. and Wolke, Dieter. (2015) Maternal sensitivity in parenting preterm children: a meta-analysis. Pediatrics, 136 (1). e177-e193. ISSN 0031-4005 Brandon. M, Danya Glaser, Sabine Maguire, Eamon McCrory, Clare Lushey & Harriet Ward Missed opportunities: indicators of neglect – what is ignored, why, and what can be done? Research report November 2014– Childhood Wellbeing Research Centre Cuthbert, et al (2011) All babies count: prevention and protection for vulnerable babies: a review of evidence (NSPCC) Evans GW, Gonnella C, Marcynyszyn LA, Gentile L, Salpekar (1987). The role of chaos in poverty and children's socioemotional adjustment. Farmer and Callan 2012 Domestic Violence, Breaking the Cycle a Report for the Centre for social Justice. Fish, Munro & Bairstow: Learning Together SCIE 2010 Guy. J, with Leon Feinstein and Ann Griffiths Early intervention in domestic violence and abuse Hanscombe KB, Haworth CM, Davis OS, Jaffee SR, Plomin R J National Scientific Council on the Developing Child, 2005, 2007, 2010) Chaotic homes and school achievement: a twin study. Child Psychiatry. 2011. Johnson, M.P. (2008) A Typology of Domestic Violence: Intimate Terrorism, Violent Resistance, and Situational Couple Violence. The North-eastern series on gender, crime, and law. Lebanon, New Hampshire, US: UPNE Office for National Statistics: http://www.ons.gov.uk/ons/rel/child-health/gestation-specific-infant-mortality-in-englandand-wales/2012/index.html Office of National Statistics: Sudden Infant Death Statistics 2015. Radford, L, Ruth Aitken, Pam Miller, Jane Ellis, Jill Roberts and Ana Firkic Early intervention foundation. Meeting the needs of children living with domestic violence in London Research Report Refuge/NSPCC (research project funded by the city bridge trust November 2011) Robyn Johnson and Richard Cotmore. National Evaluation of the Graded Care Profile. NSPCC Evaluation department. Oct 2015 Sidebotham. P, Brandon, Sue Bailey, Pippa Belderson, Jane Dodsworth, Jo Garstang*, Elizabeth Harrison, Ameeta Retzer and Penny Sorensen. Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final report May 2016 University of Warwick University of East Anglia The physical environment and development of children. Handbook of environmental psychology (pp. 281–328). New York, NY: Plenum Press Working relationally with couples where there is situational violence’. A policy briefing paper from: The Tavistock Centre for Couple Relationships www.tavistockrelationships.ac.uk/policy. |
NC52305 | Death of a baby girl in 2017. The cause of Molly's death was unascertained, however there were factors present similar to those found in cases of Sudden Infant Death Syndrome. Learning: identifies opportunities where communication and information sharing could have been better; a lack of professional curiosity and an over-optimism of all agencies in relation to the assessment of the future risk of domestic abuse; lack of professional challenge as well as a lack of awareness of disguised compliance from parents; and an increased risk of neglect to the children due to the interlinking of several parental risk factors including poverty, domestic abuse, substance misuse, nonengagement with services and poor and overcrowded housing conditions. Recommendations include: ensure that thresholds in respect of neglect are clearly understood; ensuring there is an agreed process which ensures that multi agency decision making when challenged has an appropriate escalation process; the need for an antenatal missed appointment policy; review the effectiveness of and compliance with the was not brought policy.
| Title: Serious case review – Baby Molly. LSCB: Durham Local Safeguarding Children Board Author: Sharon Hawkins Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. SERIOUS CASE REVIEW – BABY MOLLY Independent Reviewer Sharon Hawkins February 2019 1 Chapter Page Number Introduction 2 Publication 3 Reason for the Review 3 Specific Terms of Reference 4 Timescale 6 Family Involvement 6 Parallel Processes 7 Independent Reviewer and Panel 7 Process and Methodology 8 Family Composition, Ethnicity, Diversity and Cultural Issues 9 Background Narrative as Known to Agencies 9 Chronology of Significant Events Identified in the Timeline 11 Appraisal of Practice and Analysis of the Key lines of Enquiry. 17 Conclusion and Recommendations 24 2 1 INTRODUCTION-The Child’s Journey 1.1 This Serious Case Review is about the services provided to Baby Molly and her family prior to her death in the autumn of 2017. In her second interim report titled ‘The Child’s Journey’1, Professor Munro identified the importance of understanding the ‘child’s journey’ through services and for families to receive effective help at the earliest point for problems arising from family and social circumstances. 1.2 On the morning of her death, it is reported Molly woke for her feed at approximately 4am, Molly took four ounces of formula milk from a bottle and was settled back in her Moses basket, which was located at the bottom of the parent’s bed. 1.3 Molly was discovered lying on her back in her Moses basket by her parents and there were no signs of life. The mother called for an ambulance and Molly was transported to hospital and despite resuscitation throughout this was unsuccessful and she was pronounced deceased. 1.4 In the bedroom where Molly slept there were two cots on either side of the Moses basket where Sibling 2 and 3 normally slept. On the evening before Molly died Sibling 3 slept in Sibling 1’s bedroom as Sibling 1 had spent the night with her grandparents and Sibling 2 had co-slept with her parents. 1.5 Molly was the youngest of four siblings. Sibling 3 was her half sibling from the father’s previous relationship and she had come to live with the family shortly before Molly was born. 1.6 Initially there were no suspicious circumstances and it was considered that Baby Molly had suffered an unexpected sudden infant death and the post mortem was undertaken by a Forensic Paediatric Pathologist. Preliminary results indicated that cause of death was unascertained pending further investigation. 1 The Child’s Journey- 2nd Interim report https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/206993/DFE-00010-2011.pdf . 3 1.7 Toxicological analysis of samples from Molly’s parents showed use by both of them of cocaine, and similar analysis of samples from Molly showed the presence of cocaine metabolites at what was described as an extremely low level probably attributable to environmental contamination. The unlikely possibility of the exposure to parental use of illicit drugs having played some part in Molly’s death means the cause of death remains unascertained, albeit there were factors present similar to those found in cases of Sudden Infant Death Syndrome (SIDS). 1.8 Coronial proceedings were completed after the Serious Case Review Report was completed where a narrative conclusion was given. 2. PUBLICATION 2.1 This report has been anonymised to protect the identity of the child and family involved; the subject child shall be known as Baby Molly. 3. REASON FOR THE SERIOUS CASE REVIEW 3.1 In England, Regulation 5 of the Local Safeguarding Children’s Boards (LSCB) Regulation 2006 sets out the functions for LSCB’s. This includes the requirement for LSCB’s to undertake reviews of serious cases in specified circumstances. How LSCB’s undertake the review is not set out in statutory guidance however “Working Together to Safeguard Children 2015”2 identifies that “Reviews are not the ends in themselves. The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children.” 3.2 Working Together 2015 requires SCRs to be conducted in such a way that: 2 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/592101/Working_Together_to_Safeguard_Children_20170213.pdf 4 recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings 3.3 The Durham LSCB Serious Case Review Sub-Committee met in May 2018 to consider the case and made a unanimous recommendation to the chair of the Board that the case did meet the criteria for a Serious Case Review as Baby Molly had suffered serious harm and abuse/neglect was suspected to be a factor in the case. The Serious Case Review was to consider all four children. 4. SPECIFIC TERMS OF REFERENCE 4.1 The Review will: Determine whether decisions and actions in the case comply with the policy and procedures of the named service and Durham LSCB. Examine inter-agency working and service provision for the child and family. Determine the extent to which decisions and actions were child focused. Was previous relevant information or history about the child and/or family members known and considered in professionals' assessment, planning and decision-making in respect of the child the family and their circumstances? How did that knowledge contribute to the outcome for the child? Establish what lessons can be learned about the quality and effectiveness of agency and multiagency working, 5 The impact of equality and diversity factors on practice. Were there obstacles or difficulties in this case that prevented agencies from fulfilling their duties? This should include consideration of both organisational issues and other contextual issues? Seek contributions to the review from appropriate family members and keep them informed of key aspects of progress. Take account of any parallel investigations or proceedings related to the case. How much information was self-reported and was there evidence of professional curiosity and challenge. Was information regarding parental risk factors such as domestic abuse and parental substance misuse considered as part of assessment and decision making. Key Practice Episodes The decision making and timeliness of the response to the referral on 5 September 2017 in terms of whether the escalation process and challenge process was followed appropriately. The delay in the commencement of the single-assessment following the referral on 5 September 2017. The discussion and decision making regarding the allocation of the case to the One Point Service when the initial referral in September 2017 was graded as a Level 4. The co-working arrangements between the Social Worker for the Sibling 3 and the Social Worker for the Molly and whether Sibling 3 had been included in the single-assessment. The response and actions by the Health Visitor regarding the issue of the tongue tie. 6 The significant delay by CDDFT in submitting a retrospective referral to Children’s Services following Sibling 2’s attendance at hospital on 15 October 2017 where parents left the department before Sibling 2 was treated. The discussion and actions from the GP Safeguarding Meeting. 5. TIMESCALE 5.1 The timescale for the active period of the review is from the period prior to Molly’s birth until after her death and covered a 12 month timeframe. 6. FAMILY INVOLVEMENT 6. 1 The LSCB Business Manager met with the parents of Baby Molly following the decision for a serious case review to be held. The purpose of the meeting was to explain the Serious Case Review process and to obtain the views from family members about the services they had received. 6. 2 Both parents advised that they did not feel that anyone could have done anything differently. The mother expressed concern that the Social Worker had explained that she would not be told of Baby Molly’s cause of death until the Serious Case Review had been completed. Clearly this information was not accurate and has raised an expectation in the parent which will not be addressed by the review when only coronial process will potentially give mother the answers she requires. The coroner has asked to be updated regarding the progress of the Serious Case Review. 6. 3 Positively the parents identified strengths in the services they had received. The mother identified the consistent relationship with the Health Visitor over a six-year period. She felt if she had any problems then the health visitor would respond and come out to see her. The father concurred with this view stating that they had confidence in the health visitor and that the mother would not speak to any other professionals other than the health visitor. 6. 4 Support was also offered by other health professionals to the family at different times particularly the GP and Midwifery Service. An example of support from the GP was identified when Sibling 3 came to live with the family. Both the GP and Health Visitor 7 supported the couple to register Sibling 3 with their GP Practice and the Social Worker supported them to get the father’s name added to his daughter’s birth certificate. 7. PARALLEL PROCESSES 7. 1 Coronial proceedings were completed after the Serious Case Review Report was completed where a narrative conclusion was given. 8. INDEPENDENT REVIEWER AND PANEL 8.1 Independent Reviewer, Sharon Hawkins was commissioned to undertake this Serious Case Review. Sharon qualified as a Social Worker in 1994 and after 18 years of being employed in Local Authorities in the North West of England she became an Independent Safeguarding Consultant in 2012. Sharon has 24 years of experience of both social work and management at various levels including Head of Service and Assistant Director in frontline children’s services. She is experienced in completing Serious Case Reviews, Managed Reviews and reflective learning reviews and completed the national training programme for Independent Reviewers in 2013. Chronologies were requested from the following agencies: County Durham and Darlington NHS Foundation Trust - CDDFT North East Ambulance Service NHS Foundation Trust Primary School 1 Primary School 2 CYPS Durham Police General Practitioner Harrogate and District NHS Foundation Trust 8 8.2 The members of the Serious Case Review Panel for Molly comprise of senior managers from the key statutory agencies who have had no direct involvement with the case. The panel members identified authors within their own agencies to complete the chronologies. The role of the panel was to actively manage the review and to provide oversight and scrutiny through all aspects of the process. The Independent Reviewer and Business Manager chaired this panel. 8.3 The following agencies were represented on the Panel. Children and Young Peoples Service- CYPS Durham Constabulary Education Development Service North Durham and DDES CCG’s County Durham and Darlington NHS Foundation Trust North East Ambulance Service NHS Foundation Trust Harrogate and District NHS Foundation Trust 9. PROCESS AND METHODOLOGY 9.1 The Serious Case Review Panel met to consider the timeframe and Terms of Reference for the review. This review was undertaken using a systems approach and is compliant with Working Together 20153 and 20184. Each agency with knowledge of the family has completed a Timeline of their involvement and this was utilised alongside a Learning Event with practitioners. The Learning Event was an integral part 3 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/592101/Working_Together_to_Safeguard_Children_20170213.pdf 4 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/729914/Working_Together_to_Safeguard_Children-2018.pdf 9 of the review, ensuring that the voice of practitioners was heard and that they had the opportunity to actively contribute to the process. Using a systems approach, the emphasis of the Learning Event was on understanding what happened, why some decisions were made and what learning could be captured. The Learning Event was based on the Welsh Child Practice Review Model5. 10. Family Composition, Ethnicity, diversity and cultural issues Name / Acronym Relationship Age Molly Subject Child 33 days Mother Mother of Molly and Sibling 1 and 2 27 years Father 2 Father to Siblings 2,3,4 27 years Father 1 Father of Sibling 1 N/K Sibling 1 Oldest Sister 5 years Sibling 2 Middle Sister 16 months Sibling 3 Half -sister 14 months 10.1 Baby Molly and her Siblings and the parents are of White British heritage. The family lived in a small two bedroomed rented property which was overcrowded for their needs. There was up to five people sleeping in the bedroom occupied by Molly. 11. Background Narrative as Known to Agencies 11.1 Baby Molly and her family had been known to universal services for many years. The father was known to the police and the family where considered to be at the edge of criminality due to their links to people known to the Police. There was a history of domestic abuse involving father and his previous partners. Within this family network, both parents self-reported to professionals that there was no domestic abuse within their relationship. However, some agencies were aware of at least two incidents drying this scoping period which are reflected below. 5 Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews, Welsh Government, 2012 10 11.2 In 2014 the police were called to a disturbance regarding a male who had two knives. They discovered the father at the end of the road with a knife to his throat he was making threats to the police officers. Father was arrested, and a welfare visit was undertaken to the home address and there were no concerns. 11.3 In February 2015 the father attended the address of his ex-partner under the influence of alcohol; he kicked the front door in. The father wanted to know who his ex-partner had at the home. He was subsequently arrested and charged with using violence to enter premises and was found guilty in court. 11.4 In January 2016 there was a domestic incident between the father and the mother. Mother, at this time was pregnant with Sibling 3. It was alleged that the mother was abusive towards the father and that he had retaliated, grabbing her arm, pushing her and punching a cupboard door. The father was arrested for assault, but no further action was taken. 11.5 In June 2016 HV1 undertook a home visit to carry out a family needs assessment, the father advised the health visitor that he binge drank occasionally and drank alcohol regularly. The mother admitted to smoking cannabis in her teenage years. She also admitted to smoking cannabis in the period before Sibling 1 was born. She did not disclose current drug misuse. 11.6 In July 2016 HV1 undertook the new birth 4-6 week visit to Sibling 2. Sibling 2 was observed to be sleeping on her stomach. The risks around allowing the baby to sleep in this position were explained to the mother by HV1. HV1 also observed that the kitchen window was broken, the parents informed HV1 that a neighbour had thrown wood through the window and that this had resulted in them having to ring the police. There was no explanation offered as to why the neighbour had carried out this action and HV1 did not explore this further with either the parents or the police. 11.7 In September 2016 Sibling 1 started at Primary School 1, she was aged four at this time. Her attendance was very poor at 68.4%. Due to her age the school were unable to take any action however her attendance was monitored by the Educational Welfare Officer. Reasons for non-attendance included illness. She was noted to have a bad 11 cough, frequently arrived at school late, was unkempt and smelt strongly of cigarette smoke. 11.8 In November 2016 a further incident of domestic abuse was reported to the police. The referrer reported that the incident was ongoing. Police attended at the property and the parents and Sibling 3 were present. The parents admitted to having had a verbal disagreement, no concerns were noted in respect of the children. 11.9 There was a history of non-engagement with health appointments including immunisations and antenatal care during mother’s pregnancies. During mother’s pregnancy with Molly there were concerns regarding mother’s physical health, but she failed to attend consultant appointments. 12. Chronology of significant events identified in the timeline 12.1 In January 2017 Sibling 1 left Primary School1 unexpectedly. The school had very little interaction with Sibling 1’s parents and she was brought into school by her aunt on most days that she had attended. Her aunt was also the primary person who collected her. 12.2 The mother booked in for ante-natal care at the GP surgery in February 2017. She was 13 weeks pregnant. The pregnancy was perceived as high risk and the mother needed care following the birth. The mother also was a heavy smoker and would not engage in any cessation treatments and had an elevated BMI of 306. 12.3 An ante-natal risk assessment was completed at 13 weeks gestation, both parents were unemployed at time of booking. They did not report any mental health issues or substance misuse, they denied a history of domestic abuse or police involvement. Mother stated she did not drink alcohol. 6 A BMI of 25 to 29.9 is considered overweight. A BMI of 30 and above is considered obese. Individuals who fall into the BMI range of 25 to 34.9, and have a waist size of over 40 inches for men and 35 inches for women, are considered to be at especially high risk for health problems 12 12.4 Also, in February 2017 Sibling 1 and Sibling 3 attended health appointments due to illness. Sibling 3 was admitted to hospital with breathing problems. 12.5 The following week HV2 undertook the nine-month review of Sibling 2 at the home address. Smoking cessation was discussed with the mother and safe sleeping was revisited. 12.6 In March 2017 the mother failed to attend three appointments with the midwife. She also walked out of the clinic on another occasion when she was due to see the midwife. Follow up letters were sent to the mother including one which was hand delivered. Also, during the same month Sibling 2 attended the GP on two occasions with gastroenteritis and an upper respiratory tract infection. 12.7 At the beginning of April 2017, the mother again failed to attend her ante-natal appointment with the midwife, Sibling 3 also was not taken to her appointment for her immunisations. Mother further DNA ante-natal appointments rearranged for later in April. 12.8 By April 2017 Sibling 3 was now living with her father and the mother following an incident between Sibling 3’s mother and her current partner. The father was not in agreement to Sibling 3 returning to her mother’s care. 12.9 Also, in April 2017 the police were contacted by an anonymous person to advise that the father was wanted by the police and that he had taken his daughter (sibling 3) from her mother’s care. 12.10 The same month CYPS received a referral alleging that the father was substance misuser and domestic abuse perpetrator. The referrer stated that there were often other adults in the property and there was anti-social behaviour. 12.11 The matter was progressed with a recommendation for a Single Assessment to be completed. Sibling 1 was spoken to in school and expressed no concerns about her home life. Observations of the other children’s engagement with their parents was positive. The assessment did not include the views of either the midwife nor the GP and given the history of DNA ante-natal appointments this information was important 13 and should have been considered. The assessment did not conclude until June 2017 and it was identified that there was no ongoing role for CYPS. 12.12 Due to the incident between Sibling 3’s mother and her partner a Single Assessment was commenced in that household. A different social worker had been allocated to this. Despite Sibling 3 having moved to her father’s house both social workers completed their assessments in isolation. Sibling 3 was not considered in the assessment that was undertaken regarding the allegations that her father was using and dealing drugs and a domestic abuse perpetrator. The assessment undertaken in respect of Siblings 1 and 2 did not consider the impact of Sibling 3 joining the household which was already overcrowded and the parenting capacity of the mother and father to meet the needs of all the children. 12.13 At the end of April 2017, the mother attended her scan appointment with the midwife. During this appointment the history of DNA appointments was not discussed with the mother and there was no challenge around the risks to the pregnancy due to this history. Mother had been classed as having a high-risk pregnancy due to her own health problems and this should have warranted some discussion. Mother’s heavy smoking was again discussed with her, but she refused smoking cessation support. 12.14 In May 2017 Sibling 3 attended the GP with wheezing and breathing difficulties. At the end of May 2017, the mother also attended for a growth scan with the community midwife. The pregnancy was noted to be progressing well and a further growth scan was scheduled for 28 weeks gestation. Mother was again advised of her options regarding smoking cessation support but declined this. 12.15 Some weeks later the mother failed to attend her 28-week appointment with the consultant. The mother was contacted by the midwife initially by telephone and stated that she would be late. When she failed to attend she was again contacted and advised the midwife that she was still at home and would not be attending. This was discussed with the Consultant and the scan was rearranged for the following month. 12.16 The following month the GP Surgery identified that the family were a cause for concern. This was due to numerous DNAs for immunisations, midwifery checks and GP appointments. A discussion was held at a practice safeguarding meeting. There 14 was multi-disciplinary attendance at this meeting, but this was not a multi-agency meeting as this is not routine practice. 12.17 The rest of the summer period was largely uneventful until September 2017 when the mother contacted the police regarding Sibling 1 being missing. The mother advised the police that Sibling 1 had not been see for over half an hour. Sibling 1 was subsequently found under blankets in a corner of a room”. 12.18 Following this incident, the police made a referral to CYPS, and following screening by the First Contact Service it was agreed that the case needed statutory intervention and the referral was escalated to Families First Team to complete a Single Assessment of the child and family’s needs. This threshold decision to progress was made in early September however 17 days later the Team Manager of One Point7 discussed the decision with the Families First Manager and given there had been a positive single assessment completed in June 2017, which had concluded that social work intervention was not needed the case was agreed as a Level 3 case and deemed as not in need of a social work assessment. 12.19 In late September 2017 Baby Molly was born. The Newborn & Infant Physical Examination (NIPE) was undertaken and Baby Molly was noted to be doing well and no concerns were noted apart from tongue tie8. A feeding assessment for tongue tie was completed by the acute midwife and it was noted that Molly could lift her tongue past her mid mouth and no feeding issues were identified. 12.20 Mother was persistent that she and Molly be discharged from hospital the same day. Molly had been born at lunchtime and the mother and baby were discharged some eight hours later. The reason for wanting to be at home was not explored with mother, although it was known that she had three children at home. Tongue tie had been recorded in the discharge summary and that a referral for this had been completed. The outcome of the referral is not known. 7 http://www.durham.gov.uk/onepoint 8 https://www.nhs.uk/conditions/tongue-tie/ 15 12.21 In October 2017 a family worker from One Point undertook a joint visit with the HV1 to introduce herself to the family. The family worker discussed the information regarding Sibling 1 hiding under blankets. The parents advised the family worker that they had panicked and called the police when they realised she was missing. 12.22 The home was very crowded during the visit as the grandparents and a neighbour was in the home. Mother was provided with the initial One Point paperwork and a further visit was organised for two weeks later. On this visit it was proposed that a Home Environment Assessment Tool would be completed9. 12.23 In mid-October the mother contacted 111 as she was concerned as Sibling 2 was unwell. The call was transferred by the Health Advisor to 999 as an emergency. The mother informed the operator that Sibling 2’s lips kept turning blue, she was vomiting and had a rash on her abdomen which had been there for the past three days; Sibling 2 was also drowsy. 12.24 A rapid response vehicle was dispatched to the address and Sibling 2 was taken to the Emergency Department (ED) with her mother and father. The parents detailed a history of vomiting for two days and said that she had been off her food. Sibling 2 was given treatment and her parents were informed that she would need a further blood test prior to being discharged home to ensure her blood sugars were back to normal. However, the parents left the hospital before Sibling 2 had the blood test. Following this the hospital had to contact the Police, who along with the ambulance service responded, and Sibling 2 was found at her grandparents’ home and brought back to hospital with her mother and father in the early hours of the following day. Sibling 2 received treatment and was discharged home with her parents. There was no evidence within CDDFT’s records that a referral was made to Children’s Services following this incident. 12.25 Four days later, HV1 undertook a home visit and discussed Sibling 2’s attendance at ED with the parents. The issue of the parents removing Sibling 2 from the hospital 9 http://www.durham-lscb.org.uk/wp-content/uploads/sites/29/2016/06/Home-Environment-Assessment- Tool-37918-CYPS-Nov-16.docx 16 before receiving treatment was addressed with the parents by HV1. The HV1 records indicate that a referral was made by the hospital to Children’s Services, there was no evidence in the hospital notes to indicate a referral had been made and had the HV followed this up she would have ascertained that one had not been received. There is no indication that HV1 followed this up to ascertain to outcome of the referral. 12.26 Also, in October HV1 undertook a home visit, present was the mother and Molly. The mother advised the HV that she felt that the tongue tie had resolved itself and that Molly was moving her tongue more freely. HV1 observed a small amount of blood in Molly’s mouth; it is not clear if HV1 checked the mouth to ascertain if the blood was from the tongue tie or another cause. It was evident that a four-week-old baby with blood in her mouth should have generated curiosity from the HV as to the mechanism and source. 12.27 During this visit HV1 also did not carry out the home environment assessment however HDFT10 policy states that it should be completed before the child is eight weeks of age. 12.28 Four days following HV1 visit a 999 call was received regarding a baby in cardiac arrest, paramedics attended the household and Molly was transported to hospital and despite resuscitation throughout this was unsuccessful and she was pronounced deceased. 12.29 Following Baby Molly’s death witness statements were taken from both parents by the police. Father was interviewed, and he admitted to using cocaine whilst at a stag party the weekend before Baby Molly’s death. Mother when interviewed as a witness, stated, that she did not normally take cocaine, however, had done so as a one-off and smoked cannabis on the previous Saturday night also. It was agreed that a Strategy meeting would be convened. 10 https://www.hdft.nhs.uk/services/childrens-services/ 17 12.30 A skeletal survey was undertaken and nothing untoward was found. The post mortem did not establish a cause of death which was determined to be unascertained pending further investigations. 13. APPRAISAL OF PRACTICE AND ANALYSIS OF THE KEY LINES OF ENQUIRY. Introduction 13.1 This section will provide the overview, appraisal of practice, analysis of the key lines of enquiry and the findings of this serious case review, with recommendations for Durham Local Safeguarding Children Board and its partners. The findings relate to what has been learnt about the strengths and developmental areas in the multi-agency system. 13.2 The findings of this serious case review do not indicate that inter-agency practice nor the practice of any individual or organisation could have altered the outcome of this case. There are multiple factors of poverty, poor housing, mental health, domestic abuse and drug misuse all of which have a negative impact on children’s life chances. However, inevitably, in any review where a child has died there will be lessons to be learnt. In this case there are a number of areas where practice could have been better, but this is unlikely to have altered the outcome for Baby Molly. The scrutiny undertaken across the partnership following Baby Molly’s death has meant that some areas of practice have already improved considerably. 13.3 A Learning Event took place and was attended by practitioners and managers from the main agencies. Some key information was shared during the Learning Event which clarified information already provided by agencies. Attendance at the practitioner event was good and those attending participated actively in assisting with analysis of events and identifying learning from the case. Practitioners at the Learning Event identified several missed opportunities and areas where practice could be improved. 18 Analysis of Events during the period under review. Theme: Communication and Information Sharing 13.4 In the analysis of serious case reviews evaluated by Ofsted between 2009 and 2010 it was identified that in most of the serious case reviews analysed there were sources of information that could have contributed to a better understanding of the children and their families. They also highlighted concerns about the effectiveness of assessments and shortcomings in multi-agency working. That analysis has resonance with aspects of this serious case review. 13.5 There are many opportunities where communication and information sharing could have been better. The handover of information between School 1 and School 2 when Sibling 1 transferred was an area whereby the family vulnerabilities could have been highlighted. Sibling 1 left her first primary school abruptly and with no notice. The poor handover of information meant that School 2 did not have the knowledge or understanding of the concerns in respect of Sibling 1. Had this information been known then a TAF11 may have been considered at an earlier point. 13.6 There was also poor information sharing between the Midwifery Service and the Health Visiting Service post birth. Baby Molly is reported to have had a tongue tie which was identified to the Health Visitor by the mother. There was no handover between the Midwife and Health Visitor which should have taken place. The HV did not have any scepticism or curiosity about the tongue tie and did not check back with midwifery as to whether this had been picked up in the post birth examination. At the Learning Event practitioners identified that tongue-tie needs a process for accurate recording and observation and it should not rely on the parent or carer. 13.7 They also identified that practice has moved on in this area since the death of Baby Molly and there are now top-to-toe observations of new-born babies by the Health 11 https://www.durham.gov.uk/strongerfamilies 19 Visitor at all primary visits and any concerns are clearly recorded and information triangulated. 13.8 At the Learning Event it was also identified that the scrutiny following the death of Baby Molly had resulted in vastly improved communication between the two services due to the implementation of new procedures. This includes midwifes now sending information regarding feeding to Health Visitors. They advised that there was still some way to go and that the process needed to be continually developed. Theme: Lack of adherence to Safeguarding Procedures 13.9 CYPS have a duty to undertake Child Protection enquiries when they suspect that a child is either at risk of significant harm or has been harmed. The point of these enquiries is to establish what action needs to be taken and by whom. During the period under review there was a couple of incidents whereby enquiries under S47 should have been considered and may have been appropriate. 13.10 When the health visitor attended and observed blood in Baby Molly’s mouth she did not record if there was any consideration as to whether the there was an injury or consideration of a non-accidental injury given the presenting symptoms. She did not arrange for Molly to be examined by a doctor to see if there were any other medical reasons for the blood in Molly’s mouth. Not alerting a doctor or health professional to the observation of blood in a non-mobile baby’s mouth did not allow for medical tests, further inquiries or response to this unexplained incident. 13.11 When Sibling 2 was removed from the hospital by the parents in the October before she received treatment was a missed opportunity to share information and concerns regarding the family and their presentation. The hospital failed to refer the matter to Children’s Services despite the police and ambulance service having to be dispatched to collect Sibling 2 from the grandparent’s home. This incident should have triggered a Strategy Discussion to share information about the children and the family. 13.12 Prior to the death of Molly, the parents had attended the hospital on other occasions with the children and were observed at times to appear under the influence. This information was not shared with other agencies who were involved with the children 20 at the time and was first mentioned at the Learning Event. Drug misuse was not challenged or explored with the parents. Working within statutory timeframes 13.13 Working together 2015 identifies that within one working day of a referral being received by the local authority a social worker should decide about the type of response required. This will include determining whether: Child requires immediate protection and urgent action is required. Child is in need and should be assessed under section 17 of the Children 1989. Any services are required by the child and family and what type of service; and Further specialist assessments are required in order to help the local authority to decide what further action to take. 13.14 Following the police referral following Sibling 1 being missing; the case was allocated to a support worker to make contact with the family. A referral decision was not made until 13 days later when the threshold decision was made that the case should be progressed to Level 3. This was significantly outside of the statutory timeframe. This decision was discussed four days later by the manager of the Families First Team with the Team Manager at One Point and agreed it was Level 3 work and One Point would work with the family. The case then transferred from Families First Duty Tray to One Point Duty Tray. This is 17 days following the referral being received. 13.15 At the learning event there was concern raised about the multi-agency threshold decisions made in September 2017. Many practitioners believed that the case had initially been identified as a Level 4 case needing a social work assessment and that this decision had been overturned following a discussion between the two team managers in Families First and One Point and ‘de-escalated’ to a Level 3 case. A screenshot of the decision making was provided by CSC which identified a discussion between the both managers which clearly shows a Level 3 decision. However, there was clearly miscommunication and confusion across the partnership about what 21 decision was made in this case initially in the MASH and what actions would subsequently be undertaken. 13.16 Practitioners were also concerned to know what mechanism would be in place if there is a disagreement between a MASH decision and the receiving Team Manager. MASH practitioners at the learning event acknowledged that timescales are generally tight, and discussions do not always take place when more information comes to light. If an operational manager decides to either step down or step up a case, then MASH are not consulted or informed. The professional network in attendance identified that there needed to be a procedure around this. A new electronic child recording database has been introduced and is starting to show impact in this area. 13.17 The Joint Targeted Area Inspection12 undertaken in July 2018 identified that there was often an over-optimism of all agencies in relation to the assessment of the future risk of domestic abuse, and this included a lack of professional challenge as well as a lack of awareness of disguised compliance from parents. Since that time a cumulative risk assessment tool has been introduced which enables a better analysis of these cases to take place at the point of contact and this is making a difference to practice and outcomes. 13.18 Delays were also identified in respect of the statutory timeframe for the completion of Single Assessments to conclude and for a decision on next steps being reached. This should be no longer than 45 working days from the point of referral13. In this case the assessment started in April 2017 did not conclude until June 2017 placing it outside of the statutory timeframe. However, the school nurse was contacted in the May to advise that the case was closing. The outcome of the assessment in June was for no further action from CYPS and the family were signposted to other services. 12 https://files.ofsted.gov.uk/v1/file/50015171 13 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/592101/Working_Together_to_Safeguard_Children_20170213.pdf 22 13.19 The assessment did not include the views of the full multi-agency network involved with the family and this therefore brings into question the robustness of this assessment. The Health Visitor and school nurse had been spoken to however if the information held by the GP and Midwife had been considered it would potentially have changed the outcome of the assessment and subsequent work may have taken place with the family. 13.20 Although the decision reached following the assessment was for no further action by CYPS following the April referral, the record for Sibling 1 was never closed. It also appeared that there was a delay in closing the case on the electronic case management system and the other Siblings case records were not closed until July 2017. Working Effectively with Neglect. 13.21 Long term neglect has a profound impact on children’s lives and developmental outcomes. Research evidences that a robust assessment which has a clear focus around parenting concerns, causal factors and how those impact upon children is crucial. The assessments should to be followed with a plan which has identified actions, outcomes to be achieved, and timeframes for change. 13.22 There was an increased risk of neglect to the children due to the interlinking of several parental risk factors which included poverty, domestic abuse, substance misuse, non-engagement with services and poor and overcrowded housing conditions. Home conditions were often described as cluttered and with six people living in a small two bedroomed property it is easy to see why this may have been so, but it was not clear in the recordings what was meant by ‘cluttered’. At the learning event practitioners were able to identify that the home was not dirty, but conditions were poor and there was a lack of storage, but the mother managed the best she could in such cramped conditions. 13.23 The impact on the children on living in such poor conditions was never fully assessed. Sibling 1 was described in her first primary school as unkempt and smelling strongly of cigarette smoke; which it appears all the children were exposed too, despite the mother informing the family health visitor that both she and the father smoked outside 23 of the home. The impact on Sibling 1 and 2 was not considered in the assessment undertaken in April 2017 when Sibling 3 Sibling 3 joined the household which was already overcrowded . Mother was also pregnant with Baby Molly. 13.24 Mother’s non-engagement with antenatal services was not viewed through the lens of neglect in respect of the unborn child and on many occasions the other Siblings’ missed health appointments and were late for immunisations. Theme: Lack of Professional Curiosity and Professional Challenge. 13.25 The 2005-07 Biennial Review notes the importance of trust in family and worker relationships but ‘respectful uncertainty’,14 should accompany this as it can take time to recognise and respond to disguised compliance. 13.26 On a number of occasions the parents concealed the full extent of their drug misuse from professionals and it was only following the death of Baby Molly that the full knowledge of this became known and although there is no suggestion that this was a factor in the death of Baby Molly had it have been known and triangulated with the other information known about the parental risk factors including domestic abuse and missed health appointments then it may have resulted in earlier intervention and support to the children. 13.27 There were occasions where professional curiosity was required. For example, the incident when Sibling 1 was reported missing and despite this incident, professionals did not consider why she had disappeared and remained hidden under blankets. For a small child to be missing and stay still and hidden for over 30 minutes this was of concern... The father had a history of domestic abuse and there had been allegations in respect of domestic abuse in his relationship with the mother. When HV1 visited the family, 14 Lord Laming – Victoria Climbie Enquiry 24 following this incident, domestic abuse was not considered as a possible pre-curser to this incident. Conclusion and Recommendations 13.28 Statutory guidance requires that Serious Case Reviews provide a sound analysis of what happened in the case and what needs to happen to reduce the risk of recurrence in future cases. In 1989 the United Nations Convention on the Rights of the Child (UNCRC) set out in detail what every child needs to have for a safe, happy and fulfilled childhood15. 13.29 In this Serious Case Review there were multiple factors which impacted upon the children’s life chances and are circumstances in which many other children live in the UK. The multiple factors of domestic abuse, drug and alcohol misuse, smoking, poor housing, missed health appointments and lack of aspiration in respect of education all have an impact on the outcomes for children and they are not something that LSCB’s and SCR processes will solve alone. In England and Wales in 2016 there were 219 unexplained infant deaths, a rate of 0.31 deaths per 1,000 live births16. 13.30 Research undertaken by Melissa Bartick and Cecilia Tomori in 201817 identified that populations with the world's lowest rates of SUID/SIDS have low income‐inequality or high relative wealth. One of the key messages to come out of the report was that comprehensive approaches to infant mortality are needed that address poverty, inequality, and racial discrimination and include structural interventions for smoking cessation and breastfeeding. 13.31 However, recognition of how these factors impact is needed by professionals working with vulnerable families so that they can ensure that children receive the right support 15 https://www.unicef.org/french/adolescence/files/Every_Childs_Right_to_be_Heard.pdf 16 https://www.lullabytrust.org.uk/professionals/statistics-on-sids/ 17 Sudden infant death and social justice: A syndemics approach- https://onlinelibrary.wiley.com/doi/full/10.1111/mcn.12652 25 to limit the impact of these circumstances and to help the family to fulfil their children’s needs. The vulnerability of children under one years of age is well evidenced in research and 45% of serious case reviews in England are in respect of children of this age. Timely responses to referrals and assessments in respect of the families in which these children live is crucial. The delay in threshold decision making and completion of the Single Assessments in this case had an impact on the quality of support and services this family received but would not have prevented the death of Baby Molly. 13.32 This review has identified that there is confusion in respect of threshold decisions. There is not a clear and agreed process in place when there is disagreement in respect of the threshold decision made within the MASH. Recommendation: The DSCP should assure itself that there is an agreed process which ensures that multi agency decision making in the MASH when challenged has an appropriate escalation process to mediate on such decision. 13.33 A key learning point from this review was also in respect of the mother’s non-engagement in ante-natal care and in respect of the missed health appointments for the children. There was not a recognition that non-engagement in the antenatal period was potentially harmful to the unborn child. It was the mother’s choice to miss her screening, consultant and scan appointments and by doing so this did evidence neglect towards Unborn Baby Molly. 13.34 In respect of the missed appointments for the siblings this was also evidence of neglect, but this was not recognised as such and so was not responded to. Recommendation 2: An Antenatal Missed Appointment policy is in place. This policy to be to be reviewed, updated and compliance to be reviewed. Recommendation 3: There needs to be a meaningful discussion by the midwifery service with women who DNA about lack of engagement. Recommendation 4: The DSCP should review the effectiveness of the ‘Was Not Brought’ policy and agencies who have implemented the policy to be requested to provide assurance that it is being complied with. 26 Recommendation 5: The DSCP should assure itself that thresholds in respect of neglect are clearly understood across the partnership. Recommendation 6: The Home Environment Assessment to be completed at the antenatal or primary care visit. It is good practice that the Home Environment Assessment Tool is completed at every visit, but this should be done in liaison with the One Point Service to reduce the impact on families. 13.35 It was identified at the learning event that there was not a handover visit between the midwife and the health visitor. At the point of transition between the two services the information regarding whether Baby Molly had tongue tie or not was not clear. The health visiting service identifies that they were not informed that Baby Molly had tongue tie and that this was self-reported by the mother during the primary visit with the health visitor. As the Midwifery and Health Visiting Service is managed by two different Trusts, this was considered to be a barrier to joined up working. Recommendation 7: Consideration should be given to ensuring that there is a handover visit/discussion between the midwifery service and health visiting service at the point of transition. Single Agency Recommendations - CDDFT 13.36 Ensure maternity records and child health hand held record are fully completed to include all relevant information on discharge from hospital. 13.37 A referral to children’s services to be made automatically when a child leaves ED/ UCC against medical advice or without completing necessary treatment. |
NC52534 | Long-term sexual abuse of three siblings in foster care. The abuse was perpetrated by the male foster parent. Learning includes: professionals should not assume that when a child has had therapeutic interventions this will be protective in the longer term; as children with disabilities are more vulnerable to sexual abuse, professionals need to ensure that this is considered when their behaviour is being assessed; professionals need knowledge and confidence about adult behaviours that might indicate a sexual risk to children; professionals need to be able to consider the 'unthinkable' about carers they may know well and be alert to the possibility of sexual abuse; when professionals predominantly work with one carer, they need to ensure that equal professional scrutiny applies to the second carer; opportunities should always be taken by trusted professionals to have age and ability appropriate discussions about sexual abuse with children in care; schools are key in providing an environment where children know who they can talk to about sexual abuse and what will happen if they tell someone; children in care in long term placements need significant relationships with professionals and/or their carers if they are to disclose sexual abuse. Recommendations include: ensure professionals are thinking and talking about the risk of sexual abuse of children in care; learning from the review is shared with the local corporate parenting panel; training foster carers about intra-familial sexual abuse; and assurance of the local plan to include direct information from respite carers in child in care reviews.
| Title: Child safeguarding practice review: the long-term sexual abuse of children in care. LSCB: Wiltshire Safeguarding Vulnerable People Partnership Author: Nicki Pettitt Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Final Version March 2022 Child Safeguarding Practice Review The long-term sexual abuse of children in care Contents 1. Introduction Page 1 2. The process Page 1 3. Case information Page 2 4. Family engagement Page 2 5. Learning Page 3 6. Recommendations Page 9 1 Introduction 1.1 The Wiltshire Safeguarding Vulnerable People Partnership (SVPP) agreed to undertake a Child Safeguarding Practice Review (CSPR) to consider the risk of sexual abuse for children living in foster care. Consideration was given to a case where allegations of long-term sexual abuse from their foster carer were made by siblings in 2021. Although a rapid review had taken place which had identified some learning, the seriousness of the allegations meant that the SVPP wanted to consider additional learning about the way that agencies work together to safeguard children in foster care and commissioned this review. 1.2 Learning has been identified in the following areas: • The vulnerability of children in care to sexual abuse • That there may be no obvious child or adult behaviours that indicate sexual abuse • The need to always consider the potential for sexual abuse • The importance of consistent and meaningful relationships with professionals, so that children living outside of their birth families have regular contact with people they have confidence in and can trust • The need for professionals to take opportunities for introducing the subject of sexual abuse in conversations with children • The need for full engagement of both carers, even if one is seen as the ‘primary carer’ • The need for training for foster carers about intra familial sexual abuse Although it is recognised that much of what was found in this case is not new learning, it was agreed that this was a good opportunity to highlight what was found in order to provide points for discussion amongst professionals in partner agencies. 2 2 Process 2.1 An independent lead reviewer was commissioned1 to undertake the review alongside a group of local professionals. This report2 summarises the learning from the review, which built on the detailed information provided as part of the Rapid Review process undertaken shortly after the allegations were made. Good practice in how practitioners worked with the siblings and the carers is evident throughout the case, however relevant learning has still been identified. 2.2 Despite the impact of COVID 19, professionals involved with the children at the time were meaningfully involved in discussions about the case and practice more generally, as part of the review. Those involved in processes for assessing and scrutinising of placements were also part of a focused discussion. 2.3 The key lines of enquiry established at the start of the review were to; consider the confidence of professionals in this area of safeguarding; ensure a more curious approach by professionals regarding sexual abuse; and to establish how professionals can speak to children about sexual abuse in long term placements, including children with special needs. It was agreed that the review should include a detailed understanding of the management of the sibling’s daily care plan, safer care assessments and plans, the assessment and oversight of the secondary carer and the transitional care plan for the eldest child. 3 Case Information 3.1 The children considered are a sibling group of three who were placed with the carers in 2012. It was their first placement after coming into the care of the local authority. There had been significant concerns about abuse and neglect from their own family, including suspected intra-familial sexual abuse. It was later agreed that they should remain with the carers as a long-term fostering placement. 3.2 The eldest was 18 years old at the time that the abuse was disclosed but was a child living in the household during the period the sexual abuse has taken place. She has global development delay, learning difficulties and ADHD. She attended a special school and is now at a residential college. The middle child was 16 years old and attends a mainstream school. She is making good educational progress and aspires to go to university. The youngest child was 15 years old and has an EHCP for behavioural and emotional health needs and learning difficulties and attends a special school. 3.3 The foster carers considered are a male and female couple who have been fostering for around 15 years. They were assessed and supported by an independent fostering agency (IFA). They live in another local authority area. The placement was long-term, stable, and seen as child-centred and nurturing. 3.4 Disclosures of sexual abuse perpetrated by the male carer were made by the middle child to her female foster carer. She stated that the abuse had been happening repeatedly for around nine years. When interviewed3 her younger sibling also made allegations of sexual abuse from the male carer. Having admitted numerous counts of rape and sexual assault, the male foster carer is currently serving a lengthy custodial sentence. 4 Family engagement 4.1 The lead reviewer met with the female foster carer and the two younger children during the review, along with a representative of the SVPP. Learning was established from this engagement and is included in this report. 4.2 The children’s mother will be informed of the learning from the review. She was not interviewed as she does not have contact with her children. 1 Nicki Pettitt is an independent social work manager and safeguarding consultant. She is an experienced chair and author of Serious Case Reviews and LCSPRs and is entirely independent of the WSP. 2 This report has been written for publication. It only contains the specific case information that is required to identify the learning. 3 Timely Achieving Best Evidence (ABE) interviews were undertaken with the children. Child protection medicals were not undertaken as the foster carer admitted to the abuse, but the children’s health needs were appropriately considered. 3 5 Learning identified 5.1 It is apparent that, even with the benefit of hindsight, there were few if any indicators that the children in the household were being sexually abused prior to the disclosure. Research shows that children who are being sexually abused often show symptoms that may lead those caring for them or working with them to wonder if something is wrong. Classic symptoms in teenage girls are eating disorders, self-harm, anxiety and depression, drug and alcohol misuse, and difficulties in coping with stress. 5.2 The middle child was doing well at school and had friends. There was no indication that she was particularly unhappy or distressed. The youngest child has learning difficulties which presented her with challenges, but she was receiving appropriate educational support. She was exhibiting some self-harming behaviours, such as scratching herself with a ruler at school, which professionals’ thought was linked to issues with her peers and to her diagnosed longer-term attachment difficulties. There was no indication from the child or the carers that there were any issues within the home. She was thought to be happy with the foster carers and wanted to change her surname to theirs. This reassured professionals of the strength of the placement, however it can now be acknowledged as an indicator of the complexity of the emotional impact for children who are being abused by someone they care about. 5.3 The eldest child, who has complex special needs, has not disclosed sexual abuse, but was very unsettled in the two years preceding her sister’s allegations. She was possessive of her female foster carer and the relationship with her siblings was difficult. Much of the support and professional engagement at the time was in respect of this child, due to concerns that she may not be able to remain living with the foster carers as an adult, which had originally been the plan. Both younger siblings voiced the difficulties they had in managing and living with their sister’s difficult behaviour, which included shouting and throwing things. It is not known if this behaviour was due to sexual abuse, but any changes in behaviour need to be considered as a possible indicator of abuse, particularly when the child has communication difficulties and may not recognise abuse, as was the case here. Learning point A child who is being sexually abused may not show any obvious symptoms that suggest they are being abused. 5.4 When a child in care does show challenging behaviours or signs of distress, it is often ascribed to negative experiences when they were younger or to other experiences since coming into care, such as placement breakdowns. Professionals need to ensure that they are alert to the possibility of other causes, including current sexual abuse. While any child can potentially experience sexual abuse, some are likely to be more at risk, for example children who have experienced other forms of abuse4 like those being considered by the review. Children in care are particularly vulnerable to sexual abuse due to their previous experiences5. York University and the NSPCC conducted research in 2014 and concluded that while the vast majority of foster carers do an excellent job in often difficult circumstances, most abuse or neglect of children in foster care is perpetrated by their carers rather than outside of the home. They found that there are between 450–550 confirmed6 cases of different types of abuse or neglect in foster care across the UK each year7 and that around 11 per cent of this abuse is sexual. 4 Finkelhor, Ormrod, and Turner (2007) Poly-victimization: A neglected component in child victimisation 5 The Prevalence of Child Sexual Abuse in Out-of-Home Care: A Comparison Between Abuse in Residential and in Foster Care. Saskia Euser et al (2010) 6 These findings are likely to underestimate the true extent of the problem, as over half of the unsubstantiated allegations could not be proven one way or the other. 7 The figures were taken from referrals to the LADO (Local Authority Designated Officer) in respect of carers, to ensure they did not include abuse of children in foster care outside of the home. 4 Learning Point Any challenging behaviours need to be considered in light of the child’s current life, as well as past events. 5.5 Research tells us that despite the scrutiny of professionals and oversight of the placement, children placed with carers outside of their birth family remain at risk of abuse and neglect and can be re-abused in these situations. In this case it was suspected that the children had been sexually abused while living with their birth family, and extensive work had been undertaken with the children earlier in the placement to support appropriate sexual behaviours and relationships. Both PCAMHS8 and the NSPCC provided individual direct work appropriate to each child’s learning needs in 2014-15. This provided a degree of reassurance in this case because this work had been undertaken and was seen as successful at the time. Both the rapid review and the CSPR discussed the potential need to revisit work such as this as the children get older, and for the work to be reviewed and adjusted in response to new situations such as at puberty and when the plan changes, as it was when the older child was moving to a residential college. Both of the children had some memories of the work undertaken, but when discussing this with the lead reviewer they stated that they did not particularly consider it when the abuse started and continued. Learning Point Professionals should not assume that when a child has had therapeutic interventions that this will be protective in the longer term. 5.6 Two of the children in the placement have learning difficulties and this too can increase their vulnerability. One of these children has disclosed sexual abuse from the male carer, and there is the possibility that the other may also have been abused although she has not disclosed. Those who were spoken to as part of the review were aware that children who have disabilities are at an increased risk of being abused compared with their non-disabled peers9. Studies10 have shown that disabled children are three times more likely to be sexually abused and that just less than a third of disabled children suffer at least one form of abuse compared with 9% of the non-disabled child population. 5.7 One of the difficulties for professionals when a child has a disability is how to determine what behaviours are due to the disability and what may be an indicator that something else is going on. The Children’s Commissioner Report ‘Protecting Children from Harm’ states that “children with a learning disability may exhibit behaviour which, although indicative of sexual abuse, may be attributed to the learning disability itself.” In this case some concerning behaviours were noted but as they could be attributed to other issues that the children were experiencing at the time, sexual abuse was not considered. It was recognised that in the two years prior to the disclosures much of the professional focus was helping the carers to manage the increasingly difficult behaviours of the eldest child. Most of the direct and indirect contact between the fostering agency and the female foster carer involved discussions about this, which was understandable as a lot of support was required. The impact of this child’s behaviour on the other children was also considered regularly, and it was noted that things were incredibly difficult for the whole family. The concerns led to a plan to provide a residential educational setting for the eldest child, which in turn exacerbated the child’s distress as there was uncertainty about how to best meet her needs and some delay due to issues about funding of the placement. This was thought to account for any difficulties in the home at the time. 8 Primary Child and Adolescent Mental Health Service 9 Jones et al (2012) Prevalence and risk of violence against children with disabilities 10 Sullivan, P. M., & Knutson, J. F. (2000). Maltreatment and Disabilities: A Population-Based Epidemiological Study. Child Abuse & Neglect 5 Learning Point As children with disabilities are more vulnerable to sexual abuse, professionals need to ensure that this is considered when their behaviour is being assessed. 5.8 Not only were there no historic concerns in relation to sexual abuse from the male foster carer, there were no concerns whatsoever about the quality of care provided to the children or the motives of the carers at any stage during the placement. In the foster carers annual review in 2020 the IFA fostering panel stated that they would like to ‘give huge thanks and praise to (the carers) for the ongoing love, care and dedication they continue to give to (the children). The “togetherness” they show as a family, despite challenges, is remarkable.’ All of those involved at the time agreed during the review that the placement was thought to be excellent. All of those who observed the children with the male foster carer noted a close and appropriate relationship. There were no indicators that anything was wrong or that his relationship with the children was inappropriate in any way. This CSPR reflected that as a foster father he was visible, while he kept his abuse of the children invisible. 5.9 The middle child told the review that if professionals are not looking for sexual abuse they won’t see it, while acknowledging that it was well hidden in her case. No one involved at the time considered the possibility of sexual abuse from a well liked and trusted foster carer; such a thing was ‘unthinkable.’ Due to the high regard for the carers and their commitment to the children in this case, and despite the eldest child’s behaviours, there was no consideration of abuse within the placement. The child told the review that her male foster carer was very confident that he would not be detected and took any opportunity to abuse her. For example, he would sexually assault her in the kitchen while her female carer had turned away to the cooker. He also made her question her knowledge about sex and relationships, undermining the female carer’s careful work in this area. 5.10 Even with the benefit of hindsight, there were few common ‘grooming’ techniques used by the male foster carer that could have been known to the female carer or any professionals working with the family. The purpose of grooming is to reduce the likelihood of detection or the child disclosing, and reducing the chance of the child being believed if they do disclose. As well as grooming children, perpetrators also groom and manipulate the adults around the child and the professionals involved. Perpetrators can be charming, or they may intimidate and frighten professionals so that they are distracted from their abusive behaviours. Grooming behaviours can be very subtle. They include favouritism within a family of a particular child and making the child depend on them. 5.11 The disclosure made by the middle child at the time included information on how her carer groomed her. He sometimes gave her cash and gifts of downloadable video games, seemingly chosen as the female carer would not have been aware of this. He also made threats, including about her having to leave the household and her much loved female carer if she disclosed what was happening. He successfully groomed both children and avoided detection for a considerable number of years. The children told the review that the abuse progressed from sexual touching to rape over the course of the offending. Neither sibling knew that the other was being abused as well, although they both were alert to the possibility so tried to monitor the male foster carer around the other child. This gives an insight into the ability of the abuser to keep the abuse from each sister, as well as from his wife. 5.12 The SVPP published a CSPR in May 2021 (Family N) that featured sexual abuse in the home. The learning from the review highlights that children are less likely to disclose sexual abuse than other forms of abuse and that it is often ‘silent and hidden.’ Many of the ways that a perpetrator can silence a child were evident across both reviews, and entirely unknown to professionals at the time. The Child N review quite rightly points out that any direct work with children needs to understand the ‘silencing methods’ and not be too direct. Unlike the foster carer being considered here, the perpetrator in Family N was known to be a sexual risk and was intimidating and threatening to professionals. 6 Learning Points All professionals need knowledge and confidence about adult behaviours that might indicate a sexual risk to children. All professionals need to be able to consider the ‘unthinkable’ about carers who they may know well and who they may work closely with and be alert to the possibility of sexual abuse. 5.13 There was reflection from the professionals involved in this case that the majority of their contact was with the female foster carer who was a ‘stay at home’ carer and undertook most of the day-to-day tasks in respect of the children. She met most of the fostering expectations such as report writing and liaison with professionals. She was particularly efficient and exceeded expectations of the role. This type of division of childcare and fostering tasks is not unusual in a placement were one of the carers stays at home and the other works. The roles are not always determined by gender, although it was a ‘traditional’ set-up in this case. There is often learning within case reviews that fathers or males in households are not considered equally by professionals. In this case, while the vast majority of contact was with the female foster carer, the expectations of the male carer during assessments and reviews were clear and largely complied with, including him attending supervision with the IFA social worker when required. Both carers were seen with the children. The male carer was well known to the fostering agency, would attend fostering agency events such as barbeques, and had attended some men’s group sessions in the past. 5.14 The supervising social worker and others in the IFA felt they had a good relationship with both carers although the majority of their contact was with the female carer. The male carer’s job involved him being ‘on-call’ and this was known to have an impact on his availability to meet with professionals. This was not unusual in the experience of the professionals spoken to about the case however, and there was no indication at the time that he was avoiding professionals or had any issue with their oversight and presence in his home. A number of different professionals saw him regularly with the children and described positive and appropriate contact and relationships. It was pragmatic that the majority of professional engagement was with the stay-at-home carer, but this means that the other carer will not be as well-known to professionals and subject to less scrutiny. Learning Point When professionals predominantly work with one carer, they need to ensure that equal professional scrutiny applies to the second carer. 5.15 One of the issues considered by the review is the length of time that the children were being abused without detection and without them telling. The middle child disclosed that the abuse had been happening for around nine years. It is important that professionals are aware that any child who is being sexually abused is unlikely to make an allegation, particularly when the perpetrator lives with them. NSPCC data suggests that seven years is the average time from start of sexual abuse to disclosure for those that do disclose11. Many children never disclose, only partly disclose, or disclose and then withdraw their allegations. The younger the child is when the sexual abuse starts, the longer it takes for them to disclose.12 5.16 It is a reflection of her faith in the adults she trusted, particularly her female foster carer, that the middle child made her allegations when she did. She spoke to the lead reviewer about what would have helped her to disclose sooner, and the main motivator would have been if she had known that her younger sibling was also being abused. She was not aware of this however and planned to tell prior to going to university so that her sister would be ‘safe’. She stated that she wanted to control when her disclosure was made, and that she would have struggled had a disclosure been ‘forced’ 11 ‘No one noticed no one heard' 2013 12 Debbie Allnock and Pam Miller (2013) No One Noticed, No One Heard (NSPCC) 7 from her, for example by direct questioning, until she was ready to tell. She was very clear that she wanted to control the narrative in this regard, and that she was able to ‘put on an act’ to ensure no one knew what was happening in order to have this control. She said that she feels sad that her sister was not able to decide when to disclose, as the younger child’s disclosure closely followed her sister’s. 5.17 The 2017 report published by the Children’s Commissioner ‘Making Noise: children’s voices for positive change after sexual abuse’ found that concern about being believed and the absence of support following a disclosure was one of the most common silencing mechanisms in these cases. The middle child told the review that the foster carer’s threats had been escalating over time. She knew that she wanted to disclose, but she wanted to get evidence to ensure she was believed. She was able to record her foster carer making threats to her, which she shared with her female carer when she made the disclosures. It is important that professionals and foster carers are aware that sexual abuse and emotional abuse co-exist. In this case both children were subjected to on-going emotional harm from their male carer. The children spoke about him having a ‘look’ that he gave them when he was intending to abuse them. This was often in front of his wife or other family members. This led to them being fearful and watchful at home. 5.18 All of the professionals spoken to as part of this CSPR acknowledge the importance of taking opportunities to check in with young people in care about how they are, and that this could include a discussion about sexual abuse. Asking their opinion on current issues in the media or on a popular TV show is a good way to introduce the subject with teenagers, as is speaking to them about what advice they would give a friend who was being abused. The IRO remembers having a discussion about The Handmaid’s Tale with the middle child and now wonders if she could have pursued the content of abuse of girls and women with her. The child told the review however that she would not have disclosed at the time, as she needed to be ready to speak out and wanted control over this. The younger child, however, believes she would have told if she had been asked by a trusted professional, and that they would have known that she was lying if she denied she was being abused. 5.19 More generally however, there is a need for more openness about sexual abuse in families. As stated in Making Noise13 there is a need to challenge the ‘cultures of silence surrounding child sexual abuse’ and that the more we speak about sexual abuse, the safer children will feel about disclosing. Schools are well placed to be a part of this cultural shift to more open discussion, as well creating environments where children know who they can talk to and what will happen if they tell someone. The middle child said that she had almost told one of her A-level teachers following a discussion about domestic abuse, as she felt he would believe her. She did not think the time was right, however. The youngest child told the review that she wanted to tell her female carer and almost did a number of times. She felt conflicted however about the impact it would have on the woman she loves and calls ‘Mum’. This is a known barrier to disclosure for children being sexually abused. 5.20 The NSPCC report ‘Child Sexual Abuse: Learning from Case Reviews’14 states that professionals should ‘take the time to build a consistent, stable, and long-term relationship with the child. This includes talking to children away from parents and carers and fostering an environment where children feel safe to talk.’ Case reviews show that children in care often experience multiple changes of professionals, including their social workers, Independent Reviewing Officers (IRO) and those providing therapeutic interventions. This was not the case for the children considered by this review. There had largely been consistency while the children had been in the care of the local authority. They have had two IROs. They have had one social worker with the exception of one temporary social worker for around a year while their social worker was on maternity leave15. 5.21 The foster carers had just two supervising social workers from their IFA during the course of the placement. The review was told that all handovers were well managed and that information sharing, 13 Children’s Commissioner (2017) The Making Noise research project focuses on children and young people’s views and experiences of help-seeking and support after child sexual abuse in the family environment. 14 Child sexual abuse: learning from case reviews - Summary of risk factors and learning for improved practice around child sexual abuse. NSPCC January 2020 15 The eldest child has had a recent change of social worker due to her age. 8 and introduction meetings were prioritised. Reflecting on the support provided by the IFA and the local authority, the female foster carer told the review that she has been well supported, that supervision was regular and helpful and that she attends regular training. The only gap she identified was that she had never had any training on intra-familial sexual abuse. She gained a lot from training provided about sexual exploitation, but the focus was on the risks from outside of the home and she had very little understanding about sexual abuse in the home prior to the allegations being made. 5.22 The children regularly saw trusted adults at school, from the fostering agency, their social worker, their IRO, and health workers such as a consistent child in care nurse who undertook their annual medicals in the home. A NSPCC and University of York study16 published in 2014 stated that children in care need a professional they can talk to and have access to when required, and that ‘visiting children, listening carefully to what they say and spending some time with them away from placements are of fundamental importance’ as is communication and information sharing between agencies. In this case there is evidence of good relationships between the children and the professionals around them, and many examples of them being seen alone outside of the placement. Two of the children were actively involved in the Children in Care Council and met a number of professionals outside of their allocated workers due to this. They also all received care from consistent respite foster carers that they developed good relationships with, and positive contact with the female foster carer’s extended family members who provided support to the children and the carers as required. There was some learning identified by the individual IRO about the need to ensure that a respite carer’s information is sought directly by them prior to the child’s review. This would enhance practice. However, the IRO reported having a good sense of the respite placements being a positive experience for the girls and it is now known that the respite carers had absolutely no concerns about the children in respect of sexual abuse and were very shocked when the allegations were made. Learning Points Opportunities should always be taken by trusted professionals to have age and ability appropriate discussions about sexual abuse with children in care. Schools are a key part of the system of providing a general environment where children know who they can talk to about sexual abuse and what will happen if they tell someone. Foster carers require training on intra-familial sexual abuse. 5.23 There is no evidence of any significant impact on contact or the support provided to the children and the foster carers due to the Covid-19 pandemic. Face to face visits continued during the lockdowns, including from the youngest child’s special school. She told the review how much she likes school and spoke about good relationships with trusted adults there. There was regular contact from agencies both virtually and directly and all statutory visits took place. Although the placement was long-term, consideration of less frequent visiting (lighter touch) from the children’s social workers was dismissed as it was acknowledged that there were likely to be ongoing challenges and because the children voiced that they liked their meetings and visits from their social worker. This was respected. 5.24 The carers were subject to the IFA and the Local Authority’s expectations regarding safer care, and this was checked with them regularly. The daily care plans that are agreed with foster carers take into consideration the need to ensure that children are safe, and this case was no exception. Both carers and the children regularly spoke positively about how the placement was working well. The agreed plans included one to one time with the male carer when he came home from work, something that was requested and apparently enjoyed by the children. As the girls grew older the daily care plans evolved and were formally updated and reviewed regularly. There was no indication to any of those involved that things were not as they seemed. 16 Nina Biehal, Linda Cusworth, Jim Wade with Susan Clarke (2014) 9 5.25 In this case there was a significant amount of support from the IFA who built relationships with the children as well as the foster carers. There is evidence of direct communication with the children and meaningful contact from the IFA supporting social worker with the family and with the local authority social workers. The foster carers received good quality support and training, with reflective supervision and the support of a therapeutic specialist. The IFA reported that they successfully use dyadic developmental psychotherapy in order to help their carers understand the impact of abuse and neglect in their early years on children. This is said to be largely successful as they have a lot of long-term placements where children are meeting and exceeding expectations. 5.26 For the professionals involved, this case has been distressing and shocking. They had all seen the relationships within the placement as positive and healthy. None of them had any of the negative ‘gut feelings’ that professionals often describe when working with a family and sexual abuse later emerges. It was concluded that the perpetrator was extremely successful in grooming the children and the adults around them, including the experienced and skilled professionals involved. He also avoided detection for a considerable period of time. Sexual abusers will seek out roles where they have access to vulnerable children to abuse, as appears to be the case here. Those involved are aware that if it can happen in this placement, it can happen in any placement. The challenge following the review is how the Partnership can ensure that all professionals are aware of this fact. 5.27 The investigation into the allegations was timely and thorough. Both of the children and the female carer spoke about the difficulties but also the support they received. The carer shared the difficulty in being the non-abusing carer/parent and how difficult it was to get information and explanations, as the family were not entitled to a police service Family Liaison Officer in these circumstances. The review agreed that this would be shared with Wiltshire police for their consideration and a recommendation has been made. Learning Points Children in care in long term placements need significant relationships with professionals and/or their carers if they are to disclose sexual abuse, but even then, many children do not disclose their abuse. Consideration should be given to how support and information is provided to families when there is an on-going investigation into abuse in the home. 6 Conclusion and recommendations 6.1 The rapid review meeting that was held shortly after the allegations were made felt strongly that a CSPR was required in this case due to the children being in the care of the local authority and the extensive contact they had with professionals for the nine years that the abuse had been happening. This CSPR has found good practice across agencies in how they worked with the children, the carers and each other, and that there were no indicators prior to the allegations made that the placement was not safe. The review has also found good practice that often went beyond that which is expected and has seen a high standard of care from the female foster carer. 6.2 Much of what was found in this case was not new learning, but this is a good opportunity to highlight what was found here in order to raise awareness and provide points for discussion amongst professionals in partner agencies. It shows how devious and manipulative perpetrators of sexual abuse can be and the need to provide every opportunity for children in care to be able to speak about what is happening to them, while also being aware that they may not disclose. This will involve a culture across all agencies of awareness that sexual abuse happens and the knowledge that while this area of safeguarding is complex and that not all children will disclose, many will if the opportunity arises. The younger child in this family was clear that she was looking for the right moment to speak out. 10 6.3 There has been meaningful cooperation with this review from the partner agencies and those involved with the family who had a wish to learn from this distressing case. The children continue to receive good care and support with additional therapeutic interventions in light of the abuse and imprisonment of the male foster carer. 6.4 In Wiltshire there has been a focus on intra-familial sexual abuse and on improving awareness and practice in this area. There is a commitment locally to continue this focus as well as a parallel focus on exploitation. CSPR Family N recommended that professionals are briefed about the way that perpetrators silence children when they are being sexually abused, and the patterns of behaviour of abusers. There is also a plan for this to be included in the SVPP workforce development programme and be used to inform the content of future planning. These briefings can now also include examples from the case being considered by this CSPR. 6.5 Having considered the learning stated above, the following additional recommendations are made: Recommendation 1 The Partnership to consider how it can ensure that all professionals are aware of the learning from this review and the need for them to be thinking about and talking about the very real risk of sexual abuse of children in care. Recommendation 2 The learning from this review should be shared with the Corporate Parenting Panel. Recommendation 3 The Partnership to request that the learning from this review is used in foster carer training by the local authority and IFAs, including the need for training about intra-familial sexual abuse. Recommendation 4 The Partnership to request that the Local Authority provides assurance of the plan to include direct information from respite carers in child in care reviews. Recommendation 5 The Partnership to consider how they ensure that professionals are confident in safeguarding children from sexual abuse. This should include: • Work with schools to consider how they can implement the recommendations from the Children’s Commissioners report from 201717 to ensure that all children are aware that sexual abuse happens and what will happen when they speak to someone. • Extend the work being undertaken on ‘making every contact count’ to include using opportunities to speak to children about sexual abuse. • That support is provided to partner agencies regarding enabling professionals to feel confident about this area of safeguarding work. Recommendation 6 The Partnership to ask Wiltshire police to consider the need for support for the non-abusing partner when investigating and prosecuting child sexual abuse cases. Recommendation 7 The Partnership to consider whether they provide sufficient oversight and scrutiny of child sexual abuse. 17 Preventing Child Sexual Abuse. The Role of Schools. |
NC047748 | Death of a 14-month old girl in July 2014. Cause of death was not ascertained but there were concerns that Child B had died while co-sleeping with her mother and maternal grandmother, who were both believed to have been under the influence of alcohol. Child B and her siblings were on a child protection plan under the category of neglect due to concerns about their mother's alcohol misuse. Mother was involved with a number of agencies, and practitioners described her as being pleasant, intelligent, and having insight into her difficulties. In total there were five critical incidents related to the children's mother's alcohol misuse. Key findings include: there was evidence of poor practice and a number of missed opportunities to safeguard Child B and her siblings; there was a tendency to parent-centred practice; Child B's mother was involved with a number of agencies yet was not challenged or confronted about her behaviour; there were no records of any inter-agency communication before the initial child protection conference; professionals did not listen to Child B's siblings who said they were left to care for Child B and did not want to live with their mother; there was failure to involve birth fathers in assessment and planning. Uses the Social Care Institute for Excellence (SCIE) Learning Together systems methodology. Makes recommendations around involving fathers and other significant men connected to a child in child protection cases; listening to the voice of the child; and interagency communication.
| Title: Serious case review: Child B. LSCB: Staffordshire Safeguarding Children Board Author: Mick Muir Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Staffordshire Safeguarding Children Board Serious Case Review Child B Final Report Endorsed by the SSCB: 15th October 2015 Published on: 3rd January 2017 SCR Report-Child B – Final Page 2 1. Introduction 1.1 Why this case was chosen to be reviewed Child B died on 3rd July 2014. At the time of her death, she was the subject of a child protection plan on the grounds of neglect attributable mainly to concerns about her mother’s alcohol misuse. Following her death, Child B was the subject of a post-mortem examination which noted that while the cause of death was unascertained, there were concerns that Child B had died while co-sleeping with her mother and maternal grandmother, both of whom were believed to be under the influence of alcohol. Child B’s case was considered at the Serious Case Review (SCR) Scoping Panel meeting on 14th September 2014. There was unanimous agreement by all present that the criteria for a SCR, outlined in Working Together 2013, were met and a recommendation was made to the Chairperson of the Safeguarding Board to conduct a SCR. The recommendation was accepted by the Board Chair on 14th October 2014. Working Together 2013 states that LSCB’s may use any learning model which is consistent with the principles in the guidance, including the systems methodology recommended by Professor Munro*. It was agreed that this review would be conducted using the SCIE Learning Together methodology. A Glossary of the acronyms and references used in this report can be found in Appendix A on page 53 of this document. * The Munro Review of Child Protection: A Child Centred System (2011) SCR Report-Child B – Final Page 3 1.2 Succinct Summary of the Case Family Composition: Maternal Great-grandfather Adult W Maternal Great-grandmother Adult V Maternal Grandmother Adult S Mother Father Child L Adult T Father Child M Adult U Father Child B Child L Half-brother (12 years) Child M Half-sister (9 years) Child B Subject (14 months) SCR Report-Child B – Final Page 4 Child B first came to the attention of Children’s Social Care (CSC) in September 2013, following an allegation that Adult S had been intoxicated with alcohol while she was breastfeeding Child B. Child B was four months old. CSC made enquiries with the various agencies involved with the family at the time who were unable to provide any information to corroborate the expressed concerns and a decision was made by CSC to take no further action. Child B was re-referred to CSC five months later following an incident when she and her older siblings were found in their mother’s care while she was intoxicated with alcohol. CSC began a section 17 (Children Act 1989) child social work assessment which concluded that all three children should become the subjects of a child in need (CiN) plan. Over the next two months there were three further incidents when Adult S was found to be intoxicated while caring for her children which necessitated their removal to different members of the extended family. A decision was made to take the case to an initial child protection conference in May 2014, the outcome of which was that Child B and her older siblings were all made the subjects of child protection plans on the grounds of neglect. Following the Conference, Child B remained in the care of her mother (living with Adult W) and the other children lived with Adult T. There were no further incidents when Child B’s mother was found to be intoxicated, though there was some evidence to suggest that she continued to drink. After a relatively short period of time the relationship between Adult S and Adult W became strained and Adult S made plans to move to a different address. As a precursor to this move, she went to stay overnight with Adult V, where it is believed both adults were drinking during the course of the evening. Later that night, Child B died while co-sleeping with her mother and grandmother. Following Child B’s death Adult S was arrested, but was released without charge. SCR Report-Child B – Final Page 5 1.3 Timeline of Key Events Date Event 03-09-2013 HV for another family reports to CSC information that Adult S was seen to be drunk while breastfeeding Child B. Lateral checks undertaken with Child B’s health visitor (HV) and Child L and Child M’s school. No evidence to corroborate concerns. CSC decides on no further action (NFA). 18-10-2013 Adult S contacts HV complaining she is depressed and discloses difficulties in her relationship with Adult U. HV advises Adult S to contact Pathway (DV Support Service) which she does later that day. 26-11-2013 Adult S consults GP about her depression and reports that she is receiving support from Pathway and HV. Her general practitioner (GP) prescribes anti-depressant medication. 28-01-2014 HV visits Adult S and completes the Edinburgh Post-Natal Depression Scale (EPNDS) which scores 23. HV recommends Adult S seeks a referral to a Post-Natal Group in the area the child lived. Adult S remains in contact with the Pathway worker. 28-02-2014 Adult T contacts CSC Emergency Duty Service (EDS) at 12:45am to report that he had been contacted by Child L because Adult S is ‘passed out’ under the influence of alcohol. Adult T reports that Adult S had threatened to ‘slit the older children’s throats’. Adult T tells EDS that he is taking the older children to his address and Child B will be cared for by a neighbour. Adult T says these are the usual arrangements when Adult S is drunk. Given the lateness of the hour, EDS accept this arrangement and refer the matter to the Area Team in the area the child lived the following morning. 28-02-2014 Upon receipt of the referral later the same morning, it is allocated to SW1 for a child social work assessment. SW1 does not complete any lateral checks, but does speak to Child L and Child M who confirm that Adult S ‘drinks all the time’. When SW1 speaks to Adult S, she admits that she had been drunk and identifies the use of drink as a coping mechanism to help her with her complex relationships with Adult T and Adult U. SW1 concludes that the case can be managed by CiN level underpinned with a written agreement and this conclusion is endorsed by her Team Manager. SCR Report-Child B – Final Page 6 02-04-2014 A neighbour of Adult S contacts the NSPCC to report that she is drunk and that her three children are with her. The neighbour says this is a common occurrence and the children are being neglected. The neighbour is advised to call the Police and she does so. The Police attend and find Adult S in a highly intoxicated state. They consider the use of S.46 powers but do not use them as Adult T arrives (having been contacted by Child L) and agrees to care for Child L and Child M. Adult S persuades the Police to contact Child B’s father, Adult U, who agrees to attend and stay overnight to care for Child B. 03-04-2014 In the early hours of the morning Adult S takes an overdose of Diazepam and she is admitted to hospital where her condition is monitored. She is the subject of a Rapid Assessment Interface and Discharge (RAID) assessment and is discharged with an urgent referral to the Community Mental Health Team in the area the child lived. 20-04-2014 Adult S calls 999 to report Adult U had taken Child L and Child M to Birmingham Airport en-route to a holiday abroad. She requests that the children are returned to her care. The Police collect Child L and Child M from the airport and attempt to reunite them with Adult S but she is not at home. The children are taken to the local police station from where Adult T is contacted and he agrees to take the children into his care. The Police attend Adult S’s address to inform her about what has happened and find her intoxicated and unable to care for Child B. Adult S persuades the Police to contact Adult W (Child B’s maternal great-grandmother) who agrees to look after Child B. 25-04-2014 A single agency strategy meeting is convened, involving SW1 and Team Manager. A decision is made to take the case to a Child Protection Conference. 30-04-2014 At 5:00pm the Police receive a report that Adult S is drunk and in the street screaming at her older children. The Police attend and find Adult S intoxicated and in a highly emotional state. They make arrangements for Child L and Child M to be cared for by Adult T and for Child B to return to the care of Adult W. 02-05-2014 Adult S attended a mental health assessment appointment accompanied by SW1. She denied that she had attempted suicide and attributed her actions to her low mood, brought on by her complex personal relationships. She denied that she drank excessively and this was not challenged by SW1. The conclusion of the assessment was that Adult S would benefit from cognitive behaviour therapy (CBT) and she was advised to self-refer to the ‘Wellbeing Matters’ service. SCR Report-Child B – Final Page 7 12-05-2014 An initial Child Protection Conference is held, the outcome of which is that all three children become the subject of a child protection plan on the grounds of neglect. The plan recommends that Child L and Child M remain in the care of Adult T and that Child B and Adult S live with Adult W until Adult S finds suitable accommodation, close to Adult W and away from the area where they used to live. 21-05-2014 The first Core Group meeting is held. This is arranged in two parts to accommodate confidentiality issues associated with the different paternities of Child B and Child L and Child M. Adult S becomes upset over Adult T’s plans to apply for residence orders for Child L and Child M. The meeting ends abruptly and no detailed child protection plan is agreed. 30-05-2014 Home visit by Family Support Worker (FSW) to administer unannounced breathalyser test. Adult S tells FSW that she intends to move out of Adult W’s address in the near future to a house a few doors away. 05-06-2014 SW1 makes statutory visit to Child L and Child M at Adult T’s address. Both children state they do not wish to return to Adult S’s care. Child M tells SW1 that she thought Adult S had been drinking the last time she saw her. 06-06-2014 Adult T calls EDS to report that Child L and Child M have been returned to his care early following contact with Adult S. He says that he believes Adult S has been drinking. EDS contact Adult W who confirms that Adult S had had a drink but that she was capable of looking after Child B with her (Adult W’s) supervision. 18-06-2014 Decision to reallocate the case to SW2 as SW1 is leaving the local authority. 27-06-2014 Statutory visit by SW1 to Child B who was living with Adult S at her maternal niece’s home. The visit is uneventful and Adult S tells SW1 that she intends to move into her own rented property in the near future. 01-07-2014 Adult S telephones SW2 to inform her that she is staying temporarily with Adult V prior to a move to her own address on the following day. 02-07-2014 SW1 phone call to Adult T to inform him that the case has been transferred to SW2. Adult T reports two incidents of Adult S drinking. 03-07-2014 Child B reported as a child death at 02:27 hours. SCR Report-Child B – Final Page 8 1.4 Methodology The case review used the systems methodology called Learning Together (Fish, Munro & Bairstow, 2009). The focus of a case review using a systems approach is on multi-agency professional practice. The goal is to move beyond the specifics of the particular case – what happened and why – to identify the ‘deeper’, underlying issues that are influencing practice more generally. It is these generic patterns that count as ‘findings’ or ‘lessons’ from a case and changing them will contribute to improving practice more widely. The methodological heart of the Learning Together model has three main components: Reconstructing what happened – unearthing the ‘view from the tunnel’ and understanding the ‘local rationality’. Appraising practice and explaining why it happened through the analysis of Key Practice Episodes (KPE’s). Assessing relevance and understanding what the implications are for wider practice – using the particular case as a ‘window on the system’. Using this approach for studying a system in which people and the context interact requires the use of qualitative research methods to improve transparency and rigour. The key tasks are data collection and analysis. Data comes from structured conversations with involved professionals, case files and contextual documentation from organisations. 1.5 Review Team The review has been carried out by a Review Team led by Mick Muir, an Accredited Learning Together Lead Reviewer. The Review Team received support throughout part of the process from the SSCB Business Manager and SSCB Business Support Officer. It is usual for ‘Learning Together’ reviews to be undertaken using two Lead Reviewers. However, in this case, it was decided due to time and financial constraints to proceed with one Lead Reviewer with additional support from SCIE. This was provided by the SCIE Head of Learning Together in the form of case consultation, supervision and a findings clinic for the Lead Reviewer. Collectively, the role of the Review Team is to undertake the data collection and analysis and author the final report. Ownership of the final report lies with the SSCB as a commissioner of the SCR. SCR Report-Child B – Final Page 9 The Review Team was made up of senior representatives from the different agencies that had been directly involved with Child B. The role of the Review Team Member is to provide expert knowledge in relation to the practice of their individual agency, to contribute to the analysis of practice and to the development of the findings from the review. No members of the Review Team had any direct case management responsibility in relation to the services offered to Child B. The Review Team was made up as follows: Designation & Agency of Review Team Members SCIE Accredited Lead Reviewer – Mick Muir Detective Chief Inspector, Staffordshire Police County Manager, Specialist Safeguarding, Staffordshire County Council Named Nurse for Safeguarding Children, South Staffordshire and Shropshire NHS Foundation Trust Head of Safeguarding, Staffordshire and Stoke-on-Trent Partnership NHS Trust Safeguarding Children Lead Nurse, Sandwell & West Birmingham Hospital Designated Nurse for Safeguarding Children, South Staffordshire Clinical Commissioning Group (CCG) South Staffs Designated Nurse for Safeguarding Children- Sandwell & West Birmingham CCG (Designated Nurse for Child Death Reviews) Safeguarding Lead, West Midlands Ambulance Service Operation Director, Pathway Services Principal Social Worker (Children), Staffordshire County Council Staffordshire SSCB Development Officer Staffordshire SSCB Board Manager 1.6 Structure of the review process The SCIE model uses a process of iterative learning, gathering and making sense of information about a case that is a gradual and cumulative process. Over the course of this review there have been a series of meetings between the Lead Reviewer, Review Team and Case Group members. Initially there was a meeting between the Lead Reviewer and the Review Team to explain the SCIE Learning Together model and the role of the Review Team in the process. The Review Team then decided the membership of the Case Group based on their individual involvement in the case. SCR Report-Child B – Final Page 10 An introductory meeting took place with the Case Group at which the Review Team was also present. At this meeting the SCIE model was explained to the Case Group and their role in the review process was clarified. Case Group members were informed they would be involved in individual conversations with Review Team members and Lead Reviewer and given the opportunity to reflect on and explain their involvement with the case. They were also informed that they could be accompanied by a supporter at the conversation if they wished. There were 14 individual conversations which took place over a period of three days. In addition, there was a telephone conversation between the Lead Reviewer and the EDS Manager. During the course of the review the Review Team met on seven occasions and, in addition, attended a reading day. The Case Group met on three occasions, one for the introductory session and then for two Follow-on meetings, where the emerging analysis was discussed and challenged. The Review Team were also present in these meetings. The review followed the process and meeting structures as outlined by SCIE with one additional final meeting of the Review Team to agree and sign off the report and reflect on the experience of using the SCIE model. In total, the Review Team met on ten occasions, including three which involved Case Group members. 1.7 Timeframe and mandate In line with qualitative research principles, reviewers endeavour to start with an open mind in order that the focus is led by what they actually discover through the review process. This replaces the terms of reference (that have a specific focus of analysis before the review process has begun) which are a fundamental feature of traditional Serious Case Reviews. The timeframe for the review was set at the initial meeting between the Lead Reviewer and the Review Team on 3rd February 2015. It was agreed that the timeframe was from 4th December 2012 (the date of Adult S’s booking-in appointment) until 3rd July 2014. Within the period under review, eight key practice episodes (KPE’s) were identified (covering the period from 3rd September 2013 until 19th June 2014). These KPE’s were then analysed in detail to provide insight into not only what happened with Child B but also why things happened as they did. It was from this process of analysis that the learning from the review (presented later as findings) was generated. SCR Report-Child B – Final Page 11 1.8 Sources of data The systems approach requires the Review Team to avoid hindsight bias in the case analysis and to discover how people saw things at the time – the ‘view from the tunnel’. This process reveals what sense practitioners made of what was happening at the time of their involvement and begins to explain why they acted as they did. This is known as the ‘local rationality’. It requires those who had direct involvement in the case to play a major part in the review in sharing information about how the ‘safeguarding system’ works and analysing how and why practice unfolded the way it did, while at the same time explaining the broader organisational context. Data from Practitioners Information was provided by members of the Case Group who were directly involved with the family through a process of individual conversations. They were invited to share their experiences of working with Child B and her family in the context of their knowledge of the systems and practice at that time. A total of 14 conversations were held with individual practitioners (who fulfil the roles outlined below), who together formed the Case Group for the review. Two members of the Review Team were involved in each conversation, with the exception of the telephone conversation between the Lead Reviewer and the EDS Manager. Designation and Agency of Case Group Members Police Officer 1 ) Staffordshire Police Police Officer 2 ) Area Team Manager ) Staffordshire County Council Area Social Worker ) Mental Health Professional ) South Staffordshire & Shropshire NHS Community Psychiatric Nurse ) Foundation Trust Health Visitor ) Staffordshire & Stoke-on-Trent Partnership School Nurse ) NHS Trust Named Nurse for Safeguarding ) Health Visitor Sandwell & West Birmingham Hospital GP South Staffordshire CCG GP Sandwell & West Birmingham CCG Case Worker Pathway Services Independent Conference Chair ) Staffordshire County Council EDS Manager ) SCR Report-Child B – Final Page 12 Data from Documentation In the course of the review the Review Team members had access to the following documentation: Referral information following incident on 3rd September 2013 Referral information following incident on 28th February 2014 Social Work case records from 6th March to 30th June 2014 Record of SW initial visit on 6th March 2014 Police records of incident on 2nd April 2014 Ambulance record of Adult S’s admission to hospital on 3rd April 2014 Hospital record of Adult S’s admission on 3rd April 2014 Hospital admission record RAID Assessment EDS record of incident on 30th April 2014 Written agreements to secure children’s placements, 28th April 2014 Record of strategy discussion to move case to ICPC Police records of incident on 30th April 2014 Mental Health and Risk Assessment on Adult S, 21st May 2014 Social Worker report for ICPC, 12th May 2014 ICPC minutes and copy of initial CP plan First Core Group minutes, 21st May 2014 Post-mortem report, dated 25th February 2015 Ofsted Inspection Report for the period 14th January to 5th February 2014 Staffordshire County Council ‘Summary of Audit Findings’ from Q3 2013/2014 – Q1 2015/2016 Edinburgh Post-Natal Depression Scale, completed on Adult S on 8th august 2013 (13/30); 28th January 2014 (25/30); 9th April 2014 (25/30) Staffordshire County Council ‘written agreement’ protocol. Data from Family, Friends and Community The SSCB Business Manager wrote to Adult S, Adult T, Adult U and Adult V shortly after the decision to conduct a SCR was made in October 2014 to inform them that a review into the circumstances of Child B’s death was to be completed. She wrote to them again following the commencement of the review in February 2015 to offer them the opportunity to make a contribution to the process. Adult U responded positively and he and the Lead Reviewer had an extended telephone conversation in which he provided useful information about family relationships and dynamics. The SSCB Business Manager made two further attempts to make contact with the other adults involved with Child B to invite them to contribute to the review process but they declined to do so. SCR Report-Child B – Final Page 13 The issue of whether to involve Child B’s siblings in the review was discussed at the first meeting of the Review Team. It was decided that it would be inappropriate to approach Child L and Child M, given their ages and relatively recent loss of their younger sister. 1.9 Local Context Child B died at the end of what had been a very difficult period for the CSC Area Teams in the district the child lived in. The district is covered by two separate CSC teams which at the time of Child B’s death were effectively operating as a single team, due to the long-term sickness absence of one of the team’s Team Manager. The consequence of this was that the other Team Manager assumed responsibility for managing both teams with 20+ direct reports from Social Workers and Family Support Workers. In addition, there were difficulties in recruiting and retaining experienced staff with the consequence that the staffing of both teams was comprised largely of a mixture of newly qualified staff and agency workers. At the time of Child B’s death one team had just under 400 open cases. SW1 was a relatively inexperienced social worker and there is a note on her supervision record that on 22nd April 2014 she had 43 open cases. The inevitable consequence of this volume of work in these circumstances was a deterioration in the quality of decision making and case planning. This situation was recognised by Senior Management in June 2014 and an action plan was implemented to address the identified difficulties. The plan included the recruitment of an interim Team Manager to cover for the absent Manager’s sick leave plus an additional Manager to catch up on the backlog of work that had accumulated, improved levels of support for all three Team Managers, an audit of all open cases and robust tracking of cases to improve management oversight and decision making. In addition a piece of work was undertaken with Social Workers, led by the Principal Social Worker, to help them refocus on their performance and behaviours to improve the quality of interventions with the children and families. Following this initial response, work continued over the following twelve months to consolidate and improve on the changes that had been made. The situation at present is that systems and processes are now in place to ensure that the two teams operate as two separate teams. They have their own dedicated Team Co-ordinators and separate duty and intake of work systems. There has been investment in training and team development and an increase in the level of support offered to Team Managers by the County Manager. The situation at present is that both teams are fully staffed with no agency workers in either team, with 230 open cases in one of the teams being carried by 10.5 wte social work staff. SCR Report-Child B – Final Page 14 The particular circumstances that existed in the area the child lived at the time of Child B’s death have implications for the extent to which the key features of professional practice in this case are representative of practice generally. The Review Team has considered this issue carefully to ensure that for each finding there is sufficient evidence to say that it represents an underlying pattern of practice or (where there is insufficient evidence to say for certain) the issue is of such importance as to merit further enquiry. Those practices which were evident in this case which were peculiar to the particular area team where the child lived and which have already been addressed, are identified later in the report. SCR Report-Child B – Final Page 15 2. The Findings What light has this case review shed on the reliability of our systems to keep children safe? 2.1 Introduction A case review plays an important part in efforts to achieve a safer child protection system. Consequently, it is necessary to understand what happened and why in the particular case, and go further to reflect on what this reveals about gaps and inadequacies in the child protection system. The particular case acts as a ‘window on the system’ (Vincent 2004: 13). For this to happen, the outcome of the review has to say more than what happened in this particular case and needs to provide messages to the LSCB about usual practice and normal patterns of working. These messages are presented as Findings and they provide the LSCB with an insight into the underlying patterns that influence professional practice and outcomes for children. These Findings exist in the present and potentially impact on the future. By responding positively to the Findings the LSCB has the opportunity to change how the child protection system operates and to make it safer. It makes sense, therefore, to prioritise the Findings to identify those that need to be tackled most urgently for the benefit of children and families, even though these may not be the issues that appeared most critical in the context of this particular case. In order to help with the identification and prioritisation of Findings, the systems model that SCIE has developed includes six broad categories of these underlying patterns. The ordering of these in any analysis is not fixed and will change according to which issues are felt to be most fundamental for systemic change. The categorisation of Findings is as follows: 1. Innate human biases (cognitive and emotional) 2. Family-professional interaction 3. Responses to incidents 4. Longer term work 5. Tools 6. Management systems The Findings from each category convey a message to the SSCB about how that element of the child protection system is working currently. They state succinctly what is problematic about the system and are therefore helpful to the reader. It is not uncommon for there to be overlap between the categories of findings. SCR Report-Child B – Final Page 16 2.2 Appraisal of professional practice in this case – a synopsis This section of the report sets out the view of the Review Team on the quality of multi-agency practice evident in this case, given what was known and knowable at the time. The Review Team is grateful for the contributions made by the members of the Case Group, some of whom found the process of the review quite difficult and personally challenging. The period under review in this case stretches from 4th December 2012 until 3rd July 2014. However, in reality, Adult S’s confinement and the first four months of Child B’s life were uneventful and the events that formed the basis for the review extended from 3rd September 2013 to 2nd July 2014. Within this period there were five critical incidents, each of which represented a missed opportunity to take protective action on behalf of Child B. The Review Team was aware of the problems that were being experienced by CSC in the area the child lived during the timeframe of the review and was sympathetic to the difficulties that these presented. Nonetheless, it was the view of the Review Team that the quality of the service provided by CSC throughout this time fell below expected standards. The Review Team was also critical of the practice of a number of partner agencies, particularly in relation to sharing information and their willingness to share responsibility in the safeguarding process. The Review Team noted the good practice of the Police Officers involved in the three incidents in April 2014 who, within the confines of their role, demonstrated effective, child-focused, safeguarding practice. What follows are the key issues that emerged in the course of the review. Where possible, a satisfactory explanation will be provided for the practice or an indication will be given where the issue will be discussed more fully in the findings. Persistent failure to recognise risk When Child B was referred to CSC EDS by Adult T on 28th February 2014 and the case was picked up by the CSC Area Team in the area the child lived, there was sufficient evidence of likely significant harm to justify a strategy discussion and a S.47 enquiry. Instead, the case was allocated for a S.17 child social work assessment, the outcome of which was a decision to manage the case at CiN level. There were three further incidents when Adult S was found to be intoxicated with some or all of the children in her care, each of which was of sufficient significance to warrant a S.47 enquiry. It is a matter of some concern that despite the repeated presentation of likely significant harm (particularly in relation to Child B), that no S.47 enquiry was ever conducted in this case. This is evidence of poor practice and a number of missed opportunities to safeguard Adult S’s children. SCR Report-Child B – Final Page 17 The Review Team was concerned that the practice in this case was representative of practice of CSC in Staffordshire generally but was reassured that it was not by the evidence from a recent Ofsted Inspection Report and quality assurance data provided by CSC from quarter 3 of 2013-2014 to quarter 1 of 2015-2016. The Ofsted inspection took place during the timeframe for this review. It found that safeguarding services were ‘good’ with evidence that “the vast majority of assessment (of risk) demonstrate good analysis of children’s needs and circumstances which supports sound decision making and planning”. This judgement represents an improvement on the previous inspection of safeguarding arrangements in November 2012 when the judgement was that these were ‘adequate’. The quality assurance data indicated that CSC practice relating to the assessment of risk (which included a section on the ‘recognition of risk’) had been good or outstanding in 90% of cases from October 2013 until June 2015. These two pieces of evidence, together with the evidence of the remedial action that has been taken over the past twelve months in the area the child lived, has persuaded the Review Team that the practice in this case could be attributed to the pressures and circumstances that were present in this particular Area Team at the time of Child B’s death and did not evidence a systemic weakness within CSC. As a consequence, there is no finding in relation to this issue as it relates to CSC. The Review Team did consider that partner agencies could have been more active in challenging the CSC responses to the concerns about the children as they arose and this issue is explored further in Finding 1 and Finding 4. Tendency to parent-centred practice Almost without exception, the members of the Case Group who had direct contact with Adult S liked her and were positively disposed to her. She was described as pleasant, intelligent and articulate. She was believed to have insight into her difficulties and appeared to be help-seeking and keen to overcome the problems she associated with her complex relationships with Adult T and Adult U. She was involved with a number of agencies, each of which believed she was actively engaged with their service with the intention of improving her own circumstances and, as a consequence, improving her children’s circumstances. In reality, Adult S did not engage with any agency in any meaningful way throughout the period of the review. As a consequence, she never changed and her children’s circumstances never changed. Despite this fact, there is no evidence that Adult S was ever challenged or confronted about the consequences of her behaviour for her children (except for one conversation with a Police Officer during the incident on 30th April 2014). The failure of practitioners working with Adult S to see beyond her presenting difficulties and recognise the impact of what she did on her children’s safety and welfare was evidence of poor practice. What lay behind this response is explored further in Finding 6 and Finding 7. SCR Report-Child B – Final Page 18 Poor inter-agency communication Following the referral to CSC on 28th February 2014 there is no evidence that any lateral (multi-agency) checks were undertaken prior to the commencement of the S.17 child social work assessment. Thereafter, despite Adult S’s involvement with a number of agencies and the fact that all three children were nominally the subjects of CiN plans, there is virtually no record of any inter-agency communication prior to the initial child protection conference on 12th May 2014. The agencies that were involved with Adult S all had information that was relevant to the safeguarding process and the failure to share this information may have impacted adversely on the outcomes for Child B and her siblings. The explanation for this poor practice on the part of CSC staff is to be found in the circumstances that were prevalent in the Area Team where the child lived at the time. In relation to the partner agencies, this issue is considered further in Finding 3 and Finding 4. Failure to take account of the child’s voice In the course of the four significant incidents that lie at the heart of this review, Child L and Child M were spoken to by Police Officers and CSC staff on a number of occasions. On each occasion that they were spoken to, they repeated the same two things. The first was that their mother drank all of the time and that they were frequently left to care for Child B; the second was that they no longer wished to live with Adult S and wanted to stay with Adult T. There is no evidence that the information about Adult S’s drinking was taken seriously when assessing the risks to which the children may be exposed. On the contrary, the minutes of the conference of 12th May 2014 which record “it was believed that Adult S’s excessive drinking represented the exception rather than the rule”, would suggest that the children were disbelieved and their information discounted. The fact that the children eventually went to stay with Adult T following the serious incident on 30th April 2014 was due largely to circumstance rather than as a consequence of the children’s voices having been heard. They had been returned to Adult S’s care three times previously (between 28th February and 28th April 2014) despite having said on each occasion that they wished to remain with Adult T. The failure of CSC staff to take seriously what the children were saying about the extent of Adult S’s problematic drinking and to take action to move them to a safe place and intervene more robustly to secure Child B’s safety represents poor practice and an important missed opportunity to safeguard and promote their welfare. The Review Team recognised the importance of this issue and was minded to develop a finding to bring the matter to the Board’s attention. It was dissuaded from doing so by the conclusions of the Ofsted inspection (referred to earlier) and the quality assurance data provided by the CSC representatives on the Review Team. SCR Report-Child B – Final Page 19 The Ofsted inspection identified the ‘voice of the child’ as a strong point in the Staffordshire safeguarding system. It stated: Social workers had a good understanding of the children they work with and appreciated the importance of listening to children’s experiences and views when making decisions that affect their lives. Social workers were able to articulate the importance of understanding the child’s experiences and views. There were strong examples of records which told the child’s story very well. There has been a significant improvement in the voice of the child being heard at case conferences. The quality assurance data from CSC between quarter 3 of 2013-2014 to quarter 1 of 2015-2016 indicated that there was evidence of the child’s views, wishes and feelings impacting on intervention and outcomes was present in (on average) 75% of cases. From this information the Review Team concluded that the poor practice in relation to hearing the child’s voice that was evident in this case was attributable to the circumstances that prevailed in the CSC Area Team where the child lived at the time of their death and did not represent practice in Staffordshire generally. The use of written agreements At the conclusion of the S.17 child social work assessment it was decided that the case should be held at CiN level, with a written agreement in place to address the risks that had been identified (though there is no record that such an agreement was drafted). Following the incident on 2nd April 2014, when Child L and M went to stay with Adult T, there is a record of a telephone conversation with Adult S to inform her of a written agreement to secure the children in Adult T’s care. Following the incident on 20th April 2014 there is a written agreement drafted by EDS requiring Child B to live with Adult W and Child L and Child M to live with Adult T. There were further, identical, written agreements drafted on 28th April 2014 (confirming the children’s places of residence and a requirement that Adult S will not drink while she has care of the children) that were signed by all parties two days before the fourth serious incident that required the children to be moved once again. SCR Report-Child B – Final Page 20 The written agreements were put in place in order to provide the Local Authority with assurances that Adult S and her extended family shared its concerns about the children and were prepared to act to secure their safety and welfare. In reality, the agreements were of no value. All of the agreements, both verbal and written, were breached almost immediately by Adult S and her family with no action taken in response to these breaches, only for them to be replaced with identical agreements following the next incident. At best, the agreements clarified the concerns of the Local Authority for the family, though they provided no added protection for the children. At worst, they served to undermine the protection of the children by providing a false sense of security about their welfare. The CSC representative on the Review Team reported that the inappropriate use of written agreements had been widespread across the County and had come to the attention of senior management following the outcome of a Stage Two complaint and two case review reports from the SSCB. In response, a protocol was drafted which tightened the criteria for the use of written agreements and increased the level of management oversight of their use (up to County Manager level). The new protocol was signed off by the Policy and Procedure Board in October 2014. Following the implementation of the new protocol there has been a significant reduction in the use of written agreements and CSC quality assurance activity has not revealed any inappropriate written agreements in case file audits. It was the view of the Review Team that the above constituted a satisfactory response from CSC and that as a consequence, no finding was necessary to bring this issue to the Board’s attention. Non-engagement with men Adult T and Adult U were key figures in the way the concerns about the three children were managed during the period under review. Adult T was important because he regularly reported concerns about Adult S’s drinking habits and he was the person that looked after Child L and Child M in times of crisis. Adult U was important because he was allegedly a source of distress to Adult S (which she claimed was a trigger for her problematic drinking) and also he was seen as a protective factor for Child B during the incident on 2nd April 2014 and subsequently when Adult S left Adult W’s home a short time after the child protection conference in May 2014. Both men attended the conference and both attended the subsequent core group, but there is no evidence that they were involved in the S.17 child social work assessment or spoken to alone about the nature and extent of Adult S’s use of alcohol or the nature of their relationships with any of the children. There is no record either that they were challenged when they breached the agreements that were made following the series of critical incidents. SCR Report-Child B – Final Page 21 The conversation between the Lead Reviewer and Adult U revealed that he had lots of information that would have been helpful in the assessment of Adult S. It is reasonable to assume that Adult T could have been equally helpful. The failure to engage fully with Adult T and Adult U, both in the assessment and in the longer term planning for the children, was evidence of poor practice and a significant missed opportunity in this case. What lay behind that pattern of practice is considered in Finding 5. Recognition of the impact of neglect When the concerns about Child B first came to light in September 2013 the neighbours who spoke to her Health Visitor alleged that Adult S neglected Child B. A similar allegation was made by Adult S’s neighbour when she raised concerns about the children on 30th April 2014. In the records of the interventions from all agencies prior to the case conference in May 2014, there is no mention of neglect or the impact of Adult S’s alcohol misuse on her children. Instead, the focus is on Adult S and providing her with the support she said she needed to address her personal difficulties. Even at the case conference, when the children became subjects of child protection plans on the grounds of neglect, there is no acknowledgement of the impact of the neglect that the children had experienced (particularly Child L and Child M) and there is no recommendation to address any therapeutic needs they might have. From the information provided by Adult U it is likely that all of the children had experienced the consequences of Adult S’s problematic drinking behaviour throughout their entire childhoods. The failure to recognise this and take appropriate remedial action is evidence of poor practice and an important missed opportunity. An explanation for this practice is provided in Finding 2, Finding 7 and Finding 8. 2.3 In what way does this case provide a useful window into our systems? As with all cases, there were features of this case that were unique to Child B and her family in terms of the relationships that existed between the significant adults and the difficulties and challenges these presented for Adult S which impacted on her children’s safety and welfare. It is also clear from the ‘appraisal of practice’ that there is evidence that some of the omissions and failures in this case were the consequence of the circumstances that prevailed in the CSC Area Office where the child lived were not representative of multi-agency practice in Staffordshire generally. SCR Report-Child B – Final Page 22 Nonetheless, it was the view of the members of the Case Group and Review Team that there were a number of aspects of this case that were typical of practice across the County, though it is necessary to point out that on a number of issues there was far from unanimous agreement that what happened in this case represented normal or usual practice. The wording of the findings is suitably nuanced to reflect these differences. The areas in which there was some agreement included: the challenges of working with disguised co-operation; problems in inter-agency communication; difficulties in engaging with men in the safeguarding process; offering appropriate challenge to both clients and professional partners where there are safeguarding concerns and using child protection conferences effectively to develop outcome focused child protection plans. The Review Team has identified eight findings for the Board to consider. Finding 1 Is the capacity of multi-agency partners to provide sufficient challenge to social workers risk assessments undermined by their levels of understanding about risks to children? (Management Systems) Finding 2 The presentation of apparently episodic neglect caused by alcohol misuse makes it more likely that professionals will underestimate its adverse effects on children’s safety and welfare and compromise their ability to take appropriate protective action. (Response to Incidents) Finding 3 Is there a pattern of practice in the area where the child lived, whereby people don’t think to make contact with colleagues from other agencies to share or seek information that may have safeguarding implications, which leaves some professionals unaware of concerns about children which impacts adversely on their ability to safeguard and promote their welfare? (Longer Term Work) Finding 4 When decisions about safeguarding issues are being made, there is a tendency for some partner agencies to defer to CSC (who they believe ‘know best’) or assume that CSC involvement automatically means that safeguarding issues are being properly addressed. (Response to Incidents) Finding 5 There is a pattern of practice in Staffordshire where professionals routinely fail to engage with or challenge men in the safeguarding process, leading to untested assumptions about their role in promoting the safety and welfare of their children. (Family/Professionals Interactions) SCR Report-Child B – Final Page 23 Finding 6 Is there a pattern of practice in the area the child lived whereby some professionals are inclined to accept what parents tell them about their behaviour (without challenging them with available information that contradicts what they say) which leads to errors in assessment of risk to which children are exposed and compromises their ability to take protective action? (Family/Professionals Interactions) Finding 7 Is there a pattern of practice whereby neither multi-agency forums nor supervision in any agency are effective in challenging and disrupting a fixed view of a case (once established) as a means of checking its accuracy? (Cognitive Biases) Finding 8 The way in which child protection conferences operate in the area the child lived makes it more likely that they do not provide the necessary rigorous challenge to professionals’ assessment of parents’ capacity to safeguard their children’s welfare and do not produce sufficiently clear and risk focused child protection plans. (Management Systems) SCR Report-Child B – Final Page 24 Finding 1 Is the capacity of multi-agency partners to provide sufficient challenge to social workers risk assessments undermined by their understanding about risks to children? (Management Systems) Multi-agency involvement in the safeguarding process is intended to ensure that all available information is brought together and shared. The goal is to bring a healthy check and challenge to the difficult task of analysing the information to determine the level of risk to which children may be exposed. In this case there were a number of opportunities when partner agencies could have challenged the decision making of CSC in the management of risk in this case but failed to do so. How did this issue manifest itself in this case? The early decision making following the incident on 28th February 2014 was made unilaterally by CSC as it did not share information with partner agencies before concluding that the case could be managed at CiN level. Following the incident on 2nd April 2014 the case remained at CiN level. The Health Visitor was informed of the incident on 9th April 2014 by Adult S, but did not make contact with CSC and did not challenge the decision not to escalate to child protection. There were two further incidents on 20th and 30th April, both of which left Child B at risk of significant harm which were resolved on both occasions by a decision to allow Adult S to retain care of Child B under the supervision of her maternal great-grandmother. While the first of these decisions may have been understandable in the circumstances, the second (following the incident of 30th April 2014) was less so, given that the family were clearly in breach of a written agreement drafted only two days earlier. Neither of these decisions was challenged by the Police Officers who attended both incidents. How do we know it is an underlying issue and not something unique to this case? The evidence in relation to this Finding is equivocal. A number of members from the Case Group said that they understood risk and that they had received risk assessment training. They also said that they were comfortable to challenge social workers where there was an opportunity and when necessary. The evidence from the CSC members of the Case Group suggested that challenge was sporadic and while it did occur from time to time, it tended to vary in relation to the confidence of the practitioner offering the challenge. Very few requests for formal escalations were reported. SCR Report-Child B – Final Page 25 How prevalent and widespread is this issue? It is difficult to state categorically how prevalent and widespread this practice may be in Staffordshire, but there is evidence to suggest that it has the potential to be an issue of some significance given that between August 2014 and July 2015 there were 9040 S.17 child social work assessments completed across the county (660 in the area the child lived) and in the same period there were 5534 children who were the subject of CiN plans (with 261 in the area the child lived). What are the implications for the reliability of the multi-agency child protection system? Working Together (2015) identifies the Local Authority as the lead agency in safeguarding and promoting the welfare of children and goes on to clarify the role and responsibilities of partner agencies in supporting CSC in this function. Accurate assessment of risk is an essential element of developing appropriate and proportionate intervention strategies at or near the significant harm threshold. For the system as a whole to be safe it is important that all agencies contribute to this process and that practitioners from partner agencies have the necessary knowledge, skills and confidence to act as a check and balance to social work assessment and formulations of risk. (See also Finding 4) SCR Report-Child B – Final Page 26 Finding 1 Is the capacity of multi-agency partners to provide sufficient challenge to social workers risk assessments undermined by their understanding about risks to children? (Management Systems) Accurate assessment is the cornerstone of effective risk management, but assessing risk is itself a risky business. The sources of error and bias in risk assessment are well known* and it is easy for social work practitioners to arrive at false positive or, more dangerously, false negative conclusions from the process. In order to counter these tendencies, it is important that staff from partner agencies have the necessary knowledge and skills to understand what is happening in families, form their own view about the levels of risk that are present and have the confidence to offer robust challenge to what they perceive to be inaccurate formulations or risk. The absence of such challenge has the potential to allow children at risk of significant harm to remain avoidably unprotected. *See: Contemporary Risk Assessment in Safeguarding Children (Calder, 2008) Questions for the Board Given the equivocal nature of the evidence for this Finding, is the Board minded to make further enquiries into the issue? Do all partner agencies have in place ‘fit for purpose’ training strategies to enable practitioners to recognise and respond to risk to children? Is there sufficient clarity of expectation of partner agencies in relation to challenging the outcome of risk assessments and formulations of risk completed by CSC? If the obstacle to challenging CSC decision making in respect of risk is due to a lack of confidence on the part of partner practitioners, what can be done to overcome this obstacle? What arrangements are needed to reassure the Board that this issue has been resolved? SCR Report-Child B – Final Page 27 Finding 2 The presentation of apparently episodic neglect caused by alcohol misuse makes it more likely that professionals will underestimate its adverse effects on children’s safety and welfare and compromise their ability to take appropriate protective action. (Response to Incidents) The adverse effects for children living with long term parental alcohol misuse are well established and include both physical and emotional harm. Despite the fact that Adult S repeatedly presented or was reported to be intoxicated while caring for her children, there was considerable delay before professionals perceived this as evidence of neglect or considered the implications of her behaviour on her children’s emotional wellbeing. How did this issue manifest itself in this case? The concerns about Adult S’s problematic drinking first emerged in September 2013, following an allegation that she was often drunk and that she had been intoxicated while breastfeeding Child B. These allegations were discounted as malicious, partly on the evidence from the Health Visitor that Adult S was a ‘good mother’ who looked after Child B well. Following the referral to CSC on 28th February 2014, a S.17 child social work assessment was completed, the outcome of which was that Adult S was a ‘good mother’ who attended well to her children’s basic needs but who was in need of help with her complex personal difficulties. There is no record that Adult S’s behaviour was considered neglectful. There were two further serious incidents on 2nd and 20th April 2014, when Adult S was found to be intoxicated which required the children to be removed to members of the extended family. Neither of these incidents attracted a S.47 enquiry. A single agency strategy meeting was held on 25th April 2014 which concluded that the case needed to be taken to a child protection conference. While the category of ‘registration’ was neglect the main cause for concern was Child B’s safety and there was no other reference to the issue of neglect. The minutes of the conference state “when not under the influence of alcohol there were no concerns regarding mother’s basic care, however under the influence of alcohol significant concerns have arisen regarding her capacity to provide safe care to the children”. There is no reference to the impact of Adult S’s chaotic alcohol misuse on the children’s emotional wellbeing and no recommendation in the plan to address these issues. SCR Report-Child B – Final Page 28 How do we know it is an underlying issue and not something unique to this case? The representatives from the Health Services on the Case Group thought that this finding was a fair reflection of the current situation in Staffordshire. The CSC members believed that such practice was evident from time to time, but tended to reflect the practice of individual workers, rather than indicate a pattern of practice. It was noted that this practice is less likely when cases are managed within the Public Law Outline (PLO) process, though these by definition are the most serious cases. How prevalent and widespread is this issue? Information from the CSC Children in Need Census 2014-2015 indicate that 2,445 child social work assessments were completed within the period under review, out of which 350 were identified as evidencing the toxic trio (domestic violence, mental health issues, substance misuse). There is no data on how many child protection plans there are for neglect due to alcohol misuse nor how many plans have strategies to address children’s therapeutic needs caused by living with alcohol. What are the implications for the reliability of the multi-agency child protection system? Child neglect is a complex and multi-faceted issue. If practitioners focus their attention solely on the ability of parents to meet their children’s basic care needs and keep them safe, then they risk failing to recognise and address the less obvious consequences for children living with neglect, particularly if it is associated with substance misuse. Hidden Harm* refers to the multiple and cumulative adverse consequences for children living with adult substance misuse which can lead to a wide range of emotional, cognitive, behaviour and other psychological problems. It also emphasises the importance of listening to the voices of children and to help them deal with ‘the hurt, rejection, shame, sadness and anger they feel over their parents’ drug problems’. The message from this is that it is not sufficient to ‘rescue’ children from neglect caused by adult substance misuse, but that it is necessary also to provide therapeutic support to help them overcome their abusive experiences. Without the routine consideration of the need to provide such support, the system could be accused of failing to fully address the needs of children neglected through adult substance misuse. *See: Hidden Harm – responding to the needs of problem drug users (ACMD, 2003) SCR Report-Child B – Final Page 29 Finding 2 The presentation of apparently episodic neglect caused by alcohol misuse makes it more likely that professionals will underestimate its adverse effects on children’s safety and welfare and compromise their ability to take appropriate protective action. (Response to Incidents) When substance misuse is the root cause of children suffering neglect, it is important that practitioners see beyond the quality of their physical care and consider the emotional and psychological damage their neglectful experiences cause. The messages from Hidden Harm are clear and need to be embedded into practice across all partner agencies. The indications from this review suggest that this may not yet have happened. When this Finding is considered in the light of a recommendation from the NSI0 SCR in 2010 which stated: “That the revision of the ‘Hidden Harm’ guidance becomes a strategic priority for the LSCB and encompasses not only awareness raising and training among professions but considers the commissioning of educational material to inform the general public.” It would appear that there is further work to be done on this issue. Questions for the Board Is the Board aware of the extent of substance misuse based abuse and neglect across the County`? Does the Board understand the barriers to the messages from ‘Hidden Harm’ being embedded in multi-agency practice? Are there any additional measures that would help to achieve this objective? Does the Board have a means to inform itself that the voices of children who experience substance misuse based abuse and neglect are heard and responded to appropriately? Is the system adequately equipped to meet the therapeutic needs of children neglected through substance misuse? How will the Board be assured that its remedial actions have been successful and progress maintained? SCR Report-Child B – Final Page 30 Finding 3 Is there a pattern of practice in the area the child lived whereby people don’t think to make contact with colleagues from other agencies to share or seek information that may have safeguarding implications which leaves some professionals unaware of concerns about children which impacts adversely on their ability to safeguard and promote their welfare? (Longer Term Work) The first edition of Working Together published in 1991 to support the implementation of the 1989 Children Act emphasised the importance of inter-agency communication for an effective safeguarding system. This message has been repeated in every subsequent version of Working Together. In this case, despite the fact that there was multi-agency contact with Adult S and her children throughout the period under review, and apart from the referrals from the Police to CSC, there was virtually no inter-agency communication prior to the children becoming the subjects of child protection plans in May 2014. How did this issue manifest itself in this case? When the case was allocated for a S.17 child social work assessment on 28th February 2014, no lateral checks were completed and partner agencies were not informed of the concerns about the children. This pattern was repeated following the incidents of 2nd, 20th and 30th April 2014. Adult S was visited by the Health Visitor on 9th April 2014 when she was informed of the events of 2nd and 3rd April 2014. At this visit the Health Visitor completed an EPNDS which scored 25/30* (an increase from 28th January 2014 when it was 23/30). Following the visit the Health Visitor did not contact the Social Worker to discuss the incident or to report Adult S’s EPNDS score nor did she share this information with Adult S’s GP. Adult S was seen on a number of occasions by her GP during the period under review and she was prescribed anti-depressant medication. The GP also attempted to refer Adult S to the Peri-natal Psychiatry Service. The GP did not inform the Health Visitor of these actions. When the GP became aware of Adult S’s overdose on 3rd April 2014 he did not contact the Social Worker or Health Visitor. Adult S received support from Pathway throughout the period under review. This was known to both the Social Worker and the Health Visitor, but there is no record of any communication between the agencies to share information. *a score of 12/30 suggests the need for intervention.SCR Report-Child B – Final Page 31 How do we know it is an underlying issue and not something unique to this case? The response of Case Group members to this question was mixed. There was a view that inter-agency communication can be an issue and this can be due to capacity or the strength of the relationships between professionals from different agencies. Case Group members also felt that information sharing is often driven by CSC and there is frequently a mismatch between what information CSC want about a child and what they are prepared to share in relation to the concerns that have been expressed to trigger their enquiry. There was some support for the view that the practice in this case was representative of practice generally and a belief that this issue is not confined to practice in the area the child lived in. This statement is at odds with the findings of the Ofsted inspection which found that ‘information sharing between agencies is effective’. How prevalent and widespread is this issue? The effectiveness of inter-agency communication is a difficult thing to measure or assess. There is evidence that problems with information sharing are a national issue as reflected in a fairly recent Ofsted report on SCR’s* The report makes a number of comments about information sharing, including: Agencies were found to have important information about the family circumstances but this was not shared early enough. Most of the SCR’s identified sources of information that could have contributed to a better understanding of the children and their families. What are the implications for the reliability of the multi-agency child protection system? Effective information sharing is an essential element of a safe and fair child protection system. With such arrangements in place, alerts about children at risk of significant harm are made in a timely fashion; the quality of assessment of risk and unmet need is improved; proportionate risk mitigation plans can be developed; the effectiveness of intervention strategies can be assessed and the ability to judge whether desired outcomes have been achieved (as a precursor to step-down or closure) is enhanced. Without effective inter-agency communication all of the above are compromised with the potential to render the child protection system unsafe. *See: Learning Lessons from Serious Case Reviews 2009-2010, Ofsted evaluation of SCR’s from 1st April 2009 – 31st March 2010 SCR Report-Child B – Final Page 32 Finding 3 Is there a pattern of practice in the area the child lived in, whereby people don’t think to make contact with colleagues from other agencies to share or seek information that may have safeguarding implications, which leaves some professionals unaware of concerns about children which impacts adversely on their ability to safeguard and promote their welfare? (Longer Term Work) Concerns about effective inter-agency communication pre-date the Ofsted report of 2010 and have been a feature of a number of high-profile reviews and reports since that time. The need for effective inter-agency communication is well established and it is a state to which all LSCB’s aspire, yet it is a state which very few seem able to achieve. The evidence to suggest that this is an ongoing concern in Staffordshire is not unequivocal, though the outcome of this review indicates that this issue is not wholly resolved. Questions for the Board Is this an issue which the Board would wish to explore further? Are expectations about inter-agency communication and information sharing sufficiently clear? Do the Board and member agencies have a means of gauging what the blockages to routine inter-agency communication might be or identifying when new ones emerge? Does the Board need to offer additional guidance to support inter-agency communication and information sharing? How will the Board assure itself that inter-agency communication and information sharing is ‘fit for purpose’ and supports a safe child protection system? SCR Report-Child B – Final Page 33 Finding 4 When decisions about safeguarding issues are being made, there is a tendency for some partner agencies to defer to CSC (who they believe ‘know best’) or assume that CSC involvement automatically means that safeguarding issues are being properly addressed. (Response to Incidents) Working Together states that “Safeguarding is everyone’s responsibility: for services to be effective each professional organisation should play their full part”. This review has suggested that the lead role of the Local Authority, as defined in statutory guidance, to co-ordinate the protection of children has been interpreted to mean that, in practice, the Local Authority owns the responsibility to protect children from harm, rather than this being a shared responsibility. How did this issue manifest itself in this case? There were at least three examples of practice in this case to illustrate this finding: Following the incidents on 20th and 30th April 2014 the Police Officers in attendance were aware of the arrangements to secure the children’s safety following the incident on 2nd April 2014. They were minded to use S.46 powers on both occasions but did not do so on the basis that CSC wanted to place the children in the extended family secured with written agreements. When asked in conversation about these actions, one of the Police Officers said he had some reservations about the proposed plan but “it’s their (CSC) decision”. The Health Visitor was informed of the incident of 2nd April 2014 by Adult S in a home visit on 9th April 2014. The Health Visitor clearly recognised the safeguarding issues inherent in the incident, but did not contact CSC, as she assumed that appropriate protective action had been taken. In the course of the mental health assessment on 2nd May 2014 (when Adult S was accompanied by Social Worker), the CPN was aware of the concerns about the children but did not speak to the Social Worker about these issues, as she assumed that the matter was in hand. SCR Report-Child B – Final Page 34 How do we know it is an underlying issue and not something unique to this case? The Case Group members from partner agencies felt that though this practice was evident in this case, it was not representative of practice generally and made reference to escalation procedures if they are unhappy with CSC actions. They raised the interesting point about the tensions that exist between the need to challenge the decision making of professionals in all parts of the safeguarding system with the need to respect their professional knowledge and expertise. The view of the CSC members of the Case Group was that, in reality, there was very little challenge in respect of day-to-day activity and the attitude of partners is often ‘I have told you about it, now it is over to you’. It was reported that very few formal escalation requests are received. How prevalent and widespread is this issue? This is a difficult question to answer locally, given that the finding relates to the attitudes and beliefs of practitioners about their relative roles and responsibilities and the ‘culture’ of shared responsibility. However, there is evidence from a number of Serious Case Reviews that this is a regular occurrence in inter-agency working and is a national issue. “Findings from the ‘Analysis of Serious Case Reviews’ demonstrate that the problem of joint responsibility has not yet been fully resolved. For example, the ‘silo’ working mentality continues to be a repeated feature of cases which go seriously wrong. Achieving cultural change and getting agencies to work together is extremely challenging and requires cross-sector commitment”.* What are the implications for the reliability of the multi-agency child protection system? Statutory guidance and relevant procedures outline the responsibilities of partners in the safeguarding of children. Responsibilities are overarching and apply to all safeguarding partners. *See: The Munro Review of Child Protection, Final Report: A Child Centred System Munro (2011) SCR Report-Child B – Final Page 35 Ensuring the correct balance between the leadership role of the Local Authority, compared to the shared responsibility by partners, is a challenge for every LSCB. The evidence from this review suggests that despite the existence of multi-agency processes and procedures, there is a belief amongst partner agencies that the final responsibility for safeguarding lies with Children’s Social Care. This can lead to a lack of ownership by other agencies, evident in a lack of multi-agency challenge of social care decisions and a lack of contribution of professional opinion in assessment, analysis and decision-making. Shared ownership and responsibility between agencies and professionals that have different roles and expertise, and at different stages of intervention (including universal, targeted and specialist services) is required if children are to be protected from harm and their welfare promoted. To invest in one service alone the sole responsibility for owning how children are safeguarded is unsafe. SCR Report-Child B – Final Page 36 Finding 4 When decisions about safeguarding issues are being made, there is a tendency for some partner agencies to defer to CSC (who they believe ‘know best’) or assume that CSC involvement automatically means that safeguarding issues are being properly addressed. (Response to Incidents) This finding is essentially about the “ownership” of the safeguarding system. ‘Safeguarding is everyone’s responsibility’ is a meaningless statement unless it is evidenced by collective ownership of how children are safeguarded, both at practitioner and strategic levels. The challenge of safeguarding children is multi-faceted. It presents challenges to individual practitioners, multi-agency teams and strategic managers and LSCB’s. In this landscape a safe system depends upon partnerships characterised by shared ownership, professional challenge and debate across and within safeguarding partnerships. For this state to be achieved there needs to be clarity of expectation at the strategic level to ensure the correct balance is struck between the leadership role of the Local Authority, compared with the shared responsibility of partners in safeguarding work. This finding raises questions about the extent to which this situation exists locally. Questions for the Board How effective is the SSCB in modelling shared ownership of the safeguarding system? How can the SSCB promote dialogue and debate about what shared responsibility for safeguarding, led by the Local Authority, looks like in practice to ensure ownership is shared as fully as possible? What steps can be taken to promote a culture in which challenge and debate across partner agencies at practitioner and managerial levels become the norm? How can the Board evaluate how shared responsibility to safeguard children is put into practice? SCR Report-Child B – Final Page 37 Finding 5 There is a pattern of practice in Staffordshire where professionals routinely fail to engage with or challenge men in the safeguarding process, leading to untested assumptions about their role in promoting the safety and welfare of their children. (Family/Professionals Interactions) There is a considerable body of evidence which refers to the need to engage with men in the safeguarding process both to assess their potential to introduce risk into the child’s life, but also their ability to promote the child’s safety and welfare. The danger of failing to engage with men and making assumptions about their role in children’s lives is well documented*. Despite the fact that Adult T and Adult U played a significant role in the case, particularly in the management of the periodic crises created by Adult S’s chaotic drinking behaviour, they were never involved in any assessments and were never questioned about Adult S’s behaviour and her relationship with her children. How did this issue manifest itself in this case? Adult T referred the concerns about Adult S to CSC EDS on 28th February 2014. He alleged that Adult S frequently put herself in this condition and he took Child L and Child M to live with him. He had care of the children for the next three weeks but apart from one telephone call about contact, he was not spoken to by the Social Worker and there is no indication that he was involved in the assessment that resulted in a recommendation that the case could be safely held at CiN level. Adult T raised concerns about the children again on 2nd April 2014 and again took Child L and Child M to his home. He was contacted two days later about signing a written agreement to retain the children in his care, but he wasn’t challenged about why he had returned them to Adult S (following the incident of 28th February 2014) without consulting with CSC (as agreed), nor was he asked about Adult S’s behaviour and her use of alcohol. Adult T breached the written agreement of 2nd April 2014 by returning Child L and Child M to Adult S’s care without informing CSC and he did this on two further occasions, following the written agreements of 20th and 28th April 2014. He was never challenged about what he did or questioned about why he continued to return the children to Adult S’s care (and put them in harms way) when he was clearly aware of her issues with alcohol misuse. *See The Child’s World: Assessing Children in Need Howarth (2001) SCR Report-Child B – Final Page 38 Adult U looked after Child B on the night of 2nd April 2014. He was not contacted after the incident and he was not involved in any planning in relation to Child B’s future safety. There is no record of any conversation between the Social Worker and Adult U, though he is referred to in the minutes of the strategy meeting on 25th April 2014 as a participant in the domestic abuse in his relationship with Adult S and is described as controlling and argumentative. Arguments with Adult U are identified as a trigger for Adult S’s drinking, but there is no record that these issues were ever addressed with Adult U. How do we know it is an underlying issue and not something unique to this case? It was the almost unanimous view of the Case Group and Review Team members that the failure to engage with and challenge the men in this case was representative of practice generally. The groups identified three principal reasons for this practice: The personal challenges (and possible concerns about safety) of speaking to men about their risky behaviour. Where there are a number of children in a family with different fathers (as in this case) professionals are more likely not to engage with any of them. Problems that derive from working with families where there is regular movement of partners, often on a short timescale. How prevalent and widespread is this issue? It was the view of the Case Group and Review Team that this is a County-wide issue. Evidence from the now defunct DCSF* from as far back as 2007 would suggest that this is a longstanding, national issue. There is no data available to indicate at what level men are engaged or involved in the child protection system in Staffordshire. The potential for involvement is however enormous, given that currently there are 640 children subject to child protection plans and 5356 children subject to CiN plans (as at July 2015). *See: Understanding SCR’s and their impact: A biennial analysis of SCR’s 2005-2007 (DCFS, 2009) SCR Report-Child B – Final Page 39 What are the implications for the reliability of the multi-agency child protection system? It is axiomatic that all children have fathers and there is a body of evidence* which argues that the quality of fathering, as well as mothering, mediates the child’s psychological and emotional outcomes. It is also the case that men are often the source of risk of harm in families. They are therefore significant figures in family life and the failure of professionals to engage with men leaves them uninformed about the nature of the relationship they have with their children and whether they are a source of safety or danger. A safe system requires practitioners to have a full and proper understanding of the roles that all significant adults play in safeguarding and promoting a child’s welfare. If men are routinely not included in the safeguarding process, it is possible that practitioners will come to erroneous conclusions about the role that they play in the lives of their children and make false assumptions about their ability or otherwise to keep them safe. *See: Fathers and Family Support Services: London Family Parenting Institute (O’Brien, 2004) SCR Report-Child B – Final Page 40 Finding 5 There is a pattern of practice in Staffordshire where professionals routinely fail to engage with or challenge men in the safeguarding process, leading to untested assumptions about their role in promoting the safety and welfare of their children. (Family/Professionals Interactions) The importance of engaging with men in the child protection process is self-evident. It is clear from this review and from national data that practitioners find this difficult and do not routinely seek to make contact with men to enable them to become actively involved in the process of safeguarding their own children (or the children with whom they have contact). There clearly are barriers for professionals in achieving the desired outcome of greater involvement on the part of men that need to be acknowledged and addressed before any meaningful progress can be made on this issue. Questions for the Board How well does the Board understand the barriers to involving men in the child protection process? What are the expectations of the Board in relation to professional engagement with men in the child care system? Are there any criteria or standards against which to assess the engagement of men and are there means available to evaluate the impact (positive or negative) of such involvement? What additional help can the Board offer to overcome the obstacles to improved practice? What data would be helpful to the Board to understand the engagement of partner agencies with men in the child protection/childcare process? SCR Report-Child B – Final Page 41 Finding 6 Is there a pattern of practice in the area the child lived in, whereby some professionals are inclined to accept what parents tell them about their behaviour (without challenging them with available information that contradicts what they say), which leads to errors in assessment of risk to which children are exposed and compromises their ability to take protective action? (Family/Professionals Interactions) For professionals to work effectively with adults to safeguard and promote the welfare of their children it is necessary to form meaningful relationships with them. However, professionals need to understand properly the dynamics of these relationships and be aware of the tendency of adults who are the subject of assessment to deny, minimise or distort the extent of their risky behaviour so as to reduce the level of professional concern about their children. Adult S was the subject of a number of assessments by practitioners from different agencies during the period under review. The records indicate that she was never truthful about her use of alcohol and that at no point was she ever challenged over her denials and minimisations in her accounts of her drinking behaviour. How did this issue manifest itself in this case? When the case was allocated for a S.17 child social work assessment on 28th February 2014, it was known that allegations that Adult S “drank all the time” had been made in the referral on 3rd September 2013. The referral information on 28th February 2014 (provided by Adult T) reported that it had become a regular occurrence for Adult S to ‘pass out’ through drink. In the course of the assessment Adult S admitted that she had been drinking prior to the incident but she denied that she had a problem with alcohol and that she used it merely to ‘help her cope with difficult personal relationships’. She was not challenged about the discrepancy between her account and the reported concerns. Over the next seven weeks there were three incidents when Adult S was so intoxicated the children had to be removed from her care. In the course of those incidents Child L and Child M repeatedly said that Adult S drank all the time and frequently passed out but there is no record that the issue of Adult S’s chaotic alcohol misuse was ever revisited. SCR Report-Child B – Final Page 42 Adult S was the subject of a mental health assessment in May 2014, in the course of which she reported that CSC were involved and her children had been moved because she had been found ‘passed out’ while caring for her children. She said that “she hardly ever drinks” and that she did so on 3rd April 2014 in order to get some sleep. Adult S was not challenged about the discrepancy between these two statements. Also, it was known that when Adult S presented at hospital, she had drunk at least half a bottle of vodka and taken between 14 and 20 Diazepam and had said that ‘she wasn’t meant to wake up’. In the course of the assessment she said that she had not intended to kill herself, merely that she wanted some rest. This statement was not challenged, despite the fact that it was at odds with the referral information from the RAID assessment. In the course of the assessment the Social Worker was present and she did not challenge Adult S’s claim that she hardly ever drank nor did the assessing Mental Health Worker question why her children had been ‘removed’ if she did not have a problem with alcohol misuse. How do we know it is an underlying issue and not something unique to this case? Opinion was divided on this issue among members of the Case Group. While all agreed that there was evidence of such practice in this case some felt strongly that this did not represent practice generally, others believed that the finding was largely true and could be relevant on a County-wide basis. Members from the third sector pointed out the problems of being too robust in challenging ‘voluntary’ service users, as to do so can lead to them withdrawing from the service. This issue has been flagged previously in Staffordshire and was captured in a recommendation from the Child A SCR in 2009 which stated: “The LSCB and partner agencies should ensure that training and staff development activities have specific reference to and a focus on helping practitioners develop the skills and confidence they will need to maintain professional curiosity and respectful uncertainty when working with children and families”. How prevalent and widespread is this issue? This is another issue on which it is difficult to collect hard data. Anecdotal evidence from some members of the Case Group would suggest that the practice is quite prevalent and likely to be evident on a County-wide basis. The Ofsted report on Serious Case Reviews referred to earlier would tend to support the view that the practice is a national issue and quite prevalent when it states: “Reviews found that there had been insufficient challenge by those involved. The statements of parents or others in the family should not have been accepted at face value”. SCR Report-Child B – Final Page 43 What are the implications for the reliability of the multi-agency child protection system? When undertaking assessments in relation to safeguarding matters, it is generally in the interest of the adult being assessed (but not the child’s) that the person undertaking the assessment does not know the full extent of the issues and behaviours under assessment. In order to manage the professionals’ access to this information, the person being assessed may misdirect, minimise, deny and lie about their behaviours and circumstances. In order to counter these strategies and offer appropriate challenge it is necessary for practitioners to approach assessments with a degree of healthy scepticism and to adopt the position of ‘respectful uncertainty’ recommended by Lord Laming in 2003*. It is important that those responsible for managing the safeguarding system at a strategic level do not underestimate the difficulties and personal challenges that are inherent in this expectation, particularly for practitioners who may be newly qualified and relatively inexperienced. Arrangements need to be in place to help practitioners develop the necessary skills to do this difficult work and to ensure that they receive the support they need while doing so. The failure to address this issue would make it more likely that professionals undertaking assessments will base their outcomes on partial or inaccurate information, making it more likely that they will reach false negative conclusions about children’s safety, with the consequence that children may be left at risk of avoidable harm. *See: Victoria Climbie Inquiry: Report of an Inquiry by Lord Laming (HMSO, 2003) SCR Report-Child B – Final Page 44 Finding 6 Is there a pattern of practice in the area the child lived in whereby some professionals are inclined to accept what parents tell them about their behaviour (without challenging them with available information that contradicts what they say) which leads to errors in assessment of risk to which children are exposed and compromises their ability to take protective action? (Family/Professionals Interactions) Fair, proportionate and effective safeguarding strategies can only be developed on the basis of accurate and comprehensive assessments of risk and unmet need. These can only derive from the professionals involved obtaining a true picture of the protective factors present in a family along with the risks to which a child may be exposed. The obstacles to achieving such outcomes are manifest. A safe child protection system is one in which partner agencies have in place the necessary arrangements to ensure that practitioners develop the appropriate mindset for undertaking safeguarding work and receive the training and support they require to offer robust challenge to adults whose behaviour may pose a risk to children. Questions for the Board Is the Board aware of this as an issue facing practitioners? Is there an adequate understanding at strategic level about the nature and role of relationships in safeguarding work? Does the Board know what progress has been made with the recommendation about this issue from the Child A SCR? How does the Board assure itself that learning from SCR’s is consolidated and retained? What are the Board’s expectations of partner agencies in addressing this issue? How might the Board help practitioners overcome this obstacle to effective practice? How will the Board assess the effectiveness of any remedial action on this issue? SCR Report-Child B – Final Page 45 Finding 7 Is there a pattern of practice whereby neither multi-agency forums nor supervision in any agency are effective in challenging and disrupting a fixed view of a case (once established) as a means of checking its accuracy? (Cognitive Biases) There is a tendency for professionals, once they have come to a view about a situation or service user, to retain that view despite emerging evidence that it may be misguided or in need of revision. Almost without exception, the professionals that were involved with Adult S had a positive view about her and regarded her as a ‘good mother’. This view did not change, despite mounting evidence that her behaviour presented a significant risk of harm to her children. How did this issue manifest itself in this case? Adult S was the subject of a number of assessments throughout the period under review. The records of these assessments are surprisingly similar. They all note that Adult S is pleasant, engaging, insightful and help-seeking. She presented as motivated to change and willing to accept whatever help she was offered. She never disagreed or argued with any of the professionals with whom she came into contact and she invariably accepted their recommendations about what she should do to improve her circumstances. The record shows that while she made contact with Pathway, Mental Health Services and GP, she never in fact engaged with these services in any meaningful way. The view of the professionals with whom she was involved was that she a ‘good mother’ who had her children’s interests at heart, but who was troubled with personal difficulties as a result of her complex relationships with Adult V, Adult T and Adult U. When the concerns about Adult S’s drinking increased and it was necessary to move the children on three occasions, she attributed her behaviour to anxiety and low mood, brought on by her problems with Adult U. At these times she acknowledged the concerns of professionals and was co-operative in helping EDS make alternative arrangements for Child B. Despite these events, the professional’s attitude to Adult S and the belief that she was a struggling, but essentially ‘good mother’ did not change. Within the period under review Adult S and her children were discussed in supervision by both Health and CSC practitioners on more than one occasion. Despite the evidence that Adult S had repeatedly put her children in harms way, had threatened to ‘slit her children’s throats’ and denied the older children a holiday at the very last minute because she had fallen out with Adult U the perception of Adult S as a ‘good mother’ did not change. SCR Report-Child B – Final Page 46 When the case went to conference on 12th May 2014, Adult S accepted, without argument, all the concerns that were expressed. She spoke to the conference about the arrangements she had made to obtain help and was very positive about the fresh start that a move to live near Adult W would offer. The minutes of the conference refer twice to the fact that there are no concerns about Adult S’s parenting while not under the influence of alcohol and she is urged to address the root cause of her drinking. The question about whether it was safe for Child B to remain in Adult S’s care was not raised. How do we know it is an underlying issue and not something unique to this case? Case Group members accepted the finding in relation to this case but largely felt unable to comment more generally. The CSC members felt that the practice in this case was attributable to the circumstances that prevailed in the area the child lived in at the time, but were not representative of practice generally. How prevalent and widespread is this issue? There is no data available on how prevalent of widespread this practice is. However, it would appear that similar issues have emerged in the past in Staffordshire, reflected in a recommendation from the NSIO SCR, which stated: “That the Directorate for Children, Young People and Families undertakes further work with its frontline managers to ascertain what, if any, are the barriers to the supervision of practitioners being a reflective process that enables them to consider the implications of new information”. What are the implications for the reliability of the multi-agency child protection system? The practitioners in this case (who had formed a positive view about Adult S at an early stage of their involvement) failed to recognise that she was engaged in a process of seductive coercion in her relationships with them, evidenced by her apparent willingness to engage and feigned co-operation. In reality, Adult S did not properly engage with any of the services with which she had contact and did not change at all. In addition she repeatedly behaved in ways that put her children at ever increasing levels of risk. All of these things were known and the subject of discussion in both supervision sessions and the case conference with no apparent impact on professionals’ view of Adult S as a mother. SCR Report-Child B – Final Page 47 The quality of the safeguarding service for any child is directly related to the quality of the risk assessment of his or her family and circumstances. Two fundamental principles of risk assessment are: They are prone to error and bias They are dynamic (the level of risk changes as circumstances change) When these two principles are considered in the light of the natural tendency of professionals not to revise a view about a family once a judgement has been formed*, the potential for unsafe practice becomes evident. A safe child protection system needs to have in place arrangements (in the form of challenging, reflective supervision and robust child protection conference practice) to act as a check and balance against these normal practice errors. *See: Common Errors in Reasoning in Child Protection Work: Child Abuse and Neglect, Vol 23- Munro (1999) SCR Report-Child B – Final Page 48 Finding 7 Is there a pattern of practice whereby neither multi-agency forums nor supervision in any agency are effective in challenging and disrupting a fixed view of a case (once established) as a means of checking its accuracy? (Cognitive Biases) The task of completing risk assessments and carrying child protection cases is difficult. The task of providing oversight in the management of such cases, without direct contact with children and families, is probably more difficult. There is an innate cognitive tendency on the part of practitioners to retain a view about a family or situation once it has been formed despite the emergence of disconfirming information. In order for the child protection system to be safe it needs strategies and processes in place (in the form of reflective supervision and independent multi-agency challenge) to ward against this. A safe child protection system recognises this cognitive tendency as almost inevitable and has in place the means to routinely revisit initial formulations of risk to retest their validity. Questions for the Board Is the Board aware of progress made in relation to the recommendation in NSIO SCR? Is the Board assured that multi-agency supervision arrangements are sufficiently robust to respond to the challenge this finding presents? Are there any outstanding training needs for individuals charged with the responsibility of challenging risk formulations and intervention strategies? Would the Board wish to develop a multi-agency best practice forum to address this issue? How can the Board be assured that appropriate measures to address this issue are in place and working in partner agencies? SCR Report-Child B – Final Page 49 Finding 8 The way in which child protection conferences operate in the area the child lived in makes it more likely that they do not provide the necessary rigorous challenge to professionals’ assessment of parents’ capacity to safeguard their children’s welfare and do not produce sufficiently clear and risk focused child protection plans. (Management Systems) The purpose of the child protection conference is “to bring together and analyse relevant information and plan how best to safeguard and promote the welfare of children”*. Implicit in this statement is the need for the conference to exercise rigour in the analysis of risk and demonstrate clarity in the development of risk management strategies. How did this issue manifest itself in this case? There was only one case conference held on Child B, which resulted in her (and her siblings) becoming subjects of child protection plans on the grounds of neglect. The analysis of the information presented at conference lacked rigour, as evidenced by: the failure to challenge Adult S’s version of events that was clearly at odds with the seriousness of the events themselves; the failure to analyse in detail the risks posed by Adult S’s alcohol misuse; the failure to address the fact that the family had breached a number of safeguarding agreements; the failure to consider the increased risk to Child B caused by Child L and Child M living with Adult T; the failure to consider Child L and Child M’s therapeutic needs (having lived with Adult S’s alcohol misuse for probably their entire childhood) and the failure to consider the fundamental question about whether action was necessary to share parental responsibility to secure Child B’s future safety. The child protection plan contained 17 recommendations, some of which related to risk, some to unmet need, some to monitoring arrangements and a statement that ‘parents should work in an open and honest manner with CSC’. The only reference to Adult S’s alcohol misuse was ‘whilst caring for any of the children, Adult S is strongly advised to refrain from any use of alcohol’. *See: Working Together to Safeguard Children: DfE, 2015 SCR Report-Child B – Final Page 50 How do we know it is an underlying issue and not something unique to this case? There was broad agreement from the Case Group and Review Team that the quality of child protection plans is variable and that they would benefit from being SMARTER and more risk-focused. The representatives from CSC disputed the suggestion that conferences do not present rigorous challenge to professionals’ assessments, while Health representatives believed that the finding was a fair reflection of practice generally. While the evidence about whether this practice is a systemic weakness in Staffordshire is limited, the case conference is such an important part of the safeguarding process that the Board may, nonetheless, wish to explore this issue further. How prevalent and widespread is this issue? There are no arrangements in place currently to assess the quality of initial child protection plans in Staffordshire. The potential for this to be a significant issue for both initial and review conferences is evident from the sheer volume of child protection conference activity that takes place across the county annually (between 1st September 2014 and 22nd September 2015 there were 629 initial and 2171 review conferences across the County). What are the implications for the reliability of the multi-agency child protection system? At its heart, the initial child protection conference is the arena of risk management. It has two key tasks to perform: To understand, analyse and make explicit the risks that are present – including drilling down into the information presented and challenging the assessments, views and perceptions of professional participants. To develop proportionate outline risk management plans that clearly identify the sources of likely harm and what needs to happen to mitigate the identified risk. At the conclusion of the conference all present, professionals and parents/carers alike, should be in no doubt about what are the causes for concern, how serious these are, what needs to be done, by whom, to effect change and within what timescales. If the Case Conference process does not routinely yield these outcomes, then it cannot be regarded as ‘fit for purpose’. SCR Report-Child B – Final Page 51 Finding 8 The way in which child protection conferences operate in the area the child lived in, makes it more likely that they do not provide the necessary rigorous challenge to professionals’ assessment of parents’ capacity to safeguard their children’s welfare and do not produce sufficiently clear and risk focused child protection plans? (Management Systems) An effective child protection conference process is the cornerstone of a safe child protection system. The need for fearless and rigorous analysis of risk and the ability to develop clear, concise, risk-focused child protection plans are key elements of the process. A safe system is characterised by an adequately resourced child protection conference service populated with a trained and competent body of conference chairs who themselves have access to challenging reflective supervision. Questions for the Board Is the child protection conference service adequately resourced across the County? Does the pool of Conference Chairs have any outstanding training or support needs? Does the Board have a view about a preferred model for producing ‘outline’ child protection plans? Are there any arrangements in place to ensure ‘consistency of product’ in terms of outline plans from initial child protection conferences? What options are available to assess analytical rigour in the conference process? How will the Board assure itself that the child protection conference process remains ‘fit for purpose’? SCR Report-Child B – Final Page 52 Appendix A: Glossary ACRONYM MEANING CBT Cognitive Behaviour Therapy CiN Child in Need CP Child Protection CSC Children’s Social Care Services EDS Emergency Duty Service FSW Family Support Worker GP General Practitioner HV Health Visitor ICPC Initial Child Protection Conference KPE Key Practice Episode LSCB Local Safeguarding Children Board NFA No Further Action PLO Public Law Outline RAID Rapid Assessment Interface & Discharge SCIE Social Care Institute for Excellence SSCB Staffordshire Safeguarding Children Board SW Social Worker REFERENCE MEANING Child Anyone who has not yet reached their 18th birthday. Safeguarding and promoting the welfare of children Defined in Working Together to Safeguard Children (DfE) 2015 as: • protecting children from maltreatment; • preventing impairment of children's health or development; • ensuring that children are growing up in circumstances consistent with the provision of safe and effective care; and • taking action to enable all children to have the best life chances. Child protection Part of safeguarding and promoting welfare. This refers to the activity that is undertaken to protect specific children who are suffering, or are likely to suffer, significant harm. Abuse A form of maltreatment of a child. Somebody may abuse or neglect a child by inflicting harm, or by failing to act to prevent harm. Neglect The persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development. Lateral checks ‘Lateral checks’ means information gathering between agencies. This involves the local authority contacting key partner agencies such as the Police and health services (this could also include adult services and any known voluntary and community agencies working with the child and their family) to both share information and request information for the purposes of promoting the welfare and safety of children. SCR Report-Child B – Final Page 53 Child Protection Conference An Initial Child Protection Conference (ICPC) must be convened when concerns of significant harm are substantiated and the child is judged to be suffering, or likely to suffer, significant harm. The conference must consider all the children in the household, even if concerns are only being expressed about one child. There are two types of conferences; the first one to take place after a section 47 enquiry is called an ‘Initial Child Protection Conference’; subsequent conferences are called ‘Review Child Protection Conferences’ (RCPC). Child Protection Plan If a decision is made at an initial or review child protection conference for a child to be made the subject of a child protection plan, the local authority might draw up a plan to protect the child. This is called a child protection plan. It names the members of the Core Group, sets out what the risks are, what needs to be done to reduce the risks and needs of the child (these must be specific and measurable); identifies who is responsible for what actions or changes; sets out what will happen if the plan is not kept to; and provides a date to review the progress being made. Core Group If the conference decides that a child should be made the subject of a child protection plan, a group of professionals will be identified to work with the child and their family. The first meeting has to be held within ten days of the child protection conference. The child (where appropriate), their family and professionals will meet on a regular basis to discuss the child protection plan- this meeting is called a ‘Core Group Meeting’. The Core Group will always include the child (where appropriate), the parent(s) / carers, the social worker for the child (who is the keyworker); and other identified professionals involved in working with the child and their family. The Core Group has to meet on a regular basis and at a minimum of once a month. Its aim is to support working together arrangements to help to reduce the risks identified for the child in the child protection plan. Section 17 of the Children Act 1989 Section 17(1) states that it shall be the general duty of every local authority: (a) to safeguard and promote the welfare of children within their area who are in need; and (b) so far as is consistent with that duty, to promote the upbringing of such children by their families. by providing a range and level of services appropriate to those children’s needs. Section 17(10) states that a child shall be taken to be in need if: (a) the child is unlikely to achieve or maintain, or to have the opportunity of achieving or maintaining, a reasonable standard of health or development without the provision of services by a local authority under Part III of the Children Act 1989; SCR Report-Child B – Final Page 54 (b) the child’s health or development is likely to be significantly impaired, or further impaired, without the provision of such services; or (c) the child is disabled. Section 47 of the Children Act 1989 Section 47(1) states that: Where a local authority: (a) are informed that a child who lives, or is found, in their area (i) is the subject of an emergency protection order, or (ii) is in police protection; or (b) have reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm: the authority must make, or cause to be made, such enquires as they consider necessary to enable them to decide whether they should take any action to safeguard or promote the child’s welfare. Section 46 of the Children Act 1989 Under section 46 of the Children Act 1989, where a police officer has reasonable cause to believe that a child would otherwise be likely to suffer significant harm, the officer may: • remove the child to suitable accommodation and keep him there; or • take reasonable steps to ensure that the child’s removal from any hospital or other place in which the child is then being accommodated is prevented. No child may be kept in police protection for more than 72 hours. |
NC043822 | Serious injury of a 32-day-old baby boy. Antonio was taken into the care of the local authority; his father was found guilty of causing grievous bodily harm (with intent) and jailed. The case did not meet the criteria for a serious case review (SCR) however Kent safeguarding children board decided to conduct a review, largely following the SCR process. Family were known only to universal services and the review did not find any significant weaknesses in the services provided before or after the incident. At the time of the incident, detailed information about the case was published in the national and local press, which led to a public disturbance at the family home and the home of maternal grandparents. Identifies key learning points and missed opportunities, including: a lack of coordination in the arrangements for setting up the review process; leak of confidential information regarding the case, which led to significant public disorder.
| Title: 'Antonio': a case review LSCB: Kent Safeguarding Children Board Author: Kevin Harrington Date of publication: 2012 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 1 of 19 Kevin Harrington Associates Limited “ANTONIO” A CASE REVIEW Kevin Harrington JP, BA, MSc, CQSW On behalf of the Kent Safeguarding Children Board Completed in October 2012 This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 2 of 19 TABLE OF CONTENTS TABLE OF CONTENTS ............................................................................... 2 1. INTRODUCTION ...................................................................................... 3 2. CASE REVIEW PROCESS ...................................................................... 3 3. BACKGROUND INFORMATION ............................................................. 5 4. NARRATIVE CHRONOLOGY ................................................................. 5 5. THE AGENCIES ...................................................................................... 8 5.1 Darent Valley Hospital ............................................................................. 8 5.2 Kent Community Health NHS Trust ........................................................ 8 5.3 Kent Police ............................................................................................... 9 5.4 Kent County Council Children’s Services ........................................... 10 5.5 Kings College Hospital .......................................................................... 11 5.6 General Practitioners ............................................................................. 11 6. SPECIFIC ISSUES IDENTIFIED IN THE TERMS OF REFERENCE FOR THIS REVIEW ............................................................................................ 11 6.1 Introduction ............................................................................................ 11 6.2 What was your agency’s involvement with Antonio and his family from January 2011 until this review was initiated? ................................... 11 6.3 Did your agency hold any significant history of any member of this family prior to this time? ............................................................................ 12 6.4 Evaluate the nature of support provided within the Maternity Unit including preparation and support arrangements in relation to discharge, and transition from midwifery to health visiting services. .... 12 6.5 How did your agency take into account parents’ previous history, family and social relationships when assessing their parental capacity prior to the incident? ................................................................................... 14 6.6 If predictive risk factors were known, were they acted on appropriately and shared across all agencies? ........................................ 14 6. 7 What lessons can be learned from this case in relation to the way local professionals and agencies worked together to safeguard and promote the welfare of the child? ............................................................... 15 6. 8 What was the quality of work undertaken by each agency and how did it contribute to the wider multi agency response? ............................. 15 6.9 Is there evidence of good practice illustrated by this case? ............. 16 7. CONCLUSIONS: KEY LEARNING POINTS AND MISSED OPPORTUNITIES ...................................................................................... 17 8. RECOMMENDATIONS .......................................................................... 18 8.1 Introduction ............................................................................................ 18 8.2 Recommendations to Kent Safeguarding Children Board ................. 18 APPENDIX A: Biographical details of report author ............................. 19 This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 3 of 19 1. INTRODUCTION 1.1 Antonio was 32 days old when he was brought to Darent Valley Hospital (DVH) by his parents, Mr and Mrs B. He had very serious injuries which were believed to have been inflicted. He was taken into the care of the local authority. His father faces criminal charges in relation to his injuries. 1.2 These incidents were considered by the Kent Safeguarding Children Board (KSCB) to determine whether a Serious Case Review (SCR) should be carried out. Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 requires Safeguarding Boards to undertake reviews of serious cases. The Regulation defines a serious case as one where (a) abuse or neglect of a child is known or suspected; and (b) either – (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 1.3 It was decided that the criteria for conducting a SCR were not met. This decision was based on the fact that there had been very little contact between the family and any police, health or social care agencies. There was no history suggesting any child protection issues in relation to this family. There were no social concerns and they were not known for any reason to police or social workers. Their contact with NHS agencies during Mrs B’s pregnancy had not raised any concerns. There was therefore no indication of cause for concern about the ways in which agencies had worked, separately or together, to safeguard Antonio. It was decided that there was insufficient evidence to indicate that it was appropriate to carry out a Serious Case Review. 1.4 However the injuries to such a young child were very serious. It was decided that, while the statutory criteria for a SCR were not met, it would still be right to examine what agency involvement there had been. This is the Overview Report from that exercise. 1.5 There are some learning points arising from the review but it is right to emphasise that the injuries inflicted on Antonio could not have been predicted or, consequently, prevented by the agencies contributing to this Review. 2. CASE REVIEW PROCESS 2.1 The process for conducting SCRs was largely followed. Chronologies of agency involvement with the family were drawn up. That involvement was analysed by agencies in Individual Management Reviews (IMR). The information contained in those reports has been drawn together and further analysed in this report, which has been prepared by an independent person1 1 See Appendix A with experience of such reviews. This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 4 of 19 2.2 The organisations contributing to the Review were • Kent Community Health NHS Trust: this Trust provided the health visiting service to the family. • Kent Police: Kent Police investigated the injuries to Antonio • Kent County Council, Specialist Children’s Services (KCS): KCS investigated the injuries with police and made arrangements for the care of Antonio after he had been injured • Maidstone and Tunbridge Wells NHS Trust: this Trust had no direct involvement in this case but contributed to Review Panel discussions. • Dartford and Gravesham NHS Trust: this Trust, via Darent Valley Hospital (DVH), provided midwifery services to the mother, and care to the baby immediately after the incident. • Kent & Medway NHS and Social Care Partnership Trust: this Trust had no direct involvement in this case but contributed to Review Panel discussions. • NHS Kent and Medway: this agency provided an overview of health service provision to the family • Kings College Hospital: this agency provided specialist medical care to Antonio after his injuries 2.3 There was some confusion in the original arrangements for this Review. The report from Kent & Medway NHS Trust states that it includes a review of Primary Care records carried out by the Named GP2 , but contains no analysis of GP involvement against the Terms of Reference. The GPs were able to contribute as the review came to completion but should have been more fully involved. 2.4 The participating agencies were asked to draw up a detailed chronology of their contact with family members between April 2011, when Mrs B first made contact with ante-natal services, and 22/1/12, when this review was initiated. They were further asked to evaluate their involvement with the family generally and with specific reference to the following questions: 1. What was your agency’s involvement with Antonio and his family from January 2011 to the present day? 2. Did your agency hold any significant history of any member of this family prior to this time? 3. Evaluate the nature of support provided within the Maternity Unit including preparation and support arrangements in relation to discharge, and transition from midwifery to health visiting services. 4. How did your agency take into account the parents’ previous history, family and social relationships when assessing their parental capacity prior to the incident? 5. If predictive risk factors were known, were they acted on appropriately and shared across all agencies? 6. What lessons can be learned from this case in relation to the way local professionals and agencies worked together to safeguard and promote the welfare of the child? 2 Each locality has a “Named GP” to provide a General Practice lead role in child protection. This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 5 of 19 7. What was the quality of work undertaken by your agency and how did it contribute to the wider multi agency response? 8. Is there evidence of good practice illustrated by this case? 3. BACKGROUND INFORMATION 3.1 Mr & Mrs B, a white British couple in their thirties, married some five years ago and Antonio is their first child. Their housing, employment and general social circumstances seem to have been stable. Mr B has suffered from a chronic health condition which has required frequent contact with medical services. Mrs B has had a series of illnesses since her late teenage years. 4. NARRATIVE CHRONOLOGY 4.1 Mrs B commenced her ante-natal care in 2011, advising hospital staff that this was a planned pregnancy. She also told staff that she had previously suffered from a medical condition and that treatment for this had ceased some three years previously. This information was checked against GP records and highlighted as a possible risk factor in the pregnancy but it was decided by maternity services that referral to specialist medical services would not be necessary. 4.2 Mrs B was entirely compliant with ante-natal care which raised no matters of concern. Throughout her pregnancy and subsequently Mrs B also saw a student midwife as part of the midwife’s training. 4.3 The birth of Antonio was straightforward. He had a minor physical condition which made feeding difficult. This was identified at an early stage and specialist midwifery advice was given. The feeding problem was notified to community midwives when mother and child left hospital, on the second day after Antonio’s birth. 4.4 Midwives visited more frequently than usual to monitor the feeding problem. After a check at DVH, five days after Antonio was born, a referral was made to a specialist clinic at Kings College Hospital (KCH). After four home visits by midwives care was transferred appropriately to Health Visiting services. 4.5 Prior to her first booked visit the Health Visitor happened to meet Mr B in the course of her duties. She has subsequently reported that he seemed relaxed and happy about the birth of his first child. The Health Visitor called at the home two days later. Antonio was now two weeks old. Mrs B talked about the medical condition she had previously suffered from and also told the Health Visitor about some other difficulties she had experienced as a younger woman. Mrs B’s mother was present during the visit. The Health Visitor undressed Antonio as part of her routine checks, noted no cause for concern and planned her next visit in three months’ time. 4.6 There was no contact with any services during the next two weeks, until Mrs B contacted her GP, as she was concerned that Antonio had “chesty” This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 6 of 19 symptoms. A GP appointment was made and attended that same morning. The GP thought the baby might have a minor infection and prescribed saline drops. The GP noted no evidence of injury to the baby and had no concerns about the interaction between mother and baby. Antonio was peaceful and appeared relatively well throughout the consultation. 4.7 The following day the student midwife, who had been in touch with Mrs B during the pregnancy, called on the family to get an evaluation form signed and to terminate her involvement. This was not a pre-arranged visit. The student midwife held the baby and has subsequently reported that he appeared well and she had no concerns for him. 4.8 Two days later in the early morning Antonio was taken to DVH by his parents. He had multiple serious injuries. The parents had not called an ambulance. Mr B said that resuscitation had been attempted at home. The nature of the injuries immediately suggested to staff that they had been non-accidentally caused. Child protection procedures were implemented without delay. 4.9 A Consultant Paediatrician, CP1, called police to advise of his concerns that Antonio had been non-accidentally injured. Hospital staff telephoned KCC Children’s Services (KCS), leading to a discussion between KCS and police. It was decided that there would be a Strategy Meeting3 later that morning, when all key agencies could be represented. In view of the nature and extent of the injuries it was also decided that the child’s immediate safety be ensured by formally taking him into police protection4 . This was done at 10:55. Checks were made with the family GP and it was confirmed that the child had been seen three days previously. 4.10 The Strategy Meeting was held at 11:20 and was attended by senior officers from KCS, police and health services. KCS and police had no previous knowledge of the family. CP1 advised of the account he had been given by Mr B, who had said that he had found Antonio cold and blue when going to feed him at 04:20 that morning. Mr B had said that he had made attempts to resuscitate the baby although Mrs B said that she was unaware of any such attempts. Mr B said that he had immediately noticed bruising and Antonio’s swollen head but had not thought it necessary to call an ambulance. He then discussed the situation with Mrs B and they decided to bring the child to hospital. Both parents said that they had not seen any injuries the previous evening and both made suggestions as to how the injuries might have been accidentally caused. 3 An inter-agency meeting held under child protection procedures to share information and determine whether and how a formal investigation should be carried out. 4 Whenever a police officer has reasonable cause to believe that a child would be at risk of significant harm unless action is taken immediately s/he may: remove the child from the situation and take them to a place of safety take action to prevent the child's removal from a place of safety. When a police officer has taken such action the child is deemed to be in police protection. No legal order is necessary. The child may be in police protection for no longer than 72 hours. This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 7 of 19 4.11 CP1 gave the meeting an evaluation of each of the injuries and the extent to which they might have been accidentally caused. He said that he was highly suspicious of some non-accidental causation. It was agreed that KCS would apply for an order to protect Antonio on the expiry of the police protection arrangements (and this application was duly made and granted). In the late morning Antonio was transferred to KCH for specialist intensive care, accompanied by his mother and a police officer. 4.12 Later that day both parents were arrested on suspicion of having assaulted Antonio. They gave an account of their actions and both denied any criminal acts. They were given bail with various conditions including no contact with the child. It was subsequently agreed, after police enquiries, that both sets of grandparents could visit Antonio, under the supervision of hospital staff. 4.13 Two days later detailed information about these events was published in the local and national press, including information which enabled the family to be identified. This information had apparently reached the press from within one of the agencies involved with the family, either deliberately or through carelessness. All agencies investigated this but neither the agency nor the person(s) responsible have been identified. 4.14 This led to public disturbance at the family home, and at the home of the maternal grandparents. This required police attendance and subsequent arrangements for the parents and grandparents to be moved to undisclosed addresses. 4.15 A few days later a further Strategy Meeting was held, attended by all the agencies now involved in this matter. There were signs of improvement in Antonio’s medical condition. A detailed multi-agency plan was agreed, covering the further investigations and assessments necessary and the exploration of possible care arrangements for Antonio when he was ready for discharge from hospital. 4.16 Antonio subsequently came into the care of the local authority and the usual planning processes were put in place, considering all options for his future care. 4.17 Mr B was subsequently charged with one count of “Causing Grievous Bodily Harm (with intent)”. This is the most serious assault charge short of homicide offences. The matter came to trial and Mr B was found guilty and jailed. This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 8 of 19 5. THE AGENCIES 5.1 Darent Valley Hospital 5.1.1 The principal involvement of DVH for the purposes of this Review, was Antonio’s ante-natal care, birth and follow-up by maternity services. He was also brought to DVH after suffering his injuries. 5.1.2 Mrs B booked in for ante-natal care in a timely fashion. There were no indications of concern from her presentation. At this first contact she talked openly about the medical condition from which she had previously suffered. This was largely dealt with appropriately as discussed below. 5.1.3 Mrs B was fully compliant with ante-natal care, having seventeen contacts with maternity services during the course of her pregnancy. Recording of those contacts is generally positive. There are references to her “engaging well”, “feeling excited about the birth” and being “happy, well supported and prepared for the baby”. Towards the end of the pregnancy she was noted to be feeling “anxious and stressed” but this was not felt to be unusual or unexpected at this stage of the pregnancy. At birth Antonio was a good weight and no unusual concerns arose from the birth and immediate follow up. 5.1.4 As noted above Antonio had a minor condition which might affect feeding. This was identified without delay and specialist advice and support were provided by midwives. Mother and baby were able to be discharged home after two days. Care was transferred to community midwives who visited routinely four times in the next nine days, noting nothing unusual. One of the visits was by a midwife with specialist expertise in feeding, who discussed the baby’s medical condition and made a referral to KCH. 5.1.5 The report from DVH also deals with Antonio’s presentation there after being injured. This appears to have been dealt with appropriately and comprehensively. Concerns that his injuries had been inflicted were identified and acted on without delay. Antonio was then well cared for in DVH until his transfer to KCH for paediatric intensive care services. 5.2 Kent Community Health NHS Trust 5.2.1 This agency was responsible for providing a health visiting service to the family. Involvement was very limited. 5.2.2 When Mrs B was first pregnant and saw midwifery services, health visiting services were routinely notified. Health Visitors will sometimes make contact with a family before a child is born, depending upon the family’s level of need as assessed by the midwives. In this case it was judged that there was no need for pre-birth contact by Health Visitors. However, as mentioned below, the Health Visitors should have been advised that this issue had been discussed. This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 9 of 19 5.2.3 The Health Visitors became directly involved after Antonio was born. A Health Visitor made a routine visit to the family home by appointment when Antonio was two weeks old. The Health Visitor saw Antonio and his mother. His maternal grandmother was also present. A standard “Family Needs Assessment” and an “Infant Mental Health Assessment” were carried out. The IMR reports that Mrs B told the Health Visitor that “she had good support, had never experienced any form of abuse, and did not have contact with anyone who posed a risk to children”. 5.2.4 Mrs B did talk to the Health Visitor about the medical problems she had previously mentioned to the midwives. She said that these problems had occurred when she was in her late teens, had required treatment for 2-3 years and that she was now well. The Health Visitor, who was appropriately trained and experienced, judged that there was nothing in the presentation of Mrs B or the baby to cause any concern. The IMR notes that “The Family Needs Assessment together with the Mother and Infant Mental Health Assessment did not show any concern that would impact on the parent’s (sic) parenting capacity”. 5.2.5 The Health Visitor weighed and measured Antonio and confirmed that he was gaining weight adequately despite the minor medical issue which might have hampered his feeding. The Health Visitor arranged to see them again routinely in three months. 5.2.6 There were no immediate indications of concern either in Antonio’s presentation or in Mrs B’s conduct. It was encouraging that Mrs B talked openly about previous difficulties. There is no information about the extent to which Mrs B’s mother was involved in the discussions, if at all, but her presence at the home suggested a supportive relationship. It was not documented at the time but, when interviewed for this review, the Health Visitor recalled that Mrs B and Antonio had good interaction and Mrs B’s handling of the baby was good. Mr B was at work and therefore not seen. 5.3 Kent Police 5.3.1 Prior to the hospital admission which led to this review Kent Police had no involvement with Antonio or his parents. 5.3.2 When the injuries to Antonio were reported by DVH, police responded rapidly and appropriately. They attended the hospital, liaised with colleagues there and at KCS and took immediate action under their statutory powers to protect the child and prevent any attempt to remove him from hospital. Their management report notes that “This information sharing and decision making process was clearly designed to ensure Antonio’s safety and development was properly addressed. This mutual co-operation greatly assisted the investigative process”. 5.3.3 The management report goes on to judge that “The main area of learning centres around the way in which agencies respond to cases which have attracted the attention of the national media”. This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 10 of 19 This comment relates to the unauthorised disclosure of information, some of which was subsequently found to be inaccurate, to local and national press. Investigations were carried out by all agencies but the source of the disclosure could not be traced. Agencies largely worked together to manage this situation, which was of concern both in terms of public order and because it might have hampered the police investigation. Generally there were good lines of communication between police and KCH, although these became strained when police decided to disclose information about Antonio’s injuries and the arrangements for his discharge from hospital. Police report that this was a considered decision, made to end speculation and some inaccurate press reports. It served to “ease the growing public concern, and diffused a potential public order problem”. 5.3.4 However police have acknowledged that their dialogue with KCH on this decision could have been better. The information necessarily referred to investigations and treatment at KCH. It would therefore have been appropriate to ensure that KCH were consulted, both about the disclosure in principle and about what was being disclosed. By this time, because of the legal steps taken, KCS had shared parental responsibility for Antonio and should also have been consulted about the actions proposed by police. 5.3.5 The management report identifies one recommendation, arising from the issue of press coverage: “This case should be used to trigger discussions between agency media departments with a view to establishing protocols and good practice when dealing with high profile cases involving potential child abuse or neglect”. 5.3.6 This is appropriate and is reinforced by a recommendation from this Overview Report. 5.4 Kent County Council Children’s Services 5.4.1 KCS had no knowledge of Antonio or his parents prior to the events giving rise to this report. Their involvement with the family began when he was brought to DVH with injuries. They responded promptly that day, ensuring that checks were carried out with other agencies and attending a Strategy Meeting at DVH that morning. KCS continued to be closely and appropriately involved in planning with the other agencies. 5.4.2 While Antonio was in hospital KCS carried out a “Core Assessment5 ”. The IMR notes that this assessment lacked detail and appropriately suggests that it would have been sensible to wait until there had been a fuller engagement between KCS and the family before trying to complete this assessment. KCS have subsequently reported that a revised Core Assessment has been carried out to a satisfactory standard. 5 An in-depth assessment of a child’s needs and his family’s capacity for responding to those needs – a key part of the national Framework for the Assessment of Children in Need and their Families (Department of Health 2000) This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 11 of 19 5.5 Kings College Hospital 5.5.1 KCH was involved only after transfer from DVH (except that they had also received the referral in relation to Antonio’s minor feeding problem). The IMR submitted by KCH is extremely thorough, describing excellent clinical care, sensitive management of family contact issues and well-considered assistance in the police investigations. The report describes how learning from previous serious incidents, relating to use of guidance and thoroughness in documentation, was implemented in this case. The problems caused by the police decision to release information are acknowledged and the report demonstrates that KCH has confidence and expertise in cases where media management is an issue. The report also recognises how difficult it was for staff, including senior and experienced nurses, to deal with a child as young and as seriously harmed injured as Antonio was, and describes the arrangements which were put in place to support them. The IMR recognises some areas where practice might have been improved relating to parental consent for investigations, recording and inter-agency communications but, overall, KCH’s response to the challenges in this case was impressive. 5.6 General Practitioners 5.6.1 Initially the arrangements for this review did not adequately include the family’s general practitioners. Basic information was established from GP records but the GPs were not directly involved until they were provided with a draft copy of this report. They had no further comment to make but should have been involved from the outset. 6. SPECIFIC ISSUES IDENTIFIED IN THE TERMS OF REFERENCE FOR THIS REVIEW 6.1 Introduction 6.1.1 There was a lack of co-ordination in the arrangements for setting up this review. As described above, the GPs were not fully consulted. Some management reports were submitted before the Terms of Reference had been finalised. This probably would not have happened if this had been a statutory SCR. 6.1.2 The government has indicated that Safeguarding Boards should conduct a range of different reviews, including reviews of cases, such as this, which do not meet the statutory SCR criteria. The Board is currently considering various review models and a framework will be developed which includes learning from this case. There is a recommendation from this report to the Safeguarding Board highlighting the need for clearly agreed Terms of Reference to be put in place before any case review is initiated. 6.2 What was your agency’s involvement with Antonio and his family from January 2011 until this review was initiated? 6.2.1 This has been dealt with in the preceding sections of this report. This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 12 of 19 6.3 Did your agency hold any significant history of any member of this family prior to this time? 6.3.1 Police, KCH and KCS had no contact with this family prior to the events leading to this review. 6.3.2 Health services held no information relevant to this review about Antonio himself. There had been no unusual problems before or during his birth. The only health issue arising after birth was his minor feeding problem. Feeding difficulties in a small baby, with inexperienced parents, may be a cause for concern but there is no evidence to suggest that this was not managed and dealt with appropriately. Advice and support had been given in hospital and follow-up arrangements had been promptly put in place. 6.3.3 Health services had been involved with Mr B, to perhaps a greater extent than is generally the case, since his childhood. It does not appear however that he had had any recent contact with health services, nor that his previous involvement had any direct significance to the matters leading to this review. 6.3.4 In respect of Mrs B it was reported that there “seemed to be a distinct deterioration in her …health at the age of 19 following the death of her grandmothers and her uncle”. This led to continuing input from health services although prescribed medication was terminated by Mrs B after two months and she then “seemed to settle well over the next 2 years”. 6.3.5 At the age of 21 there was a recurrence of similar problems. Mrs B was prescribed medication which she again terminated after two months. She also declined any continuing contact with other services in relation to this problem. Some 9 years later, three years before Antonio was born, Mrs B was again similarly unwell. She again terminated treatment after about two months. She then had no significant known contact with any health service until her pregnancy with Antonio. 6.3.6 The nature of Mrs B’s health condition and its recurrence do indicate a degree of vulnerability. The agencies’ recognition of that and their response are discussed below. 6.4 Evaluate the nature of support provided within the Maternity Unit including preparation and support arrangements in relation to discharge, and transition from midwifery to health visiting services. 6.4.1 The medical problems disclosed by Mrs B at her first ante-natal appointment with midwives were not shared with Health Visitors. She had seen a Consultant Obstetrician with specialist experience and it was judged that no onward referral was necessary at that stage, given the nature of those problems and the time that had elapsed since her last illness. This Review This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 13 of 19 concluded that this was a reasonable decision but Health Visitors should have been notified of it. 6.4.2 In relation to subsequent ante-natal care the report from NHS Kent & Medway advises that “Mrs B attended all appointments and fully engaged with the service, not raising any concerns for her emotional health or well being. Contact with Mr B during this time again does not raise any health or social concerns. When visits took place at home there was no reason to find that this would be an unsuitable place for a child, and they appeared well prepared for a baby. ... The family assessment was completed, father’s assessment was completed and mother’s mood assessment was thoroughly checked throughout her whole maternity pathway …Mother’s care provided was text book and unremarkable”. 6.4.3 It is not clear from the reports submitted how the report reaches these conclusions about the home or about Mr B. The report does not mention any home assessment which would confirm that adequate preparations had been made for the baby. That report also refers to a ” midwifery assessment on the father” but there does not appear to be evidence of any direct contact with Mr B recorded by any professional, prior to the parents bringing Antonio to hospital after he had been injured. The author of that report no longer works in Kent and it has not been possible to confirm this, but the Panel concluded that these comments were based on incorrect assumptions. 6.4.4 Antonio’s birth was relatively straightforward. He spent three hours in special care as a precautionary measure but it was rapidly established that he could be returned to standard post-natal care arrangements. While in hospital there is evidence that Mrs B received and responded well to good advice and guidance in relation to feeding. This continued after discharge from hospital. Midwives visited four times in nine days without any concerns arising. They continued to provide advice and support about Antonio’s feeding problems, and a referral for specialist intervention was made without delay. On one visit Mrs B was reported to be tearful but this was not felt to be unusual in the circumstances of a first-time mother experiencing feeding problems with a young baby. There is no evidence of any contact with Mr B. 6.4.5 The agencies involved have not provided a detailed account of handover from midwifery to health visiting provision, probably because this was judged to be straightforward. The implication is that no particular arrangements were necessary and care was transferred routinely. That was confirmed in discussion at the Review Panel. 6.4.6 A Health Visitor made one visit at which she saw Antonio, Mrs B and Mrs B’s mother, The report of that visit describes that: “During the visit a Family Needs Assessment was (routinely) completed, to determine (whether) additional targeted services (should) be planned. Mrs B reported that she had good support, had never experienced any form of abuse, and did not have contact with anyone who posed a risk to children. Mr This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 14 of 19 B was not reported as having any physical or mental health problems. During the assessment, Mrs. B disclosed a history of (a medical problem) when she was 18 years old and that she had taken (medication) for 2-3 years. She stated she was currently well”. 6.4.7 As detailed above the medical problem which Mrs B mentioned had actually affected her three separate times, requiring treatment on each occasion for a period of months. It may be significant that Mrs B did not disclose the extent of this problem, or she may understandably not have wanted to present as an over-anxious new mother. 6.4.8 Mr B “was not reported as having any … health problems”. This may mean that Mrs B said that he was well at the time of the assessment. In fact we know that he had above average contact with his GP, and a long history of reported medical problems. 6.4.9 The final contact with any professional prior to Antonio’s presentation in A&E was the unscheduled visit by a student midwife. This was less than 36 hours before he was brought to hospital. The student midwife held the baby and noted nothing that caused her any concern. 6.4.10 This was an educational rather than a clinical visit, and consequently was not recorded in medical notes. The Panel judged that this practice was not ideal and that all contacts between patients and professionals ought to be recorded. Revised guidance will be issued accordingly. 6.5 How did your agency take into account parents’ previous history, family and social relationships when assessing their parental capacity prior to the incident? 6.5.1 Again there was no contact with police, KCH or KCS prior to the injuries. 6.5.2 Maternity services appear to have taken appropriate and considered account of Mrs B’s previous medical history. 6.5.3 The Family Needs Assessment, as discussed above, was completed during the one contact from the Health Visiting Service after Antonio was born. It reflects what the Health Visitor was told by Mrs B and, as it stands, would not have triggered any further enquiries or referral to the GP. 6.5.4 Any information-gathering about previous history appears to have related only to Mrs B. It may be that it would be helpful also to make similar enquiries about fathers. 6.6 If predictive risk factors were known, were they acted on appropriately and shared across all agencies? 6.6.1 The only potential “predictive risk factor” was the knowledge about the previous medical histories of Mrs B and, to a lesser extent, Mr B. This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 15 of 19 6.6.2 The “predictive risk factors” relating to Mrs B’s medical history led maternity services to refer her for assessment by a Consultant Obstetrician with expertise in that area. This doctor was satisfied that no onward referral was necessary. 6.6.3 NICE guidelines suggest that Ms B should be asked whether she wished to be referred to more specialist services, and a written care plan should be drawn up. 6.6.4 It is not clear that Mrs B was asked about referral to specialist services. If she had declined such a referral, that should have been recorded and a care plan drawn up which ensured regular review of the situation. In fact, although no targeted care plan was drawn up, it is reported that “ there is evidence that due to the past history the mother’s (condition) was considered at each visit or appointment (and) closely monitored with a system that DVH have in place in accordance to their policy which has been revised according to NICE guidance (submitted separately). They use a traffic light system to refer to the specialist team if deemed to meet the threshold. No concerns were identified during the whole of maternity interaction”. 6.6.5 However, I think that hindsight may over-inform a view expressed in the report from NHS Kent and Medway that “it may have been appropriate to convene a multi-professional meeting at an early stage”. It does not seem to me that there was any evidence to suggest that a multi-agency meeting was necessary. Mrs B had talked openly about her health and gave no indication of being currently unwell or unsupported. Certainly there was no evidence to indicate that a referral to children’s social care services ought to have been considered at any point. 6. 7 What lessons can be learned from this case in relation to the way local professionals and agencies worked together to safeguard and promote the welfare of the child? 6.7.1 Reviews of this nature, with the benefit of hindsight, can often identify actions and processes, within and between agencies, which could be improved. In this case there was no evidence which should have led any professional or agency to suspect that Antonio might be deliberately injured, let alone that those injuries would be substantial. 6. 8 What was the quality of work undertaken by each agency and how did it contribute to the wider multi agency response? 6.8.1 This is not a situation where serious concerns arise about any of the agencies: • The Dartford and Gravesend NHS Trust was responsible for maternity services. Their general management of Mrs B throughout her pregnancy and beyond, appears to have been of a good standard. • The Kent Community Health NHS Trust was responsible for health visiting services and had only one contact which was satisfactory. This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 16 of 19 • Kent Police became involved after Antonio had been injured. Their response was swift, authoritative and appropriate. • Kent Children’s Social Care also became involved after the injuries to Antonio. Their involvement in the immediate response to Antonio’s presentation was again rapid and robust. • Kings College Hospital again only became involved after the injuries. The care provided to Antonio was excellent, as was the sensitivity to child protection issues. 6.8.2 As discussed below agencies worked well together in their immediate response to Antonio’s injuries. 6.9 Is there evidence of good practice illustrated by this case? 6.9.1 OFSTED6“Good practice… with appropriate consideration of its potential for wider implementation”. has suggested that the “best” case reviews will identify Good practice should also mean more than complying with agencies’ routine expectations of staff and services. 6.9.2 In this case it is right to recognise the impressive speed and thoroughness displayed in the multi-agency response to the discovery of Antonio’s injuries. Agencies made time urgently to research the situation, meet, share information, plan and work together to manage a distressing and difficult situation. 6 OFSTED SCR Descriptors January 2009 This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 17 of 19 7. CONCLUSIONS: KEY LEARNING POINTS AND MISSED OPPORTUNITIES 7.1 There is no evidence arising from this review to suggest that Antonio’s injuries could have been predicted or prevented. There was never any information which might have suggested a risk of physical harm. 7.2 This review has not identified any significant weaknesses in the services provided by any agency during the period under review. 7.3 It was decided that no referral for specialist medical assessment was necessary when Mrs B first engaged with ante-natal services. Her condition was monitored throughout her pregnancy although this was not fully recorded. She was fully co-operative with Maternity Services and remained well. 7.4 There was a “leak” of confidential information about this case to the press. Despite a thorough investigation the source of this has not been traced. This “leak” led to significant public disorder. In the wake of these events police disclosed information about Antonio’s discharge from hospital without adequate liaison with the hospital or KCS. This has highlighted the need for a co-operative approach to working with the media in such circumstances. 7.5 Terms of Reference for this Review should have been more clearly drawn up and agreed. This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 18 of 19 8. RECOMMENDATIONS 8.1 Introduction 8.1.1 As has been described above, the agencies contributing to this review had either or no knowledge of the family, or no significant contact during the period under consideration, or previously. It was appropriate to conduct this review but the only issues leading to recommendations are about inter-agency practice after such a tragic incident. 8.2 Recommendations to Kent Safeguarding Children Board 8.2.1 The Board should establish inter-agency protocols and good practice guidance for dealing with high profile cases. 8.2.2 The Board should ensure that there are clear Terms of Reference for all case reviews, whether or not they reach the threshold for carrying out a statutory Serious Case Review. This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 19 of 19 APPENDIX A: Biographical details of report author Kevin Harrington trained in social work and social administration at the London School of Economics. He worked in local government for 25 years in a range of social care and general management positions. Since 2003 he has worked as an independent consultant to health and social care agencies in the public, private and voluntary sectors. He has a particular interest in Serious Case Reviews, in respect of children and vulnerable adults, and has worked on more than 35 such reviews. Mr Harrington is also involved in professional regulatory work for the General Medical Council and for the Nursing and Midwifery Council. He has undertaken investigations for the Parliamentary & Health Service Ombudsman and has served as a magistrate in the criminal courts in East London for 15 years. |
NC52365 | Sustained assault of a 1-year-old girl by her father in August 2019. Father was later convicted of assault and imprisoned. Learning focuses on: the offer of early help; ante-natal visits by the health visitor; application of a non-mobile protocol; child protection planning and decision making; impact of maternal mental health on the child; effectiveness of professional safeguarding actions, assessment and response to domestic abuse; and child-focused practice. Recommendations for the safeguarding partnership include: promote usage of the early help assessment; have a communication system to confirm pregnancy in a timely manner so that health visitors can undertake the required antenatal visits; practitioners should implement the non-mobile protocol; consider the links between domestic abuse and child abuse; child protection plans should not be stepped down to support as a child in need prematurely; consider training for practitioners in domestic abuse, stalking and honour risk assessments; ensure mental health services and children's social care collaborate effectively when maternal mental health issues are relevant to child protection or child in need planning; ensure that any safeguarding implications of hospital attendances by parents as a result of self-harm are fully explored and referrals made where appropriate when children are involved.
| Title: Child safeguarding practice review (CSPR) – Child V. LSCB: Barnsley Safeguarding Children Partnership Author: David Mellor Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Strictly Confidential 1 Barnsley Safeguarding Children Partnership Child Safeguarding Practice Review (CSPR) – Child V Contents Page Number Introduction 2 Terms of Reference 3-4 Glossary 5-7 Synopsis 8-29 Family contribution 30-36 Analysis 37-62 Findings and Recommendations 63-69 References 70-71 Appendices Strictly Confidential 2 1.0 Introduction 1.1 During August 2019 a one year old child, who will be referred to in this report as Child V, was subjected to a sustained assault by her father which was captured on CCTV which had been installed by the child’s paternal grandparents. The father was arrested, charged and later convicted of assaulting his daughter and sentenced to a term of imprisonment. Fortunately, Child V’s injuries were much less serious than might have been anticipated in an assault of the severity recorded. 1.2 Child V had been subject to support under a child protection plan since injuries, which were presumed to be non-accidental, had been observed on her body when she was less than a month old. The child and her family had been stepped down to support as a child in need less than three months prior to the assault by her father referred to above. 1.3 Barnsley Safeguarding Children Partnership decided to conduct a local child safeguarding practice review (CSPR). David Mellor was appointed as the independent reviewer. He is a retired police chief officer who has eight years’ experience as an independent reviewer/author of serious case reviews – which CSPRs have replaced - and other statutory reviews. He has no connection to services in Barnsley. A description of the process by which the review was conducted is set out in Appendix A. Strictly Confidential 3 2.0 Terms of Reference 2.1 The period on which the review has focussed is from the point at which agencies became aware of mother’s pregnancy with Child V (early 2018) until 16th August 2019 when the serious assault on the child was reported. 2.2 The key lines of enquiry addressed by the review are as follows: • Whether mother and father could have benefitted from the offer of Early Help? • How effective was the action taken to safeguard Child V when she was taken to the hospital accident and emergency department on 27th August 2018 with bruising over her left eye? • How effective was the action taken to safeguard Child V when scratching and bruising above her left eye was noted by a health visitor on 5th September 2018? • Was the local procedure for ‘injuries to non-mobile infants or children’ followed on each occasion? • How comprehensive was the assessment of Child V and her family when safeguarding concerns arose in September 2018? How well understood was parenting capacity and family functioning? • How effective was the Child Protection Plan for Child V? • When it was decided to step Child V down from the Child Protection Plan to support as a Child in Need on 29th May 2019, was this decision fully informed by all concerns of which partner agencies had become aware? • How effective was the support provided to Child V and her family after she had been stepped down to Child in Need? • Were there any opportunities for practitioners to have become aware of the fracture to Child V’s left ulna which she sustained between two weeks and three months prior to the 16th August 2019 serious assault? Strictly Confidential 4 • How appropriate were agency responses to indications of maternal mental health concerns and how were any risks to Child V arising from maternal mental health issues addressed? • How effective was the response of agencies to the incident of domestic abuse involving the parents which was reported on 13th March 2019? Was the potential impact of domestic abuse on Child V fully considered? • Was professional practice sufficiently child-focussed? Strictly Confidential 5 3.0 Glossary A Child in Need (CiN) is defined under the Children Act 1989 as a child who is unlikely to achieve or maintain a reasonable level of health or development, or whose health and development is likely to be significantly or further impaired, without the provision of services; or a child who is disabled. Domestic violence and abuse is any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality. This can encompass, but is not limited to, psychological, physical, sexual, financial and emotional abuse. The term Early Help describes the process of taking action early and as soon as possible to tackle problems and issues emerging for children, young people and their families. Effective help may be needed for at any point in a child or young person's life. A Family Group Conference is a process in which families can meet together, to find solutions to problems that they and their children are facing, within a professionally supportive framework. The Family Group Conference process involves all family members, friends and other adults who the family feel can contribute to making plans for the children. Health visiting levels of service. The health visiting service provide four levels of service as follows (1): • Community: health visitors have a broad knowledge of community needs and resources available e.g. Children’s Centres and self-help groups and work to develop these and make sure families know about them. • Universal: health visitor teams ensure that every new mother and child have access to a health visitor, receive development checks and receive good information about healthy start issues such as parenting and immunisation. • Universal Plus: families can access timely, expert advice from a health visitor when they need it on specific issues such as postnatal depression, weaning or sleepless children. • Universal Partnership Plus: health visitors provide ongoing support, playing a key role in bringing together relevant local services, to help families with continuing complex needs, for example where a child has a long-term condition or additional concerns such as safeguarding, domestic abuse and mental health problems. Strictly Confidential 6 A Legal Gateway meeting is an opportunity to discuss a case fully, and to consult with colleagues to ensure that children are the subject of active case management and effective child protection planning and that appropriate legal action is taken when required to promote and safeguard the welfare of the child. Multi-Agency Risk Assessment Conference (MARAC) is a meeting where information is shared on the highest risk domestic abuse cases between representatives of local police, health, child protection, housing practitioners, Independent Domestic Violence Advisors (IDVAs) and other specialists from the statutory and voluntary sectors. A victim/survivor should be referred to the relevant MARAC if they are an adult (16+) who resides in the area and are at high risk of domestic violence from their adult (16+) partner, ex-partner or family member, regardless of gender or sexuality. The perinatal period refers to pregnancy and the first 12 months after childbirth. Specialist community perinatal mental health teams offer specialist psychiatric and psychological assessments and care for women with complex or severe mental health problems during the perinatal period. SafeLives DASH (Domestic Abuse, Stalking and 'Honour'-based violence) is a commonly accepted tool which was designed to help front line practitioners identify high risk cases of domestic abuse, stalking and ‘honour’-based violence and to decide which cases should be referred to the Multi-Agency Risk Assessment Conference (MARAC) and what other support might be required. Section 47 Enquiry is required when children’s social care have reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm. The enquiry will involve an assessment of the child’s needs and the ability of those caring for the child to meet them. The aim is to decide whether any action should be taken to safeguard the child. A Strategy Discussion must be held whenever there is reasonable cause to suspect that a child has suffered or is likely to suffer significant harm. The purpose of the Strategy Discussion is to decide whether a Section 47 Enquiry under the Children Act 1989 is required and if so, to develop a plan of action for the Section 47 Enquiry. Strictly Confidential 7 Synopsis 4.1 On 15th January 2018 mother, accompanied by father, attended a booking appointment with the community midwife. They were both 17 years of age at the time. Mother was documented to be epileptic, to have mental health issues (‘depression, overdose and self-harm’) and noted to present with low mood during the appointment, to have misused substances previously, to be a smoker and to be living with her mother and her younger siblings in an over-crowded environment. Mother was referred to a specialist teenage pregnancy midwife, to the maternity stop smoking service and a mental health midwife. Mother’s alcohol intake prior to pregnancy was documented as 4-5 units per day which was said to have ceased since she became pregnant. (No further assessment of mother’s alcohol intake was undertaken during pregnancy). 4.2 Early Help was mentioned to mother and father and it was intended that this would be further discussed with the specialist teenage pregnancy midwife to whom mother had been referred. It is not documented whether such a discussion took place, whether or not Early Help was offered or, if offered, whether it was declined. Mother was documented to have declined a referral to the ‘mental health team’. Mother and father would also have been eligible to access the Having a Baby programme to support them to prepare for the birth but there is no record of them being offered or attending that programme. 4.3 Mother initially stopped smoking but was unable to sustain this. 4.4 On 12th March 2018 mother was seen in Hospital 1 Emergency Department (ED) after a seizure at home. After an antenatal check she was discharged home. She was referred to neurology as this was her second seizure since 2017. 4.5 On 11th April 2018 mother, accompanied by father, attended a community midwife appointment. She said she continued to see Child and Adolescent Mental Health Services (CAMHS) although by this time, she had actually been discharged by CAMHS. 4.6 On 15th April 2018 mother again attended Hospital 1 ED with pain to her legs and thighs, radiating to her back. After review, she was discharged home. 4.7 During May 2018 mother and father moved into Address 3, a property which had been purchased by Child V’s paternal grandparents for mother, father and Child V to live in. Strictly Confidential 8 4.8 On 6th May 2018 mother again attended Hospital 1 ED. On this occasion she was experiencing reduced movements due to pyelonephritis (inflamed kidney). She was admitted to the Hospital Birth Centre. She was discharged home after four days. 4.9 On 12th May 2018 (two days after previous discharge) mother attended Hospital 1 with right sided abdominal pain (This was her fourth unscheduled hospital attendance since her maternity booking appointment). On this occasion and at her later obstetric review (23rd May 2018) mother’s mental health needs were not documented. 4.10 At around 1am on 29th May 2018 mother attended Hospital 1 reporting reduced foetal movements. An obstetric review documented normal maternal observations and she was discharged. Mother, this time accompanied by father, again attended Hospital 1 reporting reduced foetal movements shortly after midnight on 16th June 2018. Foetal movements were seen and felt by staff. 4.11 On 29th June 2018 mother attended Hospital 1 Triage with pain in her legs, lower abdomen and vagina. Whether or not she was accompanied and by whom, was unrecorded. The domestic violence question was not asked. 4.12 On 18th July 2018 the specialised midwife conducted a mental health review of mother who reported to be ‘feeling well’. 4.13 At 3.45am on 22nd July 2018 mother attended the Hospital 1 Birth Centre Triage reporting reduced foetal movements after a ‘fall down stairs at home’ between 2.30 and 3am. Whether she was accompanied and by whom was not recorded and the domestic violence question was not asked. 4.14 Shortly after midnight on 31st July 2018 mother attended Hospital 1 Triage with excessive foetal movements and an unspecified discharge. An obstetric review took place. Whether she was accompanied and by whom was unrecorded, and the domestic violence question was not asked. 4.15 At 1.20am on 6th August 2018 mother attended Hospital 1 reporting reduced foetal movements after being involved in a ‘road traffic incident’, in respect of which no further details were recorded. Mother was reviewed and discharged. Whether she was accompanied and, if so, by whom was unrecorded, and the domestic violence question was not asked. Mental health issues were not identified as a risk factor. No further details of the ‘road traffic incident’ have been shared with this review. 4.16 At 1.20am on 8th August 2018 mother attended Hospital 1 Triage with visual disturbances and reduced foetal movements. Foetal movements were seen by staff. Strictly Confidential 9 When assessed, mother was noted to look tired. Whether she was accompanied and, if so, by whom was unrecorded, and the domestic violence question was not asked. Mental health issues were not identified as a risk factor. 4.17 Child V was born in mid-August 2018 in Hospital 1. Mother and child were discharged the following day to paternal grandparents’ address although Address 3 was recorded as mother’s home address. The new born and infant physical examination (NIPE) documented no marks on the child’s body. 4.18 The community midwife completed the first home visit two days after Child V’s birth and no marks on the child’s body were documented. She was unable to obtain a reply on a planned visit three days later. 4.19 On 19th August 2018 the community midwife was able to make a home visit and no marks were documented on Child V’s body. 4.20 On 24th August 2018 the community midwife saw mother at a family centre. Child V had been put on ‘hungrier baby’ formula milk. The midwife discussed smaller feeds more often, including waking the baby in the night. 4.21 On 27th August 2018 Child V was taken to Hospital 1 ED by her parents. The practitioner who saw the parents and child during triage noted ‘query bruising around left eye darker, reddish purple skin’. Mother and father left with Child V at 11.25pm ‘due to long waiting times’ before the child could be further examined. They had been waiting for just over an hour. ‘No concerns with parent’s behaviour’ was documented and the safeguarding question on the relevant ED form was answered in the negative. The following was also recorded ‘Approached by parents, due to waiting time and having the health visitor visit at 8.00am tomorrow, they did not want to wait that long and were to get the health visitor to check her eye in the morning’. There is no indication that the injury was discussed with a doctor, or communicated to the Hospital 1 safeguarding team, or a referral made to children’s social care. A ‘communication form’ was sent to the health visitor but not received by that service until 29th August 2019. (The communication form is a paper form completed by ED staff when they wish to share information regarding a child’s attendance in ED with the health visiting service or where the child requires follow up in the community by the latter service. The form is collected by the health visiting service and scanned onto their information system. This is not a timely process and so there is an expectation that in more urgent cases the information contained in the communication form would be communicated by telephone. This did not happen in this case). Strictly Confidential 10 4.22 The health visitor new birth visit took place the following day (28th August 2018) at Address 3. There was a delay in completing the health visitor new birth visit which took place two days later than the mandated 10-14 days after birth. Mother advised the health visitor that Child V had been taken to Hospital ED the previous evening after she had noticed bruising to Child V’s inner eye, that the child had been seen by triage but that they had left after being told that ‘she could be waiting for five hours’. The health visitor did not document what she observed, later advising an internal management review that she did not perceive the mark to be a bruise, and advised mother to register Child V with a GP and take her to see the GP that day. Child V was not taken to see the GP for three days and the health visitor did not verify whether the GP visit took place. 4.23 The next day (29th August 2018) Child V was examined by a community midwife at a family centre. No concerns were documented. Mother said that she had taken the advice given by the community midwife in respect of feeding (Paragraph 4.20). The child was seen by a specialist midwife a day later who documented no concerns and recorded that mother and child were staying with ‘grandmother’ for a few days for support. 4.24 On 31st August 2018 Child V was taken to the GP by maternal grandmother. The reason for the visit to the GP was not recorded. Child V was examined and no concerns were documented. A ‘strong’ history of epilepsy in the family was noted. (At the initial strategy meeting subsequently held on 6th September 2018 it was documented that the GP had not been concerned about Child V during this 31st August 2018 visit). 4.25 On 5th September 2018 the specialist midwife – the same specialist midwife who had seen Child V on 29th August 2018 - made a planned home visit and documented that the child’s eyes became swollen and bruised during the early hours of the previous day and two marks had appeared on her abdomen. Mother told the specialist midwife that she had tried to obtain a GP appointment, but none had been available. The specialist midwife telephoned the GP and requested an urgent appointment. It was arranged that the GP would contact mother that afternoon with an appointment time. 4.26 Child V was taken to see the GP at 3.20pm the same day by mother and maternal grandmother. The GP documented a small bruise on the child’s left eye over the upper eye lid on the left side. Two linear marks on the child’s left abdominal wall were also noted. The GP also documented that mother was unable to say how the bruising had occurred. The GP concluded that the injuries were ‘most likely’ non-accidental. Strictly Confidential 11 4.27 The GP practice made a referral to children’s social care and the screening team spoke to mother who said she had no idea of the cause of the bruising, stating that ‘it looks like she had a bang’, although it was noted that the child’s cot, moses basket and pushchair were all soft in padding. Mother said she first noticed the bruise on Child V’s left eye on 28th August 2018, after father had got up to attend to her when she woke. Father then woke mother up to show her the bruise to Child V’s eye. Mother went on to say that she took Child V to Hospital ED on 28th August 2018 where she said she had been advised to register Child V at the local GP Practice. (It is assumed that mother was referring to the 27th August 2018 visit to Hospital ED (Paragraph 4.21)). Maternal Grandmother confirmed that Child V had been taken to the GP on 31st August 2018, adding that the GP was ‘not worried about the mark to Child V’s eye’. 4.28 Child V was taken to Hospital 1 where a full child protection medical took place at 8.30pm the same evening which disclosed a non-blanching (does not fade when pressed) mark on the left side of the forehead near the supra orbital ridge (eye bone above the eye), another mark on the upper eyelid, and a further mark on the right medial part of the eye below the eyelid. Additionally, two marks were noted under the left arm and two further marks on the abdomen. A sub conjectural haemorrhage was also noted in the left eye. The initial skeletal survey disclosed no acute or healing bony injury. 4.29 The paediatrician concluded that whilst marks and bruises on the face and a sub conjunctival bleed can be caused by forceps (forceps had been required to deliver Child V) they are usually apparent at birth, but these were not noted by practitioners at the time or subsequently. There was no history of vigorous coughing and vomiting. No explanation had been given for two linear bruises on the left armpit and the left side of abdomen. The parents had raised concerns that Child V’s arms and legs twitched during sleep and provided a video recording which the paediatrician felt looked like benign myoclonus (spasmodic jerky contraction of the muscles). Child V remained in hospital overnight as part of safety planning. Her parents were not allowed unsupervised contact. 4.30 The following day (6th September 2018) a strategy meeting took place at which the marks on Child V’s body were described as ‘unexplained’, although it was noted that the outcome of the child protection medical suggested that the injuries were ‘non-accidental’. It was stated that further medical investigations were being undertaken. Family members were said to have given varying accounts of seeing marks and then not seeing marks. Reference was made to mother’s presenting behaviour and some concern regarding her being anxious about her parenting which had resulted in Child V being cared for by various family members. Concerns had also been raised by paternal grandmother about father’s volatility and anger issues. Strictly Confidential 12 Checks had been made of both parents and nothing was known about father whilst mother’s family had been known to services. 4.31 It was agreed that the threshold for risk of significant harm was met in this case and that the current joint police/children’s social care Section 47 investigation should continue with the case to be presented at an Initial Child Protection Conference (ICPC) and further legal advice sought. Child V would be placed in the care of her paternal grandparents following discharge from hospital under Section 20 of the Children Act. A viability assessment was undertaken in respect of the paternal grandparents which was positive. (Maternal grandmother was not considered as a carer due to what was documented as a ‘fractured relationship’ with mother). 4.32 No concerns were noted in respect of mother and father’s observed behaviour and interaction with Child V. Nor were concerns noted in respect of the parent’s relationship or issues pertaining to mental health (it is assumed that mother’s mental health history must have been overlooked at this time), alcohol or substance use. Although they were a young couple, they were surrounded by a large extended family who were considered to be supportive practically, emotionally and financially. 4.33 On 7th September 2018 the police arrested the parents who were interviewed under caution. The police established that the injuries to Child V took place whilst the parents were caring for her. However, the parents made no admissions of guilt during the interviews. The police ultimately concluded that extensive medical examinations could not ‘state the injuries were intentional’. They documented the injuries to Child V to be ‘unexplained’ rather than non-accidental. It is understood that no crime was recorded. 4.34 On 10th September 2018 the paternal grandparents contacted children’s social care to report that on three separate occasions Child V had cried for prolonged periods which had resulted in the bruise/mark becoming visible once again – assumed to be in and around the left eye. Images of the bruise/mark were shown by the paternal grandparents and the plan appeared to be to compare them with images obtained during the child protection medical. Contact was made with the hospital by email for this purpose but no response from the hospital was recorded. 4.35 On 13th September 2018 the case was presented at a Legal Gateway panel. It was agreed that subject to any new or additionally concerning information coming from the further medical tests, the threshold had not been met for the issue of care proceedings, but that Child V should be made subject to a child protection plan (CPP). Although the marks on Child V could be said not to be serious they were considered to be extremely concerning due to the age of the child. The question of whether the injuries to Child V’s could have been caused by epilepsy seizures was to Strictly Confidential 13 be explored as the females in mother’s family suffered from epilepsy. It was decided to discharge Child V from Section 20 of the Children Act once the final test results were known, and if there were no further concerns, the ICPC was to be arranged and it would be agreed for the parents to live with the paternal grandparents in order to be supported. 4.36 A second strategy meeting took place on 17th September 2018 at which practitioners were in agreement with a recommendation to proceed to an ICPC for consideration of child protection planning in respect of Child V in view of the ongoing concerns around the unexplained bruising to this pre-mobile baby. Child V was to remain at the paternal grandparent’s home. Section 20 was to be discharged and mother and father were said to have moved into the paternal grandparents address to share Child V’s care. A repeat skeletal scan of Child V was to take place in two weeks and if nothing of concern was disclosed by this, Child V would then return to her parent’s primary care. 4.37 On 20th September 2018 Hospital 1 confirmed Child V’s repeat skeletal scan was normal with no injuries shown. The following day, Section 20 ceased and Child V was returned to the care of mother and father who were said to have moved in with the paternal grandparents on the same date. However, in their contribution to this review mother, maternal grandmother and the paternal grandparents stated that mother, father and Child V did not move in with paternal grandparents and continued to reside in address 3 where they cared for Child V alone. 4.38 On 25th September 2018 Child V was taken to Hospital 1 and seen on the Child Assessment Unit by a paediatric doctor. Eye swabs were taken for chlamydia – which can arise from a serious eye infection in a new born child. The eye swabs proved negative. The hospital records documented that a child protection medical had recently taken place. In the absence of notification that a CPP was in place, no information about this hospital attendance was shared with children’s social care. 4.39 On 27th September 2018 mother made a housing application to Berneslai Homes – which is Barnsley Metropolitan Borough Council’s (BMBC) social housing company which manages 18,500 homes on their behalf - in respect of herself and Child V. There was no mention of father. In their contribution to this review, mother and the maternal and paternal grandparents have stated that mother, father and Child V moved out of Address 3 on 5th November 2018 and so it is possible that this housing application was made in anticipation of the departure from Address 3. 4.40 On 28th September 2018 the health visitor carried out the 6-8 week home visit at ‘grandmother’s’ house (the first name of the grandmother was recorded but since Strictly Confidential 14 both grandmothers have the same first name it is unclear at which address the visit took place). No concerns were documented. 4.41 On the same date the Section 47 enquiry concluded. The enquiry report noted that extended tests such as skeletal, CT, Ophthalmology review and extended blood tests for clotting had all been ‘clear’, disclosing no underlying organic reason for the marks on Child V nor providing further evidence to conclusively indicate a non-accidental injury. A manager from children’s social care decided that as the injuries to Child V remained unexplained but considered likely to be non-accidental due to her being a non-mobile baby, it was therefore appropriate to progress to child protection planning for further assessment and work with the family. 4.42 On 2nd October 2018 an ICPC decided that Child V would be made subject to child protection planning under the category of physical harm. Although the conference was quorate, the police did not attend, sending a report. The grandparents were invited but did not attend. Because the child protection plan had been put in place, the health visitor service began supporting the family at ‘Universal Partnership Plus’ level which provides ongoing support from the health visiting team and bringing together a range of local services, to help families who have complex additional needs. 4.43 On 15th October 2018 a core group meeting took place but there is no record of the information shared at that meeting as no minutes were taken. A child protection visit took place on the same date and no immediate concerns were noted. Child V was seen to be fit, well and alert with emotional warmth displayed by mother. It is assumed that the core group meeting and child protection visit coincided with each other and took place at paternal grandparents’ address. 4.44 On 26th October 2018 father contacted the police to report receiving a text message from a friend of mother’s cousin’s in which the person threatened to set father’s house on fire. Another message stated, ‘you shouldn't beat your missus’. The matter was investigated by the police and filed ‘evidential difficulties’. 4.45 On 2nd November 2018 the social worker made a child protection visit to the ‘grandparents’ home. Child V presented as clean and content during the visit. Her parents were observed to interact and respond to Child V appropriately who was observed to smile, babble and make noises when interacted with. Mother said that an incident had been reported to the police after her cousin ‘had started rumours’ that father had assaulted mother. Mother was spoken to quietly alone when father was out of the room and did not disclose any current or previous domestic abuse. Mother added that her cousin had ‘caused lots of trouble for other family members Strictly Confidential 15 in the past’. Father said that the texts also included threats to burn down their house. 4.46 In her contribution to the review, mother said that on 5th November 2018 she, father and Child V moved out of Address 3 and she and Child V moved in with maternal grandmother. Agency records indicate that when she, father and Child V moved out of Address 3, they initially moved to paternal grandparents’ address until mother and father’s relationship temporarily ended on 4th December 2018. 4.47 On 12th November 2018 the social worker made a referral for a family group conference, the focus of which was unclear, other than improving the relationship between maternal grandmother and father. 4.48 On 19th November 2018 a core group meeting and a child protection visit took place at paternal grandparents’ address. No concerns were noted although Child V was being weaned. The parents were advised to stop solids and seek advice from the health visitor in view of the child being only 13 weeks old. The health visitor later discouraged weaning until the child was six months old. 4.49 On 5th December 2018 mother rang the social worker to say that she and father had split up the previous night due to constant arguing. Mother added that she had stayed at paternal grandparents’ address the previous night but had collected her belongings together and intended to move to maternal grandmother’s address with Child V that day. 4.50 On 10th December 2018 a core group meeting took place at maternal grandmother’s address at which mother’s separation from father and tensions which existed within the wider family were discussed including conflict between mother and paternal grandfather who had said mother was lazy. The core group meeting coincided with a child protection visit at which no concerns were noted. Child V was described as clean and happy, well presented and responsive to mother and maternal grandmother. 4.51 On 12th December 2018 a Review Child Protection Report was completed which, given that it was early in the child protection plan and Child V was of a very young age and completely dependent on her parents to meet her care needs, recommended that a further period of child protection planning was necessary in order to evidence the parents’ ability to continue to safeguard and meet the care needs of Child V and complete the child protection plan actions. The recommendation was endorsed by the social worker’s team manager. Strictly Confidential 16 4.52 The review child protection case conference took place on 17th December 2018 at which it was confirmed that Child V would remain subject to child protection planning. Actions included: • mother to use strategies to remember to take her epilepsy medication. • mother to be referred to Family Intervention Service for support towards independence, housing, routines and safety (Berneslai Homes Family Intervention Service have no record of any referral being received) • funding to be sourced for alarmed wrist watch to Central Call System in preparation for independence (mother’s epilepsy) • referral to the Family Group Conference • any disagreement within the families to be totally away from Child V. • police to provide information relating to threatening and abusive messages to father on 26th October 2018 (Paragraph 4.44). The grandparents were invited but did not attend. 4.53 Mother and Child V’s move to maternal grandmother’s address necessitated the transfer of their case to the health visitor North East team on 28th December 2018. 4.54 On 30th December 2018 the police were called by mother who was at a friend’s address when father attempted to attend. He was told to leave but refused. The police attended and spoke to both parties and assessed the risk as standard. Mother and father went to separate addresses to prevent further issues. Child V was not present. 4.55 On 7th January 2019 the duty social worker made a child protection visit and no concerns were noted. Child V, who was seen with mother and maternal grandmother, was teething, not sleeping and was unsettled. The following day a health visitor from the North East team made a ‘movement in’ visit and no concerns were documented. 4.56 On 16th January 2019 children’s social care received a police referral in respect of the incident on 30th December 2018 (Paragraph 4.54). Child V had not been present. A visit to the family was to be arranged. (Mother had not disclosed the incident to the duty social worker during the 7th January 2019 visit). 4.57 A core group meeting was held on 17th January 2019, but no notes of the meeting were taken. The children’s social care chronology states that this was the responsibility of the duty social worker, who was also chairing the meeting. Paternal grandmother requested a home visit from the social worker to discuss the issues raised at the core group which was arranged for 25th January. In her contribution to this review paternal grandmother said that father asked her to attend the core group Strictly Confidential 17 meeting on 17th January 2019 in order to support him. Father had told paternal grandmother that mother had been physically abusing him and had ‘blacked his eye’. At the core group meeting, paternal grandmother said she raised the issue, saying that she wanted it to be known that mother had been hitting father. Paternal grandmother said that, at that point, father ‘backed down’ and said that he and mother had only been play fighting. 4.58 On 18th January 2019 Child V was seen by the GP and referred for paediatric advice in respect of possible lactose intolerance. 4.59 On 21st January 2019 mother was admitted to Hospital 1 after taking an overdose of amitriptyline and dihydrocodeine. The hospital ED documented that mother had taken an intentional overdose as a result of stress arising from the death of a friend in a road traffic collision and also having an argument with her boyfriend. She was referred to the hospital based mental health liaison service who carried out an assessment which identified (unspecified) risks. Mother described a deterioration in her mental health since the birth of Child V, she presented as quite flat in mood and it was difficult to gather information from her. The plan was for the perinatal mental health team to be contacted the following day to discuss a referral to that service. Mother was discharged from hospital and encouraged to return to ED if she experienced further thoughts of self-harm. SWYFPT records state that Children’s Services EDT was contacted as Child V had been present in the house when mother took the overdose. SWYPFT records state that the EDT advised them that mother had been visited by a social worker the day before she took an overdose and that the social worker would visit again when mother was discharged. Children’s Services state that there is no record of contact with the EDT by SWYPFT. Their records indicate that they found out about mother’s overdose only when the family group conference practitioner made a pre-arranged visit to mother – see next Paragraph. Hospital 1 has not shared any information about mother’s admission with this review. 4.60 On 22nd January 2019 the perinatal mental health team were contacted and they arranged an appointment for a perinatal assessment on 6th February 2019. On the same date the family group conference practitioner visited mother to discuss the process. Mother felt that the family group conference process could be helpful but said she was worried about what father’s family would say. 4.61 On 24th January 2019 the social worker made a child protection visit and discussed the recent overdose with mother who reported being upset by paternal grandmother’s comments at the core group about her parenting and that she (mother) was abusive to father. Mother advised that Child V had been upstairs in bed at the time of her overdose, which took place downstairs. Mother was found by Strictly Confidential 18 maternal grandmother who called an ambulance. Mother said she felt low in mood and was encouraged to engage with mental health support. Mother said she still had feelings for father but said she would not resume her relationship with him unless he received support with his anger. It was agreed that the social worker would speak with father about this, however the social worker advised that he needed to seek support if he was willing to engage with it. A discussion took place over disclosures made by mother following the last core group meeting that father had physically assaulted her, pulled her hair and dragged her in the car which had not been reported to police. 4.62 Throughout the visit Child V was in a bouncy chair in front of the TV and mother did not interact with her. The social worker talked to mother about stimulation, floor time, play time and interaction with Child V and also discussed possible baby groups for Child V which mother said she was interested in. It was agreed that the social worker would look at groups at local children’s centres. The social worker would also inform the health visitor about mother’s overdose. 4.63 The following day the social worker discussed the case in supervision. It was documented that the CPP was progressing with ‘no concerns’ regarding Child V. The plan would continue to address issues relating to the parent’s relationship and concerns relating to mother's health including her mental health which would help to support her in caring for Child V independently. 4.64 On 25th January 2019 the social worker made a child protection visit to Child V who was in the care of her father and paternal grandparents at that time. Father said that he and mother were trying to make their relationship work and confirmed that mother would like father to address his anger, which father accepted he struggled to manage. The paternal grandparents said that this had been an issue since father was around six years old and that a referral had been made to CAMHS but his parents had been offered and completed a Webster Stratton parenting course. Father was asked about mother’s disclosure that he had hit her and pulled her hair. Father said the incident had taken place whilst he was setting off in the car with mother as a passenger. He said that she kept trying to get out of the car so he had grabbed her and accidentally pulled her hair, adding that he pulled mother back into the car by her shoulder and she hit her hand on the dash board which led to a bruise on her finger. Father said that mother had also hit him. The grandparents said that mother had told lots of lies to different people about what had happened and about her relationship with father. Child V was in her walker throughout the visit, babbling loudly, laughing and interacting with father and her paternal grandparents. Strictly Confidential 19 4.65 On 29th January 2019 children’s social care advised the health visitor of mother’s overdose and the health visitor followed up with a home visit on 4th February. 4.66 On 6th February 2019 the perinatal mental health team conducted an initial assessment of mother and assessed her risk of intentional completed suicide in the near future to be low, her risk of impulsive self-harm as low to moderate and there was a risk of deterioration in mother’s mental health without intervention. It was identified that mother needed to develop coping strategies, build her self-confidence and manage her anxiety. She agreed to seek help immediately if suicidal thoughts recurred. A moderate risk of carer stress in respect of maternal grandmother was identified as she was also managing the diagnosed needs of mother’s younger siblings and there was overcrowding in the family home. Maternal grandmother was advised to contact SENDIASS (special educational needs, disability information and advice service) regarding issues in school and BMBC housing department to arrange a meeting regarding overcrowding. A further appointment with the perinatal mental health team was to be arranged for mother. 4.67 A core group meeting took place on 7th February 2019 at which father asked about an anger management referral which the social worker was to follow up on. A child protection home visit took place at the same time as the core group meeting during which no concerns were noted. Also on the same date the case was audited by the Head of Service as a follow up from the earlier Legal Gateway meeting (Paragraph 4.35) which identified that the CPP was safeguarding and supporting the child. 4.68 On 14th February 2019 the perinatal mental health team made a home visit. Self-care was discussed with mother including enjoyable activities and future plans. The perinatal team were to liaise with the social worker and the health visitor. 4.69 On 27th February 2019 the case was allocated to a new social worker as a result of the extended sickness absence of the previous social worker. 4.70 On 28th February 2019 the perinatal mental health team made a further home visit and completed a perinatal mental health care plan and crisis plan and referred mother to improved access to psychological therapies (IAPT). Mother reported an improvement in her mood but disclosed issues around low confidence, a lack of assertiveness, and ongoing difficulties in coping with stressful situations, describing feeling unable to cope with multiple stressors. She said she had resumed her relationship with father but felt she could not tell maternal grandmother who would not let her see him. Strictly Confidential 20 4.71 On 1st March 2019 the new social worker made a child protection visit. Mother reported that she and father had resumed their relationship. Domestic violence was discussed with mother who said that she was willing to work with domestic violence services. Mother was observed to attend to Child V although there was some lack of warmth. 4.72 A core group meeting took place on 5th March 2019. There were no concerns about the child. Mother was waiting for an IAPT appointment. There was a discussion with father about a referral to ‘Inspire to Change’ – a programme designed to help participants find ways to manage and control their abusive behaviour - to which father agreed. Apologies were received from mental health services. 4.73 On 6th March 2019 Child V was taken to Hospital 2 – which is situated in the neighbouring Wakefield Council area - due to increased vomiting. No safeguarding concerns were identified or communicated from the hospital. 4.74 On 9th March 2019 the police were called after father visited maternal grandmother’s address to see Child V and mother declined to take the child outside to see him because she felt that the weather was too cold. Father began to shout at mother as a result. The police assessed the risk as standard and filed the incident as a non-crime verbal domestic incident. 4.75 On 11th March 2019 the social worker discussed the case in supervision during which mother’s concerns about father’s anger issues - which were said to have previously been perceived to be historical – were considered. Father had reported he was willing to engage with work in this area and the social worker was to refer him to ‘Respectful Relationships’ and to refer mother to independent domestic abuse services (IDAS). (Respectful Relationships is a course which may be offered as part of the previously mentioned ‘Inspire to Change’ programme). 4.76 Also on 11th March 2019 father contacted the police to report what was recorded as a domestic assault by mother. Father reported that he and mother had split up on Saturday (9th March 2019) and that mother had denied him access to Child V. Father disclosed that mother had historically assaulted him by hitting and kicking. Father declined to engage with any police investigation 4.77 On 12th March 2019 mother phoned the social worker to request an urgent visit. She said that father had ‘slammed the brakes’ on the car causing her knees to hit the dashboard. She also said that he had been texting her to demand that she came out of the house with Child V and making threats to her and her family. Mother said that she had contacted the police. The social worker visited mother the Strictly Confidential 21 same day and she disclosed that the domestic violence in her relationship with father was more significant than she had initially indicated. She said that he hit her when they were living together with paternal grandparents. She said he pulled her hair and dragged her into the car and threatened to drive her to the moors and leave her there. She also said he pulled her hair, dragged her into the car and drove with her legs hanging out. Mother said that this occurred prior to her recent overdose. Mother showed photographs of fingertip bruising on her shoulder which had been taken during her hospital admission following the overdose. Mother agreed to a referral to IDAS. She said that the police ‘had offered to put an injunction in place’ which she had agreed to. No other information has been shared with this review to suggest that an injunction had been considered. Obtaining an injunction was not a police responsibility. 4.78 On the same date the social worker contacted Berneslai Homes to support a housing application from mother due to overcrowding issues in maternal grandmother’s home. 4.79 On 13th March 2019 children’s social care received the DASH risk assessment from the police which appeared to relate to the 9th March, as opposed to the 11th March, contact. Risk had been assessed as standard and mother had answered the question in relation to father ever hurting the child in the negative. 4.80 The following day the social worker received a text from mother to say that she and father had resumed their relationship. 4.81 On 19th March 2019 the social worker made a child protection visit. Father and mother had resumed their relationship and mother and Child V were living with him at paternal grandparents’ address as maternal grandmother would not speak to mother because she had resumed her relationship with father. Father said he would address his anger issues. Father and mother were said to have agreed a referral to Inspire to Change to look at their relationship. Child V was seen and noted to be smiling with lots of eye contact and was clean and well dressed. A discussion took place about the importance of Child V being safeguarded and not left alone with her parents to help reduce conflict. 4.82 On 22nd March 2019 a family group conference took place which was attended by Child V’s parents, paternal grandparents, maternal grandmother and wider family members. The family plan which emerged from the meeting included father’s referral to Inspire to Change, that Child V would not be exposed to any arguments and that the wider family would be engaged in ensuring that Child V was safeguarded. Strictly Confidential 22 4.83 A child protection visit also took place on the same date at which no concerns were noted in respect of Child V. Mother expressed concern about her rising anxiety. 4.84 On 23rd March 2019 mother was seen by IAPT and disclosed that since the perinatal mental health team assessment, her diet had become more restricted and she had been experiencing increasing symptoms of anxiety and agoraphobia. She also disclosed ‘ongoing threats from her ex-partner’. IAPT referred her to the core CMHT as there had been a change in her presentation since her referral from perinatal to IAPT. 4.85 A further child protection visit took place on 25th March 2019 at which relationships and the ‘cycle of violence’ were discussed with mother who said she was awaiting contact from IDAS. 4.86 On 26th March 2019 a core group meeting took place at which it was documented that father had been ‘referred to mental health services by college’. Children’s social care understood this entry in the core group minutes to refer to paternal grandfather speaking to father’s college tutor about support for his son. In their contribution to this review, the paternal grandparents said that father was referred to a counsellor by the college he attended on one day a week as part of his apprenticeship. They said that father not infrequently came into conflict with his college tutor who would sometimes send him out of class. When this happened, father would go and see the counsellor. If he couldn’t locate the counsellor, father would just return home for the rest of the day. Child V’s 6th March 2019 attendance at Hospital 2 (Paragraph 4.73) was shared with the core group by the health visitor. Child V was seen at the core group meeting. 4.87 On the same date the social worker followed up mother’s referral to IDAS who stated that they had contacted her on 15th March 2019, and she had told them she had never heard of the service and did not know why they would be contacting her. The social worker asked IDAS to recontact mother. 4.88 On 3rd April 2019 the social worker followed up on father’s referral to Inspire to Change who confirmed that father had been offered, and accepted, an initial appointment on 16th April 2019. 4.89 On 8th April 2019 a child protection visit took place. The social worker was concerned about the extent to which Child V was moving between family addresses as mother was splitting their time between maternal and paternal grandparents’ homes. Strictly Confidential 23 4.90 On 16th April 2019 father attended the initial Inspire to Change appointment and was assessed as suitable for the ten week Respectful Relationships programme. The following day Inspire to Change completed a victim/partner which was sent to IDAS. The referral identified father as the perpetrator and mother as the victim of domestic violence which was documented to include ‘grabbing hair, punching on the arm and pushing and shoving’. Father was said to be ‘very much minimising’ the physical harm but admitted that he had a ‘temper’ which scared mother. He was said to be motivated to address this issue. The risk level was documented to be ‘medium’. 4.91 On 18th April 2019 a core group meeting took place at which mother’s self-reported mental health was documented as ‘poor’. Mother rejected the suggestion that she had declined one to one support from IDAS. A child protection visit took place on the same date and there were no concerns. 4.92 On 21st April 2019 Child V was again taken to Hospital 2 ED with an upper respiratory tract infection. No safeguarding concerns were identified or communicated from the hospital. 4.93 On 23rd April 2019 the social worker discussed the case in supervision. It was documented that the initial concern was the physical injury to Child V however the cause of this was ‘inconclusive’. Since that time mother had disclosed that father had been verbally and physically abusive to her. The parents remained in a relationship and there was said to have been no further domestic violence reported. Child V was in the care of her mother, who moved between maternal grandmothers and paternal grandparents - where father lived. The next Review CPC was to take place on 29th May 2019. The recommendation to the CPC was to be determined by mother’s mental health and engagement with services. Safety provided by the extended family was to be considered within the recommendations. The team manager directed that mental health were to be invited to core groups. 4.94 On 25th April 2019 the social worker was advised by Inspire to Change that father had not attended a session arranged for that day. The purpose of the session was to complete some preliminary work in advance of the first Respectful Relationships session. The social worker rang father who said he has been busy at work and had forgotten about the appointment. The social worker arranged to see father on 2nd May 2019. 4.95 The following day children’s social care received a letter from IAPT to advise that they had referred mother for input from a core CMHT practitioner for her symptoms of agoraphobia which was not treatable by IAPT. She would also receive support regarding restriction of diet in an attempt to lose weight following the birth Strictly Confidential 24 of Child V. It was reported that mother still felt at risk from her partner as his anger outbursts could be unpredictable. 4.96 The social worker met father on 2nd May 2019 to discuss his relationship with mother and his issue with anger management. No further details were documented. On the same day father attended the Inspire to Change session which had been re-arranged from 25th April 2019. He said that his relationship with mother was currently ‘good’. During the session he and his keyworker discussed the issues which triggered his anger and how to manage these. 4.97 On 8th May 2019 the health visitor saw Child V for her 8-12 month assessment. She was being cared for by her maternal grandmother as mother was away on holiday. Delayed development in gross and fine motor skills was noted and so the health visitor planned to review the child in three months. Activity sheets were provided. Gross motor skills are larger movements with arms, legs, feet or the entire body such as crawling. Fine motor skills are smaller actions such as picking things up between finger and thumb. On the same date the health visitor emailed the social worker to provide further detail on Child V’s attendances at Hospital 2 on 6th March and 21st April 2019. The health visitor said she would follow up the second attendance with the GP as maternal grandmother had told her that Child V had been prescribed a course of antibiotics and an inhaler as and when required but this was not recorded in the Hospital ED notes. 4.98 On 13th May 2019 a child protection visit took place at which Child V was seen crawling very well. Mother was said to be keen to show the child crawling following concerns from the health visitor that her development was delayed in gross and fine motor skills. Mother reported that she was binge eating and making herself sick afterwards. 4.99 A core group meeting took place on 15th May 2019 at which mother reported continuing struggles with her mental health, not eating, feeling anxious when leaving home and struggling to take her epilepsy medication. Father had a forthcoming Inspire to Change appointment. Mental health services were unrepresented at the core group meeting but the social worker contacted the service in an effort to expedite mother’s appointment with the core practitioner which was arranged for 3rd June 2019. 4.100 On 16th May 2019 father attended his first Respectful Relationships session having been unavailable for the first session on 9th May. He subsequently attended sessions during the remainder of May, June (missing one session that month) and July 2019. His arrest on 16th August 2019 prevented him from fully completing the course. Strictly Confidential 25 4.101 On 24th May 2019 the social worker completed the review child protection report which stated that whilst there were worries in respect of mother's mental health and father and mother's relationship, and Child V being exposed to arguments, it was thought that there were protective factors in place such as being able to rely on family support, and parent’s engagement with services. Therefore, it was recommended that Child V should no longer be subject to child protection planning and that the family be supported through a child in need plan. The team manager agreed with this recommendation as there had been no evidence of significant harm to Child V during the review period. Father was said to be engaging with the respectful relationships course. Throughout the Child Protection process Child V had presented as a happy, well cared for and content child. 4.102 On 28th May 2019 a child protection visit took place at which the Review Child Protection report was shared with the parents who agreed to work with a child in need plan. 4.103 At the review conference meeting on 29th May 2019 it was the unanimous decision of the practitioners present that Child V should be de-planned. Apologies had been received from the police and mental health services. Whilst it was accepted that there continued to be concerns about mother’s mental health, there had been no concerns about the care afforded Child V. Father was said to be engaging with Inspire to Change. The child in need plan was to include the following: • Mother and father to register Child V with a dentist. • Social Care to look at any possible support for an epilepsy alarm for mother. • Father to continue to engage with Inspire to Change. • Mother to engage with ‘health’ and Inspire to Change. • Social Care to support with housing. 4.104 On 3rd June 2019 mother did not attend the CMHT core practitioner appointment. A further appointment was to be offered. 4.105 On 6th June 2019 father’s Inspire to Change key worker emailed the social worker to pass on a concern about father’s behaviour. The keyworker wrote that father’s engagement with the sessions was ‘fine’ but when he attended sessions, mother accompanied him and waited in the vehicle in which they had travelled to the evening session. The key worker said that father had been asked about this and replied that mother wanted to accompany him. The keyworker went on to write in the email that ‘bearing in mind the concerns about (his) controlling behaviour, it might be that he is making her come with him because he has to do the group’. The Strictly Confidential 26 keyworker concluded the email by writing that this might be an issue the social worker wanted to speak to father about. There is no record of this email or any action in response to the email in the children’s social care chronology. 4.106 On 14th June 2019 the police were called to an argument between mother and father. Mother said she had become anxious during the argument and texted a friend to contact the police on her behalf. Mother disclosed to the police that she suffered from anxiety and panic attacks from a previous relationship. The incident was assessed as a standard risk and filed. 4.107 On 17th June 2019 a person reported that father had threatened to smash his face in with a hammer during a phone call. The incident was categorised to be neither familial nor domestic related and the case was filed by the police under ‘evidential difficulties’. 4.108 On 24th June 2019 the CMHT practitioner visited mother at home where she was feeding Child V. She said she currently spent most days in the house or at her maternal grandmother’s house when her partner was at ‘college/work’. She said she had low self-esteem and did not like her 'body image' since having her daughter. Due to being anxious and not accessing the community she had been unable to attend parenting classes and mother and baby groups. She said that Child V’s christening was taking place in August and she was become increasingly anxious about it. Mother said that she would like to be able to 'talk to someone' about her mental health who was not a member of her family or a friend. She said she would like to be able to access the community with her daughter and increase her confidence. Graded exposure work and the Recovery Skills Training Course (RSTC) were discussed with mother. She described fleeting thoughts of harming herself but confirmed that these were 'just thoughts' and cited her daughter and partner as strong ‘protective’ factors. 4.109 On 25th June 2019 children’s social care received a referral from the police in respect of the verbal dispute between mother and father on 14th June 2019. Child V was present in the home but did not witness the verbal argument. 4.110 On 2nd July 2019 the first child in need meeting took place. Mother was said to be accessing mental health support and now taking anti-depressants. Father was said to be engaging with his course but had missed one appointment (on 27th June 2019). Father said he was enjoying the course, had learned a lot from it and could see other’s points of view. The recent verbal argument was addressed. Mother said she was being ‘paranoid’ about the past, but became scared when father raised his voice. Mother and father were living with paternal grandparents as mother was said to have fallen out with maternal grandmother over the christening arrangements for Child V. Mental health services did not appear to have been invited to the first child Strictly Confidential 27 in need meeting, the date of the meeting having been set at an earlier meeting at which mental health services were unrepresented. 4.111 On 3rd July 2019 the social worker discussed the case in supervision. The recent dispute between mother and father was discussed. Mother’s emotional health remained a concern. Whilst she did not present as having significant mental health problems, her mood peaks and troughs could intensify arguments with father. Mother’s mental health worker was to be invited to the child in need meeting to ensure mother was getting the support she needed. Paternal grandmother was also to be invited. 4.112 A child in need visit planned for the same day did not take place as no-one answered the door. The social worker phoned mother and received no reply. She phoned father who said that mother would be in bed. 4.113 A planned child in need visit by a duty social worker did not take place on 15th July 2019 as no-one answered the door. 4.114 A child in need visit was completed by a duty social worker on 17th July 2019 and no concerns were noted. Child V was clean and well presented. Mother was said to be eating well and engaging with her mental health worker and taking her antidepressant medication. 4.115 On 22nd July 2019 mother was seen at home by the CMHT practitioner. Father was also present on arrival. Mother said she had been spending most of her time at home or going to maternal grandmothers when taken by father. She said she had been experiencing 'mood swings' adding that she could often cry for no reason and become upset but struggled to identify any particular triggers. She questioned the benefit of the antidepressants. She denied any current suicidal ideation and had no plans or intent. She reported that she may have 'thoughts' of harming herself, adding that these were just thoughts and cited her daughter as a strong ‘protective factor’. 4.116 The health visitor was unable to obtain a reply to planned home visits on 24th and 25th July 2019. When she visited again on 1st August 2019, the health visitor was told by maternal grandmother that mother was living between addresses and that she was unable to contact her. A successful home visit was made on 2nd August 2019 when Child V’s development was assessed to be age appropriate. 4.117 On 5th August 2019 the CMHT practitioner visited mother at home. Father was present during the visit. She said her medication was making her ‘tired all the time’ and that she could sleep for 12 hours and still be able to nap during the day. Strictly Confidential 28 However, she felt that the medication was having a positive effect on her mood and also reported that she had caught a bus to maternal grandmother’s address recently which she would not have had the confidence to do before. She said that Child V’s birthday and christening were taking place the following week and she was looking forward to this. She said she remained conscious about her weight and body image. She has been referred to a dietitian but if this did not help her to lose weight she would explore the option of a gastric band. 4.118 On 7th August 2019 the social worker discussed the case in supervision. It was agreed that it was necessary to ensure that mother was engaging with mental health services and father was engaging with ‘domestic violence’ services. Further reference was made to the need to invite paternal grandmother to the child in need meeting. 4.119 On 8th August 2019 Child V was seen by a consultant paediatrician following the earlier GP referral to assess lactose intolerance. The child was discharged as her symptoms were said to be ‘resolving’. 4.120 On 12th August 2019 the social worker rang the CMHT to check on mother’s progress and was advised that there were no concerns around risk and possible discharge plans were to be discussed with mother at the next appointment. 4.121 The social worker made a child in need visit on 13th August 2019 and no concerns were noted. Child V was happy and content throughout the visit and moving normally. The child in need meeting also took place on this date. No details have been provided other than a reference to a ‘growth review’ being requested. 4.122 On 15th August 2019 the health visitor received no reply to a planned home visit. She contacted mother by telephone who agreed to attend clinic for a weight review in September. 4.123 On 16th August 2019 Child V’s paternal aunt took the child to Hospital 1 ED after noticing that she had some bruising to the side of her face. She explained to staff that covert cameras had recently been fitted by the paternal grandparents. When the recording from those cameras was viewed it showed that Child V had been the subject of a very violent assault by father who was the only other person in the room at the time. The cameras had been fitted two days prior to the assault as the paternal grandparents were concerned that Child V was being neglected when they were out of the house as they often returned to find her in soiled nappies and left in her cot. They had also experienced an incident of some money going missing. Strictly Confidential 29 4.124 The further medical examinations of Child V revealed that she had a healing fracture to the left ulna (bone in the forearm) believed to have been sustained between two weeks and three months prior to the incident reported on 16th August 2019. There was bruising to her left arm, bruising to the palm of one of her hands, a three centimetre by two centimetre bruise over her left eye and some haemorrhaging of her eye. Strictly Confidential 30 5.0 Contribution of family members 5.1 Mother and maternal grandmother met the independent reviewer together, although mother was spoken to alone for part of the conversation to enable her to have a private discussion about more sensitive issues. 5.2 The paternal grandparents also met the independent reviewer together and were joined by their daughter (paternal aunt) for part of the conversation. 5.3 At the time the conversations took place both families were understandably preoccupied with the ongoing care proceedings in respect of Child V which may have influenced some of the comments they made to the independent reviewer. 5.4 The recollection of key events by family members is presented as a single narrative. To aid clarity the contribution of the paternal grandparents is shown in italics. 5.5 At the time she became pregnant with Child V, mother said that she was attending College, adding that father wasn’t working at the time. She recalled that she had quite a difficult pregnancy. 5.6 Mother said that the paternal grandparents purchased a property (address 3) for mother, father and Child V to stay in which she said was ‘lovely’. Mother added that she and father moved into this address in May 2018 in order to ‘get it ready’ for the child’s birth. 5.7 Mother confirmed that forceps were used during Child V’s birth. She said that she took Child V to a doctor’s appointment when the child was around 10 days old. (This may have been the 31st August 2018 GP appointment (Paragraph 4.27)). 5.8 Turning to the incident on 5th September 2018 when marks were observed in and around Child V’s left eye, under her left arm and on her abdomen, mother said that ‘everyone put it down to the forceps’ used in Child V’s delivery. She added that she understood that the marks had initially been investigated as a non-accidental injury because of the young age of Child V but eventually it had been concluded that the use of forceps was the cause. She said that if the marks were believed to be non-accidental, she questioned why had the child been returned to the care of herself and father? Strictly Confidential 31 5.9 Mother confirmed that Child V was allowed to stay with the paternal grandparents for around two weeks after being discharged from hospital following the 5th September 2018 incident. She said that the child was then returned to the care of mother and father who continued to live at Address 3. 5.10 The paternal grandparents also confirmed that Child V was discharged from hospital into their care. They said that they believed this was because they had not had contact with the child in the days prior to the marks being seen on 5th September 2018 and because children’s social care deemed them capable of looking after her. 5.11 During this period of two weeks or so, the paternal grandparents said that they managed contact between Child V and her parents, including mother’s breastfeeding of the child. Around five days after the child was discharged from hospital, the paternal grandparents said that ‘the bruising reappeared in the same place’ when Child V began ‘screaming’ for her milk. The paternal grandparents added that at the time Child V had been discharged into their care from hospital, the marks observed on 5th September 2018 were no longer visible but the marks seen in and around her left eye appeared to return when the child cried to be fed. They said that they contacted the social worker and arrangements were made for Child V to be taken back into hospital. They said that the child was taken away and examined but they didn’t hear anything more about it. They added that the marks were no longer visible by later that same day (Paragraph 4.35 refers to this incident). 5.12 The paternal grandparents said that they were told by children’s social care that they could return Child V to the care of mother and father and they recollected that this took place during the first week in October 2018 (This actually took place on 21st September 2018). They also said that mother and father then began caring for Child V in the house that they (paternal grandparents) had purchased for them (Address 3). 5.13 The paternal grandparents said that they were never told whether the marks observed on Child V’s body on 5th September 2018 were accidental or non-accidental. They say they assumed they must be non-accidental because of the decision to return Child V to the care of her parents in September 2018. 5.14 Mother said that she thought that the child protection plan was ‘just a procedure’ for ‘keeping an eye on things’ as Child V had been under a certain age at the time the marks were observed on 5th September 2018. Strictly Confidential 32 5.15 The paternal grandparents said that at the beginning of November 2018 mother, father and Child V moved in with them, adding that their daughter (paternal aunt) moved out of the family house into address 3 to facilitate this. 5.16 Mother said that she didn’t settle in Address 3 because she wanted to live nearer to her mother and Address 3 was closer to the paternal grandparents’ address. After Child V was returned to the care of herself and father, father would regularly drive her and the child to maternal grandmother’s address before going off to work with his father, so she was not actually spending much time at address 3. She said she tried to make things work at address 3 but said she was struggling. Mother said that she had anticipated more support from the paternal grandparents whilst she and father were living at address 3 with Child V but claimed that this had not materialised despite paternal grandmother cutting her working hours. 5.17 Mother said that she, father and Child V moved out of Address 3 on 5th November 2018 and she and Child V moved in with maternal grandmother. Mother added that she had never actually lived at the paternal grandparents’ address. She said that she would take Child V to see the paternal grandparents, who also looked after Child V on some weekends. (Agency records indicate that mother and Child V were living with the paternal grandparents at times). 5.18 The paternal grandparents said that after a short period staying with them, mother and Child V moved back to maternal grandmother’s address because mother and father were frequently arguing and falling out. They said that the couple would periodically split up and then ‘make up’ a few days later. 5.19 Shortly after moving out of address 3, mother said that she and father split up, adding that they remained friends and were civil with each other. 5.20 The paternal grandparents said that they had very little contact with children’s social care after Child V was returned to the care of her parents in September 2018. They said that the service never approached them to ask how things were with Child V. They said that they were not invited to core group meetings and that if they had been invited, they could have attended as both of their jobs were flexible. The paternal grandparents said that they were unaware that Child V had been stepped down to support as a child in need until advised of this by this independent reviewer. (It is not documented whether the paternal grandparents were consulted as part of the process of compiling the review child protection report (Paragraph 4.102)). The paternal grandparents felt that children’s social care had relied too heavily on information provided by mother and father who they felt were immature and were not always truthful. Strictly Confidential 33 5.21 Paternal grandmother said that father asked her to attend the core group meeting on 17th January 2019 in order to support him (Paragraph 4.57). Father had told paternal grandmother that mother had been physically abusing him and had ‘blacked his eye’. At the core group meeting, paternal grandmother said she raised the issue, saying that she wanted it to be known that mother had been hitting father. Paternal grandmother said that, at that point, father ‘backed down’ and said that he and mother had only been play fighting. 5.22 The paternal grandparents also recalled the family group conference although they said that they understood the purpose of the meeting was to ensure that if mother and father ‘fell out’, they (paternal grandparents) would be able to have access to Child V. The purpose of the family group conference was much wider than the paternal grandparents recalled and the concerns in respect of Child V would have been summarised and a discussion of the role the wider family could play in safeguarding Child V would have taken place. 5.23 They said they had been unaware that the police had been called to their address in respect of domestic abuse incidents until after the 16th August 2019 incident. They said that they were also unaware of difficulties practitioners experienced in gaining access to their address, although paternal grandfather was aware of practitioners ringing father, who worked with him, to enquire about the whereabouts of mother and Child V. The paternal grandparents said that they were both at work all day and so were not always aware of events which had taken place whilst they were out. 5.24 However, they became concerned that mother was neglecting Child V and began returning home at random times during the working day and found mother in bed and Child V with a nappy which needed changing. These concerns and an incident in which money went missing convinced them to install CCTV cameras in the house. Less than 48 hours after their installation, the incident in which father subjected Child V to a sustained assault was captured by the cameras. The paternal grandparents were away at the time but were able to access the recording of the incident remotely. 5.25 Mother’s recollection of the assault captured on CCTV was that father told her that Child V had ‘head butted him deliberately’ so he had put her back in her cot, adding that the child was at an age when she could be told off and that she couldn’t be allowed to ‘get away with it’. Mother checked Child V at this point and saw what she described as a ‘black eye’. 5.26 The paternal aunt, who was also in the house at the time, took Child V to hospital. In her contribution to this review, paternal aunt said that when she took Strictly Confidential 34 Child V to hospital on 16th August 2019 (Paragraph 4.123), she says that she asked staff in the Hospital ED to contact the police and says that she was told that the police would not be contacted until the following morning so she decided to report the matter to the police that evening. BHNFT records indicate that both the paternal aunt and nursing staff contacted the police on the evening of 16th August 2019. 5.27 The paternal grandparents said that they told children’s social care about father’s anger management issues at the time that the marks observed on Child V were investigated in September 2018. They said that he had struggled to control his temper all of his life and they recalled two referrals to CAMHS during his childhood which they say were rejected by that service. 5.28 Mother said she was concerned about father’s anger issues which she understood he had had difficulty in managing for many years. She felt that the paternal grandparents tended to play down concerns about father’s anger management which she felt may have prevented him getting the help he needed. However, mother acknowledged that the paternal grandparents were not aware of all of the incidents in which he had lost control of himself. 5.29 The paternal grandparents didn’t feel that the Respectful Relationships course did father any good. Although they said he didn’t really speak about the course, they say that he did tell them that it wasn’t really about anger management. They went on to say that the course didn’t prevent his anger worsening. They said he became so angry with paternal grandfather that he left his apprenticeship with him and he and mother ‘banned’ them from attending the christening of Child V. 5.30 Mother felt that father’s attendance on the Respectful Relationships course had been of benefit to him. She said he seemed to become a totally different person, adding that it was like ‘waking up in a new relationship’. Maternal grandmother concurred with her daughter, saying that she noticed a difference in him. 5.31 Mother confirmed that there had been arguments over the christening but portrayed these as primarily arguments between herself and paternal grandfather. 5.32 The paternal grandparents also said that father had been referred to a counsellor by the college he attended on one day a week as part of his apprenticeship. They said that father not infrequently came into conflict with his college tutor who would sometimes send him out of class. When this happened, father would go and see the counsellor. If he couldn’t locate the counsellor, father would just return home for the rest of the day. Strictly Confidential 35 5.33 Paternal grandmother said that she had become so concerned about father’s ability to manage his anger that, with his agreement, she arranged an appointment for him to see his GP which was scheduled to take place on 19th August 2019, three days after his assault on Child V came to light. The GP appointment had been arranged prior to the assault on Child V. 5.34 Mother was asked whether there was any domestic violence and abuse in her relationship with father. She said that there were three main incidents. She said that the first incident took place when Child V was a couple of weeks old. The child had had a restless night and so mother had taken her out of her Moses basket and put her in the bed she shared with father. However, the child was still unable to settle, and she said that father was getting more and more annoyed. So mother removed the baby from the bed and sat in a swivel chair in the bedroom with the child wrapped in her dressing gown. She said that father pulled her off the swivel chair. Mother said she was able to protect the child, but her elbow was injured in the incident which she said ‘really, really hurt’. She said that father may not have realised that mother was holding the baby at the time he pulled her off the chair. Mother said he then snatched the baby from her and took her into his car, telling mother to get in the car also and then drove them onto the moors and threatened to leave her there, making her get out of the car for a time. She said that she cried all the way there and all the way back. She said she had been scared and in pain (This disclosure is similar in several respects to an incident mother recounted to the social worker in March 2019 (Paragraph 4.77)). 5.35 In their contribution to this review, the paternal grandparents said that they did not believe the incident described by mother in the above paragraph ever happened. 5.36 The second incident mother shared with the review took place when she and father were leaving a friend’s house. Child V was not present. She said she carried her shoes and handbag out to the car and sat in the front passenger seat with her feet out of the stationary car whilst she put her shoes on. She said that father pulled her towards him, hurting her hand and she quickly shut the car door as he drove off. When they arrived at paternal grandparents’ house, she said that ice was put on her injured hand and paternal grandfather drove her to her mother’s address. She said that this incident took place shortly after they had moved out of address 3 and that she and father split up after this. This incident was not reported to any agency until January 2019 when mother disclosed it to the social worker (Paragraph 4.61). Father later largely confirmed mother’s account (Paragraph 4.64). Strictly Confidential 36 5.37 In their contribution to this review, the paternal grandparents confirmed that this incident took place although they said that mother ‘tried to jump out’ of the car and that father grabbed her in order to pull her back in. 5.38 The third incident mother disclosed to this review was when she asked her friend to contact the police as a precaution after father raised his voice to her which she said had panicked her (Paragraph 4.105). Strictly Confidential 37 6.0 Analysis In this part of the report each key line of enquiry will be addressed in turn. The offer of Early Help 6.1 When mother, accompanied by father, attended the booking appointment in respect of her pregnancy with Child V, the community midwife documented a number of concerns (Paragraph 4.1) She and father were young parents. Father was due to turn eighteen in two weeks whilst mother was two months away from that milestone. Mother was documented to be epileptic, to have mental health issues (‘depression, overdose and self-harm’) and noted to present with low mood during the appointment, to have misused substances previously, to be a smoker and to be living with her mother and her siblings in an over-crowded environment. 6.2 It would have been appropriate to offer mother and father Early Help in these circumstances. Early Help means providing support as soon as a problem emerges, at any point in a child’s life, from the foundation years through to the teenage years (2). Early Help was discussed with mother and father at the booking appointment by the community midwife and it was intended that this issue would be further discussed by the specialist teenage pregnancy midwife to whom mother was referred. When the specialist teenage pregnancy midwife subsequently met mother and father, whether Early Help was discussed, offered or declined was not documented and the subject does not appear to have subsequently been returned to despite mother’s unusually large number of unscheduled attendances at hospital during the course of her pregnancy. 6.3 Irrespective of whether mother and father declined the offer of Early Help, which was support which would have required their consent, the specialist teenage midwife could have completed an Early Help Assessment (EHA) to better inform the care and support provided to the family. The Barnsley Assessment Framework states that an EHA should be commenced when a child appears to have an additional need that cannot be met by a single agency (3). Completion of the EHA would have enabled a thorough exploration of issues such as family functioning and relationships in the home, home stability, physical, emotional and mental health needs, domestic abuse, antenatal care and readiness for the baby’s arrival – including encouragement to attend the Having a Baby programme - substance misuse, social Strictly Confidential 38 isolation, access to services, formal and informal support from wider family networks, employment, training and finance and housing conditions. 6.4 A more thorough exploration of issues may have prompted contact with CAMHS whom mother said continued to support her with her mental health. (Mother had been referred to CAMHS in August 2016 following the first of two overdoses. Her final contact with CAMHS was in May 2017 which was seven months before her January 2018 booking appointment with the community midwife). A more thorough exploration of issues may also have prompted consideration of a referral to children’s social care for a pre-birth assessment, although it seems unlikely that that agency would have considered a pre-birth assessment to be necessary given the support mother was receiving from the specialist teenage pregnancy midwife and the support being provided by the paternal grandparents. 6.5 However, the Barnsley Assessment Framework makes clear that the EHA process is a consensual process (4) and does not encourage practitioners to complete an EHA, or complete it as far as possible, when consent is refused or withdrawn. 6.6 An area of antenatal support that mother did not benefit from was the nationally mandated visit by a health visitor at 28 weeks or later in the pregnancy (5). This is the first time the health visitor meets with the parents to discuss any concerns or issues they may have about becoming parents and is particularly important for first time parents – as in this case. During this visit the health visitor would be expected to explain the health visiting service and complete the initial holistic family health needs assessment. The assessment includes: emotional support, transition to parenthood, attachment, identify families who need additional support, infant development, feeding, and the Healthy Start programme (https://www.healthystart.nhs.uk/). The antenatal visits also help the health visitor identify the appropriate level of health visitor support a family requires. 6.7 The reason mother and father did not receive this antenatal visit was because an incorrect estimated date of delivery (4th October 2018) was sent to, or incorrectly recorded by the health visiting service. It is understood that this may not be a problem exclusive to this case. The health visiting service realised that mother’s estimated date of delivery may have been incorrectly recorded a few days prior to the birth of Child V when an entry in mother’s notes made by the epilepsy service indicated that delivery was imminent. Efforts to contact the specialist teenage pregnancy midwife prior to the birth proved unsuccessful. Strictly Confidential 39 The effectiveness of action to safeguard Child V when she was taken to Hospital 1 emergency department on 27th August 2018 with marks on her eye 6.7 Neither the practitioner who saw Child V in Hospital 1 ED during the late evening of 27th August 2018 (Paragraph 4.21), nor the health visitor who saw the child the following morning (Paragraph 4.22) followed the Barnsley Safeguarding Children Board Protocol for the management of actual or suspected bruising in non-mobile infants which had been issued in March of that year (6), hereinafter referred to as the non-mobile protocol. The non-mobile protocol states that ‘bruising in babies who are not rolling, or crawling is unusual. National and local serious case reviews have identified the need for heightened concern about any bruising in a baby who is not independently mobile. It is important that any suspected bruising is fully assessed, even if the parents feel they are able to provide a reason for it’. In cases in which the infant the infant does not appear seriously ill or injured – as in Child V’s case - practitioners are expected to record what is seen, using a body map or line drawing if appropriate and record any explanation or comments by the parent/carer word for word. The protocol goes on to state that a referral must be made to children’s social care without delay and they would arrange further multi-agency assessment, the first part of which would be a paediatric assessment. The protocol advises practitioners to use their own professional judgement to determine if they need to stay with the child in order to maintain the child’s safety. 6.8 The practitioner who saw Child V in Hospital 1 ED documented ‘?bruising around left eye darker, reddish purple skin’ but did not go on to describe the location, appearance, size, or colour in more detail which may have helped in the management of the case. On the ED form the practitioner wrote ‘no concerns with parents behaviour’ which indicates that the practitioner gave some thought to whether the mark noted could have been non-accidental. There is no record of the practitioner discussing the case with a doctor and no contact was made with children’s social care. The question on the ED form which asks whether there are any safeguarding concerns was answered in the negative but no rationale for this response was provided. When the parents decided to leave ED after waiting for just over an hour, advice should have been sought from a doctor. The ED practitioner may have taken some comfort from being told by the parents that a health visitor was scheduled to visit the family the following day, although the time the ED practitioner documented for the visit (8am) was outside standard working hours and therefore could have been queried. The only communication the ED practitioner made with any other agency was with the health visitor service via a standard ‘communication form’ which was not received by the health visitor service until 29th August 2018, which was the day after the health visitor appointment. Care of the Strictly Confidential 40 child was still under midwifery but details of the child’s visit to ED were not shared with that service. 6.9 The ED practitioner would have been working in a busy, pressurised environment in which communication with colleagues can be difficult at the time she saw Child V. It is not unusual for parents who bring children into Hospital 1 ED to be unwilling to wait to be seen. It is not known what explanation was provided by the parents for the mark observed by the ED practitioner, but it seems likely that they may have linked the marks to the forceps used in Child V’s delivery. The ED practitioner would not have had routine access to maternity records as the majority of these are in paper form and stored elsewhere. However, BNHFT has confirmed that there are processes in place for ED staff to request maternity records. If the ED practitioner came to the conclusion that the mark was not a bruise this should have been documented and advice sought from a doctor. The ED practitioner has since offered the explanation that she believed that the child had been seen by a doctor in ED, although there is no documentation to support this. The Barnsley Hospital NHS Foundation Trust (BHNFT) Safeguarding Children Guidelines stress the importance of taking a bruise or injury in non-mobile children very seriously, adding that the child should be seen by at least an ED middle grade or consultant. The BHNFT Guidelines, which were written in April 2012 and reviewed in February 2015 do not include any reference or link to the subsequent Barnsley Safeguarding Children Board non-mobile protocol. 6.10 When the health visitor saw Child V during the new birth visit the following day, she did not document the mark on the child. During the visit mother told her that Child V had been taken to Hospital 1 ED the previous evening after she had noticed bruising to Child V’s inner eye, that the child had been seen by triage but that she had left after being told that ‘she could be waiting for five hours’. The health visitor advised mother to take Child V to see her GP but did not verify whether the child had been taken and what the outcome was. 6.11 The health visitor was subsequently interviewed as part of an internal review and had some difficulty in recalling the visit in any detail. She was not the named health visitor for Child V and had been asked to fit in this visit because the named health visitor was on leave. She recalled that the visit was the fifth visit in a busy day. She said she observed the mark to be a red mark in the corner of Child V’s eye with slight ‘shadowing’ which could have been interpreted as bruising although she felt that it could have been trauma from the child’s birth or an infection such as conjunctivitis. However, the health visitor recalled checking the midwifery notes and child health records for Child V and found no reference to trauma at birth. She said that she forgot to check whether the child had been taken to see the GP due to workload pressures. Strictly Confidential 41 6.12 Both practitioners (Hospital ED practitioner and health visitor) who did not follow the non-mobile protocol, or adequately document their reasons for not doing so, were coping with quite challenging work situations at that time. When under pressure, it is not unusual for practitioners to complete tasks less fully, or to ‘cut corners’ or for the quality of work to diminish. Nor is it unusual for practitioners and their managers to prioritise tasks depending on their importance. However, following the non-mobile protocol is a critical element in the whole system for safeguarding children and it is therefore concerning that practitioners, when managing tasks whilst under pressure, do not appear to have prioritised following this protocol. The effectiveness of action taken to safeguard Child V when marks to her eye and body were observed by practitioners on 5th September 2018. 6.13 It is unclear whether the ‘query bruising around left eye’ observed by the ED practitioner on 27th August 2018 (Paragraph 4.21) could have been linked to whatever trauma caused the ‘small bruise on the child’s left eye’ observed by the GP nine days later on 5th September 2018 (Paragraph 4.27). It seems unlikely given the length of the intervening period and the fact that Child V was seen by several practitioners during that intervening period - including the same specialist midwife who noted the marks on the child’s eye and body on 5th September 2018 – and none of those practitioners noted any concerns. 6.14 Although the specialist midwife response to the marks observed on Child V on 5th September 2018 ultimately safeguarded the child, she did not follow the non-mobile protocol in that she did not refer the case to children’s social care without delay. The author of the BHNFT chronology also observed that the specialist midwife did not inform the hospital safeguarding team. However, the aforementioned BHNFT guidelines are focussed primarily on the action to be taken when a non-mobile child presents at hospital rather than when seen in the community. 6.15 A GP appointment was promptly arranged by the specialist midwife and the GP who examined Child V followed the non-mobile protocol and referred the child to children’s social care without delay. A full child protection medical took place on the same evening followed by a strategy meeting the next day and a joint police/children’s social care Section 47 investigation commenced during which further medical investigations took place to rule out any underlying organic reason for the marks observed on Child V. The case was promptly presented to a Legal Gateway Panel and by 2nd October 2018 the initial child protection conference had taken place at which Child V was made subject to child protection planning under the category of physical harm. The initial child protection conference could have taken place earlier had it been triggered by the first strategy meeting on 6th Strictly Confidential 42 September 2018 rather than the second strategy meeting which was held on 17th September. However, it was not until the second strategy meeting that most of the health investigations had been completed and there is no indication that any delay in holding the initial child protection conference adversely affected Child V. 6.16 The criminal investigation was quickly concluded. Both parents were arrested and interviewed under caution by the police on 8th September 2018 and later released on bail. The case was filed on 21st September 2018. As stated in Paragraph 4.33 the police established that the injuries to Child V took place whilst the parents were caring for her. However, the parents made no admissions of guilt during the interviews. The police ultimately concluded that extensive medical examinations could not ‘state the injuries were intentional’. They documented the injuries to Child V to be ‘unexplained’ rather than non-accidental. It is understood that no crime was recorded. South Yorkshire Police has advised this review that they do not routinely record non-accidental injuries to children as crimes when such injuries are considered to be ‘unexplained’, as in this case. They add that the fact that an injured child is non-mobile ‘must be considered when making (such) decisions’. In deciding whether to record the incident as a crime, the police appeared to be looking for positive proof that the injuries had been inflicted intentionally rather than taking the view that in the absence of any credible alternative explanation for marks on the body of a non-mobile child who was less than a month old, a crime was indicated. 6.17 There is no indication that the response to the 5th September 2018 incident included consideration of the possibility that this may have been the second non-accidental injury to Child V in her short life if the mark observed on her left eye by different practitioners on 27th and 28th August 2018 was a separate and distinct event as it seems likely to have been. 6.18 Additionally, the paternal grandparents’ concern that the mark Child V’s left eye became visible again when she cried excessively (Paragraph 4.34) was not fully investigated. The comprehensiveness of the assessment of Child V and her family and how well understood were parenting capacity and family functioning? 6.19 As it was not possible for Child V to be returned to the care of her parents until the investigation had been concluded and the medical position was clearer, the viability of the child being cared for by members of the extended family was rapidly explored. A viability assessment undertaken in respect of the paternal grandparents was positive. Paternal grandmother was a nurse, the paternal family were not known to children’s social care or the police and the paternal grandparents demonstrated commitment to work with services for the benefit of Child V. Strictly Confidential 43 6.20 Child V had been admitted to Hospital 1 on Wednesday 5th September 2018 and when she was discharged on Friday 7th September 2018, she was discharged into the care of her paternal grandparents. It was stipulated that the parents were not to have contact with the child over the forthcoming weekend. 6.21 At the second strategy meeting held on Monday 17th September 2018 it was agreed that the parents could move in with the paternal grandparents to share the care of Child V. On Thursday 20th September 2018 it was decided that Child V could return to the care of her parents the following day and Section 20 of the Children Act was discharged at that point. It was clear that the expectation of children’s social care was that the parents would continue to live with the paternal grandparents to be supported to care for Child V (Paragraph 4.35). 6.22 However, children’s social may not appear have been aware that the paternal grandparents had purchased a property for the parents and Child V to rent from them (Address 3). In their contribution to this review, the paternal grandparents said that once Child V was returned to the care of mother and father, they (the parents) and Child V lived in address 3 until they left the address in early November 2018. If this is correct, and address 3 was recorded as the parent’s address by both maternity and health visiting services, Child V was in the sole care of mother and father in address 3 for over a month. Mother, father and Child V do not appear to have moved back to the paternal grandparents’ address until they left address 3 around 5th November 2018, a move facilitated by paternal aunt moving out of paternal grandparents address and into address 3. 6.23 The author of the children’s social care chronology observes that whilst the Section 47 assessment in respect of the presenting issue (the injuries to Child V) was detailed and of good quality, the assessment of the wider family and social and environmental factors was left blank although these issues were addressed in the body of the report. At the time the positive viability assessment of the paternal grandparents took place it was noted that further assessment would be required. However, the viability assessment was not further developed because care proceedings were not instigated and so it was not necessary to further assess the paternal grandparents as primary carers for Child V. Additionally the placement plan relating to the discharge of Child V into the care of the paternal grandparents and the transition plan for the return of Child V to the care of her parents both lacked detail. The lack of detail in the transition plan may have been as a result of the assumption that the paternal grandparents would continue to be heavily involved in the care of the child. Strictly Confidential 44 6.24 In their contribution to this review, both the paternal grandparents and mother separately said they assumed that the return of Child V to the care of the parents on 21st September 2018 indicated that the marks observed on the child on 5th September 2018 had been found to be non-accidental. Clearly this was not the case and seems highly unlikely to have been communicated to the paternal grandparents or parents by any practitioner. However, the lack of precision in the placement and transition plans may have left some room for the parents and paternal grandparents to misinterpret events or possibly create a narrative with which they felt more comfortable. How effectively did the Child Protection Plan safeguard Child V? 6.25 The initial child protection plan conference took place on 2nd October 2018 and the decision to step down to child in need support was taken almost eight months later at a review child protection conference on 29th May 2019. Nine core group meetings and a further review child protection conference took place during the eight month period. The meetings were generally attended by the social worker (with a duty social worker deputising on a small minority of occasions), the health visitor and the parents. An epilepsy nurse attended quite frequently. Maternal and paternal grandmother attended two meetings and one meeting each respectively. The police do not appear to have attended any core group meetings and sent apologies to the two review child protection conferences. Mental health services did not attend any core group meetings although they began to be invited only after mother’s overdose of prescribed medication on 21st January 2019. 6.26 Given the importance of the role of the paternal grandparents in supporting mother and father to parent Child V, their absence from all but one core group meeting is unfortunate. Having said that, their absence from core groups may have been an accurate reflection of their role in supporting father and mother with the parenting of Child V, which appeared to diminish over time and the ill feeling which appeared to develop between the paternal grandparents and mother, which may have been a factor in mother dividing her time between maternal grandmother’s and paternal grandparents’ addresses. Children’s social care have advised this review that whilst there was a lack of written invitations to grandparents to attend core group meetings there may have been informal invitations through telephone contact and child protection visits. The service also points out that the grandparents and members of the wider family were represented at the Family Group Conference at which concerns in respect of Child V would have been shared with attendees. In her contribution to this review mother said that she and Child V never lived with the paternal grandparents although this is not confirmed by agency records of visits to Child V. At the practitioner learning event arranged to inform this CSPR, attendees suggested that the times at which core group meetings are held should be more Strictly Confidential 45 flexible in order to facilitate the attendance of family members with work commitments. However, in their contribution to this review, the paternal grandparents both said that their work commitments were sufficiently flexible for them to be able to attend meetings during the working day. 6.27 The absence of mental health practitioners from core group meetings will be dealt with later in the report. The police do not appear to have been invited to core group meetings but having been invited to the initial child protection conference and the two review child protection conferences, including the conference at which it was decided to step down Child V’s case, they sent apologies to all three meetings. Given the reason for the child protection plan was suspected physical abuse of a non-mobile child and given their involvement in most of the domestic abuse incidents involving the parents, it would have been preferable for the police to have prioritised attendance at the two review child protection conferences. The lack of police involvement may have prevented the timely sharing of information held by the police in respect of an incident in which a threat was made to set father’s house on fire (Paragraphs 4.43). The children’s social care chronology questions whether the review child protection conferences were actually quorate in the absence of police representation. 6.28 Two core group meetings were not minuted, and attendance at one core group meeting was not recorded. One set of core group minutes included a narrative of the discussion which took place at that meeting alongside the attendees and actions from a much later meeting. Children’s social care have advised this review that it is the responsibility of the key social worker to ensure that core group meetings are minuted and distributed. However, their chronology was far from clear on this point, indicating that minute taking is a joint agency responsibility and that core group members are responsible for keeping their own record of the outcomes of the meetings but at another point in the chronology noting that the social worker was responsible for both chairing and minuting the core group meetings, a combination of tasks that many people find quite difficult. Without sufficiently detailed and accurate minutes and actions, completed and circulated promptly, both the ability to progress child protection plans and review progress achieved is compromised. 6.29 Child protection visits tended to coincide with core group meetings in the early months of the child protection plan, but eleven child protection visits took place on dates outside of core group meetings. There was a change of social worker five months into the child protection plan which was necessitated by the extended sickness absence of the previous social worker. There was also a change in health visiting team three months into the child protection plan when it became clear that mother and Child V were largely residing with paternal grandmother in a different area of Barnsley. Strictly Confidential 46 6.30 This was quite a dynamic case to manage, with issues arising during the period in which Child V was being supported under a child protection plan which had the potential to present a risk to the child. Concerns that mother may be the victim of domestic abuse from father arose early on and persisted for several months. Father later disclosed that mother physically abused him although he was unspecific about the circumstances in which this took place. A pattern developed of mother and father’s relationship ending then resuming. Mother and Child V moved from paternal grandparents’ address to live primarily with maternal grandmother, who had been found to have a ‘fractured’ relationship with mother at the time of the viability assessments and in a house in which concerns had been expressed about overcrowding. Additionally, maternal grandmother was parenting mother’s younger siblings who had complex needs which may have limited the extent to which she could support mother and Child V. It gradually became clear that father’s anger management issues were current and not wholly historic. Mother took an overdose of prescribed medication and disclosed mental health issues which risked isolating Child V. Indications began to emerge that the parents were not always engaging openly with services including taking Child V to Hospital 2 on two occasions, mother’s denial that IDAS had offered her support etc. Delayed development in Child V’s gross and fine motor skills were noted. 6.31 Children’s social care and the health visiting service responded promptly and effectively to most of these issues, maintaining a strong focus on the welfare of Child V throughout. Mental health services provided mother with largely effective support although clarifying the issues on which she needed support took some time and resulted in some delay in her being connected to the most appropriate team. A family group conference took place which sought to involve the wider family in safeguarding Child V and it is significant that it was one of the attendees at that event, paternal aunt, took Child V to hospital on 16th august 2019 after the child had been assaulted by father. The social worker followed up on issues such as mother’s overdose and emerging concerns about father’s anger assiduously and liaised effectively with other services such as mental health services, IDAS and Inspire to Change. 6.32 However, reflecting on the case, particularly the gradual emergence of issues of concern over the course of the child protection plan, emphasises the need for as thorough an assessment as possible at the outset. The prior concerns about mother’s mental health appear to have been overlooked in the assessment carried out by children’s social care, father’s anger management issues came to be regarded as historic, the existence of Address 3 appeared to be overlooked and the assumption that the paternal grandparents were a vital protective factor who were in a position to step in and safeguard Child V should the need arise ought to have Strictly Confidential 47 been questioned given the fact that mother and Child V began spending an increasing amount of time living with maternal grandmother from early December 2018 and the paternal grandparents only attended one core group meeting. It may have been useful to explore why the engagement of the paternal grandparents, who were initially seen as pivotal to safeguarding Child V, diminished over time. 6.33 The social worker was able to regularly discuss the case in supervision, a process which clearly added value at times, including direction on the need to engage mental health services and paternal grandparents in the core group process for example. However, the author of the children’s social care chronology commented that the record of supervision did not always reflect the level of concern which began to emerge about the conflict in the relationship between mother and father. The effectiveness of the response to father’s anger management issues 6.34 Concerns were first raised about father’s ‘volatility’ and difficulties in controlling his anger at an early stage in the investigation of the marks observed on Child V on 5th September 2018 (Paragraph 4.30). However, children’s social care appear to have perceived these concerns to be historic rather than continuing (Paragraph 4.75) until January 2019 when mother disclosed a physical assault by father to the social worker following a core group meeting, later adding that she wasn’t prepared to resume her relationship with him until he received support with his anger (Paragraph 4.61). 6.35 When spoken to by the social worker, father accepted that he struggled to manage his anger, and largely confirmed the details of the disclosure of physical assault made by mother (Paragraph 4.64). During the same meeting, the paternal grandparents disclosed that father’s anger management issues had been present since his early childhood. With father’s agreement, the social worker subsequently referred father to the Inspire to Change programme. However, he failed to attend a preliminary session on 25th April 2019 (Paragraph 4.94). He subsequently began to engage with the ten week Respectful Relationships course offered as part of the Inspire to Change programme. Father missed the first evening Respectful Relationships session on 9th May 2019 as he was on holiday and attended his first session on 16th May. His Inspire to Change keyworker prepared a report for the 29th May 2019 review child protection conference on 21st May 2019 and sent apologies. At the time the Inspire to Change report was completed father had missed the preliminary session, which had been re-arranged, had missed the first of ten Respectful Relationships sessions because he was on holiday and had attended only the second Respectful Relationships session. Strictly Confidential 48 6.36 The Inspire to Change programme is provided by South Yorkshire Community Rehabilitation Company (CRC) who prepared a report describing father’s engagement with the Respectful Relationships course. During the initial interview father acknowledged that he ‘got wound up quickly’ and had sought help from his GP but felt he had ‘nowhere to go’. At this initial appointment he said that he wanted to learn how to manage anger better. He was assessed as suitable for the ten week Respectful Relationships course. He did not attend a further meeting to complete work in preparation for the start of the Respectful Relationships course, saying he had forgotten about it. This meeting was re-arranged for 2nd May 2019. At this meeting he said that his relationship with mother was ‘good’ and when asked what he was doing to achieve this improved state of affairs, he replied that when he began to feel ‘wound up’, he had started to take time out. He said that one of the main triggers to his anger was when mother said things about him under her breath. He later linked this to bullying he had experienced at school when other pupils would say things about him including sometimes whispering about him. Father went on to say that he eventually hit one of the pupils who was bullying him and ‘they didn’t bother him again’. 6.37 Father attended eight of the ten scheduled evening Respectful Relationships sessions. He was observed to be quiet during these sessions but apparently focussed on the content. He began to engage more fully in the later sessions when he acknowledged the impact of his non-verbal communication, recognising that his tendency to clench his fist during disagreements could be seen as intimidating. He was said to have put a great deal of effort into the skill of active listening and into seeing things from another’s perspective. The final Respectful Relationships session took place on 18th July 2019 and he was invited to an exit interview scheduled for 17th September 2019 which he did not attend as by this time, he had been arrested for the assault on Child V. 6.38 Father’s Inspire to Change keyworker expressed concern that mother accompanied father to the Respectful Relationships sessions and waited for him outside in his vehicle (Paragraph 4.106). When asked about this, father said that mother wished to accompany him. The keyworker was concerned that this could be evidence of controlling behaviour on father’s part and alerted the social worker by email. 6.39 Mother felt that engaging with the programme had been of significant benefit to father (Paragraph 5.30) whilst paternal grandparents felt that the course did not do him any good, adding that in their view it wasn’t really about anger management (Paragraph 5.29). Father told the first child in need meeting on 2nd July 2019 that he was enjoying the course, had learned a lot and could see other’s points of view (Paragraph 4.108). What is clear is that father continued to struggle with his anger Strictly Confidential 49 whilst engaging with the programme. On 14th June 2019 mother texted a friend to call the police during an argument in which he raised his voice to her (Paragraphs 4.105 and 5.38) and three days later a person contacted the police to report that father had threatened to ‘smash his face in with a hammer’ during a phone call (Paragraph 4.106). The police shared the details of the first incident with children’s social care but not the second. 6.40 Paternal grandparents have shared with this review that father’s anger was becoming more problematic despite his involvement in the Inspire to Change programme, describing not infrequent conflicts with his college tutor, that shortly before his assault on Child V, he had fallen out with paternal grandfather and left his employment but had agreed to paternal grandmother arranging a GP appointment to seek further help with his self-control. This information was not known to children’s social care or any other agency at the time. 6.41 Given his assault on Child V and the sustained severity of that attack, father’s anger management issues have assumed greater prominence than they may have been afforded prior to the 16th August 2019 assault on Child V. Once children’s social care understood that father’s anger was a current, rather than a historical issue, they took appropriate action to refer him for support and monitored his attendance and engagement with the programme to which he had been referred. However, father’s anger appeared to be viewed primarily in the context of his relationship with mother and the need to safeguard her from domestic violence and abuse and prevent Child V being affected by the domestic violence and abuse in her parent’s relationship. Indeed, Inspire to Change is a programme for men and women who have been abusive, controlling or violent towards their partner. There is little indication that father’s anger was seen as a direct risk towards Child V. Appropriateness of agency responses to maternal mental health concerns and the extent to which any consequent risks to Child V were addressed? 6.42 Mother’s mental health was a periodic, although usually fairly low level concern throughout the period covered by this review. Prior mental health issues were documented by the community midwife at the booking appointment where she presented with low mood (Paragraph 4.1). 6.43 Although she was generally documented to be mentally well during the pregnancy with Child V, the substantial number of unscheduled attendances at hospital during this period could have prompted enquiry about whether she was experiencing anxiety. There was a lack of consistent documenting of her mental health needs by maternity services during several of these hospital attendances. Strictly Confidential 50 6.44 Mother was admitted to hospital in January 2019 after taking an overdose of prescribed antidepressant and pain relief medication. When assessed by hospital mental health services, she described a deterioration in her mental health since the birth of Child V, although the core group meeting four days previously at which it had been alleged that she had physically abused father (Paragraph 4.57) may have precipitated the overdose. She subsequently disclosed that father had assaulted her shortly before she took the overdose and showed the social worker photographs of fingertip bruising on her shoulder which she said had been taken during her hospital admission following the overdose. Mother had previously taken overdoses of medication on two occasions during 2016. 6.45 In early February 2019 the perinatal mental health team assessed mother’s risk of intentional completed suicide in the near future to be low, her risk of impulsive self-harm as low to moderate and there was a risk of deterioration in mother’s mental health without intervention (Paragraph 4.66). She was subsequently referred to IAPT who then re-referred her to core mental health services as there had been a change in her presentation - agoraphobia – which was not treatable by IAPT (Paragraph 4.84). 6.46 After a fairly long interval – 4th April to 24th June 2019 – although mother did not attend a CMHT appointment arranged for 3rd June 2019, mother was seen by a CMHT practitioner who documented that mother was experiencing low self-esteem, low confidence and anxiety which was preventing her accessing community support for herself and Child V. She described fleeting thoughts of harming herself. Child V was documented to be a strong ‘protective factor’ on this occasion and another by the CMHT practitioner (Paragraphs 4.108 and 4.115). Previous serious case reviews have found that whenever practitioners perceive children as ‘protective factors’ in respect of paternal mental health, the unintended outcome is invariably to increase risks for the children who in this case was a ten-month-old child (7). 6.47 When it was decided that Child V should be stepped down to support as a child in need, continued concerns about mother’s mental health were acknowledged, but it was stated that there had been no concerns about the care afforded to Child V (Paragraph 4.103). However, there had been limited joint working between children’s social care and mental health services to assess the potential impact of mother’s mental health needs on her parenting of Child V. After the social worker’s manager had directed that mental health services were to be invited to core group meetings (Paragraph 4.94), mental health services were unrepresented at the next core group meeting (Paragraph 4.100) invited to, but did not attend the review child protection conference (Paragraph 4.103), did not appear to be invited to the first child in need meeting (Paragraph 4.108) and it is not known whether they attended the second child in need meeting (Paragraph 4.121) as no details of the meeting Strictly Confidential 51 have been shared with this review. However, the social worker contacted the CMHT prior to the second child in need meeting and established that the service were considering discharging mother from mental health services (Paragraph 4.120). The social worker had also contacted mental health services on an earlier occasion in an attempt to expedite an appointment for mother. Additionally, IAPT wrote to children’s social care to update them on the treatment being provided to mother (Paragraph 4.96). During the period when mother’s case was first transferred from the perinatal team to IAPT and then onto core CMHT, lack of continuity of mental health worker may have impeded communication between SWYPFT and children’s social care for a time. 6.48 Had joint working between children’s social care and mental health services been more substantial it may have enabled a more complete understanding of the potential impact of mother’s mental health on her parenting capacity. Whilst it is important to note that most parents or carers who experience mental ill health will not abuse or neglect their children, mental health problems are frequently present in cases of child abuse or neglect. An analysis of 175 serious case reviews from 2011-14 found that 53% of cases featured paternal mental health problems (8). Additionally, the risks to children are greater when paternal mental health problems exist alongside domestic abuse, paternal substance misuse, unemployment, financial hardship, poor housing, discrimination and a lack of social support (9). Together, these problems can make it very hard for parents to provide their children with safe and loving care (10). In mother’s case domestic violence and abuse was present in her relationship with father and there was overcrowding in maternal grandmother’s home, where mother and Child V appeared to spend the majority of their time. 6.49 Turning to the potential impact of mother’s mental health needs on her parenting of Child V, the primary issue appeared to be a degree of social isolation and lack of stimulation for Child V, because mother’s anxiety and lack of self-confidence prevented her from taking the child to mother and baby groups in the community. Additionally, although mother was often noted to demonstrate emotional warmth towards Child V, in the period which followed her overdose she was noted to be less emotionally available to her child during visits by practitioners (Paragraphs 4.62 and 4.71). 6.50 Additionally the mental health practitioner did not enquire how Child V’s needs were being met when mother disclosed that she was sleeping for twelve hours because her medication was making her ‘tired all the time’ (Paragraph 4.119). Effectiveness of the response of agencies to disclosures of domestic violence and abuse in the relationship between father and mother? Extent Strictly Confidential 52 to which the potential impact of domestic abuse on Child V was fully considered? 6.51 The police attended three domestic incidents between mother and father (Paragraphs 4.54, 4.74 and 4.105) and all were assessed as ‘standard’ risk. Child V had been present during the latter two incidents but did not witness either incident. Additionally, father had reported what the police documented as historical assaults by mother by hitting and kicking but declined to assist any investigation (Paragraph 4.76). 6.52 Mother shared her concerns about father’s anger in late January 2019. At that time she also disclosed to the social worker an incident in which father had pulled her hair and dragged her into the car he was driving. Father later accepted that he struggled to address his anger and paternal grandparents confirmed that this had been an issue for him since the age of six. Father also largely confirmed the above domestic violence disclosure mother made to the social worker. Mother later made a further disclosure to the social worker of what may have been domestic abuse when father was said to have ‘slammed the brakes’ on the car causing her knees to hit the dashboard. At this time mother also disclosed that father had hit her whilst they were staying with the paternal grandparents and threatened to drive her onto the moors and leave her there. This latter disclosure is similar in some respects to the disclosure of domestic abuse mother made to the independent reviewer (Paragraph 5.34). 6.53 In Barnsley there is no policy of automatically referring a case to MARAC after three non-high risk domestic abuse incidents in a twelve month period as is the case in some areas of the country. South Yorkshire Police has advised this review that they deal with around 37,000 repeat domestic abuse incidents each year. If three non-high risk incidents in a twelve month period were to automatically generate a MARAC referral, they take the view that this would be unmanageable. 6.54 In this case three incidents of domestic abuse were reported to the police by mother over a period of six months which were all assessed as standard risk. During the same period father appears to have reported an incident or incidents of domestic abuse by mother to the police which were considered to be historic. During the same period mother disclosed three incidents of domestic abuse by father to the social worker, although the dates on which these incidents occurred are not completely clear. None of the disclosures of domestic abuse mother shared with the social worker were reported to the police and no DASH risk assessments were conducted. This prevented these incidents being considered alongside the other domestic abuse incidents involving father and mother which had been reported to the police and may have prevented the consideration of a MARAC referral. Whilst Strictly Confidential 53 South Yorkshire Police are clear that there is no automatic referral to MARAC on exclusively numeric grounds, a referral to MARAC could have been considered on the grounds of professional judgement. 6.55 At the practitioner learning event arranged to inform this review, the view was expressed that it was not necessary for the social worker to conduct DASH risk assessments when mother disclosed domestic violence and abuse to her because this would be considered alongside all other information relevant to the child protection process. Whilst it is clear that mother’s disclosures of domestic violence and abuse were considered as part of child protection planning, the absence of DASH risk assessments limited the opportunity to consider a MARAC referral as stated in the preceding paragraph. 6.56 Father’s Inspire to Change keyworker raised concerns with the social worker that father was exhibiting controlling behaviour towards mother as she accompanied him to the Respectful Relationships evening sessions and waited for him outside in his vehicle. The keyworker questioned whether father might be making her accompany him because he ‘had to’ attend the course. It is not known what action the social worker took in response to the keyworker’s concerns. 6.57 Additionally there appeared to be a lack of professional curiosity when mother attended Hospital 1 on 22nd July 2018 having ‘fallen down the stairs at home’ (Paragraph 4.13). It seems likely that mother, who was over eight months pregnant at that time, was living with father at address 3 at that time. Whether mother was accompanied and by whom was not recorded and the domestic abuse question was not asked. 6.58 Documentation of the domestic abuse question being asked was not completed on a number of occasions when mother attended hospital. Whilst it is BHNFT policy only to ask the question at least once in private, good practice would be to ask on a number of occasions. 6.59 It is not known whether the possibility that father’s anger management issues and mother’s disclosures of domestic abuse by father prompted consideration of whether father was capable of physically abusing Child V. CAADA (co-ordinated action against domestic abuse) research indicated found a major overlap between domestic abuse and direct harm to children (11), finding that ‘the perpetrator of domestic abuse was very often the perpetrator of direct harm to the child’. When it was decided to step Child V down from the Child Protection Plan to support as a Child in Need on 29th May 2019, was this decision fully informed by all concerns of which partner agencies had become aware? Strictly Confidential 54 6.60 The child protection plan was first reviewed in December 2018 (Paragraphs 4.51 and 4.52). Given that the plan was at an early stage and Child V was of a very young age and completely dependent on her parents to meet her care needs it was recommended that a further period of child protection planning was necessary in order to evidence the parents’ ability to continue to safeguard and meet the care needs of Child V and for the actions in the child protection plan to be completed. Progress was acknowledged as was the fact that Child V had experienced no further injuries. 6.61 It was entirely appropriate to continue with the child protection plan. In addition to the injuries to Child V noted on 5th September 2018 - assumed to be non-accidental – which had precipitated the child protection plan - by the time of the first review child protection plan conference there had been a threat to set father’s house on fire, the first indication that mother may be the victim of domestic abuse by father, mother and father had separated ‘due to constant arguing’, mother and Child V had moved to maternal grandmother’s address where there had been concerns about overcrowding and where paternal grandmother had caring responsibilities for mother’s younger siblings who had complex needs. The updated child protection plan envisaged mother being supported to attain independent living and a referral to the Family Intervention Service was to be made to assist her in this regard. The paternal grandparents were invited to the first review child protection conference but did not attend. 6.62 The second review child protection conference took place on 29th May 2019 at which a unanimous decision was taken to de-plan Child V and support her as a child in need (Paragraph 4.103). Although the decision was unanimous the meeting was attended only by the chair, the social worker, the health visitor, the epilepsy nurse and mother and father. Apologies were received from the police and mental health services. 6.63 Whilst there are limitations on the usefulness – and fairness - of ‘second guessing’ decisions taken by practitioners in good faith based on the information available to them at the time they made their decision, it is appropriate to review the information which was known to partner agencies at the time the decision to step down Child V was made and the extent to which the actions in the child protection plan had been accomplished. 6.64 The key consideration was that Child V was not known to have suffered any further physical harm, although as previously stated the injuries observed on Child V on 5th September 2018 appear to have been treated as the only incident in which the child sustained non-accidental injuries even though prior marks had been noted Strictly Confidential 55 on the non-mobile child which may also have been non-accidental. However, by April 2019 the cause of the injuries to Child V was documented to be ‘inconclusive’ (Paragraph 4.94) which was unhelpful. Whilst it was true to say that the injuries to Child V had not been conclusively proved to be non-accidental, unexplained bruising in a non-mobile child is highly suggestive of non-accidental injury unless proven otherwise. 6.65 Additionally Child V had been regularly observed by a range of practitioners at both her paternal grandparents’ address and maternal grandmother’s address and always presented as a happy, well cared for and content child. Although she was well cared for, social isolation could have been considered to be a developing concern. There were also concerns over the frequency with which she was being moved between her grandparents’ addresses and delayed development in gross and fine motor skills had been noted by the health visitor. 6.66 Other issues of concern arose or developed further during the five months in between the December 2018 and the May 2019 review child protection conference which are summarised below: • Mother and father were young parents whose personal relationship had come under strain. Mother and father split up in early December 2018, had resumed their relationship by late February 2019, split up again in early March but resumed their relationship within a few days. • Mother and Child V divided their time between paternal grandparents’ and maternal grandmother’s addresses from 5th December 2018. On 6th February 2019 the perinatal mental health team identified a moderate risk of carer stress for maternal grandmother as she was managing the complex needs of mother’s younger siblings and there was overcrowding in her home. Her capacity to support mother in parenting Child V may have been affected by the other demands on her time. • Although there was a well-attended family group conference, conflict between mother and the paternal grandparents continued. • Mother took an overdose of prescribed medication on 21st January 2019. The trigger appeared to be paternal grandmother’s criticism of her parenting of Child V and her disclosure that mother had physically abused father which were made at the core group meeting on 17th January 2019. Child V was present in the house at the time mother took the overdose. During her subsequent engagement with mental health services, mother disclosed low confidence, lack of assertiveness, ongoing difficulties in coping with stressful Strictly Confidential 56 situations, symptoms of anxiety and agoraphobia when leaving home and struggling to take her epilepsy medication. • Largely as a result of her mental health issues, mother was unable to make progress towards independence, which had been a key objective of the child protection plan agreed at the December 2018 review child protection plan. • Although mother had expressed an interest in taking Child V to baby groups in late January 2019, she had not had the confidence to do so by the time of the May 2019 review child protection conference. • Mother’s concerns about father’s anger emerged in late January 2019. At that time she also disclosed to the social worker an incident in which father had pulled her hair and dragged her into the car he was driving. Father later accepted that he struggled to address his anger and paternal grandparents confirmed that this had been an issue for him since the age of six. Father also largely confirmed the above domestic violence disclosure mother made to the social worker. Mother later made a further disclosure to the social worker of what may have been domestic abuse when father was said to have ‘slammed the brakes’ on the car causing her knees to hit the dashboard. At this time mother also disclosed that father had hit her whilst they were staying with the paternal grandparents and threatened to drive her onto the moors and leave her there. • The police attended two domestic incidents between mother and father (Paragraphs 4.54, 4.74) and both were assessed as ‘standard’ risk. Child V had been present during one of the incidents. Additionally father had reported historical assaults by mother by hitting and kicking but declined to assist any investigation (Paragraph 4.76). • During April 2019 mother disclosed ongoing threats from father, describing him as her ‘ex-partner’ to IAPT who wrote to children’s social care on 26th April 2019 to advise them that mother felt at risk from father as his anger outbursts could be unpredictable. • Father agreed to a referral to the ‘Inspire to Change’ programme. It was also learned that he had been referred for support with his mental health by the college he attended one day a week. He forgot to attend an Inspire to Change appointment on 25th April 2019 but by the time of the May 2019 review child protection conference was said to be engaging with the programme’s Respectful Relationships course and self-reported positive effects on his life. However, father had attended only one of the ten Strictly Confidential 57 Respectful Relationships sessions by the time his keyworker prepared a report for the review child protection conference on 29th May 2019. • Child V was twice taken to Hospital 2 – which is situated in the neighbouring Wakefield Council area – and is further away from Hospital 1 where mother received her antenatal care, where Child V was born and had previously been cared for (6th March and 21st April 2019). • Mother did not engage with domestic abuse services (IDAS). 6.67 The review child protection report concluded that Child V was no longer at risk of significant harm. Mother was engaging with mental health services and there was said to be no evidence that her anxiety, which appeared to be low level given it was not thought mother required medication, had impacted on the care of Child V (mother was in fact taking antidepressants, prescribed by her GP, which she said were contributing to her sleeping for twelve hours at a time). The domestic abuse between the parents was also considered to be low level. Mother’s concerns about father’s anger was being addressed through his engagement in the respectful relationships course. There was said to be no evidence to suggest that domestic abuse had escalated as mother’s disclosures of physical violence were said to pre-date the most recent DASH risk assessment conducted by the police on 9th March 2019. 6.68 It was said that Child V had never been present during paternal disputes and therefore would not be impacted by the behaviour. This was incorrect as Child V had been present during one of the incidents reported to the police (Paragraph 4.74) and it is unclear if it had been established whether or not the child had been present during the two or three incidents which mother had disclosed to the social worker. In her contribution to this review mother said that she was holding Child V when assaulted by father (Paragraph 5.34), although this does not appear to have previously been shared with any practitioner. Additionally, it is unwise to assume that domestic abuse in a relationship is limited only to the incidents disclosed. 6.69 The possibility that father’s anger management issues and mother’s disclosures of domestic abuse by father prompted consideration of whether father was capable of physically abusing Child V when the social worker discussed the case with her team manager in supervision in March 2019 but does not appear to have been revisited thereafter. 6.70 The paternal grandparents continued to be seen as protective factors. Paternal grandmother was described as a paediatric nurse whose professional background would enable her to recognise if Child V was at risk of harm or her needs were not Strictly Confidential 58 being met. The paternal grandparents were said to be aware of concerns in respect of the parents but, on the basis of their contribution to this review, this may not have been an entirely correct assumption. The positive viability assessment of paternal grandparents was referred to, but this had been conducted nearly nine months earlier and their absence from the child protection plan process since that time could have raised questions, although they had participated in the family group conference. Children’s social care have advised this review that the paternal grandparents were not seen as a significant protective factor in the decision to step down to child in need support. Maternal grandmother was said to be providing practical support to mother and was considered to be able to step in to care for Child V if the parents were unable. This was a challengeable assumption. The parents were said to be engaging with services although the two recent presentations of Child V at Hospital V challenged this view. 6.71 The review child protection conference concluded that the ongoing concerns could be met through a child in need plan. Given the range of concerns set out in Paragraph 6.64 and the potential impact on Child V of domestic violence and abuse in father and mother’s relationship, father’s long term anger management issues which he had only recently begun to address and mother’s mental health issues, it could be argued that a further period of child protection planning would have been beneficial. For child in need support, paternal engagement would be vital. Whilst the parents had engaged in the child protection process, there were some indications to the contrary. Effectiveness of support provided to Child V and her family after she was stepped down to support as a Child in Need? 6.72 The social worker continued to work diligently to safeguard Child V after the child began to be supported as a child in need and her manager maintained oversight of the case. Two child in need meetings were held. 6.73 However there was a discernible change in paternal engagement with two no-access child in need visits and four no-access health visitor home visits during this period. It is unclear whether the parents were deliberately seeking to avoid Child V coming into contact with practitioners during this period but their decision to present Child V at Hospital 2 ED on two occasions in March and April 2019 after routinely taking her to the geographically closer Hospital 1 could have merited further enquiry. Additionally, the child continued to be unobserved in community settings as mother was unable to take her to mother and baby groups because of her anxiety. 6.74 Children’s social care were notified of a further domestic incident involving mother and father (Paragraph 4.105) although the police did not consider it Strictly Confidential 59 necessary to notify children’s social care of an incident in which father made threats to a person who was not a member of his family (Paragraph 4.106). Children’s social care were made aware of what may have been father’s controlling behaviour of mother who accompanied him to Respectful Relationships sessions and then waited for him in his vehicle (Paragraph 4.106). Children’s social care were not made aware of the concerns about father’s anger management which led paternal grandmother to arrange a GP appointment in an effort to seek help for him (Paragraph 5.33). Were there any opportunities for practitioners to become aware of the fracture to Child V’s left ulna which she sustained between two weeks and three months prior to the serious assault reported on 16th August 2019? 6.75 It is difficult to answer this question given the substantial period during which the injury could have been sustained (between two weeks and three months prior to the serious assault on Child V). 6.76 Examining the period from mid-May 2019 – which is the earliest point at which the injury could have been sustained – until the assault on Child V was reported on 16th August 2019, Child V was observed by practitioners on at least seven occasions. She was seen three times by the social worker - during one child protection and two child in need home visits, once by the health visitor, once by the CMHT practitioner and once by a consultant paediatrician. No concerns about Child V were noted by any of these practitioners. However, as stated earlier, there were two no-access child in need visits and four no-access health visitor home visits during this period. Additionally, the child was not being observed in community settings as mother was unable to take her to mother and baby groups because of her anxiety. 6.77 The health visitor had noted delayed development in gross and fine motor skills on 8th May 2019 (Paragraph 4.98) which raises the question of whether pain from the fractured ulna could have adversely affected Child V’s crawling. However, the date on which the health visitor observed Child V is just outside the three month window when it is estimated the fracture took place and the child was seen to be crawling ‘very well’ when seen during a child protection visit a few days later (Paragraph 4.99). Whilst there are several potential factors in delayed development of gross and fine motor skills such as home environment and parenting capacity, there is no indication that physical abuse was considered as a factor despite the child being on a child protection plan for physical abuse. Child V’s lived experience. Extent to which professional practice was sufficiently child-focussed? Strictly Confidential 60 6.78 The ‘lived experience’ is what a child sees, hears, thinks and experiences on a daily basis which impacts on their development and welfare. Practitioners need to actively hear what the child has to communicate, observe what they do in different contexts, hear what family members, significant adults/carers and professionals have said about the child, and to think about history and context. Ultimately practitioners need to put themselves in that child’s shoes and think ‘what is life like for this child right now?’ 6.79 Child V was invariably noted by practitioners to present as happy and contented, with generally positive interaction from mother and father although in the period following mother’s overdose, a lack of interaction by mother was noted (Paragraph 4.62) as was a lack of warmth (Paragraph 4.71). The effect of the antidepressants mother was prescribed appeared to increase the amount of sleep she required which may have affected the attention Child V received. 6.80 Child V appears to have lived in three addresses during her first year of life, address 3, paternal grandparents address for a period and then living between paternal grandparents and maternal grandmother’s address. This may have been unsettling. Maternal grandmother’s address was described by several practitioners as overcrowded and the social worker supported mother’s application for social housing for herself and Child V. 6.81 There was clearly tension in the relationship between Child V’s parents which led to break ups, arguments and violence. Child V was present during two of the three domestic violence and abuse incidents reported to the police although she did not witness either incident. It is not known whether Child V was present during the two or three incidents of domestic violence and abuse mother disclosed to the social worker but in her contribution to this review mother elaborated on one of these disclosures and said that she was holding Child V when father assaulted her (Paragraph 5.34). There were also tensions between Child V’s mother and her paternal grandparents and between father and her maternal grandmother. The relationship between mother and maternal grandmother was described as ‘fractured’ in a viability assessment. 6.82 Child V was subjected to a sustained assault by her father which must have been very frightening and distressing. Her left ulna had been broken in an undocumented incident between two weeks and three months prior to the assault by father which must have been painful for the child and caused her pain when moving her arm. She sustained injuries which were assumed to be non-accidental on one, or possibly two occasions during the first month of her life. She encountered a substantial amount of violence in her young life which appears likely to have affected the child’s sense of being in a secure, loving environment. Strictly Confidential 61 6.83 Although she saw family members frequently, Child V was isolated from contact with children outside the extended family as a result of mother’s anxiety which prevented her accessing community groups. 6.84 Concerns that Child V was being neglected, by being left in dirty nappies for example, led the paternal grandparents to install CCTV in their home address. Multi-agency communication and information sharing 6.85 Child V’s presentation at Hospital 1 on 25th September 2018 (Paragraph 4.38) did not generate any contact with children’s social care. The hospital noted that a child protection medical had recently taken place but this hospital attendance took place prior to the child protection plan commencing which suggests that hospital attendances during the period in which a Section 47 enquiry is being conducted may be missed. 6.86 Child V was taken to Hospital 2 on two occasions and on neither occasion was a safeguarding concern identified and communicated by the hospital (Paragraphs 4.73 and 4.93). The attendances were shared with the health visitor who then shared them with the social worker. There is therefore a concern that there could be a delay in being notified of out of area hospital attendances in respect of children subject to child protection plans. 6.87 The police did not share the details of father’s threat to a non-family member with children’s social care (Paragraphs 4.106). Given the concerns about father’s anger management it would have been beneficial for this information to be shared but there did not appear to be a formal mechanism for doing so. 6.88 Berneslai Homes state that they have no record of any referral to the Family Intervention Service following the review child protection meeting on 17th December 2018 (Paragraph 4.52). 6.89 Children’s social care have advised this review that they were not notified of mother’s overdose either by the hospital or the hospital based mental health liaison team. The information provided by BHFT does not indicate whether any safeguarding children issues were explored with mother but the SWYPFT chronology states that the Children’s Services EDT was informed. It has not been possible to resolve this inconsistency and so there remains a concern an overdose by the parents of a child on a child protection plan may not have been promptly notified to children’s social care. Strictly Confidential 62 Continuity of practitioner involvement 6.90 In the postnatal period mother and Child V were seen by four different community midwives in a relatively short period. The health visitor new birth visit was not carried out by mother’s allocated health visitor. Duty social workers conducted several child protection visits. Child V’s case was transferred to a different health visitor team when she and mother moved to maternal grandmother’s address and the case was allocated to a new social worker in the original social worker’s sickness absence. Good practice • Mother’s epilepsy and the impact of this on her parenting capacity through experiencing seizures or not taking her medication was carefully monitored through the child protection plan and an epilepsy nurse attended the majority of core group meetings. • The child protection medical documented the marks on and around Child V’s left eye and on her body very clearly. • The health visiting service promptly undertook an internal review after the non-mobile policy was not followed by the health visitor (Paragraph 4.22). • The family group conference was attended by members of Child V’s wider family, including paternal aunt who subsequently took Child V to hospital after the child had been assaulted by father. • Inspire to Change notified children’s social care of father’s non-attendance at the first group session on the same day. They also notified children’s social care of possible controlling behaviour by father towards mother. • IAPT shared mother’s concerns about father’s outbursts of anger with children’s social care. • There was much solid and proactive practice by the social worker to whom Child V’s case was allocated in February 2019. • The social worker liaised with mental health services in an effort to expedite appointments for mother. Strictly Confidential 63 7.0 Findings and Recommendations Early Help 7.1 Mother and father would have benefitted from Early Help but whether or not they were offered Early Help was not recorded. They received valuable specialist support from the teenage midwife and the Smoke Stop midwife, but the offer of Early Help might have assisted in organising the support provided and improving information sharing and liaison with other agencies. Additionally, the support offered would have been underpinned by an Early Help Assessment which could have enabled practitioners working with the family to have a more sophisticated understanding of their needs. 7.2 The review has been advised by BHNFT that community midwives have received awareness training in respect of Early Help and an internal pathway to streamline the process is under development. Additionally, all practitioners are required to notify the Hospital 1 safeguarding team of all offers of Early Help. 7.3 At the learning event arranged to inform this review, practitioners expressed the view that whether or not Early Help was offered, and if offered and declined, completion of the Early Help Assessment would have been beneficial. This view appears to have much to commend it but is not currently explicitly reflected in the Barnsley Assessment Framework. 7.4 It is therefore recommended that Barnsley Safeguarding Children Partnership seek assurance that the changes introduced by BHNFT have had the desired effect and that community and specialist midwifery understand and apply the threshold for the offer of Early Help and record that offer and whether or not it is accepted or declined. The Safeguarding Partnership may also wish to consider promoting the wider use of the EHA as an assessment tool to understand need and inform service provision, irrespective of whether Early Help is offered or accepted. Recommendation 1 That Barnsley Safeguarding Children Partnership seeks assurance from Barnsley Hospital NHS Foundation Trust that midwifery services understand and apply the threshold for the Early Help offer and record that offer and whether or not it is accepted or declined. Recommendation 2 Strictly Confidential 64 That Barnsley Safeguarding Children Partnership considers promoting the wider use of the Early Help Assessment as an assessment tool to understand need and inform service provision, irrespective of whether Early Help is offered or accepted. Antenatal visits by Health Visitors 7.5 Mother and father did not receive the nationally mandated antenatal visit by a health visitor. Given their vulnerabilities, this was a significant omission. The reason for this omission was that mother’s estimated date of delivery had been incorrectly notified to the health visitor service. It is understood that this issue was also identified by an earlier Serious Case Review (Child T). 7.6 Barnsley 0-19 Public Health Nursing Service has shared an internal action plan with this review which is designed to address the problem. The action plan includes reviewing antenatal communication pathways in order to improve information sharing. It is recommended that the Safeguarding Partnership seeks assurance that the 0-19 Public Health Nursing Team has a sufficiently robust system to ensure the timely arrangement of the antenatal visit by a health visitor. Recommendation 3 That Barnsley Safeguarding Children Partnership seeks assurance that the Barnsley Hospital NHS Foundation Trust Midwifery Service and the Barnsley 0-19 Public Health Nursing Team have an agreed robust system of communication in place to provide confirmation of pregnancy in a timely manner so that health visitors can undertake the required antenatal visits. ‘Non-Mobile’ Protocol 7.7 The Barnsley Safeguarding Children Board Protocol for the management of actual or suspected bruising in non-mobile infants was not followed by practitioners from three different disciplines (ED practitioner, health visitor and community midwife) after observing marks on Child V when less than a month old. This suggests that at that time – the summer of 2018 – professional awareness of the non-mobile protocol and the need for heightened concern about any bruising in a baby who is not independently mobile was insufficiently embedded within the safeguarding children workforce. 7.8 The ED practitioner and the health visitor were both under workload pressures at the time they did not follow the non-mobile protocol. It seems unlikely that the type of workload pressures experienced by these two practitioners will diminish in the near future. Strictly Confidential 65 7.9 The BHNFT Safeguarding Children guidelines contain no reference or link to the Barnsley Safeguarding Children Board non-mobile protocol, although the former was written before the latter. Additionally the BHNFT guidelines are primarily focussed on action to be taken when a child is brought to hospital and may therefore need to be developed to provide appropriate guidance to BHNFT practitioners who work in the community such as the community midwife who did not follow the non-mobile protocol in response to the marks she observed on Child V on 5th September 2018, although the action she took helped to safeguard the child. 7.10 It is therefore recommended that the Safeguarding Partnership seeks assurance that all relevant practitioners receive the necessary training and/or briefings to ensure they are fully aware of the non-mobile protocol, the principles which underpin it and understand the action they need to take in order to follow the protocol. The Safeguarding Partnership may also wish to seek assurance that working practices are put in place to support practitioners to follow the non-mobile protocol when they are under workload pressures or operating in a challenging environment such as a hospital ED. Additionally, the dissemination of learning from this case will provide the Safeguarding Partnership with a further opportunity to emphasise the importance of following the non-mobile protocol. Recommendation 4 That Barnsley Safeguarding Children Partnership seeks assurance that all relevant practitioners receive the necessary training and/or briefings to ensure they are fully aware of the non-mobile protocol, the principles which underpin it and understand the action that they need to take to follow the protocol. Recommendation 5 That Barnsley Safeguarding Children Partnership seeks assurance that working practices are put in place to support practitioners to follow the non-mobile protocol when they are under workload pressures or operating in a challenging environment such as a hospital ED. Recommendation 6 That Barnsley Safeguarding Children Partnership disseminates the learning from this review and takes that opportunity to further emphasise the importance of following the non-mobile protocol. Dissemination of learning will also provide the opportunity to consider links between domestic abuse and child abuse (See Paragraph 7.22). Strictly Confidential 66 Child Protection Planning in respect of Child V 7.11 It was the clear expectation of children’s social care that once Child V was returned to the care of mother and father on 21st September 2018, they would be living with the paternal grandparents who would thereby be well placed to support mother and father in caring for the child and would be in a position to step in to ensure the child’s needs were met and that the child was safeguarded. 7.12 Children’s social care’s expectations do not appear to have been met. The paternal grandparents had purchased a property for father, mother and Child V (address 3) which they appear to have occupied until early November 2018. Both mother and the paternal grandparents have advised this review that mother, father and Child V lived in address 3 from the point at which Child V was returned to them (21st September 2018) until they moved out of address 3 to stay with paternal grandparents (around 5th November 2018). 7.13 This situation appears to have arisen in part because the placement plan – under which Child V was placed with paternal grandparents under Section 20 – and the transition plan – which covered the transfer of care for Child V from the paternal grandparents to mother and father – lacked detail. Mother’s mental health history may also have been omitted and it appears that the impression was gained that father’s anger management issues were historic rather than current. Gaps in the assessment may have contributed to children’s social care finding themselves responding to issues as they cropped up rather than being in a stronger position to anticipate them. 7.14 The paternal grandparents were regarded as pivotal to the child protection plan, and there was an assumption that they were supporting mother and father in caring for Child V and that they would step in to safeguard Child V should this become necessary. This assumption remained unchallenged even after mother and Child V largely moved to live with maternal grandmother, tensions developed in the relationship between mother and paternal grandparents and despite the paternal grandparent’s lack of involvement in child protection planning. 7.15 Once they had conducted the criminal investigation into the injuries sustained by Child V in September 2018, the police involvement in child protection planning for Child V was negligible. The police should have attended the review child protection conferences at which key decisions were taken in respect of a non-mobile child who had sustained injuries which were presumed to be non-accidental. 7.16 Not all core group meetings were adequately minuted in terms of information shared and outcomes agreed. Strictly Confidential 67 7.17 Child V was stepped down to support as a child in need prematurely because the assumption that the paternal grandparents were in a position to ensure the child was safeguarded was not revisited (although their CCTV system ultimately revealed the assault on Child V by father), concerns about domestic violence and abuse by father had not been fully risk assessed, father had only recently begun the Inspire to Change programme to address his anger management in relationships and the possibility that a domestic abuser could also be a child abuser did not appear to have received sufficient attention. 7.18 It is therefore recommended that the Safeguarding Partnership seeks assurance in respect of the following child protection planning issues: • That placement and transition plans are completed fully, • that assumptions which are critical to the safeguarding of a child - such as the role of the paternal grandparents as a protective factor in this case – are reviewed in the light of information which challenges those assumptions, • that police involvement in child protection planning is sufficient and • that the outcomes of core group meetings are documented sufficiently. 7.19 It is also recommended that child protection plans are not stepped down to support as a child in need prematurely. Recommendation 7 That Barnsley Safeguarding Children Partnership seeks assurance in respect of the following child protection planning issues: • that placement and transition plans are completed fully, • that assumptions which are critical to the safeguarding of a child - such as the role of the paternal grandparents as a protective factor in this case – are reviewed in the light of information which challenges those assumptions, • that police involvement in child protection planning is sufficient and • that the outcomes of core group meetings are documented sufficiently. Recommendation 8 That Barnsley Safeguarding Children Partnership seeks assurance child protection plans are not stepped down to support as a child in need prematurely. Domestic Violence and Abuse 7.20 Mother made disclosures of what appeared to amount to three separate domestic violence and abuse incidents to the social worker who recorded this information and ensured that it was considered as part of child protection planning. Strictly Confidential 68 7.21 Each disclosure should have been subject to a DASH risk assessment in order to understand the risk to mother and Child V. Had DASH risk assessments been carried out, there would have been a more complete understanding of domestic abuse incidents and a referral to MARAC could have been considered on the grounds of professional judgement, given the apparent escalation in abuse over a relatively short period of time and father’s anger management issues. However, children’s social care’s position appears to be that social workers should not complete DASH risk assessments. If this is to remain the position then children’s social care need to share with the police any new disclosures of domestic abuse made to social workers so that the police can conduct DASH risk assessments. 7.22 Consideration of the risk of physical abuse of Child V by father given father’s anger management issues and mother’s disclosures of domestic abuse by father did not appear to be prominent in this case. Dissemination of learning from this review could highlight research evidence relating to the potential overlap between domestic abuse and direct harm to children (12). See Recommendation 6 above. 7.23 It is recommended that the Safeguarding Partnership share this report with Barnsley Safer Barnsley Partnership, so that the latter partnership can consider whether to support practitioners from a range of disciplines, including children’s social care, to complete DASH risk assessments when disclosures of domestic violence and abuse are made to them. Recommendation 9 That the Barnsley Safeguarding Children Partnership share this report with the Safer Barnsley Partnership, so that the latter partnership can consider whether to support practitioners from a range of disciplines, including children’s social care, to complete DASH risk assessments when disclosures of domestic violence and abuse are made to them. Impact of maternal mental health on Child V 7.24 There was an absence of joint working between mental health services and children’s social care to gain an understanding of how concern’s about mother’s mental health in the wake of her overdose of prescription medication may affect the care she was able to provide for Child V. This could have been discussed had mental health services attended those core group meetings to which they were invited or sent reports. Strictly Confidential 69 7.25 It is therefore recommended that the Safeguarding Partnership seeks assurance that mental health services and children’s social care collaborate effectively when maternal mental health issues are relevant to child protection and/or child in need planning. Recommendation 10 That Barnsley Safeguarding Children Partnership seeks assurance from Barnsley Children’s Services and South West Yorkshire Partnership NHS Trust that mental health services and children’s social care collaborate effectively when maternal mental health issues are relevant to child protection and/or child in need planning. 7.26 When mother was admitted to Hospital 1 following an intentional overdose Child V was present in the house. Child V was being supported on a child protection plan at that time. There is no indication that Hospital 1 considered or made a safeguarding referral as a result of mother’s overdose. SWYPFT, as provider of the hospital mental health service to which mother was referred during her hospital admission state that they contacted the Children’s Services EDT but children’s social care has advised this review that they have no record of this contact. 7.27 It has not been possible to reconcile the differences in the records of SWYPFT and children’s social care but it is clear that Hospital 1 did not make a safeguarding referral. It is therefore recommended that the Safeguarding Partnership seek assurance from BHNFT that they have systems in place to ensure that any safeguarding children implications of hospital attendances by parents as a result of self-harm are fully explored and referrals made where appropriate. Recommendation 11 That Barnsley Safeguarding Children Partnership seeks assurance from Barnsley Hospital NHS Foundation Trust that they have systems in place to ensure that any safeguarding children implications of hospital attendances by parents as a result of self-harm are fully explored and referrals made where appropriate. Single Agency Learning 7.28 There is much single agency learning arising from this case, some of which has been referred to in this report. It is recommended that Barnsley Safeguarding Children Partnership request the agencies involved in this review to reflect on the contents of this report and share their single agency learning and any consequent action plans with the Safeguarding Partnership. Strictly Confidential 70 References (1) Retrieved from https://www.england.nhs.uk/ourwork/qual-clin-lead/hlth-vistg-prog/ (2) Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/779401/Working_Together_to_Safeguard-Children.pdf (3) Retrieved from https://www.barnsley.gov.uk/media/4110/barnsley-assessment-framework-final.pdf (4) Retrieved from https://www.barnsley.gov.uk/media/3081/early-help-assessment-frequentley-asked-questions-docx.pdf (FAQ number 8) (5) Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/464880/Universal_health_visitor_reviews_toolkit.pdf (6) Barnsley Safeguarding Children Board Protocol for the management of actual or suspected bruising in non-mobile infants - March 2018. (7) Retrieved from https://library.nspcc.org.uk/HeritageScripts/Hapi.dll/retrieve2?SetID=F01AF3CF-F58F-42AD-B89A-96A4A692DF77&searchterm=maternal%20mental%20health&Fields=%40&Media=%23&Bool=AND&SearchPrecision=20&SortOrder=Y1&Offset=10&Direction=%2E&Dispfmt=F&Dispfmt_b=B27&Dispfmt_f=F13&DataSetName=LIVEDATA (8) Retrieved from https://www.nspcc.org.uk/preventing-abuse/child-protection-system/paternal-mental-health/ (9) ibid (10) ibid (11) Retrieved from https://safelives.org.uk/sites/default/files/resources/Final%20policy%20report%20In%20plain%20sight%20-%20effective%20help%20for%20children%20exposed%20to%20domestic%20abuse.pdf Strictly Confidential 71 (12) ibid Strictly Confidential 72 Appendix A Process by which the CSPR was conducted It was decided to adopt a broadly systems approach to conducting this SCR. The systems approach helps identify which factors in the work environment support good practice, and which create unsafe conditions in which unsatisfactory safeguarding practice is more likely. This approach supports an analysis that goes beyond identifying what happened to explain why it did so – recognising that actions or decisions will usually have seemed sensible at the time they were taken. It is a collaborative approach to case reviews in that those directly involved in the case are centrally and actively involved in the analysis and development of recommendations. Agency reports including chronologies which described and analysed relevant contacts with Child V and her family were completed by the following agencies: • Barnsley Children’s Services • Barnsley Clinical Commissioning Group • Barnsley Hospital NHS Foundation Trust • Barnsley Public Health Nursing Service • Berneslai Homes • South West Yorkshire Partnership NHS Foundation Trust • South Yorkshire Police The independent reviewer analysed the chronologies and identified issues to explore with practitioners and managers at learning events facilitated by the lead reviewer. Child V’s mother, maternal grandmother and paternal grandparents contributed to the review and were later provided with an opportunity to comment on the report prior to publication. Both families expressed their support for the findings and recommendations. The independent reviewer then developed a draft report to reflect the agency reports and the contributions of practitioners and managers who had attended the learning event. The report was further developed into a final version and presented to Barnsley Safeguarding Children Partnership. Strictly Confidential 73 |
NC52291 | Significant non-accidental injuries to a 3-year-6-month-old girl in August 2018. Child L's father was convicted of grievous bodily harm and sentenced to nine years in prison. Learning focuses on: issues around communication and information sharing between agencies; reluctance to initiate early help assessments; the need for curious and holistic practice, and getting the whole picture by knowing the whole family; the need to engage with fathers and male carers, instead of the focus being primarily on the mother. Makes no recommendations but includes details of actions initiated as a result of learning, including: revision of midwifery and health visitor pathways; revision of multi-agency protocol on bruising and injuries in non-mobile babies and children, including guidance for parents; a thematic review into significant physical injuries to children under 1-year-old; a pilot project focused on engaging fathers and developing models of good practice.
| Title: Serious case review Child L: significant non-accidental injuries to a young baby. LSCB: Wiltshire Safeguarding Children Board Author: Mark Gurrey Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Page 1 of 8 Serious Case Review Child L Significant non-accidental injuries to a young baby Contents Context, family background and case summary page 1 Case Analysis page 4 Views of the Family page 5 Findings from this review and response to learning page 6 Page 2 of 8 Context In August 2018, Child L was admitted to hospital and was placed in intensive care with life threatening injuries. She was three and a half months old. Her Father has been convicted of GBH and sentenced to 9 years in jail. The injuries sustained by Child L were such that they meet the criteria set out in ‘Working Together 2015’ for a Serious Case Review (SCR). An alternative model for this review was agreed. Following the completion of the required Rapid Review, agencies agreed to foreshorten the traditional SCR methodology of “commission – review – delivery to practitioners”. Instead it was agreed that the involvement of practitioners (through 4 multi-agency workshops) would constitute the review itself and that we would use those workshops to discuss the case, explore the issues and identify some ways forward: the workshops were the SCR. These workshops were independently facilitated by Research in Practice (RIP) and involved 82 participants from a range of agencies. The outcome from those externally facilitated workshops form the basis of this review which has been authored by the Independent Chair, Mark Gurrey with support from the LSCB (as was) Quality Assurance Lead, Julie Upson who is also independent of the partner agencies involved. The workshops were constructed to: • promote reflection and objectivity; become one’s own internal supervisor to enhance hypothesis generation, analysis, reflection and critical thinking in assessment and intervention • set out the importance of forming effective relationships and the crucial role played by observation • encourage the adopting an ‘eyes wide open’, strengths-based approach with outcomes for children in clear sight and mindful of misplaced or unevidenced optimism • ensure hearing and understanding the family’s history and story (including fathers) within an attachment and systems framework • ensure practice is narrative not episodic • encourage a culture of urgency, with courageous conversations (with families and colleagues) from the outset An evaluation of the process followed and is included at the end of this report. One key finding however, worth stating here, was that the evaluations of the workshops evidenced that 98% of participants rated the content quality as very high and the likely impact on practice as very high/high(98%). Family Background and Case Summary Mother, Child B and Child C were known to children’s social care and had previously been subject to periods of Child in Need and child protection planning as Mother was a victim of domestic abuse from Adult D. Mother had a history of depression and suicidal threats and on several occasions made threats to kill herself and Child B and Child C whilst drunk. She was described as an “alcoholic” and disclosed that Child L Subject of this report aged 3 and a half months at time of injury Child B Half sibling of Child L and sibling of Child C aged 4 years Child C Half sibling of child L and sibling of Child B aged 7 years Mother Mother to Child L, Child B and Child C, aged 31 at time of incident Father Father of Child L, aged 21 at time of incident, serving soldier Adult D Mother’s ex-partner and father of Child B and Child C Paternal Grandparents Parents of Father, living in another local authority area with their 2 other children, none of whom were previously known to children’s services or the police Page 3 of 8 both her parents had been heavy drinkers and that she had been binge drinking since the age of 18. She was assessed by both mental health and substance misuse services and offered support. However, her engagement with these agencies was inconsistent and sporadic. Eventually, because of poor engagement, support from the substance misuse service was removed and she was provided with an online service only for a period of time. Mother became pregnant with Child L following a short relationship with Father, a serving soldier living in Barracks when they met. Concerns were raised throughout the pregnancy about Mother’s alcohol consumption by the Midwife and Mother told professionals that she was attending her mental health appointments and accessing support for her alcohol dependency. The midwife completed two MASH Referrals and a single assessment was completed to assess Mother’s drinking and the impact of this on her unborn baby. The outcome of this assessment was that the case sat below Child in Need (CiN) status and a Family Key Worker from the Council’s Support and Safeguarding Service was allocated. Child L was born at the end of April. The case was closed in May 2018 and although a CAF Early Help Assessment was discussed as part of the step-down process, agencies deemed this was not needed. Child L was spending weekends with her Father at his parent’s house at this point. By June 2018 concerns about Mother’s mental health and drinking resurfaced and there were a number of crises events that resulted in Strategy Discussions and Section 47 enquiries. It was agreed that Mother was to have no unsupervised contact and a safety plan was put in place. This included the agreement that Father was not to return Child L to Mother’s care if Mother was intoxicated. The support from Maternal Uncle and a friend of Mothers’ to supervise Mother’s care of Child L quickly broke down and it was agreed between Mother and Social Worker that Child L should remain in the care of her Father. Child L was made subject to a child protection plan at the end of July, under the category of neglect. At this point Child L was being cared for by her Father and Grandparents at Paternal Grandparents’ home and had started attending a local nursery. Injuries and bruising to Child L were observed on three separate occasions between 6th and 15th of August: the first was observed by the nursery; the second by Mother at the Contact Centre; the third again observed by the Nursery. On August 19th Child L was admitted to hospital with life threatening injuries. Child L had been in the sole care of Father at the time, he was not able to provide an explanation for the injuries and was arrested for GBH with intent. Child L is now in Foster Care. She has significant neurological impairment resulting in profound disabilities. Child B and Child C are living with Adult D. Page 4 of 8 Case Analysis Concerns relating to how agencies worked together begin during the pre-birth period. There is evidence of over optimism by agencies in relation to Mother’s ability to control her drinking and engage with support services. Midwifery spoke directly to the substance misuse service to find out if Mother was engaging with them in the way that she was reporting and were persistant in raising their continued concerns regarding her use of alcohol. In addition, there is no evidence of any agency exploring the reasons behind Mother’s drinking despite her disclosure of her own childhood experiences and domestic abuse whilst in a relationship with Adult D. It is not clear from the chronologies reviewed that information shared between Health Visiting and Midwifery within meetings was recognised and recorded appropriately. This meant that there was no opportunity for targeted ante-natal visits earlier on in the pregnancy. The outcome of the single assessment completed following the referral from the midwife was that the case should sit at Support Level, between Early Help and Child in Need. The assessment lacked a critical view of Mother’s history and insufficient focus was given to whether a more formal statutory level of intervention was warranted. Although there were regular multi-agency meetings including key professionals, the case remained managed at too low a level with the current and future risks not well defined as part of a robust multi-agency assessment. Following the birth of Child L, Support and Safeguarding and Health Visiting were reassured by Mother’s assertions that she was not drinking, did not feel the need to and was happy and coping. Considering Mother’s history, this was very optimistic and suggests a lack of understanding of addiction. Mother has since said that in fact she was not coping at this time and needed continued support. This optimism by professionals resulted in the case being closed just 3 weeks after Child L’s birth. Mother was the focus of concerns by all agencies with Father and his family seen as protective. However, there is little reference to him being in meetings and references to him in assessments appears limited. It is stark that within the agency chronologies reviewed as part of the Rapid Review there is no evidence of Father actually being spoken to until June 2018. Contact with agencies was often through Paternal Grandparents and Child L was often in their care whilst Father remained in Barracks. No agency ever challenged this view of ‘good Father vs bad Mother’ – the drive to find a safe(r) placement for Child L appeared to override a fuller assessment of Father. As a result, it was agreed that Child L would be cared for by Father without any assessment of either his parental capacity or indeed that of Child L’s Grandparents and there was little observation of any of them with Child L. No agency knew how much time Father had spent independently caring for Child L whilst living with her at the family home. The home LA did not inform the LA in which Child L was now living that she was a child subject to a child protection plan, which would have been good practice. The response to the bruises and injuries in the week leading up to Child L’s admission to hospital was of concern and did not follow procedure. The nursery was not active enough in ensuring the social worker knew about them and Father’s explanations on two occasions were accepted with no further assessment or examination sought. Even though the nursery was not made aware by the home LA that Child L was subject to a child protection plan the expectation would have been that the bruising was responded to and reported appropriately. A further bruise was noted by Mother whilst at the Contact Centre; again, this was not appropriately reported and Father’s explanation accepted. There was a significant failure in not reporting these injuries and bruises and highlights the importance of ensuring all professionals understand Page 5 of 8 the significance of bruising in non- mobile babies, are able to retain a respectful doubt about parental explanations in such circumstances and are confident in the reporting process. Relevant Safeguarding Partners will need assurance that issues regarding reporting of bruises by agencies have been addressed within the nursery and other settings. Agencies Involved As part of this review the following agencies were contacted to provide information and their staff attended the practitioner workshops: • Adult Mental Health Services • Local Authority Families and Children’s Services • Health Visiting Service • Children’s Centre • Salisbury Hospital NHS Foundation Trust • GP Surgeries for both Mother, Father and Child L, Child B and Child C • University Hospital Bristol NHS Foundation Trust • Police • Adult Substance Misuse Service • Contact Centre • Army and Unit Welfare • Nursery in neighbouring local authority area (where Paternal Grandparents lived) • Children’s Social Care in neighbouring local authority area (as above) • Out of Hours GP Service In addition, a Case De-brief workshop was held attended by 20 practitioners and line managers directly involved in the case. Views of the family Mother, Father and Paternal Grandfather have contributed to the review. Mother identified the period just after the birth of Child L as difficult: the case was closed 4 weeks after Child L’s birth. From Mother’s perspective all agencies were saying everything was going well and Mother described not feeling confident enough to disagree with this view and say that she was not OK; that she was struggling and was worried she might have post-natal depression. Mother could not identify if there were things that professionals could have done to make her feel more able to speak out about how she was feeling at this time. A few weeks after the case had closed Mother was drunk whilst in the care of Child L. Mother described professionals’ viewing this incident as a “blip” rather than an indication that she was finding it hard to cope. Mother felt that if support been put back in place at this time this may have made a difference. Within a couple of weeks there was another incident where Mother was drunk whilst in the care of Child L and it was at this point that arrangements were made for all her children to be cared for by their respective fathers. She had no family she could fall back on to provide supervision of her care of Child L which meant there was little choice but for Child L and her other two children to live elsewhere. Child L was less than 2 months old at this point and Mother said that it was very hard to be separated from her when she was so young, even though she now recognises that she would not have been able to care for Page 6 of 8 her at that point. Mother also felt that she was not kept up to date about when the children might be returned to her care or about how Child L was, and this led to her feeling excluded. She did not know that Child L was attending nursery until the incident and would have liked, for example, the Health Visitor to phone her to tell her about Child L’s progress. Mother felt that had there been a suitable mother and baby unit available this would have helped her to get well whilst continuing to be able to care for Child L. Father was spoken to in prison and he described feeling overwhelmed by the circumstances of becoming a new father in the context of a difficult relationship with Mother and disruption of his army career. He said he did not feel able to talk about how he was feeling with professionals. No professional came to visit him at his barracks and had they done so he stated that he may have felt more able to be open. He said that his relationship with Mother became very difficult after the birth of Child L and this added additional pressure to the situation. Father also commented that he did not feel he understood his rights as the father of Child L, for example understanding that he had parental responsibility and that it was not just the mother who could make decisions about the child. As a new father he was shown the Dad pad, but he described this as being unappealing and not something he would have referred to. Paternal Grandfather also contributed to the review. He shared the view that his son’s voice had not been fully or properly heard in the work and, conversely, that too much weight was given to Child L’s mother. He and his wife had been active in Child L’s care when she moved, and the injuries occurred when they were on a long-planned holiday to Florida. Needless to say, they remain devastated by what happened to her. Findings from this review and response to learning Wiltshire has not waited for the review to conclude before acting on the learning and action has already been taken in relation to some of the learning from this case: • The Midwifery/Health Visitor Pathway has been revised and relaunched • Multi-agency Protocol on Bruising and Injuries in Non mobile Babies and Children has been revised in the light of this case and relaunched across the agency network. The new protocol and guidance includes a Leaflet for parents which has been well-received by professionals in supporting their confidence in following the guidance. • Wiltshire has also undertaken a thematic review into significant physical injuries to children under 1yr . The circumstances of Child L and learning from this case have been incorporated into this review. Learning from the workshops: Practice Themes There were four major practice themes inherent in this case that emerged from the practitioner’s workshops. These are set out below including some detail about how they manifested in this case and the agreed enablers that could help address them and improve practice outcomes. Theme 1 - Communication and Information Sharing Issues • Reluctance or lack of confidence in phoning other agencies and checking things out • Not knowing who to contact either individual or agency; understanding roles because of service changes Page 7 of 8 • Being able to articulate concerns clearly – to parents/in referrals and assessments/ in case notes • Being heard and feeling listened to; confidence to challenge - if we don’t have this how do we create it? Responses • List of local agencies and contact details – this to be kept electronically to aide updating and accessibility • Shadowing of roles in other agencies as part of induction and professional development • Sharing prompts for language to use in referrals and other useful tools/guidance: “ if nothing changes the impact on the child will be …” • Good record keeping – for yourself but also for others taking over a case • Make use of ‘My conclusions are … my evidence is ….’ • Being clear and concise • Summarise/reflect back what has been said (to both parents and other professionals) • Prepare scripts for conversations • Say and write what you mean • Clarify consent to share information Theme 2 - Early Support Issues • Reluctance to initiate an Early Help Assessment – seen as onerous and burdensome • Services actively discouraged not to initiate (focus on their core purpose and early help assessment not seen as part of this) • Lack of ownership across agencies • TAC meetings poorly attended – so commitment to attend falls • Lack of available services to support even if needs are identified Responses • Development of the Early Support Hub within Wiltshire MASH • Roll-out of the revised Early Support Assessment and shared IT systems as part of FACT Project • Improve understanding and ownership of the Early Support Assessments function as a multi-agency framework for working together and sharing information about a child and their family Theme 3 – Curious and Holistic Practice “To get the whole picture we need to know the whole family” Issues • Don’t want to upset families – don’t have the emotional capacity to get into a difficult conversation • Assuming others have done it • Understanding the difference between information and evidence • Starting with and retaining a fixed mind set/bias • Have concerns that remain but don’t know what to do with them • MASH seen as the place where all information is held Responses • Clarify role of MASH in logging and storing information • Use of genograms • Revisit difficult questions (e.g. keep asking about domestic violence) Page 8 of 8 • Use tools to help analyse the information you have and what type of information it is (e.g. Wonnacott’s Discrepancy Matrix; Socratic questions) • Good supervision and use of tools in supervision to reflect on cases • Describe what we see/hear • Hypothesising • Understand the why and the when (e.g. in relation to substance misuse not about what and how much) • Respond to feelings not the words; they need to feel their concerns are being listened to and addressed • Time to ensure record keeping is comprehensive, clear and up to date • Absence of thing is as importance as the presence • Understand “so what makes me think that?” – evidence? Feeling? Theme 4 - Working with Fathers/Male Carers Issues • Focus is always on mothers therefore we don’t think about fathers • Don’t feel able to challenge fathers – what are you doing to support the mother of your child? • Fathers often referred to as protective with no evidence for this or based on self-reporting by mother • Fathers seen as either ‘good = supportive’ or ‘bad = risk’ – need to develop more balanced view • Reliance on mothers telling us about fathers • Some systems/documentation don’t prompt questions about fathers Responses • Having systems that prompt you to record information • Engage with men in their spaces • Ask fathers questions – “how are you feeling about…?” • Review content and use of Dad pad, including gathering the views of fathers to inform any improvements and updates • Ask questions in supervision – “What about the Father in this case?” Summary In summary, this report sets out the circumstances that led to the significant injuries sustained by Child L and an analysis of the practice. Since this case was reviewed, there has been some significant development and investment in relation to a number of the learning themes, including: • The identification of funding to develop a pilot project focused on engaging fathers and developing models of good practice • External evaluation of the Support and Safeguarding Service by Oxford Brookes University with recommendations informing further service development as part of the Families and Children’s Transformation Project (FACT) In addition, the issues highlighted in this report have been picked up in a parallel report published by Wiltshire’s Safeguarding Vulnerable People Partnership (SVPP) in November: Thematic Review in to Significant Physical Abuse in Children under 1. The learning from this review will be brought together with that from the Thematic Review and work will be undertaken, overseen by the SVPP, to ensure that learning is actioned. |
NC046075 | Death of a 17-year-old boy, as a result of hanging. Ryan was found with a ligature around his neck in a cell in a Young Offender Institute (YOI); Coroner's inquest concluded accidental death. Ryan had been in the care of Leeds City Council since he was 16-months-old; when he was 13-years-old his long-term foster placement broke down and he did not have another stable placement. History of: extensive record of offending; chaotic lifestyle and risk-taking; aggressive behaviour; and frequent movement between accommodation. Issues identified include: focus of interventions on symptoms rather than causes of Ryan's difficulties; failure to agree a multi-agency response that included contingency planning for repeated crises; and failure to address frequent requests for contact with family members. Makes recommendations covering: corporate parenting responsibilities for promoting education, training and employment; and provision of suitable, specialised accommodation for young people with high support needs. Report was originally completed in February 2012 and reviewed in 2013. Report includes response to Coroner's Inquest, which was completed in January 2014.
| Title: Serious case review in respect of Ryan Clark (Child V): overview report. LSCB: Leeds Safeguarding Children Board Author: Pamela Shelton Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Leeds Safeguarding Children Board Serious Case Review In Respect Of Ryan Clark (Child V) Overview Report Published 19th March 2015 2 CONTENTS Page Introduction 3 Conclusions, Recommendations & Response to Coroner’s Inquest 3 Reasons for a Serious Case Review 10 Terms of Reference of the Review 11 Methodology 12 Sources of Information 13 Summary of Key Events 13 Analysis 26 Views of Family Members 44 Conclusions and Key Learning 44 Recommendations 45 Learning Lessons from Serious Case Reviews 46 Appendix1 Terms of Reference 48 Appendix2 Methodology 49 3 1. INTRODUCTION 1. This Serious Case Review (SCR) was commissioned by Leeds Safeguarding Children Board following the death of Ryan Clark, a 17 year old male, who died whilst remanded in custody to a Young Offenders’ Institution (YOI). Ryan had been in the care of Leeds City Council since he was 16 months old. 2. CONCLUSIONS & RECOMMENDATIONS (repeated in sections 8 & 9 and written in February 2012, prior to the inquest of January 2014) 2. Having carried out this SCR, the SCR Panel and overview report author have reached the following conclusions. 3. The Inquest completed in January 2014 concluded that the death was accidental. From evidence produced for the Panel, there is no indication that Ryan expressed any intention to harm himself. In fact, when asked directly, he expressed satisfaction with his life, although the manner in which he lived his life suggested otherwise. Staff involved with Ryan, including those in the YOI, could not reasonably have predicted Ryan’s death. However, they were insufficiently alert to the emotional turmoil that underlay his overt behaviour. 4. There are clear indications that Ryan was vulnerable from early childhood, and stark evidence that, in the 12-month period leading to his death, there was an acceleration in his personal difficulties and social exclusion. Staff focused their attention on the individual crises with which Ryan regularly presented them and did not stand back and consider the underlying causes of his behaviour. 5. There was an absence of regular and thorough assessments and re-assessments of Ryan’s situation that gave due recognition to his vulnerabilities based on the level of risk factors and lack of protective factors in his life. 6. When Ryan was in the YOI there was insufficient assessment of his vulnerability and the care he received was not always child centred. 7. Whilst it is evident that Ryan had a close attachment to his first, long-term foster carers, this placement broke down when he was 13 years old and he never had a stable placement thereafter. This is likely to have had an impact on his sense of security. 8. Agencies invested considerable time and money in providing a range of interventions aimed at supporting Ryan, much of it positive and well planned at an individual agency and worker-level. However, the interventions were insufficiently coordinated and focused upon the symptoms rather than the 4 cause of Ryan’s difficulties. The review system established to monitor the efficacy of care planning for looked after children failed in its purpose. 9. The serious case review did not identify a causal link between Ryan’s death and the nature of the services provided to him in the community. However, the efficiency and effectiveness of interventions were considerably undermined by the failure to agree a multi-agency response that included contingency planning for the repeated crises in Ryan’s life. This conclusion links to the City Council’s responsibilities as a corporate parent for its population of looked after children. The guidance makes clear that councils can expect the full cooperation of partner agencies in fulfilling these responsibilities. Evidence presented to the Panel suggested that those groups that had responsibility for ensuring the wellbeing of looked after children were not fully functioning. 10. There is some evidence of sensitivity to Ryan’s racial, cultural, linguistic and religious identity. There is also evidence of individuals ascertaining and taking account of his wishes and feelings. However, his frequent requests to have contact with family members and to know more about his father’s family were overlooked over a lengthy period. 11. At a personal level, the collective corporate system let Ryan down despite the best efforts and good intentions of individual members of staff. There was no one person who assumed responsibility for Ryan as a looked after child, ensuring that his overall wellbeing was promoted and safeguarded. The organisation legally charged with parental responsibility did not adequately discharge it. 12. All agencies involved in this SCR produced good quality IMRs that facilitated learning and contributed to the overall SCR. None of the IMR authors had any operational involvement with Ryan and each was at an appropriate level of seniority for undertaking the review and challenging agency practice. In all instances, a more senior manager countersigned the report. The individual agencies made recommendations that were appropriate to them and progressed and completed actions in response. The following, additional, recommendations are few in number and have wider application than this individual case. They also reflect the Panel’s understanding that changes and developments in practice pre-date this review. 1. The LSCB should satisfy itself that multi-agency arrangements for care planning and reviewing looked after children have improved and are efficient and effective. 2. The LSCB should satisfy itself that the programme of work being undertaken to improve corporate parenting responsibilities in Leeds includes promoting access to education, training and employment opportunities and enhancing emotional wellbeing. 3. The LSCB should review the sufficiency of provision of suitable, specialised accommodation for young people with high support needs, with a particular focus upon looked after young people. 5 4. The LSCB should promote more effective approaches to risk management and assessment of children and young people with complex needs. 5. The LSCB should endorse the IMR recommendations and require their implementation and should satisfy itself that actions are completed and embedded. 13. At the end of October 2012, Ofsted published a report – Ages of concern: learning lessons from serious case reviews. It is a thematic report based on an analysis of 482 serious case reviews that Ofsted evaluated between 01 April 2007 and 31 March 2011. The main focus of the report is upon babies less than one year and young people aged 14 or above. It came to the attention of the overview report author after completion of the final draft of the overview report. However, the report conclusions in respect of young people aged 14 or over clearly resonate with the findings of this review and are reproduced below for reference: Agencies had focused on the young person’s challenging behaviour, seeing them as hard to reach or rebellious, rather than trying to understand the causes of the behaviour and the need for sustained support; Young people were treated as adults rather than being considered as children, because of confusion about the young person’s age and legal status or a lack of age-appropriate facilities; There was no coordinated approach to the young people’s needs and practitioners had not always recognised the important contribution of their agency in achieving this. The overview report author recommends dissemination of this useful and relatively brief report. The Response of the Serious Case Review Panel to the Findings of the Coroners’ Inquest concluded on the 28th January 2014. 1. The Serious Case Review (SCR), in respect of Ryan was completed in February 2012 and revised in April 2013. Both the original report and the revision predated the Inquest touching the death of Ryan which ended on the 28th January 2014. Following the Inquest the SCR Panel was reconvened under the Chairmanship of Sheila Sutherland and met on the 27.02.14 and the 13.03.14 to consider the issues raised by the Coroner and also the Youth Justice Board Report, “Deaths of Children in Custody: Action Taken, Lessons Learnt”, 2014. 2. The conclusion of the Inquest was accidental death, the medical cause of death being attributable to hanging. Additional to the verdict the Assistant 6 Coroner, in her Regulation 28 report, identified several concerns which required action to be taken by Leeds Children’s Social Work Service, Leeds Children’s Services (Targeted Services) and the National Offender Management Service (NOMS). These concerns and responses are as follows: (a)To Leeds Children’s Social Work Service and Leeds Children’s Services (Targeted Services/Youth Offending Service); ‘That all relevant information, concerns and issues about a young person who goes into custody are imparted to, and discussed with Young Offender Institution staff by the said young person’s social worker and Youth Offending Team Case Manager as soon as the young person arrives in custody and within 24 hours thereof ‘. 3. Response from Leeds Children’s Social Work Services ( Targeted Services/Youth Offending Services) Response to concerns: “The following procedure has been agreed between Leeds Children’s Social Work Service (“CSWS”) and Leeds Youth Offending Service (“YOS”) in response to the above concerns set out by Miss Melanie J Williamson, Assistant Coroner, in her regulation 28 report, dated 3 February 2014: When a child appears in court with the potential to be remanded or sentenced to custody, the YOS Court Officer will collate all relevant information, concerns, vulnerabilities and issues known about that young person from existing YOS engagement. The YOS Court Officer will also check if the child has a social worker. If the child does have a social worker the YOS officer will contact the social worker to request all relevant information, concerns, vulnerabilities and issues about the young person. If the social worker is unavailable, enquiries will be escalated to the relevant team manager. If the team manager is not available, enquiries will be escalated to the relevant Service Delivery Manager. This information will form part of a joint report to be delivered to the relevant institution within 24 hours of the young person arriving in custody. Where there is no allocated social worker, the YOS Court Officer will provide an individual report within 24 hours of the young person arriving in custody. Where the child has a social worker but the YOS Court Officer has been unable to collate information from the social worker, the YOS Court Officer will inform the social worker at the receiving institution of this, will provide an individual report and will inform the relevant CSWS Head of Service who will expedite the sharing of any additional relevant information within 24 hours of the young person arriving in custody.” Agreed and signed by Saleem Tariq Chief Officer, Children’s Social Work Service and Jim Hopkinson, Head of Targeted Services (b)To the National Offender Management Service (NOMS); 7 ‘ At HMYOI Wetherby (i) The Personal Officer Scheme was not properly implemented and did not operate effectively vis a vis trainees; (ii) ACCT checks of a trainee were not made and/or were not made in accordance with the times prescribed by the trainee’s ACCT document; (iii) The correct procedure when conducting a roll count of trainees was not adopted by Prison Officers; (iv) Prison Officers were not fully conversant in the administration of first aid and CPR and had not received regular refresher training in relation thereto.’ 4. Response from NOMS “The four concerns raised are addressed in turn. Personal Officer Scheme Prison Service Instruction (PSI) 08/2012 Care and Management of Young People requires that young people are assigned a Personal Officer/ Caseworker during the induction stage of their imprisonment. This arrangement aims to achieve the following: • Each young person understands to whom they can turn to, to discuss all issues of concern, including resettlement. • The personal officer or caseworker attends each training plan review during the custodial period • There is appropriate contact with, and involvement of, each young person’s family and supervising officer and that links between all parties are strengthened In addition to this, PSI 75/2011 Residential Services sets out the need for all staff to engage positively with prisoners (and young people, as at Wetherby) and describes the key part that residential staff have to play as positive role models. In October 2013 HMP and YOI Wetherby implemented a revised personal officer scheme that aims to ensure greater continuity in the allocation of staff to young people and includes a ‘relief’ arrangement whereby a paired officer is available to cover during the periods of absence that are inevitable with staff working shifts. The new scheme emphasises the supportive element of the role, and staff have been briefed on this. A copy of the new policy document is attached for your” (the Coroners) “information. More generally, the Governor is aware that even the best personal officer scheme has limitations, and encourages all staff to establish and maintain positive relationships with all young people in the establishment. ACCT Checks The governor is confident that the failure of one officer to conduct an ACCT check on one occasion is not representative of practice amongst staff at HMP and YOI Wetherby, and the incident in question was the subject of a 8 disciplinary investigation. Staff are now briefed on the timings of ACCT checks and the need for good quality interactions and observations at the start of each shift. In addition, full ACCT guidance has been reissued, and priority is being given to providing ACCT refresher training for all staff. In order to provide further reassurance, the Governor has introduced an additional layer of management checks of all ACCT documents. Roll Checks The two failures to follow the procedure for roll checks identified in this case have been the subject of investigations, and disciplinary action has been taken against the staff involved. All staff have been briefed on the importance of roll checks, and these are now subject to covert checks by managers. If, following a covert check, there is any doubt as to whether or not a proper roll check was carried out, CCTV evidence is examined, and a disciplinary investigation is instigated where necessary. First Aid and CPR PSI 01/2014 First Aid describes the process for ensuring effective provision of first aid that enables NOMS to discharge its duty of care to its employees, to prisoners and to visitors to our premises. Governors are required to ensure that at all times such numbers of suitably trained first aiders as is sufficient and appropriate for the circumstances are available. A First Aid risk/needs assessment is undertaken by the local Health and Safety Advisor to determine the appropriate numbers. Governors must ensure that first aiders are trained to levels which are appropriate for the circumstances and hold a valid certificate of competence in either First Aid at Work (FAW) or Emergency First Aid at Work (EFAW). This policy is being implemented at HMP and YOI Wetherby. In accordance with it, all 16 custodial managers will be trained in FAW by the end of June 2014 and all of the 27 operational support grades who carry out night patrols in residential areas will be trained in EFAW during 2014. This arrangement will supplement the 24 hour healthcare cover at the establishment, which includes the availability of two trained nursing staff at all times, including overnight”. Signed by Jacqueline Townley, National Offender Management Service 5. The progress in the implementation of these responses and actions will be monitored and followed up by the Leeds Safeguarding Children Board Serious Case Review sub- committee through six monthly reports to it by the agencies concerned. 9 6. The SCR Panel also considered the following issues from the Youth Justice Board Report “Deaths of Children in Custody: Action Taken, Lessons Learnt” 2014, some of which had particular relevance to the circumstances of Child Ryan.: “Improving the quality of information shared with the YJB Placement Service and the secure estate from Youth Offending Service” The Youth Offending Service (YOS) Deputy Service Manager and the Governor of Wetherby Young Offenders Institution both confirmed to the SCR Panel that information sharing is mentioned in both the YJB Report and the Regulation 28 recommendations. Current practice in Leeds is that Placement Information Forms and Post Court Reports usually are sent to the YJB via Connectivity and followed up by secure email to the YJB placements team to ensure receipt. Asset assessments are sent by secure email due to Connectivity validation issues in the Leeds YOS case management system. The correct information being sent to the relevant secure establishment is the responsibility of the YJB not the individual YOS. A national notification system has been established by the YJB to ensure any omission in information regarding a young person’s placement is flagged up to the YOT Head of Service. The YOS manager reported that the number of young people in Leeds receiving custodial sentences is greatly reduced when compared to the situation at the time of Ryan’s sentence to custody. There is confidence that young people receiving custodial sentences are the subject of detailed planning and information sharing. Regarding the YJB Report p15. Re Placement Information Form (PIF) – this is a standard pro forma that has been in established use for a long time. “All children remanded now become ‘looked-after children’ and are therefore entitled to additional support from their home local authority when remanded.” Children and young people who are on remand in custody are given ‘Looked After Child status’. This change has been implemented since the introduction of the Legal Aid, Sentencing and Punishment of Offenders Act of 2012. The SCR Panel were asked whether agencies were aware of this and the implications it brings. It was confirmed that across the secure establishments, YOS and CSWS, all relevant people are aware and the relevant flowcharts have gone into guidance which has been distributed to social workers. All young people on remand in custody are now allocated a Social Worker as 10 well as a Youth Justice Officer. There are now dedicated Social Workers within Wetherby HMYOI; this has been implemented approximately from the time that the SCR V was commenced. The Panel Health representative confirmed that Looked-After Children Health Reviews are overseen by Nurses within the HMYOI establishment. The reconvened SCR heard that since the time of Ryan’s death, services to young people who both were vulnerable and challenging to work with, had greatly improved. There was now a reduction in the numbers of children receiving custodial sentences, which was felt, to be due to the much improved multi agency work with those children at risk of becoming involved in, or responsible for criminal activity. The Governor HMP & YOI Wetherby amongst other detail was able to inform the Panel that all children in custody were regarded as Looked After and a Social Worker working within the YOI responded to them as such. Panel members described the present multi agency response, to children in similar circumstances to those Ryan had experienced, as well coordinated and responsive. Leeds Children’s Social Work representative gave an account of an improved response to corporate parent responsibilities for Looked After Children with further developments in hand. 3. REASONS FOR A SERIOUS CASE REVIEW 14. Ryan’s long-term foster placement disrupted when he was 13 years old following difficulties that included offending behaviour. He first became involved with the Leeds Youth Offending Service (YOS) around the same time and they supervised him under a range of orders over the next four years. 15. At 17 years of age, Ryan appeared in court again; he was remanded to custody and was admitted the same day to a YOI. 20 days later an officer found Ryan in his cell with a ligature round his neck. Staff attempted resuscitation until paramedics arrived and took over. Ryan was transferred to hospital by ambulance where he was pronounced dead. 16. The decision to undertake a Serious Case Review (SCR) was made by the Leeds Safeguarding Children Board (LSCB) Executive Committee acting in the capacity of the Serious Case Review Standing Sub-committee. The LSCB Chair, who has ultimate responsibility for deciding to undertake a SCR, was in attendance. The decision was, in this instance, straightforward in that the guidance (Working Together to Safeguard Children [WTSC], March 2010) states in paragraph 8.9 that: “a SCR should always be carried out when a child dies in custody”. 11 17. A Prison and Probation Ombudsman investigation has been undertaken within a similar timescale to the SCR. The Panel Chair and LSCB Assistant Manager have liaised with the Ombudsman service in order to ensure that information about the circumstances of Ryan’s death is shared as appropriate. 18. An inquest will in due course be held in order to establish how Ryan died and record a verdict. The Coroner is aware that a Serious Case Review is being undertaken. 4. TERMS OF REFERENCE 19. The purposes for any SCR carried out under the WTSC guidance are to: • Establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; • Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and • Improve intra- and inter-agency working and better safeguard and promote the welfare of children. 20. WTSC guidance states that SCRs are not inquiries into how a child died or who is culpable. “These are matters for coroners and criminal courts to determine as appropriate. Rather, they are intended to enhance learning within the agencies involved with the child or young person who was the subject of the review in order to inform future operations, planning and developments.” 21. The LSCB agreed the time period of the review as the last 12 months of Ryan’s life. Ryan was a looked after child and had been in the care of Leeds City Council since he was 16 months old. The LSCB decided that the case review should not encompass Ryan’s entire time as a looked after child but focus on events leading up to his remand into custody. 22. However, in order to provide a context to the review, agencies were asked to look at their records from when Ryan’s long-term foster placement broke down when he was 13 years old and provide a summary of their involvement during this period. A chronology was not required for that part of the review. 23. The LSCB agreed six terms of reference specific to this case and agencies contributing to the review were asked to address each of these in their Individual Management Reviews. These are listed in appendix 1 of this Overview Report. 12 5. METHODOLOGY Agencies and individuals involved in the review 24. A SCR panel was convened with an Independent Chair and representatives of relevant agencies. In addition an Independent Overview Report Author was commissioned who was not a member of the SCR Panel but who attended Panel meetings in connection with writing this Overview Report. 25. The Independent Chair was Sheila Sutherland who has over 30 years’ experience in children's social care, both as a social work practitioner and operational manager, including fourteen years as Head of Service/Assistant Director. Since October 2009, she has worked as an independent consultant carrying out case reviews and investigations into staff conduct issues. In addition, she acted as social care consultant to the Centre of Education Leadership at Manchester University on the design and delivery of Social Care Leadership Programmes. 26. The Independent Overview Report Author was Pamela Shelton who has over 35 years’ experience in children’s social care, including as a frontline social worker and senior operational manager. She has worked independently since 2000 undertaking a wide range of assignments that include: inspections and reviews of children’s services; safeguarding audits; complaint investigations; serious case reviews; improvement programmes in local authorities, and the development of programmes to support newly qualified social workers and advanced practitioners. 27. Sheila Sutherland and Pamela Shelton have never worked for Leeds City Council and have no interests in any of its dealings. 28. A full list of the membership of the SCR Panel is included as appendix 2 of this report. 29. The recommendations made were acted on during the process of the review in order to ensure delay was not incurred in using the learning as it emerged. 30. The Overview Report has been reviewed and revised by Peter Ward in preparation for publication. In carrying out the revision Mr Ward has considered the report of the investigation into the circumstances of the death of Ryan carried out by the Prisons and Probation Ombudsman which was not available when the overview report was completed. 31. Mr Ward has a background in social care and has worked in management and front line social work. He is qualified to degree level in social work and has a post-graduate diploma in management studies. He is now the Director of Arrow Social Care Consultancy Limited and as such undertakes investigations and other consultancy work on an independent basis. This has 13 included involvement in numerous Serious Case Reviews. He has no involvement or interest in any of the dealings of Leeds City Council. Sources of Information 32. The SCR Panel and overview report author received an individual management review (IMR) from each of the public and voluntary sector agencies that had had involvement with Ryan and his family. Each IMR included a detailed chronology of the agency’s involvement during the last 12 months of Ryan’s life. These chronologies were combined into one integrated chronology for the benefit of the Panel members and the overview report author. 33. Other agencies provided information about involvement that fell outside the timescale of the review and brief involvement that did not warrant an IMR. (Agencies contributing to the review are listed in appendix 2). 34. The Panel chair, Assistant LSCB Manager and overview report author had a pre-meeting to plan for the review. Subsequently, the Panel met on four occasions and all but two of the IMR authors joined the Panel for its first two meetings in order to introduce their reports and participate in the subsequent discussion. 35. For the purpose of this review, the overview report author referred to relevant City Council documents and national research reports, legislation and guidance. These are listed in appendix 2. Family Information 36. A genogram was constructed to provide Panel members and the overview report author with information about Ryan’s family. Interviews were carried out with Ryan’s mother, a sibling of Ryan’s who Ryan had indicated he felt close to and the long term foster carers who Ryan had been living with up to 13 years of age. 37. Ryan’s father died shortly before Ryan’s 16th birthday and The Panel was interested to establish, in particular, his cause of death and any potential relevance to Ryan. It proved very difficult to find any information about him but very late in the review, information was received which indicated the cause of death and provided an insight into Ryan’s father’s background. 14 6. SUMMARY OF KEY EVENTS Initial period 38. Agencies were asked to review their records from when Ryan’s long-term foster placement broke down when he was 13 years old up to 12 months before he died, a period of three years and four months. They were asked to provide a summary of their involvement during this period. A chronology was not required for that part of the review. However, the chronology that formed part of the CYPSC IMR incorporated key events that occurred during this period and they have been included in the integrated chronology. 39. Supervision notes from six months before the placement broke down, in the records of CYPSC, state that Ryan’s long-term foster placement was stable with no significant problems. However, two months later, the foster carers reported that they were finding it increasingly difficult to manage Ryan’s behaviour. There is evidence of efforts by the social worker to support the placement. 40. Ryan was attending a high school and Education staff attended the six-monthly reviews required for a looked after child. There is evidence in school records of a Personal Education Plan having been partially completed and sent to the social worker at this time but no prior or subsequent plan. 41. Around this same time, Ryan was excluded from school on three occasions for poor behaviour. At a review meeting in this period, an action was to produce a Behaviour Support Plan as required but there is no evidence that this occurred despite continuing problems. Subsequently Ryan was without a school place for three months up to the end of the school year. 42. During this same period, Ryan committed an offence and entered the final warning programme organised by the Youth Offending Service (YOS): a pre-court voluntary intervention that is brief and restorative in nature, usually offered when a young person has been arrested on no more than one or two occasions. 43. YOS staff and the social worker communicated frequently and also liaised with Ryan’s school. The YOS worker completed a full ASSET assessment. According to guidance from the Youth Justice Board: “Asset is a structured assessment tool to be used by Youth Offending Teams in England and Wales on all young offenders who come into contact with the criminal justice system. It aims to look at the young person's offence or offences and identify a multitude of factors or circumstances - ranging from lack of educational attainment to mental health problems - which may have contributed to such behaviour.” 44. Ryan’s score was medium/high, which is unusual at a final warning stage and reflected a number of indicators that Ryan was likely to re-offend. 15 45. A statutory Looked after Child (LAC) review was held and the case record notes that Ryan’s needs were met and the plan was appropriate. However, the IMR author was not able to locate the review form or report of the meeting. The supervision record shortly after states that the placement had irretrievably broken down and that Ryan was missing. The agreed plan was to locate Ryan and place him in an emergency placement to allow an assessment to be made to inform future placements. It also states that every effort should be made to return Ryan to his long-term placement, though this view was revised within the month to acknowledge that there was little likelihood of Ryan returning to the previous carers. The placement disruption was not reported to the Fostering Panel and no disruption meeting was held. Within two weeks, Ryan had been arrested and placed in an emergency foster placement. 46. Four months later Ryan moved to another short-term foster placement after expressing unhappiness with the first placement. According to the LAC review, the plan remained to identify a long-term placement for him. However, by 12 months later, there was agreement that the social worker should apply for a change of status of the current placement to long-term. Ryan was present at these LAC reviews. 47. Ryan commenced at a new school when he moved foster placements but was excluded two months later at which point the school gave notice that they were returning him to the first school. He remained out of school for the next 11 weeks on an authorised basis. Ryan then entered a phase of persistent absences from school and, from five months later, attended alternative education provision with four different providers. One provider requested a Personal Education Plan but the school did not have one available. 48. The nurse from the LAC nursing team completed Ryan’s Health Needs Assessment (the annual statutory health review for looked after children) shortly before his 15th birthday at his foster home (after considerable effort on her part). 49. At 14¾ years of age, Ryan was sentenced to a 10-month supervision order. He responded very positively to this order and, during the first six months, experienced a stable period, including being well settled with his foster carer. The YOS case manager also carried out eight sessions of anger management work with Ryan. The assessment completed towards the end of the order indicated that the risk of Ryan re-offending remained medium/high but his attitude towards offending had improved, particularly his recognition of the consequences for self and victims. However, Ryan committed another offence seven months later, for which he received a further supervision order that superseded the earlier one. Over the next few months, Ryan’s school attendance decreased and he spent time away from his foster home. 50. Shortly after his 15th birthday, Ryan started to attend the City Council’s teaching and learning provision but his attendance was terminated four months later following an incident. He moved back to alternative provision 16 and, in the time until he left school that summer, received some positive comments about his progress and abilities. 51. At the LAC review held when Ryan was 15½ , the record indicates that the plan to transfer the status of the current foster care placement to long-term was hampered by Ryan’s increasing absences from the placement. It was agreed to make a referral to the Pathway Planning team (the team within CYPSC that caters for young people aged 16 and over who are or have been looked after) to ask for the appointment of a personal advisor. 52. Ryan appeared before the court again the following month on new charges and for breaching his supervision order. He entered the bail support scheme: an intensive form of support for young people awaiting sentence who are otherwise at risk of a remand to custody, and responded well during the three-week period. However, the ASSET assessment indicated a significant increase in risk factors, as well as concerns about his behaviour and wellbeing. 53. The following month, the court imposed a new 12-month supervision and curfew order. Ryan returned to live with his foster carer and, four months later, the social worker reported that the placement had stabilised. Ryan cooperated well with the new order and was seen 54 times – virtually an appointment every week during the year. The YOS substance misuse worker met regularly with Ryan who was cooperative, although the involvement had little impact on his substance misuse. 54. Around the same time, Ryan’s case transferred to a new social worker because the current worker could not provide Ryan with the level of input he required as a result of other demands. Two days before Ryan’s 16th birthday, the social worker was informed of the death that day of Ryan’s father. The social worker offered Ryan bereavement counselling, which he declined. The YOS worker noted that Ryan had expressed a wish to have got to know his father better. Staff encouraged him to discuss his feelings but Ryan claimed to be unaffected, although his foster carer reported that he became emotionally distant. 55. Over a four month period, when Ryan was 16 years of age, he missed many appointments with YOS and his order was breached and a 12-hour reparation order substituted. He spent increasing amounts of time away from his foster carer’s home, effectively moving to live with his relatives. 56. When Ryan was 16½ years of age, a social work student completed a risk assessment that identified four concerns. The resulting action plan was non-specific. 57. Immediately following this assessment, the social worker requested an alternative foster placement for Ryan. No reason was evident. Later that same month, the social worker recorded that Ryan was refusing to consider any alternative placement and stated that the plan was to pursue an independent living arrangement for Ryan. 17 58. Ryan refused a foster placement and continued to live with his relatives. The social work student had discussed his case with the Pathway Planning team and arranged for the involvement of a support worker from the Supported Independent Living Service, a voluntary sector organisation, commissioned by the Supporting People service, that provides ‘floating’ housing support and tenancies for young people aged 16-25. One of its projects relates specifically to care leavers and involves both housing support and support in relation to education, employment and training. Summary of events during the last 12 months of Ryan’s life 59. The following summary focuses on key events and details deemed relevant. It does not, therefore, fully reflect the high level of activity undertaken by the staff involved with Ryan, including both the direct contact with him and the liaison between agencies. Month 1 60. During this month, the social worker completed a Pathway Plan, which was agreed by Ryan although not signed off by the manager. This recorded that Ryan was to be assisted in registering with a local GP practice, which was done the following month, and supported regarding his substance misuse. It was noted that he was ‘open’ to counselling following the death of his father but no action was recorded to address this. 61. Concern was expressed to the social worker that Ryan was not looking after himself and a request was made for him to be placed in secure accommodation. The social worker’s response was that he did not meet the criteria although the IMR notes that there is no record of the social worker discussing this request with her team manager or supervisor. Month 2 62. The social worker acknowledged during supervision that Ryan’s placement was not meeting his needs. There was agreement that the social worker would look for long-term accommodation for Ryan. At the LAC review later that same day, Ryan agreed to a referral to an independent sector organisation commissioned by Leeds City Council that provides supported accommodation and flexible and intensive packages of support. The application was necessary because the Supported Independent Living Scheme had no accommodation in an area suitable for Ryan: that is, one where Ryan identified he would not be at risk from other adults. However, it was clear that the Supported Independent Living Scheme would continue to provide the support in view of its staffs’ established relationship with Ryan. 63. In the middle of the month, Ryan was arrested and charged by West Yorkshire Police (WYP). Month 3 18 64. Early in month 3, Ryan agreed with the social worker, that he needed more support. 65. At a court appearance, Ryan was bailed for three months and complied well with the bail support requirements: he had 28 appointments with staff in the three-month period, missing just one appointment. 66. Ryan’s placement with his relatives ended a few weeks before his 17th birthday following an alleged incident. Leeds Housing Options (part of the Environment and Neighbourhood Directorate) assisted in securing Ryan accommodation at Hostel1, a hostel for single homeless males over 16 years with 24-hour staffing, commissioned by the Supporting People Programme (also part of the Environment and Neighbourhood Directorate). The social work student made enquiries about Ryan’s application to Ryan Housing for a tenancy and the latter expressed concerns about Ryan’s behaviour in previous accommodation. Month 4 67. Early in the month, the social work student noted that Ryan reported being ‘hassled’ by other residents in Hostel1. 68. Ryan did not attend the registration appointment with the practice nurse at the new GP practice; he said he would not attend for his Health Needs Assessment and was advised that he should be seeking medical advice. He was continuing his substance misuse. 69. The independent reviewing officer’s note of a LAC review states that the social worker requested a personal advisor for Ryan because of his high level of need; also, that Ryan would like more information about his father’s family and this was an action for the social worker. The IMR author could find no record to indicate any action taken. The IMR author also notes that there was no entry in the section on Emotional and Behavioural Development. 70. During the month, Ryan was evicted from Hostel1. The hostel advised Leeds Housing Options of the position and they, in turn, informed the social work student. The latter asked for help about alternative accommodation options and was told that Housing Options had discharged its duties to Ryan under the legislation and suggested that Ryan looked at private rental accommodation. The personal advisor at the Pathway Planning team confirmed that the housing position was as set out by Housing Options and recommended Hostel3, although it was not accommodation registered by the Council as part of its Supporting People Programme. The social work student arranged a bed and breakfast placement at Hostel3, provided Ryan with money and requested that the Supported Independent Living Scheme support worker explore housing options with two providers. 19 Month 5 71. At the beginning of the month, the CYPSC team manager decided that Ryan’s needs would be better met by a social worker from the Pathway Planning team; further, that Ryan’s relationship with his current social worker was not of significance so a change would not have a negative impact. The Pathway Planning team had capacity to take on the case and the social worker was asked to prepare a transfer summary within a week. The social work student maintained contact with Ryan. 72. The updated Pathway Plan included reference to Ryan having been allocated a housing support worker from the Supported Independent Living Scheme; that Ryan was still not in any form of employment, education or training (bail support and Supported Independent Living Scheme workers to assist); that he would benefit from advice about healthy eating from the nurse or GP; and that he wanted contact with specific relatives. 73. Hostel3 closed down in the second half of the month for refurbishment and Housing Options again advised that the duty to accommodate Ryan lay with CYPSC. Ryan moved from Hostel3 to Hostel4 due to factors outside anyone’s control. This was a similar establishment to Hostel3, and he remained until his court appearance the following month. During this period he received a high level of support from the bail support worker. The ASSET assessment completed during this time triggered a vulnerability management plan with actions intended to minimise the identified risks in relation to substance misuse, attitude to offending and emotional wellbeing. Month 6 74. Leeds Housing Options received a housing application from Ryan for housing with Leeds Homes who manage the lettings process and ALMOs (arms-length management organisations) on behalf of Leeds Council. 75. Following his period of bail support, Ryan was sentenced for the offences committed four months earlier by way of a Youth Rehabilitation Order (a further period of supervision) with a requirement to complete 80 hours of unpaid work. Ryan did not comply well with the order and his overall situation remained very unsettled. He was asked to move out of Hostel4 and went back to Hostel3. The YOS requested longer-term planning to provide him with more appropriate accommodation. 76. At the end of the month, the LAC nurse visited Ryan in his bed and breakfast accommodation to undertake his Health Needs Assessment. The nurse noted that: he appeared to be generally well and had no worries about his health despite his lifestyle. Ryan indicated that he was not worried about his health, felt happy with his life and intended to continue with his current lifestyle. He chose not to be immunised. He identified who he would approach if he were sad or worried. 20 Month 7 77. The nurse passed on the written information to CYPSC the same day and had a discussion with the social worker the next day: the nurse recommended that Ryan needed a supported living placement. The social worker reported that Ryan’s issues were all being dealt with by YOS or CYPSC. 78. Three days later, Ryan contacted the social work student to say he was concerned about staying at the current accommodation because ‘people were after him’ On advice from the Supporting People manager, the student arranged for Ryan to move to Hostel2, provided by a voluntary sector organisation that catered for an adult male population. The hostel support worker contacted the social work student three days later to say that Ryan was not cooperating and they wanted a meeting that would include YOS staff. 79. In supervision the social worker noted that apart from awaiting his move to the Pathway Planning team, there were no other matters relating to Ryan that required discussion. In the middle of the month, Ryan received a final warning from the YOS in relation to him missing his unpaid work. The social work student completed a case summary that stated that Ryan needed to register with another, more local GP; he was not in education; and there were concerns about his behaviour. 80. Near the end of the month, the social worker undertook the statutory LAC visit to Ryan who agreed to meet the hostel support and Pathway Planning workers. At a meeting at the hostel next day, Ryan reluctantly agreed to attend sessions with the support staff – a requirement for maintaining the placement. The Pathway Planning team worker contacted Leeds Housing Options to set up the arrangement that would allow Ryan to bid for council properties. Month 8 81. Having been charged with an offence Ryan was bailed for two weeks early in the month and made subject to an Intensive Surveillance and Support order. He cooperated well. When he returned to court for sentencing 16 days later, he was made the subject of another Youth Rehabilitation Order with an Intensive Surveillance and Support Order. The latter requires young people to be seen on a daily basis for the first three months and to be subject to a curfew, in Ryan’s case between 9.00pm and 7.00am with an electronic tag. It is a demanding programme and Ryan struggled to comply. He returned to court on three occasions for breach proceedings and each time the court agreed to allow the order to continue. Although Ryan did not fulfil the expectations of the order fully, he did derive considerable benefit from the contact with staff. 82. YOS staff reviewed the vulnerability management plan and identified an emerging issue of concern as Ryan’s reports of intimidation from other adult offenders. He was never specific about the threats made to him but indicated that they were connected to the supply of drugs. Staff were sensitive when 21 making arrangements to meet Ryan to avoid areas of the City where he felt unsafe. This information was shared with the Police and they were active in seeking to assist but Ryan did not provide further information. The lack of detail about the individuals concerned meant they could not investigate the matter further. 83. The case transferred within CYPSC to the Pathway Planning team. During a visit to Ryan near the end of the month, the social worker advised him that he was not currently in a position to make housing bids because the continual breaching of his court order meant that he would lose any tenancy. The following day, the hostel worker advised Ryan that the amount of damage caused by him and another resident was unacceptable. 84. The next day, the social worker received notice from Hostel2 of Ryan’s immediate eviction as a result of an incident the previous night. The social worker spent considerable time, including liaising with the Supporting People team, in order to arrange alternative accommodation. The manager in the Supporting People team requested that a case conference should be convened in view of the complexity of Ryan’s needs. Ryan spent at least one night in a voluntary sector resettlement hostel where residents can stay for up to six months whilst seeking permanent accommodation. It caters for adult males who are mostly offenders. By the end of the month, he had returned to Hostel1. The social worker noted in supervision that day that Ryan was not happy in his accommodation. It was agreed that the social worker would contact previous bed and breakfast accommodation to enquire whether he could return there. Month 9 85. During a visit from his social worker early in the month, Ryan said that at times he felt he wanted to be violent to people. He agreed to the social worker arranging therapy for him but said that it had not worked in the past. Six days later, Ryan expressed concern to his social worker that a young person moving into Hostel1 wanted “to beat him up”. The social worker moved Ryan back to Hostel3. 86. In the middle of the month, YOS staff requested a meeting to discuss the risk Ryan presented to others, which the social worker duly arranged for later in the month. The following day, Ryan was arrested. He was held in custody overnight but no further action was taken. The social worker explained in an email to the YOS and Supporting People workers that it was not possible to pursue a council tenancy for Ryan because of the risk of him going into custody. He was due to be breached for non-compliance with the ISSP order. 87. YOS staff and the social worker met a week later to discuss a recent incident when Ryan had been physically aggressive. This was the first evidence of such behaviour. It was acknowledged that Ryan was at risk of a custodial sentence. Further action to support Ryan in relation to his offending behaviour was agreed. 22 88. Just before the end of the month, the social worker noted in supervision that Ryan had been breached for not complying with the conditions of the ISSP; his risk status had risen to medium; the application for council housing had been made. Month 10 89. Early in the month, YOS sent Ryan a formal and final warning about his missed appointments. Ryan attended his LAC review at which the IRO noted the repeated request from Ryan to have contact with specific relatives, and a further request for information about his father’s family. (The IMR author notes that this same action was included in two previous LAC reviews and there is no record that any action was taken.) 90. In addition, where Ryan had previously refused offers of counselling, he was now willing to consider the same. The action from the review was for the social worker to make a referral to the therapeutic social worker as soon as possible. 91. Ryan appeared in court accompanied by his social worker, for non-compliance with the ISS programme. He was given four weeks (again) to comply or would face a custodial sentence. Ryan told his social worker that the YOS worker was trying to get him sent down. The social worker took him to the ISSP that day but Ryan failed to attend the following day. He did, however, keep an appointment about his housing with the Supported Independent Living Scheme worker. 92. In the middle of the month, Ryan visited his social worker and said he had been thrown out of Hostel3. The social worker confirmed that Ryan still had a place there despite an incident that had occurred. Ryan indicated his determination to be thrown out on the basis of his belief that he could not be breached if homeless. Ryan failed to attend the ISS programme on three out of the next four days. He was then arrested. He attended various sessions at YOS. 93. Also at this time, the Supported Independent Living Scheme worker met Ryan to look at his housing papers and to make bids for flats. 94. The following day, Ryan was the subject of discussion at the Drug and Offender Management Unit (DOMU), a team responsible for managing the Deter Young Offender (DYO) cohort. This is a group of offenders identified by the YOS as presenting the highest risk of re-offending. Officers from DOMU work closely with staff from the YOS to manage the DYO cohort. Following the meeting, there was an increased level of activity from DOMU officers reflecting the concerns about Ryan’s poor compliance with the YOS and the associated heightened risk of re-offending. 23 95. One day later, the Housing Support Service received a care leaver referral for Ryan. The application attracted an additional needs classification and was backdated to Ryan’s 16th birthday. 96. Over the next 18 days, Ryan’s compliance with the ISS programme was spasmodic. A police officer from DOMU was due to meet with Ryan about his fears of attending YOS because ‘people were after him’. Ryan failed to turn up. He appeared in court for breach of the ISSP order: the outcome was that the order should continue with a three-month curfew requirement and electronic tagging in addition to the original sentence. However, Ryan continued his pattern of part-compliance. Month 11 97. In the middle of the month the social worker was contacted about a letter inviting Ryan to view the new-build council accommodation for which he had made a bid. 98. Four days later, Ryan received a final warning about his non-compliance with the curfew. That night, Ryan was arrested and held in custody so could not attend the housing open day the following day. Subsequently, Hostel3 indicated that they did not want Ryan back. In a case discussion, the social worker stated that Ryan had exhausted all the accommodation options. 99. The Supported Independent Living Scheme and Pathway Planning workers found Ryan overnight accommodation in another hotel. The social worker later negotiated for him to stay longer. Leeds Homes received a bid for a council property. The Supported Independent Living Scheme agreed to offer a trainer flat to Ryan and the social worker applied for his leaving care grant. 100. Later in the month, Ryan made a trip to an adult prison as part of an initiative within his ISS order aimed at deterring young offenders: ‘Prison Me No Way’. 101. Two days later, Ryan received the offer of a tenancy from one of the arms-length management organisations within Leeds City Council. He subsequently viewed and accepted the property. Four days afterwards he was arrested and charged with possessing a controlled drug. He was also not complying with his ISS order by failing to attend sessions. Month 12 102. At the beginning of month 12, Ryan attended an interview with a police officer to discuss his lifestyle and welfare, and identify what additional help and support he needed. The record indicates that Ryan was not amenable to help and support at this time. 103. Ryan failed to appear at court and a warrant was issued for his arrest. Two days later, he was arrested and appeared in court, the outcome being that the ISS order was to continue with an additional three-month curfew. He did not attend ISS sessions the next day and a week later received a final warning for 24 his failure to comply with the ISS programme. Meanwhile, the Supported Independent Living Scheme advised the YOS that Ryan’s flat would be ready in two weeks. 104. In supervision, the social worker from the generic childcare team (who remained involved until the case transfer was fully completed) noted that Ryan was getting on well with the Pathway Planning social worker. Agreed actions were that the social worker would discuss Ryan’s education with Connexions and ask the LAC nurse to see him about his dental health, Ryan having agreed the latter. 105. The following day, Ryan received a final warning from YOS for curfew violations. 106. Five days after receiving the final warning, Ryan signed up for his tenancy with his social worker acting as trustee and an agreement that the Pathway Planning team would pay his rent until he was 18. He began buying items for the flat. 107. Later that day, Ryan was arrested and detained in custody to appear at the next available court. He was subject of a risk assessment as part of the custody booking-in process, and answered in the negative to all the questions relating to any concerns about his physical and mental health. Subsequently, Ryan did not have an appropriate adult present when questioned because he was over 17 years and was not assessed as a vulnerable person who required such support. 108. Having received legal advice, Ryan was placed in a cell and began to bang his head and fists on the cell door. He was abusive to staff and refused to see the SERCO nurse. His risk was re-assessed by the custody sergeant and nurse and they formulated a care plan that stipulated that Ryan should be visited every 30 minutes and roused should he fall asleep, in view of the bangs to his head. 109. Ryan appeared in court the next day. He was remanded into custody and transferred from court to the Young Offender Institution. The escort form from court stated “Previous self-harm by banging head on cell wall” but gave no further information as to when or why the incident occurred. Ryan later told the nurse that he had received the injuries (grazes to his knuckles and forehead) during a fight two days previously. Any indication of self-harm should be notified to the receiving establishment on a specific form. The YOI did not receive any such notification. 110. On admission, in line with normal practice, Ryan underwent a comprehensive risk assessment process by staff, including a registered nurse. The interviews covered an assessment of: o immediate and longer-term welfare needs; o any vulnerability concerns; o any risks posed to individuals with whom he might share a cell; and o a full health assessment including mental health. 25 111. This assessment was considered alongside information received from West Yorkshire Police and the Youth Offending Service, including the lengthy ASSET document, which together provided a comprehensive profile of Ryan throughout his formative years up to the present time. There was no indication in any of these documents or from the interview with Ryan that he posed a risk of self-harm. All such documents are held electronically in the YOI so as to be available to any member of staff as necessary. 112. Ryan underwent a ‘first night in custody’ interview with a member of staff trained to complete such a task. There was no indication of any risk of harm to self. 113. On reception, Ryan was allocated a key worker whose role was to support him throughout his time in custody. The latter had regular contact with Ryan on the unit and held two formal meetings during the 20 days he spent in the YOI: his five-day remand review and another review. The key worker drew up a remand plan that was maintained throughout his period on remand. 114. A doctor saw Ryan on day two and noted that he was calm and relaxed, and was assessed as having no suicidal thoughts. The nurse saw him again and advised him of the need to complete his immunisations, which he refused. He also had a routine sexual health screening. 115. The Chaplaincy team conducted an initial interview with Ryan after which he attended Chapel services on two occasions. Staff described him as quiet and unassuming. Ryan later indicated a wish to be baptised and participated in baptismal preparations the same day. 116. Ryan spent the first six days on the ‘first night in custody’ suite and underwent a full induction programme. During his five-day remand review, attended by both his YOS worker and social worker. He declined any assistance with substance misuse (although it was part of his remand care plan); said he felt settled and had no concerns regarding self-harm; and only required help with writing and finding accommodation on his release. 117. Later that same day, there was an incident of note during which Ryan verbally abused and threatened a member of staff and caused damage to his room. He moved the following day to another residential unit, the aim being to de-escalate the situation and provide him with a fresh start. It is, in any event, common practice to move to another unit within this time frame. Ryan appeared before a Governor and received a punishment based on a tariff system that takes into account any mitigating circumstances. 118. Ten days after being detained in the YOI Ryan appeared at court in Leeds. Staff, including a nurse, interviewed him on his return and raised no concerns about him. 26 119. A worker from the Young People’s Substance Misuse Service within the YOI saw Ryan on two occasions but he declined involvement with the service, stating that he had no current drug dependencies. 120. Five days after he appeared in court, the Connexions personal advisor in the YOI visited Ryan to complete his Individual Learning Plan that set out what he wanted to achieve whilst in custody. The worker discussed the courses available within The YOI but Ryan expressed no clear idea about what he wanted to do. 121. 20 days after being detained in the YOI, Ryan was found dead in his cell room. The details are set out in the first section ‘Summary of events leading to a Serious Case Review’. 7. ANALYSIS Analysis based on the Terms of Reference 122. The terms of reference agreed by the LSCB are considered in turn below, whilst also taking into account the purpose of Serious Case Reviews as set out in WTSC guidance. Was adequate support provided to the subject to ensure his safety and wellbeing whilst he was living independently in the period leading up to his remand? 123. In the 12-month period up to his remand to custody, there were seven agencies that had substantial and/or significant involvement with Ryan. These were: • The Youth Offending Service (YOS) who supervised him almost continuously as a result of his offending behaviour; • NHS Leeds Primary Care Trust whose LAC nursing team assessed Ryan and provided or offered him access to health services; • Housing Services who provided advice about accommodation and ultimately offered him a tenancy; • The Supported Independent Living Scheme, which provided advice and ongoing support in relation to accommodation, training and employment; • West Yorkshire Police who arrested and held him in custody on 36 occasions during the period covered by this review; • The Young Offender Institution in whose custody he was held for the last 20 days of his life; and • Children and Young People’s Social Care in whose care Ryan remained under a care order. 124. In some of these agencies, more than one worker was involved with Ryan. He experienced four social workers, including two social work students, in the generic child care team before being transferred to the Pathway Planning team. The latter is the specialist team responsible for care leavers and young 27 people, such as Ryan, who remain subject to a statutory order but who are moving to greater independence. The YOS has different workers for the different programmes they administer, such as the bail support programme and the intensive supervision and surveillance programme. 125. Both CYPSC and YOS have recognised the difficulties for a young person of having a range of workers involved at any one time, a situation that hardly supports the development of a sustained and meaningful relationship. It also runs the risk of inconsistency in the response to the young person. For a young person like Ryan this situation is highly significant as, so far as the Panel is aware, he lacked any consistently positive and meaningful relationship with any other young person or adult. 126. The YOS Panel representatives reported that the service has been restructured to ensure, wherever possible, that one case manager holds a case involving a number of different staff throughout all the court orders. Other staff will necessarily have to be involved as well but the case manager provides continuity. 127. The CYPSC is reviewing its looked after children service and is planning a restructure to four locally-based 13-plus teams in order to reduce the unnecessary change of social worker. In each instance the motivation to make some change pre-dated Ryan’s death. It is a welcome development that both services are considering the implications of discontinuous relationships when young people are likely to have suffered poor or damaging attachments previously. 128. The overview report author now considers the input of the various services in turn. Youth Offending Service 129. The YOS had almost continuous involvement with Ryan during the last 12 months of his life, as well as substantial involvement in the previous three years. Staff worked very hard to help Ryan to change his behaviour, by providing support and confronting him with the consequences of his activities. Their immediate focus was his offending behaviour but they also took account of, and sought to assist with improvements to, other aspects of his life (such as substance misuse) that had an impact upon his offending. Ryan was not easy to help as he fluctuated between positive compliance with the programmes resulting from the court orders and hostile rejection of both court requirements and the support proffered. The IMR author considers that staff persevered beyond normal expectations despite the occasions when Ryan failed to cooperate. As an individual service, YOS made tremendous and positive efforts to help Ryan, including liaising with the other services involved. However, the service operated too much on its own and did not secure the full involvement of other agencies, and CYPSC in particular, in agreeing actions on a multi-agency basis to ensure Ryan’s safety and wellbeing. 28 Health service 130. The LAC nurse made considerable effort to contact Ryan and assess his health needs as a looked after child shortly before his 15th birthday and again soon after he was 17; and to offer health services to him. Following the second of these assessments, she advised the social worker, both verbally and in writing, of her concerns about Ryan’s lifestyle and disregard for his health; she received assurances that action was in hand to deal with the concerns. However, the LAC nursing team was not being invited to attend or contribute to the LAC reviews and so had no way of knowing whether matters relating to Ryan’s health were receiving attention. Ryan never completed his registration at a GP practice nearer to where he lived, which might or might not have encouraged him to seek medical attention. His evident self-neglect was a clear sign that Ryan was not in control of his life and should have triggered a better response involving a discussion between key agencies to decide what realistically could be achieved. The LAC nursing team could have played its part in ensuring this happened. Accommodation and housing support services 131. After his 16th birthday, Ryan began spending increasing amounts of time away from his second foster home. By the time he was 16½, the foster placement had ended (though the precise reason and timing of this are not recorded). The options for a young person like Ryan thereafter became limited: there was no formal remand-fostering scheme in Leeds at that time. Ryan said that he would not consider another foster placement but may have accepted a scheme specifically geared to his needs. There is no evidence that staff considered a residential placement within CYPSC, and a supported tenancy or training flat was either not available or not acceptable to Ryan because of its location, the latter linked to his fear of other unknown persons. Thus, despite the recognition that Ryan was unlikely to succeed in a tenancy on his own, the plan became, by default, to pursue an independent living arrangement for him: he was now aged 16½ years. 132. From this time onwards, accommodation became a problematic and time-consuming matter. Over the 12 months prior to his death, Ryan lived with relatives, in a bail hostel, in three hostels for homeless males aged 16 upwards (one of them on two occasions), and three bed and breakfast hotels, two of them on two and three separate occasions. Each arrangement ended as a result of incidents of aggression on Ryan’s part (sometimes involving offending behaviour), save once when the social worker moved Ryan because he was in fear of another resident. On one occasion, Ryan pretended that he had been evicted from a placement in the belief that he could not be breached by YOS if he were homeless and then remanded into custody – an indication of his sense of desperation. 133. Panel members agreed that there was an insufficient range of accommodation options in Leeds that was suitable for young people like Ryan who are challenging but also have high support needs. At the same time there was an absence of sufficient forward or contingency planning for Ryan 29 that attempted to insert some coherence and consistency into his situation. The placements were all responses to crises, which is not an efficient or effective basis on which to make plans. 134. Housing Options provided assistance to the social worker in arranging a hostel placement on the first occasion but declined assistance thereafter, quoting the legislation that places on CYPSC the duty to arrange accommodation for a looked after young person. The IMR author for housing services acknowledges that, although legally correct, this was an unhelpful stance and not conducive to fulfilling the City Council’s corporate responsibility towards its population of looked after children. However, he rightly asserts that having to respond to crisis situations inevitably limited the options available and did not help the formulation of longer-term plans. In addition, it no doubt did little to enhance positive relationships between the two departments. 135. The Housing Service IMR makes clear that the two hostels in which Ryan was placed are commissioned by the Supporting People service and hence subject to monitoring. In addition, staff undertake a risk assessment to be sure that young people are not put at undue risk from being placed alongside adults, some of whom will be offenders, including sex offenders. In Ryan’s case, there is evidence that his behaviour, in fact, put other residents at some risk and he was, as a consequence, evicted on more than one occasion. This is evidence of a young person whose life was getting out of control where his risk to others became a focal point and the underlying vulnerability was overlooked. 136. The Children and Young Persons Act 2008 introduced a general duty on the local authority to secure sufficient accommodation within its area to meet the needs of its looked after children. The Panel did not have evidence that Leeds City Council has reviewed its provision for looked after children population in the light of this legislation. 137. The Supported Independent Living Scheme began their involvement with Ryan five months before his 17th birthday and 13 months before his death. Workers drew up plans to guide their involvement though it proved difficult to maintain contact with Ryan and hence fulfil their objectives. There is evidence of regular liaison by the Supported Independent Living Scheme staff with both the CYPSC service and YOS and of attendance at LAC reviews. West Yorkshire Police 138. West Yorkshire Police had substantial involvement with Ryan from the start of the period covered by this review until his remand to custody shortly before his death. Two months before Ryan was remanded to custody, his case was discussed at DOMU following nomination by YOS. 139. DOMU is the umbrella department for several crime reduction programmes and initiatives within West Yorkshire, with five district hubs across the area. Each hub accommodates a multi-agency partnership team, including 30 personnel from the Police, Probation, Youth Offending Teams and Prisons plus substance misuse experts, housing advisers and staff to assist with education and training. The Deter Young Offenders programme focuses on young people aged between 10 and 17 years who have already been sentenced to a community order or detention and present the highest risk of re-offending. There is clear evidence of the programme’s efficiency and effectiveness in reducing the level of re-offending. 140. YOS referred Ryan because of his poor level of cooperation during supervision, linked to a negative attitude towards staff. He was accepted on to the programme and a police officer nominated to work with him. It was agreed to review the situation in 12 weeks or sooner should circumstances indicate the need. However, Ryan rejected the officer’s approaches, either failing to attend arranged interviews or to cooperate despite positive efforts from the Police. At this juncture in his life, Ryan was entrenched in his opposition to offers to help him. 141. On a number of occasions during the last 12 months of Ryan’s life, he informed his social worker and YOS staff about people “being after him”. When the concerns were raised with the Police, Ryan refused to provide any detail so making it impossible to proceed. However, this type of information should have featured as part of multi-agency discussions in relation to Ryan so that agencies could assure themselves that all the relevant information had been shared and necessary steps taken to protect him. The Young Offender Institution 142. The role of the YOI is considered in a later section. Children and Young People’s Social Care 143. There is evidence of the social workers involved with Ryan responding to his concerns and demands promptly; they discussed his case in supervision, and dealt with the regular crises in his life, in particular his homelessness and offending. However, the response was reactive rather than a proactive approach to assessing and planning for Ryan on the basis of the information available from the various agencies involved. During a supervision session two months after Ryan’s 17th birthday, the social worker noted that apart from awaiting his move to the Pathway Planning team, there were no other matters relating to Ryan that required discussion. This came at a time when, a few days previously, the LAC nurse had raised concerns about Ryan’s self-neglect; Ryan had reported that he was at risk from other people; he was not in settled accommodation and his level of offending was considerable. This assessment amounted to a failure from a social care team to fulfil its responsibility for young people looked after. 144. At three LAC reviews, there are references to Ryan asking to have contact with family members and to know more about his father’s family. There is no evidence that the social worker followed up these requests, despite them being agreed as actions from the review. This lack of response can only have 31 served to increase Ryan’s sense of his worthlessness in that his reasonable requests merited little attention. It may not have been appropriate for him to have contact with the family members but for the request to be ignored on more than one occasion demonstrates a lack of care and sensitivity. Conclusion 145. There is evidence of positive interventions and much energy and activity devoted to Ryan. There is also no doubt that he was difficult to help and that he rejected proffers of support or did not cooperate with agreed interventions. However, the plethora of interventions did not add up to a sufficient plan designed to ensure his overall safety and wellbeing. Too many of the interventions were responses to a crisis and, as such, were not an efficient or effective use of resources. Ryan may not have responded positively whatever the arrangements made for him but was entitled to expect a coordinated plan for providing support that included contingency planning to manage crisis situations. This was particularly important in the absence of any other responsible or actively caring adults. As such, the nature of the support provided to him was not adequate to ensure his safety and wellbeing in the period leading up to his remand. Were mental health services appropriately involved? 146. According to Better Mental Health Outcomes for Children and Young People, emotional wellbeing has been defined as: “a positive state of mind and body, feeling safe and able to cope, with a sense of connection with people, communities and the wider environment.” 147. When Ryan was aged 13½, the foster carers and school were clearly struggling with his behaviour, which exhibited the symptoms of a conduct disorder: defiance, physical and verbal aggression, offending behaviour that in turn led to truancy and exclusions from school, and the breakdown of the foster placement. 148. The significance of a conduct disorder is not to be underestimated. Better Mental Health Outcomes for Children and Young People states, “conduct disorder is the most common mental disorder in childhood. By the time they are 28 years old, individuals with persistent antisocial behaviour at age ten have cost society ten times as much as those without the condition.” According to the Office for National Statistics, in a study carried out in 2004, conduct disorder is the most common disorder amongst the one-in-ten 5-16 year-olds defined as having a clinically significant mental health problem. 149. From the time of their initial involvement, the YOS assessments of Ryan identified strong indicators consistent with conduct disorder as above, as well as a dismissive attitude towards offending and a view that crime was a way of life. Subsequent assessments, including a risk assessment by the social work student when Ryan was 16½ , identified a series of further, serious concerns about Ryan and his lifestyle. 32 150. Ryan’s father died two days before Ryan’s sixteenth birthday. Ryan refused the offer of counselling subsequently made by his social worker. The Panel became aware latterly that Ryan had been in contact with his father in recent years and was, in fact, present when his father died. There is no indication from any of the other information presented to the Panel that those involved with Ryan were aware of these events. 151. According to the CYPSC IMR, it was reported that Ryan became emotionally distant after his father’s death, and the YOS worker recorded that Ryan had previously expressed a wish to get to know his father better. 152. In month 1 of the last 12 months of Ryan’s life, concern was expressed to the social worker that he was not looking after himself and a request made that he be placed in secure accommodation. The social worker noted in month 2 that Ryan had made a reference to other people being ‘after him’ – subsequently a recurring theme. In month 8, the YOS reviewed Ryan’s vulnerability management plan and identified an emerging concern about intimidation from adult offenders. At the Health Needs Assessment undertaken by the LAC nurse two months Ryan affirmed that he was not worried about his health and felt happy with his life yet, in month 9, he admitted to his social worker that at times he felt he wanted to be violent to people. Ryan agreed at this point to a referral for therapy although he said it had not worked in the past. 153. Throughout the 12-month period leading up to his death, Ryan engaged in risky behaviour and neglected himself. At no time, however, did he give any indication that he would directly harm himself. The incident in Police custody when he banged his head and fists on the cell door occurred at the point he was remanded to custody and the Panel was not made aware of any earlier incident, although Ryan’s mother has said that there had been a previous incident of self harm when Ryan was in a police cell. This incident would not, on its own, have led staff to consider that Ryan presented a danger to himself. But his overall behaviour conveyed a sense that he did not value himself. In turn, he behaved in a manner that alienated those around him or, at least, made it very difficult for them to help him. Despite the level of concern about his lifestyle and emotional wellbeing, none of the agencies considered a referral to mental health services. The social worker offered counselling or therapy but did not take action when Ryan finally indicated his willingness to a referral. 154. Panel members heard from the General Manager for Safeguarding, Child and Adolescent Mental Health Service (CAMHS), that those cases of children and young people diagnosed as having a conduct disorder amount to almost one third of the service’s caseload. In addition, the service has successfully piloted multi-systemic treatment for hard to reach 11-18 year olds and their families, and has increased the availability of this intervention as a result of funding secured from the Department for Education, with strong support from CYPSC. 155. The General Manager indicated that, in the case of a 16 year old who is causing workers a lot of concern, the first step is a referral to the monthly Therapeutic Services Prioritisation Panel, which can refer on to CAMHS or the 33 therapeutic social work team: a (long-standing) dedicated service for looked after children and young people that offers direct work with the child or young person or consultation and advice for staff. In addition, he noted that there are three and a half full time equivalent CAMHS workers in the Youth Offending Service. The overview report author has looked at the CAMHS information leaflet for professionals, which is concise and informative about the process and criteria for referrals to the service. 156. Improving the emotional and behavioural health of looked after children and young people includes a review of the evidence about which interventions work for young people. On the basis of current knowledge, they conclude that enhanced foster care and multi-systemic therapy have the best chances of success, including a positive effect on offending behaviour. The Panel heard that Leeds has a specialist-fostering scheme and information about its multi-systemic treatment service is referred to above. What prevented staff from appreciating Ryan’s need and referring him for therapeutic input? 157. The lack of adequate multi-agency planning for Ryan is considered in a later section and better planning may have identified the need for therapeutic input. The IMRs indicate that staff said in interview that Ryan would not have cooperated with a referral to mental health services, and his level of cooperation with services offered to him was indeed variable. However, there were occasions when he worked well with YOS interventions, and there is evidence of positive involvement with the alternative education provision during a six month period prior to his 16th birthday. In addition, in month 2 of the 12 month period prior to his death, he agreed with his social worker that he needed more support and the following month a referral went to the Supported Independent Living Scheme who subsequently became involved in supporting Ryan. In month 9, Ryan agreed to the social worker arranging therapy for him (on an occasion when he expressed feelings of violence towards other people), despite asserting that it had not worked in the past; at his LAC review in month 10, it was noted that Ryan was now willing to consider counselling and an action was for the social worker to refer him to the Therapeutic Social Work Service. However, there is no evidence that the referral for therapeutic input was made on either occasion. It was as though the social worker did not appreciate the extent of Ryan’s malaise and the urgency of his situation and was responding to a specific event in his life – though this in no way justifies the inaction. 158. It is not possible to second-guess whether Ryan would have responded positively to an intervention from CAMHS or the Therapeutic Social Work Service. The overview report author concludes that Ryan’s lack of cooperation could be linked to a sense that there was little point in making the effort to change things: adults let him down (such as, not following up the action from no less than three LAC reviews to explore contact with family members and to find out more about his father’s family). 159. However, irrespective of how Ryan responded, a referral should have been made to the Therapeutic Services Prioritisation Panel to allow discussion of his current needs whilst taking account of his historical circumstances. If Ryan 34 would not accept a therapeutic service, staff would have benefited from advice about how to intervene more effectively. By failing to recognise his needs (or in the case of the social worker, not taking action to make a referral), staff were responding to Ryan’s presenting behaviour rather than understanding and assessing the underlying causes of that behaviour. 160. Apart from the need for therapeutic input, it is clear that Ryan lacked a pivotal and stable carer who would provide boundaries to give him some sense of security but, who he also knew, would ‘look out for him’ and ‘fight his corner’: in other words be a surrogate parent to him. At this stage, all the evidence indicates that he had little reason to care about himself or the effects of his behaviour on others. Staff from the various agencies involved with Ryan, and the YOS staff in particular, made considerable efforts to assist him but their input is necessarily professional and impartial. Ryan had no one person with whom his relationship was special for him alone. Conclusion 161. Ryan may have suffered from a conduct disorder but this cannot be confirmed. Nevertheless, his behaviour was both socially unacceptable and deeply concerning. The evidence indicates that the focus of attention by professional staff was upon the manifestations of his behaviour rather than the underlying emotional turmoil. The nature of his highly problematic behaviour inevitably forced attention upon it. However, there was insufficient regard to the reasons for that behaviour. Mental health, including therapeutic, services were not appropriately involved to assist staff in understanding Ryan’s behaviour and planning appropriate interventions. What support was in place to ensure that the subject was either in education or employment? 162. Ryan’s time in secondary school falls outside the 12-month timescale set for the serious case review. However, the Education Service has provided detailed information in its IMR, which is highly relevant to understanding Ryan’s experiences. From when he was 13 years old until he left school at 16, Ryan had serious difficulties in school as evidenced by the number of exclusions, some of which were for serious incidents of aggression. 163. The first school arranged a ‘managed move’ to another school but the IMR author notes that the process was “unstructured, not conducive to effective transition, not child centred” and hence “unlikely to meet Ryan’s needs”. The move proved ineffective in that it lasted only two months before another serious incident precipitated Ryan’s exclusion and return to the first school. Following an unsuccessful reintegration, Ryan began to attend alternative provision with four different providers. Some reports from them indicate that Ryan was receptive to learning if given the right opportunity. 164. The school made efforts to avoid a permanent exclusion of Ryan, albeit with two lengthy periods of authorised absences and an unsuccessful move to another school. However, records on Ryan were not adequate and there was 35 a less than thorough adherence to policies relating to looked after children. The school did not fully complete or maintain a Personal Education Plan, or develop a Behaviour Support Plan, despite it being an action from a LAC review meeting. School staff attended the LAC reviews but there is no evidence of internal meetings to discuss the management of Ryan in school. All this is indicative of insufficient action to support a young person who was without doubt challenging yet highly vulnerable. 165. At the point that Ryan completed his full-time education, there is no indication of discussions with him about his future. In fact, there are very few references in the management reviews to discussions regarding his further education, training or employment opportunities. Agencies were reacting to the immediate challenges that Ryan presented rather than taking a longer-term approach based on a full assessment, in the context of his personal history, or his current and future needs. 166. Leeds City Council has produced a leaflet, entitled ‘Our promises to you’, that summarises its promises to its population of looked after children. This reflects the City Council’s understanding of its role as corporate parent, a concept - introduced by central government in 1998 as part of the Quality Protects initiative - that places collective responsibility on councils to achieve good parenting for all their looked after children. The Minister said that councils should judge the quality of their provision to looked after children by asking: “would it be good enough for my child?” The concept reflects evidence demonstrating that looked-after children experience poorer outcomes than other children across a range of measures, including health and education, as a result of their circumstances and experiences. Information about educational attainment from the Department for Education in December 2010 demonstrates that a third of children previously looked after are not in education, employment or training at age 19 (Statistical data on educational attainment of looked after children). 167. The revised Children Act 1989 Guidance and Regulations relating to care planning (March 2010) states (paragraphs 1.14 & 1.15): “The role of the corporate parent is to act as the best possible parent for each child they look after and to advocate on his/her behalf to secure the best possible outcomes. However, they cannot fulfil this responsibility without the full cooperation and support of a range of other agencies which provide services to children and their families”. 168. In Leeds City Council, there is a Corporate Carers’ Elected Members’ Group and also a Multi-agency LAC Partnership of agencies with responsibilities towards looked after children in the city. The Panel has not received information about the terms of reference of the Corporate Carers’ Group or what action it has taken in the interests of children and young people looked after in Leeds. The Multi-agency Partnership has recently been re-launched with revised terms of reference. The work plan has yet to be agreed but the priority for the first six months is to “coordinate work on a full review of the Looked after Children’s Strategy”. Some councils take positive action to offer looked after young people shadowing or mentoring opportunities within the 36 council, or trainee posts as an acknowledgement of their parenting responsibility. Conclusion 169. In the leaflet Our promises to you, under the section Support you to achieve your goals in life, the City Council states its promise to: “provide you with support, guidance and the resources to help you achieve your goals in life” and “support you to find a job when you leave school”. Overall, there is limited evidence that this promise was fulfilled in respect of Ryan or that his future training or employment was made a priority. Were links adequately made between services to address his offending behaviour and services to address his health and social care needs? 170. The agencies that had involvement with Ryan in the last 12 months of his life are listed in the section relating to the first of the terms of reference. In addition, the Education Service was involved until Ryan completed his compulsory education. There was evidence of much activity by the various workers involved and of regular communication and exchange of information between the various agencies. The question is whether the individual interventions of individual agencies and the totality of the interventions were sufficiently linked up to deal with Ryan’s needs effectively. 171. YOS operated in a structured manner in its approach to Ryan, as dictated by the court. There is clear evidence of liaison between YOS and CYPSC, although the YOS IMR makes the point that the quality of communication improved once Ryan’s case was transferred to the Pathway Planning team with their more specialist experience of young people. 172. YOS staff had more involvement with Ryan than any other agency, particularly in the 12-month period leading up to his remand in custody, and were, therefore, in the best position to build up a relationship with him. It is easy to see how the CYPSC social worker might, therefore, leave management of the case to YOS in these circumstances and only respond when a crisis occurred. There is a telling comment from the team manager in month 5, when arranging for the transfer of Ryan to another social worker, to the effect that there was no meaningful relationship with the current worker. This may realistically have been so in view of the level of involvement from YOS. However, this was not a valid stance, undermining as it does the statutory role of the social worker in ensuring that a plan was in place that encompassed all Ryan’s needs and was based on agreement from the various agencies involved about their actions, as well as the views of the young person. 173. The LAC nursing team was not invited to attend LAC reviews on a regular basis and, although the responsibility rested with CYPSC to organise invites, the team had no system to alert them to this oversight. The exclusion of other professionals from LAC reviews can be deliberate and appropriate in recognition of the young person’s views. However, were that to be the case 37 (and there is no evidence one way or the other in relation to Ryan), there is an onus on the relevant personnel to obtain or provide information pertaining to the young person in order to inform the review. 174. The nurse in the YOS was not involved directly with Ryan. This is appropriate in circumstances where a young person is looked after and, therefore, is dealt with by the looked after children nursing service. However, in Ryan’s case, there was no liaison between the LAC nursing team and the nurses in YOS that would ensure a full exchange of information relating to Ryan’s health to inform planning for him. 175. The Housing Service, operating as part of the Environment and Neighbourhood Directorate, reacted to requests for assistance with accommodation but played no part in assessment of Ryan. This was appropriate in view of Ryan’s status as a looked after young person and hence the expectation that assessments would have been completed by CYPSC. However, whereas it is not expected that the Housing Service would take a lead role in responding to the difficulties that Ryan faced, their actions were limited in scope. 176. The Housing Service IMR author duly notes his department’s shared responsibility as corporate parent to looked after young people and the “inconsistencies in the service” provided to Ryan. He also refers to the protocol (Joint Working Protocol Between Environment & Neighbourhoods Directorate and Children’s Services Directorate – Provision of Accommodation for 16 and 17 year olds who are Homeless or Threatened With Homelessness) and recommends a revision to incorporate early intervention procedures when a threat of homelessness is apparent; and to clarify arrangements for placing 16/17 year olds in accommodation. This is welcome. However, the protocol does not specifically clarify responsibilities to young people who are or have been looked after and this requires attention. 177. CYPSC commissioned the Supported Independent Living Scheme to provide support to Ryan. It was not the responsibility of a voluntary sector organisation to initiate multi-agency care planning in respect of Ryan, though senior staff should reflect upon their responsibility to raise any concerns they might have had about the direction and overall management of the case with other agencies. It was incumbent upon CYPSC as the service commissioners to be clear about their expectations for the Supported Independent Living Scheme’s involvement and how it fitted with the work of other agencies. 178. Ryan was discussed at the Drugs and Offender Management Unit (DOMU) in month 10, having been nominated by YOS. A police officer from that unit sought thereafter to assist Ryan but to no avail. Ryan would have benefitted from a multi-agency approach at a much earlier stage of his life (see below), and it is incumbent upon both the Police and YOS to consider how they might raise their concerns about Ryan’s level of offending in a multi-agency forum. These two agencies were in a prime position to recognise that a young person was out of control, a situation that is more likely to lead to offending behaviour. 38 179. CYPSC had overall responsibility to undertake the planning for Ryan in view of his status as a looked after child. As such it was the social work team’s responsibility to: [i] coordinate the number of professionals involved with Ryan and [ii] agree a strategic approach to interventions when Ryan’s life was chaotic and at times out of control. 180. The revised Children Act 1989 Guidance and Regulations state: “The child’s care plan provides the overarching vehicle for bringing together information from the assessment across the seven dimensions of the child’s developmental needs [regulation 5] and from any other assessments of the child and his/her family. The health and education dimensions of the care plan are populated by the health plan [regulation 7] and the personal education plan (PEP) [regulation 5(b)(ii)].” 181. As such, the care plan builds upon the assessment that brings together information about the child’s developmental needs, parenting capacity and family and environmental factors. Assessment “is thus an iterative process which for some children will continue throughout work with the child and the family and caregivers. In order to achieve the best outcomes, the framework should be used also at important decision making times when reviewing the child’s process and future plans” (Framework for the Assessment of Children in Need and their Families [April 2000]). 182. There is no evidence in the social work records that Ryan’s needs were re-assessed during this difficult and highly problematic period of his life – or indeed in the previous three years. In addition, planning was undertaken within the forum of the arrangements for reviewing looked after children and did not include input from Health or the Youth Offending Service. The care plans drawn up for the purposes of the LAC review were not completed in full and give an impression that they were prepared in a formulaic manner to fulfil the requirements of statute, rather than being the vehicle whereby actions to support and sustain a young person - who was highly vulnerable and in considerable need - could be formulated and agreed. Ryan presented considerable challenges but that made it all the more important to formulate a plan that included the other relevant agencies. 183. Children and Young People’s Social Care had the lead responsibility for ensuring that effective planning took place. There is, in addition, a function enshrined within the Children Act 1989 (and amended and strengthened by the Children and Young People Act of 2008) that places a responsibility upon local authorities to oversee the provision of care to looked after children by independent reviewing officers (IROs). “The independent reviewing officer must— (a) monitor the performance by the local authority of their functions in relation to the child's case; (b) participate, in accordance with regulations made by the appropriate national authority, in any review of the child's case; 39 (c) ensure that any ascertained wishes and feelings of the child concerning the case are given due consideration by the local authority.” 184. The CYPSC IMR confirms that the Leeds policy and procedure that were in place in 2010 specify “the responsibility of the IRO to accurately record actions and time scales and to follow up any actions not completed”. However, the IMR author notes that some actions were not specific as to what was required; they all lacked a completion date; and there was no record of the reasons why actions from one review had not been carried out by the time of the next review. This included Ryan’s request made in three reviews to have contact with family members and information about his father’s family. In addition, the IRO did not refer to the review team manager or operational managers the significant lapses in carrying out agreed actions from the review. 185. In Ryan’s case, the LAC reviews represented the only evident forum for reviewing the planning of his care and for involving, either in person or through written reports, other relevant agencies. Again, the process had all the hall-marks of an arrangement intended to comply with legislative requirements rather than ensuring that the needs of looked after children and young people were appropriately assessed; that meaningful plans were drawn up; and that action was taken for which individual workers (and their managers) were held to account. The Panel heard an acknowledgement from CYPSC that the reviewing unit was not functioning well during the period leading up to Ryan’s death. 186. However, the Panel was advised that substantial changes have now been made to address the problem, including robust arrangements for quality assurance, such that Leeds has now received national recognition of its sound practice. In addition, the overview report author has seen a recent document that sets out the role of the independent reviewing service and its key aims and objectives; this is in the context of an enhanced status for the service as reflected in an increased number and regrading of its staff. If the aims and objectives are translated into robust processes, this will substantially improve the arrangements for safeguarding looked after children and young people in Leeds. 187. In any event, the last year of Ryan’s life indicated the need for multi-agency planning via a professionals’ meeting. In this regard, other agencies had a responsibility as well as CYPSC. The YOS had considerable involvement with Ryan. It could have done more to insist on a coordinated approach to Ryan that sought to tackle the many other problems facing him that inevitably had an impact upon his offending behaviour. The staff in the looked after nursing team were rightly concerned about Ryan’s lifestyle and his risk-taking behaviour in respect of his health and overall wellbeing. The LAC nurse conveyed concerns to the social worker and received reassurances that the situation was in hand; but there was no follow-up, including ensuring progress at the point of the next review. The manager in the Supporting People team appropriately expressed the view that CYPSC should convene a case conference in order to discuss Ryan’s situation because it was so serious. 40 The social worker apparently did nothing about this proposal; equally, there is no indication that the Supporting People manager followed the matter up. When professionals in one service are not satisfied with the response from another agency, the facility to involve more senior managers should be clearly understood. The Panel understood that there is an escalation policy to allow for just such a situation. Conclusion 188. Ryan’s record of offending was extensive and his life beyond his offending was chaotic and involved very risky behaviour. There is a clear link between offending and a lack of stability and emotional wellbeing in a young person’s life. Overall, the effectiveness of the interventions by the individual agencies involved with Ryan was considerably undermined by the failure to agree a multi-agency response that responded to his offending and his health and social care needs; and included contingency planning for the repeated crises in his life. In addition, the system of reviews for ensuring that appropriate care planning took place was ineffective and did not fulfil its function. All agencies bear some responsibility to ensure that appropriate planning takes place but CYPSC bears the major responsibility in view of its statutory duties in respect of looked after children. Was sufficient consideration given to the young person’s vulnerability in a custodial setting (with reference to family contacts, peer relationships and bullying)? 189. The overview report author and SCR Panel considered this issue based on the information in the YOI IMR, Panel discussion and the exchange of letters in July 2011 between the Acting Assistant Ombudsman and the Governor of the YOI. However greater detail emerges from the investigation carried out by the Prisons and Probation Ombudsman and the key points have been incorporated within this analysis. 190. There is an admission process in place within the YOI whereby prison officers and health staff undertake a comprehensive risk assessment that includes reference to the mental health of trainees. The assessment takes account of information from the Police and YOS, including the ASSET document, thus providing an extensive picture of the young person’s current situation and history. Note is taken of whether this is a young person’s first time in custody. In Ryan’s case, the assessment revealed no concerns regarding his mental wellbeing and no indication of a risk of harm to self – in line with the assessments of other agencies. However, the Prisons and Probation Ombudsman comments that the mental health assessment relied on self reporting by Ryan as to his mental health needs and did not consider existing records. 191. Ryan’s mother referred in interview to the forms that accompanied Ryan from court to the YOI that included reference to the incident in the police cell where Ryan was held after arrest before appearing at court the next day: he banged his head and fists on the cell door but refused to see the nurse; the custody 41 sergeant and nurse then formulated a care plan to ensure his safety. She considered that this incident indicated Ryan’s vulnerability to self-harm and should have led to him being monitored accordingly. The escort form did not specify when the incident occurred and Ryan told the nurse during his health assessment on arrival at the YOI that he had sustained the grazes to his knuckles and head during a fight two days previously. Ryan was, therefore, managed within the YOI in the normal manner: that is, no exceptions were deemed necessary to take account of assessed vulnerability or risk of harm to self. The Prisons and Probation Ombudsman concludes that the note from the police about this incident of self-harm was “insufficiently followed up by staff at court and (the YOI’s) reception and also that “the first night vulnerability assessment was confused and there was scope for a fuller mental health assessment.” 192. Elsewhere, the overview report author concludes that, prior to Ryan’s remand to custody, staff from the range of agencies involved had not fully appreciated Ryan’s level of vulnerability. However, although Ryan lived a life that was harmful to himself, as far as can be ascertained, he had not deliberately inflicted physical injuries upon himself prior to this incident. Therefore, the overview report author considers that even if the form had correctly specified how the injuries occurred, they would not on their own have reasonably led YOI staff to consider that Ryan posed a risk of self-harming when set against the other evidence. Furthermore, day-to-day records reveal that Ryan portrayed himself at times as viewing his detention as a comfortable setting and, further, that he would be prepared to use violence against others. 193. Following the incident when Ryan was threatening and abusive to staff, he appeared before a governor who applied sanctions involving a number of deprivations. The IMR author judges that the adjudication award was “below the medium range punishment for this offence”. The YOI has instigated a Rewards and Sanctions scheme that, according to the IMR, Her Majesty’s Inspectorate of Prisons judged, at its visit to the YOI to provide motivation to trainees to behave positively. It concluded that the scheme was applied consistently across units. Notwithstanding the above, the Ombudsman concluded that, in this case, the incident was not adequately investigated or documented, insufficient consideration was given to mitigating factors, the response was not child centred and the punishment was severe 194. The YOI allocates a key worker to each trainee on admission. In Ryan’s case, the officer had an initial remand review meeting with him shortly after admission and a further review took place after five days with his YOS worker and social worker in attendance. The purpose of these meetings is to set sentence plan targets in relation to behaviour; education, training and employment; family and personal relationships; and substance misuse. Additionally, residential personal officers provide the day-to-day support to trainees. However, although the YOI tries to maintain some continuity of care, the pattern of deployment of staff is subject to the overall demands of the establishment and the shift working arrangements. Advice from the Governor, reported to the Panel, is that the “personal officer scheme is in need of an overhaul and clarification”. In a similar vein the Ombudsman expressed 42 concern that, due to weaknesses in the personal officer scheme, there was limited scope for Ryan to have a member of staff whom he could trust and with whom he could share some of his concerns. Consequently the overview report author welcomes the recommendation arising from the YOI IMR to review how the establishment meets the specific needs of looked after children. 195. Prior to the night of Ryan’s death, there was no evidence that he was subject to bullying. He indicated on admission that he had problems with some young people outside the YOI but this did not translate into concerns raised about potential difficulties with any other trainees within the establishment. After Ryan died, other trainees from the YOI made allegations of verbal abuse and threats being shouted at and by Ryan on the night of his death, although relevant staff on duty that night did not make any record of such threats being made and have stated that they did not hear them. These specific allegations remain unsubstantiated but during the Ombudsman investigation the investigators found that the “shouting out policy” was not implemented as it should have been. They concluded that whilst the YOI had good policies to tackle bullying, staff had not been adequately trained to implement them. 196. Trainees in the YOI have access to telephones by which to contact their family. Ryan used the phone twelve times during a nine day period shortly before his death to speak to family members but only spoke to people on two occasions for a very brief time. 197. The Panel was advised that another young person in the YOI attempted to hang himself 10 days prior to Ryan’s death. He was subsequently assessed as vulnerable and moved to a specialist Unit. There is some suggestion from other trainees interviewed after Ryan’s death that Ryan wanted to follow the same pattern. The Panel has discussed whether the YOI should have considered this Unit as an option for Ryan and the overview report author has looked at the relevant documentation about the unit. 198. The Unit is a national facility whose purpose is “to provide a specialist service to 15 to 17-year-old young men who for a variety of reasons are not engaging – or are unlikely to engage - with the normal regime in a young offender institution” (Placement Protocol). Placements in the Unit are co-ordinated by the Youth Justice Board. Having reviewed the referral criteria and considered how Ryan presented within the YOI, the Panel concluded that Ryan did not fulfil the criteria for admission and it was rightly not considered as an option. The Ombudsman reached a similar conclusion. 199. The Prisons and Probation Ombudsman concludes that it would have been extremely difficult for YOI staff to have identified the extent of Ryan’s vulnerability. Nevertheless the report includes several criticisms of the way in which his vulnerability was assessed and the care he received. The report from the Ombudsman contains 15 recommendations. 43 Conclusion 200. Whilst it would have been extremely difficult for YOI staff to identify the extent of Ryan’s vulnerability, there were specific occasions when assessments and/or communication should have been more thorough. As a result of this insufficient consideration was given to his vulnerability. Was the young person’s level of risk and vulnerability appropriately assessed and monitored (with defensible decisions to support assessments)? Was risk/vulnerability management and monitoring consistent with the level of assessed risk? 201. Ryan grew up in a variety of settings and faced a range of risk factors. This review has found a lack of protective factors to help mitigate these risks. 202. Assessments by YOS, including assessments of Ryan’s risk and vulnerability, were appropriately completed according to nationally prescribed formats, and captured the current concerns about Ryan’s functioning. These assessments were translated into plans that were subject to regular review. YOS staff worked extremely hard with Ryan to try to maintain him successfully on the various programmes imposed by orders of the court, and to have an impact on issues that contributed to his offending, such as substance misuse. Staff liaised regularly with CYPSC to exchange information. 203. Staff within Health who had some responsibility for Ryan’s health and wellbeing included the GP, the LAC nursing team and the nursing team in the YOI. The GP did not see Ryan within the time span for this review but did receive copies of the LAC reviews. As the GP had no direct experience of Ryan, it is reasonable that he or she took no action in relation to any concerns that the LAC reviews might raise. Ryan never got round to completing his re-registration with another GP practice nearer to where he was based, despite the efforts of his social worker. It is not possible to conclude whether a transfer would have made any difference to his contact with health services but at least those services would have been more accessible to him. 204. The LAC nurse made considerable effort to track Ryan down and complete a Health Needs Assessment shortly after his 17th birthday and, subsequently, discussed concerns arising from that assessment with the social worker. The latter gave assurances that all matters were in hand and the nurse did not press the issue. Taken with the lack of involvement with the LAC reviews, the LAC nursing team had no assurance that Ryan’s health needs, which encompass his mental health and emotional wellbeing, were being properly looked after. In view of the level of concern on the part of the LAC nursing staff, they should have pursued the matter in order to satisfy themselves about the situation. 205. The Supported Independent Living Scheme completed an assessment, including an assessment of risk, and drew up plans for their involvement, to which Ryan signed up. Like other workers, they struggled to maintain regular contact in line with the agreed plans because Ryan did not live an orderly life 44 and keep to planned arrangements. The support worker assessed, rightly, that Ryan would need support if he were to maintain a tenancy successfully. Ryan had not previously had responsibility for managing a household and the experience up till then of him handling his finances was not promising. The decision, therefore, by agencies to support Ryan in having a council tenancy comes across as a desperate response. It was not a decision based on sound judgement and subject to robust planning that would have provided some assurance of success. 206. Within CYPSC there was no systematic approach to assessment let alone the assessment of risk; in fact, there is evidence of just one risk assessment undertaken by a social work student. There was no evidence of a core assessment following the foster placement breakdown when Ryan was 13 years old or a placement disruption meeting, which would have provided an analysis of what went wrong and an assessment of Ryan’s needs. It is as though having completed the care proceedings, the focus became solely about responding to Ryan’s current behaviour. The history and context, which explained who he was, were lost and, as a consequence, some understanding of why events turned out as they did. Conclusion 207. Assessments during the period under review were not overall adequate. The YOS assessments took some account of family circumstances but for the purpose of their interventions focused upon current behaviour. CYPSC did not re-assess Ryan on a regular basis and there is no evidence of a recent assessment that reviewed his current functioning in the context of his problematic history. Again, their interventions focussed upon responding to Ryan’s behaviour rather than having an agreed plan that sought to respond to all his identified needs. As such, the author concludes that the significance of what had happened to Ryan in his early life was not understood and, therefore, his high level of risk and vulnerability was not taken sufficiently into account when formulating interventions. The views of family members 208. Regarding the interview with Ryan’s mother, her concerns about the manner in which she learned of Ryan’s death, the time taken by the YOI to formally inform her of his death and her concerns about staff action in trying to resuscitate Ryan are outside the scope of this SCR and are rightly addressed in the report from the Prisons and Probation Ombudsman. 209. The overview report author has dealt with the issue of Ryan’s vulnerability to self-harm in an earlier section. 210. Ryan’s mother was critical of the service provided by the Pathway Planning team. The Panel was advised that a review of the service has been underway since February 2011 aimed at identifying gaps in the service and ensuring continuity of staff. The review should have regard to the conclusions of this serious case review before finalising its conclusions. 45 8. CONCLUSIONS & KEY LEARNING 211. The Inquest completed in January 2014 concluded that the death was accidental. From evidence produced for the Panel, there is no indication that Ryan expressed any intention to harm himself. In fact, when asked directly, he expressed satisfaction with his life, although the manner in which he lived his life suggested otherwise. Staff involved with Ryan, including those in the YOI, could not reasonably have predicted Ryan’s death. However, they were insufficiently alert to the emotional turmoil that underlay his overt behaviour. 212. There are clear indications that Ryan was vulnerable from early childhood, and stark evidence that, in the 12-month period leading to his death, there was acceleration in his personal difficulties and social exclusion. Staff focused their attention on the crises with which Ryan regularly presented them and did not stand back and consider the underlying causes of his behaviour. There was an absence of regular and thorough assessments and re-assessments of Ryan’s situation that gave due recognition to his vulnerabilities based on the level of risk factors and lack of protective factors in his life. When Ryan was in the YOI there was insufficient assessment of his vulnerability and the care he received was not always child centred. 213. Whilst it is evident that Ryan had a close attachment to his first, long-term foster carers, this placement broke down when he was 13 years old and he never had a stable placement thereafter. This is likely to have had an impact on his sense of security. 214. Agencies invested considerable time and money providing a range of interventions aimed at supporting Ryan, much of it positive and well planned at an individual agency and worker-level. However, the interventions were insufficiently coordinated and focused upon the symptoms rather than the cause of Ryan’s difficulties. The review system established to monitor the efficacy of care planning for looked after children failed in its purpose. 215. The review did not identify a causal link between Ryan’s death and services in the community. However, the efficiency and effectiveness of interventions were considerably undermined by the failure to agree a multi-agency response that included contingency planning for the repeated crises in Ryan’s life. This conclusion links to the City Council’s responsibilities as a corporate parent for its population of looked after children. The guidance makes clear that councils can expect the full cooperation of partner agencies in fulfilling these responsibilities. Evidence presented to the Panel suggested that those groups that had responsibility for ensuring the wellbeing of looked after children were not fully functioning. 216. There is some evidence of sensitivity to Ryan’s racial, cultural, linguistic and religious identity. There is also evidence of individuals ascertaining and taking account of his wishes and feelings. However, his frequent requests to have contact with family members and to know more about his father’s family were overlooked over a lengthy period. 46 217. At a personal level, the collective corporate system let Ryan down despite the best efforts and good intentions of individual members of staff. There was no one person who assumed responsibility for Ryan as a looked after child, ensuring that his overall wellbeing was promoted and safeguarded. The organisation legally charged with parental responsibility did not adequately discharge it. 9. RECOMMENDATIONS 218. A study of recommendations arising from serious case reviews 2009 – 2010 reports an impression that recommendations are becoming more clearly focused and specific though rarely few in number, despite repeated recommendations to the contrary: see in particular paragraph 8.52 of WTSC. The above study also notes: “Putting the child at the forefront of our thinking and understanding is crucial. However there is always a tension in trying to learn from serious case reviews about whether we focus on the powerful learning from unique features of interactions in the individual case or whether we concentrate on the wider transferability of lessons and learning.” 219. All agencies involved in this SCR produced good quality IMRs that facilitated learning and contributed to the overall SCR. None of the IMR authors had any operational involvement with Ryan and each was at an appropriate level of seniority for undertaking the review and challenging agency practice. In all instances, a more senior manager countersigned the report. The individual agencies made recommendations that were appropriate to them and progressed and completed actions in response. The following recommendations are few in number and have wider application than this individual case. They also reflect the Panel’s understanding that changes and developments in practice pre-date this review. 1. The LSCB should satisfy itself that multi-agency arrangements for care planning and reviewing looked after children have improved and are efficient and effective. 2. The LSCB should satisfy itself that the programme of work being undertaken to improve corporate parenting responsibilities in Leeds includes promoting access to education, training and employment opportunities and enhancing emotional wellbeing. 3. The LSCB should review the sufficiency of provision of suitable, specialised accommodation for young people with high support needs, with a particular focus upon looked after young people. 4. The LSCB should promote more effective approaches to risk management and assessment of children and young people with complex needs. 47 5. The LSCB should endorse IMR recommendations and require their implementation and should satisfy itself that actions are completed and embedded. Learning lessons from serious case reviews 220. At the end of October, Ofsted published a report – Ages of concern: learning lessons from serious case reviews. It is a thematic report based on an analysis of 482 serious case reviews that Ofsted evaluated between 01 April 2007 and 31 March 2011. The main focus of the report is upon babies less than one year and young people aged 14 or above. It came to the attention of the overview report author after completion of the final draft of the overview report. However, the report conclusions in respect of young people aged 14 or over clearly resonate with the findings of this review and are reproduced below for reference: Agencies had focused on the young person’s challenging behaviour, seeing them as hard to reach or rebellious, rather than trying to understand the causes of the behaviour and the need for sustained support; Young people were treated as adults rather than being considered as children, because of confusion about the young person’s age and legal status or a lack of age-appropriate facilities; There was no coordinated approach to the young people’s needs and practitioners had not always recognised the important contribution of their agency in achieving this. The overview report author recommends dissemination of this useful and relatively brief report. 48 APPENDICES Appendix 1 – Terms of Reference 221. The LSCB agreed the following additional terms of reference that are specific to this case: 1. Was adequate support provided to the subject to ensure his safety and wellbeing whilst he was living independently in the period leading up to his remand? 2. Were mental health services appropriately involved? 3. What support was in place to ensure that the subject was either in education or employment? 4. Were links adequately made between services to address his offending behaviour and services to address his health and social care needs? 5. Was sufficient consideration given to the young person’s vulnerability in a custodial setting (with reference to family contacts, peer relationships and bullying)? 6. Was the young person’s level of risk and vulnerability appropriately assessed and monitored (with defensible decisions to support assessments)? Were risk/vulnerability management and monitoring consistent with the level of assessed risk? 49 Appendix 2 – Methodology 222. The following people were members of the Serious Case Review Panel. Position Agency Panel Chair Independent Assistant Manager Leeds Safeguarding Children Board Head of Service, Safeguarding Children and Young People’s Social Care, Children’s Services Directorate, Leeds City Council Head of Region (Yorkshire, Humber and the North East) Youth Justice Board Deputy Service Manager Youth Offending Service, Children’s Services Directorate, Leeds City Council Operational Manager Youth Offending Service, Children’s Services Directorate, Leeds City Council Strategic Manager Education Services, Children’s Services Directorate, Leeds City Council Operations Manager Housing Support, Environment and Neighbourhoods Directorate, Leeds City Council - one meeting Performance Management Officer Environment and Neighbourhoods Directorate, Leeds City Council - two meetings Designated Nurse, Safeguarding Children NHS Leeds Governor, Head of Residence The Young Offender Institution Detective Chief Inspector, Safeguarding Unit West Yorkshire Police Senior Services Manager Supported Independent Living Scheme 223. In addition, the LSCB Administrator attended Panel meetings in order to take minutes and Pamela Shelton attended in her capacity as the overview report author. 224. In retrospect, the overview report author considers that it would have been helpful to have someone with expertise in mental health as a Panel member. However, the General Manager for Safeguarding, Child and Adolescent Mental Health Service, acted in an advisory capacity and attended one meeting. The Head of Service for Looked after Children in Children and Young People’s Social Care attended one meeting to advise the Panel on recent developments within the department. The following agencies undertook Individual Management Reviews as part of the SCR: Children and Young People’s Social Care, Leeds City Council Education – Schools and Services, Leeds City Council Environment and Neighbourhoods, Leeds City Council NHS Leeds Primary Care 50 Leeds Community Healthcare NHS Trust NHS Leeds (Health Overview report) Youth Offending Service, Leeds City Council West Yorkshire Police The Young Offender Institution A Supported Independent Living scheme 225. After attending Panel meetings IMR authors made amendments (some minor and others more substantial) to their agency reports in order to clarify the text or include additional material that the Panel considered important to provide the evidence to support their conclusions. The discussion between Panel members and authors was very constructive and helpful. Authors responded positively to the critique of their report and made amendments that have greatly improved the quality of the IMRs and hence enhanced the overall quality of and learning from the review. There has clearly also been learning for the individual report writers, to the benefit of those agencies, some of whom had no previous experience of participating in a serious case review and completing an IMR. 226. In addition, the Child and Family Court Advisory and Support Service provided a summary of the agency’s involvement with Ryan’s family which falls outside the timescale for the review. 227. The Connexions service, known in Leeds as the Integrated Youth Support Service (IYSS), provided a one-page statement of its limited involvement with Ryan. Staff had one interview with him when he was 16/17 years old and offered other appointments, which he failed to keep. There was one interview with Ryan in the YOI during which the personal advisor suggested courses that might be of interest. Panel members agreed that this level of involvement did not merit an IMR. 228. The NSPCC provided brief information about involvement when Ryan was a toddler. This clearly falls outside the timescale for this review. 229. The Panel has had sight of a letter from the Acting Assistant Ombudsman of the Prisons and Probation Ombudsman Service. It sets out a summary of her preliminary findings following her investigation into the circumstances of Ryan’s death. The Panel has also seen the letter from the Governor of the YOI in response. 230. The Panel has seen the letters sent to family members inviting them to participate in the review. The Overview Report Author considered the following documents: Title of document Author and date Leeds City Council documents Joint Working Protocol: Provision of Accommodation for 16 and 17 year olds who are homeless or threatened with Environment and Neighbourhoods Directorate and Children’s Services Directorate, undated 51 homelessness Leeds Child and Adolescent Mental Health Service – Information for Professionals NHS Leeds Community Healthcare (Leeds PCT), October 2010 Multi-agency Looked after Child Partnership draft terms of reference Leeds City Council, undated Memorandum of Understanding Leeds Youth Offending Service, Leeds Children and Young People’s Social care, Leeds Housing Service, undated Our promises to you Leeds City Council, 2009 Service Level Agreement Leeds Youth Offending Service and Housing Services, Environment & Neighbourhoods Directorate, May 2010 National documents Ages of concern: learning lessons from serious case reviews – a thematic report of Ofsted’s evaluation of serious case reviews from 1 April 2007 to 31 March 2011 Ofsted, October 2011 Asset – Young Offender Assessment Profile Youth Justice Board guidance, May 2011 Better Mental Health Outcomes for Children and Young People National CAMHS Support Service, Child and Maternal Health Observatory The Children Act 1989 Guidance and Regulations Ryanolume 2: Care Planning, Placement and Review HM Government, March 2010 The Children and Young Persons Act 2008 HM Government, 2008 Framework for the Assessment of Children in Need and their Families Department of Health, April 2000 HMYOI: Placement Protocol relating to specialist unit Youth Justice Board, October 2010 How do you know you are a good corporate parent? Local Government Improvement and Development Agency, Website, December 2010 Improving the Emotional and Behavioural Health of Looked After Children and Young People Centre for Excellence and Outcomes in Children and Young People’s Services, 2010 Statistical data on educational attainment of looked after children Department for Education website, December 2010 A study of recommendations arising from serious case reviews 2009 - 2010 Marian Brandon, Peter Sidebotham, Sue Bailey, Pippa Belderson: University of East Anglia, University of Warwick. Published for Department for Education, 2011 Working Together to Safeguard Children HM Government: department for children, schools and families, March 2010 Child V Composite Action Plan – March 2015 1 Serious Case Review Action Plan Regarding Ryan Clark (Child V) March 2015. Ref No Recommendation Action Responsible Agency/Lead Person Outcome and Date 1 The LSCB should satisfy itself that multi-agency arrangements for care planning and reviewing looked after children have improved and are efficient and effective. 1) C&YPSC Safeguarding & Reviewing Section (ISU) to provide a report which sets out statutory requirements for LAC and identifies what has changed in Leeds 2) The LSCB performance management sub group (via multi agency audit programme) to audit the effectiveness of those arrangements. 3) Enhance care planning and communication re 13+ LAC by regular link meetings between Team Managers. YOS & Children Head of Service LSCB Assistant Manager Chair of Joint Agency Decision Review Panel Completed February 2012 Completed LSCB Audit Nov 2013 Completed March 2012 2 The LSCB should satisfy itself that the programme of work being undertaken to improve corporate parenting responsibilities in Leeds includes promoting access to education, training LSCB and Corporate Parent Links to be strengthened by: 1. LSCB to provide overview of Annual LSCB Manager Completed Child V Composite Action Plan – March 2015 2 Ref No Recommendation Action Responsible Agency/Lead Person Outcome and Date and employment opportunities and enhancing emotional wellbeing. Report and Business Plan annually to Corporate Parenting Board 2. Corporate Parenting Board to identify priorities from LSCB report for further Board scrutiny and action in response to Report and Plan 3. Children’s Services to provide summary of LLRs and SCRs to be reported to Corporate Parenting at publication. 4. Children’s Services to work with Corporate Parenting Board to provide annual report of Corporate Parenting Board activity to LSCB Corporate Parenting Board to strengthen oversight of issues relating to employment and training and emotional health by: 1. Children’s Social Work Services to provide update report on MALAP work and action to be submitted to the CC Board 2. Corporate Carers Board to identify issues for further CC Board scrutiny and action HoS LAC CS Improvement Hub CS Improvement Hub HoS LAC HoS LAC Feb 2015 Completed Feb 2015 Completed Jan 2015 Completed Feb 2015 In hand Agreed for 2015/16 Completed New thematic format developed for CCB Child V Composite Action Plan – March 2015 3 Ref No Recommendation Action Responsible Agency/Lead Person Outcome and Date 3. Children’s Social Work Services to extend performance reporting to CC Board to include regular data and performance analysis on related issues of employment and health. LSCB to receive updates on progress to promote access to education, training and employment opportunities and enhancing wellbeing HoS LAC HoS LAC Completed Data set routinely provided to CCB meetings Completed Reports to LSCB: • 22.05.14. • 15.01.15 3 The LSCB should review the sufficiency of provision of suitable, specialised accommodation for young people with high support needs, with a particular focus upon looked after young people. 1) LSCB to receive updates from the two current work strands addressing accommodation issues for young people: o Leaving care Accommodation Strategy o Environments & Neighbourhoods Youth Accommodation review 2) To reflect concerns re accommodation in LSCB Annual Report and to share with the Children’s Trust Board. LSCB Assistant Manager LSCB Manager & LSCB Chair Completed May 2014 Completed August 2013 Completed Sep 2013 Child V Composite Action Plan – March 2015 4 Ref No Recommendation Action Responsible Agency/Lead Person Outcome and Date 4 The LSCB should promote more effective approaches to risk management and assessment of children and young people with complex needs. LSCB to promote a programme of work and events including: 1) Review of referral pathways, assessment & appreciation of thresholds for intervention. 2) Conferences to promote intervention and management of risk within the community. LSCB Assistant Manager Completed Nov 2012 Completed LSCB Conference 2013 5 The LSCB should endorse IMR recommendations and require their implementation and should satisfy itself that actions are completed and embedded. 1) Partner agencies to provide evidence of action plan completion 2) Sample audit of partner agencies recommendations to check extent actions have been embedded Partner agencies Performance Management Sub Group Completed Dec 2013 Completed Sample Audit Jan 2014. |
NC52173 | Death of a 4-month-old boy in August 2018. Steven's death was initially suspected to be an overlay but inquest concluded a verdict of accidental death due to co-sleeping. Steven had been subject to a pre-birth assessment due to Mother's children from a previous relationship being taken to live with their father. Assessment concluded that support for the family was needed via a Child in Need plan which ceased in July 2018. Both Steven's parents had mental health difficulties and there were concerns about alcohol misuse. In July 2017 Mother attempted suicide. Several domestic incidents occurred between Mother and Father, even after bail conditions for Father stated that he should not go within 100m of Mother's house and not to contact her. Learning includes: victims of domestic abuse are given responsibility of keeping their children safe from the perpetrators of abuse without an assessment of their capacity to do so; perpetrators of violence, though identified as the source of risk to children, are not directly worked with to address concerns; relationships characterised by domestic abuse and between people with alcohol, substance and mental health issues rarely end without periods of reconciliation and contact; clear up-to-date records and effective, comprehensive information sharing are the foundations on which effective child safeguarding practice are built; workforce understanding of the risks of domestic abuse, particularly the risks associated with post separation are poorly understood. Ethnicity and nationality not stated. Review does not make any recommendations.
| Title: Safeguarding practice review (complimentary learning): Child E: Version 7. LSCB: Kirklees Safeguarding Children Partnership Author: Becki Hinchliffe Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. SAFEGUARDING PRACTICE REVIEW (COMPLEMENTARY LEARNING) CHILD E Version 7 February 2020 Becki Hinchliffe 1 Contents Introduction ............................................................................................................................................ 3 Family composition ............................................................................................................................. 3 Reason for this review ........................................................................................................................ 3 Purpose of the review ......................................................................................................................... 3 Style of review..................................................................................................................................... 3 Overview of this case .............................................................................................................................. 4 Findings and analysis linked to recent reviews ....................................................................................... 8 Finding 1 – Workforce understanding of the risks of domestic abuse, particularly the risks associated with post separation are poorly understood .................................................................... 8 Victims of domestic abuse are given the responsibility of keeping their children safe from the perpetrators of abuse without an assessment of their capacity to do so Perpetrators of violence, though identified as the source of risk to children, are not directly worked with to address concerns 8 Relationships characterised by domestic abuse and between people with alcohol, substance and mental health issues rarely end without include periods of reconciliation and contact. ....... 8 Link to recent reviews (found in Appendix 1) ..................................................................................... 8 Illustrative evidence from this case for Finding 1 ............................................................................... 8 Research supporting Finding 1 ............................................................................................................ 9 Finding 2 – Clear, up-to-date records and effective, comprehensive information sharing are the foundations on which effective child safeguarding practice are built................................................ 9 Link to recent reviews ......................................................................................................................... 9 Illustrative evidence from this case for Finding 2 ............................................................................. 10 Research supporting Finding 2 .......................................................................................................... 12 Finding 3 – The support arrangements post Child in Need are not clear and co-ordinated and the circumstances under which Children’s Social Care may want to consider re-opening a Child in Need case after the closure are not specified to the agencies who remained in contact with the family ................................................................................................................................................ 12 Link to recent reviews ....................................................................................................................... 12 Illustrative evidence from this case .................................................................................................. 12 Research supporting Finding 3 .......................................................................................................... 14 Additional findings and analysis particular to this case ........................................................................ 14 Finding 4– For those agencies primarily addressing parental issues, child safeguarding does not appear to feature in their assessments, decisions or direct work. ................................................... 14 Illustrative evidence .......................................................................................................................... 14 Research supporting additional Finding 4 ........................................................................................ 16 Finding 5 – The safe sleeping advice, given consistently to mother, was not effective in reducing the risks to Steven ............................................................................................................................. 16 Research supporting additional Finding 5 ........................................................................................ 18 2 Finding 6 – The risk of a return to problematic alcohol use by mother was not understood, assessed or managed. ....................................................................................................................... 18 Research supporting additional Finding 6 ........................................................................................ 19 Good practice evident in this case ........................................................................................................ 19 Reflective questions .............................................................................................................................. 20 Bibliography .......................................................................................................................................... 21 Appendix 1: Relevant Findings / learning points from previous reviews referenced in this addendum .............................................................................................................................................................. 22 3 Introduction Family composition Child Steven Mother Joanne Father Mark Mother’s ex-husband, father of older children Robert Friend of mother Liz Reason for this review On 30th August 2018, KSCB were informed of the death of Steven, a 4 month old baby, on 23rd August 2018. The death was initially suspected to be an overlay. The inquest has concluded a verdict of accidental death due to co-sleeping. A historic bruise on Steven’s chest was also noted which was thought may be innocuous or may have been indicative of a broken rib1. Steven had been subject of a pre-birth assessment as Joanne’s previous children had been “removed”2 and were in the care of their father. Both of Steven’s parents were known to have mental health difficulties and there were concerns in relation to current and previous alcohol misuse. The pre-birth assessment concluded that the family should be supported on a Child in Need plan. This plan ended on the 9th July 2018. Purpose of the review At the time of writing the review it was not known whether any police action was being taken in respect of Steven’s death. The pathologist has ultimately determined Steven’s death as unascertained and the police have now confirmed that they are not pursuing a criminal investigation in relation to Steven’s death. In any event, Safeguarding Practice Reviews are not written to determine causes of death or to assign blame to either family members or practitioners involved with or previously involved with the family, but to seek to understand the child’s life, experience of services and whether anything can be learnt to improve practice and prevent future harm to other children. In 2018, KSCB commissioned 3 Safeguarding Practice Reviews, all on children aged 2 and under. When the notification of Steven’s death was received it was clear that there were many similarities to these 3 cases and the emerging learning coming from it. As such the specific purpose of this review is as follows: 1. To act as complementary learning to those other reviews and to identify learning that mirrors that of the Kirklees Cases Child A, Children B+C and Child D and whether Steven’s life and death can deepen our understanding and response to that learning. 2. To understand the multi-agency response to Steven, Joanne and Mark to ascertain if any learning can be gained to strengthen future practice 3. To identify learning that differs from those other 3 reviews and highlight this for the agencies involved. Style of review This review differs from those usually commissioned by KSCB for a number of reasons. Firstly, its similarity to other reviews already in the process of being written meant that much of the learning 1 The Post mortem ultimately did not find any evidence of a broken rib, the bruise appears to be in the process of healing and was not considered significant by the pathologist. 2 This author can find no evidence of Joanne’s older children being legally removed, they appear to have been living with her ex-husband, the children’s father, by mutual agreement. 4 and the context of safeguarding practice in Kirklees has been identified and, as such, it was felt that commissioning another “full” review would be repetitious. Further it would take longer for a full review to be completed and any action needed from additional learning would be delayed. This review has not arranged Practice Learning Events which seek to engage first the practitioners involved in the case and then the senior managers of the involved agencies. Again though highly valued parts of most reviews these learning events take time to organise and it was felt would not add much more to the understanding than had already been gleaned from previous Practice Learning Events on the other cases. This author has however had the option to contact agencies to clarify events where necessary. The structure of this review has therefore been as follows: 1. Initial information gathering from all involved agencies 2. Compilation of a full detailed multi-agency chronology 3. Analysis of written information including additional information (CIN minutes, pre-birth assessment) 4. Review of the learning arising from Child A, Children B+C and Child D for comparative purposes This review is therefore written in three parts: 1. Overview of the case 2. Findings and analysis linked to recent reviews 3. Additional findings and analysis linked to this particular case Parts 2 and 3 will both provide evidence from this case to support the finding and also provide excerpts from relevant research to inform future practice. Although this review is conducted with a lighter touch, it is a thorough and comprehensive review at the case, with a focus on Steven and his needs. This reflects the national move to conduct more agile reviews which draws out learning quickly for agencies Overview of this case In February 2017, Robert (Joanne’s ex-husband and father of her 3 eldest children) contacted Kirklees Children’s Social Care with numerous concerns for his children. These included Joanne’s excessive drinking and deteriorating mental health, poor home conditions, allegations by the children of being physically abused by their mother and violent and aggressive behaviour between Joanne and her friend Liz which was being witnessed by the children. A single assessment was conducted but no further action was taken as Robert assumed full time care of the 3 children out of the Kirklees area with only supervised contact allowed3 between the children and Joanne. In July 2017, Joanne attempted suicide by overdose (prescription medication and alcohol). In August 2017, Joanne attended an antenatal booking appointment at 8 weeks pregnant. She did not disclose her alcohol and mental health issues, including the overdose she had taken the previous month. Nor did she mention that her 3 older children no longer resided with her as a result of her issues. In November 2017, however, Joanne’s midwife became aware of Joanne’s older children and that CAFCASS were currently assessing those children. The midwife made a referral to Children’s social care at this point but was told no further action would be taken. Shortly after this referral that was closed CAFCASS contacted Children’s Social Care to ascertain the progress of the pre-birth assessment and were told that they were awaiting the outcome of the CAFCASS section 7 report. CAFCASS 3 Again the contact arrangements appear to have been by mutual arrangement between Joanne and her ex-husband. 5 informed Children’s Social Care that they were only completing a report on the 3 older children not the unborn and highlighted the concerns they currently had regarding Joanne’s care of them, they also highlighted that they did not have any information about Mark apart from the fact that he had a previous child who was under a Special Guardianship Order. Following this a pre-birth assessment was commenced. This pre-birth assessment concluded that a Child in Need plan would help support the family and manage any risks to the unborn child. Referrals were made for Joanne to access support for her mental health through the single point of access but South West Yorkshire Mental Health Trust (SWYMHT) records note that Joanne did not feel she required the support of mental health services, she felt her support network around her was enough. On 20th October 2017 Joanne asks her GP for a report for court regarding her mental state. On the 19th December 2017 the court hearing was held regarding the custody arrangements for the older children, the CAFCASS recommendations were followed and Robert was awarded full custody of the children with Joanne allowed fortnightly supervised contact. For the duration of her pregnancy Joanne appears to engage fully with all antenatal, Child in Need and health appointments. There is however, very little reference to Mark, Steven’s father, with whom Joanne is still in a relationship. Steven is born on 7th April 2018 and Joanne and Steven are discharged from hospital the same day. Following Steven’s birth Joanne continues to engage with all agencies, including self-referring to IAPT services. South West Yorkshire Mental Health Trust are very active with Joanne at this time assessing her for the most appropriate service. Psychology liaised with the Perinatal Mental Health Specialist and it was agreed that the perinatal period was not the right time to engage in a course of therapy sessions, however, the nature of her case indicated longer term support was needed, therefore she was referred to and accepted by the Core Mental Health Team. There are no concerns noted regarding Steven’s health, development or care and though there is little detail in any agencies records in relation to Mark it is clear they are still in a relationship and caring for Steven together with no apparent issues. On 28th May 2018, there is a domestic dispute as Mark attends Joanne’s home wanting to stay but Joanne’s refuses as he is under the influence of drink and drugs and she has her older 3 children with her on their first overnight unsupervised stay. The police are called to Joanne’s home by Robert, who is not present but who has presumably been contacted by one of the children and informed of what is happening. When the police attend Mark has already left. He appears to have gone to Dewsbury District Hospital from Joanne’s house to present himself to the A+E department for his mental health issues, he is advised to attend local substance misuse agency CHART, which he does late the next day. At the subsequent Child in Need meeting it is noted that Joanne “acted protectively” by calling the police. She was not the person who contacted the police, though by refusing Mark entry in the home was clearly prioritising the needs of her 4 children. Mark is present at the Child in Need meeting on 7th June and recommendations are made for him in relation to addressing his mental health difficulties, alcohol misuse and unstable housing. It is made clear he is not have unsupervised access to Steven. At this stage the status of Joanne and Mark’s relationship is not clear, nor is Mark’s place of residence. On 12th June Mark is again assessed by the crisis mental health team following police detention under sec.136 of the Mental Health Act. This is due to the police being contacted by a member of the public who was concerned that Mark was on a bridge threatening suicide. 6 During the mental health assessment it is noted that Mark’s partner, Joanne, informed the team that Mark could not return to the family home due to Social care assessing him as not being safe around their new-born son due to his substance misuse. This would seem to indicate that the relationship was continuing. The mental health assessment concludes that Mark may have been trying to get a hospital bed in order to have somewhere to stay and “prove” to Children’s Social Care that his issues were mental health in origin not alcohol and therefore “not his fault”4. Mark did not meet criteria for detention or informal admission under the Mental Health Act so he was allocated to the Intensive Home Based Treatment Team, support was given by this team and the Emergency Duty Team to expedite his housing needs with the council housing department. In the interim, it was agreed he would attend appointments at Folly Hall. The mental health assessment was sent to housing and to Children’s Social Care, though neither were contacted as part of the assessment therefore clear information regarding the unsupervised access to Steven and the direction not to reside at Joanne’s address was not gained. As neither the Housing Department or Children’s Social Care contacted mental health services upon receipt of the mental health assessment to clarify information contained within clarity was not gained regarding contact and living arrangements for Mark. Joanne also discusses with her Community Psychiatric Nurse (CPN) that the domestic incident with Mark which was witnessed by her children has strained her relationship with the children’s father who has stopped contact and this was “negatively impacting her mental health”. Joanne’s CPN discussed her emotional wellbeing and available support networks with her but does not appear to have fully explored with her the possible coping mechanisms she may employ or how this might impact on her care of Steven. Joanne continues to engage with her CPN, her Community Care Officer (working in a specialist council service supporting families with mental health issues) and her Health Visitor though she raised the limited contact she had with her Social Worker to her Health Visitor. Mark is engaging with his mental health team though not with CHART who close his case following his repeated failure to attend for the completion of his initial assessment. There is no apparent liaison between the parents’ mental health team despite Joanne and Mark still being in contact with each other at this time. On 4th July, the Health Visitor is contacted by a newly allocated Social Worker who asks what the date of the next Child in Need meeting is and for a telephone contact number for Joanne. It is subsequently recorded in Children’s Social Care’s records that a Child in Need meeting is held at Joanne’s home on the 6th July, however as only the social worker and Joanne were present this would more accurately be called a Child in Need visit. Joanne is informed by the new Social Worker that the Child in Need plan is closing and it is noted in the social care records that “parents are caring for the child well and addressing mental health concerns”. Children’s Social Care appear to have made this decision unilaterally and neither the Health Visitor nor the mental health team appear to be clear about any plan going forward. As the Social Worker closed the plan, it would be expected that they would notify the other professionals involved, including the rationale given it was done in isolation. Both the managers who compiled the agency chronologies note that it would have been prudent for the practitioners to clarify what the closure plan was with the Social Worker. Between 15th and 26th July Joanne reports to her Health Visitor, mental health team and GP on separate occasions that her mood was low and that she was emotionally distressed due to the 4 Chronology record from SWYMHT on 13th June 2018 7 restricted access to her older children, Mark’s deteriorating mental health and ongoing housing issues. Although not alcohol specific, Joanne’s CPN discussed her wellbeing, support network and coping strategies. However, again, a possible relapse into alcohol use and the impact of her ability to care for Steven does not appear to have been discussed. On 23rd July, Joanne contacts the mental health crisis team stating that Mark was angry, in drink and banging his head against a wall. Mark can be heard swearing in the background of this call but refuses to talk to them. There is no indication of where this incident is taking place, whether Steven is present, whether Joanne is safe herself and no liaison with either the Police or Children’s Social Care. Joanne is advised to contact the Police herself if she does not feel safe without consideration of whether she could safely do so. On 26th July, Mark contacts the Intensive Home Based Treatment Team to cancel an appointment as he is looking after his son. This was not explored or challenged though the mental health team were aware that he should not have unsupervised contact with Steven. Later that night Joanne contacts the Police to state that Mark is present at her home, in drink, being physically aggressive towards her and demanding her bank card. This incident is discussed in the Daily Risk Assessment Management Meeting (DRAMM) the following day and it is clear from the Police and Social Care records on the incident that Joanne stated Mark was at the property to have supervised contact with Steven. However, despite this clarity in the records, the police representative at the DRAMM, GP and Health visitors records from the DRAMM at which this incident was discussed state that it is not clear whether Steven was present and that Children’s Social Care must ascertain whether he was or not and to assess if he was. It is unclear where this confusion has arisen. Further to this, no agency appears to have noticed that the incident was called into the Police at 10.30pm which would be an unusual time for a supervised contact visit to a 4 month old baby, especially as the attending Police Officer records that Steven was asleep upstairs at the time. Mark was arrested at this incident and given bail conditions not to go within 100m of Joanne’s house and not to contact her, directly or indirectly, except via services to arrange child contact. On 3rd August at 11.15pm Joanne contacts the Police to say she is concerned about Mark’s welfare as he may be suicidal and she has not heard from him for 18 hours. This would seem to indicate firstly that she had had contact with him in the early hours of the morning (around 5am) despite the bail conditions in place and that it was out of the ordinary for Joanne to not have contact with Mark for that length of time. On 5th August, Mark is again detained by the police under section 136 of the Mental Health Act after he again threatened to jump from a bridge. During his assessment he states that he attempted suicide by overdose 3 days earlier too. He is discharged the same day and following this Joanne contacts the police reporting that Mark is breaching his bail conditions by contacting her directly and indirectly (via a friend) including threats to cause criminal damage. On the 7th August Joanne’s CPN visits her and discusses domestic abuse, Joanne informs her that she has been allocated a Domestic Abuse worker, it is not clear who Joanne is referring to. On the 9th and 16th August Joanne’s Community Care Officer visits her and acknowledges the domestic violence incidents and her low mood. Again neither worker appears to have discussed coping mechanisms including, a possible relapse into alcohol misuse and the impact of her stressful current situation and low mood on her parenting capacity. On 23rd August, in the early hours of the morning the police are notified by the ambulance service of the sudden death of Steven. Joanne reports that she had been drinking wine with her friend Liz at Liz’s 8 home until 3pm then had returned home with Steven who had fallen asleep in the pram. She had got home about 7pm and continued to let Steven sleep in the pram until 11pm when she took him into bed with her. Findings and analysis linked to recent reviews Finding 1 – Workforce understanding of the risks of domestic abuse, particularly the risks associated with post separation are poorly understood Victims of domestic abuse are given the responsibility of keeping their children safe from the perpetrators of abuse without an assessment of their capacity to do so Perpetrators of violence, though identified as the source of risk to children, are not directly worked with to address concerns Relationships characterised by domestic abuse and between people with alcohol, substance and mental health issues rarely end without periods of reconciliation and contact.5 Link to recent reviews (found in Appendix 1) Child A learning points 8, 20, 23, 33 and 34 Child D Finding 5 Illustrative evidence from this case for Finding 1 Following the 1st recorded domestic abuse incident between Joanne and Mark on 28th May 2018 there is a Child in Need meeting on 7th June where recommendations for Mark to address his mental health, alcohol and housing issues are discussed. There is no formal record of this meeting, nor a written Child in Need plan so it is not clear what support was offered to Mark to achieve this. Further it is at this meeting that Mark is told he is not allowed unsupervised access to Steven but there is no detail about how this contact should be supervised so presumably this fell to Joanne to organise despite the history of abuse and the fact that they have only recently separated.6 During one of the supervised visits on the 26th July Mark arrives under the influence of alcohol refuses to leave when asked by Joanne, assaults her and demands her bank card. Discussions with Joanne about this incident and the safety plan put in place are centred around what Joanne can do, not what agencies are doing or what Mark is expected to do (other than comply with his bail conditions of no contact). Though Joanne did “act protectively” by contacting the police when assaulted there is no explanation of why the supervised contact with Steven was taking place so late at night. No worker appears to have discussed with Joanne how she could facilitate safe contact between father and son, if the responsibility for doing so was to rest with her, for example, in a public place not her 5 Some women with abusive partners may not end relationships because they have been threatened with increased violence if they leave. Others fear for the safety of their children, family, or friends. Although some women stay in relationships because they believe their partners will change, others stay for fear that the violence will escalate against themselves or their loved ones should they leave. (Fleury et al, 2000) 6 It is to the credit of the last social worker involved in the case that she did have a discussion with Joanne about facilitating contact and different support options available to her. 9 home, in the day, with another adult, for a set period of time, with agreement for a support worker (from any organisation with whom Joanne was engaging) to check on her at an agreed time to check that there had been no issues. This incident and the following call from Joanne to the police on the 3rd August concerned that she had not heard from Mark for 18 hours, despite the no contact bail conditions, indicate that they were in more than daily contact with each other, if not, had actually resumed their relationship fully. Research supporting Finding 1 Finding 2 – Clear, up-to-date records and effective, comprehensive information sharing are the foundations on which effective child safeguarding practice are built Link to recent reviews Child A – Learning points 1 and 17 Children B and C – Finding 5 Child D – Findings 5, 7 and 9 Research suggests practitioners initially related to women as victims, however, as time progressed and abuse continued workers made increasing demands of women to ensure child safety (Jenney and colleagues, 2014). The construction of mothers as being primarily responsible for childcare sets women up for blame for the perpetrator’s abusive actions, and renders the abusive partner’s behaviour invisible to social services (Mandel, 2010). The Institute for Research and Innovation in Social Services (2017) Relying too much on mothers for essential information Professionals sometimes rely too much on mothers to tell them about men involved in their children’s lives. If mothers are putting their own needs first, they may not be honest about the risk these men pose to their children. Professionals do not always talk enough to other people involved in a child’s life, such as the mother’s estranged partner(s), siblings, extended family and friends. This can result in them missing crucial information and failing to spot inconsistencies in the mother’s account. NSPCC Hidden men: Learning from Case Reviews Domestic abuse often relies on isolating the victim: the perpetrator works to weaken her connections with family and friends, making it extremely difficult to seek support. Perpetrators will often try and reduce a woman’s contact with the outside world to prevent her from recognising that his behaviour is abusive and wrong. Isolation leads women to become extremely dependent on their controlling partner. Women’s Aid: Why don’t women leave abusive relationships? 10 Illustrative evidence from this case for Finding 2 This case notes concerns regarding record keeping across all partner agencies. Children’s Social Care records submitted for the chronology for this review are incomplete for example; No record of when the pre-birth assessment was completed No record indicating when the Child in Need starts (Locala notes that it was Joanne, not Children’s Social Care, that informed them that there was a Child in Need in place) Not clear which agencies were involved in the Child in Need No Child in Need plan on file and this was not shared with any agency No minutes from the Child in Need meeting on 7th June 2018 Difficulties in Children’s Social Care regarding effective record keeping at this time are well documented and an extensive programme of improvement to address this issue has been in place through the Strengthening Practice Programme which has focused on Recording, Assessment and Planning (RAP). The information presented to DRAMM on 27th July 2018 is contradictory and confusing. The police callout information is clear that Steven is present at the DV incident on 26th July 2018 yet at the DRAMM the police representative questions this and task Children’s Social Care with finding out. Children’s Social Care do have a conversation with Joanne about this incident where she clarifies that Mark was there for his supervised contact. This information does not appear to have been shared back with the DRAM / other agencies who may then have picked up on the issues highlighted in the previous finding regarding the unusual timing for a contact visit. Further the Child in Need plan appears to have been closed without prior discussion with the other involved agencies and the decision to close was only communicated to the other professionals by Joanne. The South West Yorkshire Partnership Foundation Trusts records provided to this author in the first instance were difficult to follow with a lack of clarity regarding which team from their service a record related to and a lack of richness in the entries in relation to what a worker had specifically discussed, in particular with Joanne. Further work was done to clarify this and the report has been amended accordingly. Though they respond to requests for information from Children’s Social Care when asked, SWYPFT appear to have had little pro-active contact with them or any other agencies working with the family including the sharing of information that would indicate increasing risk of harm to Steven. This is detailed further in under Additional findings: Finding 4 Examples illustrating this finding include at Joanne’s first contact with the service when she informs SWYPFT that she is subject to a pre-birth assessment but no contact is made with Children’s Social Care to confirm the reasons for this or to notify CSC of their involvement with Joanne. On 14th June, Joanne discloses the Domestic incident between herself and Mark on 28th May when she had overnight care of her 3 older children as well as Steven. There is no follow up with Children’s Social Care but perhaps more noteworthy is that there is no contact with the crisis mental health team who also had contact with him on the same day. The records relating to Marks care under SWYPFT have little information related to him as a father. On 26th July Mark calls his Mental Health Nurse to cancel his appointment due to looking after his son. This is not explored or checked to see whether this is supervised contact or not and it is not shared with CSC. 11 In total there are 21 instances this author can find where information is not shared either with CSC, between Joanne’s and Mark’s MH workers or with other agencies. SWYMHT may wish to assure themselves that this case is an aberration rather than indicative of wider practice. The GP’s involved in Joanne’s care also have instances of poor information sharing which are linked to the additional finding discussed later in this report regarding adult facing agencies. In relation to information sharing and record keeping specifically, on 20th October 2017 Joanne asks her GP for a report for court regarding her mental state. She gives information regarding her previous alcohol use, recent overdose, the fact that she is no longer taking anti-depressants and her current status as 17 weeks pregnant. There is no record of the response to this request or what safeguarding checks or action was taken (if any). On 3rd May 2018 an Answer machine message is left by the GP to the Social worker regarding a request made for Joanne’s medical records, the message asks whether these records are still needed. The request was made by Children’s Social Care on 11th January 2018 in order to complete Steven’s pre-birth assessment. This request was clearly not actioned, or followed up and at this stage the pre-birth assessment had already been completed and Steven born. The unclear or incomplete records of agencies and the instances of a failure to share information impacted on the risk assessment for Steven in the following ways: Incomplete Pre-birth assessment that did not have a complete picture of the mental health difficulties or alcohol misuse of either parent or how these might therefore impact on Steven when he was born. Failure to recognise when there might be a live safeguarding concern for a child due to a lack of flagging of concerns Failure to challenge parents when they give information that actually indicates they are breaching bail conditions, increasing the risk that Steven may be exposed to further incidents of domestic abuse Lack of consistency in the approach to parents from partner agencies, even within an organisation, decreasing the likelihood of effective interventions. For example; some agencies were responding to Joanne and Mark as a separated couple where other agencies clearly had information that they were still in regular contact, if not, still in a relationship. An overall lack of clarity and consistency to interventions that gives a poor impression to parents about the seriousness of concerns raised, the reason for intervention and the need to make change and reduce risks to Steven 12 Research supporting Finding 2 Finding 3 – The support arrangements post Child in Need are not clear and co-ordinated and the circumstances under which Children’s Social Care may want to consider re-opening a Child in Need case after the closure are not specified to the agencies who remained in contact with the family Link to recent reviews Child A – Learning Point 7 Children B and C – Finding 3 Child D – Finding 4 Illustrative evidence from this case On 6th July, the newly allocated Social Worker visited Joanne for the first time and decided to close the Child in Need plan. The case closure summary outlines the reasons for this as being Joanne’s good care of Steven, the fact that she had separated from Mark, Joanne’s good understanding of the risks posed to Steven by Mark and the need for ongoing supervised contact. No discussion had taken place with the other agencies prior to the decision to close the case being made and only appears to have been communicated to Joanne’s Mental Health Core worker afterwards. SWYPFT’s chronology compiler noted that the forward plan was not recorded by their staff including what action to take should there be any further domestic incidents. Joanne’s CPN received a telephone call from her social worker and was informed that the CIN was being closed, no plan received. Joanne reported to her CPN that she was not clear on the future contact between Mark and Steven, social worker told CPN that Joanne was fully aware and understood all her options etc. regarding options for Mark to see Good quality case recording is essential in ensuring: •Continuity of service to children and families when staff are unavailable or change, or when a service resumes after a period of time •Effective risk management practices to safeguard the well-being of children, especially in emergency situations; •Effective partnerships between staff, children, their families, their carers, other agencies and service providers; •Clarity of information for everyone involved in the planning and delivery of services, and in the event of investigations, inquiries, or audits; •Adequate information for staff and managers to ensure the best possible utilisation of available resources; •As a means by which to ensure accountability and adherence to procedures and statutory responsibilities West Yorkshire Consortium Procedures [accessed 12.3.19] 13 baby. This lack of contingency planning for when risks may re-appear or worsen is mirrored in other recent local reviews. Joanne contacted her Health Visitor to inform her of the Social Worker visit and decision to close the Child in Need. She reports that she informed the Social Worker that she was disappointed by the poor service provided by CSC (records indicate that this was dealt with appropriately by the social worker who listened, apologised and gave information regarding the complaints procedure). The chronology compiler for Locala notes the lack of challenge by the Health Visitor regarding the decision to close in light of the recent domestic abuse incidents and Marks deteriorating mental health. Joanne had engaged well with mental health services, appeared to have ended her relationship with Mark, the Health Visitor had no concerns about Joanne’s bonding with or care of Steven. In light of this the closure of the Child in Need at this point is understandable, however, it would have perhaps been prudent to have a multi-agency Child in Need meeting to enable all involved professionals to have the opportunity to discuss any remaining concerns they had and develop a clear, co-ordinated plan for ongoing support for Steven and his parents following closure. In particular, this plan could have specified the remaining risks and a contingency plan which specified under what circumstances Children’s Social Care might be concerned and feel that a Child in Need may need to be re-commenced. As no Child In Need plan appears to have been written it is hard to judge whether it met its original objectives and if objectives remained for other agencies to continue to address. Following the closure of the Child in Need plan, both Joanne’s and Mark’s mental health deteriorates, this is evidenced by a number of entries from Joanne’s MH team stating that she is “lower in mood” in “increasing emotional distress” etc. and started to take antidepressants. Whilst it is accepted that Mark had a lifestyle characterised by increasing use of substances which led to risk taking behaviour and crises requiring intervention from the Police and Mental Health services at this point he has made threats of suicide and is self-harming (banging head against wall) which indicates both that he is struggling and that there may be an increased risk for those around him, included Steven. Added to this there is a lack of clarity about the status of his relationship with Joanne and the contact arrangements for Steven and there is an increasing frequency and severity of domestic abuse incidents. These do not appear to have been assessed holistically by any agency which may have then been enabled to make a robust referral back into Children’s Social Care. 14 Research supporting Finding 3 Additional findings and analysis particular to this case Finding 4– For those agencies primarily addressing parental issues, child safeguarding does not appear to feature in their assessments, decisions or direct work. Illustrative evidence As previously mentioned this case has raised concerns regarding information sharing between SWYPFT and other agencies. This is evident in some of the GP contacts too and there is no evidence that Mark was asked about children or contact with children in his initial contact with CHART though it is acknowledged that Mark never completed his full initial assessment with CHART. On 3rd July Joanne discloses to her CPN that she is struggling with sleep, breastfeeding, finances to visit her children and concerns about Mark who is still under the mental health crisis team. There is no signposting to or liaising with other agencies who could have offered further support and no liaison with Mark’s mental health team in particular to try to ascertain whether their relationship has resumed. On 23rd July, Joanne contacts Marks Intensive Home Based Treatment Team (IHBTT) concerned that he is angry, in drink and banging his head against a wall. Joanne is not asked whether she is safe, needs police to attend, whether Steven is present, where they are. This incident is later discussed in a multi-23. Effective sharing of information between practitioners and local organisations and agencies is essential for early identification of need, assessment and service provision to keep children safe. Serious case reviews have highlighted that missed opportunities to record, understand the significance of and share information in a timely manner can have severe consequences for the safety and welfare of children. 24. Practitioners should be proactive in sharing information as early as possible to help identify, assess and respond to risks or concerns about the safety and welfare of children, whether this is when problems are first emerging, or where a child is already known to local authority children’s social care (e.g. they are being supported as a child in need or have a child protection plan). Practitioners should be alert to sharing important information about any adults with whom that child has contact, which may impact the child’s safety or welfare. Working Together to Safeguard Children 2018 “… it is apparent that many of these children’s cases had either been closed too soon or lacked the ongoing support services and monitoring the children and families needed.” Pathways to harm, Pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Department for Education May 2016 15 disciplinary team meeting but still not shared or referred to any other organisation. The IHBTT registered mental health nurse contacted Joanne the following day, she informed them that Mark was sleeping and a lot calmer, Mark agreed to be seen by IHBTT the following day. SWYPFT have acknowledged that the IHBTT could have made enquiries regarding the welfare of the child at the time and at the contact the next day and will be following this up with them. On 5th August, Mark is admitted to the 136 suite (for the second time) following a further suicide attempt and is discharged. Mark is signposted to CHART as his issues were related to illicit substance misuse. Clear (Community Links) was also discussed for anger management7. The suicide attempt, admittance to the 136 suite and subsequent discharge are not shared with any other agency (the police are aware as they bought him to the suite). Mark’s children are identified in the case records for this assessment and the document for the MHA assessment although this further suicide attempt and admittance to the 136 suite does not appear to have been passed on to Children’s Social Care. An example of the GP (s) having a similar approach is evident in Joanne’s contact on 24th July with her GP where she reports her dipping mood. She is prescribed anti-depressants but this information is not shared with any other agency. No consideration appears to have been given to the potential safeguarding issue this represents. 7 The appropriateness of this referral needs to be explored with SWYPFT, anger management is not the same as domestic abuse and there are concerns that treating perpetrators of domestic abuse for anger management issues can raise the risk to their partner. 16 Research supporting additional Finding 4 Finding 5 – The safe sleeping advice, given consistently to mother, was not effective in reducing the risks to Steven It is not within the remit of this review to ascertain a cause of death for Steven, however, it would be remiss not to comment on the fact that the chronology details safe and co-sleeping advice on 3 separate occasions by Locala (19th February, 24th May and 16th July) and on 8th April by the community midwife and that Steven was reported to be found dead by his mother in her bed in the early hours. The post-mortem report details that though the exact sleeping position of Steven and his mother are not known he was “placed in an adult bed with a sleeping and quite possibly intoxicated adult – a To safeguard and promote the welfare of children, assess their needs (including their role as young carers) and fully understand the family’s circumstances, children’s services practitioners should seek the expertise of adult services. Collaboration should be given greater priority because practitioners in domestic violence units, alcohol and drug services, mental health and learning disability services will have a better understanding than those working in children’s services of how these issues impact on adult family members and family functioning. Collaboration between children’s and adults’ services will allow the expertise of practitioners in these specialist services to inform assessments, judgements and plans. Joint working is likely to result in a more proactive and integrated approach to the delivery of relevant and timely services for both children and parents. To ensure joined-up service provision, specific attention should be given to creating robust professional links between children’s and adults’ services. (Children’s Needs – Parenting Capacity, Cleaver et al) Lack of information sharing between adults’ and children’s services Professionals involved with men who are fathers (such as substance misuse workers and probation officers) do not tend to share information about potential risks with other professionals supporting the children and partners of those men. This may be because they are unaware the men have contact with their children. Consequently, practitioners depend entirely on parents to share this information, which they may or may not do. NSPCC briefing: Hidden men: learning from case reviews Providers of adult services, such as adult psychiatrists, other mental health professionals and substance abuse workers, can be reluctant to refer because they focus on adults and often do not appreciate how, for example, parents’ mental health problems are impacting on their children. Safeguarding Children Across Services: Messages from Research Carolyn Davies and Harriet Ward 17 sleeping arrangement that could be considered as unsafe for an infant”. The pathologist has ultimately determined Steven’s death as unascertained. Emerging research indicates that whilst the safe sleeping message appears to have effectively reduced deaths in the general population it appears to be less effective with parents with complex needs. The Lullaby Trust has recently changed its message regarding co-sleeping to acknowledge that 76% of parents have co-slept with their baby at some point8. They have acknowledged that by giving out blanket advice about not co-sleeping at all, information about how to do so safely, or avoid unplanned co-sleeping situations is not given to parents or sought by them. Critically information about what the high risk factors in co-sleeping are, should be imparted to new parents. In Kirklees information given to new parents regarding safe sleeping is in accordance with the Lullaby Trust advice. The following section is especially emphasised: “Things to avoid • Never sleep on a sofa or in an armchair with your baby • Don’t sleep in the same bed as your baby if you smoke, drink or take drugs or are extremely tired, if your baby was born prematurely or was of low birth-weight • Avoid letting your baby get too hot • Don’t cover your baby’s face or head while sleeping or use loose bedding” Given the detail of information that is given by the midwife both during the antenatal period and after the birth of the baby and by the health visitor during the antenatal contact between 28 and 36 weeks (if there is one) and at the birth visit, the effectiveness of the method of imparting this information, or what other interventions might be needed, perhaps, for parents who could be considered high risk may need to be explored. 8 A survey of over 8,500 parents carried out by The Lullaby Trust has shown that 76% have co-slept with their baby at some point. However, over 40% of parents admitted to having done so in dangerous circumstances such as on a sofa, having drunk alcohol or as a smoker. All of these circumstances greatly increase the risk of sudden infant death syndrome (also known as cot death or SIDS). (Lullaby Trust, 2019). 18 Research supporting additional Finding 5 Finding 6 – The risk of a return to problematic alcohol use by mother was not understood, assessed or managed. Prior to July 2017, when Joanne took an overdose and then subsequently found out she was pregnant with Steven, she had been drinking heavily. It is not clear from what point she started to drink heavily and this does not appear to have been assessed by any agency during the period of this review (though this may have taken place prior). It is recognised that, as Joanne asserts, finding out that she was pregnant was motivation for her to stop drinking. However, there does not appear to be a full assessment of her alcohol use before Steven’s birth through the pre-birth assessment, or by any of the health professionals, or afterwards when, not being pregnant, Joanne no longer had the direct protection of her unborn child as motivation for her abstinence. The potential for a return to alcohol use and the risk of harm to Steven this represented was not assessed. It appears that Joanne simply she stated that she had stopped drinking in July 2017, this was accepted and although questions were asked during the Level 1 risk assessment completed by SWPFT, Joanne answered that she was not drinking although she did state that she was keen to access therapy to prevent future relapse. SWYPFT have accepted that given the history of alcohol misuse the issue should have been revisited. No other agency appears to have revisited this issue with Joanne and no work done with her to maintain this positive change. Linked to this are wider questions about coping mechanisms, where alcohol is known to have been used previously as a coping mechanism an Around half of SIDS babies die while co-sleeping. However, 90% of these babies died in hazardous situations which are largely preventable Co-sleeping and SIDS Unicef When categorised by co-sleeping environment, the multivariable risk of co-sleeping with an adult on a sofa or chair, or with an adult who had consumed more than two units of alcohol was 18 times greater than those who did not co-sleep; and four times greater for those who slept next to a parent who smoked. Notably, the risk associated with infants co-sleeping on a sofa or sleeping next to an adult in the parental bed who had consumed more than two units of alcohol was a magnitude higher than most risk factors associated with SIDS. Both of these environments pose a risk to the infant regardless of infant age. The reasons as to why infants are at increased risk when sleeping next to a smoker are not clear, but this risk seems to be far greater in the younger infants. An important implication of our findings is that to give blanket advice to all parents never to bed-share with their infant does not reflect the evidence. Bed-Sharing in the Absence of Hazardous Circumstances: Is There a Risk of Sudden Infant Death Syndrome? An Analysis from Two Case-Control Studies Conducted in the UK Blair, P., Sidebotham, P., Pease,A., and Fleming, P 19 exploration of what alternatives are being used would have been good practice. This is especially so when Joanne became under increasing stress and reporting her mood to be low following the first (reported) incident of domestic abuse on 28.5.18. Research supporting additional Finding 6 Good practice evident in this case 1. Safe sleeping advice was given on 4 separate occasions and by 2 agencies 2. Routine enquiries were made about domestic abuse by midwifery and health visiting services. 3. Upon receipt of the information in relation to Joanne’s older children being subject to a CAFCASS assessment the Midwife made an immediate and appropriate referral to Children’s Social Care Parents who are struggling with combinations of problems such as poor mental health, substance misuse or domestic abuse are less likely to be able maintain change in the long term (Duffy and Baldwin 2013; Skinner et al., 2010 Assessing Parental Capacity to Change when Children are on the Edge of Care: an overview of current research evidence Ward,H., Brown, R., and Hyde-Dryden, G. Moos and Moos (2006) found that 42% of people who received treatment for alcohol misuse had relapsed within 16 years (2.216). Hibbert and Best (2011) also found recovery from alcohol addiction to be a gradual process of change…The findings from these studies all support the argument for providing long term light touch support to help parents maintain progress, once an intensive period of intervention has been completed. However there is considerable evidence to suggest that pressure to close cases means social work services are often withdrawn prematurely, with inadequate arrangements for stepping down support (Farmer et al 2011; Farmer and Lutman, 2012; Ward, Brown and Westlake, 2012). Assessing Parental Capacity to Change when Children are on the Edge of Care: an overview of current research evidence Ward,H., Brown, R., and Hyde-Dryden, G. “What would I have to do to cause a relapse?” You don’t need to do anything. Stop using alcohol and other drugs, but continue to live your life the way you always have. Your disease will do the rest. It will trigger a series of automatic and habitual reactions to life’s problems that will create so much pain and discomfort that a return to chemical use will seem like a positive option. The relapse process does not only involve the act of taking a drink or using drugs. It is a progression that creates the overwhelming need for alcohol or drugs. Relapse does not happen when the addict takes the first drug or drink. Relapse is a process not an event.” 37 Warning Signs of a Relapse: The Phases and Warning Signs of Relapse by Gorski & Miller 20 4. Joanne’s health visitor and mental health team developed good relationships with Joanne, who felt able to share information with both sets of professionals 5. The Police response to domestic abuse incidents and Mark’s mental health crises was swift and appropriate 6. Domestic abuse incidents were referred appropriately to MARAC 7. Considerable intervention was provided by SWYPFT to both parents 8. The pre-birth assessment was completed in good time and ensured that a birth plan was in place 9. A clear and recorded rationale for closing the Child in need case was given by the social worker who also sought guidance from her manager in relation to the case 10. Upon case closure the social worker gave detailed advice about facilitating safe supervised contact Reflective questions 1. How is the workforce understanding of domestic abuse and the effective application of this knowledge into practice be evidenced? 2. What does “acting protectively” mean in the context of domestic abuse? 3. How can practitioners move from a description of events or recording a narrative given by parents to a truly analytical assessment? 4. What barriers do practitioners face to effective, comprehensive information sharing and keeping clear up-to-date records and how can these be overcome? 5. What are the best practice expectations of all agencies in relation to de-escalation of cases? 6. Should the closure of a Child in Need case be done in the context of a multi-agency discussion? 7. How can practitioners who are providing an “adult facing” service ensure they are routinely asking questions about and assessing the safeguarding needs of any children of or in contact with their client? 8. What role does the Mental Health in Families team play in facilitating closer working relationships between SWYPFT and Children’s Social Care? 9. How can we respond effectively to parents who are presenting in mental health crisis on multiple occasions? 10. How do adult facing organisations such as Adult Mental Health Services ensure that the opening and closing of cases are appropriately flagged to Children’s Social Care when the client is a parent? 11. How effective is the safe sleeping advice given to new parents? Should a tiered or different approach be considered when working with parents who have identified as having additional needs and being at higher risk? 12. What assessments or direct work is prompted (or should be prompted) with a parent who has identified previous alcohol or substance misuse issues? 13. How are the adverse childhood experiences of parents taken into account and explored when assessing parenting capacity? 14. How confident is the workforce understanding of relapse, how to identify this quickly and intervene effectively? 21 Bibliography Blair, P., Sidebotham, P., Pease,A., and Fleming, P, (2014) Bed-Sharing in the Absence of Hazardous Circumstances: Is There a Risk of Sudden Infant Death Syndrome? An Analysis from Two Case-Control Studies Conducted in the UK [Accessed on 7.2.19 at: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0107799#s5 Cleaver, H., Unell, I. and Aldgate, J (2011) Child abuse: Parental mental illness, learning disability, substance misuse and domestic violence 2nd ed. London: TSO Department for Education (2018) Working together to safeguard children. [Accessed on 7.2.19 at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/779401/Working_Together_to_Safeguard-Children.pdf Fleury, R et al (2000) When Ending the Relationship Doesn’t End the Violence: Women’s Experiences of Violence by Former Partners Michigan State University Accessed on 25.6.19 at https://vaw.msu.edu/wp-content/uploads/2013/10/Expartner.pdf Humphreys, C. and Bradbury-Jones, C. (2015) Domestic Abuse and Safeguarding Children: Focus, Response and Intervention. Child Abuse Review Vol. 24: 231–234 (2015) Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/car.2410 IRISS, The Institute for Research and Innovation in Social Services (2017) Domestic abuse and child protection: women’s experience of social work intervention [Accessed at: https://www.iriss.domestic-abuse-and-child-protection-womens-experience-social-work-intervention] Katz,E. Beyond the Physical Incident Model: How Children Living with Domestic Violence are Harmed By and Resist Regimes of Coercive Control. Child Abuse Review Vol. 25: 46–59 (2016). Published online 24 November 2015 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/car.2422 NSPCC (2018). Hidden men: Learning from case reviews. Accessed on 7.2.19 at: https://www.nspcc.org.uk/preventing-abuse/child-protection-system/case-reviews/learning/hidden-men Unicef (2019) Co-sleeping and SIDS Accessed on 12.3.19 at: https://www.unicef.org.uk/babyfriendly/wp-content/uploads/sites/2/2016/07/Co-sleeping-and-SIDS-A-Guide-for-Health-Professionals.pdf https://www.unicef.org.uk/babyfriendly/news-and-research/baby-friendly-research/infant-health-research/infant-health-research-bed-sharing-infant-sleep-and-sids/ Ward,H., Brown, R., and Hyde-Dryden, G. (2014) Assessing Parental Capacity to Change when Children are on the Edge of Care: an overview of current research evidence Centre for Child and Family Research, Loughborough University 22 Appendix 1: Relevant Findings / learning points from previous reviews referenced in this addendum Child A Learning Point 1: The chronology from Children’s Social Care was incomplete and this may be because there are records missing from their involvement with this family. If so, this may have implications for the accuracy of their records in respect of other families that may have had some involvement with social care during this period. Learning Point 7: Child in Need plans should be de-escalated to a Team Around the Family plan if low level concerns still need to be addressed when a decision is made to close the plan Learning Point 8: Children’s social care should explore how their expectations around child contact should be communicated to parents and professionals. This should include clear consequences for failure to adhere to agreed contact arrangements, recommendations for professionals in other agencies to record/flag the arrangements for supervised contact; and a clear process for reporting breaches to contact arrangements. Learning Point 17: Police should ensure that information about domestic incidents, including available evidence (i.e. visible injury, signs of struggle), is effectively shared with social care Learning Point 20: Coercive control has a detrimental impact on victims and may affect their capacity to assess risk and appropriately safeguard their children. Victims should not be expected to take sole responsibility for keeping their children safe from perpetrators, particularly when perpetrators have parental responsibility for their children. Learning Point 23: Perpetrators of domestic abuse, particularly those with parental responsibility for their children, should be directly spoken to about the impact of their abusive behaviour children and included in the assessment process/safety plan for children Learning Point 33: Children’s social care to ensure assessments of risk to children include a thorough exploration of the ongoing, cumulative impact of coercive control on victims and children Learning point 34: Key frontline professionals should continue to assess risk, and provide support for victims and children, post-separation in recognition of the increased risk posed by perpetrators during this period Child B and C Finding 3 The application of local thresholds for access to children’s social care were based on a “rule of optimism” and impaired child centred decision-making. This included the decision to allow the twin babies to be discharged into the care of their parents following their hospital birth. Finding 5 There is no evidence that messages from research and lessons from serious case reviews were used to inform the rationale behind decision-making for these children. 23 Child D 4. How did practitioners know that what they were doing was reducing risk? • To seek assurance that routine ongoing analysis takes place to include; whether or not risk is decreasing/ increasing/ static particularly paying attention to patterns of behaviour/ capacity and willingness to change. • Non –compliance with plans should be explicitly addressed at child protection meetings. • Contingency plans should be explicitly described and agreed and timescales set for intended outcomes/ interventions. 5. How were the risks associated with males, including Child D’s father, identified and assessed and responded to? To seek assurance from partners that their current single and multi-agency risk assessment approaches encourage and facilitate ‘big picture’ analysis of risk 7. Were single and multi-agency actions including communications and information sharing appropriate, accurate and acted upon? • Where there would otherwise be delays between Core Groups or other Inter or multi-agency meetings alternative arrangements must be made. A substitute chair person must be identified and the arrangements communicated with all agencies. • Whilst there is a rationale for why information in respect of the two incidents of alleged threats to children by Adult A was not shared, the KSCB and partners may wish to consider how ‘cross checks’ are carried out in future incidents of a similar nature. • Consider whether there are any common themes from previous serious case reviews or critical incident reviews and the effectiveness of agency’s actions in relation to these. 9. Determine whether National, Regional and Local policies, procedures, thresholds and practice expectations of the agencies were followed. |
NC52845 | Suicide of a 21-year-old mother in October 2019. Anna had a baby at 15-years-old and both Anna and her daughter were considered as 'children in care'. Anna had long-term physical and emotional difficulties, including personality disorder. Learning considers: effective information sharing to support both the parent and child; a 'Think Family' approach; collective consideration of the bigger picture; assessing a parent's physical and mental health needs; non-attendance of appointments and the decision to discharge; a trauma-informed approach; and the role of corporate parent. Recommendations include: children's services to consider how they have the skills and knowledge to support people with personality disorder and for all front-facing staff to have appropriate training; the establishment of a multi-agency task and finish group to address the gap in information sharing and better embed the 'Think Family' approach; relevant agencies, including the police, to consider the impact of their actions related to the protection of children on vulnerable adult family members; those working with children to be aware of the role that social care can play in supporting adults with care and support needs; seek assurance that the Escalation Protocol is fully embedded and being used effectively across all agencies; consider reviewing existing supervision methods, with a focus on the use of reflective practice and evidence-based processes; the partnership to produce short briefings on the issues of disguised compliance, the rule of optimism (around 'new partners' joining vulnerable families) and the poor care of pets; and to ensure step up/down processes are effective in cases where family mental health concerns have been identified.
| Title: Alternative learning review: ‘Anna’. LSCB: Warwickshire Safeguarding Partnership Author: Jan Pickles Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Alternative Learning Review ‘ANNA’ FINAL VERSION Author: Jan Pickles OBE Published: 20/09/2023 FINAL Anna Learning Review Report v11 30 05 2023 NO PM.docx 2 TABLE OF CONTENTS Page no 1. Introduction 3 2. Terms of Reference 3 3. Outline of Events 4 4. The Family Views 10 5. Key Decisions 11 6. Analysis of Events 17 7. Wider Significance 19 8. Responses to Questions Posed 21 9. Good Practice 22 10. Conclusion 24 11. Recommendations 25 3 1.Introduction Following the death on Anna in October 2019 a decision was made by Warwickshire Safeguarding Partnership that although the criteria for a Local Child Safeguarding Practice Review was not met the case held potentially significant learning for the agencies involved. In January 2020, the Safeguarding Review Subgroup commissioned Jan Pickles to undertake an Alternative Learning Review. Jan Pickles is independent of all services in Warwickshire. This Review was paused by the Covid-19 pandemic and restarted in August 2020. In September 2020, the Learning Review Panel reconvened, and a Reflective Learning event was attended by 21 professionals from all the relevant agencies to review the questions posed by the Safeguarding Review Subgroup and contribute their views on the management of this case. 2.The Terms of Reference The Safeguarding Review Subgroup identified ‘Key lines of Enquiry’ and posed specific questions to the relevant agencies involved in Anna ‘s care. Agencies were asked to reflect on their practice and address in their analysis why actions did or did not take place; and consider the events that occurred, the decisions made, and the actions taken or not and assess practice against guidance and relevant legislation. The review focussed on the period of the 1st of April 2018 to her death in October 2019. The questions posed were: 1. Was information sharing effective to enable partner agencies to provide appropriate support for both Anna and her daughter, if not, what were the barriers? 2. The application of ‘Think Family’ approach; support focused only on her child but overlooked Anna’s wellbeing and safety; why were no safeguarding concerns raised or referrals made to Adult Social Care, what were the barriers? 3. Consider if partner agencies working in silo, no collective consideration of the needs of the whole family (bigger picture) and assessment of what support may be required. Were assumptions made that Children in Care Personal Advisor Role held responsibility for Anna’s care and support needs as a young adult? 4. CWPT’s decision to discharge Anna without exploring the cause of her regular non-attendance of appointments; was this decision undertaken in consultation with other partner agencies supporting the family? 5. Were Anna’s physical needs seen as a representation of her mental health needs; were her medical assessments appropriate to her needs and managed suitably? 6. Consider if Anna was viewed as a whole person. was every issue was considered in isolation; her lived experience as a child was not factored/considered as part of her needs, and there is no evidence to suggest a trauma-based approach was considered; why? 4 7. Consider if assumptions were made by professionals that DWP PIP is only accessible to adults via a formal care assessment undertaken by Adult Social Care; why was there no follow-up on this to understand the process? 8. It was assumed that Jack was Anna’s carer, did his leaving impact on her stability and ultimately contribute to her suicide? 9. Is the role of Corporate Parent clear in these circumstances given Anna was a former child in care and her own child was open to Children’s Services? 3. Outline of events 1.Anna was a loving mum to her daughter Ella Rose, who was described by some professionals as her ’whole world’. Although her short life ended so tragically, she was described by a professional who worked closely with her as warm and ‘giggly’ with a strong sense of humour and was able to enjoy some parts of her life. 2. Anna was 21 years old when she took her own life on the 4th of October by 2019 by hanging. When she was aged 15 years, she had given birth to Ella Rose, the father was her then boyfriend, Owen. Ella Rose at the time of writing this Report is six years old and now lives with her father. On the 1st of October 2019, the Police attended her property due to a reported disturbance. On entry they found conditions within the home they felt to be insanitary and made a referral to Children Social Care. During the Police attendance Anna informed them that the “raised voices” the neighbour heard were due to a ‘row’ over the phone with her partner, who had been away for some days visiting family. Her partner Jack was later reported missing by a third party. Anna told the Police she needed him to come to help her tidy up and help her with Ella Rose. The photographs taken by the agencies at the time show that she and Ella Rose were living in filthy and unfit conditions with animal urine soaking the carpet that Ella Rose was walking on in her bare feet. Her bed lacked bedding tucked in a corner in a disorderly and packed room with animal faeces around. These unhygienic conditions were chronic in nature and could not be attributed to a few ‘untidy day’s due to the absence of her partner. 3. Children’s Services visited and agreed with Anna that the home conditions were unsuitable for the child, and it was agreed she stay with her grandmother’s Personal Assistant1. Anna made full disclosure to them about her mental and physical health issues. Over the next two days Children’s Services visited each day to assess the cleaning of the property and spoke with Anna about them seeking legal advice. It was agreed Ella Rose remain with her grandmother’s Personal Assistant and then spend the weekend with her father and his new partner as was routine for her. Anna agreed, stating she did not want her daughter living in the conditions she had experienced as a child. At the time Anna believed her current partner, Jack was staying with his family and their relationship had ended. In early June Anna told her Personal Adviser assigned to her from the Leaving Care Team2 that she had had a miscarriage. She had a further miscarriage in late July 2019 at 6 weeks into the 1 The Personal Assistant employed directly by the grandmother in this case to provide support with ongoing care needs. 2 The Personal Adviser is employed by Children’s Services it is a term defined in legislation Children’s Act 1989 sec 23 C 5 pregnancy. The University Hospital Coventry and Warwickshire Information reports notes that she was seen twice during this later miscarriage and although aware of her mental health this did not prompt any safeguarding action by the Hospital despite Anna being an open case to the Community Mental Health Trust (CMHT). At the time Anna herself had shared this information and was offered support from the Children’s Services team manager and duty team. Early Help were also aware Anna’s brother had been stabbed in September 2019. There is no further information to confirm this or if it did occur how serious the injuries were. We do not know if or how these events connect to Anna’s suicide, although clearly if confirmed they add to the background of trauma and dislocation of her situation. 4. Anna had several long term physical and emotional difficulties. Despite investigation including an MRI scan her physical health issues were not diagnosed but resulted in a high level of chronic back pain which significantly affected her mobility and her quality of life. She told the Social Worker on the 1st of October 2019 that she suffered with Fibromyalgia, Spondylosis, irritated nerves and slipped discs. She had been receiving significant pain medication and that this was regularly reviewed by her GP though in the seven months before her death had stopped collecting the prescriptions. She stated that she had been told her symptoms would deteriorate over time. Anna used a mobility scooter outdoors and a stick inside her home to help her get around. She was intermittently taking medication for depression, an antipsychotic drug, and opiates for pain. Her last prescription for these drugs from her GP was in February 2019. This review has been unable to establish if she was receiving medication from other unknown sources or if she was without medication. The Police had noted drug paraphernalia in the property that Anna explained as used to self-medicate with cannabis to ease her physical pain this had not previously been known to services. 5.Anna had been known to Children’s Services throughout her life from being a year old. Her childhood had been marked by the problematic drinking of her parents, Domestic Abuse and possibly a level of threat posed by her father to her, as she was advised to ‘keep her distance’ from him. In addition, her mother suffered from emotional ill health and is described as having ‘breakdowns.’ Anna as a child was referred to at points as her ‘carer’. We know that Anna aged 16 was placed in foster care with Ella Rose from her parent’s care for a period of fourteen months, due to the unhygienic conditions of her mother’s home. Both Anna and her daughter were considered to have been ‘Children in Care’. We do know that Anna was described as ‘wary’ of Social Workers due to her experience as a child. This may have affected her interaction with services. Anna, moved from her foster care placement to a supported accommodation placement, where she was living with her daughter, Ella Rose, and partner, Owen. Anna told Ella Rose’s school that the foster placement had been positive for them both, her Leaving Care Personal Adviser states Anna told her that “they (her foster family) were the family she should have had all along”. 6. It seems that Anna’s mother continued to have problems with her own mental health into Anna’s adulthood and that Anna’s mother attempted to take her own life on two occasions in May and December 2018. Anna’s father had died in 2014 and one of her two brothers had taken his own life five years previously. Anna had a 6 longstanding involvement with CAMHS, and she has previously self-harmed. Anna's mental health deteriorated when she took an overdose during early 2013. Anna was diagnosed by CAMHS with an ‘emerging Personality Disorder, Depression and Social Anxiety’. Her early life would have contained within it a number of what are now recognised as ‘Adverse Childhood Events’ (ACE’s). Anna told professionals that her own emotional and behavioural difficulties were inherited from her parents. 7. Anna was diagnosed in April 2016 aged 18 years old with ‘Emotionally Unstable Personality Disorder’ (EUPD) more commonly known as ‘borderline personality disorder’ (BPD). This is a long term and chronic illness with significant effects on emotional wellbeing and behaviour. EUPD is described by the Royal college of Psychiatrists as a condition characterised by ‘impulsivity, difficulty in controlling one’s emotions, negative thinking about self, tendency to self-harm or to make suicide attempts, relationship difficulties- sustaining or making them quickly, feelings of paranoia and depression and hearing voices, particularly when stressed’. A systematic review of research looking at associations between child maltreatment and EUPD, found that children with borderline features were more likely to have a history of maltreatment, and that children who had been maltreated were more likely to present with borderline features; other risk factors such as cognitive and executive function deficits, parental dysfunction and genetic vulnerability were also identified3. It is not known to what degree her EUPD diagnosis was a factor in Anna’s death. There were seven previous incidents described as either self- harming or attempts to end her life made by Anna between 6th March 2017 and her death in October 2019. These incidents all involved emergency services being called. 8. Anna was in education at college for a short time within the period in scope, and she attempted to take her own life whilst in education. Obviously, this was a traumatic event and may account for her eventual dropping out of education. She formally left the college in January 2018, stating her poor mental health as the reason, though she had begun a new relationship with Jack some months earlier in October 2017. Anna identified Jack as her carer. At this time Anna was receiving limited support as a Care Leaver by the Leaving Care Team (the Personal Adviser role is resourced to be of a practical and limited nature). Although she attempted on one occasion to return to education, she never managed a sustained return. 9. In June 2015 Anna’s foster placement ended, the foster carer describes Anna’s response to the placement in exceptional terms saying that the improvement she had seen with her was her proudest moment as an experienced foster carer. She described how when Anna and her daughter were both placed in their care Anna had no idea how to parent but learned and grew into a competent mother working well with Owen to care for Ella Rose. Anna continued to have regular contact with the foster family and her foster carer described Anna as ‘full of life and very focussed on Ella Rose’s well-being’. Anna, Owen, and Ella Rose moved into supported accommodation in July 2015, and Anna remained a child in care until her 18th 3 Ibrahim, Jeyda, Cosgrave, Nicola and Woolgar, Matthew (2018) Childhood maltreatment and its link to borderline personality disorder features in children: a systematic review approach. Clinical Child Psychology and Psychiatry, Vol.23, No.1. 7 birthday. Anna and her family moved into a secure rented property allocated to her by the Local Authority in March 2016. 10. The relationship with Owen ended in August 2017 but they remained friends thereafter. Anna had by October 2017 formed a relationship with Jack. Anna and her new partner left their property in February 2018, stating they wanted to get away from the area and be nearer to Jack’s family, which Anna saw as supportive. She was not to secure permanent accommodation from this point on, although she and her family were housed temporarily by the Local Authority to the time of her death. 11.Anna and Ella Rose had had several moves within Warwickshire; notes state from February 2018 onwards mostly between two towns, but she was unable to settle and establish a lasting home. There is clear evidence that she did not fit in in the neighbourhood she was last moved to, with numerous complaints made about noise, the state of the house and garden and concerns for the wellbeing of Ella Rose being made by neighbours. Although not stated it appears the housing around was mainly occupied by older people who found the family’s behaviour disruptive. In April 2018 whilst staying in the living room of a relative of Jack’s in Shropshire concerns were raised as the relative was a registered sex offender. An anonymous allegation was made in April 2018 of someone touching Ella Rose’s hair ‘inappropriately’. The Police and Social Workers attended, and Anna, Jack and Owen were informed of the risk, Anna denied the concerns describing them as ‘malicious’. A Social Work assessment describes there was no concerns about the interactions, emotional warmth, or stimulation of Ella Rose. However, this led to them being asked to leave and Anna, Jack and Ella Rose were then housed temporarily a caravan by the Local Authority. 12. Prior to the scope of this review Health Visitor records state there were on-going concerns surrounding the home conditions including a ‘smoky’ atmosphere possibly impacting on Ella Rose’s health. Ella Rose was prescribed an inhaler and Volumatic. An undated healthcare plan states Ella Rose was suffering from ‘reactive arthritis’ following an infection. Ella Rose was also described as ‘lactose intolerant’, something her ex foster carer is adamant was not the case. There was no evidence within the Health Visitor records of an assessment of need to determine whether a handover to School Nursing service was made as per standard practice in September 2018. Warwickshire School Health and Wellbeing Service were not involved with Ella Rose. Ella Rose was admitted to hospital in August 2018 aged 4 years old with leg and abdominal pains which left her ‘unresponsive’ for three minutes according to her mother 13. Anna shared the care of Ella Rose with Owen and his family. The exact arrangements are not clear as some records state Ella Rose stayed with Owen and his family from Friday to Sunday as he could not get Ella Rose to school, others that Owen and his parents looked after her for the bulk of the school week, keeping her school uniform and another wardrobe of clothes and that Anna looked after her from Friday night to Monday. It was clarified at the Reflective Learning Review meeting that Ella Rose spent Monday teatime to Friday morning with Owen and his parents and remained with Anna and Jack over the weekends. This confusion may well be 8 significant. The school report Ella Rose having to walk to and from school, approximately two miles each way and that Ella Rose was given extra portions of food at breakfast and lunch times as she was hungry. Ella Rose was found to be stealing food in September 2018, possibly due to the demands such a distance would make physically on her and possibly due to a poor diet at home. It was noted on three occasions in November and December 2018 and March 2019 that Ella Rose ‘smelt’; it was found her coat, school bag and reading books smelt of animal urine, the books were so damaged they had to be thrown away. 14.Anna due to her mobility problems did not collect Ella Rose from school, either Jack or her paternal grandparents did. Therefore, teachers only met her at Parent’s evenings and Early Help meetings. Her maternal grandmother’s Personal Assistant also cared for Ella Rose at points being more of a family friend as well as her mother’s employee, employed through her Carer Allowance Direct Payments. 15.Anna had been diagnosed with EUPD in 2016 and received support from Coventry and Warwickshire Partnership NHS Trust for two periods, the first out of scope March 2017 to February 2018 when she was assessed and accepted for a programme of treatment of Dialectical Behaviour Therapy (DBT), an intense course of 1 to 1 and group sessions to build emotional resilience and skills. Anna was unable to sustain her involvement which her Mental Health Care Co-ordinator recognised may have partly been due to her age. A second period of support was offered by the same member of staff from mid October 2018 to a final contact in February 2019 when conditions within the home were poor but clean. Her case was closed by the service in April 2019 due to lack of engagement and whilst other agencies had concerns, there is no record of a discussion around this decision. It was noted by the Mental Health Care Co-ordinator that Annas mobility had massively deteriorated; in February 2018 Anna was walking unaided and by the October 2018, she had needed a mobility scooter and was unable to walk unaided. 16.The National Institute for Health and Care Excellence and Social Care Directorate (NICE) issued4 a quality standards document, (Personality Disorders) in which it acknowledges that “People with personality disorders may have frequently been excluded from health or social care services because of their diagnosis”. Borderline personality disorder is more frequently diagnosed among women. The Guidelines further recognised the link between certain behaviour traits some of which applied to Anna and EUPD “People with borderline and antisocial disorders tend to have high prevalence of substance misuse, depression, suicide and be more likely to be unemployed and have difficulties building relationships. Criminal behaviour is central to antisocial personality disorder. These are not protected characteristics, but they can make people vulnerable to exclusion, judgmental attitude, and poor experience of care”. This suggests that the Anna’s poor engagement which excluded her from receiving services from Community Mental Health Services was likely to have been a feature of her disability and not simply a wilful refusal to engage. There is evidence 4 https://www.nice.org.uk/guidance/qs88/documents/personality-disorders-borderline-and-antisocial-quality-standard-equality-analysis-12 9 that a bespoke approach can be more successful in engaging this difficult to reach group. 17. Children’s Services state the family had been known to services “for many years.” Existing ongoing support was escalated to Child in Need (CIN) status on 25th of November 2016 due to a number of social and behavioural concerns- accommodation, managing Ella Rose, hygiene and both Anna’s and her then partner’s mental health. This support ended in January 2018, following improvements in the conditions within the house, Anna’s behaviour, and emotional stability. Ella Rose appeared to be in consistent and regular education starting at her local school in September 2018. The school reported concerns about Ella Roses’ clothes smelling, home conditions, attendance, and punctuality. They also reported that she was being bullied at school. The school reported that the previous nurseries she had attended had also identified safeguarding concerns. Throughout her time in this school the staff priority was described as making sure she was not hungry and had friends. The school applied for Pupil Premium funding to ensure all clubs and trips were paid for, as they were aware of Anna and Jack being in significant rent arrears. The school had significant contact with Jack, Anna’s partner and describe him as compliant and showing little emotion. They feel he did not understand how to care for Ella Rose, for instance when she fell and hurt herself on the walk to school, he just handed her over for the staff to comfort and tend to her injuries as he appeared not know what to do or how to comfort her. 18. In February 2018 Children’s Services visited Anna’s home following a referral from Anna’s GP with concerns about cleanliness and hygiene within the home following a visit, contrary to the Mental Health Care Co-ordinator view who had visited the home five times in the January and February of 2019. A deterioration was noted in both Annas physical condition and reported pain and that she was stressed by the ‘clutter’ her new partner had ‘brought with him’. The Social Worker provided advice; no other action was taken. The Leaving Care team remained involved in supporting Anna as she was a care leaver. It Is significant that Anna’s foster carer stated Anna had deteriorated both physically and emotionally after meeting Jack in October 2017. The foster carers view was that Anna appeared to “lose her voice and all her confidence” and that soon after meeting him she needed a mobility scooter whereas previously had not. The foster carer who saw the family frequently every few weeks at family events describes Jack as a “controlling and undermining person”. This information was not shared. 19. From March 2018 records indicate a deterioration in Anna. The Leaving Care Team identified concerns about cleanliness in the home. A complaint was received by the Police concerning Anna refusing to return two cats to their owners who had been staying at the property, and an allegation of Ella Rose being ‘touched inappropriately to her hair’ to which the Police responded and notified Children’s Services but that no further action was felt to be needed. The Police Officers attending noted the house was ‘in a state’ but were satisfied by Anna’s explanation that she had only just returned home after two months. Anna’s mother Louise made two attempts to take her own life in May and December 2018, and Anna moved to 10 Telford with her new partner Jack, to be near his family. Although housed on a temporary basis by Local Authorities from this time until her death she never acquired again a secure tenancy and what she felt to be a suitable home. Anna made a further attempt to take her own life in September 2018, stating on the 16th of September according to the West Midland Ambulance Services that “she had gypsy blood and because of this she was able to “speak to the dead” and had been having conversations with her fiancé’s Mother. She also stated she had “passed the gift to her Daughter”. A safeguarding referral was made on Ella Rose following this incident. 20. Anna was registered during the period under review with three GP practices. All were aware of her EUPD diagnosis, overdose history and suicide concerns but only GP Surgery 1 knew of her Child in Care status, the other two were unaware of her involvement with the Leaving Care Team. However, her contact with the GP’s was limited. During 2017 and 2018 she was regularly prescribed medication for depression and anti-psychotic and morphine-based pain medication, her last prescription was in February 2019. The GP Surgery 2 stated that because of her history and EUPD she was discussed at their safeguarding MDT in October and November 2018 when they noted she was engaging with the Mental Health Team. In July 2019 she left the GP Surgery 2 Practice for the GP Surgery 3 where she was not seen as she did not request an appointment. 21. In December 2018 Ella Rose was identified as a Child in Need. This was ‘stepped down’ in May 2019 to ‘Early Help’. The Deputy Head, also the Designated Safeguarding Lead (DSL) at Ella Rose’s school state they were not in agreement with this decision and that their concerns were ‘dismissed’ by the Social Worker, although the records indicate the meeting was unanimous in the decision to step down. Although not recorded in any documents seen it should be acknowledged that the effect on Ella Rose of these experiences in early life, even before the death of her mother would have been significant and difficult, with emotional and practical impact. Living with an unhygienic mess, stress, and arguments in the home, cared by three different people in different places every week and being bullied at school would have made it unlikely that she was able to feel secure or safe. It is the Panels view that the ongoing consistent care by Owen and his parents did provide her with some routine and stability. Owen, since Anna’s suicide has arranged a ‘child friendly farewell’ to Anna for Ella Rose and he should be recognised for that. These factors will likely have an impact on her development, emotional stability, and resilience into the long term. 4.The Family views The Panel discussed at length the safest and most responsible way to communicate with those close to Anna during the period under review that is her mother Louise, Ella Rose’s father Owen and her ex-partner Jack. Checks were made to establish the current addresses and if there was any agency contact and potential ongoing support available to those involved prior to letters being sent in November 2020. These letters yielded no response, and a further reminder letter was sent in January 2021. It must be noted that the country was in lockdown during the review period and all families had many other issues to contend with. Following the second letter the 11 Panels view was that further contact may be unhelpful. Without doubt this review is poorer as did not benefit from the views of those close to Anna on the events that led to her untimely death. 5. Key Decisions 1. On the available evidence it is impossible to say if different decisions had been made whether the outcome for Anna would have been any different. However, if we consider what the impact may have been of certain decisions made that seem to us to be key in the management of this case, we can ask the question; why was this decision made and what may have been the impact of it? Consideration can then be made as to whether the decision was a good one, an unavoidable one or something to consider. 2. In the Panel’s view one of the key decisions was that made by Children’s Services to end the involvement of Children in Need support and replace it with ‘Early Help’. Both periods of CIN support were stepped down to Early Help; on the 29th of January 2018 based on the progress made by Anna, that the risks were reduced and that there were ‘no safeguarding concerns’ in relation to Ella Rose. Despite her being in a very new relationship with an unknown man and having given up her College course. The second decision to end Children’s Services involvement was on the 14th of May 2019 with a transfer to Early Help on the 11th of June 2019 due to progress made. However, in July 2019 a MARF (Multi Agency Risk Form) was submitted to the MASH due to concerns similar to previous ones, Anna’s mental health issues, her ongoing struggle to provide a suitable home and care for Ella Rose and her further pregnancy. The MARF did not generate an escalation to CIN or a longer-term plan, such as a referral to the Reablement Service or to Adult Social Care. The reason for this should be explored, as it seems that there were indicators that suggested she was vulnerable as an adult and needed additional support. Was a referral considered and discounted? Was it not considered at all? And if not why was this? 3. The problem of hygiene and pets; we learned at points that there was a dog, a snake and four cats in the house throughout the period her daughter was a CIN. Problems created by these were the reason that the Police made a referral to Children’s Services when they attended her home in October 2019. Were these problems known to exist before the Police call out? If they were known were, they investigated? Given the history and background to the case it would be of value to know if this type of information if gathered was able to contribute to an understanding of the potential risks faced by Ella Rose in the home environment by the pets, and the capacity of her parents to manage her, the home, and the pets. 4. Although the report provided by Children’s Service state there is evidence of a ’Think Family’ approach, The Panel’s view is that the ‘stepping down ‘of both periods from CIN to Early Help suggest an over optimism and a lack of scrutiny of the risks presented by Anna and partner to her child, and an overconfidence in the level of improvement of both the care of Ella Rose and the environment she lived in being sustained. Jack moving in with Anna in October 2017 was seen as a positive thing, he was described by Anna and accepted by the agencies working with her as her carer. There is no evidence of any checks being made on him. The ex-foster carer 12 who saw Anna, Jack and Ella Rose regularly felt he was a controlling man who had silenced Anna and believe he was a factor in her decreasing mobility, this view was not shared with other agencies. The lack of a prescription being dispensed for her usual pain controlling medication from February 2019 may be linked to her decreasing mobility. Although described as a carer he was seen by the school and Leaving Care Team Personal Adviser as compliant but needing to be told what to do, so although an extra pair of hands he needed Anna to manage and direct him. 5.The decisions made to step down to Early Help appears based on evidence that was given more significance than it merited. The first step down decision was made in January 2018 just after Jack joined the family. He was an unknown quantity, and assumptions were made about the positives he brought that were not evidence based. The family decided to move home to be nearer his family. From the point of Anna moving out of her house in March 2018, she never regained a secure tenancy nor a home she was happy with according to records. Although she described Jack’s family as supportive, in reality, she Jack and Ella Rose were in April 2018 staying in the living room of a relative who was a registered sex offender. From here we see the local Borough Housing team providing temporary accommodation from her move and accepting a duty to house her in March 2019 and her later being placed on the priority housing list. The Leaving Care Team felt that Anna moving made the task of information sharing outside of the CIN framework more difficult. The Panel is aware these opinions are made with the benefit of hindsight not available to workers at the time. They do however highlight the importance of assessing current circumstances such as the background of a new partner, circumstances and resilience of the person receiving services using more than one source of information if possible. Anna’s foster carer did not believe Jack to be good for Anna and suggested in interview with me that although he appeared ‘passive’ Anna always deferred to him, did not challenge him as she had her previous partner Owen and was suspicious of her ‘needing’ a wheelchair shortly after meeting him. These views were not shared with Children’s Services as he was not perceived by them to be a threat to or negative influence on Anna or Ella Rose. Why was an assessment not undertaken regarding Jack and his suitability to be a carer for Anna and by default Ella Rose? In addition, why were the frequent moves and lack of secure housing not seen as indicators of increased risk in a household already beset by a number of significant difficulties, all with the capability to increase Anna and Ella Rose’s vulnerability? 6. There was evidence of recent improvement at the time of both decisions to step down support to Early Help from CIN in January 2018 and April 2019. Report of positive relationship with Jack, return to College and working with CPN, in both instances seemed to support the decision to be made to ‘step down.’ It seems that the improvements made which had only been in place a short time outweighed both the chronic and recent risk indicators such as attempts to end her life, Anna’s lived experience as a child and the resulting number of Adverse Childhood Experiences, EUPD, deteriorating mobility and health. It should be remembered that decision to step down in April 2019 was made just 6 months after three successive attempts by Anna to end her life. Risk of relapse into previous behaviour and her EUPD 13 diagnosis does not appear to figure in the decision to step down support. If this is the case what are the reasons for this? 8. Anna had been diagnosed with EUPD in March 2016, which is a serious and chronic condition which requires long term behavioural therapy and is not responsive to drug therapy. Improvement therefore is dependent on patient cooperation and engagement which Anna had already demonstrated she did not have the capacity to sustain. The nature of EUPD as described by the Royal College above brings with it conditions which can make long term work and the person receiving services buy-in problematic. This recurring feature of Anna’s behaviour, probably linked to her EUPD was not in the Panel’s view factored in by Children’s Services when considering the sustainability of change and the risk of relapse into problematic behaviour and distorted thinking. The professionals close to her described a pattern in Anna’s life of a cycle of her starting not to cope- professional help increases ability to cope- step down from help- not coping. Was this long term and difficult to treat mental Health condition factored into the assessment around the decision to step down support? If not, why was this? 9.The review was informed that an Early Help Headteacher Coach has been in post since September 2020 and that Early Help Social Workers were recruited in October 2020 to support schools and professionals to appropriately support high level and complex Early Help cases. This more robust professional response was to be reinforced by the adoption of the ‘Solihull Model’ in which more stable young parents who were themselves Children in Care offer peer mentoring. Parent mentor training was due to start but has been delayed due to Covid-19. Clearly these resources were not available to Anna and the Services working with her at the time. It is a moot point as to whether a different outcome would have been achieved had they been 10.It is the Panel’s view that the decision to reduce support from CIN to Early Help on both dates was taken on unreliable information and an over reliance on information from one source, Anna, who the Leaving Care Team knew was ‘wary’ of Social Workers. In July 2019 at an Early Help pre-school holiday meeting Anna described a packed schedule of exciting activities that Ella Rose would be enjoying over the summer. This schedule may have been partly due to her paternal grandparents’ input, but for the time in Anna’s and Jack’s care was undoubtedly either over optimistic or untrue and should have triggered concerns of Disguised Compliance. It showed a lack of understanding of the impact of Anna’s EUPD on her attitudes, capacity, and behaviour, particularly when one considers she was in chronic pain most of the time and the impact that is known to have on mood and emotions by itself. 11. Another key element in this case was the approach taken by mental health services to Anna who was not compliant but capable of inflicting serious harm on herself and on others, primarily her daughter. The NICE guidelines5 Borderline 5 https://www.nice.org.uk/guidance/cg78/chapter/1-Guidance#assessment-and-management-by-community-mental-health-services 14 personality disorder: recognition and management published in January 2009 describe in section 1.3.2 Care planning: Teams working with people with borderline personality disorder should develop comprehensive multidisciplinary care plans in collaboration with the service user. The care plan should identify clearly the roles and responsibilities of all health and social care professionals involved. The review was unable to evidence this had happened apart from a briefing given to Children Services when she was first diagnosed (not examined as out of scope). Anna was unable to sustain the DBT and so opted out but was not referred to a second line of less demanding treatment aimed at helping the person receiving services to manage their emotions. Anna disclosed hearing voices these were helpfully described by her Care Co-ordinator as ‘pseudo voices’ in that they are negative self-talk based on childhood trauma as opposed to voices telling her to act in a certain way. These undermining thoughts coupled with her multiple bereavements and loss and her belief she could ‘talk to the dead’ indicate that she needed more than mental health first aid from the professionals working with her. There is a significant drop out rate from the DBT significantly her age appeared to be a known a factor impacting on the persons receiving services completing the programme. The Mental Health Care Co-ordinator informed the review that Children’s Services were fully briefed on Anna’s diagnosis, but it appears that the skills to manage common presenting issues in those with a EUPD diagnosis were if shared with Children’s Services not integrated into the work supporting Anna. The decision by Mental Health Services to end treatment does not seem to have been made after any consultation with Children’s Services or the Leaving Care Team. The criteria used appears to have been her non-compliance with treatment offered. If the persons receiving services are known to be difficult to engage it makes the case more strongly for a different approach. They may appear reluctant and suspicious, and we have to accept our approach may not work and therefore be as flexible as we can. There is evidence to suggest an individualised approach can work. Otherwise, the implication is this group (PD) cannot be worked with. Therefore, our offer may need to be if possible individual work not groupwork, home visits to explain things not letters, co working with other professionals, consistency in their key worker will make engagement more likely with this group. 12.There are many instances within the chronology of this case in which Anna was referred to Community Mental Health Services following one of her seven attempts to end her life or self-harming episodes, for her care to be ended due to her non-attendance. There was also a lack of flexibility in terms of how they worked with Anna, mental health services making it clear that one to one contact was not available, and she would be discharged from the service if she did not attend what was on offer. The one exception to this approach was between 4th January 2018 and the 4th of March 2018 when eight home visits were made and in which Anna appeared to engage and cooperate with the Care Co-ordinator visiting after an attempt to take her own life and follow-on referral to the Community Mental Health Team. There is no evidence other than this period of Community Mental Health Services adapting what they offered to take account of Anna’s poor compliance. 15 13. This approach does not seem to be cost effective across the wider provision of services given the number of 999 calls and emergency hospital admissions, five in all within two and a half years involving Anna in terms of time and resources, as well as better outcomes for Anna and Ella Rose. In the Panels view it would have been more cost effective to have made her cooperation a priority, recognising the potential harm to herself and her daughter and resource it appropriately and flexibly. There is no evidence either of Community Mental Health Services consulting with other agencies that worked with Anna in terms of their decisions to end contact. There is no evidence of Community Mental Health Services working in collaboration with Anna or other services to seek a way to improve her engagement with them. That improvement was possible is evidenced by the maintenance of contact with Anna between January and March 2019 using home visits and a CPN she knew and trusted. 14.That the school did not escalate their concerns in the stepping down of Ella Rose’s supervision from CIN to Early Help is also pivotal despite the school having frequent concerns about the combination of the smell of animal urine to the point it ruined books, her exhausting walks to school6, bullying and her hunger. It is evident they had the most day to contact with Ella Rose and were aware of a number of risk factors; she was stealing food from another child’s plate, poor attendance, lateness, being bullied in school and her clothes, coat, school bag and books smelling of animal urine. Despite this the school did not feel able to escalate their concerns about the step-down decision. The reason for this need examining as the staff in the school were clearly concerned about Ella Rose’s welfare. Were the school not aware of the escalation process? Did they not feel it their responsibility? Or did they feel professionally unable to challenge the decision, or the Social Worker? 15. No agency working with Anna made a referral to the Reablement Service despite her increasing mobility issues, the service offers up to 6 weeks of support to improve areas such as personal care and running the household, which related to a skills deficit, lack of confidence, and/or Anna adapting to her physical disability. No agency considered or had a discussion with Adult Social Care (ASC) about a referral to assess her care and support needs in the short or longer term. It appears from the records that, because of her mental and physical health problems some which were deteriorating, she might have had care and support needs which meant that she was entitled to an assessment from Adult Social Care The outcome was that apart from the limited support that the Leaving Care Team could offer, particularly after Anna became 21, there was no agency providing long term support to Anna in her own right, despite her ongoing mental health issues and what was probably clear to the professionals involved her deteriorating mobility. 16. The MASH sought information from her GP in November 2018 following Anna’s overdose and received information via the MARF in July 2019 from the Early Help meeting due to concerns about the home, hygiene, Ella Roses’ schooling and her 6 ttps://www.nhs.uk/live-well/exercise/physical-activity-guidelines-children-and-young-people/ Children and young people aged 5 to 18 should aim for an average of at least 60 minutes of moderate intensity physical activity a day across the week 16 recent miscarriage. ASC are part of the MASH, a member of the Safeguarding Adult Team is co-located but they are not routinely involved in discussions regarding children, although they should be included where they can advise or contribute to a case. A referral to the Reablement Service was not considered. Following the Police attending on the 1st of October 2019 a strategy meeting within the Initial Response Service was held and again ASC did not attend, nor the MASH make a referral to them. The MASH appears not to have access to Anna’s full history of repeated attempts from 2013 onwards to self -harm and to take her own life by overdose or hanging. However, the triage completed by the Police Harm Assessment Unit included some details of Anna’s mental health, attempts to self-harm and medical history providing significant information to indicate Anna’s vulnerabilities. Following the Reflective Learning event, it was suggested that “some kind of bullet point document with risk indicators might have been useful for the social work staff who attended later on the 1st of October 2019”. The view at the Reflective Learning event was that ASC would not have accepted a referral as Children’s Services were involved as they would expect them to assess the whole family. This gap in information sharing within the MASH in terms of the Harm Assessment Unit and ASC was discussed at the Reflective Learning event and raised by the Police response after the Learning event is a cause for concern. At the time of writing this review we are aware a review of the MASH was due to report in January 2021. 17. On the Home Visit by Children’s Services Team 1st of October Anna was not seen by the Social Workers involved as a person with care and support needs despite her obvious mobility issues and the appalling state of the home which demonstrated a long-term failure to cope. The focus was on Ella Rose. Agencies visited the home in sequence and the Strategy meeting at the MASH which we have learned had only limited information did not identify an approach that reflected a ‘Think Family’ approach. The risks identified by the Harm Assessment Unit were not shared with the Social Workers who attended and agreed the improvements required with Anna. Their approach to their task indicates they had no knowledge of Anna’s needs as well as Ella Rose is and shaped a response which balanced support and scrutiny to what they knew of the family. The Social Workers attending did not have access to significant information on Anna’s mental and physical health, nor information from Strengthening Families or from the Police assessment made by the Harm Assessment Unit on 1st October. They adopted a “hard-line” as they understood from Anna that she had the capacity to make the property habitable with the support of a friend who they met at the property. Anna told the Social Workers attending that her relationship with Jack had ended and she was preoccupied by that. They found her to be motivated to clean up to provide a decent home for Ella Rose and confident she could do this. The Social work team that visited had the opportunity before their visit to access information held on their own system which identified Anna as a Care Leaver with other support needs and receiving support from the Leaving Care Team. They encouraged her to take a break and look after herself and as Ella Rose was in the care of her grandparents, she had time to make the property fit for Ella Rose to live in. 17 18. In the weeks running up to her mother’s death School records indicate that Ella Rose was ‘clean and happy’ in school, her reading books no longer smelled of animal urine, her homework was being checked and signed, all signs of a settled home. This picture of the child is at odds with the home conditions seen by agencies on the 1st of October 2019 and suggests she may have been with her father and his family. 6. Analysis of events In seeking to understand and evaluate the impact of the key events and decisions made there appear several key issues: 1.That the decisions to remove Ella Rose from CIN plan left services with limited oversight of mother and daughter and no Social Work support, apart from limited support from the Leaving Care Team. The school expressed concern that they were not resourced to provide the Early Help intervention that replaced the Child in Need support. The decision to withdraw was made on the evidence of progress made by Anna in her home and in cooperating and engaging with Community Mental Health Services. In addition, the presence of Jack as her new partner and ‘carer’ and his family were accepted as positive, increasing the sense that it was safe to withdraw services. Such a view ignored the evidence available; that Anna historically was non-compliant with Community Mental Health Services, that Jack and his family was an unknown factor recently introduced and crucially not checked out as to the net value they introduced into the family dynamic, and on Anna’s resilience and ability to sustain change and meet challenges constructively. In addition, it took no account of the chronic impact of Anna’s EUPD on her ability to manage stress, new relationships and destructive thoughts and feelings for which she was receiving intermittent treatment within the community due to her difficulties in engaging but also in part because of the inability of Community Mental health Services to adapt the services it provided to her. 2. We have learned that other family members had a history of overdoses and one of her brothers had killed himself in 2015. This information was not known to all agencies. It is recognised that both Anna and her family had a history of suicide and psychiatric illnesses. There is no evidence that Anna’s repeat attempts to take her own life was seen as a pattern suggesting future risk of suicide or self-harm by services working with her. 3. The introduction of Jack into the family appears of significance. He was seen by those working with Anna as a positive influence helping her in the home and collecting Ella Rose with Anna seen as the ‘dominant’ person in the relationship. A contrary view has been expressed by Anna’s ex-foster carer describing him as “a controlling individual who silenced Anna”. Jack, in terms of this review remains an unknown quantity. It was only four months from his arrival in October 2017 that Anna and her family moved from their secure tenancy in Warwickshire, and she left her college course, to be nearer Jack’s family. Anna moved home five times from February 2018 to her death. Although the local Borough Council appeared to work closely with the family, providing temporary accommodation and accepting their duty to house her, Anna never again achieved a secure tenancy. There was some 18 indication of tension that Jack’s presence had brought to the home with the Children’s Service’s Social Worker noting that Anna was “struggling” with the “clutter” he had brought to the home in a visit made on the 3rd of February 2018. The family GP had earlier referred the family to Children’s Services due the condition of the home. This was not seen as a possible relapse into earlier behaviours, and she was only given advice to contact Occupational Therapy. Potential warning signs were not picked up indicating the fragility of progress made by Anna, suggesting the impact of Jack may not have been altogether positive. This referral and follow up investigation did not appear to lead Children’s Services to reconsider its step-down decision. It is also noted by the Leaving Care Team that information sharing reduced when Anna left to be near Jack’s family, that communication outside of the CIN framework did not occur regularly. Again, making it difficult for agencies to maintain oversight of the case. 4. Good information exchange sharing between the services working with Anna was not always achieved. The CIN framework appeared positive in achieving this, and the MASH Team contacted other services appropriately but outside of that there were clear gaps. ASC are co-located within the MASH but was not involved in the Anna case discussions. The Community Mental Health Service did not regularly liaise with Children’s Services in relation to Anna, thus reducing effective working. The local Borough Council Housing Team state they were not invited to CIN meetings after 2016, despite the very real risks stemming from the family leaving their property in February 2018 and often being provided with unsuitable accommodation. Housing reported that Anna and the family were moved five times and sometimes into hotels and a caravan after they left their home. There were exceptions which are detailed below, but overall key decisions were made by agencies without consultation with others. The Leaving Care Team state they were not invited to a Strategy Meeting involving Anna on the 1st of October2019 despite having the most consistent and recent contact with her. 5. A more effective approach to Anna’s mental health care and her difficulties in engaging on a non-acute basis was never discussed with the other services. There seemed to be a culture within that service as described by the report of the Leaving Care Team for this enquiry; “the approach of the Community Mental Health Team service is that the person needs to want to engage for their work to be effective” which whilst accurate for all cases appears to be a barrier to working together on a planned approach to those with lesser motivation to engage. A view could be that it seems such an approach discriminates against patients such as Anna who have low motivation because of capacity or mistrust or other barriers to attendance but present a high risk of harm to self and others. The Panel were informed at the Learning Event that Anna was motivated to ensure Ella Rose had a better childhood than she had, a good place for all agencies to plan from. It assumed that Anna had capacity to make decisions, which was not questioned or tested despite the repeated attempts to take her life and the extremely poor standard of hygiene. This lack of cooperation, coordination and information exchange reduced the effectiveness of both oversight and ensuring the safety of Anna and her child. 19 6. Six state services worked with Anna at various times of the period in scope. There appeared to be few examples of coordination and collaboration, including information sharing. The only agency that offered consistent support to Anna was the Leaving Care Team who due to their resources (the Personal Adviser role is resourced to be of a practical and limited nature)were limited in what they could do but despite this, attempts were made to link Anna with Adult Education through English and Maths sessions, a referral was made to the Citizens Advice Bureau and invitations to several Leaving Care events one of which Anna attended. The Leaving Care Team were seen by the GP Surgery 1 as holding a case manager role. They amongst the agencies appeared the most successful in securing Anna’s cooperation. 7. Finally, the capacity of Anna to make decisions on her and her child’s behalf does not seem to have been questioned despite the poor hygiene and repeated attempts to take her life. Her decisions particularly around leaving a secure tenancy, leaving college, and making Jack, whom she had not known for very long, her carer was never it seems questioned, all significant decisions for a young adult to make but especially one with such a troubled and insecure background and no close family member to discuss this with. At no point was advice sought from ASC about whether she had care and support needs. 8.From the chronology we see a pattern of Anna struggling to cope, receiving support from agencies, making short term improvements in her standard of care of herself and Ella Rose then once support is withdrawn a return to not coping. This pattern has been recognised by the school and the Leaving Care Team. Given her level of vulnerability, pain management and mobility issues there appear no consideration of a longer-term plan to support her. ASC it seems were never consulted or involved in assessment of Anna and whether she required support to keep herself safe in the longer term. This may have been due to several factors; normalisation to her behaviour and/or the impact of vicarious trauma on professionals working with her and a lack of understanding of the role of ASC. This assumption of capacity meant that the possibility of her access to other sources of support and treatment was never explored. As a person receiving services regardless of the issue of capacity but in terms of the family’s future her options should have been discussed with her. There was nobody else in her life that could have taken the role of a ‘supportive’ parent figure. 9. This case highlights a number of training needs. At no point were the social work concepts of the ‘Rule of Optimism’ or ‘Disguised Compliance’ referred to or implicit within the evidence that has been available. The use of trauma informed approaches appeared likewise absent in all agencies contact with Anna. This despite it being known she had experienced significant Adverse Childhood Experiences and was replicating some of this in her care of Ella Rose, and her own self harm and suicide attempts. The lack of inquisitive enquiry as to the nature of Anna ‘s relationship with Jack and the reasons behind their move from their home, suggests a lack of understanding of the incidence and indicators of coercive and controlling behaviours. The lack of reference to her EUPD diagnosis and emotional management issues demonstrated in her pattern of suicide attempts suggests a need for training on this issue and a multi-disciplinary care pathway to manage the risks and aid recovery. 20 The inability of Ella Roses school to escalate their concerns about the decision made in Ella Rose’s Safeguarding Review to step down indicates a training need for the school. 7. Wider significance 1.The issues that are likely to be relevant in terms of management of future cases are firstly the lack of a holistic view of Anna’s life. She was demanding in terms of resources such as 999 calls, emergency hospital admissions and yet no service was able to establish effective control and management of her to ensure the cycle of decline in mood and coping, emergency admission, referral to community resources and failure to attend follow up was addressed. There are potentially other people receiving services in the area with similar characteristics that is low motivation due to mental health issues and beyond the control of the individual but high needs and high risk of harm to self and others within the area. There is an example out of scope of this review when in June 2017 Anna was discussed at the Leaving Care Panel who recognised that the group work intervention offered by Mental Health Services did not work for Anna. They had concerns that her lack of willingness to engage may be related to her EUPD, and which the CPN with her professional knowledge was able to confirm. This demonstrates the need for a multi-agency approach across the disciplines, involving health, adult and children’s social care, mental health, acute medical care, and the emergency services. There were at least five agencies with regular contact with Anna in the period in scope. Despite her behaviour having an impact on all of them there was little liaison and no coordination of approach to Anna. Such cases can only be managed when agencies working with the person pool information, sequence and coordinate responses and approaches. 2. This case illustrates that the method of assessing risk by Children’s Services needs to be improved. The significance of Anna’s previous behaviour and relapses do not seem to have been considered in the decisions to end the CIN status of her child. The impact of her EUPD and implications of this for the care of her child also does not seem to have been understood and decision making about the progress she was making was largely dependent on one source, Anna herself and not verified. This could be improved by the adoption of a more inquisitive and risk led approach. 3. Ella Rose attended a local primary school, representatives from the school attended the meeting at which the decision to reduce supervision from Child in Need status to ‘Early Help’ was made despite the concern expressed by the school about this. Possibly they had more contact with Ella Rose and her mother and family than any other agency. That they felt unable to escalate their concerns formally is a concern and a potential opportunity missed to achieve a better outcome. There will clearly be similar situations likely to occur in the future. This issue of reluctance to challenge the decision of Children’s Services at or after the meeting should be explored and addressed in the Designated Safeguarding Lead training. All agencies attending such key meetings need to be confident in challenging the way meetings are run, challenging the consensus, ensuring that their dissent is recorded in the minutes. managing conflict and how to escalate concerns in line with the agreed Policy. The Chairing of such meetings in an inclusive way is also necessary to 21 establish an agreed plan. This learning potentially by the role playing of practice based scenarios could be used to benefit all non-social work agencies involved in such meetings where a power differential between agencies is perceived. 4. The Panel’s view is that there was within those working with Anna a lack of recognition of the impact and characteristics on behaviour and emotions of EUPD. Anna was assumed to have capacity by all agencies in responding to her behaviour. This assumption may have been correct, but the issue was never questioned. A better understanding of the impact of EUPD and what works in terms of this group of people receiving services is something that should be considered. It is a relatively common condition but can be difficult to identify as it can mistakenly be seen as difficult and resistant behaviour inherent in the person, rather than a condition which is treatable with the right resources and approach. 5. It seems that much of the work with Anna herself in terms of supervision, oversight and practical help was done by the Leaving Care Team and the Personal Adviser of Anna. The Leaving Care Team continued their involvement after Anna’s 21st birthday, in line with her wishes and their concerns about her welfare and that of her child. Reliance on this level of support for care leavers is not sustainable as the Personal Adviser role is resourced to be of a practical and limited nature. A longer-term plan is required for those who at the end of their eligibility for this service still face difficulties as young adults. Services cannot depend in similar cases that adults will have such a resource behind them. Another way must be found to manage this high need/ high risk client group. 6. The University Hospital Coventry and Warwickshire team who dealt with Annas miscarriage on the 22nd and 29th July 2019 were on both occasions aware of her mental health history according to the chronology took no safeguarding action. At the time Anna was an open case at the CMHT. This is practice that needs to be improved. 8. Response to the questions posed 1. Information sharing. Although after her death the foster carers learnt of her death on ‘Face book’ and contacted Children’s Services. This news was deeply distressing for the foster carers who appreciate the speed with which social media disseminates news but would have benefited from an offer of support. The "Suicide, self-harm and accidental death amongst children in care/care leaver" guidance refers to contacting former foster carers and other service providers, and what appropriate services and support may be offered. This was at that time implemented by the Leaving Care Team in respect of the Children's Team and is being reviewed in light of the learning from this review to include the fostering service. The MASH referral and response did not deliver as the model of multi- agency hubs intended a multi -agency approach to the referral made by the Police following their visit to Anna. This appears a systemic fault specific to the MASH in question and is not a generic issue relating to the model. It lies with the Local Authority to address this in the current review which reports in January 2021. Following discussions of the 22 findings from the MASH review with its author there appears recognition of the issues raised by this report in its conclusions. This MASH must find a structure which enables it to collate and evaluate information, access records, secure advice, and opinion from all sources rapidly, and agree a coordinated approach. 2. A Think Family approach. There is no evidence of a Think Family approach in the case recording Annas needs as an adult were not referred to ASC or to the Reablement Service. The strategy meeting on the 1st of October 2019 at the MASH was not attended by ASC and the Leaving Care team the service with the close working relationship with Anna (though it did had access to their recording) it appears a strategic Think Family approach was not agreed which reflected Annas need for support. 3. Silo working and the role of the Leaving Care team Personal Adviser. Anna ‘s case demonstrates that Children and Adult services appear to operate in silo’s That the MASH referral although it generated a MARF did not lead to a referral to Adult Services in terms of Anna and her capacity and ability to protect herself and Ella Rose The MASH may be a vehicle for this. 4. CWPT decision making. Anna case demonstrates that decisions to close her case were made without recourse to other agencies views or intentions. Anna when not coping with the offer of DBT work was not offered a less demanding structured programme. To address the issues she faced from her EUPD. 5. Anna’s physical needs. It has not been possible to identify if Annas had a definitive diagnosis. At no point despite her declining mobility noticed by professionals was a referral made to the Reablement team. Though it appears some adaptions to her home was made at some point. 6. A trauma informed approach. There is evidence the foster carers and Personal Adviser worked instinctively in a trauma-informed way that is listening to young people carefully, helping them recognise how past experiences influence their ways of relating to the world today and offering a trustworthy relationship where they can try to build a safer life for themselves and avoid the replication of traumatic experiences. However, there was no evidence of an agreed multi-agency strategic approach to Anna who had experienced many ACEs herself. Much of the focus of the contact with Anna was on the outcomes of her care of Ella Rose rather than her own experiences and the impact on her as an individual and as a mother. 7.Understanding of DWP PIP. This review was asked to consider if assumptions were made by professionals that DWP PIP is only accessible to adults via a formal care assessment undertaken by 23 Adult Social Care, and why was there no follow-up on this to understand the process. The records reviewed have not highlighted an understanding of the DWP PIP process. 8.The impact of Jack’s leaving Anna’s suicide. The Social Worker attending on the 1st of October 2019 were clearly of the opinion that Anna believed Jack had ended the relationship and that she was preoccupied by this. As the review has had no contact with family members or Jack the review cannot comment on whether this ultimately contributed to her taking her life. 9.Role of the Corporate Parent. The role of the Corporate Parent was not referred to in the Individual Management reviews provided to the review. Corporate Parenting is the “collective responsibility of the council, elected members, employees, and partner agencies, for providing the best possible care and safeguarding for the children who are looked after by us”. This needs to be translated in to clear actions for Children in Care when they become young adults. As point 8 in the Analysis section of this report states ‘As a person receiving services regardless of the issue of capacity but in terms of the family’s future her options should have been discussed with her. There was nobody else in her life that could have taken the role of a ‘supportive’ parent figure.’ In this review we have seen Anna did not have an independent adult or advocate to discuss the significant life decisions she was making such as leaving a secure tenancy to be nearer to the family of a new partner. 9. Good Practice 1. The approach, application, and resilience of the Personal Adviser in the Leaving Care Team involved in this case is a shining example of good practice. Anna had the same worker through most of the period in scope ensuring consistency. Communication was maintained by home visit and telephone and there is evidence of regular information exchange with others. The Personal Adviser and her manager visited Anna in hospital after an attempt to take her life, a powerful message of concern and care expressed to Anna by that gesture. The Personal Adviser also communicated regularly with other agencies involved in her care. The Personal Adviser emailed Community Mental Health Services to express her concern after Anna’s discharge from hospital. She with the support of her manager also initiated a multi-agency forum on receiving a psychological diagnosis, possibly of Anna’s EUPD status in June 2017 to secure better inter-agency work and communication. The Leaving Care Team were the team that were constant in their supervision of Anna. The Panel’s view is that they exceeded their limited brief in doing this 2. Another example of good practice was that demonstrated by the Community Mental Health Team which between January and April 2019 after becoming involved following another attempt to end her life managed to maintain contact and continued to work with Anna for the longest period at any time within scope. They did this by making home visits, an adaption that was enough to secure compliance for a significant period and the CPN was a professional that Anna knew and trusted. 24 3. The local Borough Housing Team also demonstrated a positive approach to Anna. Accepting responsibility to find her temporary accommodation, and accepting their duty to house, despite Anna leaving a secure tenancy in Warwickshire voluntarily. They demonstrated by this a flexibility and sense of responsibility to help, much of which was at their discretion to do so. 4.The Children’s Services Team Manager enabled Anna to share her possible miscarriage with her and alongside the Duty team present offered her support. That Anna felt able to disclose something of significance and personal to the agency suggests that a degree of empathy and compassion was shown by those involved to have enabled this disclosure of vulnerability from Anna. 5. Although out of scope of this Learning Review, the support and care given to Anna by her foster carers and their wider family was impressive. They continued to include Anna and her family in all family gatherings after leaving the placement. Her foster carer was reportedly described by Anna as “the family she should have had all along”. 6. The Reflective Learning event identified that the Police Critical Incident debriefing process offered significant support to the professionals involved many of whom were deeply shocked by this tragedy. This policy and guidance were immediately shared with other agencies attending the event. 10. Conclusion 1. It is important when considering service improvement not to fall back onto recommendations based on training staff. This can often be a panacea that masks the real issue which can be a combination of culture, resources, the quality of supervision and even inertia, in that this is how things have always been done. 2. In this case it seems that the issue of professional optimism which may be organisational as well as worker located along with resource scarcity led to a failure by a number of agencies to recognise warning signs and to grasp ‘improvements’ which turned out to be temporary as signs of established recovery. We hope that this case will show that such an approach is not realistic and too costly in the longer term to be maintained. 3. Improvements will only be made in the management of cases such as this when there is a multi-disciplinary body that can collate information and interventions from all statutory and non-statutory services, including mental health services and direct a unified response based on known and evaluated principles. Along with a willingness to share information with other agencies consistent with GDPR. This was not reflected in the practice of the MASH at that time. 4. Anna is a tragic case that is emblematic of how our services respond on an incident basis and how workers within those services can become isolated and desensitised to the risky behaviours and levels of abuse, neglect, and chaos that we know we would not accept for ourselves or our children. In making this statement it is of concern that the CMHT were not represented on the Panel. Their involvement in working with this group of people receiving services alongside the other agencies will be critical if it is to be successful. 25 5. The Panel were informed in the significant investment into Early Help to ensure schools are resourced to fulfil their responsibilities and be part of a wider system to support families in a holistic way. The Adverse Childhood Experiences (ACE) training planned for 2020 delayed by the pandemic will support trauma informed practice and enhance the restorative offer to children and families In Warwickshire. This planned training is and to be delivered by Dr Karen Treisman to the Senior Leadership Team, Operations Managers, Team Leaders and nominated staff to embed cultural change. Anna, we know was replicating the care she received as a child and by understanding her ACEs the offer to her could have been different. 6. Specifically, the following areas need to be addressed: • That events that become historic such as suicide attempts, overdoses, trauma are recognised as current risk factors in all assessments involving adults and children irrespective of the type of assessment and are evaluated for their impact and likelihood to affect present day functioning. • That knowledge and awareness of Personality Disorder, a significant unaddressed feature in this case be spread and shared through critical person facing bodies- Children and Adult Services, Education, Pre, and Post Natal care • That change in families, situations, or people within them are seen as a potential risk factor as well as potential protective factors for example a new adult entering the family, planned relocation to another area, etc and are accurately assessed by means which does not rely on one source of information. 11.Recommendations 1. Warwickshire Safeguarding to seek assurance that the Community Mental Health Services deliver its approach to treatment for people with a Personality Disorder (PD) in line with NICE Guidance to promote improved access to treatment for this group. 2. That Children’s Services consider how they have the skills, knowledge, and case support to understand and work with people who use services with PD. In addition, a review of online training that all front-facing staff (including Reception, Ambulance Trust etc) are required to access to improve knowledge, understanding and where appropriate skill in working with people with mental health issues including PD. 3. In order to effectively assess and manage risk, those who have direct contact with the person receiving support need to have access to all relevant and current information about the person to properly support them. 4. That a multi-agency task and finish group be established to address the gap in information sharing that this case has highlighted to better embed the Think Family approach. Those relevant agencies, including the Police consider the 26 impact of their actions related to the protection of children have on vulnerable adult family members. 5. That those working with children are aware of the role that Social Care and Support can play in supporting adults with care and support needs and how referrals are made and that identifying and addressing care and support needs of adults is part of the ‘Think Family’ Approach. 6. The forthcoming review of the Children and Families Front Door ensure that the failings in information sharing identified by this review are addressed. In particular the need for a single point of contact to enable the pooling of all known information from all relevant agencies leading to a coordinated response is made on behalf of all agencies. 7. Warwickshire Safeguarding to seek assurance that the Escalation Protocol is fully embedded and being used effectively across all agencies. In addition, the Resolving Professional Differences/Escalation Policy be reissued to all staff attending decision making meetings. That Chairs of these meetings remind those attending of their duty to speak up should they disagree with the decisions taken and any dissent is recorded in the minutes. 8. Given the features of this case and the light it has shone on practice the Panel would suggest the following: i. That Warwickshire Safeguarding Partnership consider the review of existing supervision methods and frequency by sampling and evaluating a proportion of supervision sessions across the agencies that have had involvement in this case from a safeguarding perspective. This review to have a focus in particular on the use of Reflective Practice and the use of evidence-based processes. ii. That Warwickshire Safeguarding Partnership conduct a multi-disciplinary representative sample of cases to quality assure their case management processes and procedures for suitability in working with this group of people receiving services. Risks are diverse and include physical, sexual, and emotional risk to others and self and can literally escalate overnight. The brief would be to establish whether existing systems are resilient enough to cope with this group of people receiving services, and to identify strengths and weaknesses, and consider given the learning from this case what changes could be made, what help would be needed to achieve this change. 27 9. Warwickshire Safeguarding Partnership to develop a ‘Lessons Learned’ Briefing summarising this case and the learning arising from it (including Pupil Premium) and produce accompanying 7 Minute Briefings on the issues of Disguised Compliance, the Rule of Optimism (particularly around ‘new partners’ joining vulnerable families) and Poor care/ abuse of pets and safeguarding children, for dissemination to all staff within Warwickshire agencies. The 7-minute briefing on Suicide Prevention is to incorporate learning from this review. 10. Warwickshire Safeguarding gain assurance that the newly adopted Head Teacher coach is embedded in the MASH and the refreshed DSL Training includes information on the Escalation Process. 11. The added resources of an Early Help Headteacher Coach and Early Help Social workers and managers introduced in September and October 2020 should now ensure step up/down processes are effective. This case should be used to stress test and provide assurance to the Warwickshire Safeguarding Partnership that these new resources and arrangements are effective in cases that relate in particular to families in which mental health concerns have been identified. |
NC52246 | Sexual and physical abuse of a small sibling group over a two-and-a-half-year period. In 2020 the siblings were staying with their extended family and disclosed that their father had sexually and physically abused them, as well as subjected them to harsh and critical treatment. Father was found guilty of several offences for which he received a custodial sentence. Siblings' mother had died some years earlier and Father had taken responsibility for home educating the siblings as a single parent. Siblings were not registered with the local authority Elective Home Education Service. Siblings were seen by the GP for minor ailments and were not known to any other agencies. Housing department had concerns about Father's responses to requests for information and an investigation was started by the corporate anti-fraud team. Siblings are from a minority ethnic group. Learning relates to: the home education of children and young people; identification of home educated children; ensuring a stable education; safeguarding home educated children; social, pastoral and leisure needs as the foundation of child development; and bereavement support. Recommendations include: raise awareness of the importance of the identification of elected home educated children and the need for them to be registered across all agencies; make a recommendation to the National Panel to complete a thematic review of serious case reviews, rapid reviews and child safeguarding practice reviews (CSPRs) that relate to home educated children; consider the existing pathways to bereavement support for the children of terminally ill parents.
| Serious Case Review No: 2021/C8984 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. 1 Child Safeguarding Practice Review Siblings from Family H Jane Wiffin 2 This review is dedicated to the bravery and courage of the group of siblings who experienced significant physical abuse, sexual abuse, neglect and cruelty at the hands of their father, but found a way to tell adults what was happening to them. This is not an easy thing for those who are being abused and harmed at home. It is also dedicated to the extended family members/friends who were there for the siblings and enabled action to be taken. 3 Contents Pages 1. Introduction 4-5 Why this Child Practice Safeguarding Review (CSPR)1 is being undertaken Process of the review Family involvement 2. Narrative chronology of professional involvement and family background 6-9 3. Analysis 10-15 The home education of children and young people Identification of home educated children Safeguarding home educated children Ensuring a suitable education Social, pastoral and leisure needs as the foundation of child development Bereavement support for the siblings 4. Conclusions 16 5. Recommendations 17 1 In England, child safeguarding practice reviews (previously known as serious case reviews) should be considered for serious child safeguarding cases where abuse or neglect of a child is known or suspected https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Working_together_to_safeguard_children_inter_agency_guidance.pdf (pg 84). 4 1. Introduction Why this Child Practice Safeguarding Review (CSPR)2 is being undertaken 1.1 This independently led Child Practice Safeguarding Review is about a small sibling group of school age children who are from a racially minoritized ethnic community. For reason of confidentiality no further identifying details will be provided within the review. In 2020 the siblings were staying with their extended family and took the brave and courageous step to tell a trusted extended family member that their father had, for the last two and a half years, been sexually and physically abusing them, as well as subjecting them to harsh and critical treatment,. Immediate and appropriate safeguarding action was taken, and the siblings were placed with their extended family. Their mother had died some years earlier. A criminal investigation was started, and their father was found guilty of several offences for which he received a custodial sentence. The siblings are being well looked after within their family and are settled. 1.2 The local Safeguarding Children Partnership3 (SCP) undertook a Rapid Review4 of the contact agencies had with the siblings and agreed that their circumstances met the criteria for a local child safeguarding practice review (CSPR) as set out in Working Together 20185. It was noted that this was one of two sibling groups who were home educated and where there were concerns about abuse and neglect. The Safeguarding Children’s Partnership Learning Group agreed that the two CSPRs raised questions and concerns about the potential invisibility of home educated children, possibly leaving them without support or adults to talks to outside the home when they have worries or concerns and are experiencing abuse. Process of the review 1.3 The methodology adopted for this CSPR was a hybrid system approach with a focus on evaluating the practice response to the children, identifying improvements needed locally and nationally to safeguard and promote the welfare of children, and to consider whether there is a need for policy or practice changes in any identified area. This approach is consistent with the purpose of CSPRs as outlined in Working Together 2018. 1.4 All key agencies were asked to provide a chronology of their involvement with the siblings and their family over a two-year period from 2018 to 2020 and to 2 In England, child safeguarding practice reviews (previously known as serious case reviews) should be considered for serious child safeguarding cases where abuse or neglect of a child is known or suspected https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Working_together_to_safeguard_children_inter_agency_guidance.pdf (pg 84). 3 The Children and Social Work Act 2017 introduced the requirement that local safeguarding children boards be replaced with new local safeguarding partnerships led by three safeguarding partners – the Local Authority, Clinical Commissioning Group and Police; this is called the Safeguarding Children Partnership. 4 The safeguarding partners should promptly undertake a rapid review of the case https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Working_together_to_safeguard_children_inter_agency_guidance.pdf (Chapter 4, pg 88). 5 Working Together 2018 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/779401/Working_Together_to_Safeguard-Children.pdf (Chapter 4, pg81). 5 also consider any relevant historical information. This information was quite limited because the siblings had been home educated and had little involvement with services. Interviews were conducted with the few professionals who had contact with the siblings and they provided useful insights and reflections on the local practice landscape. I would like to thank for them for their time and thoughtful responses on what was a difficult set of circumstances. It has been hard for those who had regular contact with the siblings in their clubs not to worry that they somehow missed something or should have known what was happening. There is no evidence to suggest that this was possible given the presentation of the siblings and father. It is important to say that the person responsible for the harm to the siblings is their father. 1.5 The CSPR was overseen by a panel of local agency representatives (CSPR panel) who met regularly and who contributed to the analysis of the available information, helped consider practice themes, and provided appropriate, robust and sensitive challenge. The CSPR was chaired efficiently and compassionately by the Independent Chair of the SCP Learning and Thematic Review Group, managed very efficiently by the SCP Partnership Manager, and administered effectively. I would like to thank everyone for their hard work and commitment at what has been a challenging time, with all the restrictions and increased demands caused by the Covid-19 pandemic. The independent reviewer is Jane Wiffin; she is responsible for the writing of this overview report. Family involvement 1.6 The CSPR panel discussed the best way to include the siblings in this review. It has been a difficult and stressful time for them, with new educational arrangements and the trial of their father. This was also discussed with their current social worker. The siblings say they now want to get on with their lives and to focus on their future. This is of course their right and as such they do not want to talk further about what happened in the past. They are aware of the review taking place. During the trial of father, the siblings gave victim impact statements. These statements provided information about the siblings’ sense of distress during the time they were in the care of father, and how he prevented them from seeking help from others by limiting their contact with friends and family. They talked of being controlled constantly and harmed significantly by him. They also spoke of not being able to grieve for their mother and their lack of education. 1.7 The extended family members have contributed to the CSPR process. The background information they provided has been incorporated into the body of the report. No reflections on services were possible because they had no previous involvement with them. Father has not been asked for his views because these were also provided at the trial; he has not given any further insight to what happened. 6 2. Narrative chronology of professional involvement and family background 2.1 The siblings lived with their mother for most of their lives who chose to home educate them (elective home education or EHE)6 and the available evidence suggests that she provided good quality opportunities for learning and an appropriate education. The children were not registered with the local authority Elective Home Education Service (EHES) and there is no legal requirement7 to do so. If they had been registered they would have had an annual visit from the local authority home education teacher in line with existing local and national guidance. Mother enabled the children to engage with extracurricular clubs to provide opportunities for them to socialise with other children. The people running these clubs have confirmed the siblings attended regularly, presented as engaged with activities and were part of wider social family activities. The siblings received all their health immunisations and were seen by the GP for minor ailments. They were not known to any other agencies. The siblings’ father did not live with them but did have contact and would visit mother and the siblings on a regular basis. Father returned to live with mother and the siblings when an extended family member was found to be terminally ill and mother provided care. 2.2 Sadly, soon after this Mother was also found to have a terminal illness; father attended medical appointments with her. Mother told her extended family that she wished for father to take over the care of the children and expressed no concerns about his capacity to do so. She also started correspondence with the local authority housing team about father succeeding the tenancy of the family home. Mother received appropriate end of life care until she sadly died, but there was no process in place for planning regarding the possible bereavement needs of the siblings and this gap in services is addressed in the analysis section of the report. After mother died, the GP checked on how the family were with father and offered to make a referral to counselling. Father reported that he and the siblings were coping with support from the extended family and did not need any further help. There was nothing to indicate that this was not the case. The GP was unaware that the siblings were being home educated and were therefore not routinely in contact with any other services. 6 Elective home education (EHE) is a term used to describe a choice by parents to provide education for their children at home (or in some other way which they choose) instead of sending them to school full-time. 7 There is no legal duty on parents to inform the local authority that a child is being home educated. Elective home education: departmental guidance for local authorities (2019) https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/791527/Elective_home_education_gudiance_for_LAv2.0.pdf (pg 12). 7 2.3 After mother died, father was the full-time parent to the siblings, and he said that he had continued to home educate them. He took them to their club activities and had weekly contact with the extended family. The extended family and the people running the clubs had no concerns about the care he was providing, beyond some thoughts that he might benefit from additional support. Father was resistant to any support, saying he did not need it and those offering it (extended family and friends) thought he was being proud, rather than having anything to hide. They had no indication of the harm the siblings were experiencing. Father had previously had a job teaching overseas, but applied and got a teaching role locally. 2.4 Father continued with the process of becoming the tenant of the family home with the local authority housing department. There was a period when he was asked for various documents; father’s lack of responsiveness and evasions caused delays. Father was told he did not meet the criteria for succession to the property because he had not lived there for 12 months and he was told he would need to make an application to be re-housed. He sought legal advice and this dispute about succession continued until recently; it has now been appropriately resolved. 2.5 The housing department had concerns about father’s responses to requests for information and an investigation was started by the corporate anti-fraud team8. This took place over a four-week period, and although the concerns of fraud were unsubstantiated, the officer dealing with them became aware that the siblings were not in school and were not known to the Elective Home Education Service (EHES). She was concerned that when she attempted to visit father and the siblings at home, father would not allow her in, and despite it being during the day he said the siblings were asleep. It is effective practice that she contacted an extended family member to check on the siblings’ welfare and liaised with EHES and children missing from school service9 to express concerns. A discussion was held about whether contact should be made with the Multi-Agency Safeguarding Hub (MASH)10 to seek further information rather than to make a formal referral of concern. The EHE teacher11 had already been in contact with father and agreed a home visit in eight weeks’ time; it was concluded that a decision about next steps would be made after this visit. 8 Local authorities have a responsibility to protect public funds and assets to which it has been entrusted. The work of the Corporate Anti-Fraud Team (CAFT) supports this by providing a specialist independent function which provides support, advice and assistance on all matters of fraud risks. 9 Local authorities in England have a legal duty under section 436A of the Education Act 1996 to make arrangements to identify children missing education (CME) and each area has a service responsible for this as outlined in national guidance. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/550416/Children_Missing_Education_-_statutory_guidance.pdf 10 The Multi Agency Safeguarding Hub (MASH) Team is the first point of entry for referrals about children and young people made by professionals, families and the public. The team is made up of different professionals who can consider the most appropriate next steps when there are concerns about a child. 11 The local authority should provide parents who home educate with a named contact who is familiar with home education policy and practice and has an understanding of a range of educational philosophies; in this case the EHE teacher. Elective home education: departmental guidance for local authorities (2019) https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/791527/Elective_home_education_gudiance_for_LAv2.0.pdf 8 2.6 Father then contacted the EHE teacher and asked that they meet in a coffee shop rather than at home. This is not an unusual request, and as such the EHE teacher agreed. The home visit was part of the plan to determine the siblings’ welfare and whether contact with other agencies was necessary. In this context the home visit should have been pursued. The most recent EHE guidance12 (2019) provides no duty to undertake a home visit or to meet children unless there are concerns about safeguarding or the quality of education provision. The EHE teacher felt that this threshold had not been met and quoted this as her reason for agreeing to father’s request. Ultimately, father also cancelled this meeting and provided written information about his approach to home education and the curriculum he was following instead. The EHE teacher followed up with requests for more information about the education programme; father was initially reluctant to provide this, suggesting that he had fully complied with EHE guidance. He eventually provided more information, and the EHE teacher concluded that he had provided evidence of a suitable education13. The EHE teacher said the progress of the plan would be reviewed in a year’s time, but this was subsequently rescheduled to 15 months and never took place because this was after the siblings’ disclosure of abuse. This meant an assessment of both the quality of education provision and wellbeing of the siblings was delayed by 15 months, despite some concerns. 2.7 The siblings told family members that they were being physically abused, neglected, treated cruelly and subject to sexual abuse. This was reported to the appropriate agencies; they were immediately safeguarded and placed with extended family where they remain. 2.8 There were concerns regarding father’s contact with other children through his work and the clubs attended by the siblings. A referral was made to the LADO14 in the area where these activities took place; an immediate strategy meeting was convened, and action taken regarding suspension of employment; father was in detention. During the process of this review, it has become clear that it was also necessary to consider the needs of children who might have been impacted by contact with father, but who had not come forward. This was a sensitive issue for which careful thought was needed. It was found that the clubs involved had in place general safety strategies for encouraging all children and young people to talk about concerns they had about inappropriate sexual behaviour and abuse without needing to share any information about the siblings’ circumstances. 12 Elective home education: departmental guidance for local authorities (2019) https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/791527/Elective_home_education_gudiance_for_LAv2.0.pdf 13 This is defined in Elective home education: departmental guidance for local authorities (2019) https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/791527/Elective_home_education_gudiance_for_LAv2.0.pdf 14 The Local Authority Designated Officer (LADO) works within Children's Services and gives advice and guidance to employers, organisations and other individuals who have concerns about the behaviour of an adult who works with children and young people and agrees action to keep children safe. Working Together 2018 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Working_together_to_safeguard_children_inter_agency_guidance.pdf 9 2.9 Appropriate criminal action was also undertaken and father received a custodial sentence. The siblings gave a clear picture of the significant harm, abuse and cruelty they had experienced at the hands of father over a two-year period. 10 3. Analysis The home education of children and young people 3.1 At the heart of this CSPR are the needs and circumstances of children and young people (from this point I will use the term children, meaning all those age 18 and below) who are home educated. This is one of two reviews where children are home educated and have made disclosures of sexual abuse being undertaken by the same local safeguarding partnership. 3.2 In England parents have the right to educate their children at home. Section 7 of the Education Act 199615 makes clear the importance of children of compulsory school age receiving “efficient full-time education that is suitable to their age, ability and aptitude, and addresses any special educational needs they may have, either by regular attendance at school or otherwise”. The responsibility for children’s education rests with their parents; education is compulsory, schooling is not. When children are in school the quality of the education they receive is scrutinised and evaluated by external agencies. When children are educated at home this does not necessarily happen. This was a significant issue for the siblings. 3.3 The Children’s Commissioner’s review16 into the circumstances of home educated children commented that the phrase “home education” encompasses a wide range of reasons why parents home educate, including social and philosophical reasons, those who are unhappy with a secular education system, those who would like children to be in school but feel the schools which are available do not meet their child’s needs (particularly in the case of children with special educational and disability needs), and there are a small number of parents who choose to keep children out of the school system to avoid contact with public authorities for a number of reasons, including abuse and neglect. 3.4 The existing national home education guidance advocates a proportionate approach to monitoring the education provided to children in recognition of this wide continuum of reasons for choosing to home educate. The expectation is that individual home education arrangements are reviewed annually “local authorities should ordinarily make contact with home educated parents on at least an annual basis so the authority may reasonably inform itself of the current suitability of the education provided. In cases where there were no previous concerns about the education provided and no reason to think that has changed because the parents are continuing to do a good job, such contact would often be very brief”17. 15 https://www.legislation.gov.uk/ukpga/1996/56/contents 16 The Office of the Children’s commissioner (2019) Skipping School: Invisible Children: https://www.childrenscommissioner.gov.uk/wp-content/uploads/2019/02/cco-skipping-school-invisible-children-feb-2019.pdf 17 Elective home education Departmental guidance for local authorities (2019) https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/791527/Elective_home_education_gudiance_for_LAv2.0.pdf 11 Identification of home educated children 3.5 There are growing numbers of parents who decide to home educate their children; the numbers have risen by about 20% in each of the last five years and has doubled nationally since 2013/201418. This rise in numbers has also been recognised by the local safeguarding children partnership, with Covid-19 having a significant impact on numbers19. However, these national and local figures are likely to be an underestimation because parents do not have to inform the local authority that they plan to home educate; children are only known about if the parent registers them with the home education service or the children have previously attended school. 3.6 Mother had not registered the siblings as being home educated and it is unclear whether this was an active choice, or if she was unaware of the existence of the register. The children had no contact with public services except the health visitor in the siblings’ younger years, who was happy with their progress, and the GP surgery where they were seen sporadically with routine childhood illnesses. They were well known to the voluntary sector through their use of clubs. The national elective home education guidance (2019) acknowledges that the identification of children as home educated is a significant challenge for local authorities and highlights the importance of “using agreements with health bodies, general practitioners and other agencies to increase their knowledge of children who are not attending school”20. This is addressed in recommendation 1. Ensuring a suitable education 3.7 It is the responsibility of the local authority to ensure that home educated children are provided with a suitable education21. The national guidance suggests that the starting point for establishing this is to ask parents for detailed information about the education they are providing. Parents are under no duty to respond, but if information is not given it is justifiable for the local authority to conclude that the child is not receiving a suitable education and to take steps to address this22. This will be initially through informal inquiries and can include asking to see the child who is being home educated at home or in another suitable location. The parent is under no legal obligation to agree to this. Children are entitled to express their views about home education, but unless there are concerns about the quality of education provided or safeguarding matters, the parents’ decision on home education takes precedence. It is important that in any local approach to elective home education there is also a 18 https://www.childrenscommissioner.gov.uk/wp-content/uploads/2019/02/cco-skipping-school-invisible-children-feb-2019.pdf (pg 5). 19 https://www.bbc.co.uk/news/education-55004924 20 Section 4.4 Elective home education: departmental guidance for local authorities (2019) https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/791527/Elective_home_education_gudiance_for_LAv2.0.pdf 21 There is no specific definition of what this term means, but the concept is discussed in the national guidance (2019) https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/791527/Elective_home_education_gudiance_for_LAv2.0.pdf 22 This has been established through case law Phillips v Brown [1980] Lexis Citation 1003 12 focus on child-centred practice in line with co-existing legislation such as the Children Act 198923 and the UN Convention on the Rights of the Child (UNCRC)24. This is not incompatible with the existing guidance and should be part of the approach to monitoring home education arrangements and the responsibility of the home education team in partnership with the wider local authority and other agencies. 3.8 As a result of the tenacity of the corporate anti-fraud officer, the local authority became aware that the siblings were being home educated and that they had never attended school. The home education teacher made appropriate contact with father and a home visit was agreed. This was subsequently changed to a meeting in another location, and then father said that he did not want to meet the home education teacher face to face and he said he would provide written evidence of his approach to education. There were several telephone conversations requesting this information, which was eventually provided. The home education teacher sought clarifying information and concluded from the written evidence that a suitable education was being provided. 3.9 A parent who home educates does not have to agree to a home visit, meet face to face with the home education team or allow their children to be seen unless there are concerns about the suitability of the education being provided and/or there are safeguarding concerns. Father’s response was not inconsistent with the response of many parents who home educate and the proportionate approach as laid out in the national guidance. 3.10 It is the view of this review that the home education service gave up too easily on the home visit. This was not just a monitoring visit, but an agreed plan to establish the circumstances of the siblings. There was a lack of recognition that this need was not fulfilled and therefore what should and could be done about it. 3.11 The home education service is well regarded and received positive endorsement of its approach in the two most recent inspection. It was, in this case, influenced by a pervasive belief that unless there were obvious safeguarding concerns, there was nothing that could be done because of what was perceived to be the limited powers within the guidance. This was opposed to thinking about what was possible and how to make it possible. Information sharing and professional discussion could have helped to make sense of the siblings’ circumstances and to establish if any further action was necessary. Since this time, the role of this service has been further strengthened. 3.12 In this local authority there are regular meetings to discuss concerns about children missing from education and home educated children. These children’s circumstances should have been discussed in this context. Not least because national guidance suggests that it is important to consider any change in children’s circumstances. For the siblings they had been home educated for 23 https://www.legislation.gov.uk/ukpga/1989/41/contents 24 https://www.unicef.org.uk/what-we-do/un-convention-child-rights/ 13 many years, their mother had died and their father had not been resident in the home. He had taken over their care and their home education. 3.13 There is emerging evidence that the siblings were not provided with any education by their father, despite him providing paper evidence that he was doing so. There is no doubt that the lack of effective home education by father over the last two years has had an impact on the siblings’ educational attainment. The schools they attend are working hard to help them catch up on what looks like at least a year’s delay. The siblings report being happy to be home educated by their mother, but the lack of any monitoring visits makes it hard to objectively evaluate this. 3.14 The DfE does not collect data on the educational attainment of known home educated children in England. This means no assessment can be made of the impact on educational attainment of being home schooled. In December 2009, the Parliamentary Children, Schools and Families Committee25 published an inquiry into elective home education. The inquiry found that out of the 74 responding LAs, 22% of known to be home educated 16-18-year-olds were not in education, employment or training. For comparison, the national average at this time was 5%. Carefully considering whether children are being provided with a suitable education is critical. Safeguarding home educated children 3.15 Sections 10 and 11 of the Children Act 200426 give local authorities duties for safeguarding and promoting the wellbeing and welfare of children in their areas. This includes children educated at home. Section 175 of the Education Act 200227 requires authorities to plan for ensuring that their education functions are exercised with a view to safeguarding and promoting children’s welfare. Therefore, the general duties of local authorities in relation to safeguarding are the same for all children, however they are educated. In some circumstances elective home education may make it more possible for parents to prevent the independent oversight by professionals of children who are being harmed and neglected. 3.16 There have been several serious case reviews nationally28, 29, 30 & 31 that have highlighted home education as a factor in the abuse and neglect of children, although not necessarily a causal one. The main consistent finding of these many reviews is the invisibility of home educated children and their lack of contact with agencies who could monitor their safety and wellbeing. Most of these reviews suggest that parents actively prevented this contact. This is an important issue. There is considerable research which suggests that children find it difficult to tell anyone when they have been abused, particularly when 25 https://publications.parliament.ukpa/cm200910/cmselect/cmchilsch/39/39i.pdf 26 https://www.legislation.gov.uk/ukpga/2004/31/contents 27 https://www.legislation.gov.uk/ukpga/2002/32/contents 28 https://bbcdevwebfiles.blob.core.windows.net/webfiles/Files/case-reviews-home-education.pdf 29 http://www.northamptonshirescb.org.uk/scr/childab 30 https://www.cumbria.gov.uk/eLibrary/Content/Internet/537/6683/6687/17123/426059438.pdf 31 https://www.oscb.org.uk/practitioners-volunteers/serious-case-reviews/ 14 they have been sexually abused. When they do tell, they usually choose a friend, a friend’s parent or family, someone trusted in their own family, a teacher or extra-curricular activity provider. For home educated children, there may be fewer opportunities for these contacts and therefore fewer opportunities to seek help about abuse. It is important that within the existing monitoring processes, there should be discussion about children’s friendship and leisure opportunities, and action agreed where these are lacking. 3.17 The siblings were not invisible; they were provided with leisure and friendship opportunities, established and maintained by their mother. This must have been no easy task on her own. She also took an active role in the clubs, recognising their important role. Father continued this commitment, and the evidence is that he actively facilitated and ensured the siblings’ attendance and contact with friends. The clubs had in place effective safeguarding policies, those running the clubs had safeguarding training, and there were regular sessions for all children on safeguarding matters and keeping safe. These clubs have reflected on whether there was any indication of harm when father took over the siblings’ care, and they had no concerns. The siblings have reported during the trial process that father had threatened them about telling anyone about his harsh, cruel and abusive behaviour. 3.18 The siblings also had regular contact with their extended family, though this was reduced over time by father. These adults had no idea that the siblings were being physical/sexually abused and neglected by their father and there were no indications of this. The siblings did eventually feel able to tell the extended family of their abuse. 3.19 The corporate anti-fraud officer was appropriately concerned about the circumstances of the siblings, and father’s attitude when discussing them. She went to considerable lengths to ascertain their circumstances and to ensure that they were known to the appropriate agencies, including the home education service and children missing from education service. She also contacted the wider family and established what was known about the family situation. Although no specific concerns were raised, the extended family shared that father might need more support. The corporate anti-fraud officer initiated a discussion between the home education teacher and the children missing from education officer. Contact with the children’s MASH team was discussed (MASH held no information about the family) but considering the forthcoming planned home visit by the home education teacher, it was agreed that this visit would be an opportunity to explore the siblings’ circumstances and consider next steps. Given the limited available information this was an appropriate response. 3.20 The home visit did not go ahead. As with the section on establishing the suitability of the education provided, the home education teacher believed that there were no grounds to seek a home visit or see the children. Given the home visit was part of a plan to establish these siblings’ circumstances where there 15 had been possible concerns and that the siblings’ circumstances had recently changed, a home visit should have been more robustly pursued. Social, pastoral and leisure needs as the foundation of child development 3.21 It is important to note that many children who are home educated are being provided with social opportunities and care of their emotional needs, with positive outcomes. However, the Children’s Commissioner found that many of the home educated children she spoke to felt lonely, isolated and depressed. The existing national guidance does not explicitly spell out the importance for children of pastoral care, social and leisure opportunities for their wellbeing and the part that attendance at school plays within this. This raises questions about the potential invisibility of these children and whether their rights under the UN Convention of the Rights of the Child are being met, including the right to relax and play (Article 31), the right to freedom of expression (Article 13), the right to be heard (Article 12), the right to be safe from violence (Article 19), and the right to education (Article 28). 3.22 The siblings were afforded opportunities for leisure and friendship and the evidence available suggests they made good use of these, were happy and fulfilled by the clubs they attended, though more latterly did not feel able to speak about the abuse and neglect they were experiencing. They have subsequently spoken about being kept from the outside world by father, feeling trapped and controlled. It is important that the monitoring of home education includes a focus on how their pastoral needs and wellbeing needs might be met as well as their social and leisure needs. Bereavement support for the siblings 3.23 A final key issue is that one consequence of the siblings being home educated was that there was no process for overseeing their needs for bereavement support in the immediate aftermath of mother’s death and over time. The GP offered father counselling for the siblings, but he said they did not need this support. The siblings had no contact with any other professional to discuss this. The siblings have since highlighted their need for support after the death of their mother. Their circumstances highlight the importance of pastoral care needs in the home education monitoring process and establishing whether in a hospital setting there is a need for a pathway more generally for planning bereavement care for the children of bereaved parents. This pathway does not currently exist. 16 4. Conclusion 4.1 This CSPR has focused on the significant abuse, neglect and cruelty of these siblings by their father. He has appropriately received a custodial sentence and the police and justice services are to be congratulated on their hard work in achieving this. The bravery of the siblings was central to this and they are to be applauded for this. 4.2 The siblings were not known to many professionals because they were electively home educated. This was a successful arrangement for them when their mother was alive. This CSPR raises the importance of oversight of home educated children who may be at increased risk because they are not necessarily routinely seen by professionals. The national guidance proposes a proportionate approach to monitoring home education, considering the parents who make appropriate, child-centred decisions for their children and for whom good quality education is provided. The home education service interpreted this proportionate approach as limiting the ability of professionals to act. It is important that going forward the message is provided that the home education guidance needs to be viewed as co-existing with safeguarding guidance and legislation. This also requires existing systems to support staff to do this and existing systems to have the capacity to do so. There is now a system in place where home education teachers are able to access regular safeguarding supervision. This was not in place at the time and left the home education teacher role as one which was isolated. 4.3 The siblings were known to the voluntary sector who were not aware of the harm they were experiencing. It is effective practice that the corporate anti-fraud officer noticed these children and made sure they were known to appropriate agencies. 4.4 When the siblings told their extended family about the abuse, swift action was taken to safeguard them. This was effective practice. There was also appropriate action taken by the Local Authority Designated Officer (LADO) to consider whether father might pose a risk to other children 17 5. Recommendations 1. The local safeguarding children partnership should raise awareness of the importance of the identification of elected home educated children and the need for them to be registered across all agencies including education providers, the broader health economy, and private and voluntary sectors. 2. The local home education policy should be refreshed to explicitly focus on child-centred practices and taking account of the findings of the two recent local CSPRs, the 2019 national guidance, the interplay between elective home education and children missing from education. The refresh of this local guidance should consider the role of MASH for home educated children and a recognition of the possible impairment of needs or significant harm risks that arise from a lack of an appropriate education, social isolation, lack of pastoral care and little oversight by professionals. 3. The local safeguarding children partnership should make a recommendation to the National Panel to complete a thematic review of serious case reviews, rapid reviews and CSPRs that relate to home educated children. The local safeguarding children partnership should also recommend to the National Panel that a statutory register is created for electively home educated children. 4. Local partners should consider the existing pathways to bereavement support for the children of terminally ill parents, highlight any gaps and seek ways for them to be addressed. |
NC52696 | Multiple injuries including significant subcutaneous swelling to the head of a 23-month-old boy in March 2022. George was brought to nursery by his mother and shortly after his arrival staff noticed several bruises and abrasions to his face. George's mother was arrested on suspicion of assault. Learning themes include: supporting the transition to adulthood, especially for those approaching parenthood; considering the meaning behind missed appointments, late cancellations and rearranged appointments; the impact on young carers when their siblings are placed in care; ensuring the child's voice and lived experience leads decision making; critical thinking, professional curiosity and over optimism; threshold application at point of closure of cases; unseen men and their relationships with vulnerable women / those with experience of abuse; development of practice approaches for those working with individuals who have experienced trauma. Recommendations for the partnership include: consider whether transitional planning is aligned with the Care Act 2014 and whether the correct trigger points are in place to start that planning (in order to help support adolescents who have multiple areas of vulnerability as they transition into receiving an adult service offer); review the data infrastructure cross-agency to identify whether improvements can be made within current systems, for example, automatic chronological entry to be implemented, a possible positive outcome being the ability for practitioners to see real-time updates across agencies outside of set review timings.
| Title: Local child safeguarding practice review: “George”. LSCB: Wigan Safeguarding Children’s Partnership Author: Rick Bolton Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Page | 1 Local Child Safeguarding Practice Review “George” October 2022 Author: Rick Bolton, Social Worker, Business Manager Wigan Safeguarding Children Partnership. Page | 2 1.Introduction and background to the review 1.1 Introduction: Wigan Safeguarding Children Partnership notified the National Child Safeguarding Practice Review Panel of a serious safeguarding incident relating to George, a white British 23-month-old boy in March 2022. A Rapid Review was undertaken and on 28th April 2022 Wigan Safeguarding Children Partnership tripartite leadership proposed to the National Child Safeguarding Practice Review Panel that a Local Child Safeguarding Practice Review should be commissioned. This was agreed by the National Panel and the review commenced in June 2022. 1.2 Background: In March 2022, George was living with his mother (known as MG for the purpose of this report) as his sole carer. He had commenced nursery 1st Feb 2022 three days per week but was absent from 2nd March to 24th March as MG reported she had lost her employment and was unable to pay for his place. On 24th March 2022 George was brought to nursery by his mother. Very shortly after his arrival several bruises and abrasions to his face were noticed by staff looking after him, and on further observation they noted more than 20 different injuries. As part of the immediate police and social care involvement that day a Child Protection medical was undertaken, and scans determined that in addition to the visible injuries George had a significant subcutaneous swelling on his head. MG was arrested on suspicion of assault, and at the time of this review the criminal investigation is ongoing. Upon his discharge from hospital George was placed with a foster carer on an Interim Care Order and proceedings in the Family Court are continuing. George has thankfully made a full physical recovery from the injuries; however, it is early to evaluate the emotional harm caused by the physical abuse and neglect he experienced up to March 2022. People who know George have noted that he displays behaviour that carers find challenging and continues to present as being withdrawn. George, prior to March 2022 is described by professionals who knew him directly as being a toddler who was withdrawn, shy, sad, expressionless, struggling with language, didn’t really know how to play with toys, was under stimulated and wanted to avoid being touched. Since he has been removed from his mothers care he is described as doing well, ‘a very different child’, smiley, happy and is becoming confident around adults, appropriately tactile with adults, and having a good bond with his father and grandfather. Page | 3 2 The Review Process and Methodology The process of gathering facts and chronology of what happened in George’s case provided a framework of narrative from which a systemic learning approach1 could be developed. The review has therefore focussed far more on identifying root cause and understanding the organisational and practice context to contributory factors. The review comes from the premise that all organisations and practitioners involved commit on every level to safeguard children like George, and that where that has not been achieved then we should look for a systemic understanding wherever possible. The review undertakes to: a) Provide analysis where practice or guidance exceeded expectation, and to identify opportunities to further promote this good practice. b) Analyse, without hindsight bias, any areas of concern with full recognition of the complex and difficult circumstances in which professionals working to safeguard children operate. c) Facilitate reflective dialogue with professionals involved in the case on a multi-agency footing to exchange views and understand context of the lived experience of working with George and his family. d) Provide and consider organisational information and apply analysis of the provision of services to George and his mother. e) Consider George’s lived experienced centrally to all analysis and recommendations. f) Gather an understanding what was known by which agencies, at which times over the case and sufficiency of responses. g) Consider the interface in this case between services in the Children’s and Adult’s sectors. This is a Local Child Safeguarding Practice Review and therefore focuses on George first and foremost, however it was evident from Rapid Review stage that there is valuable learning to be taken forward regarding how services who have known MG over her life supported her across transition to adulthood. The Reviewer had access to all information submitted to agencies from the Rapid Review and a range of Children's Social Care information additionally requested covering February and March 2022. In addition, the review draws on 2 panel meetings and a practitioner event which took place 30th September with most agencies represented. The reviewer has also considered previous Local Child Safeguarding Practice Reviews undertaken in Wigan and their action plans in ensuring minimal replication of recommendations, and relevant learning from National Child Safeguarding Practice Review Panel reports. The report format includes: • A brief report outlining MG’s history with focus on learning rather than narrative. • Learning points are identified as such as they appear in context through the analysis. If they require changes to practice, policy or procedure, or by individual or collective agencies this is captured in a ‘Learning points’ Section in the report. • Recommendations for Wigan Safeguarding Children Partnership to consider in response to the overarching analysis of George’s case. 1 Tools including Double-Q, Behaviour Over Time (BOT) and Causal Loop were used by the Reviewer. Page | 4 3.Time period considered in the review: The Local Child Safeguarding Practice Review covers the period from MG’s pregnancy with George (summer 2019 onward) to 25.3.22. Agencies were invited to give more detailed chronologies from 1.3.22 – 24.3.22 after it was identified in the Rapid Review that there was significant agency involvement in the final three weeks leading to George’s injuries being noticed. After the Key Lines of Enquiry were developed further information regarding MG’s history with Children's Social Care and housing were requested and helpfully received as her transition across children’s to adults’ services emerged as an important systemic theme. 4 Parallel Processes: There are Care proceedings which at the time of writing in October 2022 remain ongoing and it is thought likely that the Court will order a Fact-Finding Hearing2 to be undertaken. Criminal investigations in relation to George’s injuries also continue at the time of writing. The Reviewer has been in regular contact with the Detective managing the case and undertook a joint visit to MG in July 2022 as part of the review process to gather her views. 5 Local Child Safeguarding Practice Reviewer and Panel: This review was commissioned internally within Wigan Safeguarding Children Partnership and the author is Rick Bolton, Social Worker, Business Manager for the Partnership. A Panel consisting of the Safeguarding Leads from across all agencies involved with George and his mother was informed to support this process to agree the methodology and outcomes. Attempts were made to contact George’s father during the review process, unsuccessfully. 6 Initial Key Lines of enquiry: The following KLOE’s emerged from the Rapid Review Process. Each was further developed in the Local Child Safeguarding Practice Review. 1. Practice, delays in decision making, and oversight in the Child First Partnership Hub 2. Consideration of George’s mother’s needs, vulnerability, transition. 3. Consideration of George’s lived experience and identification of sources of risk. 4. Noncompliance by NWAS with Bruising in Non-Mobile children protocol. 5. Good / exceptional practice by George’s nursery. 7 Child’s voice and experience: As will be outlined further in the review, George’s experiences are not consistently recorded in documents and case records across the partner agencies. However, 2 Practice direction 12J Family Proceedings Rules 2010. Page | 5 though secondary, it was helpful to discuss George’s lived experience with his mother, the professionals who knew him before and after the index incident of 24th March and his current social worker. 8 Key focus: MG’s background, pregnancy and George’s birth: 8.1 George is MG’s only child and was born in May 2020 when she had recently turned 20 years of age; the relevance of her age will become clear over the following sections of the review. 8.2 For a considerable period of the pregnancy George’s father was thought to be a male who his mother had briefly been in a relationship with who is considerably older than her and who has an extensive, entrenched criminal history. Towards the end of the pregnancy MG told some professionals who were working with her, though not all, that George’s father may be another male (known as FG in this report) who she knew from her previous supported accommodation, and this has subsequently been confirmed through paternity testing in the current care proceedings. 8.3 MG has a history with Children's Social Care and other professional agencies going back to 2003. Her father has never had a role in her life. She told the Reviewer that her childhood was ‘just neglect all the time’ because of her mother’s drinking and wider substance misuse; her mental health and being in domestically abusive relationships, and she described that she had ‘always’ had to look after her younger siblings. Due to educational neglect, poor home conditions and lack of appropriate boundaries being put in place by MG’s mother, MG was subject of a Child Protection Plan for 3 years from 2014 to 2017. During this time, she spent time residing with her mother’s ex-partner along with her next-youngest sibling, whilst her two younger siblings remained with her mother. MG told the Reviewer that she felt responsible for them because what was happening to them was what had happened to her, and nobody was stopping it. As far as she was concerned, she was being seen as something of a positive factor in supporting her siblings and she recounted to the Reviewer that she was told this on several occasions by the Social Workers involved. 8.4 However, in 2018 MG’s two younger siblings were removed from their mother’s care and placed in foster care due to the enduring and at times acute neglect. MG told the reviewer that people had been fine with her taking care of her siblings until that point and she didn’t really see that anything was any worse (for her siblings) at that point than it had been for years, and that she had been taking care of them. 8.5 After this unsettled period, MG moved into semi-independence with supported accommodation combined with on-site training. Her progress there from 2017-2019 was exceptional; rarely do young people in that setting sustain a tenancy that well and engage so constructively with the provision on offer. When MG became pregnant with George, she had to leave that provision, something she understood fully, and she stated to the Reviewer that she was ready to leave and live independently – she refused the option offered to her of a mother and Baby Unit. She moved into her own flat a couple of months before she gave birth to George, shortly before the first National Lockdown of the Covid-19 pandemic. Page | 6 8.6 Discussions in the Panels and Practitioner event identified that previously in Wigan a Family Nurse Partnership3 model existed but this ceased to be commissioned in late 2019 shortly before MG’s pregnancy with George. FNP would have been a wholly appropriate offer for MG. Based on her evident ability to engage and work with supportive professionals in supported accommodation it was felt by practitioners that she would have engaged Family Nurse Partnership Programme support were it available. 8.7 In 2021, MG was referred by her GP after several visits, for an assessment in relation to her learning needs and possible assessment for autism. Latterly, in late 2021 – early 2022 this assessment was completed, and MG received a diagnosis of autism. MG explained to the Reviewer that this reduced her anxiety as she had always considered that there was “something different about her” and that this helped her to make sense of it. MG was not supported to attend school by her mother, and resultantly any appreciation of whether her behaviour suggested she may benefit from an autism assessment was essentially lost. 8.8 The brief background to MG above, is relevant to the systemic understanding of what her needs were going into her pregnancy with George. MG is a young woman who has a significant history of trauma across a range of domains. She experienced sustained neglect and exposure to risky and toxic adult behaviours throughout her childhood and adolescence. Through her teenage years she experienced adversity in terms of living arrangements, separations from her siblings, educational disengagement (prior to her move into supported accommodation) and poor mental health. 8.9 MG felt that she was ready to live independently and care for George. Sadly, commencing in early July 2020 and repeated several times over following weeks, MG reported to health professionals that she felt that she was not bonding with George. 8.10 Concerns continued over July and August 2020. This included information received about MG leaving George in the care of others, MG permitting unsupervised contact with FG who was, at that stage (to some agencies) the putative father, and around whom there were on-file, concerns about him presenting a risk of domestic abuse. 8.11 There is evidence of good practice by George’s Health Visitor referring the case to Children's Social Care for further assessment in July 2020 due to these concerns and additional ones around MG allowing her younger sibling to move into her flat and his associates being there. There was timely response from Children's Social Care and a Strategy meeting on 20.8.20 resulted in a period from Sept 2020 to April 2021 of George being a Child in Need (CIN). 8.12 The CIN plan ensured a coordinated approach to supporting George and his mother which was responsive to new risks; for example, in November 2020 a Strategy meeting was convened in relation to the drug use of MG’s siblings and links to offending, and this led to a S47 investigation with the outcome of this being to continue the CIN plan. 8.13 MG was offered and engaged to some extent services in relation to both her mental health and her bonding including a specialist attachment and bonding service. The engagement was however inconsistent across services and at times the chronology 3 A programme for first time mothers under the age of 20. Offering intensive and structured home visiting, delivered by specially trained Family Nurses, from early pregnancy until the child is two. Page | 7 shows failed appointments, last minute cancellations and what practitioners in reflection have considered may have been avoidant behaviours. 8.14 The CIN process through winter 2020 into Spring 2021 provided a framework of monitoring and protection around George. Such was the presentation of MG’s needs; all agencies were looking to respond to her needs so that consequentially she would be in the best place to able to meet George’s needs. 8.15 In taking George off the CIN plan in April 2021, it is apparent that the professionals involved were heavily influenced by three factors; self-reporting by MG (certainly around her Mental Health); the desistance of further contacts or referrals to services over early 2021; and that FG had been assessed by this stage as not presenting a risk. The decision to end the CIN was unanimous but shows collective over-optimism; there had not been a sustained period of positive changes – different to a sustained period of lack of crisis – and there was an ongoing pattern of help seeking behaviour from MG that was perhaps interpreted as positive resilience but on reflection practitioners involved accepted could have been evidence that she was finding it difficult to cope. When primary care (GP and NHS111) information was received for this review, MG had more than 40 GP contacts over the preceding 2 years prior to March 2022 many of which, when reviewed by panel members, related to self-limiting childhood ailments in George; a reframing of this behaviour by professionals involved may have led to a more accurate understanding of her capacity to cope. 8.16 After closure of the CIN in April 2021, in May 2021 a referral came into Children's Social Care again. On this occasion this related to MG allowing her older sister to move in with her, who had had her own children removed from her care. The second, in July 2021 is a detailed account from an anonymous neighbour regarding neglect of George referring to him being left in the care of a 15-year-old whilst MG went to work, being made to eat ‘adult food’ and watered-down milk, and that the house was filthy with George crawling around in rubbish. The outcome of this was a check between Children's Social Care and the Health Visitor and, due to annual leave being planned, a visit 3 weeks later was planned. 8.17 Both incidents were deemed not to meet the threshold for Strategy discussion and on both occasions, MG declined offer of support at an s17 Children Act level. This rationale for this decision is not detailed; George was only recently removed from CIN and the level of concerns that had initially raised him onto that in Summer 2020 were now being repeated in 2021. There are no records to suggest that George’s lived experience was guiding responses at that time. 8.18 From reviewing the records across the partnership agencies there is only slight mention in the health records of MG going into the diagnostic pathway for autism and eventually being diagnosed. Greater sharing of this would have better informed intervention approaches, as mothers with autism face additional challenges with communication and may require tailored approaches4. 8.19 Notably, this is the first anonymous contact with services outlining concern about George, a pattern that continued. 4 Pohl, A.L., Crockford, S.K., Blakemore, M. et al. A comparative study of autistic and non-autistic women’s experience of motherhood. Molecular Autism 11, 3 (2020). https://doi.org/10.1186/s13229-019-0304-2 Page | 8 9 Concerns in January and February 2022 9.1 MG had two adolescents frequently staying at her flat; one of whom is Looked After and was repeatedly reported missing. On 9th,16th, 21st of February this young person was located by Greater Manchester Police in MG’s property and returned home yet MG, culminating with a Recovery Order being made on 2nd March. MG was clearly aware that she should not harbour these young people but continued to do so. The Greater Manchester Police attendances at the property are recorded but there is no reference to the presence of George or checks on his wellbeing in these logs; it may be that he was present, and his wellbeing assured but it is not recorded. 9.2 On the 21st of February, the Health Visitor also attended the property, and there is good practice evidence of her challenging MG about the state of the property, liaising with Children's Social Care about the adolescents present and assuring George’s wellbeing. 10 Key focus: 8th March 2022 10.1 This day gives a lens on the systemic issues in this review. Over the course of the day, there were visits to George’s home by the Health Visitor, two social workers, and Police officers however none were operating with an awareness of the any of the other’s interactions with MG and George that day. The common theme of ‘silo working’ where agency records are not shared, and professionals are working in isolation is rarely focussed on a 12-hour period and it is unhelpful to consider learning from this case as wholly aligned with where it is seen in other reviews. What occurred on 8th March was real time complexity of information sharing across agencies, and not easily ameliorated. It has been challenging even at the stage of Local Child Safeguarding Practice Review to fully sequence these events as some agencies automatically time / date entries on case records (e.g., Greater Manchester Police) whereas in others it is solely reliant on practitioners to enter a specific time for that day and some records appear as ’00:00, 08.03.22’. 08/03/2022 (1st) H.V Record Home visit by Health Visitor. Improvement in home conditions noted. George was observed throwing and spitting food on the floor. The HV discussed motivation to make improvements to the home and the risks of George being exposed to numerous visitors, which can contribute to instability within the home. MG noted she was unable to continue taking George to nursery as she had outstanding nursery fees that she could not pay as she was no longer in employment. Early help and Startwell was offered but declined. Maternal mood is self-reported as low. 08/03/2022 (2nd) Greater Manchester Police records 14-year-old female detailed above following being reported MFH was located at the address of MG and removed to her own Page | 9 carers. 14-year-old male also present. 08/03/2022 (3rd) Children's Social Care record - Unannounced home visit completed. George not present, he was in the care of CMG. Concerns raised about 2 young people who had been reported missing from home and had been found in the property. The Police were present and removed the missing teen from the property. The home was observed to be clean and appropriate for George with clean bedding and toys observed. 08/03/2022 (4th) Children's Social Care record unannounced home visit completed by the social worker for the older teen found at the address, however she had already been removed from the address by the police by this time. The SW made detailed record of being approached by youths outside MG’s address asking her if she was here to buy cannabis off MG etc and a strong smell of cannabis. There is no record of George in this visit. 08/03/2022 (5th) Children's Social Care record “Telephone call from CMG to out of hours to advise she was worried about MG’s mental health as she had returned home and told her she will throw George on the train tracks. CMG reported that MG is not allowing her to take George to a place of safety. CMG was advised to contact the police for support with this.” 08/03/2022 (6th) Children's Social Care record out of hours telephone call from CMG who reported she was going to pick George up. 08/03/2022 Also, that day Greater Manchester Police Record Report received by Greater Manchester Police that MG on several occasions has been verbally abusive and threatening in public that day towards a previous friend with whom she had fallen out. 10.2 The Health visitor and nursery nurse attending in the morning of the 8th observed George; the record captures his experience and voice, and the challenge and advice back to MG about the instability caused to George by there being a range of visitors to the property, and how this may affect his sleep and wellbeing. 10.3 Later, that day around 5pm Greater Manchester Police, pursuant to the pattern established over February of a young person who was MFH being at MG’s property, attended and removed the young person. There is no record of George in this log. 10.4 George’s Social Worker attended around the time the older child was removed from the property and was told by MG that George was with another of her family Page | 10 members (CMG in this report). There are positive recordings about the home at that point. 10.5 Slightly later that early evening, the Social Worker of the child who had been removed from the property by the police attended but was unaware of the police, other social worker or Health visitor contacts that day. 10.6 On the 8th of March 4 different professionals / agencies attended MG’s property, each not knowing of the others attendance. This is a point for agencies consideration; MG was being told by some professionals not to have so many visitors coming in an out of her property because of the effects on George, though made 4 uncoordinated attendances to her flat that day. The Local Child Safeguarding Practice Review Panel and practitioners considered that as an individual with autism, MG may have found this messaging confusing and conflicting. 10.7 Even later, CMG contacted the out of hours service with concern about George. There is an important issue to describe here relating to earlier learning in the Rapid Review and panel meetings: from the chronology Children's Social Care provided to the review (above) it reads that CMG had contacted Children's Social Care Out of Hours team with concerns for George’s safety as “MG has told her she was going to throw him (George) on the train tracks”. The record reads that she had been advised to instead contact the police and call back to the Out of Hours team with how it went. That would have been an inherently risky response in such circumstances and a significant practice concern. However, when the Reviewer interviewed the practitioner, she explained that her recording was poor and outlined that situation in better detail; CMG had contacted the Out of Hours Team saying that she was on her way to pick George up because she was concerned about threats that MG had made about George. She was calling for advice of what she should do should MG not agree to let him go with her and the practitioner advised her to call the police if that was the case when she got there. This places a different context on the interaction. The only consideration to the safety of this advice is that George’s welfare could have been assured by asking Greater Manchester Police to undertake an immediate welfare check. 10.8 There is a lack of integration of real time records across single agency (Children's Social Care) or multi agency (Children's Social Care, Greater Manchester Police, NHS) systems and this is insoluble through the scope of this review. It is important to note it though, as it is an aspect outside of practitioners control, which has a significant effect on the ability to observe and respond to situations based on real-time information. The panel and practitioners noted some possible improvements that could be made relating to use of ‘flags’ on records and significant event recording. The reality is that practitioners across agencies do not have time to review all existing history in relation to a case when they are unfamiliar with for example a practitioner in out of hours services. A detailed chronology with key risks identified assists this. 10.9 Additionally, in the lead up to 8th March there was considerable amounts of information available, that would have linked up the concerns around the teenagers who were missing from home and located repeatedly at MG’s property, MG herself and George. These opportunities were not actualised until after the 8th of March and this emphasises the necessity of mapping around young people who go missing from home, the adults with whom they associate but also the safeguarding considerations for any other children that they may encounter. Page | 11 10.10 Finally, the 8th of March shows again the repeating pattern of people outside of George’s household raising concerns about his safety and wellbeing again; in this case CMG. When extended family or neighbour concerns had been raised over the course of George’s life the response, or lack of, is not considered to be due to decisions being made about the motivation or maliciousness of the report. Practitioners described in the review process that there was always a feeling that the interventions already in place were able to respond to the new information coming in and keep George safe. 10.11 It is not possible to infer that decision making in relation to these anonymous contacts was manifestly unsafe - some did not indicate acute and immediate risk - but the rationale for decision making is not well recorded on some occasions. 11. Period 9-24 March 2022 11.1 George was not in nursery at this time, and it is notable that the only consistent adult care he had been experiencing, albeit briefly, for 3 days per week was removed. 11.2 On the 9th of March George’s social worker made an announced visit early in the morning; George was noted to be very sleepy and hard to rouse. Being minded of the concerns around cannabis use in the household from the day this may have raised more concern, and this was certainly compounded by a call from another family member on the 14th of March that they were concerned, having looked after George for a day, that he had slept almost continuously for 24 hours and that several members of the family had concerns that he had been drugged. There was management oversight of the case on the 14th, but no timescales indicated for when George should be seen. 11.3 On the 15th of March George was taken to the GP by MG in relation to behavioural problems and referred to a community paediatrician and was seen by his Health Visitor on the 16th of March. In these visits concerns were raised about George having pulled at his hair and having areas of bald patches and having problems eating. This was determined in further examination to be a form of alopecia often linked to stress. 12: Incident on 24 March 2022 On the morning that George returned to nursery for the first time in over 2 weeks the staff at the nursery showed a good level of curiosity about his wellbeing and MG relayed the information about his hair loss. Soon after being dropped off, staff noted that George had other facial injuries and bruises that prompted further examination and led to the noting of over 20 injuries. He was also noticeably ‘clingy’ and unsettled. 13. Findings: Page | 12 The findings encapsulate all the Key Lines of Enquiry (KLOE’s) and learning extracted via the review process, document review, panel meetings and practitioner learning event. 13.1 KLOE 1: Regarding delay in the Child First Partnership Hub highlighted in the Rapid Review was explained during the Local Child Safeguarding Practice Review as being due to a weekend when screening of referrals / contacts does not take place in the manner it does Monday to Friday. There may be a consideration for Wigan Safeguarding Children Partnership to improve this to make it a 7-day process, but this would be a strategic response and the impact of this delay in this review is not so great as to lead to it becoming a Recommendation. Capacity, system demand and covid pandemic impact all interacted negatively in George’s case. George was born within a few weeks of the first national lockdown of the Covid-19 pandemic. Services abjectly, and in some cases permanently changed the way that they operated in the space of a matter of weeks. On a very practical level, for MG as a young mother with undiagnosed (at that stage) autism, and who had moved from a highly supportive semi-supported accommodation with routine to living alone the changes to the working relationships on top of practical arrangements would have been especially difficult to cope with. For services, demand even pre-pandemic was at a stage of risking safe delivery5 but after an initial reduction in demand this demand on safeguarding partners services increased towards the middle of the pandemic period with schools reopening etc6. Practitioners involved in the review from health and social care spoke of caseloads that were in March 2022 and continue to be far more than optimal levels and their belief that this impacts safe decision making from the perspective of not having time to review and reflect on information from across a range of agencies to inform better decision making. 13.2 KLOE 2: Regarding MG’s experiences, understanding of her needs and transition. Services to MG over her adolescence and transition to adulthood offered her practical stability (e.g., supported accommodation), but without an overarching Transitional Safeguarding strategy; a context that is not unique to Wigan7. As MG left supported accommodation to give birth to George aged 19 a process that pulled together professionals that knew her over the previous 2 years and a pooling of her history would have better informed the next steps for her and the unborn George. Practitioners in the review considered that services needed to be better ‘trauma informed’ – an inexact phrase to describe a whole culture of working, but this need can be exemplified by adult services practitioners having no idea about some of the most salient parts of her background and the abuse / neglect she had experienced. 5 https://www communitycare.co.uk/2020/04/03/social-work-caseloads-70-percent-childrens-practitioners-struggle-survey-shows/ 6 Baginsky, M., Manthrope, J. (2021) The impact of COVID-19 on Children’s Social Care in England. Science Direct Available at: The impact of COVID-19 on Children’s Social Care in England | Elsevier Enhanced Reader 7 Cocker, Christine, Cooper, Adi and Holmes, Dez (2022) Transitional safeguarding: transforming how adolescents and young adults are safeguarded. British Journal of Social Work, Vol.52, Iss.3 Page | 13 Working with MG with an active knowledge of her background would have contextualised some of her behaviour and choices, particularly in understanding her attachments and rejections of services, her help seeking behaviour and early attachment difficulties with George. It may have also offered useful insight on why throughout the period of living in her own flat she sought unhealthy relationships with younger teens and how best to work with those issues at a level deeper than advising her against doing it – essentially getting practitioners to be able to understand ‘why’ MG behaved like she did rather than just ‘what’ was happening. A significant underlying, unexplored to some extent, factor was what is now known to be MG’s autism; early diagnosis would have allowed practitioners to consider alternative and perhaps more effective ways of working. There is a balance to be struck in all this with MG’s self-determinism and choices as she hit 18 years of age but with a young person with her history approaching parenthood in late teens a consolidated strategic and operational transition approach would assist. On a more practical level specific to this case, MG has never presented as being reluctant to talk about her past. The Care Act 2014 places a duty on local authorities to conduct transition assessments for children, children's carers and young carers where there is a likely need for care and support after the child in question turns 18 and a transition assessment would be of 'significant benefit'8. 13.3 KLOE 3 George’s lived experience; his voice is not consistently captured due to lack of collaboration between agencies in key periods of his life. Some records offer high quality observations of George and his interactions with his mother, however what is not clear is how this formed part of the decision making. To evidence this point; George was variously described by practitioners who knew him in late 2021 – early 2022 as withdrawn, shy, expressionless, avoidant of being touched etc. This was at the same times as there were concerns across other records about home conditions and various people residing there, concerns from extended family about him being drugged and him being left in the care of teenage acquaintances of MG, and latterly of him pulling his own hair out. The recordings are broadly agency exclusive and not shared in real time, so the usefulness of noting his experiences and what George was telling us through his behaviour was lost. 13.4 KLOE 4 regarding NWAS not following the Bruising in Non-mobile infants Protocol on an occasion they attended George’s house was, candidly, one that NWAS had put forward at Rapid Review stage. NWAS had attended the home in Feb 2021 on an occasion where MG said that George had fallen off the bed. This was investigated robustly by NWAS and there is a context that there were no apparent bruises or external injuries seen on George by the crew, he seemed soothed by that stage, and that MG was happy to assume responsibility for his care should his condition change. NWAS have reiterated practice guidance across their workforce to undertake referrals and addressed it with the crew involved. As such the response is commensurate and there is no benefit from a recommendation in this respect. 13.5 KLOE 5: Exceptional practice by George’s nursery: The practice of the nursery on the morning of the 24th of March was an example of excellent practice. The curiosity of staff greeting George that morning after a period of absence led to them 8 Care Act (2014) Available at:Care Act 2014 (legislation.gov.uk) Page | 14 having appropriate concern about the injuries / abrasions on his face and undertaking the full examination of his body very shortly after he arrived. The nursery was asked by Greater Manchester Police to take photographs of the injuries and to send them via email. The manager had the awareness of Safeguarding Policy to challenge this request initially and point out how it went against their guidance. It was acknowledged by GMP that requesting these images had been custom and practice, however it was recognised that this policy wasn’t appropriate given safeguarding processes. Therefore, there has been a change of policy within GMP, which has been cascaded to all Wigan staff and disseminated through WCSP. Throughout the initial response, George was supported by staff who knew him and could comfort him whilst management proceeded to action the concern. The Reviewer and Local Authority Early Years Safeguarding Lead visited the nursery as part of the review process to get a better understanding of the systemic reasons for this good practice. It is a nursery which is part of a private regional group, and they have a requirement for all staff in their settings to be Level 2 Safeguarding trained; considerably above the expectations laid out in national guidance. The staff could also describe how a ‘safeguarding first’ culture is fostered through it being in every level of performance monitoring and staff briefings, and how a comprehensive debrief had been undertaken at the time and subsequently with staff involved with George. In this review it was apparent that there is a clear thread of safeguarding being important through practice, guidance, monitoring, leadership and senior leadership systems. Other findings outside of the KLOE’s 13.6 Missed appointments, late cancellations and rearranged appointments were not consistently responded to. The National Child Safeguarding Practice Review Panel’s 2020 Annual Report outlines the importance of following up on ‘missed appointments, blocking of communications, and cancelled visits’, which are typical signs of parental avoidance (CSPRP, 2021c). Skills in critical thinking and analysis alongside managerial oversight may promote early identification of such patterns and encourage deeper exploration providing the opportunity for practitioners to work differently. Also impacting on this is the lack of considering MG’s known Learning Difficulty and her, at that stage undiagnosed but impactive autism which would have offered some context to her behaviour. 13.7 There is evidence of professional over-optimism in the case regarding MG’s capacity and likelihood to change. The decision to end CIN in April 2021, whilst agreed by all agencies, was not made with full reflection and consideration of information available and the learning pointed to in the findings of KLOE 2 above. The possibility of MG returning to the unsafe practice of allowing friends and risky adults to stay at the property was predictable based on recent behaviour where MG had not recognised the impact on George or in fact herself from a criminality perspective, further, the push and pull factors that lead to MG behaving that way do not appear to have been understood or influential in the decision to end the CIN intervention. Practitioners appear to have been heavily influenced by self-report from MG, and her assurances that she would continue to engage but this was not backed by consideration of her capability to do this. Page | 15 13.8 MG experiences of losses of her relationship with her siblings linked with her identity as a young carer was not understood. MG was known to be a young carer by services working with her and her siblings; this was not a sudden change for her – she told the Reviewer that taking care of them and assuming responsibility for practical and emotional support for her siblings in the absence of appropriate care given by her own mother was a developmental part of her identity. In the Local Authority taking appropriate steps to protect her siblings in 2018 and place them in Care, there was no evident consideration to how this may affect MG’s self-identity or support put in place – MG thinks that this would have helped her understand9. 13.9 There are ongoing challenges in achieving the same level of intervention that the Family Nurse Partnership (FNP) scheme offered until slightly before MG’s pregnancy with George. The FNP model was developed with the support of young women like MG in mind and had considerable success in Wigan, however the commission was discontinued in late 2019. The capacity of 0-19s services offer an equivalent level of intervention, with the benefits it brings of consistent intensive contact with midwifery and health visiting and the coordination of other agencies into the plan, is not currently in place. A review of the 0-19 offer is underway at the time of writing this Local Child Safeguarding Practice Review, and the reviewer encourages the use of MG / George’s experience in that review process. 13.10 Missed opportunities to share information across partners. In many LCSPRs there is evidence of information not being exchanged efficiently within a closed system such a CP, CIN, or Early Help Processes so it is not helpful to just log information sharing as a problem in this case. There are set-piece methods of coming together to share information; in George’s case most recently, this was via CIN reviews but these at best are monthly. The amount of change, the differing factors and multiple contacts between George and professionals meant that period information sharing at set points e.g., CIN reviews would not capture them. For example, the frequency of notable contacts in the first 2 weeks of March 2022 across agencies was difficult to unpick in chronologies for this review, let alone for practitioners potentially working with George and his mother over the course of a single day like the 8th of March. This requires investigation of whether there are opportunities in the increasingly agile digital world to share data between practitioners involved in a case across agencies in real-time. Whilst this might not be possible, the Reviewer thinks it is important to note the disabling rather than enabling effect that lack of shared systems causes and that this is soluble for practitioners. 13.11 Unseen men and unexplored individuals. There is evidence in the case of services responding appropriately in calling a Strategy Meeting when there was a suggestion putatively that George’s father was a known, entrenched and dangerous offender who had been recently released from a long custodial sentence. By the time he was to be assessed, he had been recalled to prison, so this became a low risk. Subsequently, when MG disclosed that another male may be the father, there was a similar response. There is accepted learning in the case about a lack of follow through when MG was advised to get a Domestic Violence Disclosure in relation to the (now confirmed) father ; Greater Manchester Police failed to action this request. It is conceivable that this perhaps led to MG thinking that the lack of response was a positive sign, however in the broader sense the risk itself was worked with by all 9 Helena D. Rose & Keren Cohen (2010) The experiences of young carers: a meta-synthesis of qualitative findings, Journal of Youth Studies, 13:4, 473-487, DOI: 10.1080/13676261003801739 Page | 16 agencies. Overall, the risks that both the putative father and George’s father may present were recognised and George’s wellbeing was well protected. What was less understood and considered contemporaneously was the nature of the relationships MG had with them considering what was known about her vulnerabilities and what this might have told services about her needs. MG is increasingly vulnerable to abusive partners due to her own experiences of abuse and neglect10, and this risk continues into her adulthood. There were other individuals known to be frequenting MG’s property, for example the two adolescents who were repeatedly missing from home, and other acquaintances ; there is insufficient evidence of enquiry about these individuals by agencies who had contact with MG and who had on occasion met them. There is ongoing work in Wigan Safeguarding Children Partnership to address variable practice around professionals exhibiting appropriate child-centred curiosity, and this case provides further examples of the need for this improvement. 13.12 Demand on services and the workforce: Practitioners and managers involved in this review cited their frustrations at the lack of time, caused by service demand, impacting on whether the requisite previous history of an individual / family can be consistently considered in decision making. Caseloads across the partnership were described as far higher now than they were pre-pandemic. 14 Conclusions and Summary: 14.1 The cause of the injuries to George that prompted this review cannot be commented on. However, in the first 23 months of his life George was neglected; omissions in his care, being left with children who were unable to competently care for him, material neglect in poor home conditions, and exposure to drugs and anti-social behaviour in the household from his mother’s associates. The reasons underpinning his mother’s inability of lack of motivation to provide quality parenting were insufficiently considered. 14.2 Collectively, the CIN approach over 2020-21 provided a framework for the observation of George and collaborative working across agencies ; at times this was effective but even without hindsight bias it can be said that the decision to end the CIN was based on false positives (i.e. relatively unchallenged self-reporting by MG of positive change and a period of no professional concerns for George – an issue which is only as patent as being measured against previous concerns and there is a lack of, for example, Graded Care Profiling). The onset of behaviours in summer 2021 that had previously caused concern, such as having teens staying in the flat when they were MFH, coupled with MG refusing to work with services being offered on a voluntary basis, should have at least caused multi-disciplinary consideration of escalation. 14.3 George’s case offers Wigan Safeguarding Children Partnership an opportunity to understand how the effect of trans-generational abuse and neglect can manifest in parenting behaviours, and how the lack of understanding the childhood trauma can undermine attempts made by agencies to promote good parenting practice. 10 Ravinder Barn, Nadia Mantovani, Young Mothers and the Care System: Contextualizing Risk and Vulnerability, The British Journal of Social Work, Volume 37, Issue 2, February 2007, Pages 225–243, https://doi.org/10.1093/bjsw/bcl002 Page | 17 15 Recommendations for Wigan Safeguarding Children Partnership to consider and action: 15.1 There are findings in the review which are repetitious of findings in other Wigan Safeguarding Children Partnership Local Child Safeguarding Practice Review’s that the Reviewer has considered, so if their occurrence in George’s case acts to reinforce those themes and workplans. These action plans can be revisited to ensure that they respond to the context of them in George’s case. These include: • Critical thinking, professional curiosity and undue optimism – a recurrent theme. • Consideration of threshold application at point of closure of cases (in this case the CIN closure). • Ensuring the child’s voice and lived experience is central to the case and is leading the decision making of professionals. • Unseen men (however specific focus needs to be developed on the effect of these men in relationships with vulnerable women / those with experience of abuse). • Development of practice approaches and practitioner skills that show an awareness and responsive empathy in the work and planning for individuals who have experienced trauma. • Variable practice quality in the written plans and targets in cases at all levels of intervention. 15.2 However, the following recommendations are made with specific reference to George’s case: 1. Wigan Safeguarding Children Partnership should ensure that the learning from this review is shared across practitioners in all agencies. This should, wherever possible, be in multi-agency groups so that group reflection is encouraged, and it provides an opportunity for practitioners to gain greater understanding of the roles of each other’s agencies in cases like this. 2. Wigan Safeguarding Children Partnership and Wigan Safeguarding Adult Partnership should both receive this review and consider the sufficiency of current transitional planning, whether this is aligned with the expectations of the Care Act 2014 and whether the correct trigger points are in place to start the planning based on George’s case. Achieving this would mean that better, earlier, informed planning would be in place for adolescents known to services to have multiple areas of vulnerability as they transition into receiving an adult service offer. 3. The partnership should consider directing a review of the data infrastructure cross-agency to identify whether improvements can be made within the current systems. The review identified opportunities for automatic chronological entry to be implemented, discussions around easier flagging of key incidents arose in multi-agency practitioner discussions, and considerations of whether better recording Page | 18 practices can be achieved. These issues need further exploration. A positive outcome for this would be the ability for practitioners so see real-time updates across agencies outside of set review timings and without the necessity to rely on either email or phone updates. 4. Wigan Safeguarding Children Partnership should review and consider the sufficiency of intensive support to young mothers in the 0-19 pathway, and in partnership with WSAB consider review how the partnerships supporting young women like MG who may go on to have another child/children. Health and Local Authority partners in the review may wish to cite and use this case in the ongoing local dialogue around how the local area reaches the expectation in the Health and Care Act 2022 of creating commissioning models that do not compete across the child to adult transition11. 16 Next steps – Progress Report and learning 16.1 Steps have been taken across the partnership to make progress against the learning and recommendations set out in this case. Learning products have been produced and disseminated virtually and face to face across the partnership. 16.2 A number of agencies have progressed learning and provided assurances from rapid review stage, inclusive of single agency learning identified and responded to by NWAS relating to the injuries in non-mobile infants protocol. 16.3 GMP have implemented several systemic and process changes around responses to Domestic Abuse and the consistent application of Clare’s Law. 16.4 WWL Safeguarding team, have also introduced a number of systemic and process changes alongside reviewed training materials and increased training opportunities for the workforce. These changes relate to pre-birth assessments, responses to domestic abuse, trauma informed practice, professional curiosity & having difficult conversations. Further work is being undertaken to improve practices to capture the daily lived experience of the child. 16.5 All partner agencies have expressed their recognition of the work required to embed the learning highlighted in this report and are in the developmental stages of workstreams to reflect this. Due to the pace at which this case has reached completion, partners feel that they would benefit from more time to produce robust evidence that progress and learning is embedded. Partners are committed to the WSCP business unit quality assurance process for the completion of action plans and will provide further updates and evidence via that process. 11 Get in on the Act, Health and Care Act 2022, LGA Get in on the Act: Health and Care Act 2022 | Local Government Association Page | 19 Appendix A Panel Members: Job Title Agency Business Manager Wigan Safeguarding Children Partnership Specialist Nurse for Safeguarding Children Wrightington Wigan and Leigh NHS Foundation Trust Targeted Commissioned team manager Homes, Wigan Council Deputy Designated Nurse, Children in Care GM Integrated Care Partnership Named Nurse for Safeguarding Wrightington Wigan and Leigh NHS Foundation Trust Interim Designated Nurse GM Integrated Care Partnership Service Lead for Children’s Safeguarding Wigan Council Senior Lettings Officer Allocations, Wigan Council Safeguarding Practitioner North West Ambulance Service Safeguarding Leads, Children and Families Greater Manchester Mental Health NHS Foundation Trust Operations Manger across Wigan & Leigh We Are With You (Substance Misuse Service) Safeguarding Lead for GM North West Ambulance Service Detective Constable Greater Manchester Police Case Review Unit Agencies represented at Practitioner Learning Event: Job Title Agency Safeguarding Specialist Nurse - Children Wrightington Wigan and Leigh NHS Foundation Trust Team Manager Building Attachment and Bonds Service Health Visitor Wrightington Wigan and Leigh NHS Foundation Trust Operations Manager Semi Supported housing provider Nursery Manager Private Nursery Group Senior Manager Private Nursery Group Social Worker Wigan Local Authority Children's Social Care Team Manager Wigan Local Authority Children's Social Care Service Manager Wigan Local Authority Children's Social Care Safeguarding Lead for GM North West Ambulance Service Page | 20 Appendix B : Abbreviations: Abbreviation Full Terminology CIN Child in Need CMG Family member of George’s mother FG George’s Father FNP Family Nurse Partnership GMP Greater Manchester Police GP General Practitioner HV Health Visitor KLOE Key Line of Enquiry MFH Missing from home MG George’s mother NWAS Northwest Ambulance Service SW Social Worker |
NC048969 | Death of a 2-year-old boy in January 2014. Primary cause of death was bacterial pneumonia infection with secondary causes of dehydration, failure to thrive, norovirus and cerebral palsy. Following his death, mother received a police caution for cruelty against Child K contrary to Section 1 of the Children and Young Person's Act 1933. Child K and his sibling had been subject to a child protection plan for neglect for a month prior to the incident. Maternal history of: childhood abuse, time spent in the care of the local authority, offending, self harm and homelessness. Father was nine years older than mother and also had a history of childhood abuse and time spent in the care of the local authority. Child K was born 24-weeks prematurely, which affected his lung development causing chronic lung disease. Child K had additional complex needs resulting from a hole in his heart, concerns about his hearing and vision and a bleed in his brain resulting in him developing cerebral palsy. Analyses key themes, including: the impact of Child K's disabilities on assessment of risk and inconsistency in the level of professional concern; inconsistent perceptions of mother's understanding of Child K's needs or of her ability and commitment to meet them; pattern of concerns about Child K's weight being raised but not being seen as evidence of risk; lack of professional understanding of father's role; and lack of professional understanding of the interaction between Early Help, Early Support and Child in Need systems. Identifies lessons learnt, including: need for professionals to be clear about the purpose of letters and of the expectations of recipients. Makes various recommendations, including the provision of training on neglect and disability.
| Title: Serious case review into the death of Child K: overview report. LSCB: Cambridgeshire Local Safeguarding Children Board Author: Jane Scannell Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. SERIOUS CASE REVIEW INTO THE DEATH OF CHILD K OVERVIEW REPORT Author: Jane Scannell March 2015 2 Contents Page 1. Summary of findings 3 2. Introduction to SCR 3 3. Introduction to case 3 4. Family structure 4 5. Terms of Reference 4 6. Process 4 7. Background 5 8. Analysis of key practice events 6 9. Analysis of themes 16 10. Conclusions and lessons learned 28 11. Recommendations 30 12. References 32 Appendices 1. Genogram of family 33 2. Terms of Reference 34 3. Template for Agency Reports 36 3 SERIOUS CASE REVIEW INTO THE DEATH OF CHILD K 1. SUMMARY OF FINDINGS 1.1 The conclusion of this review is that Child K died from an overwhelming infection which he may have succumbed to regardless of the care he had received. However the underlying dehydration and malnutrition that the post mortem revealed contributed to his vulnerability to, and lack of resilience to recover from, the infection. Professionals, as well as his Mother had had concerns about his weight and nutrition during the last six months of his life. 1.2 This review has sought to identify any factors that either promoted or inhibited agencies and individuals to act effectively to ensure his safety. Although professionals were aware of and were actively seeking to support this vulnerable mother and child, the review has identified a number of key lessons for agencies that would improve safeguarding arrangements. 2. INTRODUCTION TO THE REVIEW 2.1 Working Together (2013) states that where abuse or neglect of a child is known or suspected and the child has died, then the Local Safeguarding Children Board (LSCB) must initiate a Serious Case Review (SCR). The purpose of a SCR is to enable the professionals and organisations involved with the child and their family to reflect on both their own practice and that of others, to identify improvements that are needed and to consolidate good practice. 2.2 Working Together (2013) also says that SCRs should be conducted in a way that � recognises the complex circumstances in which professionals work together to safeguard children; � seeks to understand the underlying reasons that led individuals and organisations to act as they did; � tries to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; � is transparent about the way data is collected and analysed; and � makes use of relevant research and case evidence to inform the findings. This serious case review has been undertaken in a way that ensures these principles have been adhered to. 3. INTRODUCTION TO CASE 3.1 The child who is the subject of the review is referred to in this report as Child K. His parents are called Mother and Father. Other family members are referred to by their relationship to Child K e.g. Sibling. 3.2 Child K was born 24 weeks prematurely. As a result of his prematurity Child K had very complex needs which made caring for him substantially more complicated than caring for another child of a similar age. His prematurity affected his lung development causing chronic lung disease. He had a hole in his heart and there were concerns about his hearing 4 and vision. He also suffered a bleed in his brain which resulted in him developing cerebral palsy. 3.3 Child K was 2 years and 5 months old when he died unexpectedly at home in the early hours of the morning on January 1st 2014. At the time both he and Sibling, who had just had his first birthday, had been subject to a child protection plan for neglect for a month. The concerns which led to the children becoming subject to child protection plan included a failure to attend medical and other appointments, Child K's very low weight as well as the domestic abuse that occurred between the parents. 3.4 Child K's death certificate identified that the primary cause for his death was a bacterial pneumonia infection (with secondary causes of dehydration, failing to thrive, norovirus and cerebral palsy). The Coroner's report referred to his level of wasting as being severe and associated with chronic malnutrition. No other underlying causes for the malnourishment were found. Mother has subsequently been given a Police caution for the offence of cruelty against Child K from his day of birth to the date of his death contrary to Section 1 of the Children and Young Person’s Act 1933. 4. FAMILY STRUCTURE 4.1 Child K was the Mother's first child. Father, who is White British, has four older children. Mother is believed to have an Irish heritage. No information has been made available to the review about any religious affiliations the family has. A genogram is attached at appendix 1. 5. TERMS OF REFERENCE 5.1 The period of time of the review is from Child K's birth on 23rd July 2011 to his death on January 1st 2014. Agencies who had been involved with the family were asked to complete reports providing a summary of their involvement with Mother, Father, Child K and Sibling. 5.2 The Terms of Reference are attached at appendix 2 and detail the specific issues for consideration the report authors were asked to consider. The format for agency reports that the authors were given is attached at appendix 3. The LSCB's SCR sub-committee subsequently realised that maternity services had been provided to Mother by another health trust and information to inform the review was then requested from them. 6. PROCESS 6.1 The LSCB's SCR sub-committee group met on the 28th January 2014 and recommended that a decision on whether to initiate a serious case review should be informed by the conclusion of the post mortem. There was a delay until June in the post mortem results being available and so this review was not initiated until the 1st July. Terms of Reference were agreed on 9th September 2014 . A meeting for authors of individual agency reports was held on 30th October 2014 where the review process and expectations of the agency reports were discussed. 6.2 On 28th November the agency report authors met with members of the SCR sub-committee and the overview report writer to review the reports, to discuss emerging themes and to 5 identify further information needed to produce a final version of their reports. All participants had view of all the reports prior to the meeting to ensure everyone attending was able to fully understand the multi-agency context of the review. 6.3 A full day's Practitioners' Event took place on 9th December 2014. All the agencies who had submitted full reports were represented as well as some of those who had done only background reports. Front-line staff and line managers who had been involved with the family during the reviewed period were invited as were the agency report authors. The Event was very well attended and enabled a “window on the system” and the discussions and reflections that emerged informed this report. 6.4 The Overview Report Writer and a representative from LSCB met with Father and Maternal Grandmother on 18th December 2014 to give them an opportunity to share their views some of which have been integrated into this report. Efforts to establish where Mother is currently living so that she can be contacted to be offered the opportunity to participate in the review process have not been successful. 6.5 The Overview Report writer is an independent child protection social work manager and consultant. Her previous operational experience includes managing a children's disability team. She is the author of several Serious Case Review Overview reports. 7. BACKGROUND PRIOR TO CHILD K'S BIRTH 7.1 Mother had her 19th birthday two days before Child K's birth; Father was 28 at the time. Mother had had a troubled childhood and adolescence and Children's Social Care (CSC) were involved and she had spent some time in care and by the age of 16 was living independently. When she was 17 years old she served a short custodial sentence. Staff involved with the Mother at the time of Child K's birth were aware of the stress she appeared to be under due to being a witness in a court case in relation to abuse she had been subject to as a child. 7.2 Father also recalls a troubled and abusive childhood during which CSC were involved. Whilst CSC have no records for him, they do have substantial records about his brothers and family. Father has four other children besides Child K and Sibling. He has remained involved with them all, even when living with Mother. He is now caring for Sibling (under a Supervision Order) and is living with his partner (mother of three of his children), their children and Father's Partner's two other children. 7.3 Maternity Service's notes record that Mother was homeless at the time that they met with her. Because Child K was born so prematurely they had only met with her twice – once at her “booking” at nine weeks and again for a 16 week's gestation appointment. They would have met her again at her 24 week appointment but Child K's early birth superseded this ` and so they had very little contact with her prior to Child K's birth. The review noted that women generally have “hand held” records i.e. ones they keep themselves and it was indicative of some of the organisational issues that later became apparent in Mother's life that she mislaid hers. This means that the Maternity Services' record of involvement is not complete. The information that Maternity services rely on – in the absence of any other information being brought to their attention – is self-reported by the pregnant woman. 6 In Mother's case a note was made that she was currently homeless, had limited support networks and that she “had difficulties” with reading and writing. Father and Maternal Grandmother were noted to be her next of kin. As a result of the vulnerabilities noted, the midwife made a referral to the teenage pregnancy worker. 8. ANALYSIS OF KEY PRACTICE EPISODES 8.1 In order to gain an understanding of the circumstances that led to Child K's death, the time period under review has been divided into a series of key practice episodes. Key practice episodes are episodes that are judged to be significant to understanding the way that the case developed and was handled. The term ‘key’ emphasises that they do not form a complete history of the case but are a selection of the activity that occurred, and include key information to inform the review. Crucially, not all the activity that was focussed on Child K and his family on an ongoing basis is listed so it is important to keep in mind the significant amount of professional activity/energy that was being concentrated on the family beyond that which is explicitly mentioned. Key Practice Episode 1: 23rd July 2011 - 5th December 2011 8.2 The first key practice episode covers the period from Child K's birth until his discharge home from hospital on 5th December 2011. 8.3 Child K was born at 24.5 weeks' gestation at Hospital 1 and transferred when he was 10 hours old to the Neonatal Intensive Care Unit (NICU) at Hospital 2. At birth he weighed 790g (1lb 11.9oz). Medical staff confirmed that such prematurity means the baby's hold on life is very tenuous and those professionals initially involved will be focussed on the baby's medical needs. Child K's parents did not “stand out” to the staff at NICU from the other families who were there with their very sick babies. The parents were appropriately involved, Mother expressed milk for Child K and both parents visited most of the time. When they were unable to do so, Mother would contact the ward for updates. 8.4 After about six weeks Child K's condition had stabilised enough for him to leave Intensive Care. Because initially there was not a bed for him at Hospital 1 (the hospital local to the parents' home address) he spent over three weeks in the Special Care Baby Unit (SCBU) at Hospital 3 (some 25 miles from the parent's home address) before returning to Hospital 1 in October 2011. While he was in Hospital 3 staff noted that although Mother sometimes stayed in the accommodation provided for parents, at other times she was unable to visit because of financial problems. Once Child K was back at Hospital 1 professionals started to note some concerns. These included more sporadic visiting by Mother and no other visitors. Although Mother was noted to be able to meet Child K’s physical needs appropriately, she appeared not to be very emotionally involved and, for example, did not pick him up and cuddle him as much as would be expected. However, Child K made good progress within the limitations of his prematurity, and plans were developed for his discharge from hospital. 8.5 While Child K was an inpatient at Hospital 1 Mother told a member of staff that she was involved in a court case as a witness and that she had self-harmed. Health Visitor (HV) 1 met with Mother and Child K while he was still in hospital and she was concerned enough about Mother’s mental health and lack of support networks to refer her to the Perinatal Mental Health Visitor. However, when the PMHV undertook a planned home visit on 14th 7 November, Mother told her that her visit was “inconvenient”. No evidence has been provided as to what happened subsequently to follow this up . 8.6 A member of the Ward staff completed a Common Assessment Framework (CAF) assessment, focussing on housing needs, but including other concerns and the need for long term support for a child with complex health needs. At the Practitioners’ Event staff confirmed that that the CAF was seen as a tool to pull together “niggling worries” about Child K going home and was being used as a way of bringing all agencies’ concerns together to form a robust plan for his discharge. Subsequently a referral was made to CSC (referral 1) on 10th November resulting in the case being allocated for assessment. 8.7 A discharge planning meeting was held on 11th November and was attended by a range of health professionals as well as the parents and a Young Parent Support Worker and a Housing Officer. Concerns about parents’ preparedness for caring for Child K at home and their lack of contact led to a Professionals’ Meeting being convened on 22nd November. This meeting was attended by a social worker from CSC and, because of the number of concerns being raised, which included Mother’s parenting capabilities and ability to meet Child K’s complex health needs, her lack of family support and concerns about her mental health, it was agreed that the social worker would discuss the option of Child K being accommodated under s201 with parents. 8.8 The social worker completed an initial assessment on 23rd November, the possibility of s20 accommodation having been discussed with parents by the team Manager on the same day. There is no evidence as to the content and outcome of the discussion about s20 accommodation but the initial assessment concluded that a Child in Need (CiN) meeting should be held. This meeting took place on 28th November with the outcome that Child K would be discharged to his parents' care and would receive services as a child in need. The discrepancy between the level of concerns voiced at the meeting on 22nd November and the outcome of the CiN meeting a week later was reflected on both in Agency Reports and at the Practitioner Event. In retrospect, staff concluded that Mother (agencies’ involvement with Father at this time was negligible) was able to reassure staff - “to say the right thing” – about her commitment to working with professionals to meet Child K’s needs and this had been sufficient to allay concerns. Hospital staff remained very concerned with one nurse stating that she was “more worried about Child K than any other in her time on SCBU”. However there was no use made of the LSCB’s escalation procedure to address their concerns. There were two days in between the CiN meeting on November 28th and Child K's discharge home when Mother did not visit him. CSC were notified of this by both the HV and SCBU but no other concerns were raised with CSC about the discharge and on December 5th Child K was discharged to his Mother's care. 8.9 This is a key practice episode because there were early signs that Mother’s ability to give Child K the intensive, consistent care a very premature baby needed was variable. Staff with concerns did not follow them through to conclusion. There was untested optimism about Mother’s ability to cope and an emerging theme of Mother being able to calm professional nervousness by her responses. 1 . S20 Children Act 1989 states Local Authorities' duty to provide accommodation for children in need. 8 Key Practice Episode 2: 5th December 2011 - 10th December 2012 8.10 This episode covers the period between Child K's discharge for Hospital up until the birth of Sibling on 10th December 2012. If Child K's age is adjusted to take account of his prematurity he was four weeks old at discharge (although chronologically he was nearly 4½ months old). He weighed 4.79 kg (10lbs 9oz) and was being bottle fed. He had an ongoing need for oxygen (which was supplied to the home). 8.11 At this time Mother was living at Address 1. In the meeting with the LSCB Manager and Reviewer, Father was clear that he lived with Mother and the children throughout the time under review until October 2013 but this was not the perception of professionals who attended the Practitioners' Event. 8.12 Some of the professionals who had been involved with Child K while he was in hospital remained active in his care, affording a degree of continuity and in January he was referred to Early Support. Early Support is a model which aims to improve the delivery of services for children who have complex additional needs and their families. It is delivered through services working together using the CAF and the Family Support Plan as tools for a single holistic assessment and planning process with a lead professional taking a key worker role. Despite Child K being referred to Early Support soon after he was discharged to a community setting, a Family Support Plan was not developed until July 2013. This was because for much of the intervening period Child K was receiving support (from CSC) and the subject of child in need plans. The interplay between the various planning/support mechanisms which are considered further in the analysis section. 8.13 The case remained open to CSC and in January a core assessment was completed which noted a “good bond” between Child K and Mother and was positive about the care Mother was providing and noted that parents ensured he attended necessary appointments. However, the assessment concluded that given Child K's complex needs the case would stay open with a plan that CSC would ensure locality services were in place. Child in Need (CiN) meetings were held in December, January and March although no detailed recording of what was discussed in them was available on the CSC case record. CSC closed the case in March. Health timeline notes that a CiN meeting took place at the beginning of March but there is no other evidence to clarify whether this meeting was used to clarify the ongoing involvement of the Early Support services. 8.14 Specialist professionals involved with the family at this time included the Physiotherapist, the Occupational Therapist (OT), Portage2 and Consultant Paediatricians. All experienced some difficulty in gaining access to Child K or in having him brought for appointments. At the Practitioner Event staff spoke of their frustration about how many appointments were missed and were eloquent in speaking about the harm the lack of therapies could mean to Child K. There was evidence that staff were not unsympathetic to the difficulties a young, financially-challenged mother with little support would have in attending the numerous appointments and that they did their best to ameliorate them by, for example agreeing to come to the home rather than Mother bring Child K to them. However, the need to reschedule missed appointments further added to the burden. Staff also reflected that 2 Portage is home visiting educational service for pre-school children with additional support needs and their family 9 Mother appeared reluctant to accept offers of help with, for example transport, from professionals, preferring to rely on friends who then sometimes let her down. 8.15 A Team Around the Child (TAC) meeting (referred to as Professionals' meeting in some Agency Reports) held at the beginning of July resulted in another referral (referral 2) to CSC with the identified concerns being that Child K was not receiving the occupational therapy he needed and that Mother was 16 weeks pregnant. The referral was passed to the Disabled Children' Team (DCT) for an initial assessment. 8.16 The assessment (which was completed within time scales3) concluded that there was no current role for CSC as Mother “could manage Child K's health care needs with the support of professionals”. Mother's pregnancy, in so much as it impacted on her ability to meet Child K's needs at the current time was given consideration but there was no assessment of how Mother's ability to care for him might be compromised by the birth of another baby. There was no contact with Midwifery services as part of the assessment process. Although the plan at the conclusion of the assessment was for health professionals to “monitor Mother's attendance at health appointments” there is evidence that key professionals were not told the case was closed on 24th July – 2 weeks after the referral had been made . The OT, who later became Child K's lead professional under the Early Support arrangements only found out in August when she contacted CSC to reiterate concerns about missed appointments. 8.17 At the end of the month Child K and Mother moved to Address 2. Agency authors and staff at the Practitioner's Event reflected that this move was to enable Mother to be closer to her network of friends but felt that the hoped-for support did not materialise. During this time the Vulnerable Women's Midwife (VWM)was involved. The Midwifery service had recognised the additional impact Child K's care needs would have on Mother's pregnancy and ability to cope with the newborn baby and so had involved the VWM. This midwife visits pregnant women in their own homes rather than expecting to see them at clinics and there is no evidence that Mother failed to be available for any of her appointments with the VWM. The Midwifery service is now strongly promoting CAFs (Common Assessment Framework) as a way of collating information and concerns about pregnant women. In this case, the agency representative felt completion of a CAF would have been “advisable” to inform whether the threshold for a pre-birth assessment was met. 8.18 In September 2012 CSC opened another referral (referral 3) from Consultant Paediatrician 1 expressing further concerns about Mother not bringing Child K to medical appointments and not engaging with professionals. The OT and the HV had both contacted CSC during August expressing similar concerns but these were considered to be the same referral as referral 2 (as they repeated the same information). As a result, CSC initially took no further action in relation to these contacts, considering that the assessment completed in July had addressed these concerns. However on receipt of Consultant Paediatrician 1's letter in September, CSC decided that a core assessment was needed and the case was allocated to a social work unit. At about this time a diagnosis that Child K had cerebral palsy was made and discussed with parents by health professionals. 3 At this time Cambridgeshire were working to the requirements of Working Together 2010 which required initial assessments to be completed within 10 working days from referral and core assessments within 35 working days. 10 8.19 The core assessment was completed in November with an outcome that ongoing support under s174 was needed. Although the identified issues included that Mother needed to keep health appointments the plan did not address how she would be supported in this other than to say that if appointments were not kept, action under s475 may be taken. However the plan also noted that CSC would explore what support Mother would need once the new baby was born. The assessment was particularly concerned about the poor housing the family were living in and identified that this would be addressed. 8.20 Sibling was born by Caesarean Section on 10th December 2012, 4 weeks early. 8.21 This is a key practice episode because the issues with Mother ensuring that Child K was taken or made available for professional appointments became apparent, professionals ceased to consider Father's role and his ongoing involvement in the care of Child K. Parents were coping with the news of Child K's diagnosis and prognosis and Mother's pregnancy. CSC closed the case after five months' involvement but received two further referrals during this episode expressing very similar concerns and the Disabled Children's team became briefly involved. Key Practice Episode 3: December 2012 – November 2013 8.22 This key practice episode covers the period from Sibling's birth in December 2012 up until November 2013. During this time Mother was caring for two very dependent children – Sibling was very young and Child K's complex needs meant that, despite his chronological age – he would have been 16½ months at the start of this period – he would have needed at least as much care as a newborn – and the care of two such dependent children would have challenged the most organised and supported parent. Mother needed advice and equipment to meet the demands Child K's special needs presented, especially around eating which required patience, time, correct handling and positioning and a special chair. It was noted that it was virtually impossible for Mother to use public transport with both children's buggies. 8.23 CSC remained involved throughout the first three months of 2013 having transferred the case to a CiN Unit shortly after Sibling's birth with the intention that the Unit would co- work with a social worker from the DCT. However, this arrangement was never activated, neither was the plan, recorded in February 2013 for “Sibling to be closed. Child K to transfer to DCT” (CSC Timeline). CSC records do not provide the reason why the plans to involve the DCT were not implemented. CSC records are also sparse in the information they provide about the focus of the social work intervention but the outcome was that Mother took Child K to his appointments regularly. The CSC agency report author hypothesised that Mother was aware that CSC could take statutory action and so complied. There was an anomaly in that Mother was casual about keeping appointments with the social worker but was more diligent in keeping the other appointments when social work was involved during this period. 4 S 17 Children Act 1989 states the duty of Local Authorities to safeguard and promote the welfare of children who are in need. 5 Under s47 Children Act 1989 an enquiry is initiated to decide whether and what type of action is required to safeguard and promote the welfare of a child who is suspected of, or likely to be, suffering significant harm. 11 8.24 In February the family moved again to Address 3 and some staff commented that this was positive time for the family. Paternal grandfather helped decorate the house, more support via Mother's friends was available and a Disabled Facilities Grant was agreed which would have enabled the house to be adapted to meet Child K's needs and lessen the physical demands - such as carrying him upstairs – on Mother. Practitioners recalled that Mother seemed to have some health problems at this time. She was also observed to have lost weight during the next few months and was often seen drinking energy drinks to “keep herself going”. 8.25 In March 2013 CSC planned to close the case with the recorded intention that that it should transfer to the Short Breaks Team6 . Families who get high rate Disability Living Allowance (care) and who don’t currently have an allocation of social care services have an automatic entitlement of up to £2000 funding via this team and Child K qualified for this support. However despite the team receiving a referral Mother did not respond to their efforts to contact her. 8.26 Child K missed an appointment with both Consultant Paediatricians in March and April. Consultant Paediatrician 1 is a hospital consultant and responsible for Child K's chronic needs relating to prematurity. Consultant Paediatrician 2 is a community paediatrician to whom responsibility for Child K's ongoing developmental progress would have transferred as his health stabilised. The Consultant Paediatricians tried to see Child K together at clinics to both save Mother bringing him to separate appointments and also as part of the process of transferring responsibility to community based services. However, because of missed appointments, Consultant Paediatrician 2 had only met Child K in October 2012 when the diagnosis of cerebral palsy was given to parents. In March the Portage Worker also contacted the social work unit after becoming very concerned about how was Mother coping with a variety of issues including her own health needs, Child K's constipation and problems with her benefits. A CiN meeting was held on 17th April where a plan was made for the lead responsibility to transfer to Early Support Services. CSC closed the case on 29th April with the instruction that further referrals were to be passed to the CDT. 8.27 Mother took Child K to an appointment with Paediatrician 1 in May and expressed concern about Child K's weight. He was weighed as part of the consultation and his weight was 9.35 kgs (9th centile). This represented a deterioration from December 2012 when his weight had been on the 50th centile. A referral to the Paediatric Dietician was made although this appointment was not kept. 8.28 In June 2013 the Police were involved following Mother reporting an assault by Father when both the children were present. Father was initially bailed not to have any contact with Mother and was subsequently convicted for the assault and given a conditional discharge. CSC were notified of the incident via the usual process (referral 4). The Police notification included the information that Father made allegations about Mother's care of the children. The Integrated Access Team (IAT) responded to the referral by completing a 6 This team co-ordinates services to enable disabled children and young people to experience time away from their primary carers, contributing to their personal and social development and reducing social isolation; giving parents and families a break and enabling families with disabled children to do more things together as a family. 12 threshold assessment7 which concluded that further assessment was needed. The case was allocated to an Access Unit - not the DCT - for assessment. The reason why it was not allocated to the CDT, as had been stated when the case had been closed in April was because the concerns were not seen as ones relating to Child K as a disabled child and were therefore did not need the specialist lens provided by DCT. 8.29 The case was closed by the Unit six weeks later on 12th August 2013. There is no evidence that an assessment was completed so no analysis of the risk to the children from exposure to domestic abuse, exploration of the allegations about the quality of Mother's care or any agency checks with the multi-agency support network were made. Consultant Paediatrician 2 wrote to CSC in August expressing concern about the number of appointments Child K had not been taken to but there is no evidence of CSC's response. 8.30 On 16th July a meeting, attended by both parents drew up the first Family Support Plan (the mechanism by which Early Support is coordinated). Although Child K had been referred to Family Support back in January 2012, during most of the intervening time he had been subject to, and his care needs coordinated by, a CiN plan. Although plans were recorded when CSC closed the case in April 2013 that Early Support would take over the coordination of Child K's support needs, arranging a meeting with Mother had proved difficult and was not achieved until July. As a result, during the time when the concerns about Child K's weight/failure to thrive were first becoming apparent, he was not subject to any planning/oversight mechanisms that would have pulled together the different agency perspectives. 8.31 Child K's identified needs in the Family Support Plan included that his “weight and height need checking” as well as noting his constipation problems needed addressing. The plan was reviewed in September where it was noted that Child K “is currently not eating, he is suffering from diarrhoea and losing weight”. The action identified was a dietician's appointment due the following month (to which Child K was not taken) and that his weight and height would be “done regularly” by Health Visitor. There is no evidence that Child K was weighed until he attended an appointment with Consultant Paediatricians 1 and 2 in November. 8.32 In September 2013 the Locality Allocation and Review Meeting (LARM8) agreed a funded pre-school placement should be offered to Child K and he started at pre-school at the beginning of November. He was allocated 5 afternoons a week in response to Mother's observation that she would find it easier to get him there in the afternoon. The interaction between the LARM and the associated Early Help arrangements and the Cambridgeshire's Early Support services (for disabled children under 5) is complex and is considered further in the analysis section. 8.33 At the end of October there was another violent incident between the parents, allegedly when both parents had been using drugs. Mother sustained injuries and Father also caused 7 The purpose of a threshold assessment is to avoid “undue escalation to statutory assessment” (IAT Manual) by gathering further information, which can include seeing the family, to inform decision-making. 8 LARMs are professional meetings used to identify appropriate resources and actions to help children and families with who have more complex additional needs but who do not require social work involvement. 13 criminal damage to home and furniture. Again, both children were present during part of this incident. As a result of the injuries she sustained Mother went to the GP surgery the next day (where she was seen by a nurse practitioner) but even though the GP practice had been receiving “multiple letters, usually addressed to other health professionals but cc'd to (the Practice)” about Child K, no consideration was given to whether any action needed to be taken in relation to the children. This is considered further in the analysis section of this report. 8.34 The Police notification of the incident resulted in CSC opening a referral (referral 5) on 31st October and the completion of a threshold assessment by the IAT. The IAT spoke with the HV who was recorded as confirming that there were no current concerns over missed appointments and also with the Pre-school. Staff from the IAT undertook an unannounced home visit where both children were seen and Mother was spoken to. She reflected on her exposure to domestic abuse between her parents as a child and of her determination to protect her children from similar experiences. An Independent Domestic Violence Advisor (IDVA) had been allocated to her and Mother wanted to attend the Freedom Programme. The conclusion was that no further involvement from CSC was needed as mother had agreed to engage with DV services and had responded appropriately to protect the children and the case was not opened to CSC. However, other professionals who were involved with the family at the time commented that this incident had had a discernible impact on the children with Child K showing he was unsettled/unhappy and Sibling becoming “clingy. 8.35 This is a key practice episode because, although the concerns about missed appointments reduced while CSC were involved, they started again after the case was close having been open for a lengthy period (8 months). There were two further referrals to CSC in the period both because of domestic abuse although only threshold assessments were completed. Mother expressed concern to professionals about Child K's weight gain and it was noted that he had not gained weight and had dropped down the centiles. This was responded to by referral to a Dietician and the Early Support Plan noting actions to be taken to monitor but the cause and impact of his weight loss and non-engagement with services was not explored. Key Practice Episode 4: November and December 2013 8.36 This key practice episode covers November and December 2013. 8.37 When Child K attended a joint clinic with Paediatric Consultants 1 and 2 on 25th November it was the first time Paediatric Consultant 1 had seen him for 6 months (she had last seen him at the very end of May. Child K had missed appointments to attend clinics in June, September and at the beginning of November). Paediatric Consultant 2 had only seen him once before (in October of the previous year). At the November appointment his weight was 9.1 kgs (he had weighed 9.35 kgs (9th centile) when he had last seen Consultant Paediatrician 1 on 30th May). In the referral (referral 6) Consultant Paediatrician 1 subsequently made to CSC by telephone that day, she described him as thin, dirty and cold and “the worst she had seen him”. She had wanted to admit him into hospital but Mother had taken him home. Consultant Paediatrician 2 confirmed the referral to CSC in a letter that was received by CSC the next day. 14 8.38 Child K was seen the following day by the Paediatric Dietician who prescribed some high calorie drinks/fortified milk. This was the first time the Dietician had seen Child K despite previous appointments having been offered since Mother had first raised concerns with Consultant Paediatrician 1 about his weight in May. 8.39 CSC's response to the referral was that social work intervention was needed and the case was allocated back to the Social Work Unit who had done the assessment June 2013. Further information was sent to CSC the next day (26th November) by the Police – informing them of Mother's disengagement from the services dealing with the domestic abuse and also by Health Visitor. The Health Visitor was concerned about the basic care of both children and alluded to the family now having a puppy which could place Child K at further risk of infection. She informed CSC that she had arranged a Professionals' Meeting for 4th December. 8.40 On 26th November (the day following Paediatric Consultants' referral) a strategy discussion with the Police was undertaken by the Consultant Social Worker (CSW) (the senior member of the Unit) which concluded that a single agency s47 enquiry should be undertaken by CSC (i.e. no criminal investigation should be initiated). The next day (27th November) the CSW and a social worker undertook an unannounced home visit to the family home. The recorded purpose of this visit was to see the children and to assess the home conditions and how Mother was responding to the children's needs. 8.41 In the meantime Child K went to pre-school on Thursday 28th November (having been absent the previous two days) and staff noted how unusually thirsty he was. The pre-school discussed this with the HV and it was decided that because of the concerns a Professionals' Meeting would be held the following Wednesday (4th December)at the Pre-school. This meeting was attended by a social worker from the Unit and eight other professional staff involved with the family including Consultant Paediatrician 1, the HV, OT, Housing representative, Pre-school and Portage workers. The social worker recorded the concerns as including failure to attend appointments, poor engagement with some professionals, Child K's poor weight gain over the past year and Mother not following professional advice. There is no record of what actions were agreed at the meeting to address these concerns and in the absence of any other evidence it appears that professionals were relying on CSC to progress a s47 investigation to an initial child protection case conference. (There are conflicting accounts as to whether professionals were given information that this was already agreed. Some attendees understood that, as the meeting included everyone from the Early Support network it was part of that process and its purpose was to gather information to see if concerns warranted a referral to CSC; others understood that the s47 had already been initiated.) 8.42 The following day (5th December) the CSW had a telephone discussion with a Local Authority lawyer about the referral information from the Consultant Paediatrician. The outcome of this discussion, referred to by both CSC and Legal Services as a Legal Planning Meeting, was that CSC needed to obtain clarity from Consultant Paediatrician 2 about whether Child K's health needs “merited the shortest possible 15 PLO9 period (4 weeks). Dependent on the response, managers should be approached for immediate permission to issue or CAM10”. 8.43 There is no evidence on either agency's records that Consultant Paediatrician 2 was consulted. However, in interview, Consultant Paediatrician 2 recalled being telephoned on her day off (probably Thursday 5th December) by someone from CSC asking for an opinion about Child K's condition. Consultant Paediatrician 2 remembers telephoning CSC back and saying that she felt he was at risk of significant harm. There is no record of these conversations in either CSC or Health records. 8.44 The next day the Group Manager decided to progress the case via an initial child protection conference and assessment. The assessment was to consider Mother's “ability to engage with social care and address the concerns..... a really tight time scale …. and if no change evidenced, progress to PLO/care proceedings”. 8.45 However, that weekend, on the Sunday evening, Child K was admitted to Hospital 1 as there were concerns he might have a chest infection. This proved not to be the case and he was discharged the next day having been seen while he was in Hospital by Consultant Paediatrician 1. Consultant Paediatrician 1 spoke with the CSW and they had agreed there was “no indication to change the current safeguarding plan”. The Reviewer has found the decision to discharge Child K difficult to understand (especially in light of the fact there was no obvious Safeguarding plan in existence) as his hospital admission could have been an opportunity to address the concerns about his weight and care that Consultant Paediatrician1 had raised less than two weeks previously when she was so shocked by his appearance that she had wanted to admit him. No evidence was presented to the review that indicated that these concerns had alleviated – his weight was “stable”, i.e. it had neither/increased or decreased since he was weighed on 25th November. In discussion staff reflected that, at the time, it had been felt that the planned initial child protection conference was the route by which concerns would be addressed and that, in light of the inherent risks of being in hospital (infection etc. which could be particularly dangerous to Child K) they felt that he was appropriately discharged. 8.46 In the week between Child K's discharge from Hospital 1 on 9th December and the initial child protection conference on 17th December, the only professional contact with the family was a home visit by the HV on 11th December to do Sibling's 12 month assessment. On the same day Child K attended pre-school (for the last time, it subsequently became apparent) who logged a concern in their own records about his clothing (he was in a sleep suit that smelt strongly of urine). 8.47 The Initial Child Protection Conference was held on 17th December. It was very well attended by personnel from a wide range of agencies including both Consultant 9 Public Law Outline (PLO) is a system for case management which came into force in England and Wales in April 2008.It aims to reduce the need for care proceedings and to speed up those that are necessary. A key change to the system was that councils had do much more of the work before the case got to court, including kinship and residential assessments, the idea being that the case would then be dealt with more speedily once it was presented in court. 10 Cambridgeshire Allocation Meeting - the authorising meeting for decisions regarding care proceedings etc. 16 Paediatricians. Some of the professionals who attended the conference told the review that the risk from domestic abuse had been the focus of the discussions rather than the concerns about the quality of the care the children received and Child K's weight. From the minutes of the meeting it is apparent that the risk of harm from domestic abuse was the first concern discussed. Other issues, including the number of appointments Child K had missed with professionals, his failure to gain weight and Mother's lack of engagement with services were also considered. 8.48 The outcome of the conference was that Child K and Sibling would be subject to a child protection plan because of neglect. The recorded reasons were : � “Mother had failed to consistently meet Child K's ongoing health needs; this has been evidenced by her missing numerous appointments with Child K's hospital, and community paediatrician and other health professionals. � Child K's weight has dropped 5 centiles and most recently Mother declined for Child K to be admitted on ward in order to enable his weight to be monitored. � Child K was noted by health on his most recent appointment to be unkempt and wearing inappropriate clothing for the cold weather”. 8.49 Three days later the Core group met and it was reported that Child K's weight had increased by 0.8 kgs to 9.9 kgs. Staff had made particular effort to ensure that the fortified milk prescribed by the dietician was delivered to the home and that Mother had enough to last over Christmas. The core group developed the detailed protection plan which addressed: the keeping of appointments; � practical care of the children (cleanliness, clothing etc) � ensuring Sibling's needs were not overlooked, � the impact of the domestic abuse � debts to Housing and issues with benefits claims � Mother's low mood � professionals' lack of knowledge about the support available from Mother's family There was no specific mention of Child K's weight or nutritional requirements or of the expected level of frequency of visits. 8.50 A Police Officer called on at the home on Christmas Eve in order to obtain further information about the domestic abuse incident in October and during her visit saw both the children. Mother and the children spent the afternoon of Christmas Day with Mother's family. Maternal Grandmother Mother recalled that Child K had been tired and had been put to bed. The social worker made an unannounced visit on 31st December but no one was in. In the early hours of 1st January 2014 Child K was found dead in his bed. 9. ANALYSIS OF THEMES 9.1 The key practice episodes identified a number of themes. These themes were explored with Agency Report authors and at the Practitioner Event and are further considered in this analysis. The overarching themes are � the impact of Child K's disabilities on professional behaviours and assessment of risk 17 � professionals' relationship with Mother � role of Father and other family members and agencies' understanding of it � systems and processes � information sharing � voice of the child Impact of Child K's disabilities on professional behaviours and assessment of risk Consistency in professional behaviour 9.2 Child K was born very prematurely - “at the edge of viability” - and so was very vulnerable but the professionals who were involved with him in Hospital 2 (where Child K was cared for in the NICU) did not have any concerns about the parents interaction with themselves or Child K. Staff at Hospital 1, however, were alert to the increasing disparity between Child K's family involvement and that of other babies in their care and raised concerns appropriately. However, it is difficult to reconcile a senior nurse's statement that she was more worried about Child K than any other child she had cared for and the fact that a professionals' meeting had agreed that parents' permission to accommodate should be explored with the acceptance by all involved that Child K should be discharged to his parents' care. 9.3 This dichotomy was explored at the Practitioners' Event with the conclusion that staff had felt that, because CSC would remain involved, there was “a safety net” which would act if Child K's care was not at an acceptable level. Whilst CSC does have the ultimate responsibility for ensuring safety, in this case the assessment of risk very much needed to be informed by the specialist knowledge of people accustomed to the care of very vulnerable babies with complex needs and those people must remain vigilant to risk and remain actively involved, working alongside the “child protection specialists” in CSC. Similarly, when Paediatric Consultants raised concerns in November 2013 that were responded to by CSC instituting a s47 enquiry, health professionals relaxed in the belief that a child protection conference would be convened. No discharge planning meeting was held to inform the responsible CSC unit (who were not specialists in disability issues) of the specific risks that Child K's condition imposed. A case conference does not protect children – it is a process. It is the robustness of the plan and the involvement of all agencies and the family, which will ensure the needs of the children are met and that they are kept safe. 9.4 The apparent lack of consistency, with professionals expressing a high level of concern and then subsequently appearing to be less concerned, was a theme that ran through the key practice events and was compounded by a tendency to focus on “the concern of the moment” rather than seeing the whole picture. The most extreme examples involved Child K's initial discharge from hospital and Consultant Paediatricians' assessment that he needed to be admitted in November 2013. On both occasions the high level concerns seemed to dissipate in a relatively short time and, although in the review process practitioners were able to explain rationales for the apparent diminishing of concerns these were not robust. Additionally, thinking from a social learning theory perspective – which acknowledges the impact that the social environment (other peoples' behaviour) has on an individual's learning - Mother did not receive a consistent message about the level of 18 concerns professionals had. Concerns about weight 9.5 Just before the second referral to CSC (in July 2012) Child K had undergone a heart procedure, which, medical professionals informed the review, would have meant he would have started to put on more weight. (While his heart was not functioning as it should, he would have been using up more energy and would not have gained weight.) Initially following the heart procedure his weight did improve but this progression stopped around November/December 2012 and the detailed dietary history taken by the Dietician in November 2013 revealed that his weight had dropped from the 50th centile to the 0.4th centile during the course of the year. It is difficult to reconcile this with the fact that he was being seen very regularly by a variety of professionals, for some of whom weight monitoring is core business, and yet little action was taken. 9.6 In January 2012, at a consultation with the Consultant Neurosurgeon Child K's weight was recorded as being on the 50th centile. There is no record of his weight at the two subsequent neurological appointments that he was taken to, one of which was in October 2013, by which time it can be assumed his weight was concerningly low. From the parents' perspective (both were at this appointment) it must have seemed that medically, there was no concern about his weight as from their experience, professionals were rigorous in following up issues they were concerned about. 9.7 Mother had raised concerns about Child K's weight at an appointment with Consultant Paediatrician 1 in May 2013 where he weighed 9.35 kgs (9th centile) and he had been referred to a dietician, indicating that although it was thought that some expert input was needed, there was not a level of concern about his care and feeding that indicated a referral to CSC was needed. There is no evidence that any particular measures such as specific input from the HV was requested. The Family Support Plan, developed in July 2013 and reviewed in September 2013 noted the need for Child K's growth (both his height and weight) to be monitored and specified who should do this, but there is no evidence that this was done. 9.8 Child K was not weighed by HVs on any systematic basis. The reason for this is two-fold: firstly, the HV felt that as Child K had regular outpatient appointments at Hospital 1 he would be weighed then and secondly, it was felt that “disturbing” Child K by undressing him to be weighed (his stiffness meant that undressing him could be difficult) was intrusive. However, it was well known to the professional system around Child K that attending appointments was an issue and so the outpatient attendances could not be relied on and, if it was felt inappropriate to undress Child K for regular weighing it would have been possible to allow for the weight of his clothes and keep a record, albeit less accurate, of his failure to gain weight. The HV team has a weight monitoring protocol which requires referral to hospital if a child's weight drops more than two centiles. Had Mother's concerns been listened to and Child K been weighed more regularly by the HV team and this protocol been adhered to, the professional system would have been alerted to Child K's failure to gain weight sooner. 19 Recognising risk 9.9 Health professionals explained to the review how, up until the age 2, a baby's developmental milestones are adjusted to take account of their prematurity. This means that a baby like Child K, born 15.5 weeks prematurely, will have an adjusted age of 8 months when he is chronologically a year old. Potentially this influenced people's perception of what was appropriate behaviour in caring for Child K. Professionals noticed that Mother continued to treated him like a baby for example in the clothes he wore and how she carried him but it is less clear that they were rigorous in clarifying with her the need to adjust his feeding regime to make it age appropriate as he grew older. Practitioners reflected that as Sibling grew older the contrast between him and Child K became more obvious as Sibling passed milestones that Child K was yet to meet. 9.10 In their report of a thematic inspection of services to disabled children (2012) Ofsted noted that according to the child in need census of March 2011, 14.2% of the children in need in England were recorded as having a disability and at the time only 3.8% of the children who were subject to a child protection plan were disabled, suggesting there was an under representation of disabled children being identified as at risk of significant harm. It is possible that this was due to disabled children being better supported and therefore any risk identified and addressed before they suffered or became at risk of significant harm. Earlier research (Sullivan and Knutson 2000) found that disabled children and young people were 3.4 times more likely to be abused than their non-disabled peers, and neglect was the most common type of abuse experienced by disabled children. Cambridgeshire figures suggest that they follow the national trend with recent figures showing during 2014 the number of disabled children subject to child protection plans ranged from 5% - 1%. (It is possible that the figures do not accurately identify all disabled children subject to plan but it is unlikely that the unidentified cases would bring the numbers up to a level where there was a proportionate representation of disabled children subject to child protection plans.) 9.11 Bearing this evidence in mind, the under identification of risk to disabled children is irrefutable. Caring for a child with Child K's level of needs would challenge many parents. Child K was the first child of a young and vulnerable mother and although there was a degree of professional recognition of some of the risks their combined needs represented there was not a consistent holistic oversight of it, with practitioners addressing their own professional concerns and expecting others to address other aspects. For example, health relaxing when they thought CSC would take care of child protection issues and CSC expecting health professionals to “monitor”. Professionals' relationship with Mother Perception of Mother 9.12 At the Practitioner's Event it became apparent that professionals did not have a consistent perception of Mother's understanding of Child K's needs, or of her ability and commitment to meeting those needs. Staff reflected, possibly with the benefit of hindsight, that Mother related to some professionals better than others and concluded that the ones she got on well with were people she viewed as being able to assist her in ways she 20 perceived as particularly useful i.e. over money, housing etc. but she was less engaged with disability “specialists”. Staff from the Children's Centre noted that despite considerable efforts on their part they were unable to ensure Mother brought Child K to playgroup although she did engage with pre-school. 9.13 Without Mother's participation in this review it has not been possible to confirm whether this selective engagement was due to the varying implications of the professionals' involvement. Attending the playgroup and “specialist “activities required her active involvement whereas the other professional involvement provided direct services to her or did not require effort on her part. Viewed through a different lens it is possible to identify this behaviour not as mercenary or callous on her part but as defence mechanisms against facing up to the reality of Child K's disabilities. Nevertheless, there is also evidence that Mother did relate better to some professionals than others in the same role suggesting that there were interpersonal issues at play not just a reluctance to engage with people in certain professional roles. 9.14 Despite the review not having had direct input from Mother it is apparent that, in caring for Child K with his significant and complex needs as well as a younger child, she was having to cope with a situation that would have challenged many carers. She was a young parent, with limited practical and emotional support, financially-challenged and who had had a difficult personal history. It is unclear whether there was sufficient appreciation amongst the professionals involved, of the implications the combination of Mother's vulnerabilities could have on her care Child K. Balancing support and risk 9.15 At the Practice Event staff agreed that professional attention had been concentrated on Mother and her needs rather than on Child K and his needs and reflected critically on this. However, as noted in the analysis of service provision to disabled children and their families (Ofsted 2012) “helping the parents (is) a prerequisite for ensuring that the children (get) the support that they need”. Given Mother's situation and lack of support networks, she was inevitably going to need more professional support than most. What is critical is that the adult's needs are not allowed to divert professionals' awareness of potential risk to the children. Research into disabled children and child protection (Scottish Government 2014) found that some professionals considered that they “had unwittingly been too sympathetic to the parent's situation and potentially underestimated the risk posed to the child”. In this case there is evidence that although professionals were appropriately concerned that Child K was deprived of opportunities to maximise his potential, until November 2013, this was not being viewed as a safeguarding concern. Disguised compliance 9.16 The review process has considered whether there was an element of “disguised compliance” (Reder, Duncan and Gray 1993) in Mother's behaviour. Disguised compliance involves a parent or carer giving the appearance of co-operating with agencies to avoid raising suspicions, to allay professional concerns and ultimately to diffuse professional intervention. Although there was not an overall consensus, it was agreed that Mother's behaviour, in general, was more consistent with a disorganised and distracted young parent 21 rather than with someone who was deliberately trying to mislead. 9.17 However staff reflected on the frustration they felt when Mother was not receptive to suggestions and offers of support they made which could have eased the organisational difficulties she was experiencing. The review has identified a dichotomy between professionals' empathy with Mother and lack of curiosity about her history which was not known to most in any detail. It is possible that had practitioners known more about Mother's childhood and adolescence they would have been able to rationalise some of her behaviours but it would have also alerted them to the additional risks. Role of Father and agencies' understanding of it 9.18 Studies of SCRs (Brandon et al 2011) have consistently identified that professionals have not sufficiently involved and taken account of men's roles in the lives of children subject to review. Other research has shown that, in the case of disabled children, professionals side-line fathers by talking to mothers and ignoring the fathers (Tower and Swift 2006). In this case there is evidence that Mother and Father were opaque about Father's involvement as Mother was claiming benefit as a single parent and Father was in employment at times during the scoped period. Nevertheless Father is explicit that, up until the domestic abuse incident in October 2013, they were living (and parenting) together. It is difficult to reconcile this with professionals' perception that he was only intermittently involved and that he “sofa-surfed” between his children's mothers' homes and was “never really” at Mother's home. 9.19 Given the amount of professional involvement, the concerns people had and the fact that two core assessments as well as a number of other assessments were completed during Child K's life time, a clearer understanding of the parents' relationship would be expected. The first assessment completed by CSC (undertaken after Child K first went home from hospital) included Father, but he is not visible in their subsequent assessments. He is recorded as having been at the Early Support meeting in July 2013 when the first Family Support Plan was drawn up. The plan itself does not identify a role for him although under Wider Family/Environmental Needs it is recorded that he “sees children regularly supervised by a friend”. As this meeting was held within a few weeks of the June domestic abuse incident it is likely that Father's bail conditions precluded him attending a meeting where Mother would be present and the record of his presence is in error. 9.20 What is apparent is that Father continued to play a role in his other families' lives – he attended a Triple P parenting course with the mother of three of his children in the autumn of 2013. He is now living with this mother and the children and caring for Sibling. This suggests he was not exclusively with Mother during Child K's life. It is apparent from meeting with Father that he considers himself as an active and committed parent to all his children. The HV for his “other” family concurred with this, saying he “was wonderful and a good father”. There was social work involvement with this “other” family – two of the children have additional needs. However there was little evidence of workers sharing information and understanding the implications – for both families – of Father's duplicate families. 9.21 It is not clear what impact this situation had on Mother's sense of security and whether 22 professionals were sufficiently curious about the relationship and the effect it was having on Mother's mental well-being. The Children's Centre staff felt that the fact that the mother of the elder children was involved with the Children's Centre was a factor that contributed to Mother's lack of engagement with them. 9.22 In the meeting with the reviewer Father was reflective about how he had struggled to come to terms with Child K's diagnosis and the implications of long term disability but was less prepared to acknowledge that Mother may have had the same experience. He was also very critical of her practical parenting, repeating similar concerns he had made when he was arrested following the domestic abuse in June 2013. Systems and process Interaction between Early Help, Early Support and CiN systems 9.23 There is evidence that at times, professionals were unclear about the role and function of the various meetings that were convened. In addition the “step up” and “step down” systems to and from CSC were not effective. From a systems perspective this confusion was contributed to by the interplay between the Early Help, Early Support and CiN processes in operation. Having three systems through which the needs of a disabled child under the age of 5 and their families can potentially be addressed seems unnecessarily complicated. 9.24 Early Support is a model which aims to improve the delivery of services for children who have complex additional needs such as they meet levels 3 or 4 of Cambridgeshire's Model of Staged Intervention (MOSI)11 and their families. It is delivered through services working together using the CAF and the Family Support Plan as tools for a single holistic assessment and planning process with a lead professional taking a key worker role. Early Help refers to preventative and early intervention and support provided to families which is aimed at stopping problems deepening, avoiding crises and ultimately reducing the demand for specialist and statutory services. Again the CAF is the tool which supports the identification of need and preventative action and a lead professional, who has the experience and the resources that are best able to meet the needs of the family, is identified. Children needing Early Help will meet the MOSI levels 2 or 3. When a child is the subject of a CiN or a child protection plan that plan “takes precedence” over Early Support's Family Support Plan and the CAF's Support Plan. 9.25 The process for transferring responsibility from CSC to Early Support was described as “work in progress”. There are ‘step up’ and ‘step down’ processes between Locality Teams12 and Social Care which have been in place since early in 2012. Logically the same 11 The MOSI provides a framework for developing a common understanding of children’s needs, a shared understanding of the roles and responsibilities of services and aids practitioners in understanding the thresholds of different services. Cases meet MOSI level 2 if there are additional needs which require a targeted approach from additional services on top of universal provision; Level 3 if they have complex needs and require professional intervention from more than one agency and level 4 if the needs are complex and enduring and cross many domains. 12 Locality Teams provide advice and support to families who need additional help with parenting including providing young people with information and advice on education, employment, training and personal development opportunities; working with students who have behavioural problems by supporting schools; helping ensure children attend school regularly and punctually; 23 process should be used when a child has needs that warrant Early Support involvement. It was suggested that, although systems work well between the Disabled Children Units and Early Support, there is less effective liaison between the Access and CiN Units and Early Support. The fact a child is subject to Early Support involvement is now flagged on the CSC electronic system and this should assist in ensuring a seamless transition between services. Without a robust process there is a risk of either duplication or absence of a plan as a child transitions between the systems. This is illustrated by the fact that once Child K's case was closed to CSC (in March 2012) after their first involvement, Child K was not subject to a support plan or any form of care coordination plan until the case was reopened by CSC in September 2012. The Guidance Notes on the Early Support Pathway (updated 2014) are complex in themselves and are not likely to be a useful working document for busy frontline professionals. 9.26 In Child Ks's case, in October 2013, when the IAT were undertaking a threshold assessment they did not contact the Lead Professional for information about whether appointments were being missed. There is now a system for flagging Early Support and Lead Professional involvement on CSC's electronic record but no such system was in place at the time to prompt IAT staff to consider whether a disabled child had a lead professional under the Early Support arrangements. The professional the IAT did contact for information following the domestic abuse incident in October 2013 was able to provide some information but also did not suggest the Lead Professional should be contacted. This indicates there was not a confident understanding of the lead professional role embedded among those professionals working in the Early Support system, or among non-specialist workers such as those in the IAT. 9.27 Cambridgeshire's CAF Board is currently considering how the learning that has developed about the Early Support Family Support Plans can be used in their development of a Family CAF so that planning for children and their families following the Early Support pathway and CAF pathway both use the same paperwork. This is a step in the right direction but further consideration needs to be made as to whether two different processes are needed and whether the needs of young disabled children and babies and their families who do not need CSC involvement can be met using the existing early help mechanisms. 9.28 CSC were involved with Child K at six different times during his life. For two of these periods (following referrals 1 and 3) the involvement was for quite a long time – five and eight months respectively. The first of these was when Child K was first discharged from hospital and the other following the referral from Consultant Paediatrician regarding missed appointments in September 2012. Both times the ongoing CSC involvement was precipitated by the completion of a core assessment. These assessments were “very comprehensive in detail” (CSC agency report) and covered most of the expected areas of the assessment framework very adequately. It is the analysis, planning and resultant intervention that was less effective. 9.29 When CSC were involved Mother was reported to better manage to keep the health appointments although it is not apparent what CSC did to help her achieve this – or what structures they ensured were in place to maintain this when the case was closed. The providing specialist support for young people needing help in the transition to adulthood 24 professionals involved believed that Mother knew from her own childhood experiences the powers CSC could exercise and so “toed the line” while social workers were involved because she did not want to her children to be taken into care. However this does not explain why she avoided appointments with CSC as often as she did with other professionals when the case was open or why, if she understood the system (and therefore knew reverting to missing appointments would result in another referral to CSC) she did not manage to maintain a good enough attendance. 9.30 The author of the CSC agency report noted that although the parents' history was a key risk factor, the assessments that were completed did not consider how this would impact on the their ability to care for a child with the significant needs Child K had. Similarly, there seems to have been little curiosity about the extended families and their role. Given that both parents had known troubled and possibly abusive experiences as children, a clear understanding of their role – and any potential risk this indicated – would be expected. It is not clear whether the fact that Child K was a disabled child lessened anxiety about this. 9.31 The referral in September 2012 (referral 3) was made by Consultant Paediatrician 1. Identical concerns had been raised the previous month by the OT and HV. The reason why no action was taken in response to the earlier concerns was because they were seen to be the same as those that had been raised in referral 2 (in July 2012) and it was considered that the initial assessment completed in July had addressed them. This is a debatable decision: it appears that no re-evaluation of the initial assessment was done to see if, in light of the concerns being raised again, whether the assessment's conclusion remained valid. 9.32 When CSC received the last referral in November 2013 the significance of the concerns were recognised to the extent it was immediately allocated to a Social Work Unit. However, it was not allocated to the Disabled Children's Team despite Child K's needs being the primary cause for concern and it had already been agreed that future referrals should go to the DCT. Child K's complex needs meant that he clearly met the threshold for the DCT involvement. The Unit to which the case was allocated was the same one as had been involved both in June 2013 as well as when the case was open between September 2012 to April 2013. It is generally good practice for the same social workers to be involved so that they are able to build on their previous knowledge, relationships and experience of a family when a case is re-referred to CSC. However the Agency Author noted that the Social Work Unit was under considerable pressure at this time –with the two social workers both being newly qualified and coping with a high number of cases. There is no evidence that this was considered in the decision to reallocate the case to the Social Work Unit or if there was active consideration given to allocating to the DCT. 9.33 The pressure the Social Work Unit was experiencing is a possible explanation why, given the significant concern the Paediatric Consultant was expressing as well as the further issues raised, there was no immediate response to the referral. Instead, the day following the Paediatric Consultant's referral, a strategy discussion was undertaken by the Consultant Social Worker (CSW) (the senior member of the Unit) and the Police. Cambridgeshire's Safeguarding Children Procedures state that face to face strategy meetings should take place when the child is disabled and that strategy meeting should include member of the 25 medical team, ideally the medical consultant responsible for the child’s healthcare. In this case, given that the concerns giving rise to the strategy discussion had been raised by a Consultant Paediatrician this would have been particularly appropriate. 9.34 It was two days before a home visit was undertaken (on the 26th November) by the CSW and a social worker. This is not a timely response and again is a possible reflection of the pressure the Unit was under. The recorded purpose of this visit was to see the children and to assess the home conditions and how Mother was responding to the children's needs. This is quite a non-specific plan given that the overriding reason for the visit was because a Consultant Paediatrician thought a child was so underweight hospital admission was indicated. The only reference to this concern in the CSC recording is a reference to the fact Mother said that that she had been telling people that Child K was not putting weight on as he should. The social worker attended the Professionals' Meeting on 4th December and the fact that the discussion with Legal Service took place after this suggests that the information heard there heightened CSC concerns. 9.35 There is no explanation why there is no CSC record of the conversation someone had with Paediatric Consultant 2 following the Legal Planning Meeting. Similarly there is no record of it in the health records either and Consultant Paediatrician 2 is unable to remember whether she made any record but recalls that she was phoned on her day off and was not back at work for a further three days which may account for why it was not on Child K's hospital record. No explanation has been offered as to why it was Consultant Paediatrician 2 that was contacted. The legal planning meeting notes stated that Consultant Paediatrician 2's opinion should be sought but there is no evidence that there was any consideration as to whether Consultant Paediatrician 2 was the most appropriate medical opinion to seek. In light of the fact that Consultant Paediatrician 2 had only seen Child K on very few occasions, and that Consultant Paediatrician 1 had had longer term involvement – and was the Paediatrician who had made the statement “worse she'd ever seen him”– it could be assumed that her opinion would have more validity. CP conference 9.36 The conference was very well attended with all the agencies involved with Child K represented. The only notable absence was that there was no legal advisor. The review learnt that some years ago a decision was made in Cambridgeshire that although Legal Services would be routinely notified of cases going to initial child protection conferences, legal advisers would not attend conferences. The basis of this decision was that if legal advice was needed it could be given to social work staff and/or the conference chair either before or after the conference – depending on the circumstances and the urgency with which the advice was needed. This approach means that legal advisers do not have the opportunity to hear the detailed multi-agency discussions and decision making that conferences allow and which could inform their advice. 9.37 The Police representative at the conference was from the Domestic Abuse Specialist Unit rather than a from the Child Abuse Unit. This may account for why the primary focus (both in staffs' recall and also reflected in the record of the meeting) was the domestic abuse. The conference record does show that the weight/growth issues were explored but in the 26 context of missed appointments and Mother's failure to robustly undertake the therapeutic activities that professionals recommended rather than the primary risk that Child K was exposed to. Nevertheless the stated reasons for making the children subject to child protection plans are clearly around issues of neglect rather than the risk of harm from exposure to domestic abuse. However the child protection plan that was subsequently developed is not focussed on risk and contains no reference to Child K's weight or feeding. Agencies' context 9.38 During the autumn of 2013 CSC were experiencing an unprecedented increase in referrals with the consequent impact on all services. The Unit that the case was allocated to was acknowledged to have been under particular pressure with a high number of cases allocated to it. In addition, the two social workers in the Unit were both newly qualified which would have placed an additional burden on the CSW. In this period, in one month alone, 91 children were made the subjects of a child protection plan (approximately four times more than the average monthly number in Cambridgeshire at the time) indicating that the child protection conference service would also have been under pressure. 9.39 This increase in volume of cases inevitably impacted on Legal Services' capacity as well although this was not the reason why there was no follow up by the solicitor to find out about the outcome of the discussion they had advised the CSW should be undertaken with Consultant Paediatrician 2. The Legal Services' report identified that it is not usual practice for Legal Services to do this because of capacity issues. 9.40 The Health Visiting Service noted that although capacity per se was not an issue for them nevertheless many of their staff were newly qualified putting an additional burden on experienced staff such as those involved with Child K. The review noted a general issues that, becoming the Lead Professional under Early Support arrangements is a considerable commitment and that capacity issues will affect staffs' ability and willingness to take on, and be effective in this role. There was no evidence that this was an issue in this case. Role of Disabled Children's Service 9.41 In between the two episodes of Child K being subject to a CiN plan (between November 2011 and March 2012 and then again September 2012 to April 2013) the case was briefly open to the Disabled Children's Team, in July 2012. The CSC timeline records that this was despite the case being “not appropriate for DCT as Child K does not have a diagnosed disability yet”. When the manager signed off the assessment that was completed by the DCT, a comment that the case did not meet the criteria for Disability Services was added. Both these statements imply that Child K, a child with profound and long term disabilities but who did not yet have a formal diagnosis should have their social work needs addressed by generic child care social workers. It is recognised there is a need to define the role of DCTs to ensure their specialist skills are utilised in the most efficient and effective way but it is questionable if using whether a child has a medical diagnosis or not is the most appropriate criteria and does not seem to be in keeping with a social model of disability. 9.42 The review has been told that the Disabled Children's Service was redesigned and re-launched in April 2012 and that the practice described above, although it was after the 27 new service had been set up, is more indicative of the earlier model than current practice. The review was told that under the new arrangements the Disabled Children's Units undertake the full range of social work tasks for disabled including undertaking s47 enquiries and undertaking responsibility for looked after children as well as providing the specialist support that disabled children and their families require. The criteria for the Disabled Children's Service to become involved with a child is defined as “the needs of the disabled child or young person are beyond those of a non-disabled child of the same age and means they are likely to require lifelong support in the future from statutory services”. It is clear that Child K would have met this criterion. 9.43 However, when a referral was made to CSC in June 2013 following the first domestic abuse incident and the Threshold Assessment completed by the IAT concluded that a CiN assessment was needed, the case was allocated to a mainstream social work unit and not to a Disabled Children's Unit. The reason why it was not allocated to the Disabled Children's Service, as had been stated it should be when next referred, was because the concerns were not seen as ones relating to Child K as a disabled child and therefore did not need the specialist lens provided by Disabled Children's Service. Had a social worker with an enhanced level of understanding about the impact of disability and prematurity on child development become involved in June 2013, a better understanding of the concerns (besides the domestic abuse) that were emerging at this time might have been obtained. Recording and information sharing 9.44 Some of the agency reports identified shortcomings in recording and it was also apparent from comparing timelines and discussing agencies' activities, that there was missing and contradictory information about events e.g. the letter about Child K's diagnosis of cerebral palsy did not get attached to his social care record and the SEN service understood that some of the meetings they were attending were CiN meetings although the case had been closed to CSC. The titles of meetings were described on several occasions differently by various agencies. What a meeting is called is more than a semantic issue. The title of the meeting clarifies who should be there, the function and expected outcomes. Parents would be expected to attend TAC, CiN and Family Support Meetings but not a professionals' meeting. A strategy meeting has a specific function in agreeing whether the threshold for a s47 investigation is met and whether the investigation will be undertaken jointly by the Police and CSC or by one or other agency alone. 9.45 There were some deficits in information sharing between agencies (although staff felt that information sharing within agencies had been strong and there was no evidence to contradict this view.) The Lead Professional cited a number of instances when she had not been made aware of significant information by CSC including the closure of the case in July 2012. The fact that the CSC electronic system did not then alert social workers to the Early Support involvement was a possible reason for this. She had also not been aware of the domestic abuse in October 2013. There is an agreed system by which CSC disseminate the Police incident reports to Health partners and how they are entered on to Systemone (the health electronic record) so that HVs and school nurses have access to the information. However, the review has identified that although Allied Health Professionals also use Systemone they do not necessarily have access to this information (due to the system having been set up differently for different disciplines). 28 9.46 However, notwithstanding this, it is difficult to understand how CSC concluded their assessments without speaking to and clarifying with Child K's lead professional her perception of the situation. This was particularly relevant considering one of the rationales for not allocating the case for assessment in November 2013 was that there were currently no concerns about missed appointments. The reviewer considers that the complexities of the Early Help, Early Support and CiN systems (discussed earlier in this analysis) led to confusion and affected practitioners' understanding of who was currently involved and therefore, who needed to be included in any information sharing. 9.47 The medical staff were diligent in copying CSC into letters although the agency report identified that they did this without an awareness of whether the case was currently open and without any clear intention i.e. were they sending the letter as a referral, for “information only” or for another reason? However there was evidence that these letters did not consistently get entered on to Child K's social care record. At the time CSC were transitioning from one type of electronic case record to another and this may have impacted on the system for entering documents on to the case file. 9.48 Child K's GP practice - who only saw him twice in his life – also received numerous letters, usually addressed to other health professionals but cc'd to them. The GP practice therefore potentially had an overview of the total of the missed appointments but did not have a robust system for identifying whether there was any action they needed to take. The Practice has recognised there were deficits in how these letters were dealt with and have taken subsequent action to improve processes. However both these examples illustrate that information sharing is about more than delivering a piece of information – context, expectations about actions and outcomes are all essential activities that need to be integral to make the process robust and effective. These letters illustrates the need to take professional responsibility for both the sending and receiving of information Voice of the child 9.49 It is appropriate to consider how Child K's voice was heard and responded to during the course of agencies' involvement with him. There are examples, quoted in the agency reports, of workers identifying his mood via his responses to them and to Mother. It is also apparent from the discussion at the Practitioners' Event that his individuality and personality were recognised and responded to by those professionals who knew him best. Nevertheless it is salutary to reflect that despite this, those professionals were not able to recognise that Child K was not receiving sufficient nourishment. 9.50 The core assessments both make reference to Child K's positive responses to his mother and how he indicated that he could differentiate her from other people from a very young age. Professionals refer to examples of Mother playing with him, getting down on the floor with him or enjoying his reaction to a stimulus. As he grew older Mother found if difficult to respond to Child K in a way that was age appropriate. It is likely that she the way she did care for him did not assist his development. For example, not establishing routines such as washing and getting dressed in the morning which would help him to start learning the difference between day and night. 29 10. CONCLUSIONS AND LESSONS LEARNT Conclusions 10.1 This review has sought to establish whether those involved with Child K were aware of the risks that he was exposed to. It also sought to identify any factors that either promoted or inhibited agencies and individuals to act to ensure his safety. The conclusion is that although Child K died from an infection which was possibly not preventable, the underlying dehydration and malnutrition that the post mortem revealed and which contributed to his vulnerability to, and lack of resilience to recover from infection, was potentially avoidable. A criminal investigation concluded that Mother had neglected Child K but process of this review has shown that professionals, as well as Mother and to some extent Father, were aware of and concerned about Child K's nutrition but effective action to address the concerns was not taken. 10.2 With hindsight a pattern of concerns about Child K’s weight being raised but not being seen as evidence of risk of harm has been identified. This review has concluded that despite the involvement of committed, experienced and concerned professionals, there was a lack of focus on risk. 10.3 Caring for Child K with his complex needs would have challenged the most supported and well-resourced parent, especially once Sibling was born. Mother was a vulnerable young woman with little informal support, living in poor housing, with financial difficulties and an ambiguous relationship with the children's father. It was inevitable that she would struggle with his day to day care. Whilst Mother clearly loved Child K and wanted the best for him, her own childhood and adolescent experiences were also likely to impact on her receptiveness to formal support and professional intervention. Lessons learnt 10.4 While some of the professionals involved were sympathetic to Mother's situation, it is not clear that they were sufficiently curious about her history and life experiences and therefore did not recognise the significance of her vulnerabilities and the consequent impact on her care of the children. The support that was provided to her was focussed on her compliance with professional advice. There was not sufficient focus on risk. Risk is more difficult to identify when it has a chronic component and when practitioners are seeing the child regularly there is a risk of them becoming desensitised to it. A recent study into neglect has also identified that practitioners become de-sensitised to children’s difficulties through habituation when undertaking medium- to long-term work (Farmer and Lutman 2012). Risk from neglect is also more difficult to identify and focus on when there is ambiguity about how much the child's disability is a factor. 10.5 The review has considered whether Child K's situation should have prompted a response under s47 sooner than it did. The conclusion is that it is not the designation that counts - child protection ‘rarely comes labelled as such’ (Laming 2009) - but it is the action and intervention that matters. Decision making must be based on an assessment of cumulative risk and harm as well as need. CSC's responses to referrals need to take account of the repetition of previous concerns and the cumulative impact on the children. Child protection processes and CSC involvement of themselves do not protect children. In addition the right people need to be involved . Whilst CSC have the ultimate responsibility for the assessment of risk and ensuring 30 safeguarding the expertise and knowledge of health professionals was needed to inform the multi-agency assessment of risk. Professionals need to take responsibility for addressing concerns through their own safeguarding systems and escalate their concerns if they feel that they are not being responded to appropriately. 10.6 The lives of children with disabilities and their families are complicated enough as it is. Systems that are there to support them need to be transparent and easily accessed and understood as possible. Despite individual practitioners' best efforts there was not a seamless transfer of plans of how Child K's and the family's needs were to be met between CSC and Early Support. The specialist knowledge of the social workers in the Disabled Children's Service could have provided a clearer understanding of the risks Child K was exposed to but despite the redesign of the Disabled Children's Service, and Child K clearly meeting the threshold for allocation to their services, their involvement with him was limited and the system for co-working and offering support to mainstream services was not effective. 10.7 The review identified learning about the need for professionals to be clear about the purpose of letters they send and of their expectations of the recipients, especially when copying others in. Similarly, agencies need to have robust systems for the receipt and consideration of the content of letters sent. Another learning point relating to communication practice was identified in relation to the need to make a record of conversations and advice given when a professional is contacted outside working hours. Good practice 10.8 The review also identified examples of strong practice by individuals and agencies. It was noted that the HV met Mother and Child K while he was still in hospital and visited “over and above” the usual amount. A good handover between HVs when the family moved house ensured continuity of professional involvement. There was good communication within agencies (if not always between them) for example between the Physiotherapist and the Occupational Therapist. 10.9 Some professionals formed respectful and trusting relationships with the family. Father said of the OT “she was the first person who made me feel Child K was a person not just a case”. In general, staff showed a willingness “to go the extra mile” when they felt it was needed e.g. HV accompanying Mother and Child K to Great Ormond Street Hospital and the Consultant Paediatricians seeing Child K opportunistically when he attended other appointments. The core group went to the family home when Mother was unable to get to the Children's Centre for the meeting. 10.10The pre-school were flexible in their provision of placement for Child K and admitted him without waiting for funding and responded to Mother's asserted difficulties in the morning with provision of an afternoon placement. 11. RECOMMENDATIONS It is recognised that actions have already been taken in relation to some of the individual agency's identified learning. In addition agency reports included a number of recommendations which this review endorses. The purpose of providing additional 31 recommendations is to ensure that all professionals in the partner agencies of the LSCB are confident that the areas identified as of concern in this review are addressed. Recommendation 1 Cambridgeshire Community Services NHS Trust review and then re-launch the Health Visitors' weighing protocol. Recommendation 2 Arrangements should be reviewed to ensure that there is sufficient streamlining between with Early Help, Early Support and CSC services so that plans can seamlessly transfer between the various MOSI levels Recommendation 3 The LSCB should assure itself that the role of lead professional in Early Support arrangements is clearly defined, understood and supported Recommendation 4 CSC ensure that the changed remit of the Disabled Children's Service is embedded and that the system for sharing their specialist knowledge to support social workers across CSC is defined and understood. Recommendation 5 The CSC reviews the current systems for the provision of legal advice. Recommendation 6 LSCB assures itself that it can be confident that it has robust data about the safeguarding of disabled children Recommendation 7 LSCB reviews the training provided on neglect and disability to assure itself that it provides sufficient focus on identifying risk when a child has a chronic health condition and that all relevant staff have received recent training. 32 References Disabled Children and Child Protection in Scotland: An investigation into the relationship between professional practice, child protection and disability. The Scottish Government 2014 Protecting disabled children: thematic inspection Ofsted 2012 Jones, L., Bellis, M.A., Wood, S., Hughes, K., McCoy, E., Eckley, L., Bates, G., Mikton, C., Shakespeare, T. and Officer, A. (2012) Prevalence and risk of violence against children with disabilities: a systematic review and meta-analysis of observational studies Lancet 380 (9845), 899-907. Sullivan P. M. & Knutson, J. F. (2000) Maltreatment and disabilities: a population-based epidemiological study. Child Abuse and Neglect, 24(10): 1257-1273. A study of recommendations arising from serious case reviews 2009-2010A Marian Brandon,Peter Sidebotham ,Sue Bailey ,Pippa Belderson DfE 2011 Reder P., Duncan S. and Gray M Beyond blame: child abuse tragedies revisited (1993) Working with Neglected Children and their Families: Linking Interventions with Long-term Outcomes Farmer and Lutman 2012 Cambridgeshire LSCB Disability Task and Finish group action plan Jan 2015 v2 Jan 9th 2015 Laming H. The Protection of Children in England: a progress report. London, The Stationary Office 2009 The Cambridgeshire Early Support Pathway updated Guidance Notes September 2014 Munro review of child protection: final report - a child-centred system DfE 2011 Behind Human Error Woods D et al Farnham Ashgate (2010) quoted in Munro review of child protection: final report - a child-centred system DfE 2011 |
NC049428 | Alleged rape of a 14-year-old girl (Child H1) by her stepfather in July 2015. The stepfather was found not guilty of rape at his trial. Child H1 was the eldest of 5 children, born shortly after her mother arrived in the UK from Rwanda seeking asylum. Her mother was known to suffer from mental health problems. The family received services from a range of agencies for a period of 11 years. At various times, the children were looked after by the local authority and the children were the subject of child protection plans (CPP). At the time of the incident Child H1s mother was admitted to hospital suffering from acute psychosis. The children were left in the care of the presumed father of the three youngest children. Key findings include: a danger that neglect is left unaddressed when the provision of practical support is prioritised; insufficient attention within a CPP of how a service might benefit the individual needs of children may result in the wrong service provision; professionals feeling uncomfortable asking about a persons background, culture and belief systems; and over-concern about the risks rather than the benefits of information sharing. This review was conducted using SCIEs Learning Together methodology, a systems approach, which seeks to understand professional practice in context. Recommendations include: a review of how communication can be improved between primary and community care to strengthen safeguarding; review learning and development plans within multi-agency services to recognise, assess and respond to risk with particular reference to males in households, mobile isolated families, immigration status and black and minority ethnic communities.
| Title: Child H1: serious case review. LSCB: Manchester Safeguarding Children Board Author: Ann Duncan and Bridget Griffin Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. CHILD H1 SERIOUS CASE REVIEW This report has been commissioned and prepared on behalf of Manchester Safeguarding Children Board and is available for publication on the 14TH DECEMBER 2017 INDEPENDENT LEAD REVIEWERS: Ann Duncan and Bridget Griffin May 2017MSCB Child H1 Serious Case Review Page i CONTENTS 1. Introduction and Context ....................................................................................... 1 1.1 Introduction ................................................................................................. 1 1.2 Involvement of Family Members .................................................................... 1 1.3 Succinct summary of the case ........................................................................ 1 2. Scope of review ..................................................................................................... 2 2.1 Research questions ....................................................................................... 2 2.2 Appraisal of practice – an overview ............................................................... 3 2.3 Background context ...................................................................................... 3 2.4. What makes learning from this case more widely applicable? ............................ 11 3. The Findings ........................................................................................................ 12 3.1 Summary of findings ................................................................................... 12 3.2 Findings in detail ........................................................................................ 13 4. Responding to the Research Questions .................................................................. 32 4.1 Responding to the Research Questions ......................................................... 32 4.2 Additional Learning: Involvement of GP’s with SCRs and communication pathways within Primary and Community Care....................................................... 34 5 Conclusion .......................................................................................................... 35 Appendix 1 Methodology ............................................................................................ 36 Appendix 2: References ............................................................................................... 39 Appendix 3: Acronyms and Terminology ....................................................................... 40 MSCB Child H1 Serious Case Review Page 1 of 40 1. Introduction and Context 1.1 Introduction Manchester Safeguarding Children Board (MSCB) initiated a Serious Case Review (SCR) in August 2015 following the alleged rape of the eldest child in the family by her stepfather at the family home; she was 14 years old. At the time of this incident her mother was detained in hospital under Section 2 of the Mental Health Act.1 Stepfather was found not guilty of rape at his trial. When agency records were reviewed by the MSCB, it was apparent that there had been long-term multi-agency involvement with all members of the family. At the request of the MSCB, this SCR has covered a period of two years and eight months (November 2012- July 2015). MSCB decided to review this case using the Social Care Institute for Excellence (SCIE) systems methodology (‘Learning Together’). For detail about the review process and methodology- see Appendix One. 1.2 Involvement of Family Members The involvement of family members is integral to the Learning Together methodology. Regretfully, the Lead Reviewers were unable to speak to any family members, the eldest child declined as she ‘didn’t want to talk about it anymore’; tragically her mother died from natural causes whilst the SCR was being undertaken; and her stepfather’s whereabouts are unknown, he is believed to be living abroad. During this SCR, the Lead Reviewers identified members of the family kinship, including a paternal aunt, the children’s godparents and members of the faith community, whom it was felt would be important to speak to. Repeated attempts were made to try and ascertain contact with this kinship through Manchester Children’s Social Care (CSC). However, details of this kinship were not shared with the Lead Reviewers and so regretfully the perspectives of family and kinship do not feature in this report2. 1.3 Succinct summary of the case Mother came to Britain from Rwanda seeking asylum, she had witnessed genocide and lost family members in the political unrest. She was known to suffer from mental health problems since her arrival in the UK. She was pregnant with her eldest child when she arrived in the UK, the father of the baby did not accompany her. There are five children in the family; the last child was born in May 2014. The family received services from a range of agencies for 11 years. At various times, the children were accommodated by the Local Authority (LA), and at various times the children were the subject of child protection plans. 1 Section 2 Mental Health Act 1983, a person may be detained in hospital for up to 28 days 2 This is an important feature of this case and is further considered in finding 4. MSCB Child H1 Serious Case Review Page 2 of 40 During the time covered by this SCR, there were ongoing concerns about the emotional wellbeing of the eldest child, neglect of all the children and worries about the involvement of an unknown male in family life. In July 2015, mother was admitted to hospital suffering from acute psychosis. The children were left in the care of the presumed father (of the three youngest children). After a few days, the eldest child alleged that her stepfather had raped her and he was arrested at the family home. The children were taken into care under a section 20 arrangement.3 2. Scope of review 2.1 Research questions A vital component of a Learning Together methodology is the formulation of ‘research questions’, which provide a framework for investigation and analysis. These questions are agreed at the outset and identify which aspects of multi- agency safeguarding work it is hoped to learn more about. MSCB identified six research questions: How well do multi-agency services identify and respond to the needs of Young Carers in Manchester when providing services to meet their emotional health and well-being? How well do multi-agency partners recognise, assess and respond to risk across services, with particular reference to males in households, mobile isolated families, immigration status and BME groups? How well does the current service configuration for adults and children support professionals to ‘think family’ in Manchester? How well is the learning from SCRs implemented on the front line? How well are faith and community groups engaged in safeguarding children in Manchester? How well are the emotional, as well as capacity issues, considered when seeking agreement to care for children under s20 of the Children’s Act 1989? It is not usual to have so many research questions set. The questions were posed by members of the MSCB SCR subgroup at a time when, following the Ofsted inspection, changes in management had taken place and there was a clear desire to make changes in as many areas as possible to improve services. During this SCR, information emerged that enabled several of these research questions to be explored and where appropriate these 3 Section 20 agreement; anyone with parental responsibility can voluntarily allow the local authority to accommodate their children under section 20 of the Children Act 1989 MSCB Child H1 Serious Case Review Page 3 of 40 have been covered in the relevant findings. Questions that are not addressed within the findings are addressed at the end of the report. 2.2 Appraisal of practice – an overview The Appraisal of Practice forms an essential component of a SCIE Review. It considers the practice in this case, looking at multi-agency decision making, assessments and interventions up to and including the professional response immediately following the incident. The historical context was also considered and has informed the review’s findings. It aims to provide an explanation of ‘why’ things happened; outlining what got in the way of professionals being as effective as they wanted to be. Any issue identified that was common across more cases in Manchester is discussed in more detail in the findings, which are cross-referenced. 2.3 Background context The appraisal of practice should be read in the context that MCC Children’s Social Care (CSC) underwent major organisational changes during the time covered by this SCR. In part, this was due to the implementation of austerity measures but also to staff shortages, particularly in qualified social workers. MSCB and partner agencies underwent an Ofsted inspection from 25.6.14 to 16.7.14. The outcome of the Ofsted Inspection was an overall judgement of inadequate.4 It is important to note that receipt of an inadequate rating can negatively affect staff morale; during this review the Lead Reviewers were struck by the continuing impact this judgment seemed to have on multi-agency staff, who described feeling ‘bruised and battered’ (some two and a half years later). Following the judgement there were widespread changes to the city-wide leadership team. The following areas were identified by the inspection and are pertinent to this case: - A large number of cases (486) had waited a considerable time for a social work assessment, resulting in a significant number of children not having been seen or their needs assessed or recorded. This potentially left children at risk. - Quality assurance and management oversight is not robust. - Across all social work services, high social work caseloads mean that staff are often unable to prioritise and address children’s needs effectively. Children and families have experienced too many changes of social worker, making it difficult to effect change. - Poor understanding of thresholds by some of the statutory partners, together with poor engagement of agencies in early help, are contributing to high demand, which is not being effectively addressed. 4 A local authority that is judged as inadequate is providing services where there are widespread or serious failures that create or leave children being harmed or at risk of harm or result in children looked after or care leavers not having their welfare safeguarded or promoted. MSCB Child H1 Serious Case Review Page 4 of 40 - Independent Reviewing Officers and conference chairs do not challenge poor social work practice effectively. During the conversations with Case Group members, the areas that had been identified during the Ofsted inspection were highlighted in the work that was undertaken with this family and are referenced in the report. This includes high social work caseloads, change of social workers for the family, the lack of challenge by conference chairs at the various case conferences, and a lack of management oversight which resulted in case drift. There was also a drive immediately prior to the inspection to ‘stepdown’ families and a new service was commissioned to support this; the family was one of the first to be supported by the new service. This challenging landscape forms the context of this appraisal. 2.3.1 Period 1: The children become Looked after Children (LAC) under section 20 (s20) and prior to returning home are made subjects of Child Protection Plans: November 2012- April 2013. This period highlights both a lack of coherence in multi-agency working and insufficient attention to the legal detail that underpins child protection work and supports the rights of the individual. In November 2012, a police response team were called to the family home and found the two youngest children alone; the home was regarded as being in a squalid condition. The police used their powers of protection to remove the children to a place of safety. Although their actions were timely and appropriate they were taken without reference to Children's Social Care (CSC), albeit that the family had been known to CSC for several years. This lack of joint working was contrary to existing guidance and procedure, and fell below expected practice. It was understood that at this time the joint working between the responsible police and CSC teams was poor, since then several significant changes have been made in Manchester to strengthen the joint work between the police and CSC when exercising emergency protection powers. Performance and quality assurance measures are in place to enable relevant data to be reported to the MSCB, and compliance with best practice standards is the subject of regular review. The Emergency Duty Service (EDS) is now co-located with the police and is fully staffed with an on-call Social Worker (SW) out of hours. Therefore, the considerable changes to this safeguarding work since 2012 means that no finding has been made in relation to this issue. After a strategy meeting, mother was charged and cautioned for neglect and the children were accommodated by the Local Authority (LA) under s20 (voluntary agreement) and placed with two separate foster carers. Although these next steps were timely and appropriate, it was not clear how mother’s consent for s20 was gained. No information was found to demonstrate that CSC had complied with the principles of good practice under s20; to satisfy themselves that mother had the required capacity to give consent, had a clear understanding of the legal framework, and was aware of her legal rights. Gaining consent under s20 is discussed further in Finding 5. MSCB Child H1 Serious Case Review Page 5 of 40 During the next five months, the children’s SW worked hard to find suitable housing and to secure a budget for rent and for household furnishings, their efforts were commendable. However, the absence of a multi-agency response and the lack of management support to expedite this situation meant that the children were separated from their mother and siblings for a prolonged period. In addition, the time and effort required to find a resolution diverted the SW from their primary task of completing an assessment of need, and resulted in the children returning to their mother’s care without an assessment of parenting. This caused significant delay in how the family was understood and the children’s needs met. Robust management support and oversight was needed to support the SW to achieve a proactive multi-agency response and to enable them to refocus on their primary task, but this was not provided. In response to the findings made by Ofsted in 2014, strengthened management arrangements have been put in place and continue to be the subject of review. Because of these changes, no finding has been made about management oversight and supervision. Just prior to the children’s return home an Initial Child Protection Conference (ICPC) was held and the children were made the subject of child protection plans under the category of neglect5, this was an appropriate decision. However, the disproportionate focus on the lack of supervision and ‘unsuitable housing’ resulted in little attention being paid to the causes and consequences of the neglect, and compounded the delays in this case. Finding 1 explores in more detail how a focus on the efficiency with which cases are progressed and a lack of understanding of root causes, particularly in cases of neglect, impacts on how services are provided. In June 2013, a review Child Protection (CP) Conference was held within the required timeframe. This conference appropriately noted a good working relationship between services and mother, and that considerable changes had been achieved. It was decided that a further period of monitoring under a CP plan was needed, this was an appropriate decision. However, education staff for three of the children were not at the conference and were not sent minutes of the conference. These were key professionals in the life of the children; it was not possible to fully understand the reason for their non-attendance. It was suggested this may be because of resource constraints and this is an issue that can impact on all agencies at certain times. Of paramount importance is that all professionals, whether they attend a conference or not, should be alerted to risks faced by children in their care for children to be safeguarded. It was understood that in Manchester, it is custom and practice not to send minutes to professionals who do not send a report or give their apologies to child protection conferences. This custom and practice is discussed further in Finding 6. 5 Neglect is currently described in government guidance as: “The persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development. Neglect may occur during pregnancy as a result of maternal substance abuse.” Under the same definition, neglect may involve a parent or carer failing to: Provide adequate food, clothing and shelter (including exclusion from home or abandonment) Protect a child from physical and emotional harm or danger Ensure adequate supervision (including the use of inadequate caregivers) or ensure access to appropriate medical care or treatment Respond to a child’s basic emotional needs. MSCB Child H1 Serious Case Review Page 6 of 40 2.3.2 Period 2: ‘Stepping down’ the case to ‘Child in Need’, the birth of the youngest child, closure of the case to CSC and referral to a newly created service (CINIS). November 2013 - December 2014. This period highlights the challenges encountered by multi-agencies when working with neglect, and with parents who have mental health difficulties. It also covers the difficulties encountered when working with families who are resistant to the involvement of services, and the importance of understanding the strengths and vulnerabilities of a child’s kinship. In November 2013, a unanimous decision was made by members of the Review Child Protection Conference that ‘the risks have significantly reduced’ and the children’s names were removed from a child protection plan. This was an overly optimistic decision; mother was pregnant with her fifth child and there was still little understanding about the causes of the neglect. Judgements about progress were predicated on mother’s ability to accept the services offered, and the children’s response to the services. This lack of understanding about the causes of the neglect resulted in interventions and service provision, which lacked an overall coherence, and impacted on the way mother understood what she needed to do to bring about meaningful change in the parenting of her children. The importance of understanding the root causes of neglect is discussed in Finding 1. The conference recommended that the children were provided with services under s17 of the Children Act 1989 (Child in Need CIN). In circumstances where there has been significant progress in reducing the harm to children and achieving plans, this can be the appropriate decision. However, working with families under this legislative framework requires a partnership with families characterised by consent and a willingness to engage. If there is evidence of this partnership being difficult to achieve (as it was in this case), the absence of the formal child protection planning framework can have a detrimental impact on progress. This was not sufficiently considered by conference members; once the children were no longer subjects of a plan, mother was regarded as increasingly distant, ‘hostile and disengaged’; this resulted in a loss of momentum in the progress that had been made. Finding 2 explores the pressures within the system and how these can impact on the way decisions are made about service provision. Throughout the time the children were the subjects of CP plans and thereafter, mother denied all knowledge of the children’s paternity; stating their conception was a result of ‘a one-night stand’. The professionals were certain there was a man involved in family life but were overly focused on seeking an admission from mother to this effect, rather than reaching a decision based on the information gathered. Thus, the potential risks he posed (and possible strengths he offered) remained unassessed for the duration of service involvement. No finding has been made in relation to this issue as it is an area of practice that has been raised in previous serious case reviews in Manchester and elsewhere, the issues are explored further in the additional learning. In September 2013, the health visitor (HV) (allocated to the youngest child in the family) started to visit the family and found mother difficult to engage. The HV was concerned about mother’s depression and the impact this had on her ability to meet the children’s needs. Mother’s mental health was managed by her GP; she had been registered with the MSCB Child H1 Serious Case Review Page 7 of 40 same practice for 13 years. Statutory guidance6 emphasises the need for communication to take place between all professionals involved with a family for information to be shared and to enable the network to work together, but this did not happen. There was no contact with the GP by the HV7 or any other professional, and there was no contact made by the GP with other professionals working with the children. Thus, professionals working with the children did not know about mother’s mental health needs; they understood she was receiving medication for depression but they wrongly assumed she was compliant with her treatment. Conversely, mother’s GP was unaware that the children were the subject of child protection plans and was not aware of the agencies involved with the family. During this review, it was understood that records kept in the GP practice on the children and the mother were not linked and this contributed to the lack of a shared knowledge about the family. So, whilst the GP practice had received information about the children’s child protection status, this information was stored on the children’s records and as the electronic records held on mother and the children were not linked, the GP treating mother was unaware of this important information. The practice has since recognised that this was a serious issue and have undertaken work to ensure that children and parents are linked within the IT system and appropriate flags are used to highlight any concerns, including safeguarding. This is being reinforced by the work currently being undertaken by the Clinical Commissioning Group (CCG) within the practice and across the city8. As a result, no finding has been made about this aspect of information sharing. However, this provides only a partial answer to the lack of communication between the professionals. Of greatest importance was the absence of an approach that considered the interrelated needs of both the adults and children in the family. Finding 3 explores how the current configuration of adults and children’s services, and the limitations of current IT systems, impact on the ability of professionals to ‘think family’. In May 2014, the four children in the family were placed in care under s20 for seven days whilst mother was in hospital for the birth of the youngest child. This was the fourth time the eldest child had been in LA care. Mother repeatedly stated that there was no one within the kinship that could look after the children, and this was accepted. There was information available to suggest there were members of the children’s community / kinship that could have been approached to provide care, but mother’s assertions were not sufficiently questioned. The task of professionals is to remain in a position of respectful uncertainty and display healthy scepticism which in practice means checking the validity of information provided by parents/adults by cross referencing/triangulating with other sources, this did not happen. As a result, the children were separated and cared for by foster carers who were in effect strangers; the emotional impact on children who experience separation from birth family is the subject of extensive research and its findings should be well known. Finding 4 explores the importance of understanding the identity of families so that information about family life (including the involvement of kinship) can be helpfully used to 6 Working Together to Safeguard Children, A guide to inter-agency working to Safeguard and promote the welfare of Children (HM Government, 2015). 7 Communication between HV’s and GP’s has been the subject of recent scrutiny and work is continuing to improve this, the additional learning (P.36) details the work that has taken place and the continued developments in this area. 8 Communication between General Practitioners and Health Visiting (2012) Health Visiting Task Force, partnership Task and Finish Group. MSCB Child H1 Serious Case Review Page 8 of 40 inform service provision. A few weeks after the birth of the youngest child, a Child and Family Assessment (CAFA) was completed. Within this assessment, the lack of a meaningful understanding of mother’s self- identity (including but not exclusive to her past experiences, her cultural practices and her religious beliefs and how this influenced her internal world and her relationships with her children and wider society) was stark. But this was not specific to this assessment; all previous assessments had been informed by an overly simplistic view of family life. In the absence of exercising curiosity about what may lie beneath the surface of what professionals were observing, plans were vague and assumptions were made. This had a significant impact on how the children were safeguarded and their needs met. The importance of understanding self-identity, beliefs and culture, is explored further in Finding 4. On completion of the CAFA, the case was closed to Children’s Social Care (CSC) and referred to the new Child in Need Intervention Service (CINIS). An intervention plan was agreed and some relevant areas were covered however, many of the areas identified in the plan should have been previously covered (and concluded) in the 11 months when the children were subject to CP plans. There was little sense that the perspectives of the children were known or their needs understood, there was no clarity about what outcomes were being pursued or what impact mother’s mental health had on her ability to meet the needs of her children or on her ability to make the necessary changes, this compounded the delays in this case. At this time, the volume of work held by CSC was very high; there was a need to either close cases or move the work to other services. Ofsted were due to make an inspection, and this provided an important incentive to move cases through the system to lower levels of intervention. Finding 2 explores how the pressures on services can have undue influence on decision making and service provision. The CINIS worker and the HV made a joint visit to mother as they both experienced her as ‘hostile’, particularly when they challenged her care of the children. Following a professional meeting in early November, mother was told that a six -week intervention plan with specific goals was her ‘last chance’. Following a visit just before Christmas, mother was recorded as ‘aggressive’ and as ‘refusing to accept the concerns’ that professionals had about her children. The endless coming and going of professionals in family life, repeated assessments, meetings and plans, meant that the family had been in a constant revolving door of service provision for several years; this perspective was not thought about and the experiences of the family were not appreciated, mother was simply regarded as not working in partnership and was viewed negatively by almost the entire professional network. Finding 2 explores the revolving door of service provision and the impact on families. 2.3.3 Period 3: ICPCC convened Jan 2015. This period highlights how a revolving door of service provision impacts on families, and the limitations of child protection conferences in challenging drift and delay. MSCB Child H1 Serious Case Review Page 9 of 40 At the end of December 2014, CINIS referred the children to CSC; the referral was both timely and appropriate and the concerns were clearly outlined. An ICPCC took place at the end of January 2015, the reasons for the conference were stated as: ‘concerns about neglect and the need to escalate the case to consider initiating the Public Law Outline’ (PLO)9. The conference was attended by key professionals, and was held within required timeframes. The children had been spoken to before the conference and ‘Have your say’ booklets had been completed, these were read out in the conference and thus the children’s voices were well represented; this was good practice. The conference decided that the children should be the subject of CP plans under the category of neglect; this was the correct decision. However, the recommendations made at the conference were vague and largely repeated the same areas covered in the many CIN and CP plans that had gone before. There were no clear outcomes or timescales and despite the minutes recording the need for a legal planning meeting, this did not feature within the plan agreed at the conference. The multi-agency network did not challenge the plan and the same type of services that the family had already received, with little evidence of any improvement, were put in place. As a result, the needs of the family were back around another process cycle of meetings, assessments, plans and service provision. Despite the extensive multi-agency services that had been provided and were being provided, the day-to-day life of the children at home with their mother had not changed. It is understood that since this time changes have strengthened case conferences in Manchester, thus no finding is made about this area of safeguarding work. Finding 1 explores some relevant issues regarding neglect, and Finding 2 explores relevant issues regarding child protection planning. The view expressed by the SW that the case should progress to PLO was correct however, it is unclear why this had not already taken place. This added process step of holding a CP conference before initiating PLO contributed to further delays. Shortly after the ICPCC, the SW appropriately attended a panel to request initiating PLO but the request was refused. The Review Team did not fully understand the reasoning behind this decision but in any event the decision was flawed, and the SW was left to go back around the same cycle of service provision again. It was reported to the Review Team that since this time: ‘the lengthy and often stressful and punitive process experienced by SW’s when attempting to progress a case through PLO has been recognised’ and the internal process has been changed. It was felt important to be clear about current expectations in Manchester in situations such as these. In line with statutory guidance10, where a child protection plan is not adequately protecting a child/ren), conference members (including the chair) are expected to make their concerns very clear and if concerns remain, these concerns must be escalated. No finding has been made about this, as it is understood that these changes have resulted in an improved process including: ‘more timely decision making and better management oversight of cases’. The review conference was held within required timeframes in April 2015, and was attended by key professionals. The conference agreed that there had been little progress 9 The Public Law Outline sets out streamlined case management procedures for dealing with public law children's cases. The aim is to avoid care proceedings if possible and for those cases where proceedings are necessary, identify and focus on the key issues for the child, with the aim of making the best decisions for the child within the timetable set by the Court. 10 Working Together 2015 MSCB Child H1 Serious Case Review Page 10 of 40 since the last conference and that the children should remain the subject of CP plans under the category of neglect. It was clear that several recommendations from the last conference had not been progressed, and these recommendations were simply repeated. Neither the chair, nor conference members challenged this lack of progress, nor had no action been taken by the conference members to escalate their concerns. It is expected that both multi-agency partners and chairs of child protection conferences provide effective challenge in circumstances such as this, and escalate matters that remain unresolved. It is understood that as part of the improvements made to services since the Ofsted inspection: ‘more effective challenge by conference chairs has been put in place’, thus no finding has been made in relation to this area of practice. Shortly after this, in line with a recommendation made at this conference, a referral was made to the Families First (FF) Service. However, insufficient consideration was given about whether this was an appropriate service. FF provided a very specific time limited service based on intensive family work and complied with a clearly defined model of service delivery. There was little room to offer something that was not within the service specification, how they were going to make any difference to the level of complex needs in this family was unclear. The service contacted mother on two occasions, but they were unable to secure mother’s engagement and so withdrew. Finding 2 explores how the pressures on services can have undue influence on decision making and service provision. 2.3.4 Period 4: The deterioration of mother’s mental health and subsequent admission to hospital. June - July 2015. This period highlights the challenges of working together across adult and children’s services when safeguarding vulnerable children and adults, and reviews practice in relation to gaining consent under s20 of the Children Act (1989). Mother’s mental health deteriorated and she presented to her GP about 10 days prior to her admission to hospital, she was feeling anxious and having panic attacks. The eldest child also visited the same GP practice, and expressed concern about the amount of stress the family were under and put this down to the involvement of CSC. The GP felt she was ‘sensible beyond her years’, and wrote a letter to CSC expressing his concerns about their involvement; the GP did not mention any concern in relation to the change in mother’s symptoms or try to speak with the SW or other members of the Primary Health Care Team to elicit a professional view or to understand why CSC were involved with the family. The GP’s lack of knowledge about the children’s child protection status, and the absence of the records being linked within the practice, has been previously explored and is discussed further in Finding 3. Mother was admitted on to a medical ward to exclude any physical condition before being transferred to a psychiatric unit; this is standard practice to ensure that any physical needs are stabilized and managed by appropriately trained staff. On admission to the psychiatric unit, it was noted that mother had bruising to her upper arm that was thought may have been due to ‘extreme force’ and the use of restraints whilst on the medical ward. The paramedics reported that the attitude and language used by the staff on the medical ward MSCB Child H1 Serious Case Review Page 11 of 40 was derogatory. These observations were appropriately reported and noted however; no adult safeguarding alert was made. This was a missed opportunity to view the mother as vulnerable adult, share information and carry out a risk assessment. The Review Team were concerned about this and made a referral to Manchester Safeguarding Adults Board, the Board have commissioned a multi-agency review to explore why professionals working with the mother did not identify her own vulnerability as an adult. On admission, mother was mute; her ‘partner’ provided the background to the days leading up to the admission. He told the Doctor that she had accused his family of witchcraft and of sexually abusing her eldest daughter. Whilst the mother was showing clear signs of being delusional, paranoid and psychotic, no matter how implausible, or regardless of the high number of allegations experienced within the service, any allegations such as these should have been investigated and the information shared with CSC. Because this did not happen, the opportunity to consider the appropriateness of the partner continuing to care for the children was lost. This fell below expected practice, particularly given the children’s child protection status. An internal management review by the Mental Health Trust has explored these issues and learning is being taken forward, therefore no finding has been made about these issues. This report should be shared with MSCB and read in conjunction with this review. A few days later, the eldest child alleged that her stepfather had raped her; he was arrested at the family home. The children were taken into the care of the LA under S20 and placed together with one foster family; this allowed the children to be together at a very difficult time and was good practice. The importance of consent when accommodating children under s20 is discussed in Finding 5. 2.4. What makes learning from this case more widely applicable? The Learning Together methodology uses an individual case to provide a ‘window on the system’ identifying whether the learning that has been identified by one case is more systematic and widespread, thereby leading to a broader understanding about what supports and what hinders processes and practice locally. The findings for the Board are identified arising out of the appraisal of practice, those areas of learning that provide the most significant illumination for wider practice are then prioritised. This case shed light on several key elements within current systems including: identification and management of neglect, the perceived pressure felt by professionals to move families through the Child Protection system quickly and ‘step down’ to universal services, a lack of understanding or curiosity about the background and belief systems of the families and how this might shape acceptance and understanding of the services provided to them. All the above make it a good vehicle for understanding practice in similar cases. This case provides us with an example of what can happen to a system that is under severe pressure and exposes how practice becomes routine rather than reflective; things happen in a timely way but not thoughtfully, and plans become focused on practical solutions and interventions rather than considering what might be the needs of individual members of the family. This in turn impacts on the quality of the multi-agency work, as the focus becomes efficiency and moving cases on quickly rather than spending time to fully explore and understand the MSCB Child H1 Serious Case Review Page 12 of 40 perspective of the individuals within families. The result is families start moving in and out of the system in a ‘revolving door’ type syndrome. This case provides wider lessons for improvement, especially in dealing with cases of neglect; this is a major concern for safeguarding children’s networks, both within Manchester and nationally. 3. The Findings 3.1 Summary of findings The Review Team have prioritised six findings for the LSCB to consider. These are: Findings Category (from typology)11 1. When the provision of practical support is prioritised over understanding the root cause of neglect, the danger is that neglect is left unaddressed. MANAGEMENT SYSTEMS 2. Insufficient attention within a child protection plan of how a service might benefit the individual needs of children may result in the wrong service provision. MANAGEMENT SYSTEMS 3. When services are configured separately for adults and children there is a danger that the impact of risk within the family is not fully understood, which can potentially leave children and adults vulnerable. MANAGEMENT SYSTEMS 4. When professionals feel uncomfortable asking about a person’s background, culture and belief systems beyond the superficial labels used for demographic data collection, children and families’ needs may remain unmet. HUMAN BIAS 5. Local authority management systems are insufficiently challenging of the custom and practice of social workers not to seek or systematically record informed parental consent for S20 accommodation, potentially leaving the support needs of parent’s unseen and making case-drift more likely. MANAGEMENT SYSTEMS 6. Over-concern about the risks rather than benefits of information sharing is resulting in professionals in Manchester being unsighted as to safeguarding risks to children. COMMUNICATION/ COLLABORATION IN LONGER TERM WORK 11 For an explanation of typology refer to ‘Methodology’ in Appx 1 MSCB Child H1 Serious Case Review Page 13 of 40 3.2 Findings in detail This section represents the main learning from this case review for MSCB and partner agencies. Each finding is set out in a way that illustrates: - How does the issue feature in this particular case? - How do we know it is not peculiar to this case? What can the Case Group and Review Team tell us about how this issue plays out in other similar cases/scenarios and/or ways that the pattern is embedded in usual practice? - How prevalent is the pattern? What evidence have we gathered about how many cases are or potentially affected by the pattern? - How widespread is the pattern? Is it found in a specific team, local area, district, county, region, national? - What are the implications for the reliability of the multi-agency child protection system? The evidence for the different ‘layers’ of the findings comes from the knowledge and experience of the Review Team and the Case Group, from the records relating to this case, other relevant documentation and from relevant research evidence. Six priority findings were chosen because they represented areas of practice which were significant in how this case was managed, but which also reflected wider patterns of practice and the systems which underpin that practice. The remainder of this section explores the six Findings. 3.2.1 Finding 1: When the provision of practical support is prioritised over understanding the root cause of neglect, the danger is that neglect is left unaddressed (i) Introduction It is well known that neglectful parenting is almost inevitably a sign of complex and long standing problems such as mental ill-health, domestic abuse, a poor physical environment or entrenched behaviour by a parent(s). To understand whether neglect is occurring, a range of factors must be considered including emotional and developmental needs as well as the immediate need for an adequate diet, warmth and shelter. It is relatively easy to measure outcomes on compliance with practical support offered and allows cases to pass through the system. It is more complex to understand root causes of neglect and measure progress against these. This easy measurement fits with the pressure in the system to move cases through to ease log jam in a system faced with constant demand and the need for quick fixes. (ii) How did the issue manifest in this case? There are several examples of how professionals working with this family prioritised practical support, rather than exploring and gaining an understanding of the causal factors. MSCB Child H1 Serious Case Review Page 14 of 40 The example chosen to illustrate this, is the accommodation of the children by the Local Authority after mother was cautioned and charged with neglect following the removal of the two youngest children from the family home under a police protection order (PPO). The children were accommodated under S20 and remained in care for five months; during this time, the focus of intervention was on securing housing. When the children were returned to the care of their mother they were subject to a CP plan for neglect and, in the absence of a parenting assessment or a plan to provide services that dealt with the causes of the neglect, a range of practical support services were provided (such as daily taxis to ensure that the children arrived at school at the correct time). It is unclear whether mother understood the nature of professional concerns about her ability to parent her children, or what she needed to change to meet the needs of her children. Although mother appeared not to accept responsibility and either blamed the professionals working with the family or the children themselves, conversely, the professionals did not seem to consider how her long-standing mental health issues might lie beneath the neglect, or on her ability to make the required changes. The family were provided with a range of practical support that mother saw largely as an intrusion rather than a solution, decision making about which services should be provided at which level of intervention was based on how well compliance with set tasks was achieved. In the two and half year timeline, the children were looked after by the LA, made the subject of CP plans, their cases stepped down to child in need services then escalated back to CP and finally looked after by the LA for a fourth time. Their cases moved in and out of services and up and down the thresholds of intervention, over this entire period the causes of the neglect were never established. (iii) How do we know it is an underlying issue and not unique to this case? It was understood that it is not unusual for children’s cases to move through the system quickly; the number of cases allocated to social workers at this time was high (although has steadily decreased since the Ofsted inspection and has met the target12). In addition, it was reported that at the time: ‘there was an over reliance on providing task focused support interventions and services’ rather than identifying and working with the underlying cause of neglect and changing patterns of behaviour. It is the experience of practitioners and managers that the constant pressure on resources and the associated pressure to step down children’s cases from a higher level of intervention (to relieve the pressures on the front door), continues and that neglect cases continue to be at risk of being too readily stepped down (because progress is measured by providing services to deal with the symptoms rather than an approach that addresses the causes). At the time this case was managed, the Review Team commented that there was no effective strategy on how to manage neglect across agencies in Manchester13 and as a result 12 At this time, SW’s were allocated 40 -45 cases, -the target figure of 20 cases was met at the end of 2016-2017. 13 ‘Those local authorities providing the strongest evidence of the most comprehensive action to tackle neglect were more likely to have a neglect strategy and/ or systematic improvement programme across policy and practice, involving the specific approaches to neglect’: In the child’s time; professional response to neglect. Ofsted (March 2014) 12. Missed opportunities: indicators opportunities: indicators of neglect – what is ignored, why, and why, and what can be done? Marion Brandon, Danya Glaser, Sabine Maguire, Eamon McCrory, Clare Lustoy and Harriet Ward- Childhood Wellbeing Research Centre (Nov 2014) MSCB Child H1 Serious Case Review Page 15 of 40 there is no common tool or risk assessment used. However, the Board has been working on developing a new Neglect Strategy, which is nearing completion and will be discussed at MSCB in February 2017. Community Health Services use a tool called CANDO (Child Assessment of Neglect and Disability Overview). The training is currently being rolled out across the city to support community staff in evidencing neglect and the impact on a child’s health. (iv) How prevalent and widespread is this issue? The findings of other Serious Case Reviews show that professionals may individually have concerns about a neglected child, but all too frequently the concerns do not trigger effective action. Research suggests that potential obstacles for effective action includes: professionals lack of knowledge, resource constraints influencing professional’s behaviours and professional ‘mind-sets’ that hamper professional confidence and action.14 Research on biases in human reasoning finds that recall is stronger for very vivid or emotive material, such as visible injuries to children (or significant weight loss) but less so in relation to signs of neglect. ‘Clearly it is important to give priority to less obvious signs and symptoms of harm, or the risk of such harm, to children and young people’15. Neglect has been described as the ‘most serious type of child maltreatment and the least understood’ (Dubowitz, 1999 p.67). It is the most common reason for a child having a child protection plan in the UK (45% in March 2015 DfE). The percentage of children in Manchester under the category of neglect is continuing to rise. In 2014 -2015 it was 50.5% rising to 61.4% in the 2015 -2016 year and the figure for the first quarter in 2016 -2017 has jumped up to 69.8%. If there is undue focus on processing these cases through the system, there are a lot of children who stand to come back into it, as happened here. (v) Why does it matter? Dealing with neglect can be difficult and at times overwhelming. A safe safeguarding system recognises these challenges and supports practice decision making based on an understanding that neglect is characterized by a cumulative pattern, rather than discrete incidents or crises. If this is accompanied by management support that is readily available, this pattern can be seen and responded to. When plans are reviewed regularly, and change measured in terms of positive outcomes for children then children are more likely to be safeguarded. In such a system, the ‘start again syndrome’16 will be averted and potential case drift less likely. In the absence of these features and when the pressure on services is high, cases of neglect will not receive the same time and attention necessary to understand and work with causal factors and therefore professionals stop seeing and identifying neglect. In these circumstances, the focus becomes practical support and moving families between services. This results in families ‘bouncing’ up and down thresholds without any clear measurable change or progress in the lives of children. 15 Ten pitfalls and how to avoid them. What research tells us Dr Karen Broadhurst, Professor Sue White, Dr Sheila Fish, Professor Eileen Munro, Kay Fletcher and Helen Lincoln. September 2010 www.nspcc.org.ukinform. 16 Change of practitioner and insufficient attention is paid to the past and work starts afresh (Brandon et al 2008) MSCB Child H1 Serious Case Review Page 16 of 40 Finding 1: When the provision of practical support is prioritised over understanding the root cause of neglect, the danger is that neglect is left unaddressed. Summary Neglect is a complex safeguarding issue that requires a complex response. Being able to respond effectively to cases of neglect requires professionals to be confident in their understanding of all aspects of neglectful parenting. When cases of neglect are managed by a plethora of short service interventions that focus on practical support and outcomes that can be readily demonstrated, there is a danger that the underlying cause for professional involvement is diminished and the cause and impact of the ongoing neglect is lost. Questions for MSCB Does the Board understand how multi-agency professionals currently work together with neglect and are the barriers understood? How will services be supported in implementing the new neglect strategy and how will progress be measured? Where will accountability be held for maintaining detailed monitoring and evaluation of the learning and development? How will MSCB be best informed of progress and consider how challenge will be provided? How will planned improvements be integrated into the MSCB Learning and Development plan? 3.2.2 Finding 2: Insufficient attention within a child protection plan of how a service might benefit the individual needs of children may result in the wrong service provision. (i) Introduction All services work within a delivery framework dictated by legislation, duties and responsibilities, a preferred model of delivery and increasingly by resource availability. In a time of austerity, it is perhaps unsurprising that services apply a model of service delivery that often dictates the terms of engagement with a family and how a service will be provided. Added to these pressures, is a further pressure to provide services constrained by time within a ‘window of opportunity’, in a desire to move need out of the higher levels of multi-agency intervention. The unintended consequence can be an increasingly rigid construct of service delivery that applies a model of ‘one size fits all’, negating a bespoke model of service delivery that is flexible enough to adapt to individual need and difference. (ii) How did this issue manifest in this case? There are several examples within the case illustrating how this issue manifested. The examples chosen to illustrate this finding are the two referrals made to the Families First (FF) Service in March 2015 and in June 2015. The family were referred to this service in line MSCB Child H1 Serious Case Review Page 17 of 40 with a recommendation made at the ICPCC, and after the SW had been unsuccessful in their attempts to escalate the case to legal proceedings. The Families First (FF) Service provide intensive intervention to families for a period of six weeks to support families: ‘to make positive changes so your family can live together safely’17. The service provides ‘intensive evidence based interventions’ and has clearly provided some much-needed support to families in crisis. However, there was a question whether this service was the right service for this family; the primary issue was one of chronic neglect, the family had received an array of different services for several years and periodic improvements had been achieved but not sustained. Mother was a single parent with five children; isolated, depressed and living on a low income, it was unclear how solution focussed brief therapy and brief intervention was going to help this family. In addition, mother was frequently regarded as disengaged from services she had previously made it clear that the intervention of the Family Intervention Project (FIP) had not been welcomed. It was recorded: ‘(Mother) does not want such intensive support, she finds it intrusive’. Critical to success of the FF service was engagement from families, although there was a clear pattern of non-engagement the SW was stuck; there had been an unsuccessful attempt to escalate the case to a higher threshold of intervention and referral to a new service seemed the only option. The involvement of FF was not discussed with mother; equally it was not discussed with the FF service. Despite the concerted efforts of the workers, attempts to engage mother in the work were unsuccessful and the service quickly closed their involvement. Two months later, a second referral was made, again the FF service attempted to work with the family but again they were not able to engage mother and so closed their involvement. Just over five weeks later, the critical incident that prompted this SCR occurred. (iii) How do we know it is an underlying issue and not unique to this case? When discussing this with the Case Group and the Review Team, these issues seemed to resonate across several services. From the perspective of the practitioners in the Case Group, their experiences were of a multi-agency system attempting to cope with the volume of need within finite resources, where there was constant pressure from within the organisation to identify need and move cases on; ‘to step down (or across) the case’ (starting at the front door of provision and out the other end to a lower threshold of intervention). It was their view that this pressure took precedence over proper consideration of whether the service being referred to would be the best fit for the needs within the family, this was said to be compounded by the need to comply with performance indicators and during times when the organisation was under strain. Members of the Review Team agreed with this view sighting as an example: ‘the constant pressure to get children off a CP plan’. They spoke about how the pressures on services (such as resource constraints, restructuring, impending Ofsted inspection etc.) significantly influenced the need to move families quickly through services. Members of the Case Group and Review Team also spoke with some feeling about the emergence of new projects in Manchester (because of restructuring, new policy drives or national initiatives - such as FIP and others), who deliver services ‘within a rigid construct of service delivery’ (such as an 17 Families First Information Leaflet (MCC) MSCB Child H1 Serious Case Review Page 18 of 40 alignment to a particular model and rigid timeframes) and can result in ‘pushing families through a cat flap, when delivering services off menu is not allowed’. (iv) How prevalent and widespread is this issue? Research completed by ‘Locality’ in association with Professor John Seldon, is relevant to this finding. The report: Saving money by doing the right thing - Why ‘local by default’ must replace ‘diseconomies of scale’18 describes research conducted into public service systems in an attempt to understand the challenges faced by services at a time of austerity cuts, mounting demand and rising expectations. Messages from this research resonate with the experiences of this family, and that of frontline professionals and managers in Manchester. ‘High volumes of re-presenting demand illustrate that demand does not go away because it is screened out of a system. When a person’s problem isn’t resolved (which is most of the time), he/she just re-enters the system through another of the bewildering array of doors a referrer can choose from. Decisions about where to refer applicants are dictated by what services exist rather than what individuals need.’ ‘If a service has been commissioned that vaguely relates to presenting needs, people will be referred there. Each time a new service is commissioned it creates yet another referral door to add to the list. The thinking behind referral is: ‘this isn’t for us, so it is up to someone else to help them’. What actually happens at the next transaction point is that the assessment (screening) process starts all over again.’ Data on children subject to child protection plans in Manchester shows that of the 953 children subject to a plan in December 2016, 8.1 % have been the subject of a plan for a second or subsequent time, this equates to 77 children who have been the subject of assessment and child protection planning for a minimum of two cycles. The report describes a system that is unable to understand people in context or respond to their needs; ‘People quickly learn that when they ask for help what they will get is assessment and referral. Some feel so overwhelmed by the many professionals now managing their life that they give up trying to help themselves. Such users are usually labelled difficult or non-compliant and sometimes visited with sanctions or refused further service. The overall consequence, however, is the same – a failure to solve the original problem, which as a result becomes worse or more complex. People with problems continue to place demands on, or be referred between, multiple services, inevitably consuming more resources across the system as a whole.’ (v) Why does it matter? Every day across the country19 children receive support from multi-agency professionals to safeguard them from harm, and improve their lives. Critical to the success of this work is the timeliness and appropriateness of the services that are provided. This complex multi-agency system works well when needs are responded to as they emerge, services are provided to match the level of need, and the system is flexible enough to provide a bespoke model of 18 Locality in partnership with Professor John Seldon (Vanguard Consulting) March 2014 19 During 2014-2015 390,000 children received support from Children’s Services: Department for Education (2015) Characteristics of children in need in England 2014-2015 MSCB Child H1 Serious Case Review Page 19 of 40 service delivery that accommodates individual difference. This is a complex and difficult task where there are no quick fixes; one size will not fit all, but if there is room for individual difference to be recognised and responded to (and clear contingency planning), children and families will receive support at the right time, in the right way, and in the right place, resulting in timely and efficient interventions that allow children to be safeguarded and positive outcomes realised. Within a context where choice cannot be infinite and resources are fewer in number and often in scope, this is far from easy to achieve. Finding 2: Insufficient attention within a child protection plan of how a service might benefit the individual needs of children; may result in the wrong service provision. Summary In a system that prioritises efficiency over reliability, where little attention is paid to how services will best meet the individual needs in a family, children’s needs will not be met and the risks to children will increase. If this is accompanied by an absence of contingency planning, delays will inevitably occur, pressures on services will continue to escalate and the opportunity to make a difference for children will not be realised. Questions for MSCB MSCB are invited to consider the Locality & Vanguard20 report and consider how Manchester might adopt a systems approach to change for the benefit of children, families, and service providers. Where will accountability be held for monitoring and evaluation of the learning and development? How will MSCB be best informed of progress and consider how challenge will be provided? How will planned improvements be integrated into the MSCB Learning and Development Plan? 20 In outline, the Vanguard Method provides the means to study services end-to-end, understanding service-user demands, following the demands through the services to understand how and how well the services work and identifying the system conditions that help or hinder achievement of purpose from the service users’ point of view (Locality in partnership with Professor John Seldon - Vanguard Consulting March 2014). MSCB Child H1 Serious Case Review Page 20 of 40 3.2.3 Finding 3. When services are configured for adults and children separately there is a danger that the impact of risk within the whole family is not fully understood or even considered, which can potentially leave children and adults vulnerable. (i) Introduction Currently, Health and Social Care services for children are not fully integrated. Adult Mental Health and Children’s Social Care have separate legal frameworks, separate guidance on policy and practice, separate management and separate lines of accountability As a result, the chances of a whole family assessment with care plans to promote the needs of both the child and the adult becomes much more challenging for all professionals. The ‘Think Family’ agenda was introduced to help professionals working in adult and children services to understand the importance of a whole family approach. Although ‘Think Family’ is not a statutory requirement (and relatively old in policy terms as it was published in 2009), many providers of services have embraced it to support staff to try and minimise the number of cases where risks were not considered from both the adult and child’s perspective. This case has shown that despite initiatives that encourage services to think about the needs of all family members, the continued separate configuration of services mitigates against this approach. (ii) How did the issue manifest in this case? There are several examples in this case illustrating how professionals involved with the family concentrated on identifying individual risks to the children but did not consider the needs of the whole family. The example used to highlight this is the lack of partnership working in relation to mother’s depression. Mother had been registered with the same GP for 13 years, and was well known to the practice. She attended the GP practice two to three times a month, and spoke candidly to the GP about how she felt. The GP had a good understanding of her mental health (including nightmares and flashbacks to the trauma she experienced in Rwanda) and appeared to have a good relationship with her. The GP made three referrals to secondary care mental health over a period; none of which the mother took up. When mother missed her appointments, the surgery appropriately followed these up. However, there was little (if any) communication with secondary mental health, the GP was unaware that the children were the subject of child protections plans, did not know about the other services supporting the family and despite existing guidance,21 there seemed to be no formal liaison between the family health visitor and the GP. The surgery is a ‘paperless’ practice and although the information pertaining to the children was recorded in their electronic notes, including the fact that they were the subjects of child protection plans under the category of neglect, the mother and children’s electronic records were not linked on the Information Technology (IT) system. The other professionals working with the family had little understanding of the mother’s mental health and at times assumed that mother was being ‘difficult’, ‘resistant to help’, or displaying ‘childish behaviour’ when she turned her back on practitioners, why she was doing 21 Communication between General Practitioners and Health Visiting (2012) Health Visiting Task Force, partnership Task and Finish Group. MSCB Child H1 Serious Case Review Page 21 of 40 this, and the possible significance of her depression, was not thought about. Mother was never seen as having needs in her own right or regarded as a vulnerable adult by any of the professionals working with her and her family. Professionals assumed mother was compliant with her medication for depression, but again did not check this out with the GP, had they done so they would have been furnished with a very clear account of mother’s mental health and why: ‘she went to sleep for 16 hours’22, it was understood by the GP that this was: ‘in the hope that she could forget her past experiences’. (iii) How do we know it is an underlying issue and not unique to this case? Within any system there is a reliance on information systems containing the right information and professionals being able to access the information in a timely manner. Currently, IT systems in Manchester are not integrated across service providers and even within health there are several different IT systems in use. When IT systems do not ‘talk to one another’ the emphasis is on professionals communicating, and sharing information in a timely way. The Case Group and Review Team told us that this was incredibly frustrating and time consuming; messages left on voicemails and time taken to respond meant that ‘nothing moved on’. When this also coincides with high volumes of cases, high turnover of staff and the introduction of new models of care it is hardly surprising the communication and information becomes fragmented. The Review Team told us that following the Ofsted Inspection there has been a recognition that service provision needs to change to ensure that the support provided by children’s, adults’ and family services is co-ordinated and focused on problems affecting the whole family to improve the outcomes for the children and adults. The introduction of the Early Help Hubs across the city and the adoption of Signs of Safety23 provide a practice framework for all services - with the aim of improving the effectiveness of multi-agency working with families. The co-location of the Adult and Children’s Multi Agency Safeguarding Hub (MASH) also supports a whole family focus and improves information sharing. However, during this SCR the Review Team had many discussions with the Lead Reviewers about service provision across Manchester and whilst they spoke of a ‘Think Family agenda’ within their own organisations, they remained pessimistic about how this agenda has been translated into tangible changes for children and families in receipt of services. (iv) How prevalent and widespread is this issue? The ‘Think Family: Improving Support for Families at Risk’, was launched in 2009 by the then Department of Children, Schools and Families. This toolkit was based on evidence identifying the lack of integrated practice between services provided to children and adults’ and defined ‘Think Family Practice’ as: ‘Making sure that the support provided by children’s, adults’ and family services is co-ordinated and focused on problems affecting the whole family’. Fundamentally it is about how professionals think, and it is therefore not surprising that professionals who work either with adults or children will have a bias towards how they see and relate to the individuals within the family. When this is put together with a system under pressure, with little time to explore and analyse the risks and possible impact, and combined with a lack of management oversight and robust supervision the likelihood is that 22 ICPCC minutes 29.1.15 23 A solution-focused, strengths- based approach to social work practice; Eileen Munro, Terry Murphy and Andrew Turnell MSCB Child H1 Serious Case Review Page 22 of 40 professionals focus on their own area of expertise and do not always consider the bigger picture. Serious case reviews involving parents who have their own needs (such as substance misuse, mental health difficulties or learning difficulties etc.), often reference the lack of integrated working between adults and children services, and the impact this has on how children are safeguarded: ‘Issues of silo practice have been highlighted in previous biennial reviews, and again were identified in several of these serious case reviews. No single profession has a monopoly of knowledge or skills for protecting children. By working in isolation, professionals miss opportunities to effectively support families and safeguard children.’24 (v) Why does it matter? Families are systems of interconnected and interdependent individuals, none of whom can be understood in isolation. When the focus of each agency starts from the position that whatever needs have been identified can only be assessed by considering each member of the family and the interdependencies that exist, services are provided that meet the needs of the whole family, the needs of an adult are considered in the context of their parenting role and the needs of a child as interdependent on those of the adults and other children in the family. A shared strategic agenda, integrated services, and strong leadership support this approach across the multiagency network and nurtures a culture of joint working, when this happens children are better safeguarded and families strengthened. The converse position of individualising family members and providing services in isolation splits the family system; needs will be divided and services provided in a furrow. When this happens, the whole picture will never be seen; assessments and plans will be inherently flawed, the needs of children and adults will be compartmentalised and despite the determined endeavours of professionals, children will not be safeguarded. Finding 3: When services are configured for adults and children separately there is a danger that the impact of risk within the whole family is not fully understood or even considered, which can potentially leave children and adults vulnerable and without the services they need. Summary Currently, systems and services designed to support families are highly complex and often fragmented, resulting in an uncoordinated and inadequate response to chronic, multi-faceted needs. As a result of this, the ability to clearly identify the needs and risks within the family as a whole becomes more challenging, there will be a focus on either the child or the adult and little consideration of the interrelated and dynamic context of the family system, leaving children and adults vulnerable and without the services they most need. Questions for MSCB How can the Board support multi-agency partners to translate their strategic agendas into tangible change on the front door of service provision? 24 Pathways to harm pathways to protection: a triennial analysis of serious case reviews 2011-2014 (Sidebotham, Brandon et al DfE May 2016) MSCB Child H1 Serious Case Review Page 23 of 40 How would the Board be confident that an integrated approach to working with families is effective? How will MSCB know whether new initiatives/service configurations (such as the Early Hubs) are providing joined up care? How might MSCB support these services in overcoming any obstacles? How might MSCB hear the perspective of children and families and frontline professionals about the opportunities and challenges faced when attempting to provide joined up family focused care? Where will accountability be held for maintaining detailed monitoring and evaluation of the learning and development? How will MSCB be best informed of progress and consider how challenge will be provided? How will planned improvements be integrated into the MSCB Learning and Development Plan? 3.2.4 Finding 4: When professionals feel uncomfortable asking about a person’s background, culture and belief systems beyond the superficial labels used for demographic data collection, children and families’ needs may remain unmet. (i) Introduction This finding relates to how the unique self-identity of a parent and/or child is understood and used to inform service provision. Understanding others fully requires us to try and see others as they see themselves and an appreciation of cultural difference is an element of that. In the absence of this, we just superimpose what we think upon others. In the context of child protection work this can be a dangerous practice as it means we never fully appreciate what motivates different individuals and therefore how we can help them to change. If this is layered with a misunderstanding that it is intrusive to ask about someone’s background and that everyone should be treated the same regardless of race or culture, then this runs the risk of severely limiting how parents and families are understood and services provided. (ii) How did the issue manifest in this case? Throughout all the case records, assessments, case conference minutes, plans and interventions it was not possible to gain a complete understanding of mother’s self-identity. Glimpses of this identity were recorded in the case records and related during conversations with the Case Group: ‘Ms X (mother) was from Africa (maybe Zimbabwe, Nigeria or Rwanda) and had sought asylum’, she followed the Christian faith, ‘she may have been catholic and she had no family or kinship in Manchester or in the UK’, these glimpses of mother’s identity were endlessly repeated but rarely checked out. By examining the full range of multi –agency records (some of which relating to the 11 years’ mother had been in the UK) it was clear that she was from Rwanda, that she left school when she was 10 years old and was 16 when the mass genocide of the Tutsi people occurred (1994). Practitioners were clear that Mother had strong religious beliefs and after reviewing all the records as part of this review it was established that she was an active member of a local MSCB Child H1 Serious Case Review Page 24 of 40 Christian church, as were the children. She was clearly known well by the congregation (who visited her daily whilst she was in hospital) and at times the children spoke favourably of ‘uncles, aunts and godparents’ (who were thought to be from within this community). When she was challenged about the completion of a task she would frequently say: ‘God will provide’. What mother’s beliefs meant in practice, how this manifested in her internal world and the part it played in her identity, her relationships and in the life of her children was unexplored and so not understood. Instead, assumptions were made and these assumptions found their way into assessments and plans. (iii) How do we know it is an underlying issue and not unique to this case? During this SCR, multi-agency practitioners were asked about mother’s identity and almost without exception, little was known about her background, her cultural practices or her religious beliefs and practices. There was evident confusion about these areas and there was a distinct lack of curiosity across the professional groups as to why these questions were being asked. Gaining an understanding of a person’s self-identity did not appear to be custom and practice, was not covered within existing assessment formats, and was not seen as core business in how children are safeguarded25. When this was explored further, beneath what appeared at first sight to be ambivalence was something more. Practitioners spoke about a fear of exercising curiosity about the cultural background of people from BME communities, there seemed to be a fear that recognising difference and diversity by asking these questions might be at best intrusive at worst perceived as racist and this had to be avoided at all costs: ‘we fear asking the question for fear of being seen as racist’. When asked how cultural diversity is understood in Manchester, the routine response was to refer to the statistical collection of data that customarily takes place on each case where boxes are ticked in a menu of demographic variables: ‘it’s about statistical collection rather than understanding how services are provided to the community, so we just tick the box…its collation and meaning is completely outside our work’. This finding generated substantial discussion and debate amongst the Review Team, there was a strong urge to get beneath what may be inhibiting practitioners, it was strongly felt that the fears about asking the questions about identity may be about something more complex than a fear of being either intrusive or potentially insulting, and the following reasoning was put forward: ‘Understanding of personal identity is a complex issue and professionals need support and education in order to see how this benefits the holistic understanding of families. It may be that working with a culturally diverse population may have a counterintuitive effect leading to assumptions, generalisations and a degree of ignorance in terms of the correct terminology and cultural contexts’. (iv) How prevalent and widespread is this issue? There is no local or national data that is entirely relevant to this finding. However, the data in relation to Manchester’s demographic profile26 provides some insight into the diverse nature of the Mancunian community. Of the overall population 40.7% are recorded as being 25 None of the recording formats specifically covers these areas, and there is no training available. 26 Manchester Migration. A Profile of Manchester’s migration patterns. Manchester City Council March 2015 MSCB Child H1 Serious Case Review Page 25 of 40 of BME identity27. The report notes: ‘Black African group appears to have grown rapidly over the last decade from 6,655 in 2001 to 25,718 whereas Black Caribbean remains relatively unchanged. There have been many immigrants from countries such as Nigeria and Somalia, and a probable increase of northern and north-eastern African immigrants following the Arab Spring’.28 Relevant research and practice guidance promotes the need to understand the cultural identity of this community so that culturally sensitive services can be provided: ‘Grounding practice in cultural competence is one element in addressing the ‘profound issue’ of practitioners’ lack of confidence. Direct work with families whose language or culture are different can raise anxiety. Practitioners may be worried about causing offence by using the ‘wrong’ terminology or feel uncertain about questioning unfamiliar family practices. Such uncertainty can hamper critical thinking, direct observation and partnership working and undermine professional confidence’.29 (v) Why does it matter? Valuing the pivotal place of self-identity in the day to day life of a parent and a child and in the life of a family provides an important starting place for getting beneath the surface of assessments of risk by facilitating an understanding of risk and resilience, strengths and vulnerabilities. With this as a starting point, meaningful partnerships with families can be built, engagement facilitated and services designed to meet their needs. Without such an understanding, at best ill-informed services are provided and at worst groundless assumptions can be made. Being fearful of asking curious questions about past experiences, culture and beliefs for fear of being seen as overly intrusive or, in the case of families from BME groups for fear of being seen as racist, has a significant impact on the ability of professionals to make assessments and provide services. It is an approach that seriously hampers the way children from all racial and cultural groups are safeguarded and as this finding has shown, has particular implications for children from BME groups. Finding 4: When professionals feel uncomfortable asking about a person’s background, culture and belief systems beyond the superficial labels used for demographic data collection, children and families’ needs may remain unmet. Summary Individual identity is an internal model unique to us all that gives us a perception of self as an individual and social being. We are all members of numerous social groupings, but we are also distinct in our own individuality from any other member of a given group to which we belong, despite some areas of commonality. Each individual interaction between a child or parent, his or her family, relationships, social context and environment, will be processed into an individual experience. If a child or a parent’s individual identity is not understood or if assumptions are made about this identity, 27 This figure includes people of mixed heritage 28 A measure of caution should be applied to this data, the report notes: it is important to be aware that the Black broad ethnic group was estimated to be one of the main types of population undercounted in the 2001 Census for Manchester, so the scale of the rise in the Black African group may be misleading. 29 Confident Practice with Cultural Diversity. Research in Practice 2015 MSCB Child H1 Serious Case Review Page 26 of 40 assessments and services will be of limited value and the safeguarding of children will be compromised. Questions for the Board How will practitioners be supported in exploring self-identity and how can this be facilitated? How well are faith and community groups engaged in the work of the MSCB? What can be done to promote on-going dialogue with these groups? What is known about non- government organizations (NGO’s)? How might they support safeguarding practice in this area? Where will accountability be held for maintaining detailed monitoring and evaluation of the learning and development? How will MSCB be best informed of progress and consider how challenge will be provided? How will planned improvements be integrated into the MSCB Learning and Development Plan? MSCB Child H1 Serious Case Review Page 27 of 40 3.2.5 Finding 5: Local authority management systems are insufficiently challenging of the custom and practice of social workers not to seek or systematically record informed parental consent for section 20 accommodation, potentially leaving the support needs of parents’ unseen and making case-drift more likely. (i) Introduction Section 20 (s20) arrangements happen for three reasons: if a child has no person with parental responsibility for them, they are lost or have been abandoned, or the person who has been caring for them is prevented (temporarily or permanently) from providing them with suitable accommodation or care. The law “does not require’ informed consent for s20 arrangements to be lawful. Statute sets out that a local authority cannot provide s20 accommodation if someone with parental responsibility objects, and can provide an alternative. Use of s20 allows children to be placed away from the home with approved local authority foster carers, with family members or in a children’s home. In some cases, the use of a s20 can work very well and be to the advantage of the children, parents and local authority in avoiding the unnecessary use of court processes (that can be extremely time consuming and stressful for families). However, good practice guidance that underpins the use of this statute dictates that informed consent is gained for this arrangement (both at the time of the accommodation and for the duration of the arrangement): ‘Consent must be treated as a process that continues throughout the duration of care and treatment, recognising that it may be withheld and / or withdrawn at any time’30. This finding has shown that the good practice principles for obtaining informed consent are not understood. (ii) How did the issue manifest in this case? The children were accommodated three times under s20 during the review period. The children were initially accommodated using s20 when mother was cautioned and charged with neglect, and the house was deemed unsafe for the children to remain there. Although the mother wasn’t happy for the children to go into care she agreed, and the children remained in care for five months. During this time, she had contact with her children for one hour a week. It is unclear how consent was obtained, how much the mother understood about what she had agreed to, and how far she understood what rights she had under this arrangement. The children were accommodated a further two times during the period under review; the first was short term, when their mother was admitted into hospital for the birth of her fifth child and the second time was when mother was detained in hospital under section 2 of the Mental Health Act (1983). (iii) How do we know it is an underlying issue and not unique to this case? During the conversations with the Case Group and Review Team as part of this SCR, they said that a s20 is commonly used in Manchester and consent by the parent (with parental responsibility) for the use of a s20 agreement is not routinely recorded. When challenged about how children’s social workers assessed whether the parent had the capacity to consent to the use of a s20 agreement, experienced social workers replied: ‘you just know’. The Review Team and Case Group said that there had been no guidance about how parental consent is recorded. It was also clear from discussions with the Case Group that there is 30 A guide for people who work in health and social care. OPG 603 MSCB Child H1 Serious Case Review Page 28 of 40 little management oversight or supervision of how consent is obtained from a parent under a s20 agreement. Unlike adult social workers and health colleagues, who receive mandatory Mental Capacity Act (MCA) training, there was no formal training provided to Children’s Social Care staff. It was subsequently understood that some training has been offered since this period under review, when it has been clarified that SW’s are expected to use the expertise of colleagues in adult social care or mental health services to carry out a mental capacity assessment, but the low uptake suggests this is not an area that has been prioritised.31 (iv) How prevalent and widespread is this issue? The use of section 20 has increased steadily since 2013 is acknowledged as both a local and national issue. The number of Looked after Children in Manchester as of the 31.5.16 was 1245 of which 172 were accommodated under a s20 agreement; this equates to 13.8%. Munby states that s20’s ‘are over used and misused’32. Recent judgements by Munby highlight failure of councils to get informed consent. Munby called ‘the misuse not just a matter of bad practice and insisted: It is wrong; it is a denial of the fundamental rights of both the parent and the child; it will no longer be tolerated; and it must stop’. Because of these concerns, Munby set out new guidance for what ‘future good practice requires’: - Where possible, the agreement of a parent to a section 20 arrangement should be properly recorded in writing and evidenced by the parent’s signature. - The written document should be clear and precise and drafted in simple and straightforward language that a parent can readily understand. - The written document should spell out that the parent can “remove the child” from the local authority accommodation “at any time”. - The written document should not seek to impose any fetters of the parent’s right to withdraw consent. - Where the parent is not fluent in English, the written document should be translated into the parent’s own language and the parent should sign the foreign language text, adding, in the parent’s language, words to the effect that ‘I have read this document and I agree to its terms.’ (Munby 2015).33 (v) Why does it matter? In a safe system, obtaining the agreement of parents to a s20 agreement involves a rigorous process of understanding the legal principles governing this statute, appreciating the vulnerabilities of a parent and ensuring that this consent is a process of appreciative and respectful enquiry, clear recording and the subject of routine discussion and review. This can work particularly well when parents are given access to independent advocacy in order that their human rights and that of their children are independently represented. If used in this way, the arrangement can work well for the child, parent and the local authority in 31 Relevant training has since been provided however, it is recognised that the uptake of this training is low and there is a lack of evidence that the training is being put into practice. 32 James Munby, President of the Family Division of High Court England and Wales 33 Recently, the Court of Appeal has ruled that; in strict legal terms consent is not required for Sc20 however, the judge also made it clear that the Munby good practice guidance should continue to be followed (Community Care 2/2/17). MSCB Child H1 Serious Case Review Page 29 of 40 providing a short term safe environment that allows a period for a safeguarding plan to be formulated and acted on without recourse to the court system (that has the danger of creating additional stress for parent/s and can risk promoting an adversarial relationship between families and statutory services). In addition, when a parent is helped to understand why accommodation of their children might be helpful and in some cases necessary, they are more likely to engage with services in making any required changes. However, if parental agreement to this arrangement is not firmly grounded in the principles of good practice, the use of s20 to voluntarily accommodate children could be regarded as potentially deceitful and in the absence of the legal framework in place during care proceedings can lead to drift in care planning and unnecessary delay in the child/ren’s return to parental care. Research has shown that families who are the subject of statutory intervention are often already marginalized and socially isolated, living on a low income and in poor housing. If this is compounded by parental learning difficulties, intellectual impairment, or existing mental health issues and there is limited access to independent legal advice or advocacy, the use of s20 has the potential of breaching the rights of children and families. Finding 5. Local authority management systems are insufficiently challenging of the custom and practice of social workers not to seek or systematically record informed parental consent for s20 accommodation, potentially leaving the support needs of parent’s unseen and making case-drift more likely. Summary Munby has provided clear good practice guidance to Local Authorities about how informed consent by a parent, who has parental responsibility, should be gained and recorded. Despite some training around section 20 for social workers, there appears to be a perception by frontline staff that there is no clear guidance for staff working in CSC about how this good practice should be used. There is a danger that by failing to support staff in this area, the system is failing to meet the fundamental rights of both the parent and child and inadvertently making successful engagement between family and professionals less likely. Questions for MSCB How will the Munby good practice guidance impact on how consent is obtained in Manchester? How confident is the Board that practitioners and managers understand the legal principles governing how parental consent is gained? Where will accountability be held for maintaining detailed monitoring and evaluation of the learning and development? How will MSCB be best informed of progress and consider how challenge will be provided? How will planned improvements be integrated into the MSCB Learning and Development Plan? MSCB Child H1 Serious Case Review Page 30 of 40 3.2.6 Finding 6. Over-concern about the risks rather than benefits of information sharing is resulting in professionals in Manchester being unsighted as to safeguarding risks to children. (i) How did the issue manifest in this case? There were six child protection conferences held during the review period. In line with expected practice, policy and procedure, these conferences presented an opportunity to bring the multi-agency safeguarding network together, share information, decide whether the threshold for significant harm had been reached and agree on a plan to protect the children and meet their needs. On reviewing the minutes of these conferences, gaps were observed in the information that was shared; this was particularly noticeable in the RCPCC held on 27th June 2013 when information from the nursery for two of the children and information from the school attended by the eldest child was missing. In addition, when the distribution list of the minutes was scrutinised it was noted that these vital safeguarding partners (who arguably knew the children best) were not sent minutes of the case conference. A statement made in several these conference minutes revealed the following custom and practice: “Anyone who has been invited to this meeting and sent apologies will be sent a copy of the record of the meeting”. Thus, if multi-agency professionals did not send a report and did not send their apologies, they did not receive the minutes. (ii) How do we know it is an underlying issue and not unique to this case? Discussions with the Review Team and Case Group confirmed that in Manchester this is part of existing custom and practice; if professionals do not attend a CP case conference and do not send apologies regardless of their involvement with a child, they are not sent the minutes. The Lead Reviewers were curious about this, and during the ensuing discussions what emerged was a custom and practice that seems to have evolved in response to an organisational pressure to comply with data protection legislation; if professionals do not attend CP conferences there is no guarantee that they are still involved with a family therefore, sending the minutes to the last known address of the professional is: ‘a shot in the dark’ (the minutes could end up on the doorstep of someone who is no longer involved or worse still, at the address of someone who is not a safeguarding professional). The high turnover of staff in the various agencies and the movement of cases through the different agency systems means that it is very difficult for social workers to keep track of these changes, thus the data base is not always a reliable way of identifying who is currently involved. Further discussions about how this may affect wider safeguarding systems, revealed that in Manchester the list of children who are the subject of CP plans is not shared with local hospitals. As a result, there is no system within the hospital databases to identify (flag) children who are suffering significant harm who present to A&E/ acute hospital settings. This means that when a child is presented to hospital, knowing that they are the subject of a CP plan/ are suffering significant harm is dependent on clinicians finding out for themselves34. 34 It was understood that work is currently underway to link up the local authority IT systems with hospital unscheduled care settings (A&E departments). This is planned to be implemented early in 2017 and should improve the management and information sharing within the safeguarding network - Child protection information sharing (CP-IS) between Local Authority and Central Manchester Foundation Trust. MSCB Child H1 Serious Case Review Page 31 of 40 (iii) How prevalent and widespread is this issue? No data or research could be found on this custom and practice either locally or nationally. It may well be that this specific issue about information sharing in the context of the distribution of child protection minutes, is particular to Manchester. However, the issue of whether data protection is placed at an organisationally higher value (however unintentional) than child protection is not. Serious case reviews going back over sixty years to Denis O’Neil (1945) have identified concerns about the sharing of information. More recently in 2009, Lord Laming stressed: ‘organisational boundaries and concerns about sharing information must never be allowed to put in jeopardy the safety of a child’. In the triennial review of SCR’s published in 2016, the author’s comment: ‘Our reviews of serious case reviews spanning more than ten years suggest that, despite national guidance and legislation, there are deep cultural barriers to effective information sharing among professionals. ……. Data protection legislation is viewed as a set of constraints limiting information sharing rather than a facilitative tool.’ (iv) Why does it matter? When multi-agency case conferences work well, information is shared in a two-way process from the child’s network to the conference and from the conference to the network (in the form of the conference minutes). This allows all those involved with the child to be clear about the risks, to know who is involved with the child, and to be clear about the CP plan and what is expected of them. Conducted in this way, they are a fundamental cornerstone in how multi-agency partners protect thousands of children every day across the country. If fears about data protection prevent the sharing of information and fetters the established child protection mechanisms- these mechanisms will be compromised and children will not be protected. Finding 6. Over-concern about the risks rather than benefits of information sharing is resulting in professionals in Manchester being unsighted as to safeguarding risks to children. Summary In Manchester, the priority given to protecting human rights to privacy is commendable. However, if this involves an arrangement where data protection is valued over and above the protection of a child a new vulnerability is created in the system. Questions for MSCB What support will be provided to partner agencies to address the concerns raised by this finding? Does MSCB know whether other areas of safeguarding practice are constrained by a misinterpretation of data protection legislation and fears of data breach? Is MSCB aware of the recent recommendation from the DfE35 ‘Local early help and safeguarding partnerships to develop a strong and coherent approach to making decisions about the balance of risk when sharing information about vulnerable 35 Information sharing to protect vulnerable children and families. A report from the Centre of Excellence for Information Sharing (DfE July 2016) MSCB Child H1 Serious Case Review Page 32 of 40 children and families? ‘How might the board support services in this decision making? Where will accountability be held for maintaining detailed monitoring and evaluation of the learning and development? How will MSCB be best informed of progress and consider how challenge will be provided? How will planned improvements be integrated into the MSCB Learning and Development Plan? 4. Responding to the Research Questions 4.1 Responding to the Research Questions Not all the research questions that were agreed at the start of this review could be explored in any depth within the scope and time available. With hindsight, they risked taking the review on too wide a journey. Rather than leave them unaddressed, the Lead Reviewers have considered them in the light of what has been learned from this case and followed each with a recommendation for the Board to consider. 4.1.1 How well do multi-agency services identify and respond to the needs of Young Carers in Manchester, in particular meeting their emotional health and well-being? During the time under review, the professionals who knew the family best identified the eldest child as a Young Carer. At the ICPCC in January 2015, it was reported that: ‘The young carers support service was considered for (name of eldest child), however it was decided that this service was not appropriate because Ms X (mother) is capable of caring for the children’; as a result, this child did not receive a service from Young Carers for the duration of agency involvement. This response by this service that was reported to the conference was surprising, it seemed that a strict criterion had been applied to how services were accessed and even though this child was clearly providing frequent care to the children in the family, she was not regarded as eligible for a service. The Lead Reviewers were told that at the time there were several third sector organisations commissioned to provide services to young people across the city: ‘How services interpreted what constituted being a ‘young carer’ seemed to be applied on an ad hoc basis rather than adhering to informed eligibility criteria’. Following the Ofsted inspection, Manchester’s Children Services introduced three Early Help Hubs across the city: ‘the aim of which is to increase the number of Early Help Assessments and identify the service interventions that a family or young person needs’. There is also work underway to determine how many young carers there are across the city: ‘the age of children caring for adults is falling with some as young as 8 being identified’. School nurses are an important source of identifying young carers, but in the last 16 months the number of school nurses has been significantly reduced (40%). Alongside this reduction MSCB Child H1 Serious Case Review Page 33 of 40 of school nurses, is a change in the service model with a focus now on: ‘delivering the healthy child programme and immunisation programme within schools’. The impact is that there is very little capacity within the school nurse service to undertake any additional or bespoke pieces of work that they would have historically undertaken, and this includes young carers. This remains an important area of service provision, the MSCB are advised to continue to monitor and take steps to enable young carers to receive the support they need. 4.1.2 How well do multi-agency partners recognise assess and respond to risk across services with particular reference to males in households, mobile isolated families, immigration status and BME? The issues in relation to assessment and care planning for children and families from within the BME community have been discussed in finding 4. No direct reference has been made to ‘mobile isolated families and immigration status’ within this report. Several the findings contain relevant issues (in particular, Finding 4). However, addressing these issues in detail was not possible within the scope of this review. In the appraisal of practice, the absence of any checks as to whether the father of the three younger children posed any risk to the family or whether he was supportive and provided stability was discussed. A decision was taken not to have a finding about this, as previous SCR’s in Manchester have identified this as a practice issue requiring improvement. This case suggests that this remains an area for learning and development within multi-agency services. Manchester is not alone in this, the triennial review of SCR’s in March 2016 makes the following recommendation: ‘Efforts must be made to increase the visibility of fathers in practice, policy and research around neglect. Too often mothers are the focus; this can mean that the risks and protective factors that fathers bring to a child’s life may be missed. Local service leaders can enable this through policy review and practice audits.’ It is recommended that the MSCB review previous learning and development plans that have attempted to improve practice in this area, and consider what more needs to be done. 4.1.3 How well is the learning from SCRs implemented on the front line? As outlined above, this case has suggested that the learning in relation to the involvement of fathers has not been implemented on the front line. In addition, the last three SCRs published by MCSB identified similar areas that are found in this case; neglect, history of mental health difficulties and poor engagement with professionals. Two recent SCRs have covered the same timeframe as this review therefore any learning from these cases would not be reflected in practice. In terms of poor engagement, professionals dealing with families who are not engaged with services often describe them as ‘hard to reach’ or ‘difficult to engage’ and as seen in this case there is a tendency to close the service rather than explore the reasons behind the MSCB Child H1 Serious Case Review Page 34 of 40 non-engagement. To employ appropriate support and challenge parents when non- engagement or disguised compliance occurs, professionals need to be supported through adequate supervision, training and management oversight. This was identified as an area requiring improvement in the Ofsted inspection. It is recommended that the MSCB reviews how the learning and development from SCRs is implemented on the front line of service provision. 4.2 Additional Learning: Involvement of GP’s with SCRs and communication pathways within Primary and Community Care 4.2.1 Involvement of GPs Whilst undertaking the SCR, the lead reviewers were struck by the absence of the services provided by the GP practice in the SCR process. General Practice was not included in the MSCB combined agency report and they were not invited to be part of this SCR. Therefore, the information held by the practice and relationship that the GPs had with the family (in particular with mother) was not known about until relatively late in the process. This issue was highlighted in a previous SCR in Manchester and the Ofsted Inspection (2014) identified that there was a ‘lack of communication within primary care and community services and that this was present in recent completed SCRs in Manchester’. It is understood that this has now been rectified and General Practice is now considered during the commissioning process for SCRs; the MSCB are invited to monitor this new development. 4.2.2 Communication pathways within Primary and Community Care In 2015, the Citywide Clinical Commissioning Group introduced the Primary Care Link Nurse Programme and part of their agenda was to: ‘strengthen and improve communication between HV’s and GPs’. At each practice visit, the level of contact each GP received from the allocated health visitor was recorded. This piece of work identified that there is still much work to be done on improving communication, only 15% of GPs across Manchester recorded that they have regular and good contact with the allocated health visitor; which would suggest the 85% of GPs did not. It is clear that health visitors and general practitioners need to strengthen their working relationship to improve outcomes for children and families. The MSCB to review how communication can be improved between Primary and Community Care to further strengthen safeguarding and to consider how best to engage with Public Health (who are responsible for commissioning health visiting and school nursing) to embed improvements in service delivery. MSCB Child H1 Serious Case Review Page 35 of 40 5 Conclusion This systems review has had two principal aims: to report and learn from what happened in a case and why, and to consider what this tells us about the wider safeguarding of children in Manchester and how this might be improved. Overall the review has highlighted the complexity of working long-term with a mother and her five children, who had been voluntarily accommodated by the local authority and subject to child protection plans for neglect, stepped down, and then the cycle repeating itself. The findings have focused on the learning for Manchester which will improve the multi-agency response to working with children and families, in particular, with families who are perceived as ‘difficult to engage’ and where there is a long history of poor parenting and neglect. The contents of this report have been the product of the Review Team and Case Group who contributed their knowledge and experience in relation to this case, as well as their wider understanding of how safeguarding systems operate in Manchester. MSCB Child H1 Serious Case Review Page 36 of 40 Appendix 1 Methodology This review was conducted using SCIE’s Learning Together methodology (Fish, Munro & Bairstow; SCIE 2008). Learning Together is a systems approach, which seeks to understand professional practice in context. Learning Together reviewers work collaboratively with practitioners and leaders to identify the factors in the system that influence the nature and quality of work with families, using the issues highlighted in the case under review as the primary evidence base. Solutions then focus on redesigning the system to minimise adverse contributory factors, and to make it easier for professionals to practice safely and effectively. The methodology is based upon several key principles: • Avoid hindsight bias: in order to understand why people acted as they did, it is Important to avoid the wisdom of hindsight; the tendency to judge actions from the standpoint of knowing what happened later, when it is easier to see which bits of information were significant and which were irrelevant. • Provide adequate explanations: appraise and explain decisions, actions and inactions in the professional handling of the case, by seeing performance as the result of interactions between the context and what the individual brings to it. • Move from individual instance to the general significance: use a single case to provide a ‘window on the system’ in Manchester, finding out whether weaknesses or strengths in its management are widespread, and so leading to a broader understanding about what supports and what hinders the reliability of the multi- agency child protection system. • Produce findings and questions for the LSCB to consider: Some findings lead to the simple recommendation of a new rule or way of doing something, but others require LSCBs to consider how to balance identified needs with other demands on agencies’ resources. • Analytical rigour: use of qualitative research techniques to underpin rigour and reliability and a very open process so that others can see how conclusions were reached. Data comes from structured conversations with involved professionals, case files and contextual documentation from organisations. These principles are supported by a suite of SCIE’s analytic tools. One such tool is a typology to help identify which aspect of the child protection system the findings are located within and thereby make it easier to know where to focus solutions. SCIE has developed a typology of 6 broad categories, each of which relate to a different (although linked) aspect of the work and within which it is common to find patterns of practice or behaviour that are systemic: Multi-agency working in response to incidents and crises Multi-agency working in longer term work Human reasoning: cognitive and emotional biases Family – Professional interaction Tools Management systems. MSCB Child H1 Serious Case Review Page 37 of 40 6.1 Findings: are structured to present a transparent and evidence based account of how the practice issue features in the particular case; in what way, it is an underlying issue – not a quirk of the particular individuals involved and in the particular constellation of one case; how widespread a problem it is perceived to be and/or data about its prevalence both locally and nationally. Finally, each Finding addresses the consequence of not doing anything about it, or why it matters in the context of multi-agency child protection work. 6.2 Organisational learning & improvement: The Findings of Learning Together reviews require debate. They highlight relevant points for LSCBs to consider when deciding upon the most appropriate course of action for local circumstance and do not tend to prescribe specific recommendations at the point of delivery. Considerable learning will have been generated for practitioners and managers as a consequence of their involvement in the review process. The discussions that take place following the completion of a review build upon this and enable the creation of a development plan going forward that is fully owned by the Board and its member agencies. 6.3 Reviewing expertise and independence: Two independent lead reviewers have led the SCR. Ann Duncan and Bridget Griffin have had significant experience of leading SCR’s and are both accredited by SCIE. Neither has any previous involvement with this case, or any previous or current relationship with Manchester Council or partner agencies. The lead reviewers have received supervision from SCIE as is standard for Learning Together accredited reviewers. This supports the rigour of the analytic process and reliability of the findings as rooted in the evidence. 6.5 The Review Team: The Review Team was made up of senior managers from the agencies involved in the case, who themselves had no direct part in it. Led by the independent Lead Reviewers, they worked as a Panel throughout the review, gathering and analysing data, and reaching conclusions about general patterns and findings. They were also a source of data in themselves, about the services they represent: their strategic policies, procedures, standards, and the organisational context relating to particular issues or circumstances such as resource constraints, changes in structure etc. The Review Team met on six occasions over the course of the review. The Review Team were: Detective Chief Inspector, Greater Manchester Police Head of Contact and Referral, Children Social Care Designated Doctor for Safeguarding Children, CCG. Designated Nurse for Safeguarding Children, Manchester North, Central and South CCG’s Named Nurse for Safeguarding Children, Central Manchester University Hospitals Named Nurse for Safeguarding Children, Manchester Mental Health and Social Care Trust Locality Manager, Early Help Hub Education Case Worker Children’s Social Care. Supported by: MSB Interim Business Manager MSB Co-ordinator MSB Business Support Officer. MSCB Child H1 Serious Case Review Page 38 of 40 6.6 Sources of data: Practitioners who were involved with the case at the time formed a ‘Case Group’. Their experiences were captured through individual conversations with Lead Reviewer and members of the Review Team. We held 14 conversations in order to build the base evidence for this review. In addition, the Case Group met on two other occasions- this allowed the Review Team to check factual accuracy, clarify any issues and build on the analysis in the review and findings. Unfortunately, the attendance at the second Case Group meeting was low (due to sickness and annual leave) and other practitioners attended who hadn’t been at the first. This made it difficult to build any momentum as time was taken up with explanations and discussion as to how we had arrived at the emerging findings. The Case Group was made up of: 3 Health Visitors Mental Health Ward Manager 2 Child Protection Chairs Pastoral Care Secondary School 2 Social Workers CSC Social Work Manager Head teacher Families First practitioner CIN Team manager Families First Manager CIN worker Nursery teacher School Nurse Mental Health Practitioner In addition to the Case Group members a conversation was held with the family GP but was not included in the Case Group. 6.7 Data from documentation: The Lead Reviewers and members of the Review Team reviewed documentation from a range of sources and agencies including but not exclusive to: integrated chronology, child protection case conference minutes, looked after review minutes, multi- agency reports to case conferences, care plans, case recordings from specific agencies, service specifications and performance management data. MSCB Child H1 Serious Case Review Page 39 of 40 Appendix 2: References Manchester Migration. A Profile of Manchester’s migration patterns (MCC - March 2015) Manchester City Council (MCC) Ofsted Inspection Report (Ofsted: September 2014) Greater Manchester Safeguarding Children Procedures (MCC – updated November 2016) Greater Manchester Children’s Service – Signs of Safety (June 2016) – Post Ofsted Improvement Plan Ten pitfalls and how to avoid them. What research tells us (Dr Karen Broadhurst, Professor Sue White, Dr Sheila Fish, Professor Eileen Munro, Kay Fletcher and Helen Lincoln - September 2010 www.nspcc.org.ukinform) Assessing Children in need and their families: Practice Guidance (DOH 2000). Confident Practice with Cultural Diversity (Research in Practice 2015). Research Briefing: Neglect (NSPCC 2012) Working Together to Safeguard Children, A guide to inter-agency working to Safeguard and promote the welfare of Children (HM Government, 2015). Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 – 2014 (DfE 2016). Safeguarding children and Young People. The RCGP / NSPCC Safeguarding Toolkit for General Practice. Dr Vimal Tiwari and Dr Matthew Hoghton (2014 Making decisions, A guide for people who work in health and social care. OPG 603 2009 (4th edition) Your child, your school, our future: building a 21st century school system (DfE –2009) Saving money by doing the right thing - Why ‘local by default’ must replace ‘diseconomies of scale’ (Locality in partnership with Professor John Seldon - Vanguard Consulting- March 2014). Information sharing to protect vulnerable children and families. A report from the Centre of Excellence for Information Sharing (DfE July 2016). Manchester’s Early Help Strategy 2015 – 2018 Missed opportunities: indicators of neglect – what is ignored, why, and what can be done? Marion Brandon, Danya Glaser, Sabine Maguire, Eamon McCrory, Clare Lustey & Harriet Ward – Childhood Wellbeing Research Centre (Nov 2014) MSCB Child H1 Serious Case Review Page 40 of 40 Appendix 3: Acronyms and Terminology CAFA Child and Family Assessment CAMHS Child and Adolescent Mental Health Services CG Case Group CIN Child in Need CINIS Child in Need Intervention Service CPP Child Protection Plan EPO Emergency Protection Order GP General Practice / Family Doctor HV Health Visitor ICPC Initial Child Protection Conference LA Local Authority LAC Looked After Children MASH Multi-agency Safeguarding Hub MCA Mental Capacity Act MCSC Manchester Children Social Care MSCB Manchester Safeguarding Children Board PLO Public Law Outline PPO Police Protection Order PPP Police Protection Power RT Review Team SAR Safeguarding Adult Review SCIE Social Care Institute of Excellence SCR Serious Case Review SW Social Worker WTE Whole Time Equivalent |
NC52800 | Three siblings, Samuel (17), Shay (15) and Joy (13), known to services as potential victims of criminal exploitation. In 2022 Samuel was involved in two altercations and received knife wounds. In December 2022, Shay was arrested regarding an assault with a knife which led to another arrest for class A drug possession. Learning themes include: working with the family, alongside the wider contextual issues regarding child criminal exploitation and serious youth violence; evaluation of assessments and interventions; the role of schools; use of knives and police and criminal justice interventions; use of social media and agency assessment of its significance; extra-familial harm versus criminal activity; use of the National Referral Mechanism (NRM); and managing the needs and risks of siblings. Recommendations for the Partnership include: adopt the term 'extra-familial harm' to describe 'child exploitation'; review the existing system of alerting senior managers to 'high risk' children in children's social care; ensure that front line practitioners have a clear understanding of adolescent development and the impact of ACE's/trauma; consider a multi-agency learning audit for children involved in the Section 47 process where there is an extra-familial harm concern; school leaders should review the effectiveness for children of separate 'on site' alternative learning provision; embed training on children's use of social media and its associated risk factors into existing training; ensure one safeguarding partner takes sole responsibility for tracking children subject to the NRM process; and where extra-familial harm is evidenced ensure siblings are appropriately assessed and interventions are put in place.
| Title: Local child safeguarding practice review: Samuel, Shay and Joy. LSCB: Pan Dorset Safeguarding Children Partnership Author: Ian Vinall Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Pan Dorset Safeguarding Children Partnership Local Child Safeguarding Practice Review Samuel, Shay and Joy Ian Vinall Independent Author June 2023 2 1. Introduction 1.1 The subjects of this Local Child Safeguarding Practice Review are three siblings, Samuel1 (aged 17), Shay (aged 15) and Joy (aged 13). All three children lived with their mother, Michelle, and her partner. Although birth father lived nearby, his only contact was with Joy. 1.2 In August 2022, Samuel had an altercation with two individuals and he received knife wounds consistent with Grievous Bodily Harm. 1.3 In September 2022, Samuel was involved in a second unrelated altercation and was stabbed with a knife. His significant injury required hospital treatment. 1.4 In December 2022, Shay was arrested and interviewed regarding an assault with the use of a knife. When he was arrested, a significant amount of class A drugs was found, and he was also arrested for Possession with Intent to Supply (PWITS). 1.5 At the time of these incidents Samuel and Shay’s case was open to the Complex Safeguarding Team (CST) because of concerns of them being criminally exploited. 2. Methodology 2.1 The report author met with Michelle, Samuel, Joy and their maternal aunt as part of the review. Shay and the children’s birth father chose not to engage with the review. Assessments, care plans, meeting minutes and single agency service reports were analysed by the author to form a chronology of the children’s circumstances together with reflective discussions with practitioners who have worked directly with the children and family or have significant knowledge of the children’s circumstances. Together, these processes identified the Key Practice Themes which were tested by two practitioner events. The agreed time frame for the review was between October 2021 and December 2022. The children remain subject to child protection, youth custody and looked after child processes. 3. Protected Characteristics2 3.1 The family are white British and do not assign to a particular religion or faith. Michelle and the children’s father are separated, and Michelle has undertaken most of the children’s care throughout their childhood, albeit with support from her partner in the last four years. Michelle has two job roles to support her family financially. There were historic concerns at school about the physical presentation of the children. 3.2 Whilst not deemed a protective characteristic, the two boys were formally notified of their NRM status, highlighting them both as potential victims of exploitation. The boys 1 Not their real names. 2 Discrimination: your rights: Types of discrimination ('protected characteristics') - GOV.UK (www.gov.uk) 3 may be victims and perpetrators of exploitation and this presents challenges to agencies. 3.3 The scale of the boy’s criminal activity has impacted on the whole family, including the trauma of armed police raids on the family home. 3.4 Both boys have been permanently excluded from school and spent periods in alternative learning provision. 3.5 Shay has been diagnosed with ADHD and his learning needs and presentation suggests that mainstream education did not recognise his speech, language, and communication needs. He only received specialist intervention at the point of involvement from the Youth Justice Service. 3.6 The area in which the family live is seen as a relatively prosperous area yet wealth is not evenly spread and significant pockets of deprivation and inequalities exist. Both boys misuse drugs and alcohol and locally, the rate of deaths from drug misuse is higher than that of England. For younger people, the rate of hospital admissions for substance misuse aged 15-24, and the percentage of 15-year-olds who have taken cannabis in the last month is significantly higher compared to England3. 4. The Children’s Story 4.1 Children’s Social Care records begin in 2016 owing to Shay’s behaviour at school and violence towards his mother and siblings. The family engaged with Early Help support and there was no further agency contact until 2020. Shay was then at risk of permanent exclusion due to ‘persistent disruptive behaviour’ and ‘unidentified learning needs’ impacting on his behaviour in school. The Team Around the Family plan was disrupted owing to the COVID-19 lockdown. Shay was placed in alternative education provision and subsequently returned to mainstream education. 4.2 The family’s first involvement with statutory safeguarding agencies was in October 2021 when the police were alerted to a social media post of Samuel holding a ‘zombie knife’. 4.3 Between October 2021 and December 2022, there were nine Section 474 investigations opened on the children and three child and family assessments undertaken. The first assessment in October 2021 prompted the completion of the first of four Child Exploitation Screening Tools (CEST). These highlighted and restated the boys increased risk of criminal exploitation and significant involvement in criminal activity. They repeat the impact on them of their unmet learning needs, school exclusions and increasing use of drugs and alcohol. The risk levels and 3 BCP JSNA 2022 4 Section 47 Children Act 1989 4 needs of Joy are commented on in the context of her increasing concern for the welfare and safety of her brothers and feeling unsettled by constant police involvement. 4.4 A National Referral Mechanism (NRM)5 referral was made for Samuel, yet police records indicate that he did not engage with the NRM process. The ‘reasonable grounds’ test for the NRM was confirmed in December 2021 with a ‘conclusive grounds’ decision made four months later in April 2022. An NRM was completed for Shay in December 2022. 4.5 A referral was made to the specialist Complex Safeguarding Team (CST) in November 2021, but this was assessed as not meeting their threshold suggesting there was limited information regarding exploitation. As a result of these judgements, the children became subject to child in need plans and transferred internally in Children’s Social Care to the Child and Families First Team (CFF). From March 2022 the CST took case responsibility for the boys and held monthly non-statutory Exploitation Team Around the Child Meetings (ETAC). Joy remained open to the CFF. 4.6 Michelle engaged with the assessments and plans yet expressed concern about not being able to keep the boys safe outside of the family home and her ability to assert effective boundaries. A plan was developed which included: - Michelle attending a “Triple P Parenting Course’6 - Emotional wellbeing support for Joy. - Support for Shay’s learning needs. - Direct work with Samuel and Shay regarding child criminal exploitation and knife possession. - Support in relation to substance misuse. - Hold a Family Network Meeting. - A male family support worker was allocated to provide mentoring and support to the boys. - The newly allocated social worker from CST would make twice weekly visits to the family. 5 The National Referral Mechanism (NRM) is a framework for identifying and referring potential victims of modern slavery and ensuring they receive the appropriate support. Modern slavery is a complex crime and may involve multiple forms of exploitation. 6 Triple P gives parents simple and practical strategies to help them build strong, healthy relationships, confidently manage their children’s behaviour and prevent problems developing. 5 - The social worker and support worker supported Samuel with college applications. 4.7 The two stabbing incidents in August and September 2022, led to the referral for a local child safeguarding practice review. The rapid review process also led to a referral to the Legal Gateway Meeting and in November 2022, the children became the subject of their first initial child protection conference. Despite all agencies stating they felt the threshold was met for the children to be subject to a child protection plan, the independent conference chair overruled this decision as they felt a child protection plan would only replicate the original plan. The second initial child protection conference was held in January 2023 and the children became subject to child protection plans. 4.8 Between October 2021 and December 2022, the boys were arrested on at least 13 separate occasions. The offences included, possession of a large zombie knife, affray, attempted shoplifting, the possession of knives, domestic burglary, robbery, possession with intent to supply, possession of cannabis, assault, GBH with intent, wounding, animal cruelty and theft. The boy’s social worker noted that both boys increasingly began wearing expensive designer clothing. Samuel consistently reported he was not under any influence from others or being exploited. There was either significant delay in progressing most of the investigations into the criminal matters or they were closed with no further action. 4.9 A Section 47 enquiry took place in early April following an incident where Joy, aged 12, was encouraged to get into a vehicle of an unknown man. Although her vulnerability to sexual exploitation was significantly heightened, Joy was removed from the child in need plan in May 2022. 4.10 Samuel completed his GCSEs in June 2022 with support from his social worker. It was reported that the situation at home seemed much calmer and positive and Shay had started to engage with reintegration into school. 4.11 In early August, it was agreed at a review ETAC that Shay no longer needed intervention from CST and the ETAC process was closed for him. 4.12 Michelle continued to struggle at home and completed an e-consultation with her GP in August 2022. She requested advice on managing Samuel’s aggressive and violent behaviour. She stated that social workers and youth workers were unable to suggest a way forward. The GP suggested looking on the CAMHS website and to also contact Samuel’s school. 4.13 When Samuel was stabbed in August and September, plans to move the family out of the area for their protection were not implemented but various safety measures were 6 proposed to keep the family safe in their home. A Dorset Police Response Plan was in place to flag any 999 calls for a priority response. All police officers working in the Bournemouth, Christchurch and Poole (BCP) Council Local Policing Area or in roles that take them into the BCP area coming on shift, received a daily briefing about the family. 4.14 Both Samuel and Shay’s arrests offered opportunities for ‘reachable moments’7 whilst in police custody. However, police were unable to engage them. 5. Key Practice Themes 5.1 There are key practice themes which seek to understand how agencies engaged and worked with the family, alongside the wider contextual issues regarding child criminal exploitation and serious youth violence. The review also advocates the need to move from the terminology ‘child criminal exploitation’ to ‘extra-familial harm’ which better describes the experiences of Samuel and Shay and other young people in similar circumstances. These terms are used interchangeably in the review report. This analysis is thematic and should be read in the context of learning from the children’s experience. Recommendation: Safeguarding Partners adopt the term ‘extra-familial harm’ to describe ‘child exploitation’ which mirrors the changes Pan-Dorset. 6. Good Practice (identified by the agencies) - The children’s social worker from CST has worked hard to engage the children with a relationship-based approach and had been the one consistent professional in the children’s lives for over a year. - Samuel was supported to achieve his GCSE grades. - There was some progress in achieving Shay’s educational goals. - The CST have provided high levels of visiting and intervention and have been responsive to new and escalating risks. - There have been swift multi-agency responses to further incidents of concern. - There has been evidence of multi-agency working to try and manage the risk more effectively, including the use of Criminal Behaviour Orders and an enforceable doorstep curfew as part of Samuel’s Referral Order. - There has been good communication and timely information sharing between agencies, attendance at meetings and the ETAC Plan was regularly reviewed. 7 The notion that something happens it opens up a moment in time in which it is possible to reach and work with a child or young person who previously agencies have been unable to engage. The key is recognising and seizing the moment. 7 - There has been a recognition and understanding of the risks for Joy by the professional network and a police response plan which supports the safeguarding of Joy in particular. - The Youth Justice Service accurately assessed Samuel’s speech, language and communication needs and this was shared with the family and wider network. 7. Evaluation of assessments, interventions, and plans 7.1 From November 2021 there have been multiple meetings held by police, Children’s Social Care and partner agencies including the strategic exploitation and knife crime meetings. The boys were reported missing on at least three occasions yet this is likely to be significantly more. There is a significant increase in offending behaviour from November 2021 and the police built an intelligence picture with each interaction with Samuel and Shay and highlighted this to other agencies in January 2022. Multiple ‘Need to Know’ documents were raised by the CST to senior leaders in Children’s Social Care, yet there was it was not clear how these were responded to. Recommendation: The existing system of alerting senior managers to ‘high risk’ children in Children’s Social Care and in the multi-agency safeguarding partnership would benefit from review. 7.2 It is difficult to evaluate how these assessments, meetings and interventions impacted on the boy’s outcomes. Despite intensive twice weekly support from CST, regular ETAC meetings, multi-agency information sharing and good partnership working, agencies have been unable to reduce the contextual safeguarding risks or reduce the serious violent incidents for the boys. Agencies have struggled to engage the boys in any activity that has reduced their level of offending or their risk of exploitation. 7.3 It took too long for safeguarding agencies to identify that Samuel and Shay were at risk of criminal exploitation, despite there being clear triggers and intelligence. Referral processes and decision-making accessing specialist CST support were not followed. This was compounded by the high threshold for accessing the CST and the determination as to what constituted actual evidence of exploitation against the evidence of emerging risk factors. This delayed Samuel’s access to specialist support. Disagreement between teams in Children’s Social Care were escalated to senior managers but this took too long to resolve and was not a ‘child led’ decision. Specific team remits, threshold criteria and limited flexibility appear to have led to the delay. 7.4 Although there is good engagement from Michelle, the assessment of parenting capacity and wider family is lacking. To understand the dynamics of exploitation an 8 understanding of parenting capacity and history is essential. Without analysis of the family’s circumstances, this can lead to inappropriate interventions that have little benefit. At stages in the process, Michelle and her partner are deemed as a couple struggling to cope with managing the boy’s behaviour, having an inability to keeping them safe yet doing their best under very challenging circumstances. At other times, they are deemed neglectful, providing inadequate supervision, and prioritising their own needs above the children. The Section 47 enquiry that prompted for the children’s case to progress to a second ICPC was following Michelle and her partner going away for a weekend break without informing professionals. Michelle made alternative care arrangements yet this was deemed to place the children more at risk than they previously were. 7.5 There are repeated references to referring Michelle to a Triple P parenting programme. This materialises three months after the original decision yet it is not clear what benefit Michelle gained from this process or the impact this has had on the child’s lived experiences. The children’s father is an absent voice. Despite his poor relationship with the boys and the known history, his involvement was not given adequate consideration. An assessment of the wider family and their role would have added value to the agency responses and safety planning. 7.6 There is limited understanding of the children’s earlier childhood experiences and how these earlier experiences may have impacted upon them. Much has been written regarding the impact on children of Adverse Childhood Experiences (ACE’s)8. These are highly stressful and traumatic experiences occurring during childhood or adolescence and can be a single event or prolonged threat to safety. All three children have experienced ACE’s, some are still very current and the assessments needed more detail on how the children’s lived experiences impacted on their development and how agencies may be able to intervene. Whilst Samuel described a somewhat blasé attitude to his experiences as a victim of knife crime, it remains that he is still a child and developmentally and emotionally he may not be able to process what happened to him. Exploited children can be exposed to repeated trauma through violence and abuse (either victim of or witness to) and can also experience trauma because of their own violent behaviour. Caregivers are also likely to experience trauma linked to their child’s exploitation9. 7.7 Adolescent development also features less in the assessments and plans. There has been much recent research into the science of the adolescent brain and how 8 https://uktraumacouncil.org/research_practice/aces-research 9https://yjresourcehub.uk/images/County%20Lines%20Pathfinder/Child_Criminal_Exploitation_Emerging_and_Promising%20_Practice_Approaches_County_Lines_Pathfinder_2022.pdf 9 safeguarding agencies need to adapt their approaches to reflect how this influences children’s decision making. Recommendation: The safeguarding partnership should assure themselves that adolescent development becomes a ‘practice fundamental’ to ensure that front line practitioners have a clear understanding of the adolescent stages of development and the impact of ACE’s/trauma. 7.8 Transitions for children can be significant events and Shay struggled significantly with the transitions in his schooling. This may have been an opportunity to provide more bespoke support particularly children who are already identified as struggling in primary education. 7.9 The purpose of the regular ETAC meeting was to ensure that all available information was shared and considered, needs and vulnerability identified and planned for, a trigger and disruption plan completed, roles and responsibilities clearly defined and timescales agreed. These meetings were primarily attended by the CST, Children’s Social Care and the police. Of the six meeting minutes reviewed, schools attended three times and health attended no ETAC meetings. School nursing professionals report they do not have the capacity to attend ETAC meetings so there is no health input into safety planning. Primarily, only two agencies were involved in safety planning and the assessment of risk. Given the nature of child criminal exploitation and the community wide issues it raises, other agencies do need to be more actively involved. Michelle and the boys were not always part of these ETAC meetings. Michelle, the boys, and the wider family could have been seen as a ‘safeguarding partner’. True collaboration with all family members could possibly have built upon the protective capacity of the agencies involved10. It would be important to analyse how much the parents, carers and wider family are engaged as a protective factor in situations of exploitation. Children’s parents, carers and wider family should be appropriately engaged as a ‘safeguarding partner’ in developing safety plans and addressing risk outside of the family home. 7.10 In August 2022, BCP Children’s Social Care began to review the use of the ETAC process. This work concluded that the ETACs offered no assurance regarding the level of risk nor the management of that risk and there was a need to return to the use of Section 17 and Section 47 arrangements. This work concluded in Sept 2022, and it took several months to get to the point of replacing the process. 10 https://tce.researchinpractice.org.uk/tce-consortium-partners/ 10 7.11 From the end of April 2023, the CST ended the ETAC meeting process and now only use the existing statutory processes11 to manage the risks for children being exploited. BCP council have recognised that the ETAC had limited impact and this review has highlighted how ineffectual those meetings have been in addressing the boy’s outcomes. Recommendation: BCP Council should review the changes to the ETAC process following implementation to ensure the changes are achieving more positive outcomes and reducing the risk for children. 7.12 It took several months and nine Section 47 enquiries before a decision was made to progress to an initial child protection conference (ICPC) which highlights the dilemma of how agencies manage this type of extra familial harm. The first child and family assessment confirmed that both boys were being drawn into criminal activity and being targeted or groomed by others. It concluded that the circumstances of the boys met the threshold at Level 4 of the Pan Dorset Continuum of Need Threshold Document. Given this, it is perplexing as to why CST did not consider the threshold met for their involvement, why the CEST concluding that no referral to CST was required, or whether any existing statutory child protection process were needed to safeguard the children. At this time, the existing ETAC process was considered an effective multi-agency risk management meeting and therefore the statutory process were not required to manage the risk. This approach failed to consider that all three children had suffered significant harm. 7.13 The decisions by the independent child protection conference chair at the first ICPC were not formally challenged, escalated, or dissented against by any professional attending the conference at the time which suggests a lack of knowledge or confidence to challenge what appeared to be a flawed decision. Concerns were raised by the Service Manager and Team Manager in CST informally with the conference service but these are not recorded or formalised. Whilst child protection conference chairs do have these decision-making powers in policy, it is rare to oppose all agencies considerations of risk and harm. It would be appropriate to remind agencies attending child protection conferences that they have the executive power to formally oppose, dissent and escalate decision making in the child protection conference process. 7.14 Three or more Section 47 enquiries on an individual child within a 12-month period should have prompted some management oversight. No agency felt the need to use 11 Children Act 1989 11 the existing escalation process to alert senior managers to the children’s circumstances. Recommendation: A multi-agency learning audit should be considered for children involved in the Section 47 process where there is an extra-familial harm concern. This should involve feedback from children and parents/carers. Recommendation: The safeguarding partnership should seek assurance that repeat Section 47 enquiries are subject to review and management oversight. 7.15 The community factors that influence children’s decisions should also be the subject of assessment, focusing on relationships, community profiles, wider societal issues, and support mechanisms in local communities. Analysis of these collective assessments could assist in determining appropriate interventions that match understood and assessed needs and address community-based issues. The current child and family assessment process may not meet these expectations and timeframes and a more bespoke specialist assessment process may need to be considered. This could also lead to determining what services may need to be commissioned at a local level. Recommendation: In cases of child exploitation, the assessment service should put in place a checklist so that the child and family assessment explicitly analyse parental capacity, wider family and the impact and influence of the wider community and contextual factors. 7.16 The CEST is a tool to assess risk and safeguarding agencies are expecting its use to be increased by a wider number of professionals. The CEST completed in November 2021 indicated that Samuel and Shay were at ‘medium’ risk of exploitation which only increased to ‘high’ risk following the NRM conclusive grounds decision for Samuel. There should be an avoidance of a ‘tick box’ exercise to complete this assessment. The analysis should encourage practitioners together to consider how to prevent the escalation of behaviour and/or exploitation. Whilst the CST remained on the periphery, the offer to the family at the time did not appear to match the complex needs that were emerging regarding criminal exploitation and criminal behaviour. Recommendation: The new CEST tool implemented in BCP should be reviewed within 6 months’ time to ensure this remains fit for purpose. 12 8. The role of schools 8.1 Prior to October 2021, the family were known to support agencies and particularly regarding Shay’s additional learning needs and his ability to manage in mainstream education. His additional learning needs, poor educational attainment, non-engagement in education and temporary or permanent exclusions had the potential to be significant triggers in increasing his vulnerability to exploitation. The impact of school exclusion is frequently mentioned in professional research and policy regarding serious youth violence12/13 and can be a significant trigger for increased association with exploitation. However, a focus on school exclusion in these contexts can also lead to other issues being ignored. These collective sources of information should prompt professionals to consider earlier intervention with children who may be experiencing temporary or permanent exclusions. 8.2 Michelle described feeling ‘let down’ by the education system with Shay never engaging in or managing mainstream education. Both boys were not subject to any formal assessment of their educational needs. An Education, Health and Care Plan (EHCP) assessment for Shay, may have indicated that his special educational needs required more specialist education provision. Legally, if parents think their child needs more help than the school can provide, they can ask for an assessment. In Shay’s circumstances, Michelle did not have the knowledge or experience to push for this. 8.3 When Shay moved to alternative learning provision it appeared to meet his needs and he thrived with smaller classes and less pressure but this arrangement was always intended to promote his reintegration back into mainstream schooling. He moved to a mainstream secondary school in Year 9 and into the schools ‘on site’ alternative learning provision. This school provided an individual education plan for Shay and he was on a reduced timetable. However, Shay told his mother that he felt further isolated in this environment and ‘different’ because of being in a mainstream school but being educated away from the other pupils. This only appeared to reinforce his negative perception. As part of BCP’s Special Educational Needs and Disability (SEND) improvement journey, there have been a series of initiatives to address the issues for children with special educational needs. This has included the expansion of ‘on site’ alternative learning provision. Whilst this may address the immediate need for school places for children with special educational needs, it may not be effective for all children. There are no indications that this approach has been 12 Vulnerable Adolescents Thematic Review February 2019, Croydon Safeguarding Children Board 13 http://www.preventknifecrime.co.uk/wp-content/uploads/2019/10/APPG-on-Knife-Crime-Back-to-School-exclusions-report-FINAL.pdf 13 evaluated and therefore may benefit from review as to how this approach has improved educational outcomes. Recommendation: School leaders should review the effectiveness for children of separate ‘on site’ alternative learning provision. 8.4 Shay displayed limited engagement at school and disrupted his mainstream schooling in attempt to return to the previous alternative learning provision that he found so positive. There was subsequent agreement and funding for a placement at the alternative learning provision this but at this stage Shay had disengaged from education and learning and this has been difficult to recover. 8.5 There had been ongoing worries at school for the emotional wellbeing of Joy in the context of the boy’s behaviour, yet she was managing her schooling well. 8.6 Whilst his attendance was relatively low, Samuel did engage with school but events outside of school influenced and impacted upon his education and learning. He was educated off site due to his risk and had periods of fixed term exclusion. Practitioners have reflected that Samuel’s view of his schooling may have reinforced his identity with direct quotes including, ‘people were scared of me..I ran that school’. 8.7 The schools needed help and guidance with the growing issues of serious youth violence and its impact. They acknowledged that these issues had been outside of their frame of reference yet criminal exploitation, gang culture, county lines and knife crime had significantly increased over the last two years and this was impacting on the school environment. They raised worries that schools were expected to manage highly complex children with special needs alongside criminal behaviour that may occur outside of school with little support from partner agencies. They report that this behaviour then plays out in school and can be difficult to manage. Whilst schools do play a key role in the shared support of children in their schools and local communities, it is important to consider how much burden is placed on the school to provide support to children where other agencies may need to step in and work alongside them. Safeguarding agencies could be more proactive in their support to the school. A partnership approach prior to exclusion at an earlier stage has the potential to prevent children spiralling into exploitation. They also can provide significant information regarding children’s friendships or associates that add value to the mapping of exploitative relationships. 8.8 The context of the school landscape in the area highlights additional challenges. 80% of schools are part of academy trusts which means the local authority has little influence in decisions made regarding children’s education or lack of it. 98% of 14 schools in BCP are currently rated as good or outstanding. This is in contrast with permanent exclusions being twice the national average. In quarter 4 (October to December 2022) there was a 51% increase in exclusions compared with the previous quarter 3. There has equally been an increase in the numbers of children moving to a part time timetable or ‘missing out on education’. In the BCP Children’s Services Overview and Scrutiny Committee Reports of June 2023, it highlights that schools are struggling to access good quality alternative provision and those alternatives are currently full. The report notes that the length of time taken for children to have an EHCP approved is impacting on the length of time children remain in schools without the required funding to support those children. The subsequent result is permanent exclusion. The increasing complexity of children’s needs has led to schools struggling to offer effective early help support and a ‘perceived lack of easily accessible support services that address pupil behaviour and issues within the family and community that cause challenging behaviour’. The report remarks that many academy trusts use a ‘behavioural approach’ in class where a more ‘relational’ approach is less of a focus. There is research evidence that highlights the crucial importance of understanding a child’s behaviour from their context, with potentially multiple influences which impact behaviour. The “Improving Behaviour in Schools Guidance Report’14 produced by the Education Endowment Foundation in 2021 emphases the relationship-based approach with pupils and personalised approaches needed to manage individual needs and behaviour. Early identification and prevention work in schools is key to good outcomes for children and whilst there is in place educational psychology and inclusion work with schools to ensure early identification of need, these interventions might benefit from wider partnership engagement to address extra-familial risks identified at an earlier stage, thus potentially avoiding children experiencing more risk when excluded from school. 9. The use of knives and police and criminal justice interventions 9.1 Samuel has relayed that he has carried a knife because of the fear of violence and victimisation, linked to the belief that other children in his community also carry knives and would be prepared to use them. Samuel perceives he has ‘social status’, respect, influence, and power over other children through carrying a knife, evidencing using a knife and being a victim of a knife crime himself. Instant communication via social media serves to reinforce this perception. Samuel has also relayed his role as the ‘ideas man’ in the context of criminal activity. Increasingly as Samuel has been 14 https://d2tic4wvo1iusb.cloudfront.net/production/eef-guidance-reports/behaviour/EEF_Improving_behaviour_in_schools_Report.pdf?v=1688535022 15 involved in criminal activity and potentially being exploited by criminal gangs, his need to carry a knife for protection has increased. There is published academic research which is useful in helping to understand the background factors that are associated with knife carrying.15 9.2 Dorset Police report that there was a reduction in knife crime incidents in the BCP area in 2022-23. However, the Youth Justice Service16 highlighted that child offences in BCP have increased in number and proportion. Analysis reveals special educational needs and temporary and permanent exclusions from school feature highly in this cohort emphasising the need for better interventions with schools at an earlier stage. 9.3 Samuel and Shay have been involved in the illegal supply of drugs and this appeared to be driving their use of knives to threaten but also to provide perceived safety. There have been several recent knife related crimes in the BCP area involving children and subject to ongoing investigation. 9.4 A BCP council Community Safety Report (December 2022) showed that over a 12-month period December 2021 and November 2022 there were 531 occurrences related to knife crime in BCP reported to police and within that, 203 occurrences were deemed to involve the physical presence of a knife. 10–19-year-olds were disproportionately represented in this dataset, making up 25.2% of the suspects and 20.1% of victims. 10–19-year-olds were also disproportionately represented within possession offences with 40.2% of suspects involved in possession offences aged 10-19. The interviews with professionals noted that this was an emerging issue that was not getting the prominence it required in both policy, practice and leadership and has only recently received the increased scrutiny it deserved. 9.5 Samuel and Shay did not get the level of interventions needed at an earlier point in their lives to impact on their increasing use of knives and violence, including the use of preventative and interventionist methods such as the increased involvement of the police neighbourhood teams to interrupt and disrupt Samuel and Shay’s activity. 9.6 Dorset Police have confirmed that significant investment has led to a more consistent workforce yet the significant role of the neighbourhood policing team for children at risk of exploitation cannot be underestimated. 9.7 The Police and Crime Commissioner (PCC) in Dorset has made representations that Dorset Police is one of the lowest funded police forces in the country and resources are significantly stretched. Whilst accepting the significant role of neighbourhood 15 Security, respect and culture in British teenagers' discourses of knife‐carrying, Marek Palasinski et al, Liverpool John Moores University 16 Youth Justice Partnership Board and Children’s Services Overview and Scrutiny Committee June 2022. 16 policing in addressing the risks for children, the force has had to focus its resources on first response policing which diverts officers away from neighbourhood teams. The neighbourhood policing teams can make a significant difference if they were authorised to remain in role for longer periods of time and be allowed to develop those relationships without moving to other police priority areas of policing. This short-term approach does not meet the needs of vulnerable children as there are positive outcomes to be achieved in relationship-based interventions. 9.8 The BCP Knife Crime Task and Finish Group has been in operation since May 2022. This multi-agency partnership meeting reviews the available intelligence and identifies the children and adults carrying and using knives. Samuel and Shay have remained on this meeting agenda since the inception of the group and RAG rated Red, highlighting the risks to themselves and others. The neighbourhood policing team17 was tasked to undertake the ‘tactical’ work with the children, attempting to build rapport with the family, ‘door stepping’ and building a developing intelligence picture regarding their contacts and involvements. At this time, the police team known as IMPACT dealt with ‘high-risk’ children harmed by or at risk of exploitation and worked closely with the neighbourhood policing teams who worked alongside ‘low risk’ children. The Inspectorate of Constabulary and Fire & Rescue Services post inspection review of how well Dorset Police kept children safe was published in 2022. It highlighted the significant resourcing problems in IMPACT and that work had to be redistributed to other teams, some without the skills and experience to deal with them. In the short term, Dorset Police acknowledged the resource gap and implemented short term measures to address this. Dorset Police has since implemented the Police Safeguarding Hub which carries out the same role as IMPACT but ensures that ‘low risk’ cases also receive more specialist responses. This team investigate exploitation with a view to identifying those that are perpetrators of exploitation. They offer opportunities for ‘reachable moments’ with children when in custody. 9.9 Multi-agency discussions regarding the oversight of children experiencing extra-familial harm began in the summer of 2022 and in January 2023, multi-agency partners introduced the Missing, Exploited and Trafficked (MET) Panel. Focusing on emerging risks in the community and the identification of children being exploited and targeted police actions against perpetrators. It took several months to implement 17 A team of police officers and police community support officers who predominantly patrol and are assigned to police a local community. Teams often comprise specialist officers and staff with expertise in crime prevention, community safety, licensing, restorative justice and school’s liaison. Response teams are assigned to deal with emergency and priority calls. 17 those changes which may be reflective of the challenges of implementing new systems and arrangements when agencies have previously viewed arrangements as successful at meeting risks and needs. Recommendation: The governance of these various panels and forums and how they interact should be made explicit with clear governance, reporting lines and accountability. 9.10 Samuel was convicted at court and sentenced to a 12-month Referral Order in November 2022 for offences committed in October 2021 some 13 months after committing the offence. That Order did not commence until January 2023. Samuel and Shay appeared in court in December 2022 for an offence of GBH committed in February 2022. Of Samuel’s eight outstanding offences from October 2021 up to January 2023, five led to no further action or were dismissed. Shay received a Youth Restorative Disposal (YSD) in April 2022 for a possession of cannabis offence. The YSD was delivered by the Safer Schools and Communities Team with no involvement from the Youth Justice Service. 9.11 This pattern of arrests, charges and no further action decisions impacted upon Samuel to the extent where he started to perceive himself as ‘invincible’ or in the words of his mother, ‘untouchable’ and that he could ‘get away with it’. Samuel himself relayed that he needed a swifter response to his charges as by the time he was sentenced, he had ‘forgotten’ about them. He was open enough to say that earlier sanctions may have impacted on his behaviour. Since coming to police notice in October 2021, he was regularly involved in what was described as a ‘shocking multitude of offences’. Professionals have argued that some of these reported offences could have been prevented if he had received swifter sentencing responses and more external controls were put in place at an earlier point. Some of the delay was related to the awaited outcome of the National Referral Mechanism (NRM). 9.12 The local safeguarding children partnership has since reflected that if agencies cannot rely on timely criminal justice outcomes does the welfare response adequately manage the risks. This review would suggest that it may not. 9.13 Following the stabbing incidents, and following senior leadership meetings, a detective inspector in the Criminal Investigation Department was tasked to review four different investigations that were ongoing regarding Samuel. There were four different officers in charge of those investigations and this detective inspector became the Senior Investigating Officer with oversight of all four. They found no evidence of criminal exploitation and no obvious pattern to the offences, appearing opportunistic and sporadic. None of the investigations involved adults and appeared to be children 18 involved in territorial drug running with the additional use of knives and offensive weapons. This senior leadership oversight and approach might well be used in other situations where children are involved in criminal exploitation. This was reportedly already in place in Dorset Police through the ‘Weekly Tasking Meeting’ and this may benefit from being more multi-agency but adds yet another layer of oversight which does not appear connected to other forums. The detective inspector has reflected that as Samuel was becoming an ‘emerging problem’ more proactive interventions should have been used to address the emerging risks. 10. Use of social media and agency assessment of its significance 10.1 Samuel’s decision to share his Instagram post was the key trigger to statutory agency involvement with the children. There was other evidence that Samuel was sharing images on social media related to his interest in drug use, knives and criminal activity. These have been the subject of police review as part of evidence gathering and they have identified other individuals that Samuel has interacted with. There is no information in the child and family assessments of the significance of Samuel’s social media use. 10.2 The “Fixing Neverland’ Final Report18 published by Crest Advisory in October 2022 considers the underlying causes and drivers of serious violence. The significance of social media and its indirect driver of violence is highlighted in the report alongside its use in the recruitment of children into being exploited criminally to distribute drugs and the push factor in glamourising drugs and violence for financial gain. 10.3 It highlights that social workers are often discouraged from using social media to engage with children to avoid crossing professional boundaries but reflects that most children now live their lives through social media. It is possibly the one place that confirms the child or young person’s views, feelings, wishes and experiences. It suggests that agencies leave huge gaps in understanding of the child ‘s world by not examining the interactions expressed via social media. The report argues that children who are vulnerable are more susceptible and influenced by radicalising concepts on social media. 10.4 Whilst the report makes a series of national recommendations, there are considerations regarding local action or activity. Not commented upon in detail is the how children’s use of social media is assessed alongside other vulnerabilities. It should be included in all child and family assessments and be considered in the context of risk and need with possible interventions to address this especially at a 18 https://www.crestadvisory.com/post/report-fixing-neverland 19 preventative level. The report also proposes local campaigns to highlight the healthy and unhealthy use of social media. Lastly, it proposes that local child safeguarding practice reviews (LCSPR) should routinely review and assess the child or young person’s use of social media with technology firms required to provide access. It is not clear whether this has ever been requested as part of an LCSPR and it may be time to test this as part of learning from reviews. Recommendation: Child and family assessments should consider and analyse the risks associated with children’s use of social media; particularly where extra-familial harm is highlighted. 10.5 The Pan Dorset Child Exploitation Risk Assessment document does ask those completing the assessment to judge using a number scale as to the child’s increased use of technology but it does not identify a specific risk factor regarding the child’s use of social media. Recommendation: The safeguarding partnership should assure itself that children’s use of social media and the risk factors associated with it are embedded into the existing training offer. 11. Complex Safeguarding Team (CST) 11.1 At the time of the review the CST was a small team working alongside children and their allocated social workers. The social workers also held a small caseload of children who are deemed ‘high risk’. The CST workers provided targeted interventions for complex safeguarding delivering a relational and youth engagement approach to working with children with complex needs and multiple vulnerabilities. This includes children missing from home, exploited through gang association, criminality, and those suffering harm through sexual exploitation. The threshold for a referral into the service was determined using the CEST and child and family assessment. The CST has had three changes of Service Manager during the review period. 11.2 It was recorded that Service Managers in Children’s Social Care discussed the need to transfer the children’s case to the CST in November 2021 yet concluded that the CST would complete work with Samuel on criminal exploitation alongside the CFF social worker. Samuel remained at ‘moderate risk’ until the NRM confirmed ‘conclusive grounds’ that he was being criminally exploited and Samuel was then identified as being at significant risk and the case was accepted by the Police 20 IMPACT Team. There remained confusion about case allocation and accountability and the CST social worker was eventually allocated to Samuel and Shay. 11.3 The complexity of the CST service model meant that Joy’s needs continued to be met via a child in need plan and the boys under the separate process of the ETAC. Despite, the new Corporate Director in Children’s Social Care being clear that children should not be dual allocated, at the time, the children’s needs were assessed and reviewed separately. The chronology of involvement clearly indicated the impact of her sibling’s behaviour had on Joy, yet her needs and risks were not the given equal weight in the context of the boy’s behaviour. The fact that Joy’s child in need plan ended in May 2022 reinforced this position. 11.4 The CST social worker has been a consistent part of the children’s lives for a year. Their relationship-based approach enabled them to continue working with the boys, despite increasing evidence of extra-familial harm and criminal activity by both boys. Holding and managing significant risk for children can impact on individual social workers and they can feel despair at not being able to influence the situation. This level of responsibility can lay heavy on social workers and can ominously increase if the young person is the victim of violence. The level of risk held by this team is significant and it can and does have an emotional impact on the staff that work within it. There are supervision and support mechanisms in place but there was a sense that the sole responsibility for some of the children rests with one or two professionals until the situation escalates. 11.5 Decisions to escalate the children’s risks to a Legal Gateway Meeting was considered by some frontline professionals to be unhelpful and time consuming at a point of crisis. Throughout the involvement of CST, there had been engagement from Michelle and despite her challenges in managing the boy’s behaviour, there was limited substantiated evidence to suggest that they were at risk of significant harm because of her inability to safeguard them. The Legal Gateway Meeting alienated Michelle and she felt blamed for the children’s exploitation and criminal behaviour. Professional anxiety at the time of these decisions, whilst well intentioned, had the opposite effect in addressing the children’s risks and needs. 11.6 The recently published Independent Review of Children’s Social Care19 proposes a national framework for the multi-agency response to safeguarding from harm to children that originates outside the family. This may be highlighted in the refresh of Working Together to Safeguard Children due for publication in 2023 and agencies may need to plan for this possibility. 14. MacAlister J, 2022 21 11.7 The CST focus has primarily been on re-engaging the boys in education and attempts at diverting them away from exploitative relationships. Direct work was found in relation to their substance misuse and of direct work with a specific contextual safeguarding focus, which went beyond mentoring and relationship building. Other agencies made assumptions that CST were undertaking ‘intensive work’ on child exploitation, yet this work was never evaluated in ETACs or other strategic meetings. It was never clear what outcomes were intended. This reflected comments from Michelle, who relayed she was never clear what the purpose of the visits to the family home were, the interventions or what was being achieved. 11.8 Following the stabbing incident in September a concerted effort was made to move the family as part of ‘circuit breaker’ to provide safety to Samuel and his family. Joy was described as a ‘gibbering wreck’ following this incident and the police wrote to the CST in September 2022, confirming that Dorset Police could not ensure the family’s safety. Michelle remains angered by the lack of decision making on this issue. She recalls making every effort to support the plan but this was changed at the last minute and the family remained living in the community and feeling very unsafe. Although, police put in place target hardening, the fact that they could not ensure safety, was deeply worrying to Michelle and had a very negative impact on Joy. These decisions are complex in nature and do not always ensure the safety of the child or family is secured, even for a short period. 11.9 The CST capacity is unable to meet the increasingly complex needs of this group of children. The high thresholds that exist have been put in place to ensure that the children at highest risk can access this more specialist support. This small team does not have the capacity to do both preventative and specialist work. It highlights that knowledge and skills in extra-familial harm should not be confined to a small number of professionals. The current approach negates the roles and skills of other professionals who should have a role to play to effectively prevent or safeguard a young person. The ‘referral’ to a more specialist service, with the expectations that may come with it, potentially removes the responsibility and accountability of others. There is a positive professional view of the CST from other partner agencies yet the specialist nature of the team does not support wider responsibility and accountability for this cohort of children. 11.10 The role of CST was under review and proposals for re-design began from July 2022 and CST staff were consulted on proposed changes. In August 2022, the whole of the Safeguarding and Early Help directorate in Children’s Social Care was reviewed and it was agreed to reduce the number of managers in the CST. This coincided with diagnostic reviews of early help services in BCP at levels two and three of the 22 threshold criteria. Family support workers in the Targeted Support Service were tasked to undertake bespoke pieces of work including working with children where risk was associated with extra-familial harm. CST at the time were working with a very small number of children and social workers had caseloads of between two and ten children. The team was reaching a small number of children and the intention to train more family support workers to deliver extra-familial harm interventions opened the opportunity for more children to be worked with. 11.11 As of April 2023, the CST underwent a restructure which changes the remit of the team. The team is reducing its staffing numbers and children will only be referred into the team following an initial screening from the Multi-Agency Safeguarding Hub (MASH). The CST team will then complete a child and family assessment and the completion of the CEST. The team will instigate the child protection process for those reaching this threshold and will hold those children in the team if subject to child protection processes. Core groups will meet every four weeks and there will be three monthly reviews of the plan with the Service Manager to avoid drift. If the child meets the child in need threshold20, these children will be returning to the local CFF teams for intervention. The youth workers in the newly restructured CST, will work alongside social workers for those children. Whole family working remains a challenge to the CST and will be agreed on a case-by-case basis. Children of medium and low risk children will be managed via the CFF, Targeted Support and Early Help support. Implementation of this approach is currently delayed following feedback. 11.12 The changes in team leadership of the CST, the team remits, staffing and the process and systems over the period of the review may reflect some of the challenges highlighted in effectively meeting the needs and risks of this group of children. This has been recognised by the leaders in Children’s Social Care and the changes proposed are aimed at addressing these issues. Recommendation: These practice changes to the CST and Early Help support require evaluation as part of the implementation programme. 12. Extra-familial harm versus criminal activity 12.1 The views from the professional network regarding the boys were conflicted. As both boys increased the level and seriousness of their offending, the welfare lens from some professionals was almost disregarded. The belief that children have a choice as to whether they continue to engage in criminal activity fails to recognise the factors 20 Section 17 Children Act 1989 23 that drew them into criminal behaviour in the first place, notably as victims of exploitation. Two possibly competing approaches with the same children and their family has the potential to confuse the focus of interventions to prevent future harm and provide safety. It is argued that the messages given to children in these circumstances must be professionally consistent. 12.2 The Police Safeguarding Hub reached a ‘tipping point’ with Samuel when he began targeting other children in criminality. As intelligence grew about the behaviour of Samuel, the more the team felt he was more of a ‘ringleader’ than being exploited. They describe having no clear picture of adults involved who might exploit Samuel but were proactive in developing the plan for a Criminal Behaviour Order. The team shifted their approach as information and intelligence began to suggest that Samuel was the ‘exploiter’. This team advocated strongly for Samuel and the family to be moved out of county. They described this approach as ‘putting an expensive plaster on a gaping wound’. They reflect that had interventions been considered earlier for Shay it may have had an impact on his increasingly criminal behaviour. The team believe that Shay was criminally exploited by Samuel. There were emerging indications that Shay was involved with adults who may have been exploiting him and this is subject to ongoing enquiry. 12.3 At an ETAC in July 2022, it was reported that ‘identifying perpetrators of exploitation and even getting charges to stick in relation to his offending is proving very difficult’. It was relayed that many of the investigations relating to Samuel would be dropped due to a lack of evidence or identification issues. It was relayed that the police did not want to criminalise exploited children but there was a worrying number of offences that were not deemed ‘exploitation related’ and that Samuel was unlikely to see ‘any consequences’. Concerns were raised that the youth justice service did not have role in earlier intervention. As no charges or convictions were made it limited the ETAC’s ability to put in place restrictions that could support disruption of negative peer relationships for Samuel. 12.4 The impact of police interventions to address criminal harm and risk where children are concerned requires a multi-agency approach. This requires the police to proactively involve other agencies in overt police responses to harm and threat, including police raids and an understanding of the covert activity being undertaken to assess risk and harm in the community. The police are understandably reluctant to share this covert activity and confirm that ‘intelligence training’ will address this issue for multi-agency partners. 12.5 There was some evidence to suggest that Samuel was being criminally exploited much earlier than the decision of the NRM In April 2022. The evidence included 24 agency identification of him going regularly missing, carrying weapons, using more than one mobile phone, having excessive amounts of money, being found in possession of different types of drugs, being secretive and refusing to share information about his associates, violent behaviour, possession of counterfeit money and changes in his behaviour highlighted by his mother which indicated some associated trauma with being exploited. All these risk factors suggest that Samuel was being criminally exploited. The fact that the growing police intelligence picture indicated no substantiated proof of criminal exploitation presented a practice and intervention dilemma. This may have reinforced the sense of feeling ‘stuck’ with how best to respond to their safeguarding needs alongside their significant criminal activity and which should take priority. Keeping the children in focus when making decisions about how to safeguard and support them means seeing the child or young person behind the presenting behaviours. 12.6 There was positive multi-agency working highlighted yet some of the interventions by agencies appeared in isolation of the activity of others. Interventions could have been carried out jointly and whilst this may present challenges it does reinforce to children that there is a joined up and consistent approach to their needs and risks whether it be both exploitation and consequent criminal activity. 12.7 Children impacted by criminal exploitation need to be seen as victims and safeguarded first. When they then engage in serious youth violence and significant criminal activity, this presents a practice challenge to safeguarding partners. Legal routes must be followed to address their offending behaviour and at the earliest opportunity to potentially achieve change, yet a welfare lens should always be used to understand the context behind that offending behaviour. 13. Use of the National Referral Mechanism (NRM) 13.1 Samuel’s criminal cases were delayed for long periods while waiting for the NRM decision on whether he was being exploited. The NRM ‘conclusive grounds’ decision can provide mitigation for sentencing or possibly lead to the case being discontinued and the social worker was keen for this to be before the court in Samuel’s case. The delays and uncertainty can make it harder to respond effectively to crimes arising from exploitation. 13.2 The review found some confusion and lack of awareness locally about the purpose of the NRM and how it might help. The social worker saw the NRM as positive in that it treated Samuel and Shay as victims rather than offenders and could keep them out of the criminal justice system. This approach conflicted with other professional views, who found it frustrating that the NRM decision could influence Samuel’s more overt 25 offending behaviour. Having the referral to the NRM accepted did not automatically mean that Samuel would not face criminal charges. 13.3 The Safer BCP Partnership Community Safety Partnership Plan for 22/23 has identified several priorities relevant to the findings of this review, including references to the NRM. The Annual Plan is developed from an annual strategic assessment of crime, anti-social behaviour, substance misuse and reoffending. It includes three priority areas all relevant to this review, including: ‘tackle violent crime in all its forms, keep young people and adults-at-risk safe from exploitation, including online risks and work with communities to deal with antisocial behaviour (ASB) and crime hotspots, including ASB linked to substance misuse. The plan has strategic plans and actions alongside key performance indicators. 13.4 There is no multi-agency shared record of which children have received an NRM reasonable or conclusive decision or any NRM’s currently in process. Recommendation: One safeguarding partner in BCP needs to take sole responsibility for tracking children subject to the NRM process. Recommendation: The local safeguarding children partnership and the community safety partnership should ensure any cross-partnership priorities are reviewed together to assess their effectiveness. 14. Managing the needs and risks of siblings 14.1 Extra familial harm has an intra-familial context. The references to Joy throughout agency intervention during the review period, suggested an increasingly anxious and traumatised child by not only the fear of what may happen to her brothers and the safety of her family and their home, but the anxiety following armed police raids, the perceptions of her peer group of her family circumstances and the gradual reality that the siblings would be in different care arrangements as the risks escalated. It is unclear as to why it felt necessary to close Joy’s case, perhaps with a sense of over optimism in relation to their own needs being effectively met. This approach gave little consideration to her own trauma. The focus on the boy’s behaviour of safeguarding agencies meant that Joy was lost in the professional line of sight and she continued to suffer as a result. It highlights the need for safeguarding agencies to increase a ‘family focused’ approach to exploitation and whilst some interventions are targeted, they are done so in the context of how this may affect the whole family. Practitioners need to be alert to the nuances of family risk and need and be more questioning of their own decisions. 26 14.2 The changes in social workers working with Joy depending on her status in the child safeguarding and welfare system did not allow for a focused relationship developing with her. The changing status of the children’s case from early help, children in need and child protection did not lead to consistency of practitioner and this was only achieved partly by the CST social worker. Changes of worker owing to agency team remits is not child centred. Recommendation: The safeguarding partnership should assure itself that siblings of children where extra-familial harm is evidenced, are being appropriately assessed and intervention put in place to support their needs. 15. Previous Local Child Safeguarding Learning Reviews 15.1 In June 2022, the Pan Dorset Safeguarding Children Partnership published a learning review with the title “A Multi-Agency Thematic Summary: Extra Familial Harm”. This considered the sad death of Child M and made a series of recommendations. Whilst the Action Plan has been in place prior to the report’s publication, there are three areas of significance to this review which have remained unresolved and are relevant to the learning for this review. Rather than repeat these recommendations, the Action Plan from this review should include reference to the learning review published in 2022 which set timescales for completion by September 2022 and January 2023. A. The Child Exploitation (CE) Screening Tool should be completed at all levels of intervention from early help and statutory levels of assessment when exploitation is the main risk and should form the basis of multi-agency decision-making with the family on whether a referral to the Complex Safeguarding Service is needed. A multi-agency audit of 20-40 children at risk of CE should be completed, led by the Partnership’s QA Group. to check individual children are accessing the right service at the right time according to need and achieving the desired outcome. The scoping of the audit should consider any barriers to completing the CE Screening tool. B. The Director of Education and Skills should consider the development of a multi-disciplinary programme to proactively support pupils at risk of exclusion, particularly where due to substance misuse and/or criminal exploitation. It should also be considered how parents/carers can co-produce policies and protocols going forward. C. Responsibilities to be clarified between CSP/PDSCP re child exploitation. 27 16. Conclusion 16.1 Samuel, Shay, and Joy have suffered extra-familial harm and despite some resilience shown by the children, their lived experience has been one of ongoing trauma. Despite the concerted efforts of the multi-agency partners, they have been unable to reduce the harm the children have experienced. The complexity of managing children in these circumstances cannot be underestimated. It becomes increasingly more complex when those children move from being exploited to potential exploiter. It challenges the multi-agency professional network, each with their differing priorities and contexts. Children impacted by criminal exploitation and then engaging in serious violence need to be seen as victims first and safeguarded as opposed to being criminalised. This presents a practice challenge at the point at which a young person’s criminal activity reaches a threshold that requires intensive work to protect the public. 16.2 The review is advocating support to be provided at a lower threshold and more engagement with preventative work. The teams involved in assessing and intervening in child criminal exploitation and criminal activity, alongside other agencies and schools, would benefit from joining together earlier to support children at risk. There is a need to ensure that once there are indications of potential child exploitation, earlier intervention is put in place to divert children away from exploiters. The specialist knowledge in these teams needs to be shared to ensure that all agencies understand their role in safeguarding children in these circumstances. There should not be reliance on referrals to ‘specialist teams’ to support children, particularly if their thresholds only permit those at highest risk to receive services. There may be benefits in the CST and the Police Safeguarding Hub working more closely together, including possible co-location. There are opportunities to join up the CST and Police Safeguarding Hub at the assessment stage providing better collaboration focused on the needs and risks of children and interventions that are then jointly run. 16.3 This area of practice is challenging and tireless work, yet the purpose of interventions and subsequent outcomes for children need to be clearly defined. |
NC047174 | Death of a 6-year-old girl and her 1-year-9-month-old sister. Children were killed by their mother who then took her own life. Family was of Polish origin but children were both born in England. Children had recently been given child in need status although the case had not been allocated at the time of their deaths. Mother had been anxious about the elder daughter's health although health professionals had assured her that there were no serious concerns. Mother reported low mood and thoughts of harming herself and her children to her GP. GP's referral to the mental health access team (known as the Single Point of Access Team (SPOA)) led to a mental health service assessment which determined that the mother did not require their support or the involvement of children's services. Issues identified include: professionals' assumptions about other teams' roles, responses and remit gave both professionals and the family false expectations about the service they would receive; and a confusing and inconsistent management system in place at the time of the GP referral, resulted in a delayed response from the SPOA team. Uses the SCIE Learning Together systems model to identify findings and put questions to the Safeguarding Children Board.
| Title: Serious case review: SOT 14 (2): Child One and Child Two: overview report. LSCB: Stoke-on-Trent Safeguarding Children Board Author: Joanna Nicolas, Carole Preston Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 STOKE-ON-TRENT SAFEGUARDING CHILDREN BOARD Serious Case Review SOT14 (2) The report 8th December 2015: v10 Authors Joanna Nicolas / Carole Preston Index Page 1. Introduction 2 2. The Family 2 3. Succinct summary of the case 3 4. Parallel processes 4 5. Timeframe under review 4 6. Timeline of events 5 7. Organisational learning and improvement 6 8. Methodology 6 9. The Findings 10 10. Findings in detail 13 11. Summary of findings 14 Appendix One 20 2 1. Introduction 1.1 Why this case was chosen to be reviewed 1.2 This case was taken to the serious case review sub-committee on 22nd October, 2014. The group decided unanimously that it met the criteria for a serious case review and therefore made that recommendation to the independent chair. 1.3 SOTSCB independent chair made the decision on 25th November, 2014 that the circumstances regarding the death of the children fully met the criteria for a serious case review, as set out in Chapter 4 of Working Together to Safeguard Children, 2013. This was because there were concerns around how agencies worked together and how agencies shared information. 1.4 In this case the mother took her own life after she unlawfully killed her children. Whilst services working with the family are considered in serious case reviews, they are considered in the context of safeguarding children. This is because serious case reviews are about children. 2. The Family The mother The father Subject Child One, aged six years at time of death Subject Child Two, aged 1 year 9 months at time of death 2.1 The family was Polish. The parents had lived in England for seven years. Both children were born and brought up in England. The father’s level of English was good and there were no issues with written and verbal communication. The mother did not have the same level of understanding or grasp of the English language but she did have a basic understanding and there was no need to involve interpreters. 3 3. Succinct summary of the case 3.1 From February 2014 the mother had concerns about a lump that Subject Child One had in her neck. The lump was seen by a number of health professionals, all of whom reassured the parents that the lump was not sinister. 3.2 On Friday, 3rd October 2014 the father took the mother to see GP1 because of her low mood and she was also expressing thoughts of harming herself and harming/killing the children. Whilst GP1 made an urgent telephone referral to the mental health service during his appointment with the family, he did not make a specific referral to Children’s Social Care. This was not done until the Single Point of Access professional made a referral on the Sunday 5th October 2014. During the course of the next few days the mental health service and Children’s Social Care were involved with the family. The mental health service undertook an assessment and concluded there was no role for them and gave the mother information about a mental health charity she could access. In view of this Children’s Social Care deemed the case to be a “child in need” case, as opposed to “child protection” (see glossary) and following managerial oversight had not allocated the case prior to the Sunday, 12th October 2014 when the mother killed both the children and then herself. 4 4. Parallel processes 4.1 Following the children and the mother’s death the police undertook a criminal investigation examining elements of homicide. The investigation concluded with a comprehensive file of evidence submitted to the Crown Prosecution Service. Given the circumstances there was clearly no further action that could be taken criminally and a file of evidence was subsequently prepared for and submitted to HM coroner North Staffordshire and Stoke-on-Trent. The inquest date of all three concerned is yet to be fixed. 4.2 The directorate governance lead for community directorate for North Staffordshire Combined Healthcare NHS Trust undertook a serious incident investigation following the deaths. 4.3 The investigation has concluded and actions are being undertaken but it is not a public document. 4.4 Individual staff practice in this case has been considered, as it always is when serious case are undertaken, and the review team considers appropriate action is being undertaken by relevant agencies. 5. Timeframe under review 5.1 Systems reviews consider how safeguarding systems and practices within a local authority area operate and we test out how safe and effective they are. Therefore when considering where to start the review we do not go back many years because systems will have changed. This does not mean that family history is overlooked but what is relevant is whether the professionals working with the family during the period under review know about the family history. 5.2 In this case it was agreed that the period under review would start from 28th February, 2014, which was the date the mother took Subject Child One to the GP with concerns about a lump in her neck. 5.3 This review concluded on the date on which the tragic events occurred (12th October 2014). 5.4 The review team has examined the changes in operations within the Single Point of Access Team that have been made up to the date of the final review team meeting which took place on 27th July 2015. Changes in operations have been noted in this report. 5 6. Timeline of events Date: Event: 28/02/14 Child 1 taken to GP surgery with a neck lump 07/04/14 Child 1 seen by a paediatric surgeon for neck lump at Hospital 1 27/05/14 Child 1 ultrasound scan of neck at Hospital 1 24/06/14 Child 1 seen by consultant paediatrician- oncology clinic at Hospital 1. Parents also concerned re chronic mouth breathing and loud snoring 01/07/14 Child 1 had an MRI scan at Hospital 1 07/07/14 Child 1 seen in clinic by general surgeon at Hospital 1 re lump 08/07/14 Child 1 seen in paediatric oncology clinic at Hospital 1 and then discharged 19/08/14 Child 1 seen ear, nose and throat clinic at Hospital 1 – referral from paediatrics due to neck lump 07/09/14 MRI undertaken under general aesthetic of Child 1’s neck lump at Hospital 2 22/09/14 Child 2 attended the GP surgery, then the Emergency Department at Hospital 1 following her putting breadstick in her eye 03/10/14 Referral to Adult Mental Health Service (Single Point of Access Team) from GP1 re the mother’s low mood, thoughts of suicide and killing/harming her children, following her appointment with GP1 05/10/14 Adult Mental Health Service contacted the mother who did not want to participate in a mental health assessment. Both parents declined support 05/10/14 Single Point of Access Team made referral to children’s services Emergency Duty Team. Emergency Duty Team visited, one Approved Mental Health Professional and one social worker 06/10/14 Single Point of Access Team completes telephone assessment. Mother denied suicidal ideation and thoughts to harm children. 06/10/14 Children’s services Emergency Duty Team referred to one of their safeguarding teams for further assessment under s.17, Children Act 1989 06/10/14 Mother contacted oncology department asking for result from MRI done on 07/9/14 on Child 1 by Hospital 2. 07/10/14 Unannounced home visit by Single Point of Access Team – continuation of the mental health assessment. No requirement for secondary mental health services. Mother signposted to Mind, mental health charity. 09/10/14 Adult mental health assessment completed. The case to be closed to the Adult Mental Health Service because the mother had been signposted to MIND and it was considered there was no requirement for secondary mental health services. 12/10/14 The mother killed her two children at the family home and then killed herself. 6 7. Organisational learning and improvement 7.1 Statutory guidance on the conduct of learning and improvement activities to safeguard and protect children, including serious case reviews states that: 7.2 Reviews are not ends in themselves. The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children. (Working Together 2013) 7.3 Stoke-on-Trent Safeguarding Children Board identified that this serious case review held the potential to shed light on particular areas of practice including addressing the following questions:- • How rare is it for someone to act out their intrusive rather than delusional thoughts to kill someone? (See glossary for the difference between the two). • The use of interpreters? 8. Methodology 8.1 Statutory guidance requires serious case reviews to be conducted in such in a way which: • recognises the complex circumstances in which professionals work together to safeguard children; • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • is transparent about the way data is collected and analysed; and • makes use of relevant research and case evidence to inform the findings. 8.2 It is also required that the following principles should be applied by LSCBs and their partner organisations to all reviews: • there should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works and promote good practice; • the approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined; 7 • reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed; • professionals should be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith; • families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring that the child is at the centre of the process. 8.3 In order to comply with these requirements SOTSCB has used the SCIE Learning Together systems model (Fish, Munro & Bairstow 2010). The serious case review has been quality assured by SCIE. 8.4 Reviewing expertise and independence 8.5 The serious case review has been led by two people, one of whom was independent of the organisations whose actions are being reviewed. Joanna Nicolas is an independent child protection consultant who is accredited to carry out SCIE Learning Together reviews, and has extensive experience in leading serious case reviews. She has been a social worker for 19 years. Carole Preston is the Stoke-on-Trent Safeguarding Children Board Manager (SOTSCB). She has had 25 years’ experience in social work, in a variety of roles and has been the Board Manager since 2006. Carole has been trained in the SCIE Learning Together methodology. 8.6 The lead reviewers have received supervision from SCIE as is standard for Learning Together accredited reviewers. This supports the rigour of the analytic process and reliability of the findings as rooted in the evidence. 8.7 Statutory guidance requires that serious case review reports be written in plain English and in a way that can be easily understood by professionals and the public alike. Writing for multiple audiences is always challenging. In the appendix we provide a section on terminology. Our aim is to support readers who are not familiar with the processes and language of safeguarding and child protection work. 8.8 LSCBs and SCIE are both keen to improve the accessibility of serious case review reports and welcome feedback and suggestions for how this might be improved. 8.9 Participation of professionals 8.10 The review consisted of two groups of professionals, the review team which consisted of a senior manager from each of the agencies involved during the period under review, none of whom had had line management of the case, and the two lead reviewers. 8 8.11 Review Team Joanna Nicolas Independent lead reviewer Carole Preston Internal lead reviewer. SOTSCB Board Manager Safeguarding Lead North Staffordshire Combined Healthcare NHS Trust Strategic Lead, Inclusion People Directorate – Learning Services Head of Safeguarding Children Staffordshire and Stoke-on-Trent NHS Partnership Designated Nurse, Child Protection Stoke-on-Trent Clinical Commissioning Group Strategic Manager Vulnerable Children People Directorate Head of City-Wide Locality Working People Directorate Deputy Chief Nurse University Hospital North Midlands Crime Policy Review and Development Team Manager Staffordshire police 8.12 The case group was made up of the key frontline professionals who had been working with the family during the period under review. 8.13 The case group Adult mental health social worker. Duty lead 3-5/10.14 North Staffordshire Combined Healthcare NHS Trust Registered nurse in mental health. SPOA duty call taker on 3.10.14 North Staffordshire Combined Healthcare NHS Trust Adult Mental Health social worker. Undertook assessment 7.10.14 North Staffordshire Combined Healthcare NHS Trust Approved Mental Health Practitioner. Sessional. Social Care’s Emergency Duty Team. People Directorate Adult Mental Health Social Worker North Staffordshire Combined Healthcare NHS Trust Registered Nurse in Mental Health. Undertook telephone assessment 06/10/14 North Staffordshire Combined Healthcare NHS Trust Play and Learning Practitioner Play and Learning Team. Children’s Centre Social Worker Social Care’s Emergency Duty Team. People Directorate Practice Manager Safeguarding team. People Directorate Practice Nurse 1 GP practice Practice Nurse 2 GP practice GP1. Locum GP. Saw mother, father and Child 2 on 03/10/15 GP practice GP Practice Safeguarding Lead GP practice Health Visitor Staffordshire and Stoke-on-Trent NHS Partnership School Nurse Staffordshire and Stoke-on-Trent NHS Partnership Year One Teacher Subject Child One’s school Support Assistant Subject Child One’s school Paediatric Oncologist University Hospital North Midlands 9 8.14 There was on-going interaction between the two groups to test out accuracy, developing analysis and findings. 8.15 Perspectives of the family 8.16 It is a family’s choice whether they contribute to a serious case review. Every effort is made to engage with the family because their contribution is recognised as extremely important and makes for a much richer review. The father of the deceased children contributed to this review. 8.17 Methodological comment and limitations 8.18 During the serious case review Stoke-on-Trent was the subject of an unannounced inspection of children’s services by Ofsted and on occasions that did impact on the involvement of some members of the review team and Carole Preston, as the internal lead reviewer and LSCB Board Manager. Despite this the review has gone smoothly with the case group being fully engaged with the process and being honest and open with the review team. Apart from the absence through Ofsted the review team have been very well engaged with the process. 8.19 The process has been extremely well supported by a highly efficient administrator and that has aided the process hugely. 10 9. The findings: 9.1 Introduction 9.1.1 Statutory guidance requires that serious case reviews provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of reoccurrence. These processes should be transparent, with findings of reviews shared publicly. The findings are not only important for the professionals involved locally in cases. Everyone across the country has an interest in understanding both what works well and also why things can go wrong. 9.1.2 This section contains two priority findings that have emerged from the serious case review. The findings explain why professional practice was not more effective in protecting the children in this case. Each finding also lays out the evidence identified by the review team that indicates that these are not one-off issues but systemic within Stoke-on-Trent. These findings will resonate with other local authorities. Evidence is provided to show how each finding creates risks to other children and families in future cases, because they undermine the reliability with which professionals can do their jobs. 11 9.1.3 First, an overview is provided of professional practice in this case. This clarifies the view of the review team about how timely and effective the help that was given to Subject Child One and Subject Child Two and their family was, including where practice was below expected standards. 9.1.4 A transition section reiterates the ways in which features of this particular case are common to other work that professionals conduct with other families and therefore provides useful organisational learning to underpin improvement. 9.2 Appraisal of professional practice in this case: a synopsis 9.2.1 The review team explored whether frontline professionals should have considered the use of interpreters however we have concluded that there is strong evidence that the mother’s level of English, supported by her husband, was sufficient for professionals to have communicated with her in writing and verbally in English, without the use of interpreters. The review team was told by all the professionals who had contact with the father that his English was very good and this was confirmed in our meeting with him. Therefore the conclusion of the review team is that the decision that professionals made around the use of interpreters was the correct one. 9.2.2 The review team considered in great detail the fact that the mother had expressed views of harming/killing her children and had thought about how she might do that. It is recognised that there is a continuum. At one end of the spectrum there will be mothers who say in frustration or anger “I could murder you”, or a variation of that sentiment but it is perfectly clear that will never happen. At the other end of the spectrum there is the mother who expresses a concern that she will harm/kill her children and then actually follows through. There is contradictory research1 as to the state of a mother’s mental health prior to killing her children. In this case there was no known evidence of a history of mental ill health or any evidence of mental ill health during the assessment period prior to the incident. We have therefore concluded that there is no specific finding in respect of the mother’s comments and then action. 9.2.3 The mother first took Subject Child One to the GP in February, 2014 with concerns about a lump in the child’s neck. Over the next few months Subject Child One was seen by a number of medical experts, including a paediatric oncologist and an ear, nose and throat consultant. She also had two MRI scans. The mother was given constant assurance that whilst there were some concerns about the lump because it may have been causing Subject Child One to snore, it was not cancerous, or anything else sinister. The mother found this hard to accept and clearly caused her anxiety. The conclusion of the review team when considering how health professionals dealt with the mother’s concerns was that they recognised the mother’s level of anxiety and responded sensitively and went out of their way to allay 1 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2174580/ 12 her concerns. It would be easy to speculate that the mother killed her children and then took her own life because of health concerns about her children however that would be pure conjecture and there is absolutely no evidence that this was the case. 9.2.4 The father made an appointment to see the local GP on 3rd October, 2014 because he was worried about his wife. The mother told GP1 she was having thoughts of harming/killing her children and suicide ideation. GP1, who was a locum GP, spent half an hour with the family because he recognised the mother’s level of need and the mental health issue, which was good practice. 9.2.5 GP1 contacted the mental health access team with the family present, known as the Single Point of Access (SPOA) Team. The parents left the surgery with the impression they were going to be contacted that day by the mental health service because GP1 had asked for that to happen. The call-taker from the SPOA team had not given that explicit guarantee although she did tell the doctor that with urgent referrals service-users will be contacted within four hours and she would try to get someone from the team to telephone the mother that day. The call taker also asked GP1 if he wanted the mother seen that day, he said yes and the SPOA call-taker said she would make a note of that. At the time in the SPOA team there does not appear to be a written policy, this appears to be custom and practice at that point (there is a policy now along with Key Performance Indicator’s for it). 9.2.6 Neither GP1 nor the SPOA call-taker thought it necessary to make a referral to Children’s Social Care, which they should have done, despite the mother having thoughts of killing her children. It is the view of the review team that if a referral had been made to Children’s Social Care on that day it would have been treated correctly as a section 47 investigation i.e. child protection. 9.2.7 It is extremely concerning that although the referral was made on the Friday, it was not acted upon until the Sunday. It has not been possible to establish where in the system the referral was for that period of time. It is the responsibility of the duty lead to oversee all referrals that come into the team. All referrals come in through the duty desk. 9.2.8 When the referral was first picked up on Sunday, 5th October 2014, it was responded to without further delay. 9.2.9 The worker from the SPOA Team was rightly concerned about this case and referred to the emergency duty team for further assessment. The family were visited that day by an approved mental health professional and emergency duty social worker from the emergency duty team. The review team accepts that without the benefit of hindsight it is understandable why, from this point Children’s Social Care considered the case to be children not in need of immediate protection because the mother’s presentation and the father’s support gave the professionals reassurance that the perceived risks had diminished. In addition to this, the following Thursday, 9th October, Children’s Social Care were informed by the mental health service that 13 they were closing the case, thus giving a clear message to Children’s Social Care that in their professional opinion there were not sufficient concerns about the mother’s mental health for them to remain involved. 9.2.10 Following the joint visit on the Sunday the mental health service continued to assess the mother’s mental health via a telephone assessment. The review team considers it poor practice that the continuation of the assessment was undertaken over the telephone. It should have been a face-to-face interview with a professional with expertise in mental health. Further to this incident the North Staffordshire Combined Healthcare NHS Trust has introduced a Key Performance Indicator to ensure that all crisis referrals receive face to face assessment within 4 hours. 9.2.11 Subsequent to this incident the North Staffordshire Combined Healthcare NHS Trust has revised their operational policy which now has additional clarity with referrals and response time. 9.2.12 There then followed an unannounced visit by a member of the SPOA team, on the Tuesday. Based on the evidence available the review team accepts that nothing from either of those contacts suggested that the mother’s mental health was deteriorating, or that she required a service from the secondary mental health service. 9.2.13 The review team consider it poor practice that on two occasions the parents were led to believe by professionals they would be visited by other professionals either the same day, or the next day and in neither case did it happen within the timescale set out. The first occasion was the parents believing a mental health worker would visit them on Friday, 3rd October 2014. Secondly it was believed by the family that Children’s Social Care would visit them on Monday, 6th October 2014. 10. Findings in detail 10.1 In what ways does this case provide a useful window on our systems? 10.2 When considering this question we consider 6 typologies as lines of enquires. These are:- 1. Tools - what have we learnt about the tools and their use by professionals? 2. Responses to incidents/Crises - are there particular patterns we have identified about how professionals respond to incidents? 3. Longer term work – are there particular patterns we have identified about ways of working over a longer period with children and families? 14 4. Management Systems - are any elements of management systems a routine cause for concern in any particular ways? 5. Family-professional interaction - what patterns of ways that professionals are interacting with different family members are discernible, and do they introduce risk into our systems? 6. Innate Human biases - are there common errors of human reasoning and judgement evident that are not being picked up through current set ups? 10.3 Our findings in this case fit into three of the categories of the typology, responses to incidents/crises, longer-term work and management systems. 10.4 Reviewing the way that professionals responded in this case is a useful test for how effectively we in Stoke-on-Trent understand levels of risk and the interface between different agencies. 11. Summary of findings 11.1 The review team has prioritised two findings for SOTSCB to consider. They are:- Finding One There is a pattern in Stoke-on-Trent of professionals making assumptions about other teams/agencies roles, responses and remit, which can leave families vulnerable and both professionals and families with false expectations. Finding Two At the conclusion of the serious case review process the Review Team found that many improvements have been made to the Single point of Access Team. At the date of the final Case Review meeting held on 27th July 2015, there were a number of concerns about how the team operates. 11.2 Responses to incidents/Crises - are there particular patterns we have identified about how professionals respond to incidents? 11.3 Finding One 11.4 There is a pattern in Stoke-on-Trent of professionals making assumptions about other teams/agencies roles, responses and 15 remit, which can leave families vulnerable, and both professionals and families with false expectations. 11.5 How did the issue manifest in this case? 11.6 The conversation between GP1 and the SPOA call-taker was made in the family’s presence and the family left with the impression they would be contacted later that day by the mental health service. 11.7 When the Emergency Duty Team social worker and the approved mental health professional visited the family on the Sunday evening they told the family they would be visited the following day by a children’s social worker from a safeguarding team. This visit did not take place. The following day the incoming manager reviewed the case and in light of the assessment concluded that there were no immediate concerns identified this as a child in need case which would be allocated in due course. The manager was unaware of the commitment made for a social worker’s visit that day. 11.8 How do we know it is an underlying issue and not something unique to this case? 11.9 The review team and the case group have all confirmed that there are different levels of understanding as well as sometimes a lack of understanding cross-agency and within agencies about different teams/agencies roles and responsibilities. Although not the sole cause of this issue it is recognised that the constant changes of staff, structures, teams, professionals titles, team titles and team bases exacerbates the confusion. 11.10 How widespread is the issue? 11.11 The review team and the case group have all confirmed this issue is a regular occurrence across teams and agencies in the City because some agencies appear to be in a constant state of change. This is not an issue unique to Stoke-on-Trent. It is a common finding from serious case reviews across the country and although not the sole cause it is recognised that the national austerity measures are impacting across local provisions. 11.12 Families may live in one local authority but access services from another. It is important to note that the Mental Health Access Team however works across the city and North Staffordshire local authorities and makes no demarcation in the consistency of the service provided. 16 11.13 How prevalent is the issue? 11.14 This confusion potentially has the ability to impact on other cases however it must be acknowledged that a considerable amount of work has been undertaken in one particular area of multi-agency working. The LSCB has led on the revision of the existing threshold criteria for the guide to Levels of Need. This document clearly sets out the range of universal, specialist and statutory services available in the City and how those services can be accessed. The LSCB recently undertook a small sample survey to ascertain professional understanding of this document and the results of the survey concur with this finding that further work needs to be undertaken to clarify professionals’ roles, responsibilities and the correct support option for the child and their family. 11.15 Why does it matter? What are the implications for the reliability of the safeguarding system? 11.16 The most effective way to improve outcomes for children and their families is by all the relevant teams/agencies working together and professionals working in partnership with families. It is unlikely we will be able to achieve that if professionals do not understand each other’s roles, responsibilities and other teams/agencies remit. One of the consequences of this will be that professionals may not be able to provide accurate information about local service support and may give parents misleading information, which is frustrating for families. Finding One There is a pattern in Stoke-on-Trent of professionals making assumptions about other teams/agencies roles, responses and remit, which can leave families vulnerable, and both professionals and families with false expectations. Summary Through this review we have established that there may be professional confusion about each other’s roles, responsibilities and teams/agencies remit. This confusion will lead to ineffective multi-agency working and will also impact on how professionals work with children and their families. Questions for consideration by the Board 1. How confident is the Board that teams/agencies working across the City understand each other’s’ roles, including responses, responsibilities within referral pathways? 2. In a time of considerable change and reorganisation how confident is the Board that each team/agency is kept up to date with those changes? 3. How can the Board test out that when agencies reorganise, risk factors caused by a lack of understanding of each other’s responses/roles and agencies are mitigated against? 17 11.17 Finding Two 11.18 Management Systems - are any elements of management systems a routine cause for concern in any particular ways? 11.19 At the conclusion of the serious case review process the Review Team found that many improvements have been made to the Single point of Access Team. At the date of the final Case Review meeting held on 27th July 2015, there were a number of concerns about how the team operates. 11.20 How did the issue manifest in this case? 11.21 The SPOA team is made up of health and social work professionals with a range of knowledge, experience, responsibility and skill levels. 11.22 The duty system that was in place at that time was confusing and inconsistent. There was no electronic system in place. There was a tray system in place, these were coloured, according to the work required. All new referrals and priority work went into the red tray. Then there was a yellow tray for those referrals that had been seen and were a work in progress and then there was a green tray that was for referrals that had been assessed and were awaiting appointments etc. There were no standard operating procedures for how to use the tray system. There were a number of more experienced workers in the team who took on the role of duty lead, each had their own way of dealing with the trays, some liked the workers to put a file “across” the tray, if it was urgent. The tray system described in this report which was in use at the time of the incident is no longer in operation and ceased to be so directly following the incident. North Staffordshire Combined Healthcare NHS Trust have evidenced that there has been an electronic system in place since January 2015. 11.23 The first contact to the team was made by GP1 on the Friday. The SPOA call taker was a mental health nurse. It is not clear what happened to the referral following the telephone call and for the next two days but the file was effectively lost in the system and no action was taken by the team. The mental health social worker who “discovered” the file on the Sunday had been in the SPOA team since August. It was his first weekend duty shift. The mental health social worker recognised the referral had not been actioned and that there was a potential safeguarding concern and made a referral to the Local Authority’s (social care) emergency duty team. That evening an approved mental health professional and an experienced social worker visited the family. The following day a telephone assessment took place by a mental 18 health nurse. Having reflected on the telephone assessment this worker thought a face-to-face assessment was required and the family was visited the following day by another mental health social worker. It should be noted that the North Staffordshire Combined Healthcare NHS Trust’s internal investigation have accepted that the referral document was not actioned in a timely way and that there were no systems in place, at the time of this incident, to track referrals. 11.24 How do we know it is an underlying issue and not something unique to this case? 11.25 The review team has found that although many improvements have been made to the SPOA team following this tragedy as, at the date of the final Case Review meeting on 27th July 2015, there were a number of concerns about how the team operates these are set out in 11.26 to 11.31. 11.26 The SPOA team has approximately ten workers who take on the role of duty lead. The review team has been told by one SPOA team member that the process still varies depending on the duty lead at the time. 11.27 There is a hierarchy in the team that may impact on the functioning of the team. 11.28 Since this case the SPOA team has implemented a 24 hour duty system. Currently the team has to physically move every evening to another office because two teams combine to offer the out of hour’s service. This is only a temporary arrangement until the team moves to a permanent location in the near future. 11.29 The role of the Duty lead has been clarified since this case and now involves: triaging new referrals for which there is a clear process, co-ordinating and allocating new referrals and work that comes in during the shift, providing leadership and supervision to junior staff, managing bed management calls and often acting as a first point of contact. Depending on levels of clinical activity and service need, if there is capacity, the Duty Lead may support other staff on duty by helping with taking phone calls, seeing walk in’s and assisting with duty screenings, though this is at the discretion of the Duty Lead, and would not be an expectation or requirement if the Duty Lead was busy with their own workload. 11.30 The review team has been told by one SPOA team member that she rarely has supervision, although there is evidence that other members of the team have monthly supervision, in line with the Trust policy. 11.31 Those taking the calls on duty may be newly qualified, or have no specialism in mental health and therefore may be ill-equipped to deal with complex mental health needs. 19 11.32 How widespread is the issue? 11.33 This finding is only in consideration of the SPOA team 11.34 How prevalent is the issue? 11.35 This finding is only in consideration of the SPOA team. 11.36 Between June 2014 and June 2015 the SPOA team undertook a total of 5,041 assessments. 11.37 Why does it matter? What are the implications for the reliability of the safeguarding system? 11.38 The SPOA team is the front door service to all adult mental health services in the city and North Staffordshire. If there is not the expertise in the team to recognise levels of risk and if clear, robust systems are not in place, some of the most vulnerable people in our community will not have their needs met and levels of risk will not be accurately ascertained. Finding Two At the conclusion of the serious case review process the Review Team found that many improvements have been made to the Single point of Access Team. At the date of the final Case Review meeting held on 27th July 2015, there were a number of concerns about how the team operates. Summary We know from research of the importance of early help when concerns are first presented. If those concerns are not addressed effectively in the first instance, concerns can quickly escalate into crises. During the period under review Stoke-on-Trent and North Staffordshire’s front door team for all mental health services was not working effectively and there is evidence that in some aspects this is still the case. Questions for Consideration by the Board 1. How will the Board assure itself that the North Staffordshire Clinical Commissioning Group recognises and is addressing the current weaknesses in the front door mental health service it commissions from North Staffordshire Combined Healthcare NHS Trust? 20 Appendix One Glossary of Terms and Acronyms Child in Need - Under Section 17 (10) of the Children Act 1989, a child is a Child in Need if: - He/she is unlikely to achieve or maintain, or have the opportunity of achieving or maintaining, a reasonable standard of health or development without the provision for him/her of services by a local authority; - His/her health or development is likely to be significantly impaired, or further impaired, without the provision for him/her of such services; or - He/she is a Disabled Child. Child protection – Section 47(1) of the Children Act 1989 states that: Where a local authority have reasonable cause to suspect that a child who lives, or is found, in the area and is suffering, or is likely to suffer, significant harm, the authority shall make such enquiries as they consider necessary to enable them to decide whether they should take any action to safeguard or promote the child's welfare. Delusion - a false belief regarding the self or persons or objects outside the self that persists despite the facts. Not in keeping with cultural norms (ie religious/spiritual beliefs etc). An intrusive thought - an unwelcome involuntary thought, image, or unpleasant idea that may be upsetting or distressing, and can feel difficult to manage or eliminate. LSCB- Local Safeguarding Children Board Secondary mental health service – Once the SPOA team have concluded their assessment if the service-user is considered to have a higher level of complexity, in terms of their mental health needs, they will be referred to the secondary mental health service. SCIE – Social Care Institute for Excellence KPI – Key Performance Indicators SOTSCB – Stoke-on-Trent Safeguarding Children Board SPOA – Single point of access team. The front door of mental health team that covers Stoke-on-Trent and North Staffordshire. Working Together to Safeguard Children, 2013. The statutory guidance for inter-agency working to safeguard and promote the welfare of children. |
NC045583 | Summary of a review into the death of 1-year-old girl in July 2012, as the result of non-accidental injury. C2 sustained injuries whilst in the care of mother's partner, A2. A2 was convicted of murder and sentenced to life imprisonment. Family were known to a significant number of agencies including a number of health services in different hospital settings. In the month prior to her death, C2 attended hospital with a head injury and what was identified as a possible bite mark, considered to be non-accidental. A Section 47 investigation was progressed but assessments did not involve all agencies with knowledge of the family and the case was closed. A2 had a previous conviction for criminal damage and possession of an offensive weapon, relating to an incident of domestic abuse with an ex-partner. Identifies lessons including: insufficient professional curiosity; lack of professional challenge; and need for robust and clear escalation procedures where there is disagreement between agencies. Makes recommendations including the review of the arrangements for taking photographs of possible injuries to ensure medical staff have access to this service at all reasonable times.
| Title: Serious case review Family V: executive summary. LSCB: Lincolnshire Safeguarding Children Board Author: David Ashcroft Date of publication: 2014 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. SERIOUS CASE REVIEW FAMILY V EXECUTIVE SUMMARY Report by David Ashcroft, Independent Overview Report Author 6 February 2014 Version 02/14 1 Introduction 1. This is the Executive Summary for the Serious Case Review commissioned by Lincolnshire Safeguarding Children Board into the case of Child V (C2). 2. C2 was born on 9th May 2011. She died on 31st July 2012 as a result of injuries sustained when in the care of her mother’s partner, who was charged with murder and subsequently convicted and sentenced to life imprisonment in November 2013. She lived with her mother (A1); elder half-sibling (C1); and from March 2012 with her mother’s partner (A2); who was also the father of her half-sibling (C3) who was born 4th August 2012, a few days after C2’s death. 3. There are two main incidents covered by this SCR. This first was in early June 2012 and the second was at the end of July 2012. These are referred to as Episode 1 and Episode 2 in this report. 4. Episode 1: C2 was brought by ambulance to Boston Pilgrim Hospital A&E Department on 1st June 2012 following a call to the 111 service by her mother concerned about a possible head injury. She was subsequently admitted to the Children’s Ward and was examined by the Consultant Paediatrician, CON2, the following day. CON2 identified a possible bite mark that he considered could be the result of Non Accidental Injury (NAI). C2 was subsequently discharged to the care of her maternal grandmother, A3. 5. A referral was made by CON2 to children’s social care Emergency Duty Team (EDT) who spoke to staff and the family on the phone but did not attend the hospital. 6. C2 was the subject of a strategy discussion between social care and the police on 3rd June and a Section 47 investigation was agreed. The possibility of a non-accidental cause for the bite mark was not followed up robustly. A decision not to proceed to an Initial Child Protection Conference was made on 12th June, although the case remained open to Lincolnshire Children’s Services as a Child in Need for the completion of the core assessment. Subsequent investigations and the assessment were progressed, but did not involve all agencies with knowledge of the family. There was contact with the family and the children were seen, but recording on the social care ICS system was limited. Workers observed positive parenting and discounted the possibility of non-accidental injury without checking this with the Consultant concerned. The case was closed by Children’s Social Care by 24th July, although health were concerned about this. At several points there were missed opportunities to escalate or resolve some of the differences of view. Version 02/14 2 7. Episode 2: C2’s principal carer, A2, called emergency services at 16.39 on 28th July as she was not breathing normally and was reported to have fallen off the settee. C2 and C1 had been in his sole care as their mother was at work. 8. C2 was taken to Grimsby Hospital by emergency services in a critically ill condition. Appropriate medical interventions were undertaken to treat her presenting conditions, but a CT scan was inaccurately reported as normal. She was subsequently transferred to Sheffield Children’s Hospital and died there early on 31st July. Investigations conducted at Sheffield, including a further CT scan, revealed a deterioration in her condition and significant brain injuries and by 17.00 on 29th July it had been concluded that there was a high likelihood of NAI due to “shaken baby syndrome”. A2 was subsequently arrested at Sheffield Children’s Hospital and charged with murder. Undertaking the Serious Case Review 9. At a meeting of the Lincolnshire Safeguarding Children Board’s (LSCB) Serious Case Review Sub-Group, on the 10th September 2012, the panel recommended unanimously that this case met the criteria under Working Together 2010, to undertake a Serious Case Review (SCR). The Independent Chair of the LSCB, Chris Cook, confirmed his decision that this case should be the subject of a Serious Case Review on the same day. An independent author, Mr David Ashcroft, was commissioned on 8th November to undertake the review. 10. The timespan for the Review was from C2’s birth (9/5/11) to her death (31/7/12). 11. This case is notable for the large number of different agencies and services that came into contact with the family. In particular health services were accessed at a number of different hospital settings. Individual Management Reviews and short information reports were requested from, and completed by, the following agencies: Lincolnshire County Council, Children’s Social Care (CSC) Lincolnshire Police Nottinghamshire Police (short report) Lincolnshire Probation Trust United Lincolnshire Hospital NHS Trust (ULHT) for midwifery services and Pilgrim Hospital, Boston Lincolnshire Community Health Services (LCHS) NHS Lincolnshire (General Practice) East Midlands Ambulance Service (EMAS) North Lincolnshire and Goole Hospitals NHS Foundation Trust (NLaG) for Diana, Princess of Wales Hospital, Grimsby (DPoW) Sheffield Children’s Hospital Foundation Trust (SCHT) NHS Direct (short report) Lincolnshire County Council Education and School (short reports) Nottinghamshire County Council, Children’s Social Care (short report) Version 02/14 3 LIVES First Responder Service (short report) 12. A comprehensive integrated chronology of the case was compiled from the details supplied by each agency. The Overview Report sets out a summary of the key events and analyses these in detail in order to learn the lessons from this review. 13. A Health Overview Report (HOVR), bringing together the analysis and issues across the health organizations involved, was also commissioned. This benchmarked the clinical practice described in the IMRs against the expectations of commissioned services and evidence of best practice, and also explored how effectively health organizations had communicated with each other and with agencies beyond health as part of the inter-agency response to the family up until C2’s death. 14. The Overview Report was compiled based on the information and analysis collected through the IMR process. It is intended for publication as the account of the learning from this case. The Overview Author has presented for discussion and challenge key themes and lines of enquiry to the SCR Panel. This Executive Summary highlights the key learning from this SCR. Learning and Actions already taken 15. Agencies have already considered some of the action points arising from this case and taken appropriate and prompt management action to address obvious shortfalls in process and operational capacity. This is positive and appropriate to ensure that learning and improvement does not wait for the completion of the formal serious case review process. Actions already taken include: • Agreement between Children’s Social Care and Lincolnshire Police and health agencies to ensure that there are suitable staffing arrangements for strategy discussions to take place outside normal business hours; • Revised arrangements for Public Protection Unit (PPU) cover outside normal working hours; • Revised arrangement for urgent checks through the Police National Database (PND) for placements of a child by Children’s Social Care; • Revised arrangements within the police for accessing Scene of Crime Officers (SOCOs) to take photographs to allow the appropriate recording of injuries to children; • Aide memoire for Strategy Discussions issued April 2012 by CSC to ensure that all children in a family should be considered; • Revisions to the Connected Persons Procedure (relating to the placing of children with family members or friends as an alternative to foster care) issued in September 2012; • Serious Untoward Incident Report commissioned by NLaG in respect of the reporting of the CT scan at Grimsby Hospital as normal. Conclusions Version 02/14 4 16. It is the conclusion of this Serious Case Review that the death of C2 was neither predictable nor preventable. The subsequent trial of A2 has established that he was responsible for the murder of C2. The judge concluded that A2’s failure to tell the truth meant that the medical teams spent time investigating other possible causes of her injuries. The judge also made clear that A1 was completely exonerated of any involvement. 17. Although there are lessons to be learnt from this case there is no evidence that any different circumstances would have modified or changed A2’s behaviour and actions, or that the outcome for C2 could have been different. However, there were discrepancies and differences in the information known by agencies; in the history reported by the family; in the judgments reached in good faith by professionals. None of these suggest unequivocally that there was a clear risk of significant harm that should have been acted upon differently, for example by removal of C2, at the time of episode 1, although the opinion of CON2 that there was an unexplained bite mark should not have been discounted. Opinion on this injury should have been clarified with CON2 as part of the S47 investigation. The failure to challenge the differences of view, or to escalate them to resolution, and to use multi-agency processes constructively to test information and agree a plan focused on the child’s best interests, together with the gaps in recording, were all missed opportunities to ask more searching questions. These are of concern and provide important lessons from this Serious Case Review. 18. At episode 2 the injuries sustained by C2 were life-threatening, and there is evidence of prompt and appropriate action to treat her by a series of teams and interventions. In general interagency liaison worked well, including with the transfer to South Yorkshire services in Sheffield. What was not picked up during episode 2 was some of the information that might have increased the probability that NAI was considered of greater likelihood at an earlier stage. This would not have changed the outcome for C2, but reveals the importance of maintaining a clear focus on safeguarding issues. 19. Episode 1 More attention to, and evaluation of, a range of safeguarding questions in June 2012 might have enabled agencies to be more alert to possible risks to C2 and also to her siblings and therefore to have developed a proactive relationship with the family that was focused on the possible risks to all three children, including the unborn C3. 20. This more proactive relationship with the family could have been through a Team around the Child (TAC) approach, a Child in Need (CiN) plan or through a Child Protection Plan (CPP). Had CON2’s view been accepted that the bite mark was a NAI or at least unexplained, a child protection conference might have been called and more detailed information about the family could have been gathered and more fully evaluated. It would certainly have presented a more complex picture to Version 02/14 5 support work with the family, but it is in my view unlikely that the case would have met the threshold for implementing a CCP even after discussion at conference, given what was known at the time. Holding an ICPC, however, might have established with the family the nature and level of the concerns shared by agencies and why these were potential risks, and placed the whole history of C2 short life in a clearer context. This would have supported closer working with the family. Instead, a more optimistic view of the risks developed during June, it was decided that a Child Protection Conference was not justified and the case was closed a few days before the final episode and C2’s death, without a TAC or CiN plan. While this is missed opportunity there is no firm evidence that it would have affected A2’s behaviour or actions, or would have protected C2 more effectively. 21. Greater professional curiosity and better exchange of information might have challenged the varying accounts and explanations provided by A1 and A2 in order to evaluate better whether there were safeguarding risks and how these might have been managed. This might have probed more closely the assumption of parental responsibility by A2 in his presentation to health agencies, and the degree to which he provided the history of C2’s injuries and well-being to professionals even when not present at the reported incidents.. 22. Episode 2 C2 was seriously ill and her condition critical from the time of the 999 call on 28th July. The emergency response was timely and appropriate to her presenting symptoms, but did not adequately consider the safeguarding implications of the case and of information provided by A1 and A2 in a number of separate comments. Medical opinion from both DPoW and Sheffield suggests that it is unlikely that C2 would have recovered. However, there was a failure to incorporate information about her previous episodes of hospital admission and possible injury or to question the likelihood of NAI, which was compounded when the initial CT scan at DPoW Hospital was incorrectly reported. 23. Overall, the case illustrates weaknesses in the robust, prompt and sceptical appreciation of safeguarding risks across several agencies, which should have placed a proper professional curiosity alongside the positive parenting observed, and the immediate priorities of care and treatment that were correctly put in place. The case illustrates that, in circumstances where there are different views and opinions, and not sufficient challenge and curiosity, safeguarding processes need to prompt the critical evaluation required to assess risks clearly and to decide on an appropriate course of action. 24. Where there is clear evidence of significant harm there are robust processes for deciding on a course of action to protect children. What this SCR indicates is that children can come to harm where there are few obvious signs and where only hindsight suggests information that might have given rise to greater concerns. Appropriate procedures and process were in place – to gather information, to Version 02/14 6 conduct a strategy discussion, to escalate concerns – but these were undermined by inconsistencies in recording, failures to challenge and check information, and by a lack of focus on the child(ren. 25. Although there is no evidence to conclude that this would have predicted or prevented C2’s death, there were weaknesses in the handling of this case by both individual workers and agencies. There are as a result several areas where lessons should be learnt from this Serious Case Review. These are: • Lack of professional curiosity, particularly in relation to the accounts given of the injuries to C2; • Discrepancies in information not challenged through checking with agencies involved; • The need for a prompt response, in person, to both the family and health staff when concerns are raised, especially out-of-hours; • The need to have clearly understood and safe discharge arrangements • The need to hold prompt, inclusive strategy discussions; • The need for robust and clear escalation when there is disagreement between agencies; • Consistent and regular supervision to challenge and question the emerging picture; • Recognition of safeguarding risks alongside clinical interventions, particularly when treating seriously ill children. In addition there should have been more explicit recognition by all agencies that there might be safeguarding risks for both C1 and C3 if there were concerns about C2. There seems to have been little consideration of the family dynamics and the fact that A2 was a relatively new part of the household, about whom there had been previous concerns of violent behaviour. 26. Overall, there should have been greater focus on the child, and consideration of the risks to, and experience of, a young child who it is now known had suffered a series of unexplained injuries about which different accounts had been given. Recommendations 27. A number of specific recommendations have been made arising from the IMRs and these are contained in the SCR Action Plan published with the full report. 28. The Lincolnshire Safeguarding Children Board is recommended to consider how it can reinforce the need for a critical and probing safeguarding mindset across all staff and agencies, so that staff are equipped be alert to potential safeguarding risks in all situations. 29. The Lincolnshire LSCB should consider the findings from this report as part of its Learning and Improvement Framework and review to what extent further audit and Version 02/14 7 training work is required to address the issues identified. 30. That urgent consideration should be given to the arrangements for taking photographs of possible injuries to ensure that this service is available at all reasonable times where there are safeguarding concerns. David Ashcroft Independent Report Author 5 February 2014 Version 02/14 8 |
NC52469 | Child sexual abuse and exploitation of a 14-year-old girl who had been coerced into a sexual relationship with a 34-year-old male, a friend of the child's brother who had been known to the family for several years. Learning includes: professionals should be professionally curious and alert to the signs of possible child sexual exploitation in situations where there are medical complaints linked to sexual activities; frontline staff need to be aware of adverse childhood experiences to be able to provide trauma informed support; building trust by showing kindness, empathy, being professionally curious and offering additional appointments to see the child again can be provide a safety net for girls at risk of CSE; aways clarify who the members of a household are during home visits; when a child "was not brought" to essential medical or mental health appointments a risk assessment should take place to consider medical neglect. Includes a message to other young people from Olivia - if you are suffering from any form of abuse then you should always talk to someone who will listen to you and help you. Recommendations include: ensure that the voice of the child is captured and acted upon, particularly in Public Law Order (PLO) proceedings; promote robust information sharing with the allocated social worker or their deputy when there are new developments or concerns about children subject of child protection and child in need plans; develop the workforce in using a more trauma informed way of working which should benefit working relationships with parents and their children.
| Title: Serious case review: ‘Olivia’. LSCB: Rochdale Borough Safeguarding Children Partnership Author: Kathy Webster Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Rochdale Borough Safeguarding Children Partnership Serious Case Review ‘Olivia’ Author: Kathy Webster – Independent Safeguarding Consultant 2 Content Item Page Introduction 3 Methodology 3 Family Composition and Context 6 Circumstances and significant events (09/07/18 till 11/01/19) 7 Analysis of practice and organisational learning 11 Recognising child sexual abuse /exploitation 11 Impact of adverse childhood experiences 22 Adolescent Neglect and Safeguarding 25 Good Practice 32 Practice Issues 33 Training and Development 33 Conclusion 34 Recommendations 35 Statement of Reviewer Independence 36 References 37 3 1. Introduction This Serious Case Review (SCR) was commissioned by the Rochdale Borough Safeguarding Children Partnership (RBSCP) on 18/04/19. The decision to conduct a SCR was made following a rapid review of the circumstances of the case and advice from the National Child Practice Review Panel that the criteria had been met for a SCR to be commissioned in line with Working Together 2018. The catalyst for this review was that a 14-year-old girl who had been coerced into a sexual relationship with a 34-year-old male who was an old friend of the child’s brother and had been known to the family for several years. The child will be known as Olivia, this is not the child’s real name to protect the child’s identity. Olivia had in the past experienced domestic abuse, parental substance misuse, parental mental health issues leading to various levels of neglect throughout her life. Olivia is a pseudonym chosen by the Independent Author to protect the identity of the child. The key learning themes identified in this review include; recognising child sexual abuse /exploitation; impact of adverse childhood experiences; adolescent neglect and safeguarding arrangements. 2. Methodology The methodology for this review was carried out using the systems model approach to learning as outlined in the Child Practice Review process provided by “Protecting Children in Wales Guidance for Arranging Multiagency Practice Reviews” (Welsh Government 2012). The overall purpose of the SCR model was to consider what happened in this case and explore why services were delivered as they were. Also, to consider how practice can be improved through changes to the system to improve outcomes for children. A Terms of Reference was developed to identify the key lines of enquiry for the review. 2.1. Key Lines of enquiry Determine whether decisions and actions in the case comply with the policy and procedures of the named services and the RBSCP Examine the effectiveness of information sharing and working relationships between agencies and within agencies Examine involvement of other significant family members in the life of the child, and family support provided to the subject child. Examine the way in which professionals and agencies work together to safeguard local children and identify and gaps within systems and processes. Identify any actions required by RBSCP to promote practice which will improve outcomes for children. 4 Serious Case Review – Undertaken when a child dies, or is seriously harmed, as a result of abuse or neglect, a serious case review is conducted to identify ways that local professionals and organisations can improve the way they work together to safeguard children. Consider the assessments used for managing chronic neglect and examine how practitioners worked with mother to identify her capacity to change Examine the effectiveness of the local safeguarding children arrangements including decision making around Public Law Orders (PLO) processes and arrangements for managing difference of opinion. Consider the effectiveness of the multiagency response to provide protection and support once it was known that Olivia was sexually active. Examine the assessment and rationale for “family arrangement” placements as opposed to having a Regulation 24 placement. Consider the effectiveness of any Child Sexual Exploitation campaign or information provision available to young people and families in Rochdale. The process for this SCR involved a Review Panel of representatives made up of senior managers and safeguarding leads who were from the organisations involved in providing services for the child and family. The role of the review panel was to provide relevant information and analysis of their organisation’s involvement in order to capture service/practice issues and to agree the key learning themes and actions required for multiagency practice improvement. A composite timeline which included all agency interactions between 09/07/18 till 11/01/19 was scrutinised by the Independent Reviewer, Review Panel members and front-line practitioners at the Practitioner Learning Event. The Practitioner Event was attended by 25 front line practitioners who knew Olivia and were able to reflect and consider the key themes of learning highlighted in this review. The learning from this review will be reflected throughout the report in a series of “Practice Learning” boxes which are intended to reinforce and promote areas of safeguarding practice to frontline professionals. At the end of the report there will be a number of “Good Practice” areas identified which reflect where professionals went above and beyond the call of duty. There will be a number of “Practice Issues” identified which are practice areas within and between the agencies which require some focus and improvement at individual practice and agency level. There are also, a number of “Progress” boxes which identify areas of practice already addressed by the local area following the onset of this review. There are 5 Recommendations for the consideration of RBSCP and it is recognised that RBSCP have the authority to act (or not) on the recommendations as they feel appropriate in the best interests of children in their local area. Public Law Order (PLO) - When a local authority makes an application for an order to safeguard the welfare of a child, the cases are usually referred to as public law cases Family arrangement - This is a relationship which involves close family or those who live in the same household and treat each other as family. A personal, non-commercial arrangement exists where no money changes hands, or any money changing hands is given outside of a commercial arrangement. Regulation 24 placement -This regulation allows Local Authorities to place children and young people with family members or connected carers subject to an assessment for immediate placement for a period of up to 16 weeks 5 Child and family focus and involvement in the reviewing process is seen as being key to understanding the nature of services provided to the individual family. Their input can provide an understanding of how helpful practitioners and services were perceived by the family members on a day to day basis. 2.2. Olivia reflections on what was happening during the timeline. Olivia enthusiastically engaged with the review process and met with the Independent Reviewer with the support of her key social workers. The Independent Reviewer was very grateful for Olivia’s contribution to the review and noted the “voice of the child” in the brief statements provided below: Olivia felt that professionals need to ask more questions and find out what is going on. “When you are in a situation like this you feel like everyone knows what is happening to you and you expect to be asked about stuff”. Olivia felt people who had worked with the family over the years looked down on her mother and this was felt not to be acceptable. She felt this was “heartless” and had not helped. Olivia said that she “just wanted someone to listen to her and support her”. School had been the biggest help. Olivia said that “they believed in me” “but I could not tell them what was happening at the time so I stopped going”. Of the time spent with the male perpetrator Olivia said that “at first, I thought I was in love with him, but later became afraid of him.” Olivia had been aware that professionals were trying to find her but the male perpetrator was keeping her away from everyone. When I met a professional, I would say “I’m fine” “but my world was crashing down”. Asked how she felt during the time period. Olivia said “I felt tired and stressed out most of the time”. “I was looking after myself and trying to help mum”. “I couldn’t tell her everything I was too scared”. Reflecting on the help that Olivia is getting now she said “My Sunrise worker is amazing she is helping me to become a better person”. 2.3. Mothers perspective Although mother and the Independent Reviewer had not been able to meet personally due to COVID 19, they did have a useful telephone conversation about the time period included in this review. Mother made a number of helpful observations as follows: Mother told the Independent Reviewer that “at the time I was in a very bad place” “I was in denial and scared”. School tried to get Olivia back to school by “nagging at me with texts” but “what I needed was practical support”. On further discussion mother suggested that it would have helped if someone had collected Olivia from home on a daily basis to make sure she was attending school. Asked where she was when Early Help Practitioners, School Welfare and Social Workers were coming to the house and knocking on the door. Mother said “I felt very anxious and just stayed hidden in my bedroom”. 6 When asked about how services helped her, she said “I felt there was no one there to support me”. “I felt that professionals should just stop messing about and bring the whole thing to a head” which they eventually did. Mother said she felt that the police should have kept her more informed about MP. Asked what would have helped her at the time? “I needed someone to come in and do it (parenting tasks) for me” until I was better. Mother now has a Sunrise Worker who she says she “meets for a coffee and a friendly chat” she said she feels “this is helping me more than any of the services I have received before”. 2.4. The Reviewer had access to a number of documents as follows: Initial individual agency rapid response timeline of significant events/analysis. Child Safeguarding Practice Review Referral Rapid review recommendation and chair’s decision Record of Strategy Discussion following arrest of the male perpetrator. Composite timeline of significant events/analysis Minutes of Initial Child Protection Conference Research evidence and national statutory guidance was considered and used throughout this review. 3. Family composition and context at time of event. Olivia White British. Girl aged 14 years with Attention Deficit Hyperactivity Disorder (ADHD) and history of asthma, anxiety, low self-esteem and self-harm. Chronic poor school attendance and was recognised as a Young Carer with a long history of poor parental supervision and neglect. Mother White British. Female aged 45 years. Unemployed. Concerns about drug use over several years. Suffered from anxiety and was avoidant of professional contact. Past history of tragic unresolved personal bereavement and domestic abuse. Poor parenting felt to be intrinsically linked to mental health issues. Half brother White British age 29 years. Living with a partner. Half brother White British age 25 years. Notified police of possible sexual abuse of Olivia to try to protect her. Half brother White British age 20 years. Not in contact during review period. Father White British. Male aged 37 years. Living in the care system following a criminal violent assault leading to serious brain damage. Olivia had very little contact with him. Male Perpetrator (MP) This adult male is known to have sexually White British. Male aged 34 years. Unemployed. Served two prison sentences over ten years for theft and domestic abuse offences. Twenty-three domestic abuse events with ex-partner with whom he has a child. He was on probation for a variety of crimes including violent assault, theft and burglary. He had been summoned to court for breach of probation order but failed to attend court and became unlawfully at large for 6 7 exploited and abused Olivia months prior to being arrested during which time he was sexually abusing Olivia. Family Friend White British. Age around 50. Described as having learning difficulties and mental health problems. Lived a few doors away from Olivia’s home address. Olivia stayed there on and off as did MP. Family friend did try to protect Olivia by contacting emergency services. Environment Housing estate on the outskirts of town, known as an area of deprivation and poverty. The home address was a privately rented property which was in disrepair with broken windows and door. Rubbish was present in the garden. 4. Circumstances and significant events – 09/07/18 till 11/01/19 The complete timeline covered 24 pages with 147 separate entries over the 6-month period. 4.1. Historical information which predates the timeframe Olivia had been known to Children’s Social Care (CSC) since birth following concerns of neglect involving Olivia’s half siblings. Poor parental supervision, domestic abuse and parental substance abuse had been lifelong features in the child’s life resulting in her being the subject of Child Protection Plans for Neglect at various stages of her life. The most recent Child Protection Plan prior to the period of this review had been in 2015 when Olivia was age 11 which lasted until 2016. It was found that although mother did not fully engage with professionals and the child protection process, she did manage to address some of the concerns identified by professionals and she was able to demonstrate an ability to parent and care for Olivia. However, once the Child Protection Plan was stepped down to a Child in Need Plan and then to a Common Assessment Framework (CAF) which was soon closed because mother failed to attend four out of five CAF meetings. Olivia was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) in 2015. Routine cardiac screening took place prior to being prescribed medication with no abnormalises or risks being identified. Olivia was commenced on medication but “was not brought” to essential hospital appointments to monitor her condition which resulted in the management of the child’s ADHD not being as effective as it should have been. Also, during this time there is evidence recorded that Olivia made a number of disclosures of deliberate self-harm. Child Protection Plan – should assess the likelihood of the child suffering harm and look at ways that the child as be protected; decide upon short and long term aims to reduce the likelihood of harm to the child and to protect the child’s welfare. Child in Need – a child will be considered in need if: they are unlikely to achieve or maintain or to have the opportunity to achieve or maintain a reasonable standard of health or development without provision of services from the Local Authority. Common Assessment Framework – is the process to identify children who have additional needs, assess needs and strengths and to provide them with a co-ordinated, multi-agency support plan to meet those needs. Attention Deficit Hyperactivity Disorder (ADHD) is a behavioural disorder that includes symptoms such as inattentiveness, hyperactivity and impulsiveness. “was not brought”- previously known as did not attend (health appointments) and relates to a child who is dependent on an adult carer to take them to an essential health check 8 School had tried working with Olivia and mother around attending school and essential hospital appointments without success. School attendance was a continual problem with attendance standing at 51% in 2018 and 49% the year before. Mother had previously been fined for Olivia’s poor school attendance and education welfare were in the process of pursing this once more as the case moved into the period identified for this review. .4.2. Significant Events during the timeframe in chronological order. July 2018 – Event (1) – Olivia was taken to the local hospital Accident and Emergency Department (A&E) in the early hours of the morning via ambulance. The ambulance had been called by “grandma” (later found to be family friend) because she had thought the child was in labour. When the ambulance arrived, the child was found in bed naked from the waist down and was complaining of severe lower abdominal pain. Grandma and “brother” (later found to be the male perpetrator) were reported to be clearly stressed and walking in and out of the bedroom. Olivia was found not to be in labour and A&E concluded the pain was related to sexual intercourse 4 weeks ago with a peer and Olivia was concerned about pregnancy having had a missed period. A pregnancy test was carried out and found to be negative and the child was referred to a Gynaecologist for further consultation. There was a request for mother to attend A&E prior to any intimate examination but Olivia left A&E with her “brother” (male perpetrator (MP) without being seen. The A&E staff nurse contacted EHASH (Early Help and Safeguarding Hub) due to Olivia having a Child Protection – Information Sharing (CPIS) flag on their electronic record system for a previous child protection status. The decision of EHASH was for further enquires to be made via Early Help to gather information to determine the level of child and family support required. July 2018 – Event (2) – Olivia randomly went into school (11 days later) on the day that school was about to break up for the summer break. Olivia told her learning mentor that she was feeling very depressed and was having tummy ache. Olivia said that she was worried that her mother had suffered a “mental breakdown” and the child had been too afraid to leave her to go to school. The learning mentor contacted the child’s GP for an appointment which was later attended by the child. School informed Early Help of the disclosure made by Olivia and their action taken to secure a GP appointment. The Early Help worker later contacted the GP for information about Olivia and was informed that Olivia had disclosed consensual sexual activity with two different 15-year-old boys. Early Help and Safeguarding Hub (EHASH) – is Rochdale’s main front door or main point of access to children’s social care. All concerns regarding a child or young person suffering or at risk of significant harm should be reported Child Protection – Information Sharing (CP-IS) – is an automated system for when a child is known to social services and is a Looked After Child or on a Child Protection Plan basic information about that plan is shared securely with the NHS. If that child attends an NHS unscheduled care setting, such as an emergency department or a minor injury unit social care are automatically alerted to ensure they are aware as part of the child’s ongoing assessment and protection. Early Help Service – It assesses the situation of the child or young person and their family and helps to identify the needs of both the children and the adults in the family 9 The GP referred the child to sexual health services for sexual health screening, advice and support. A Child Protection referral was made to CSC from Early Help regarding Olivia’s unmet health needs, poor school attendance and non-engagement by mother. The referral was declined pending further information gathering around family living arrangements. August 2018 – Event (3) An Early Help worker who knew Olivia well requested a case file audit which was undertaken by the Head of Service. Based on the findings of the audit a referral to EHASH was accepted and Olivia was allocated to a Social Worker to undertake a child and family assessment. September 2018 – Event (4) The Social Worker and Early Help worker attempted a joint home visit to engage with Olivia and her mother. Two males were seen coming in and out of the house before driving off together which looked suspicious. After the males left the area the workers knocked on the door several times believing there was someone at home but no one came to the door. The Social Worker and Early Help Worker were concerned that Olivia was involved in the suspicious activity of the visiting males in some way. October 2018 – Event (5) At a further home visit, damage was seen to the family home living room window which appeared to be made by ball bearing pellets. This was reported and followed up by the Police with an outcome that the damage had been done by an unknown person with no concerns identified relating to Olivia. The Child and Family Assessment was concluded at this point with a recommendation to progress to a section 47 (child protection). Mother continued to be uncontactable and Olivia was still not attending school. November 2018 – Initial Child Protection Conference (ICPC) with an outcome agreed for a Child Protection Plan under category of Neglect. Mother and Olivia did not attend the conference. The IRO (Independent Reviewing Officer) recognised that Olivia had been neglected for most of the child’s school life and strongly recommended that CSC urgently consider taking legal advice in respect of Olivia circumstances with a view to initiating pre-legal and legal processes. November 2018 – Event (6) – At an early evening visit to the home address the social worker was concerned to see Olivia leaving home and walking along the street with an unknown older male (MP). The pair entered the family friends’ home (situated a few doors away) and soon after the pair returned home again. The social worker contacted the police to gain entry to Olivia’s home for a “safe and well check” because despite multiple attempts Olivia had not been seen for 4 weeks. Child Protection (section 47) – Statutory requirement under the Children Act of 1989 for enquiry and assessment to be led by a qualified social worker from Children’s Social Care, who will be responsible for its coordination and completion. The social worker must consult with other agencies involved with the child and family to obtain a fuller picture of the circumstances of all children in the household, identifying parenting strengths and any risk factors Independent Reviewing Officer (IRO) – is the person who ensures that children looked after or subject of a child protection plan by the Local Authority have regular reviews to consider the care plan and placement Police “safe and well check” – also referred to as welfare checks on people who are vulnerable, the police are required to locate people at risk of harm and seek to manage any safeguarding risks. 10 On entering the property, the police found the unidentified male (MP) hiding upstairs, he refused to give any personal details and was anti-police. Mother told the police and social worker that it was she who was in a relationship with the unidentified male (MP) and not Olivia. Olivia confirmed mothers’ story and privately provided the name of the unidentified male giving a false name. December 2018 – Legal Gateway meeting – the decision was taken that the threshold for PLO (Public Law Order) had been met however, due to concerns about maintaining a placement for Olivia due to the level of loyalty she held for her mother, it was agreed that Olivia should remain on a Child Protection Plan and the case reviewed in 4 weeks. December 2018 – Event (7) – Allegations were made to the police by a male friend of MP (correct name for MP provided at this point) who stated that he had been assaulted 2 days earlier by MP after he had been drinking and smoking weed. Olivia had been present and concerns were reported about her poor level of hygiene. It was alleged that Olivia had been pushed around by MP and the male friend had concerns that MP maybe controlling Olivia in some way. Unfortunately, due to high demand on local policing resources the incident was delayed for 4 days following which it took a further 8 days for an officer to locate Olivia a total delay of 12 days. The officer closed the log because Olivia was seen to be safe and well and after speaking with child it appeared to have been a malicious call. January 2019 – Event (8) – An allegation that Olivia was in a sexual relationship with a 34-year-old male was made to the police by Olivia’s half-brother. The brother stated that he had been told by his sisters’ friend and that his mother did not know about it. The previous event in December 2018 was reviewed by the police inspector on duty who reconsidered that the previous allegation made by a third party had been correct and plans were put in place for immediate action and arrest of MP regardless as to whether Olivia supported the allegations or not. January 2019 – Event (9) – The police attended Olivia home in the early hours of the morning and found MP hiding behind the wardrobe upstairs. He was arrested on suspicion of sexual activity with a child. Mother continued to maintain that it was she who was in a relation with MP. Whilst in the property the police observed that Olivia’s bedroom had no bed and was “full of junk” and there was no room for anyone to sleep in there. A referral was made to EHASH emergency duty team. Legal Gateway Meeting – The purpose of this meeting is to obtain advice as to whether the ‘threshold criteria’ for a care order under section 31 Children Act 1989 (Child care proceedings) have been met. The legal planning meeting is usually attended by the child’s social worker, manager and a legal adviser. Public Law Order (PLO) – When a local authority makes an application for an order to safeguard the welfare of a child. Emergency Duty Team – provides an emergency social work service for urgent situations which arise out of normal office hours and which cannot be left with an appropriate degree of safety until the next normal working day. Probation Order – an order imposed by a magistrate or judge under which an offender is sentenced to probation rather than imprisonment. Offenders on probation must keep to the requirements stated by their Court Order or Release Licence. Sunrise (CSE) Team – are a multiagency team who works on the front line in Rochdale, Heywood, Middleton and the Pennines, reaching out to young people at risk of child sexual exploitation in the community. 11 January 2019 – MP was charged with the offence of Breach of Probation Order and was refused bail and remained in custody until the court hearing 2 days later. MP was then police bailed pending enquiries for sexual activity with a child and bailed to a separate address with conditions for him not to see or to make contact Olivia. The case was then transferred by police CID to a specialist police officer at Sunrise (CSE) Team to progress the investigation. January 2019 – Event (10) – A 999 emergency call by the family friend to the police 4 days following MPs court appearance. The family friend was very upset to have found Olivia together with MP at her home. The police quickly arrived to the house and forced entry where MP was arrested on suspicion of Rape. Police used their police powers to remove Olivia from the address and to place Olivia in a place of safety with a family member and mother was arrested on suspicion of child neglect. 5. Analysis of practice and organisational learning 5.1. There were three main learning themes which emerged during the reviewing process as follows: Recognising child sexual abuse /exploitation (CSE). Impact of adverse childhood experiences (ACEs). Adolescent Neglect and Safeguarding. 6. Theme 1 – Recognising Child Sexual Abuse / Exploitation (CSE) The catalyst for this SCR was that a 14-year-old girl was seriously sexually exploited and abused within a community setting. Agencies were working with the child and family at the time around neglect issues which involved poor school attendance and a lack of engagement with support services. 6.1. National information on CSE Barnardo’s have identified that a common pattern in the sexual exploitation of adolescent girls is the presence of an older boyfriend. In more than three-quarters (77%) of cases where young people were at risk of CSE and experiencing intimate partner violence, the Barnardo’s case holder recorded that the risk was increased because of the age of the perpetrator. Whilst the presence of an older “boyfriend” is most commonly seen in CSE other types of CSE may involve peer on peer, organised networks and/or adults in key positions of responsibility such as teachers, sport coaches and religious leaders. Police Protection Power (PPP) – A Police Constable has the legal right to remove a child from accommodation or prevent removal, where they have reasonable cause to believe the child would otherwise be likely to suffer significant harm. Barnardo’s – is a children’s charity that works to protect and support the UK’s most vulnerable children and young people. 12 All forms of CSE have an element of “grooming”. Grooming is when someone builds an emotional connection with a child to gain their trust for the purpose of sexual abuse, sexual exploitation, or trafficking. Child and young people can be groomed on-line or face-to-face, by a stranger or by someone they know. (NSPCC website) Statutory guidance for practitioners has defined CSE as a form of child sexual abuse. It occurs where an individual or group takes advantage of an imbalance of power to coerce, manipulate or deceive a child or young person under the age of 18 into sexual activity (a) in exchange for something the victim needs or wants, and/or (b) for the financial advantage or increased status of the perpetrator or facilitator. The victim may have been sexually exploited even if the sexual activity appears consensual. CSE does not always involve physical contact; it can also occur through the use of technology. (DfE 2017) NSPCC Messages from research on identifying and responding to disclosure of child sexual abuse (Pam Miller and Helen Baker – September 2019) demonstrates that children’s disclosure of sexual abuse varies in the mode of communication, intent spontaneity and amount of detail that is included. Verbal disclosure rates are low at the time of abuse and children say that they are trying to disclose their abuse when they show signs or act in ways that they hope adults will notice and react to. Researchers have also found that professionals often failed to pick up signs of CSE and that adolescents were more likely to disclose to peers rather than professionals (Allnock and Miller 2013). Many disclosures are either not recognised or understood, or they are dismissed, played down or ignored, which means that no action is taken to protect the child and the child’s faith in the professional to act on their behalf is suppressed. 6.2. How children and young people may disclose CSE: Direct disclosure – (may be accidental or prompted) comes often at the point when the child feels safe from the perpetrator; or where they fear the abuse more than the reprisals; or to protect someone else. Partial verbal disclosure – is when the child tells a part of their story expecting the professional to fill in the gaps or they may say the abuse is happening to someone else and not them expecting the professional to guess it is them. Nonverbal / behavioural disclosure – may be a drawing, letter, change in behaviour including becoming angry or withdrawn; secretive and dismissive; developing unresolved health issues such as panic attacks or abdominal pain. Assisted disclosure – when a child is helped to disclose by a close friend or trusted adult. The Independent Reviewer was able to ask Olivia if at any time she had been trying to disclose to professionals what was happening. Olivia responded – “yes all the time” and confirmed that Event (1) had been a cry for help. Olivia had been surprised that professionals did not ask her more questions about the situation in A&E. However, this should be balanced with the fact that the child left the department before a full examination of the situation could be carried out. 13 NSPCC recommend that professionals need to keep an open mind that any child or young person could be attempting to disclose sexual abuse/ CSE. Teachers and health care professionals are the people which children and young people will most commonly disclose to, but the process of disclosure can be helped or hindered by the way in which professionals engage with the child or young person about whom the concern exist. Children and young people want to be asked how they are doing and what is going on in their lives so there is a basis for the development of a trusting relationship and open dialogue. 6.3. Local information on CSE In 2012, Rochdale had a high profile CSE case involving underage teenage girls who were sexually abused by a number of men who were later convicted of sex trafficking and other offences involving rape and sexual activity with a child. The legacy of this case was the emergence of the Sunrise Complex Safeguarding Team established in 2013 which tackles CSE and related harm across the borough of Rochdale. From 2019 the team have further expanded to Complex Safeguarding including CSE and Child Criminal Exploitation. The team includes experienced professionals from the police, children social care and health. They provide a safe and confidential environment where young people can go for help, advice and support. Children are offered a range of therapeutic interventions including one-to-one counselling, group-work and drop-in support. Referrals for Sunrise Complex Safeguarding Team are received through EHASH. The Sunrise Complex Safeguarding Team can offer direct advice and support to professionals and family members with concerns. Sunrise has a role to provide CSE training for professionals and work in schools to deliver preventative CSE education programmes. There is a good on-line presence for professionals and young people to find further information. Project Phoenix was launched in November 2015 across Greater Manchester to raise awareness of CSE and they held a number of training events for professionals and parents. They developed a resource “It’s not OK” to help to identify CSE which is available on Rochdale Borough Safeguarding Child Partnership (RBSCP) website. Useful resources on the RBSCP website include Newsletters, video clips, links to other websites for support and a CSE measurement tool which was developed in 2015. Multiagency CSE training is available via the RBSCP website. 6.4. Historical information on Olivia and relevance to CSE Historically, Olivia had been subject to chronic neglect and one of the main features had been poor supervision. In 2011, when Olivia was age 7, there had been a strategy meeting over concerns of on-going neglect and an anonymous referral made to CSC about concerns of sexual abuse which were unsubstantiated. A further strategy meeting took place in 2014 over concerns that Olivia (age 10) was going out unsupervised and had been sexually inappropriately touched by a peer. 14 It is not apparent that this historical allegation of child sexual abuse was ever utilised in the assessment of new referrals for Olivia in terms of her being missing or being seen with an older male. The impact of any form of sexual abuse can have a long-term negative impact on mental health. A past history of sexual abuse can increase the vulnerability of a child or young person, which can make them more susceptible to the grooming process and increases their risk of potential sexual abuse and/or other forms of exploitation. (NSPCC UK). Practice Learning EHASH should ensure that any current or historical concerns about sexual abuse are flagged/highlighted within the child’s record to prompt social workers to recognise the potential increased risk and vulnerability in relation to the child’s future risk of sexual abuse and other forms of exploitation in the future. 6.5. The context of CSE found in this review At the beginning of the Olivia’s timeline there was an event (1) of a sexual nature which could be described as “odd”. A full forensic review of the facts within the event could have resulted in agencies considering sexual abuse / exploitation earlier had the details of the event been fully checked out and considered in more depth at the time. The features of the event (1) which could have alerted professionals to consider possible sexual abuse include: The ambulance being called to an address in the middle of the night for a 14-year-old child in labour. The child did not look pregnant so what was that about? The caller had said she was “grandma” but was actually a family friend. The 14-year-old child presenting to ambulance staff lying on a bed in a half-naked state. Most 14-year old girls would have covered up why not in the case? What was the child indicating? The address at which the event took place was that of a family friend’s which was just down the road from the child’s home address. Why was the child staying at that address and not at home? The ambulance staff raised concern about “grandma’s” ability to care for a child. Why was the child staying with grandma? Details of grandma? What was the lady’s capacity to care for Olivia? The ambulance staff raised that the grandma and “brother”, later found to be the male perpetrator (MP), were both acting very stressed and kept walking in and out of the room. What was the odd behaviour about? Details of brother? The nature of the abdominal pain said to be as a result of sex with 2 peers 4 weeks earlier and concern about pregnancy. Concerning history for a 14-year-old girl. Is it likely that pain from sexual intercourse with a peer on 2 separate occasions would cause pain 4 weeks after the event? The child leaving A&E with the so called “brother” without seeing the Gynaecologist, having apparently been in excruciating abdominal pain earlier. This should act as an 15 alert to professionals– often patients who do not wait to be seen have something to hide. The child’s past history of neglect and sexual abuse. Increased risk of vulnerability. The child missing from school. Children who go missing (from education) is a key indicator for CSE A&E referred to CSC that the child had been to their department and had a flag for a previous child protection plan via the CPIS system. An appropriate child safeguarding referral was made by both ambulance service and A&E to CSC at EHASH which resulted in the case being allocated to the Early Help service to forensically gather information about the child’s circumstances to identify what level of support was required to support the child and family. There were a number of suspicious factors within the context of this event which should have alerted professionals to fully address the all details of the event. Checking out names and addresses of the individuals present at the event or attending A&E is of particular importance to enable police to conduct full background checks of individuals for cases which may then become child protection. A&E had recorded the full details of the child and the first name of the “brother” and his telephone number. A&E staff had enquired about mother as the person with parental responsibility and were informed that mother was aware of the child’s attendance. A&E staff requested that mother should attend the department to support the child during the Gynaecologist consultation which is best practice. However, Olivia and brother soon left after this point. Early Help and school did initially start to piece the detail together but then unfortunately, the mother and child were uncontactable for several days and as the case “drifted” the impetus around challenging the initial event appeared to be lost. A more multiagency focus following the event may have been beneficial in terms of seeing beyond the child’s behaviour and considering the nature of the concerns at the time. A discussion with the family friend at the address the child was collected by the ambulance team may have provided earlier information about Olivia possibly being sexually active with the unknown male (MP). Whilst agencies were concerned about Olivia, they did not take the opportunity to come together to consider the meaning of the event. Olivia confirmed to the Independent Reviewer that she was demonstrating behavioural disclosure to alert professionals that she needed help. The event (1) provided actual evidence of safeguarding concerns and provided an opportunity for professionals to assertively pursue the details of the event to fully assess what was happening. (Local safeguarding arrangements to be discussed later). 16 Practice Learning Events/incidents are very useful because they provide a window of opportunity to allow agencies to fully unpick a snap shot of a child’s life. Verifying the detail of an event into a factual account including who, what, when, where and how can result in an opening up of the story to enable professionals to better assess and understand what is happening and what may be being hidden. 6.6. Olivia’s perspective on practitioner involvement. On speaking with Olivia about the event (1) the Independent Reviewer has been able to confirm that Olivia was trying to alert professionals that she needed help. She was surprised that staff at the hospital A&E did not ask her more probing questions about what was happening to her. She felt A&E staff would be able to tell that something untoward was going on. Olivia said that MP made her leave the department before being seen, she felt this was because he did not want her tell anyone about what was going on. Practice Learning Young people who are being sexually exploited need professionals to see them alone and to be more professionally curious by asking them more probing questions to try to find out what is happening to them. Record keeping should include a clear account of what the child was saying and include all relevant demographic and presenting detail including who the person was attending with the child. Persons who refuse to provide basic personal information should be viewed as suspicious and raise alarm. There were a number of other events which could have triggered professionals to be professionally curious and consider possible CSE and or other safeguarding concerns as follows: Olivia randomly going into school after a long period of not attending to report tummy pain and depression just before school holidays. Unknown males seen coming in and out of the house acting suspiciously. Police found unknown male (MP) hiding upstairs and later confirmed that Olivia had given them a false name. Olivia with an unknown older male walking down the street to the family friends address and when the social worker tried to engage Olivia at the address the couple left the property and ran down the street together. Unknown male stating he was in a relationship with mother when he was always seen with Olivia. Story that they were together because unknown male babysitting Olivia whilst mother at bingo. Especially taken into context with the history of neglect and previously being left unsupervised. Event (7) of an allegation reported to police about concerns for Olivia’s level of hygiene and being linked with MP with his real name being given to the police for the first time. Olivia had been drinking and was seen being pushed around by MP whilst he was smoking weed and being violent towards his friend. Event (8) allegation made by Olivia’s half-brother that Olivia was being sexually active with MP. This was accepted and police intervention rapidly took place. 17 During the 6-month timeline it is clear that a number of the agencies did consider CSE independently at different points but the information each agency held did not come together sufficiently to change the way the agencies worked together to try to assess her CSE risk and support to Olivia. The Core Group of staff working with Olivia appear to have remained focused on managing child neglect in accordance with the Child Protection Plan. As previously mentioned, Rochdale have a bespoke service called Sunrise Complex Safeguarding Team, for children and young people in situations where CSE may be a potential risk to the child and it is surprising that the agencies who were considering CSE did not consult with Sunrise sooner. In fact, Sunrise were not alerted until after the perpetrator was arrested. Sunrise Complex Safeguarding Team members who attended the Practitioner Leaning Event stated they were disappointed not to have been contacted sooner. Practice Learning It is important that professionals have an early consultation with the Sunrise Complex Safeguarding Team in situations where CSE is suspected – even when the assessed level of risk is low or concerns about CSE are unsubstantiated. Referrals to Sunrise are made via EHASH. Olivia was reporting to health professionals about her concerns around pregnancy and unresolved abdominal pain for several months. There was a medical focus on possible sexually transmitted diseases which resulted in the GP referring Olivia to the Sexual Health Service for screening and wider support. Olivia attended the first Sexual Health Service appointment with an aunty and was seen alone for sexual transmitted disease testing which were negative. Age appropriate relationships were disclosed during the consultation and names and age of sexual partners recorded. The service young person proforma was completed and updated at each subsequent appointment in line with best practice. Following the initial consultation Olivia was referred on to the Sexual Health Outreach Team (SHOT) to commence an education programme. Olivia did not attend 3 of the available appointments mainly because the appointments were offered in school and Olivia was not attending school. The SHOT worker visited at home to try to see Olivia and to offer a new appointment. Olivia engaged in 4 further appointments. At 2 appointments she gave new partner information which were age appropriate and at 1 appointment Olivia disclosed she had recently split up with another partner because of having a chaotic relationship with them. Again, details were recorded and seen as being age appropriate. At 1 other appointment Olivia attended with her mother for an education session. Despite health professionals being aware that Olivia was subject of a Child Protection Plan and Olivia disclosing multiple partners, CSE did not appear to be on any of the health professionals’ horizons as much as it could have done. Olivia visited the GP on 3 occasions; Sexual Health Service appointments on 5 occasions; A&E on 1 occasion. Most presentations were for sexual activity linked complaints / issues. 18 Children and young people who attend services attend because they are seeking help and support. As previously stated, children who are being sexually abused/exploited are often too afraid to provide a direct verbal disclosure and will therefore, provide an alternative story to cover up the truth whilst giving out the message that they need help through partial disclosure or behavioural disclosure. It therefore takes skill and experience to be professionally curious and to ask the right questions and to build trust to allow the child to disclose safely. Practice Learning Professionals should be professionally curious and alert to the signs of possible CSE in situations when children and young people present with medical complaints linked to sexual activities. CSE should remain on any list of differential diagnosis until there is evidence that CSE can be excluded. It was not until Olivia was sure that MP was locked away in prison that Olivia felt safe enough to fully disclose what had happened to her. This is a common trend in CSE and other cases of child sexual abuse. 6.7. The male perpetrator (MP) as an offender. The male perpetrator was a 34 years old local man, thought to be of no fixed abode but actually lodging with the family friend and was unlawfully at large throughout the majority of the timeline. The circumstances had been that MP was in breach of his probation order and had failed to attend court in respect of this resulting in a warrant being issued for his arrest which was passed on to the police by the probation service. This is not an unusual event for probation and the police and MP would have been risk assessed along other known offenders who required arrest. MP had committed a number of relatively low-level crimes including a violent assault, none of which were linked to children or sexual crimes. Practice Learning Nationally, it is recognised that police resources are not enough to arrest every known offender in a timely way. Whilst risk assessments assist the police in arresting the most dangerous criminals quickly there are occasions when offenders are at large for longer periods than the police and society would wish and this is a Public Protection issue. Progress Police locally now have a process in place whereby weekly details of any new warrants carried by the enforcement team are sent through to the Warrants Officer for information and assessment. This ensures that the Warrant Officer is sighted on any warrants that may pertain to known divisional offenders and as such can be included in activity for enforcement going forward. This is a new process and under review, this should ensure a safety net for Breach of court orders or non-payment of fine issues that relate to risk cohorts on the district. 19 It is possible that MP was “sofa-surfing” and moved in on the family friend who was a vulnerable lady by way of her learning disability and mental health issues. This is an example of ‘Cuckooing’ which is recognised as the practice of taking over a person’s home to use their property to facilitate exploitation. It takes the name from cuckoos who take over the nests of other birds. MP was said to be a lodger at the address but in reality, was probably an uninvited guest. MP was well known to the neighbourhood and people were afraid of him It would have been good practice for one of the professionals involved to have visited the family friend at home to clarify what was happening at her address on the night of the initial event (1). It was possible that the family friend may have told the professional the name of MP and shared her concerns about Olivia being involved with MP. There would have been an opportunity to identify if the lady had her own vulnerabilities in terms of possible exploitation and to consider the need for a referral to adult social care for support as a possible adult at risk. 6.8. Hidden Men It was apparent that MP was trying to remain anonymous by getting others to provide false information about him and trying to hide away from professionals. Despite these efforts he was seen with Olivia by a number of professionals. Olivia’s mother was aware of their relationship but provided false information to police and social care that it was she who was in a relationship with MP and not Olivia. Mother clarified to the Independent Reviewer that she too was afraid of MP and had lied to protect herself. Improving practice around hidden men (NSPCC 2015) reflects that professionals rely too much on mothers to provide essential information and do not often talk enough to other adults in the child’s life which can result in them missing crucial information and failing to spot inconsistencies in the mother’s account. Practice Learning NSPCC learning from other serious case reviews suggests that professionals should “identify and carry out checks on any new adults who have significant contact with vulnerable children. Always clarify who the members of a household are each time you visit a family”. 6.9. Olivia’s perspective of the grooming process. Olivia told the Independent Reviewer that she was initially “in love” with MP. The grooming process involved MP first being kind to Olivia and he spent a lot of time listening to her thoughts and feelings which made her feel special. This moved on to MP sharing his own life story with Olivia which made her feel grown up and trusted. Their relationship then moved to being sexual after which MP began to control Olivia and he would actively keep her away from school and from the professionals trying to contact her. Olivia later became afraid of MP and what she felt he was capable of doing. 20 Olivia’s story is typical of other girls who have been groomed by an older male. The initial phase of CSE is the grooming process and according to the NSPCC (2018), grooming is currently defined as: “When someone builds an emotional connection with a child to gain their trust for the purposes of sexual abuse, sexual exploitation or trafficking”. This is followed by the perpetrator isolating the child from friends and family. Once the sexual abuse is occurring, offenders commonly use secrecy and blame to maintain the child’s continued participation and silence. 6.10. Mothers perspective of what happened to Olivia. Mother told the Independent Reviewer that she was not fully aware of everything that was happening at the time. Olivia did tell her mother that she was in love with MP because he listened to her. Mother, who already knew MP as a friend of her son, became afraid of MP which led her to lie about being in a relationship with him. She had been uncontactable because she was in a “bad place” with her mental health and was using drugs to try to get herself well again. She was spending most of her time in her bedroom at home hiding from everyone. Professionals who knew mother commented that the level of avoidance exhibited by mother was not new behaviour because this was how she had behaved in the past when agencies were trying to get involved to help the family. During the review period mother was not in a good enough physical or psychological state to parent her daughter, in fact Olivia was caring for her mother in the midst of her own CSE situation. Olivia tried to raise the alarm about mothers deteriorating state of health during event (2) when Olivia attended school to speak to her learning mentor stating that she thought her mother was having a breakdown. Practice Learning When a family for whom there are concerns become uncontactable or uncooperative with agencies, a Think Family focused multiagency strategy meeting should be convened to consider the separate needs of the children and vulnerable adults going forward. To aid this process adult mental health, GP, and relevant others such as adult social care and drug services should be included. Remember when adults are vulnerable – children are vulnerable. 6.11. Arrest and prosecution In September 2018 the police were made aware during a strategy meeting (which progressed to the level of Child in Need) that Olivia had admitted to sexual activity with 2 different boys who were of the same age (14 years). The police agreed to check their systems against the named boys and provide feedback to CSC which they did and there were no concerns in relation to the boys. At this stage there was no information about Olivia being involved with an older male. The police subsequently attended an Initial Child Protection Case Conference where the outcome concluded neglect. Two weeks later the Social Worker requested a Police visit for a 21 safe and well check because there were concerns that Olivia had not been seen 4 weeks despite numerous visits to the home. Olivia was in the company of an unknown older male (MP) at the time and they were going into the family friend’s address where there was concerns about criminal activity at the address. The Social Worker spoke with the family friend at the address and was told that that she was concerned that “possibly something has gone on sexually between the lodger (MP) and Olivia”. The couple then ran off when the Social Worker tried to see Olivia at the address and they went back to Olivia’s home where the police met the social worker and a safe and well check was conducted. MP was found hiding upstairs with the explanation that mother was in a relationship with MP not Olivia. Olivia gave a false name for MP and therefore Police were unable to identify MP as a known offender. As previously stated, children and parents who have been groomed will often provide false information to the police in order to protect themselves. The following week a third-party report was made by a man who stated they were a friend of MP and made an allegation of assault against MP (Event 7). This was the first time MP had been named with the correct name and the friend said Olivia was MP’s sister which was incorrect. The third party informed the police that he had seen Olivia drinking alcohol and she had been seen being pushed around by MP. The informant was worried that Olivia was not looking after her appearance and that MP maybe controlling her. Due to high demand locally, there was no available police resource to deal with the incident for 4 days. The police then visited Olivia’s home address on 5 occasions over 5 days until Olivia was located at home. In total from the original report to the police it took 12 days to find Olivia who was already known to be at risk of significant harm. The findings of the visit was that Olivia appeared safe and well and had refuted what was said to have happened in event 7. The police log was closed as it appeared it had been a malicious call. CSC had not been informed of the incident as would have been expected. Again, there was a successful attempt to cover up the abuse to protect MP. Although there were no concerns for Olivia at the time, the fact that she was on a child protection plan and there were concerns about her hygiene needs and involvement with a violent older male. On this occasion, CSC were not informed of the allegation and concerns being made which was an omission in expected practice. Practice Learning When a child is subject of a child protection plan all professionals need to share any new information relating to the child and family with the allocated Social Worker who will be able to make an assessment of the situation as a whole in relation to safeguarding the child. Just 2 weeks later Olivia’s half-brother contacted the police and informed that Olivia was in a relationship with a 34-year-old man and that he and his brother had intervened. This led to a review of the previous log and with now 3 separate accounts of Olivia being in a relationship 22 with MP led to immediate action. This demonstrated good police management oversight of the situation and led to swift action being taken. Police called at Olivia’s address where they found MP hiding behind a wardrobe. MP was arrested but Olivia and mother did not disclose any offence at this point which is not unusual with CSE related offences. MP denied all allegations of sexual activity with a child and was therefore charged with the breach of court order which had been outstanding for 5 months and he was refused bail pending attending court appearance. Police bail conditions were issued for the sexual activity offence and required that MP stay at a different address and was told to stay there between 11pm and 7am every day and not make any approach to Olivia. But 2 days later the police were called to the family friends address where MP was found with Olivia and he was arrested on suspicion of Rape. Police exercised their Police Powers of Protection and following liaison with CSC and Olivia was taken to stay with family members. Mother was arrested on suspicion of child neglect following concerns that she had been implicit in the sexual exploitation. The criminal investigation was transferred over to a specialist police officer in the Sunrise Complex Safeguarding Team. The health professional from the Sunrise Complex Safeguarding Team who attended the practitioner learning event reflected that they had not been aware of the police bail conditions at the time. The benefit of handing the case over to the Sunrise Complex Safeguarding Team sooner would be that they have a team of specialist workers who are skilled and experienced in working and supporting children and young people who have been groomed and would have been in a better position to recognise the signs and behaviours of CSE. 7. Theme 2 – Impact of adverse childhood experiences (ACEs) 7.1. The relevance of ACE’s Adverse Childhood Experiences (ACEs) are stressful or traumatic experiences that can have a huge impact on children and young people throughout their lives. As well as the most commonly known ACEs, there are a range of other types of childhood adversity that can have similar negative long-term effects. These include bereavement, bullying, poverty and community adversities such as living in a deprived area, neighbourhood violence etc. (Collingwood. S. 2018) The ten widely recognised ACEs, as identified in a US study from the 1990s, are: # parents divorcing or separating # emotional neglect # living with a parent who is depressed or suffers mental illness # physical neglect # living with a parent who is an addict (alcohol, drugs, or otherwise # physical abuse # witnessing your mother being abused or mistreated # sexual abuse # verbal abuse/emotional abuse and humiliation # a family member going to jail 23 The impact of ACEs is that it can create harmful levels of stress (toxic stress) which can impact on healthy brain development. This can result in long-term effects on learning, behaviour and health. Evidence from ACE surveys in the US, UK and elsewhere demonstrates that ACEs can exert a significant influence throughout people’s life. ACEs have been found to be associated with a range of poorer health outcomes with shorter life expectancy. The outlook on social, educational and employment outcomes decline as the number of ACEs increase. (Frederiken, L 2018). Practice Learning ACE’s have a negative impact on child health, development and academic achievement. Front-line staff need to be ACE aware to be able to provide trauma informed support. Early action and prevention can have a profoundly positive impact upon an individual child’s physical health, academic achievement and emotional wellbeing. 7.2. ACE’s and links to CSE Barnardo’s have found that CSE is much more prevalent in girls than it is in boys and that historic abuse is particularly prevalent amongst young people at risk of child sexual exploitation. In other words, girls with ACEs have an increased risk of CSE. Of the children on Barnardo’s caseloads for CSE more than half (60%) of young people had experienced historic abuse. One in three (34%) young people at risk of CSE had experienced neglect in their childhood. 31% had been physically abused in the past. A quarter (24%) of the young people had experienced sexual abuse in childhood. Existing research by Barnardo’s suggests that childhood abuse affects young people’s self-worth and may make them more vulnerable to abuse in the future. These facts are relevant to Olivia since she was known to have suffered the whole range of abusive factors (ACE’s) as described by Barnardo’s. She was also, missing from education which is a key indicator of CSE and she was seeking out professionals on her own terms in relation to having sexual activity related medical needs. Practice Learning Teenage girls who have suffered past ACE’s are more vulnerable to becoming victims of CSE in the future. Professionals who routinely see teenage girls who are known to have ACE’s and are sexually active should be asked routine questions about their relationships and consider signs of safety. Building trust by showing kindness, empathy, being professionally curious and offering additional appointments to see the child again can be very beneficial in providing a safety net for girls at risk of CSE. 6.3. ACEs and impact on Mental Health Neuro-science have considered the links between ACE’s and the effects on mental health and suggest that the more ACE’s a person is exposed to the greater the risk of mental health 24 issues. Olivia was known to have experienced between 6 – 8 ACEs during her childhood which is a high number in terms of her risk to her future mental health. ACE’s have a direct impact on brain development during childhood, this is due to the stress hormone cortisol which is released into the brain during ACE’s. Cortisol is present in humans to help us “fight, flight or freeze” in any dangerous situation. The problem arises when stress (fight or flight) becomes a constant state which allows cortisol to build up and then becomes toxic stress which makes the person over stimulated to situations leading to distress, and psychological issues such as anxiety, depression and even brain damage. (Frederiken.L.2018) Olivia was diagnosed with ADHD in 2015 and following routine cardiac screening was prescribed medication. It is not known if this was linked to ACEs but there is a possibility that it may have been. Olivia missed out on regular reviews for her ADHD because she was not taken to essential hospital appointments (“was not brought”) by her mother and therefore, the full extent of her ADHD was not clarified. Olivia informed the Social Worker that whilst she was staying with the family friend, she was not taking her ADHD medication and she felt this was affecting her ability to sleep and increasing stress levels. The Social Worker made enquiries to the Child Mental Health Services who found that Olivia had not attended appointments in 2016 and 2017. A further appointment was made and Olivia was able to attend and medication was reissued. Practice Learning When a child “was not brought” (previously known as “did not attend”) to essential medical review or mental health appointments a risk assessment should take place to consider medical neglect in terms of significant harm. Olivia made reports of poor mental health to professionals on at least 6 occasions across the time period which included: Feeling very depressed Having panic attacks Crying through the night Not sleeping at night Told school she wanted her mental health to improve Feeling stressed Anxiety None of these signs were fully addressed with Olivia in terms of why she was feeling this way at the time. Professionals referred the problem on which led to an appointment with the local psychological services, but when Olivia did not attend the first appointment the service wanted to close the case. School managed to intervene to gain an additional appointment. 25 Practice Learning Services for children and young people should not close referrals for a one-off non-attendance. They should refer back to the referring agency to consider the risk to the child or young person in terms of the risk to the child. Later in the timeline Olivia was referred to mental health services by the GP because of concerns that Olivia was having panic attacks and had unresolved abdominal pain. Despite the child being on a child protection plan the GP did not appear to explore the wider social issues which may have been prompting her presenting clinical medical signs. Professional curiosity is key to recognising CSE and other forms of abuse. In order to provide context, it is recognised that GP’s only get around 10 minutes to see each patient and therefore in this case, a referral to specialist services to provide further assessment and support was appropriate. Practice Learning Children who have a history of abuse and neglect (ACE’s) should have their mental health taken into account at each contact to ensure their mental health and emotional wellbeing are not being further compromised. Parental failure to engage with essential mental health appointments should be considered as possible medical neglect and risk assessed in terms of significant harm Progress Health – ACEs and Trauma informed practice are included in all level 3 training programmes including GP’s. Workshops are under development to cover more in-depth training for relevant staff. In some areas training on the topic is being sourced by an external agency. Schools – ACEs and trauma are included in the 2020 update to Keeping Children Safe in Education, which comes into effect on 1 September and all education staff will be expected to read this statutory document. Children’s Social Care – are commissioning a remote training programme on Trauma Informed Practice to begin in October 2020. Adult Social Care – Trauma Informed Practice training can be run face to face or virtually but is not mandatory at the moment although staff are encouraged to attend. 8. Adolescent neglect and safeguarding 8.1. Definition of neglect In line with the definition for Neglect in Working Together 2018, Olivia appeared to have been at risk of significant harm due to neglect because the child was experiencing the following throughout the timeline: a) A persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development. b) A failure to protect a child from physical and emotional harm or danger 26 c) A failure to ensure adequate supervision d) A failure to ensure access to appropriate medical care or treatment The Children’s Society acknowledged that, just like younger children, adolescents (age 11 – 17) are more likely to experience neglect at home than any other form of child maltreatment. There is evidence that some professionals struggle to identify adolescent neglect and are unsure what to do when they come across it. 8.2. Recognising Adolescent Neglect Both mother and Olivia were well known to agencies prior to the timeline’s initial event. There had been a long history of neglect in the context of parental substance misuse, domestic abuse and parental mental health issues. All this featured Olivia being left unsupervised at home alone, becoming a young carer when mother needed support, not having her basic needs met, being a witness to domestic abuse and drug taking and had protracted poor school attendance. At the time just prior to the initial event (1) school had contacted EHASH with concerns about poor school attendance and concerns around mother and Olivia being uncontactable. This episode was viewed by EHASH as being an attendance issue and no further action resulted. At the practitioner learning event, school raised that they had been disappointed by the response taken by EHASH. However, school did not challenge the decision or take the opportunity to escalate concern to a more senior level. Practice Learning When Social Workers based at EHASH make decisions about safeguarding contacts and referrals which other agencies do not agree with, professionals should use the local area escalation policy to draw attention to their concerns to find a resolution in the best interest of the child. Agency safeguarding leads with experience in safeguarding children should be consulted for advice and support as necessary. Independent Reviewing Officers (IROs) are also a good source of advice and influence. 8.3. Recognising Private Fostering Arrangements The initial event where Olivia was taken to A&E with abdominal pain resulted in 2 appropriate safeguarding referrals from both the ambulance service and A&E and these were triaged to Early Help for more information to consider what level of support the child and family required. The whole tone of concern by CSC appeared to be around the general needs of the child rather than taking steps to forensically investigate what was an unusual presentation for a 14-year-old child with a long history of neglect. Early Help demonstrated concern for Olivia and made numerous house calls with no response. Deliberate damage to the property by unknown persons was highlighted and concern about the whereabouts of Olivia was a continual feature. 27 It became known that Olivia was staying with a family friend who lived a few doors away from her home address. She had been there for some time because her brother and his children had been living with Olivia’s mother. This should have been viewed as a possible Private Fostering Arrangement which required a full assessment as per national minimum standards (Children Act 1989 & 2004) The private foster carer (in this case the family friend) becomes responsible for providing the day to day care of the child in a way which will promote and safeguard the child’s welfare. It is the duty of local authorities to satisfy themselves, through a full assessment that the welfare of children who are, or will be, privately fostered within their area is being, or will be, satisfactorily safeguarded and promoted. (Section 66 of The Children Act 1989) Practice Learning In cases where children are found to be living continuously with someone other than a close relative for more than 28 days, the local authority should be notified to enable a full assessment of the Private Fostering Arrangement to ensure that the child is being safeguarded and their welfare is being promoted. A Private Fostering arrangement assessment would have found that the family friend was a vulnerable adult in her own right and was not best placed to care for Olivia. Also, MP became a “lodger” at the same house which should have been viewed as potential risk for both the family friend and Olivia. 8.4. Threshold for child protection under section 47 The Early Help worker came to a point where gathering further information was being overshadowed by other aspects of Olivia’s life which started to overtake the original concerns such as mother being uncontactable and Olivia being missing from home and school. A referral to CSC at EHASH was made by Early Help but this was declined with a request for yet further information about Olivia’s living arrangements which had not been forthcoming from either Olivia or mother. Although Early Help did not completely agree with the decision made by CSC, because they felt they had tried everything they could to gain the information already, they did not challenge or escalate their concern through senior management. The escalation policy was discussed at the practitioner learning event and most of the participants had not heard about the escalation policy or understood that they had a responsibility to challenge any safeguarding decisions made by other agencies that they did not agree with in the best interests of children. A Private Fostering Arrangement- is essentially one that is made privately (that is to say without the involvement of a local authority) for the care of a child under the age of 16 (under 18, if disabled) by someone other than a parent or close relative with the intention that it should last for 28 days or more. 28 Practice Learning Professional respectful challenge and escalation of concerns where there is a difference of opinion should be expected practice. Promoting a culture where this is welcomed and encouraged provides a safe environment for children, workers and organisations. Early Help continued to try to make contact with the mother and Olivia. Once they became aware that Psychological Services had become involved with Olivia the Early Help worker at the time closed Olivia’s case file recording that Psychological Services would lead on the case. However, this assumption had been misplaced because Psychological Services had not been informed of this lead role and would not have been able to monitor the situation because of their counselling role and infrequent contact with Olivia. Fortunately, a more experienced Early Help worker became aware of the closed case and requested the Head of Service to quality assure the case file. The service head found a number of outstanding concerns including Olivia being at possible risk of CSE. The case was referred back the Practice Manager (Senior Social Worker) at EHASH where it was allocated to a Social Worker for a child and family assessment. A multiagency strategy meeting took place within timescales and is was agreed for a Child in Need (CIN) Plan under section 17 (Children Act 1989) to go forward to allow the social worker to complete a Child and Family Assessment and Police to investigate sexual activity. A CIN meeting was convened but was limited because mother did not attend and the Social Worker left half way through the meeting to attend to something else. In view of the absence of mother and Social Worker the CIN plan could not build the momentum required to safeguard Olivia. Practice Leaning Child in Need review meetings are only effective when both parents and professionals are available to fully engage in the process. Consideration should be given to escalating to Child Protection in CIN cases where there is parental non-engagement and continuing risks to children are evident. Two weeks after the CIN meeting, an event (4) appeared to trigger a more concerted move towards child protection arrangements when a social worker on a joint home visit with an Early Help worker witness 2 unknown males going in and out of the home looking suspicious before driving off. The Social Worker became worried that they may be connected to Olivia in some way. This visit prompted the Social Worker to request the Core Group for Olivia to complete a Graded Care Profile (GCP) in preparation for a further strategy meeting to consider the case moving into child protection processes. There was no reference to the Adolescent GCP which is available locally and would have been relevant in this case. The Graded Care Profile – is a widely used assessment tool designed to help professionals identify when a child is at risk of neglect. The Graded Care Profile assists professionals to measure the quality of care being given to a child in respect of physical care, safety, love and esteem on a graded descriptive scale. 29 At the Initial Child Protection Conference (ICPC), mother did not attend conference with Olivia as would have been expected. This was apparently typical avoidant behaviour which had previously been experienced by professionals. The conference unanimously agreed that Olivia should be subject of a Child Protection Plan under the category of Neglect. The initial event (1), of an allegation made by a neighbour (family friend) that Olivia may be sexually active with an older male and the event (4) where men had been seen coming in and out of the home were mentioned in the conference minutes but neither of these events translated into concerns that Olivia may be being sexually exploited. In view of this, the Child Protection Plan did not include any actions pertaining to protecting a child from potential CSE. The Child Protection Plan covered the standard areas concerned with Neglect. There was nothing in the plan relating to the vulnerability of mother and how to assess and address her needs with adult health services. Professionals at the conference reflected that mother had been offered support in the past but she had not engaged or cooperated with this which did not bode well for the future success of the child protection plan agreed. Practice Learning Child Protection Plans should cover all aspects of concerns covered at the conference and not just focus on the main category of abuse agreed. Plans should reflect the needs of all family members and address all the risks and concerns identified at conference. Actions should be clear and achievable and within a defined timescale. Contingency plans should be in place for action to be taken if the plan fails to address the needs of the child. 8.5. Difficulties in safeguarding adolescents Research tells us that local safeguarding arrangements often have a “one size fits all system” and usually designed primarily to meet the needs of younger children maltreated within the family (Bilston 2006). The problem with adolescents is that they can often present as an “imperfect victim” in other words, they can typically be hard to engage, uncooperative and ungrateful, which makes addressing their needs a complex business. (Rees and Stein, 1999). It had taken agencies 4 months from the first event to get to the point of multiagency agreement that Olivia required a Child Protection Plan. Several practitioners at the learning event agreed that the threshold had been met sooner but also agreed it was not unreasonable for CSC to want to complete the child and family assessment first. The chair of the ICPC recognised the difficulties in safeguarding Olivia and recommended that CSC should obtain legal advice for a Public Law Order (PLO) for Olivia to be placed in care. This was a very reasonable suggestion given that there was no confidence that mother would cooperate with a child protection plan and Olivia was actively caring for her mother and with no one actively caring for Olivia. 30 The law is clear in line with statutory guidance and UN Convention on Children’s Rights. Adolescents under 18 years of age should not be prejudiced against because of their age. Their wishes and feelings are important, but in cases where it is clear that no one is able to take parental responsibility for an adolescent child then CSC have a duty to take the option to accommodate the adolescent in line with the legal processes available. It is usually preferable for adolescents to be accommodated voluntary (section 20) with another family member or family friend who can be assessed by CSC to care for the child. Foster care or children’s residential care can also provide useful therapeutic placements. Practice Learning Neglect during adolescence is a complex area of safeguarding which requires sensitive handling and a brave response which may include the accommodation (voluntary or through the court) of an adolescent in line with legal requirements. Whilst Olivia met the threshold for PLO, the decision by legal gateway and CSC senior management were to continue with a child protection plan. The reluctance to go forward with a PLO was because of the view that Olivia might sabotage any arrangement to move her away from her mother because of parent/child relationship and loyalty to her mother. It was agreed to go back to legal gateway to review the situation again in 4 weeks. This did occur with the additional information that Olivia may have been sexually abused by an older male. The outcome remained unchanged using the same rational as before that Olivia’s loyalty to her mother would place any new placement at risk of breakdown. Olivia’s wishes and feelings about PLO were not confirmed because no one had managed to speak to Olivia about the matter. Making assumptions about what children are thinking is not in the best interests of children. Children have a right to be consulted about decisions made about them. The decision not to commence to PLO proceedings was not challenged and this left Olivia adrift with a Child Protection Plan that was not working because of parental non-engagement and with no legal court order to protect her. The situation became stalemate with no prospect of resolution. This pattern on non-engagement with professionals and child protection plans by mother was a repeated theme throughout the child’s life and should have been viewed as high risk. It was clear that no one was taking parental responsibility for the child and it should therefore have been the local authority’s role to ensure someone was caring for Olivia. Again, practitioners at the learning event voiced their concern about the lack of PLO progress but no one escalated the situation to senior management for review and resolution. 31 Practice Learning It is important that service arrangements for engaging and working with adolescents suffering neglect are locally defined and known to professionals working with them. Any form of prejudice based on age should be challenged through the local area escalation policy. 8.6. Mother’s views on safeguarding arrangements The Independent Reviewer spoke with mother as part of the review and mother was asked what she felt should have happened to support herself and Olivia. Mother explained that she was in a very bad place with her mental health and drug taking and what was needed was for agencies to “break in” and take over the situation. She told the reviewer that she felt like she had never got any support from the agencies and it was easy just to ignore them until they went away. She felt school did a lot of nagging via texts which did not really help get Olivia to school. What mother wanted was more practical support and someone to talk to and who would be able to understand how to help her. Mother now has a key worker with the Sunrise Complex Safeguarding Team and this she said was the best support she has ever had. She appreciates the relationship she has with her key worker and this has helped her gain more support around her mental health from her GP. Practice Learning The importance of working with vulnerable adults who are parents using trauma informed practice. Working within an honest and trusting relationship is essential to managing changes in behaviour to improve parenting. Parents who do not engage with professionals should be viewed as high risk with the potential to cause ongoing significant harm to their children. 8.7. Protection of Olivia The first 6 weeks following the ICPC there was a multitude of home visits by various professionals to try to engage mother and Olivia with no positive results. The work of the Social Worker who had been temporarily allocated to the case appeared to revolve around trying to find mother and Olivia at home. The Social Worker eventually found Olivia with an unknown male resulting in the police being called for a safe and well check. The police supported the Social Worker on at least 3 occasions resulting in the new allocated Social Worker eventually managing to speak with Olivia and her mother. There was a conversation about the time Olivia had stayed with the family friend where Olivia told the Social Worker that the family friend gave her £70 every time, she got paid benefits and that Olivia would use the money to buy food and watch Netflix. The motivation as to why the family friend was giving Olivia this money does not appear to be explored or possible financial exploitation of the family friend (who was a vulnerable person) considered. The Social Worker was instrumental in getting Olivia to school for one day and made a referral to Young Carers Service in respect of the care that Olivia was providing mother. 32 The Social Worker was able to review the living conditions on one occasion. Otherwise nothing changed with regards to neglect and very little face to face contact with Olivia took place. As time progressed, the concerns of neglect became overshadowed by concerns of CSE and as previously described it was the police who finally brought an end to Olivia’s suffering by arresting MP and using police powers of protection (PPP) to remove Olivia to a place of safety with other family members. Prior to MP’s arrest concerns about CSE should have triggered a strategy meeting in line with child protection local arrangements. Practice Learning When Child Protection Plans become overshadowed with more pressing concerns a strategy meeting should be called within 5 working days in line with local safeguarding practice guidance. Following the initial arrest of MP (which occurred at a weekend) the police informed EHASH Emergency Duty Team who did not follow up on the welfare of Olivia stating this could wait until after the weekend. This does not appear to be in line with best practice guidance. Practice Learning Adolescents who are victims of CSE require an early response for emotional support and possible sexual abuse medical at a local Sexual Abuse Referral Centre (SARC). A health assessment soon afterwards is advisable to identify sexual transmitted disease or any other physical or mental health issues. 9. Good Practice There were a number of good practice examples recognised across the time period of this review as follows: 1. GP seeing Olivia alone at appointments to discuss issues around sexual activity 2. GP flagging system for children subject to child protection plans 3. Good communication by A&E and ambulance service. 4. Child Protection – Information sharing system available in the hospital A&E. 5. Police address markers on OPUS (IOPS) for children at risk 6. Experienced Early Help Worker recognising need for escalation following premature case closure. 7. Head of Service for Early Help who conducted a quality audit of the child’s record and the escalation of safeguarding concerns back to CSC. 8. School welfare lead who acted as a mentor for Olivia and was available and helpful when Olivia felt she needed support. 9. Rota for daily checks (school and early help) at the home to try to make contact and engage mother and Olivia 10. Joint home visits between Social Worker and Early Help worker including out of hours 11. Examples of good child focus. 12. Plan to ensure that a Social Worker visited the home before Christmas and New Year 33 13. Positive engagement of Sexual Health Service. 14. Ongoing work of the Sunrise Complex Safeguarding Team. 10. Practice Issues A practice issue is one that relates to practice matters for review at local provider practitioner level. 1. Record Keeping should include demographic details of the person in attendance with a child attending A&E when a parent is not present to include name, address, contact number, relationship with the child and reason why a parent is not present. 2. Professional curiosity – professionals should ask questions beyond what is on their organisations standard record keeping template. People expect to have a useful conversation with a professional and to be asked relevant questions. 3. Professionals need to be aware of the importance of referring to Sunrise Complex Safeguarding Team via EHASH as soon as CSE is suspected. This is to ensure the early availability of expert assessment and intervention. 4. When adolescents approach professionals with concerns about issues relating to sexual activity – professionals should consider the risk of CSE and know how to act accordingly. 5. Professionals should remember to Think Child, Think Family. When professionals are planning to safeguard children the adults in the child’s life need to be considered in terms of their levels of vulnerability and their capacity to provide safe parenting. 6. Children who “was not brought” (formally known as did not attend) for essential medical appointments including appointments for mental health and behavioural issues such as ADHD should be considered as possible medical neglect. 7. Professionals should be aware of the CSE tool used locally to help them make a clear judgement of a child’s risk of CSE. 8. When the threshold for PLO is met, judgements based on assumptions and the age of the child should not be the defining factor for delaying court action. 11. Training and Development The following list of topics are areas for consideration in terms of training and developing the local workforce. 1. How children make a disclosure. Types of disclosure and how to support children to disclose. 2. Awareness of ACEs and principles of trauma informed practice. 3. Adolescent neglect and safeguarding 4. Working with parents and carers who may be vulnerable adults. (Think Family) 5. Private Fostering arrangements. 34 12. Conclusion This SCR provides insight and reflection for the partner agencies of the Rochdale Borough Safeguarding Children's Partnership (RBSCP). This case is particularly useful for illumining the complexity of safeguarding adolescents and the challenge of recognising and managing cases of child sexual exploitation. This review should be widely shared to promote learning across the safeguarding partnership. Message to other young people from Olivia - if you are suffering from any form of abuse then you should always talk to someone who will listen to you and help you. 35 Recommendations The following recommendations are for the consideration of RBSCP as follows: Recommendation 1 RBSCP should continue to promote the work of the Sunrise Complex Safeguarding Team and request partner agency assurance that professionals working with children and young people are aware of: How to recognise CSE Understand what to do when they have concerns of possible CSE Adherence to the correct referral process for Sunrise Complex Safeguarding Team Intended outcome – To increase the awareness of recognising and acting on CSE concerns for the frontline workforce across the partnership. Recommendation 2 RBSCP should further implement the local Escalation Policy to instil confidence within the workforce and to promote the expectation for respectful professional challenge when there are differences of opinion about safeguarding issues between the agencies, including in cases where there is parental non-engagement Intended outcome – To increase the confidence and competence of front-line staff in escalating professional concern where there is difference of opinion for safeguarding individual children. Recommendation 3 RBSCP should be assured that the local area Public Protection arrangements for managing and arresting offenders out on warrant are being reviewed by probation and Her Majesty’s Courts and Tribunal Service alongside improved arrangements already implemented by Police and Probation for the purpose of licence warrants. Intended outcome – To ensure the early arrest of offenders who are unlawfully at large within communities. Recommendation 4 RBSCP should be assured that the Voice of the Child is captured and acted upon, particularly in Public Law Order (PLO) proceedings, and that decisions made as part of PLO are not based on assumptions. Intended outcome: To improve the safeguarding of adolescents in the local partnership area. Recommendation 5 RBSCP should strengthen their safeguarding arrangements in the following areas: Promote robust information sharing with the allocated social worker or their deputy when there are new developments or concerns about children subject of child protection and child in need plans. Child Protection Plans should be escalated within the Local Authority when parents are not engaged in the child protection process. Intended outcome: To improve effectiveness of local child protection arrangements. 36 Recommendation 6 RBSCP should consider how it can bring together multiagency learning and promote the utilisation of Adverse Childhood Experiences (ACEs) and Trauma Informed Practice (including attachment and relationship practiced) in future safeguarding children arrangements. Intended outcome: To develop the workforce in using a more trauma informed way of working which should benefit working relationships with parents and their children. Statement of Reviewer Independence The reviewer, Kathy Webster is independent of the case and of Rochdale Borough Safeguarding Children Board Partnership. Prior to my involvement with this Local Child Safeguarding Practice Review; I have not been directly concerned with the child or any of the family members or professions involved with the child, or have I given any professionals advice on this case at any time. I have no immediate line management of the practitioners involved. I have appropriate recognised qualifications, knowledge and experience and training to undertake this review. The review has been conducted appropriately and with rigours analysis and evaluation of the issues as set out in the Terms of Reference. Signature: Name: Kathy Webster – Independent Reviewer Date 37 References Working Together to Safeguard Children (HM Government 2015 & updated 2018) https://www.bing.com/search?q=working+together+to+safeguard+children+2015&qs=HS&pq=working+together+to+safeguard+children+201&sk=HS1&sc=8-42&cvid=FDF5E39011164A21B6DB63BFA7915B25&FORM=QBRE&sp=2 Protecting Children in Wales – Guidance for Arrangements for Multiagency Child Practice Reviews (Welsh Government 2012) https://gweddill.gov.wales/docs/dhss/publications/121221guidanceen.pdf New Learning from serious case reviews: a two-year report for 2009 – 2011. London. DfE. Brandon. M. et. Al. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/184053/DFE-RR226_Report.pdf The Little Book of Adverse Childhood Experiences. Lancashire University (2018) Siobhan Collingwood, Andy Know, Health Fowler, Sam Harding, Sue Irwin and Sandra Quinney. Editor: Dr Claire Coulton. The Abuse of Adolescents within the Family. Rees, G and Stein, M (1999). NSPCC. London. Trauma – Informed Approach and Trauma – Specific Interventions. www.mentalhealth.org Key messages from research on identifying and responding to disclosure of child sexual abuse. Pam Miller and Helen Baker (2019) University of Bedfordshire. NSPCC. https://www.csacentre.org.uk/resources/key-messages/disclosures-csa/ Neglected Children and their families: Issues and dilemmas Edition 2. Blackwell. Olive Stevenson (2007) No one Noticed, no one heard (2013) Debbie Allnock and Pam Miller – NSPCC publication. https://learning.nspcc.org.uk/research-resources/2013/no-one-noticed-no-one-heard Hidden men: learning from case reviews (2015) NSPCC production https://learning.nspcc.org.uk/media/1341/learning-from-case-reviews_hidden-men.pdf The developing brain and ACEs. Lisa Fredinken (2018) https://www.acesconnection.com/blog/the-developing-brain-and-adverse-childhood-experiences-aces 38 |
NC50890 | Murder of a 7-year-old boy by his mother in September 2017. Mother was found guilty of murder and sentenced to life imprisonment. E's parents separated when he was a few months old and he spent time living with both parents. Mother (ME) accessed early help services and saw her GP for mental health problems on several occasions. Several domestic abuse incidents were reported to the police between 2010 and 2017. In 2014, E's father (FE) reported concerns to several agencies about historical bruising and reported that E had made an allegation of sexual abuse by a family member. In June 2017, ME reported to the police that FE had refused to return E home and subsequently decided to stop FE's contact. In August 2017, FE made an application to enforce the contact order and a section 37 report was ordered. In the week before E's death, ME contacted E's school and GP, reporting that E had said he wished he was dead. Ethnicity/nationality not stated. Learning includes: lack of clarity about the safeguarding referral pathway across the professional network; managing allegations and concerns in respect of children of separated parents; lack of engagement with and unconscious bias against fathers. Recommendations include: clarify the decision-making process for referrals to early help and children's social care; review the notification process for section 37 reports; and create learning opportunities for reflecting on the approach to providing a whole family focus.
| 1 | P a g e Shropshire Safeguarding Children Board Serious Case Review Report relating to Child E 2 | P a g e Contents Section 1: Introduction ................................................................................................ 3 Section 2: Summary of agency involvement with E and his family ............................. 7 Section 3: Learning from research ........................................................................... 14 Section 4: Key themes ............................................................................................. 16 Section 5: Summary of review findings .................................................................... 28 Section 6: Recommendations .................................................................................. 32 3 | P a g e Section 1: Introduction 1.1 What this review is about 1.1.1 This serious case review (SCR) concerns a child known, for the purpose of this review, as E. 1.1.2 Shropshire Safeguarding Children Board (SSCB) agreed this case met the criteria laid down in Working Together 2015 for an SCR to be conducted. 1.1.3 The brief circumstances of this case are as follows; E’s parents separated shortly after his birth and contact and residency had been determined by the Court following the breakdown of their relationship. E lived with his mother, her partner and his half sibling. His eldest half-sibling would visit the family home to see E. He also spent time with his father, his wife and his paternal half-sibling although this contact had been stopped by mother three months prior to E’s death. In September 2017, E was found deceased at the maternal family home. His mother, who was also at the property, was found with critical injuries and was transferred to hospital where her injuries were treated. Subsequently E’s mother was arrested and charged with his murder. E’s mother was found guilty of murdering E who was 7 years old at the time of his death and was sentenced to life imprisonment. 1.1.4 E was found dead on the day that his parents were due to attend a Directions Hearing in the private law proceedings that had been initiated by father to address contact and residence issues. The Directions Hearing would have addressed E’s interim contact with his father pending a final decision by the Court on contact and residency matters. E’s father had made an application to Court in response to mother stopping contact between father and E in June 2017. 1.2 Why this review was conducted 1.2.1 The Independent Chair of the SSCB agreed with a recommendation of the Learning and Improvement sub-group that this case should be the subject of an SCR; under the requirements of the Local Safeguarding Children Boards Regulations 2006 Section (5)(1) (e) and (2). 1.2.2 The statutory basis for conducting an SCR and the role and function of a Local Safeguarding Children Board is set out in law by: The Local Safeguarding Children Board Regulations 2006, Statutory Instrument 2006/90. Regulation 5 requires the Local Safeguarding Children Board (LSCB) to undertake a review where – (a) abuse or neglect of a child is known or suspected; and (b) either – (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 4 | P a g e 1.2.3 Guidance for LSCBs on conducting an SCR is contained in Chapter 4 of Working Together 20151. This version of Working Together was used when deciding upon the SCR process, as it was the most current at the time decisions were taken around the review process (published in March 2015). 1.2.4 An SCR establishes the role of services in the life of the subject child and provides a rigorous, objective analysis of what happened and why, so that important lessons can be learnt, and services improved to reduce the risk of harm to children. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children. 1.3 How this review was conducted 1.3.1 Author and Review Panel 1.3.2 The author of this report was Liz Murphy, who is a qualified Social Worker, and independent of all agencies that work to safeguard children and young people in Shropshire. She has extensive safeguarding experience including reviewing cases and service provision to support improvements in how services are provided to children and their families. 1.3.3 A review panel was established. Meetings were held at regular intervals and the panel was consulted about the scope of the review. In addition, Panel Members contributed to the analysis contained in this report. The panel included a senior manager from each of the key agencies. 1.3.4 The Terms of Reference 1.3.5 This SCR has been conducted using a methodology adapted to suit the circumstances of this review and is described in more detail in the next section. The methodology established how well systems have worked, and where they can be improved. It is not a criminal or disciplinary review designed to attach blame to individuals. 1.3.6 This review focuses on the period from January 2014 to September 2017. This period was selected following a SCR Panel meeting and is of a sufficient range to include the relevant engagement that E had with agencies in Shropshire. Whilst this period was the basis for the review, contextual and relevant information falling outside of this period was also included. 1.3.7 The review was conducted in a way which: recognised the complex circumstances in which professionals work together to safeguard children; 1Working Together to Safeguard Children March 2015 - https://www.gov.uk/government/publications/working-together-to-safeguard-children--2 5 | P a g e sought to understand precisely who did what, and the underlying reasons that led individuals and organisations to act as they did; sought to understand practice from the viewpoint of the individuals and organisations involved at the time, rather than using hindsight; was transparent in the way data is collected and analysed; made use of relevant research and case evidence to inform the findings. 1.3.8 Agencies that are involved in child safeguarding are required to follow the statutory guidance laid down by government. The guidance is called Working Together to Safeguard Children. It contains all the processes that agencies are required to follow. Working Together has been through several iterations. This review benchmarks against the statutory guidance contained in Working Together 2015. 1.3.9 Methodology 1.3.10 The methodology agreed by the Shropshire Safeguarding Children Board (SSCB) review panel is based on a model consistent with the requirements of Working Together 2015. It ensures that: a proportionate approach is taken to the SCR; it is independently led; professionals who were directly involved with the case are engaged with the review process; families are invited to contribute. 1.3.11 Chronologies and Agency Reports 1.3.12 Agencies were asked to compile a report detailing their contacts with E, resulting in a combined chronology of events. In addition, each agency was asked to provide a report that described the contact they had with E and his family. Agencies were asked to identify key learning for their agency and to describe how they will embed this learning into day to day practice. All the agencies that were asked for a report provided the information requested. In cases where further clarification was required, agencies responded in an open and transparent way. 1.3.13 Learning Event 1.3.14 A learning event with front line practitioners is an essential part of the process. In the learning event, front line staff and managers that had had contact with E were brought together for discussions around themes that had been identified from the chronologies and reports. This provided a view of their engagement with E that enriched the information provided by agencies and ensured that all the relevant facts were recorded. 1.3.15 This review seeks to determine why events occurred and not just record the facts of what happened. The front-line view is invaluable in achieving this. 6 | P a g e 1.3.16 Whilst the details of discussions that took place were recorded, the comments made by the staff involved were non-attributable. For many front-line practitioners, this was the first opportunity for them to discuss with other professionals their engagement with E and his family; it was pivotal to the learning from these traumatic events. 1.3.17 Family Engagement 1.3.18 Family members were invited to contribute and the views of those that did have informed this report. 1.3.19 Parallel investigations 1.3.20 The timing of this review was managed by SSCB so as not to undermine the criminal investigation that was conducted by West Mercia Police and resulted in E’s mother being convicted of his murder. E’s death has been referred to the Coroner. It is understood the Coroner will review his decision to hold an inquest upon completion of this review. 1.3.21 How this report has been structured 1.3.22 Following the introduction, Section two provides a summary of agency involvement with E and his family whilst Section three provides a summary of the key learning from research into filicide. Section four analyses the key themes, identified by the author in conjunction with the review panel and frontline practitioners, and explains WHAT happened and WHY. Section five summarises the key findings of the review. The recommendations in Section six have been developed from these findings taking account of the work carried out by agencies since these events occurred. 1.3.23 This report has been written so that it can be read by the public. 1.3.24 In this report, the following initials represent the main subjects: E – subject of this review ME – mother of E FE – father of E Family Member 1 – Maternal half sibling Family Member 2 – Paternal half-sibling Significant Adult 1 – Mothers partner 7 | P a g e Section 2: Summary of agency involvement with E and his family 2.1 This section sets out the contact that agencies had with E and his family. It begins with a picture of E so that the reader has an insight into the child that E was. This information is provided by the family members who contributed to the review and E’s school. 2.2 What was E like? 2.2.1 E spent time living with both his parents, their partners and his half-siblings. His parents separated when he was just a few months old and his residence and contact arrangements had subsequently been determined by the Court. 2.2.2 E is described as an active child with a great sense of humour. His interests included riding his bike, go-karting, skateboarding or sledging. He also enjoyed playing computer games, watching films, making pizza and lots of bubbles when having a bath. Family trips and holidays were also an important part of E’s life. 2.2.3 E was considered to be a thoughtful and hardworking pupil who always liked to do his best. He liked talking to adults and asked lots of questions about history or programmes he had watched on television. Academically, he was at the expected level for this age and was working above the expected level in mathematics. E is described as chatty and confident when talking to his peers and adults as well as considerate and kind towards others. On occasions, E displayed indicators of distress in school and both parents shared examples with professionals of, either comments they heard E make, or behaviour they observed which would also suggest that on occasions, E was experiencing distress. 2.2.4 Professionals who attended the learning event commented that in their view, E should be considered a resilient child as given the level of parental conflict he was exposed to, further indicators of the impact of this on his emotional well-being could have been expected. This suggests that whilst being exposed to parental conflict, E had at other times received good quality care and nurturing from the adults in his life. 2.3 Summary of agency involvement 2.3.1 E was born in January 2010 and lived with ME and FE. Health visiting services provided a high level of support to ME in E’s first year of life with 18 face to face visits taking place prior to February 2011. E was last seen by a Health Visitor in February 2011 when he was aged 2; he was never seen by school nursing services. 8 | P a g e 2.3.2 In E’s early life, ME accessed a range of early help services including a group for mother’s experiencing post-natal depression, a group for victims of domestic abuse as well as Home-Start2. 2.3.3 In April 2010, ME saw her GP because of low mood. She was prescribed medication and seen on several occasions in the future about her emotional well-being/low mood. 2.3.4 In June 2010, ME contacted the Police to report an argument between herself and FE. ME reported to the Police that FE had left the family home with E in his pushchair. ME reported the incident as she was concerned about E’s welfare as FE had been drinking and was upset. E & FE were quickly located by Police and they were found with ME’s sister across the road from the family home. This incident was classified as a ‘standard’ risk domestic abuse in adult by Police and records indicate that both parties were recorded as “Domestic Abuse Undetermined”. A further 6 ‘standard’ risk domestic abuse incidents were reported to the Police over the coming years. They were usually reported by ME however, FE also made reports. The nature of the reports focused on a range of issues; child contact, verbal disagreements and parenting style. 2.3.5 In July 2010, ME and FE separated and ME describes the separation to professionals as not very amicable. 2.3.6 In November 2010, FE applied to Court for contact. CAFCASS completed safeguarding checks and did not identify any ongoing role for themselves. ME & FE completed a parenting programme and hair strand testing for alcohol. The Court ordered unsupervised contact between E and his father from May 2011 onward. 2.3.7 In April 2011, E started pre-school close to FE’s home and attended 2 days a week (the days he was resident with FE). E left this preschool in July 2014. 2.3.8 In December 2013, ME was given a new tenancy via a local Housing Association. A new tenancy visit was conducted in January 2014 and no additional support needs were identified. 2.3.9 In January 2014, FE reported concerns to the GP. He stated he had observed bruising on E’s legs in the past. E was examined and no evidence of bruising was found. The GP made a safeguarding referral to COMPASS. COMPASS is the single point of contact for receiving enquires and referrals regarding the welfare or protection of children in Shropshire. 2.3.10 In March 2014, FE reported the same concerns to the pre-school. The school sought advice from the Early Help team (based within COMPASS). The Early Help team advised that there was no need for a referral at this 2 Home -Start is voluntary sector organisation that recruits and trains volunteers to provide friendship, emotional support and practical help to families with at least one child under five years of age. 9 | P a g e stage and that the information had been registered by the GP in January 2014. The pre-school informed the review that the Early Help team commented that FE may be trying to build some sort of case against ME or he may have even inflicted the injuries himself. It would appear from the records that the Early Help team were under the impression that Court proceedings were ongoing at this time. 2.3.11 In April 2014, FE made a referral to Children’s Social Care. He reported the historical and more recent bruising as well as an allegation made by E of sexual abuse by a family member. This did not progress as a referral and instead the outcome was to write to both parents with guidance on acrimonious relationships and advise FE to contact the GP or Police if he had further concerns. FE also shared his concerns about physical and sexual harm with the pre-school who in turn shared the information with the Early Help team. 2.3.12 In May 2014, and on the advice of his solicitor, FE reported his concerns of physical and sexual harm to the police. Police visited E to conduct a safe and well check. They found no evidence of visible bruising and considered E to be a happy little boy. The information was shared with Children’s Social Care and Police Family Protection Unit. The incident was filed with no further Police action. 2.3.13 In May 2014 and on the same day that the Police conducted the safe and well check, ME contacted the Police to report FE was harassing her. She also made an allegation of a non-recent sexual assault against FE although did not wish to make a formal complaint. 2.3.14 At the end of May 2014, the GP contacted Children’s Social Care to report concerns both ME & FE had reported to him. Children’s Social Care have a record of the contact made following the concerns raised by FE however, there is no record in Children’s Services records of the contact made by the GP in respect of the concerns raised by ME. ME’s concerns centred around FE making alleged derogatory comments about her character and parenting to E. At this time, the GP was concerned that the parental relationship was causing emotional harm to E. GP records indicate that Children’s Social Care considered the allegations to be based on the ‘ongoing dispute’ between parents. 2.3.15 In June 2014, ME told the Health Visitor that E was being cruel to his pets and that he was having increased temper tantrums and some angry outbursts directed at a family member. Furthermore, ME shared that E was sleeping poorly and was having regular nightmares. ME shared this information with Children’s Social Care and information provided to the review indicates the Health Visitor also contacted Children’s Services. The outcome of ME’s contact with Children’s Services was to sign post to the Family Information Service. This advice is similar to what is recorded in health visiting records as to the outcome of their contact with Children’s Services which supports the position that the Health Visitor had contacted Children’s Social Care about this information. 10 | P a g e 2.3.16 In September 2014, E started primary school. 2.3.17 Between Autumn 2015 and July 2016, ME was supported by a range of early help services after she self-referred to a Children’s Centre. Services delivered include the Power to Change programme, The Me, My Child and Domestic Abuse programme and E attended a group work programme called Helping Hands. These programmes were provided by a specialist domestic abuse service. In addition, an early help worker from the Children’s Centre worked with both ME and E. In October 2015, E completed a Webstar (a tool designed to assist practitioners to identify a child’s needs) which indicated low happiness when with FE and some feelings of being unsafe when with ME. A total of 14 home visits were conducted to ME and E was seen on 4 occasions at home and on 7 occasions in school. 2.3.18 In October 2015, ME shared concerns with school that E was being mentally abused and wanted to be sure E’s contact with FE was safe and secure. School made a referral to Children’s Services. Children’s Services have no record of this contact. 2.3.19 In November 2015, FE applied to the Court to vary the contact order. CAFCASS completed safeguarding checks and identified no ongoing role for themselves. These proceedings concluded in February 2016 with a Child Arrangement Order which stipulated the arrangements for contact between E and FE, including during the school holidays. The information provided to CAFCASS by the Local Authority to inform the safeguarding checks did not include the allegations of sexual abuse made by FE in 2014. 2.3.20 In April 2016, family member 2 was born. 2.3.21 In July 2016, early help services (Children’s Centre) close their involvement with the agreement of ME. 2.3.22 In September 2016, the GP makes an urgent referral for ME to the Community Mental Health Team. ME had thoughts of self-harm and suicide and was suffering from depression due to a number of factors: custody dispute, relationship breakdown with current partner, bereavement/loss and job worries. ME was admitted to a short stay local mental health crisis provision for five days. This provision was used as an alternative to hospital admission. 2.3.23 ME subsequently self-referred to an NHS Wellbeing service. She had, since E’s birth, been referred to this service on 3 previous occasions and failed to engage. From October 2016 – March 2017, ME accessed 18 face to face therapy appointments. It is considered that the wellbeing service was the appropriate response to ME’s emotional wellbeing issues. The focus of this intervention was ME’s relationship breakdown with significant adult 1 and her relationship with her own mother. There was a very limited focus on her relationship with FE and no focus of the impact of her wellbeing on E. By the 11 | P a g e end of the intervention, there was evidence of positive improvement in ME’s depression and anxiety scores. 2.3.24 In September 2016, ME attended for a carer’s assessment in relation to her caring responsibilities for family member 1. The assessment did not explore other caring responsibilities that ME had i.e. E. 2.3.25 In June 2017, ME calls the Police to report FE had refused to return E home. ME was very upset and during the call said “nothing stopping me stabbing the c**t. I want him dead. It would save him having to grow up with that”. Police visited both ME and FE and determined that there was no breach of the Contact Order as it was FE’s weekend to have contact. ME has shared that this was the trigger for her decision to subsequently stop contact. She reported that she feared if she did not address what she perceived as FE’s non-compliance with the Court Order, FE would not adhere to the Order in the future. 2.3.26 This contact with the Police was recorded as a standard domestic abuse incident and discussed at the local domestic abuse triage meeting where following a multi-agency discussion, it was agreed that this incident should be responded to as a level 1 incident in terms of the SSCB levels of need as set out in the thresholds document i.e. recorded for information. At this time, local practice was for the Police to record this information. In response to the findings of the Ofsted inspection in 2017, Children’s Social Care now also record this information on their systems. 2.3.27 Later in June 2017, FE called Police to advise that his solicitor had informed him contact had been stopped by ME. FE raised concerns for E’s mental health and wellbeing and 6 days later, Police followed up with a safe and well visit. The Police concluded that FE’s call was malicious, and FE was using the Police to harass ME. Both ME and FE subsequently contacted Children’s Services and school to report concerns about each other and E. FE’s initial contact to Children’s Services at this time repeated the allegation that E had said he was being sexually abused by a family member. During this period, FE made 3 contacts in total to Children’s Services and once notified that the Local Authority were closing the case, FE contacted Ofsted to express his concerns that the Local Authority appeared prejudiced towards men and were not prepared to investigate allegations of neglect and sexual abuse. A senior officer provided a rationale to Ofsted for the Local Authority’s decision which was that there was no evidence from the Police or school that E was suffering harm. 2.3.28 At the end of June 2017, FE contacted the NSPCC Helpline. As a result of FE’s contact, NSPCC made a referral to Shropshire Council in a timeframe that was in accordance with their internal guidance. Some of the information reported by FE to NSPCC was not contained in the referral made by NSPCC and whilst most of this information had previously been shared with Children’s Services by FE, he did share some new information with NSPCC and in particular that he considered that ME had undiagnosed mental health difficulties. In addition, information about an occasion when FE shared 12 | P a g e information with E about ME’s manipulation of their contact was not included in the referral. FE also informed NSPCC of the lack of response by Children’s Social Care and Police to the allegations of sexual abuse that he had reported to them. Whilst the NSPCC referral was received by Shropshire Council in June 2017, there was no response provided to this referral. 2.3.29 Early in August 2017, FE made an application to Court to enforce the Child Arrangements Order made on 16th February 2016 and for E to live with him. CAFCASS conducted safeguarding checks and on this occasion, the information provided by the Local Authority detailed the allegations of sexual abuse made by FE in 2014. CAFCASS recommended a Section 37 report and were concerned that E was caught up in the middle of issues between parents and the associated impact of allegations and counter allegations made by ME and FE on him. At the end of August 2017, the Court ordered a Section 37 report and directed that the safeguarding letter prepared by CAFCASS was shared with the Local Authority. The Local Authority did not receive a copy of the safeguarding letter. Children’s Social Care subsequently received the request for a Section 37 report on 8th September 2017; once the referral was received the case was passed to the relevant case management team for allocation. 2.3.30 In early September, ME self-referred to a local domestic abuse service and subsequently she attended a face to face appointment. She expressed her concerns about attending the court hearing scheduled for later that month. 2.3.31 About a week before E was killed, ME attended E’s school and shared that she was feeling anxious and that no one was listening. ME consented to school making a referral to Children’s Social Care to explore support available for mother. During the contact with school, ME stated that the ‘only way to end it all would be a shotgun and shovel”. In response to the contact from the school, Children’s Social Care confirmed that ME had completed the Freedom programme and advised that the case had already been passed to the relevant case management team and was awaiting allocation. The call was not returned by the allocated team. At the same time as ordering a Section 37 report, the Court also directed that FE should have one supervised contact session with E in September 2017 however this did not take place. 2.3.32 Two days prior to E’s death, ME contacted the GP by telephone and reported that E had said he wished he was dead so that he wouldn’t have to see FE. ME asked that E was protected from the emotional abuse she was alleging. The GP made a written referral to CAMHS (via COMPASS). The referral requested that CAMHS urgently assess E and detailed the issues between the parents in relation to contact. The referral was assigned to a CAMHS practitioner who reported that it was returned to COMPASS to be reassigned to Children’s Social Care due to safeguarding concerns, however, it is understood the referral remained sitting on the CAMHS practitioner’s desktop. On the same day, the GP also contacted Children’s Social Care by telephone to refer his concerns in respect of E. This contact 13 | P a g e was passed to the relevant case management team and shared by email with the duty worker. This call was also not returned by the allocated team. 2.3.33 In the telephone call with ME, the GP advised her that she should consult the GP practice regarding her own health. This was because throughout the telephone consultation, ME presented as anxious. 2.3.34 E did not attend school on 21st September 2017. The school did not attempt to contact E’s parents to establish the reason for his non-attendance. Later that day, a call to the emergency services was made by Significant Adult 1 to report that he had found E dead at the family home. Paramedics and Police attended the scene and paramedics confirmed E’s death at 18:34hrs. 2.3.35 ME was subsequently convicted of E’s murder and jailed for life with a minimum sentence of 18 years. Information gathered by the Police during the criminal investigation into E’s death suggests that ME had told members of the community in the week preceding E’s death that she would be in prison by the following week. ME had also written letters to family members’ weeks prior to E’s death that indicated her intention to harm both herself and E. These letters were discovered after E’s death. 14 | P a g e Section 3: Learning from research 3.1 To inform the review the author has reviewed the findings of a study into filicide in the context of separation, divorce and custody disputes3. This research analysed 128 filicide killings between 1994 – 2012 and draws on other research that has been carried out in this field. Key findings from the study are: Relationship breakdown is the most conspicuous and significant characteristic of the filicide cases in the study; Depression is the most common mental illness in parents in both filicide and child abuse cases; Mental illness is an important contextual background for marital, separation and divorce conflict and/or in residence or contact disputes and can exacerbate any of those conflicts and disputes; The prevalence of mental illness among female perpetrators of filicide is significantly higher (75%) in contrast to male perpetrators (19%); That children have to be rescued from ‘something awful’ is quite common in the thinking of many filicide perpetrators; Apart from infanticide and neonaticide, the 4-7-year age group seems to be a particularly vulnerable one in filicide killings; Domestic violence is a common feature in cases of male filicide; The state of the perpetrators relationship with their (ex) partner/spouse at the time of the filicide killing is a key issue; Most filicide killings are preceded by and are wholly dependent upon an exceptionally high degree of premeditation and deception on the part of the perpetrator; The frequency of revenge as a motivator is exceptionally high but given the context in which the killings take place that may not be surprising i.e. mutual animosities and recriminations between parents; A shift in the balance of power, control and influence a perpetrator once exerted in a relationship can be a predominate feature in some cases. In some cases, a partner may lose power, control or influence as a consequence of external factors that have nothing to do with the relationship e.g. unemployment or poor physical or mental health; Public and private law proceedings can be a dangerous time, a time of enhanced risk for all concerned; The risk of parents taking some drastic action on or near the day a court is due to make decisions, will be higher if the court hearing has been proceeded by weeks, months or years of bitter wrangling between the parents, or if there has been frequent involvement by social workers unhappy with the care of a child, or when there has been recurring domestic abuse, and the issuing of non-molestation and other types of restraining orders. The final decision of a court may leave a parent seething with rage and a desire for revenge or retaliation; 3 Filicide – suicide. The killing of children in the context of separation, divorce and custody disputes. Kieran O’Hagan 2014 15 | P a g e 44 out of 128 perpetrators in the study were female; some studies conclude that the majority of perpetrators are men whilst there are probably just as many which find that the majority of perpetrators are women. There is another strand of research which finds that the numbers of mothers and fathers who kill their children is roughly equal. Research on the gender of filicide perpetrators is therefore inconsistent at best and more often contradictory. 3.2 It is important to state that the features described above are correlated with filicide rather than being causal. Many of the features are fairly common occurring risk factors in child welfare cases and therefore have low predictive value for filicide which is indeed a rare event. As a result, their significance is often only apparent with the benefit of hindsight. This helps to explain the significant challenge that agencies face in identifying the cases that could end in filicide from those that don’t and reflects the views of some of the family members who contributed to the review that there was nothing else agencies could have done to make a difference to the tragic outcome for E. 16 | P a g e Section 4: Key themes 4.1 The Terms of Reference for this SCR agreed that the review would focus on the following question “What is the learning in relation to how services respond to the needs of children of separated parents, where contact and residency are decided by the Court?” 4.1.1 The SCR Panel agreed the priority themes that emerged from their collective considerations of agency reports. Priority findings are identified because they create risks to other children, young people and families in future cases because they undermine the reliability with which professionals can do their jobs. Priority findings therefore provide useful organisational learning to underpin improvement. 4.2 Priority Finding 1 Safeguarding referral pathway – (including open unallocated cases). (This finding is relevant to all children and young people and not just those children of separated parents) 4.2.1 A range of professionals reported concerns about the safety and wellbeing of E from January 2014 up to 2 days before his death. The review has identified a lack of clarity about the safeguarding referral pathway across the professional network. 4.2.2 When a referrer calls Shropshire Council Children’s Services, call handlers based in the First Point of Contact (FPOC) receive the call. Previously, including at the time of E’s death, referrals to CAMHS were made via FPOC with one of two CAMHS nurses then deciding as to whether to accept the referral. These referrals were recorded on Children’s Social Care records rather than in CAMHS records. In December 2017, a separate front – door was created by the responsible health trust to receive CAMHS referrals and from this date, referrals to CAMHS have been recorded by the responsible health trust thereby creating a more robust system of governance for referrals to CAMHS than was in place when the GP made a referral to CAMHS in respect of E. 4.2.3 When a call is made to FPOC about a child’s welfare or safety, current practice is that the call handlers will transfer a safeguarding referral to the Initial Contact Team (ICT) who then determine if the threshold for a statutory social work service is met. If the caller wishes to book an Early Help Consultation, FPOC will arrange this consultation and if the caller is unsure about the level of their concern, FPOC transfer the call to the Early Help team who explore the options of making a safeguarding referral or seeking an Early Help Consultation to determine which service in COMPASS is best placed to respond to the concerns. 4.2.4 The SSCB thresholds document published in March 2017 requires practitioners to complete a Multi-Agency Referral Form (MARF) when they have identified the need to make a referral to Children’s Social Care i.e. complex/significant needs have been identified. Good quality MARFs will make it easier for staff in COMPASS to understand the intentions of the 17 | P a g e referrer and the nature of their concerns for the child. The version of the SSCB thresholds document that was in place between April 2013 and March 2017, made no reference to the need for a written referral for cases being referred to Children’s Social Care and the review has found that during this period, there was not a culture of submitting written safeguarding referrals. As a result, phone call was the method of ‘referral’. According to the version of the SSCB thresholds document that was in place up to March 2017, FPOC would receive calls and either: Arrange for a consultation to be provided by an Early Help Advisor (a senior social worker). This consultation would be offered within 2 working days and its purpose was to assist the caller consider their options and manage risk appropriately, Transfer calls regarding concerns that a child is at risk of suffering significant impairment to their health or development or is suffering or at risk of suffering significant harm to the ICT where a decision would be made about whether the threshold was met for social work intervention. The SSCB threshold guidance stated that to secure this response, the caller would need to advise they wished to make a child protection referral. 4.2.5 An analysis of the contact and referrals made by professionals to Shropshire Children’s Social Care has been completed and has established that professionals and in particular, the GP and school made what they believed to be safeguarding referrals however, these were not received or processed as safeguarding referrals by Children’s Social Care. The fact that up until March 2017, the phrase ‘child protection referral’ was a requirement for a case to be processed as a referral to Children’s Social Care by FPOC, coupled with the fact that there was no expectation of a written referral up until March 2017, provide an explanation as to ‘why’ this has occurred. Discussions with agency report authors and front-line practitioners at the learning event confirm that there is still a lack of clarity and understanding about the referral pathway to Children’s Social Care and furthermore that MARFs are not routinely being completed by practitioners who consider that a child meets the criteria for a social work service. The lack of written referrals to Children’s Social Care by the school and GP in September 2017 provide evidence that the use of MARFs is not fully embedded in Shropshire. 4.2.6 There are also examples were professionals have contacted COMPASS (GP in May 2014 to report concerns shared by ME, Health Visitor in June 2014 to report concerns shared by ME and school in October 2015 to request support for E) that are not recorded in Children’s Social Care records. Children’s Social Care report that regular audits and inspection by Ofsted have more recently provided assurance that there is a robust system in place to record contacts. The lack of the recording of the NSPCC referral made in June 2017, along with some information provided to this review about the practice of recording contacts on closed cases, indicates the need to confirm arrangements for recording all contacts received by Children’s Social Care. This work is being progressed as part of the review of the local referral pathway to Children’s Social Care and Early Help that has commenced because of the learning from this review and will also include 18 | P a g e embedding a system to provide written feedback to those who make referrals to COMPASS. 4.2.7 As referenced earlier, NSPCC made a referral to Shropshire Children’s Social Care in June 2017. Initially, the Serious Case Review Panel thought that the referral had not been received by Shropshire Council, however, it has been established that the referral was received on the date it was sent. At the time of this referral, Children’s Social Care already had an open contact in respect of E. The NSPCC referral should have been linked to the open contact and its content considered as part of the Local Authority’s decision making as to whether E met the threshold for a social work service. The NSPCC referral was moved into a folder in the receiving email account by an Early Help social worker and the open contact was closed later the same day by a senior social worker in the ICT which meant that the NSPCC referral was never linked to E’s records. This provides an explanation as to why it was never actioned. In terms of the information that was not included in the referral, NSPCC have advised the review that they will use the Quality Assurance Process for the Helpline to monitor that all relevant and significant information is included in referrals made to Local Authorities. 4.2.8 The referrals made by school and the GP in the days leading up to E’s death were received by Children’s Social Care. The GP made a written referral to CAMHS (Via COMPASS) and a safeguarding referral by telephone to Children’s Social Care. Similarly, the school made a safeguarding referral by telephone. At this time, the case had been opened in the relevant case management team because the request for the Section 37 report had been received from the court. These referrals were accordingly transferred to the team with case responsibility. Neither telephone call was returned by the Case Management team although the call from the GP was passed to the duty worker. 4.2.9 In exploring why this happened, the Local Authority report that the team manager was off sick, and, at the same time, an Ofsted inspection of Children’s Social Care was taking place which impacted on the capacity of the service manager and other team managers within the service and resulted in the case not being allocated in a timely way. The Local Authority reports that it was exceptional for cases not be allocated and the practice norm was for the case to be allocated and a child to be visited within 7 working days following a referral. ME has shared as part of her contribution to the review that the lack of contact from Children’s Social Care following the S37 report being ordered by the Court increased her anxiety as she was anticipating an opportunity to share her concerns in a timely way. Shropshire Children’s Social Care have introduced changes to address the service failures they have identified in responding to safeguarding concerns on open, unallocated cases and these are: A team manager protocol has been created and a robust management cover system has been implemented in the case management service. The protocol outlines the roles and responsibilities across teams when another team manager is off work due to sickness or annual leave. 19 | P a g e Training will also be provided to administrators to clarify their responsibilities in respect of concerns reported on open cases from professionals 4.2.10 The Independent Reviewer notes that in a previous SCR published by SSCB in November 2015, the findings included that there was confusion about reporting arrangements for agencies when there are concerns about children with an allocated social worker who is unavailable particularly when their manager is also absent. In addressing the learning from this review, it is recommended that SSCB review how they have previously addressed the need for the professionals involved in the safeguarding system to understand how to secure and provide a response in relation to concerns in respect of open cases where an allocated worker is unavailable. This is to ensure that awareness and practice becomes embedded. 4.2.11 Priority 2 Managing allegations/concerns in respect of children of separated parents. 4.2.12 As previously described, a range of professionals reported concerns in respect of E as did ME and FE. None of the contacts/referrals made resulted in a decision that the case met the threshold for a social work assessment. 4.2.13 The nature of the concerns reported by parents either directly, or indirectly (via professionals), included historic bruising, allegations of physical neglect which were not corroborated by professionals who were in regular contact with E, or allegations of statements made by E to either parent that were not shared or repeated to anybody else. The nature of the allegations, coupled with the fact that domestic abuse incidents reported to the Police were classified as ‘standard’ and at that time not recorded on Children’s Social Care records, plus the lack of tangible evidence of serious impairment to E’s physical health and wellbeing provide an explanation as to why referrals were responded to in this way i.e. the threshold for Children’s Social Care intervention was not readily apparent in many of the referrals. 4.2.14 The dynamics of the family will have also influenced the professional response and there were also examples of ME either intentionally or unintentionally manipulating professionals. Examples include: i) ME telling her Health Visitor in 2014 that the Police who had visited the day before in response to allegations made by FE had told her they were confident the allegations by FE were malicious. ME added that she felt the motive for these allegations was the disagreement over contact arrangements. The Police report of this incident records that ME deemed the report to be malicious due to the ongoing custody issues. ii) ME telling a domestic abuse service in September 2017 that she experienced domestic abuse from FE when he was misusing alcohol and E was 6 years old i.e. within the previous year. This information contrasts with previous reports of domestic abuse as parents had 20 | P a g e separated several years ago. In E’s 6th year, the only domestic abuse incident reported to the Police was by FE. 4.2.15 FE was likely to be seen as manipulating professionals due to what was perceived as him elaborating on his initial reports, contacting multiple agencies and repeating previous allegations. What should be noted is that when reporting his concerns in April 2014, which included allegations of sexual abuse, FE was recorded as being extremely emotional and said, “he did not know if anything was wrong or if it was just in his mind”, adding that “E has a lively imagination and he wondered if E had imagined things”. He went on to say that he would be concerned if ME was told about the referral and said that he did not know what was worse, that his child continued to be abused or that he made an unfounded referral. This does not suggest that FE was motivated to make a malicious allegation. FE went on to say that his reason for not reporting these concerns previously was concern about ME’s reaction and her ability to turn things back on him; this comment suggests that ME was able to exercise a degree of power and control over FE. 4.2.16 A common national challenge that helps provide an explanation as to how safeguarding referrals in respect of children of separated parents are managed is that they are often seen as a feature of the parental conflict, particularly for cases involving private law applications. Instead, they need to be seen as distinct issues that should be addressed in the same way as a safeguarding concern for a child who is not involved in private law proceedings. Evidence that safeguarding allegations/concerns were seen as a feature of the parental conflict in this case include: i) Advice to pre-school that “FE may be trying to build some sort of case against ME” (February 2014) ii) Comments to GP that mother should consider applying for emergency order via a solicitor to suspend contact from father (May 2014) iii) Querying FE’s motive for raising a continuous pattern of concerns once contact had been stopped (July 2017) 4.2.17 Those in attendance at the learning event identified that there is a need to “rescript the starting point” when dealing with allegations made in respect of children of separated parents. This is to enable professionals to objectively consider the safeguarding needs of the child as they would for children not involved in private law proceedings. Paternal family members have asked the following questions of the professional response: “Where was that little boy?” and “Who understood what E wanted?”. They identified that professionals should practice with a “healthy level of suspicion” and be open to the possibility that “perhaps what this parent is saying is true”. If this happened, they consider it would place the child at the centre of professional practice. 4.2.18 Whilst many of the allegations made by parents or professionals did not readily evidence the threshold for statutory children’s social care intervention there were three that clearly did: 21 | P a g e 1) Allegation of disclosure of sexual abuse by E in April 2014 reported by FE (Reports of concerning behaviour exhibited by E were also shared by ME with Health Visitor around this time); 2) Referral by school in September 2017 which included concerns about mother’s wellbeing and information that she had had thoughts of harming others; 3) Referral by the GP in September 2017 about E’s emotional wellbeing, including a report that E had said he wished he was dead. 4.2.19 An explanation as to why referrals (2 and 3) were not progressed has been provided elsewhere (see 4.2.9). Children’s Social Care accept that their response (to conduct agency checks) in respect of the allegations made by FE in April 2014 was not reflective of the concerns being shared. The decision not to conduct an assessment appears enmeshed with the view that the allegations were a feature of the parental conflict as the rationale for this decision was that FE had returned E to his mother despite the suspicion of abuse and FE had not reported the allegations of sexual abuse to the Police or GP. FE informed the review that he adhered in full to the requirements of the Court Order as he feared that if he did not ME would stop contact. Information from the pre-school corroborates this perspective as in April 2014, FE told the pre-school that Children’s Social Care had questioned why he returned E to ME’s care if he had concerns. During this discussion, FE was upset and advised the pre-school that he did so as he feared that he would be arrested for breaching the Court Order if he did not. This information provides an insight into why FE returned E to ME’s care. 4.2.20 On the advice of his solicitor, FE, approximately one month later, reported these concerns to the Police who in turn reported them to Children’s Social Care. Neither the Police nor Children’s Social Care acted in respect of the allegations of sexual abuse at this point. The Police agency report author correctly raises the question as to why there was no strategy discussion held between the agencies to ascertain if there was to be any additional action taken, and whether this would be as a single or joint agency investigation. The lack of a multi-agency assessment at this time was a missed opportunity to understand the needs and experience of E. There were further missed opportunities to identify the lack of joint Police and Children’s Social Care response to the allegations of sexual abuse at the point when Ofsted contacted the Local Authority to share the concerns that FE had raised and when NSPCC referred their concerns to the Local Authority. 4.2.21 With regard to CAFCASS’ response to concerns raised by E’s parents, it has been identified by the CAFCASS agency report author that the allegations made by both parents when information was being gathered on behalf of the court in December 2015 warranted further assessment than was carried out at the time to determine the level of risk to E. Whilst CAFCASS identified that further information was required by the court e.g. copies of the Police logs, there was no consideration as to who would assess and analyse this information before final arrangements could be made. A more in-depth assessment at this time, by way of a Section 7 report, would have informed the professional understanding of the severity of any risk and enabled a 22 | P a g e more child focused assessment to ensure that any recommendations made to the court would safeguard E from emotional and any other kind of abuse, and that the arrangements agreed were in his best interest. Had this more in-depth assessment been completed, it would have included seeing E. CAFCASS decision making at this time should therefore also be considered a missed opportunity to understand E’s lived experiences. 4.2.22 In responding to the various allegations made by ME, FE and professionals, the focus was on identifying evidence of physical harm or neglect, and in the absence of tangible evidence of these forms of abuse, it was determined that E was not experiencing significant harm or impairment to his health and development. This approach fails to recognise the emotional impact of parental conflict on children and for E, it also failed to recognise the lack of joint investigation into the allegations of sexual abuse. Practitioners in attendance at the learning event identified that the impact of parents ‘battling’ over their children should be universally viewed as a negative experience for any child. E’s behaviour at school sometimes evidenced the emotional distress he was experiencing; and the direct work he completed with the family support worker in 2015 -16 is perhaps most revealing of his reality. E completed MyLife booklets in relation to life at home with ME and another in relation to life at home with FE. There were a lot of similarities across both booklets and when asked by the Family Support Worker why his answers were so similar in both booklets, he said “I just want to make everyone happy”. Practitioners at the learning event suggested that a Family Group Conference approach could perhaps be used to support children living in these circumstances with the aim of parents being both supported and challenged to make changes to their behaviour. In the near future, a project called Inspiring Families, aimed at working with families in conflict, is being piloted in Shropshire; the findings from this initiative will assist agencies to evaluate how future services could be developed to support children exposed to parental conflict. 4.2.23 Priority 3 Working with fathers 4.2.24 The lack of engagement with fathers has been an endemic problem in safeguarding and child protection and is exposed repeatedly in all child abuse inquiries preceding Serious Case Reviews, particularly in the Tyra Henry, Kimberley Carlile and Jasmine Beckford reports; in child abuse literature (Farmer and Owen 19954, O’Hagan 19975) and in SCRs. Brandon et al’s biennial analysis of SCRs (2009)6 commented ‘information about men was very often missing’. In a more recent analysis of SCRs, Sidebotham et 4 Farmer, E. and Owen, M. (1995) Child Protection Practice: Private Risks and Public Remedies: As Study of Decision-making, Intervention and Outcomes in Child Protection Work, London: HMSO. 5 O’Hagan, K.P. (1997) ‘The problem of engaging men in child protection work’ British Journal of Social Work, 27(1): 25-42 6 Brandon, M., Bailey, S., Belderson, P., Gardner, R., Sidebotham, P., Dodsworth, J., Warren, C. and Black, J. (2009) Understanding Serious Case reviews and Their Impact: A Biennial Analysis of Serious Case Reviews 2005-07, London: Department for Children, Schools and Families 23 | P a g e al (2016)7 identify professional cultures within some agencies which potentially mitigate against effective safeguarding. An example of such a professional culture that they highlight is engagement with fathers. 4.2.25 Examples where agencies did not engage with FE have been identified by agency report authors: i) No evidence of any engagement with FE by the health visiting service despite the expectation that Health Visitors are expected to be inclusive of fathers when supporting families; ii) No evidence of contact with FE regarding the MyLife work carried out by the family support worker during the period of their involvement 4.2.26 Examples of what the SCR Panel described as an “unconscious bias” against FE have also been identified: i) The questioning by Children’s Social Care of FE’s motives for reporting safeguarding concerns; ii) The Police response to domestic abuse incident in June 2017, whereby the referral made by the Harm Assessment Unit shows FE as ‘person referred’ and ME as ‘alleged perpetrator’ however, the DASH victim assessment was completed in respect of ME, yet she had made threats to seriously harm FE; iii) E’s admission to hospital at ME’s request in April 2014 when FE, who had attended with E, was reassuring to hospital staff that he would be able to provide the recommended treatment at home and wanted to take E home; iv) Evidence of a partisan approach by primary care practitioners e.g. one practitioner described FE as “clearly manipulative” when in fact they had never met him; v) The review has been made aware that schools do not send routine information e.g. email updates to the “non-resident” parent unless the non-resident parent requests this information. FE was viewed as a “non-resident” parent for E by school. Whilst FE had requested to receive updates about E, he questions whether he received all relevant information e.g. being informed about E’s absences from school. FE informed the review that the decision by the Court in August 2017 to reduce the frequency of contact between E and FE and require it to be supervised is another example of “bias” in the system. Paternal family members do not consider that this decision took into account that FE had made the application to Court as a response to ME’s breach of the Child Arrangement Order. 4.2.27 FE’s experience of services fits with the examples of “unconscious bias” described above as he reports that he was treated differently by professionals because he is a male and because professionals accepted 7 Sidebotham, P., Brandon, M., Bailey, S., Belderson P., Dodsworth, J., Garstand, J., Harrison, E., Retzer, A. and Sorensen, P. (2016) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014, London: Department for Education. 24 | P a g e ME’s allegations of domestic abuse without exploring the available evidence or seeking his perspective and experiences of his relationship with ME and most importantly, his concerns for E. The impact of how FE was treated by professionals was that he always felt like he was “on trial” as a parent. 4.2.28 O’Hagan1 suggests that the lack of engagement with fathers may be “culturally embedded, habitual and instinctive”. The SCR Panel identified that in cases where allegations of domestic abuse have been made, professionals can be “pre-programmed” to accept the word of the female without exploring what evidence is available to support the allegations. In this case, there was also no recognition or consideration of whether FE was a victim of domestic abuse or how ME was able to control him and influence his behaviour. An example of how professionals failed to consider that FE could be a victim of domestic abuse can be seen in September 2017 when the school make a referral to Children’s Social Care for support for ME when she had shared that she had thought of harming father. The initial response from the Local Authority was to clarify that ME had attended a course for victims of domestic abuse. In all cases, professionals need to be able to recognise male victims of domestic abuse and that individuals can be both a victim and a perpetrator of domestic abuse. 4.2.29 Challenging and changing cultures is far from straight forward and requires deep understanding of the issues, creative thinking, and engagement with practitioners and management to understand why it is so challenging to routinely engage fathers effectively. O’Hagan1 concludes that reversing this practice will have a dramatic effect on the quality of assessment, and in determining the degree of risk to which children are exposed. 4.2.30 Priority Area 4 Section 37 referral pathway 4.2.31 In August 2017, CAFCASS recommended to the court that a Section 37 report should be made. Section 37 reports can be recommended or directed by the Court where it appears that it may be appropriate for a care or supervision order to be made in respect of the children subject to the court proceedings. Section 37 reports are completed by the Local Authority’s Children’s Social Care Service who undertake an investigation to consider whether they should: a) Apply for a care order or for a supervision order with respect to the child; b) Provide services or assistance for the child or the family; c) Take any other action with respect to the child. 4.2.32 In August 2017, the Court directed Children’s Social Care complete a Section 37 Order which was to be filed on 25th October 2017. A direction was also made for the safeguarding letter to be shared with the Local Authority. The Local Authority received the request for a Section 37 Order seven working days after the Court hearing. As previously stated, once this request was received, the case was transferred to the relevant case management team for allocation. 25 | P a g e 4.2.33 The CAFCASS worker who completed the safeguarding checks and produced the safeguarding letter identified that E would be impacted by the allegations and counter allegations that were a feature of his parent’s conflict. In terms of context, allegations and counter allegations are not remarkable in the Work to First Hearing stage of CAFCASS work however, the CAFCASS worker was worried that Children’s Social Care were not pursuing the concerns. In recommending a Section 37 report, the CAFCASS worker was reassured this paved a way for somebody to see E and assess the risks including E’s emotional health which was a particular concern for the CAFCASS worker. 4.2.34 At this time, E’s case was closed to Children’s Social Care and as stated earlier; the request for a Section 37 report was not received until seven working days later although the concerns will have been identified by CAFCASS a couple of weeks prior to this date i.e. when gathering information to complete the safeguarding letter. The safeguarding letter was not received by Children’s Social Care although the Order made stipulated that this should happen. Internal CAFCASS guidance currently sets out that when recommending a Section 37 report, CAFCASS officers should generally agree this course of action with the Local Authority. This did not happen in E’s case and the Local Authority were therefore not sighted on the assessment of E’s welfare that CAFCASS had completed. 4.2.35 Discussion in the learning event identified an inconsistent approach and delay in CAFCASS informing the Local Authority about any Section 37 reports they may recommend to the Court as well as requests for Section 37 enquiries being sent to Children’s Social Care, including safeguarding letters not being shared with the Local Authority. A review of the last 10 requests for a Section 37 report received by Shropshire Council confirms this position, although it is important to state that CAFCASS may not have been involved in all the cases reviewed at the point that the Section 37 report was ordered by the Court. 4.2.36 When a CAFCASS worker recommends a Section 37 report, it is because they have identified a concern about the child’s safety and wellbeing and consider that the Local Authority should be asked to consider whether it should be taking further steps to protect the child. In response to the learning from this review, CAFCASS have agreed to review their Work to First Hearing guidance so that it is a requirement for the CAFCASS Officer to notify the Local Authority when recommending a Section 37 report and also for them to consider whether to make a safeguarding referral if there are matters of significant harm that will not be addressed within the timeframe of the Section 37 assessment. 4.2.37 Discussions with CAFCASS indicate that their perspective is that when a discussion with the Local Authority takes place about a case, they consider that they have shared information in relation to concerns about a child and the Local Authority should then determine how to respond to this information. CAFCASS currently have a Child Protection Policy which requires their officers to make a child protection referral if they have concerns that a child 26 | P a g e is at risk of significant harm. There is no guidance in the Child Protection Policy for how CAFCASS officers should refer safeguarding concerns below the “significant harm” threshold. It is considered that the absence of a clear pathway for CAFCASS officers to make referrals below the threshold of “significant harm” creates the potential for misunderstanding about the purpose of contact by CAFCASS officers with the Local Authority. Given that safeguarding concerns in respect of children of separated parents can often be seen as a feature of parental conflict, it is particularly important that there is clear and mutually understood process. 4.2.38 To address the potential for miscommunication between the two agencies, CAFCASS Child Protection/Safeguarding Policy should also require their staff to make a safeguarding referral if they have concerns that the child is a “child in need”. A “child in need” is defined under the Children Act 1989 as a child who is unlikely to achieve or maintain a reasonable level of health or development, or whose health and development is likely to be significantly or further impaired, without the provision of services; or a child who is disabled”. This approach would be consistent with statutory guidance and would also mitigate against the potential delay that children, like E, can face in having any safeguarding needs identified by CAFCASS assessed by Children’s Social Care. 4.2.39 Priority 5: Whole Family Focus (This finding is relevant to all children and young people and not just those of separated parents) 4.2.40 The lack of focus on the whole family is a reoccurring finding of SCR with Sidebotham et al (2016)5 finding a lack of ‘thinking family’ in order to better understand the needs and experiences of children in their analysis of Serious Case Reviews published during 2011-14. 4.2.41 ME accessed a range of services in her own right including in respect of her mental health and emotional wellbeing. Mental health is not, in and of itself, harmful to children; it may, however, present risks in some situations, for example through delusional thoughts or self-harming thoughts or behaviour, or when combined with other parental risks. Parental mental ill health has been recognised as a potential risk factor for child maltreatment and, the presentation of an adult with mental health problems who has contact with, or caring responsibilities for children provides opportunities for further assessment and intervention to mitigate risk. It is therefore, crucially important that professionals, including GP’s and mental health workers, consider the risks and implications of any mental health problems for children living in the family. 4.2.42 A couple of days prior to E’s death the GP had positively identified ME’s emotional presentation as a concern and advised ME to seek support. There were other occasions when professionals did not consider the implications of ME’s mental health needs on E including: i) ME’s admission to the crisis unit in September 2016; 27 | P a g e ii) No exploration of childcare responsibilities and impact of ME’s anxiety and depression on E by Primary Care Well-Being Service in September 2016; iii) No consideration of the impact of ME’s current mental health on E during October 2016 – March 2017 when ME was accessing therapy; iv) Omission of information about concerns for ME’s mental health in the referral made by NSPCC in June 2017 4.2.43 Between September 2016 and March 2017, early help services were involved with ME and E. There is no evidence that the Family Support Worker attempted to or had any contact with FE even though the concerns raised by ME related to E’s contact with FE and the time he spent at FE’s home. The lack of engagement with fathers has been explored elsewhere in this report; its impact was to minimise professional understanding of E’s needs and experiences or in the words of the paternal family “to cut half his family out”. In addition, whilst some of the professionals providing early help support to ME were aware of her long-standing emotional wellbeing needs, they did not engage with the relevant professionals to understand her needs and how these were being managed. 4.2.44 A comprehensive family assessment or chronology would have increased professional understanding of the family’s history and informed the intervention. The impact of the lack of such an assessment and chronology meant the work offered was largely directed by the word of ME. Developments within Early Help services have been made to promote whole family engagement including the introduction of a whole family consent form which prompts and enables consultation with other agencies and family members. In addition, and as a matter of good practice, it is now a requirement across Local Authority Children’s Services (Early Help and Children’s Social Care) that interventions are informed by a family chronology to ensure that the whole family story is considered. 28 | P a g e Section 5: Summary of review findings 5.1 This section summarises the key findings from the review to inform the recommendations that are made in the next section. In advance of setting out key findings, it is important to stress that the system challenges identified in this or any SCR, can have no responsibility for the perpetrator’s motivation or their actions. Responsibility for the death of any individual rests firmly with the perpetrator. 5.1.1 A lack of clarity regarding the safeguarding referral pathway to Children’s Social Care has been identified and in particular, professionals understood they were making safeguarding referrals however they were not received as such by the Local Authority. One factor influencing the response by the Local Authority to those ‘referrals’ will be the previous version of the SSCB thresholds document which stated that for referrals to be passed to ICT, the referrer had to state they wished to make ‘a child protection referral’. In addition, and prior to March 2017, referrals were to be made by telephone rather than in writing. Whilst MARFs were introduced in March 2017, these have not yet been embedded across the partnership and there is therefore further work to do in respect of embedding a clear process for making safeguarding referrals as well as increasing understanding of the stages of decision making in the referral pathway. Children’s Social Care have also identified a need to review how referrals that are received electronically are linked and added to a child’s records. 5.1.2 Many of the referrals made by ME or FE did not evidence the threshold for Children’s Social Care intervention had been met. However, on 3 occasions, referrals were made either by FE or professionals that should have resulted in a service being provided by Children’s Social Care (April 2014 (FE), Sept 2017 (School) and September 2017 (GP)). 5.1.3 NSPCC made a referral to Shropshire Children’s Social Care which was not acted on by the Local Authority. The NSPCC referral did not fully reflect all the information that had been reported to them. Whilst it cannot be known whether a response to this referral by Children’s Social Care would have resulted in them taking action, the Independent Reviewer considers this to be unlikely largely because the Local Authority response to the safeguarding concerns raised was to view them as a feature of parental conflict. 5.1.4 The absence of a team manager who had oversight of cases in the relevant Case Management Team, including those requiring allocation, and the demands of the Ofsted inspection, provide some explanation as to why the case was not allocated once the report for a Section 37 report was made. There was a system for a Duty social worker to respond to issues in respect of unallocated cases in the Case Management Team however, this did not result in a response to the two referrals from the school and GP passed to the Case Management Team in September 2017 by FPOC. The review has noted that a finding from an SCR published by SSCB in November 2015 was “agencies are unclear about who to contact when there are urgent concerns on open cases and the allocated social worker is unavailable”. That review 29 | P a g e identified that there was a potential that this was a relevant issue for all children who are open to Children’s Social Care and have a social worker. In this case, whilst E did not yet have a social worker, the issue about urgent concerns being dealt with on open cases is the same as that identified in 2015. SSCB should therefore take action to assure itself of the arrangements to respond to urgent concerns on open cases including how well these arrangements are understood by all agencies. 5.1.5 Family dynamics, and either the intentional or unintentional manipulation of professionals by ME, will have impacted on their response and influenced their perception of the validity of the concerns being raised by FE. In addition, professionals who had contact with both parents have described how they both said unpleasant things about each other resulting in an impression they were deliberately adversarial. This discord will therefore have contributed to the likelihood of professionals forming a view that the allegations stemmed from the parental conflict. 5.1.6 It is not uncommon for the safeguarding system to view safeguarding concerns/reports as a feature of parental conflict, particularly in cases involved in private law proceedings and this practice is not unique to Shropshire. When this happens, safeguarding concerns are inappropriately considered as matters to be resolved by the Court. 5.1.7 The review has found a combination of factors influenced the response to the safeguarding concerns that were raised: i) Nature of allegations made by FE and ME e.g. historic allegations of bruising that meant there was no current corroborative evidence; ii) A focus by professionals on identifying physical evidence of neglect or physical abuse at the exclusion of considering of the risk, or indicators, of emotional abuse and sexual abuse. iii) A scepticism amongst the workforce about FE’s motivation for reporting concerns; iv) The lack of a clear system to respond to urgent concerns on cases open to Children’s Social Care. 5.1.8 Professional scepticism about FE’s motivation for reporting concerns is likely to have been influenced by the culture of working with fathers that prevails within the multi-agency safeguarding system. Again, this practice is not unique to Shropshire. A pattern of non-engagement with FE across some services or the questioning of his motivation has emerged alongside a practice norm of accepting ME’s allegations of domestic abuse whilst not recognising or exploring the risk of domestic abuse for FE. His lack of involvement in the early help intervention prevented a more holistic and comprehensive understanding of the nature of family relationships and dynamics and most importantly their impact on E. 5.1.9 The pathway for notifying the Local Authority for requests for Section 37 enquiries/reports has been considered as part of the review and delays and inconsistency found. When such requests are received from the Court, the Local Authority does not necessarily receive all the relevant information, as 30 | P a g e was the case for E, which is likely to impede the response provided by the Local Authority. 5.1.10 CAFCASS have internal guidance that addresses when and how referrals should be made when there are concerns that a child is at risk of significant harm however there is no similar guidance when “child in need” concerns have been identified. The lack of clear pathway for making such concerns creates the potential for miscommunication between CAFCASS and the Local Authority and given that safeguarding concerns in respect of children of separated parents are often seen as feature of parental conflict, it is important that there is a clearly understood process amongst CAFCASS and the Local Authority as to how these concerns are referred. 5.1.11 Like many other SCR’s, the review has identified an insufficient whole family focus in many of the interventions that were provided, and, there is learning in respect of how professionals considered the impact of ME’s long-standing mood disorder on the care of E. In E’s case, Children’s Social Care were not aware of ME’s mental health needs until after E’s death. A further and again common finding, from SCRs is that there was a lack of understanding of E’s lived experiences. Whilst E’s views were obtained through early help services, there were other important opportunities for these to be better understood by professionals. A family member (other than ME and FE) who it is considered was able to talk objectively to E about his parents shared that he loved ME and FE and wanted to see them both. This view is based on their discussions with E and illustrates that E was able to share his wishes and feelings. 5.1.12 During the course of the review, a number of strengths in the safeguarding arrangements in Shropshire have been identified that will have a positive impact on future similar cases. These include: Availability of specialist support for male and female victims of domestic abuse; Provision of College of Policing Vulnerability training for all frontline West Mercia Police Officers; Introduction of ECINS as a recording system for services provided by Early Help Workers. This system can be accessed by over 800 external users including schools, health, housing and voluntary and charitable organisations including Domestic Abuse Services; Training for Social care staff on child sexual abuse; Training for Early Help workers in whole family assessment, consent and whole family action plans; Pilot of Inspiring Families project to work with families in conflict; 5.1.13 The above strengths are in addition to the learning that agencies have identified within their agency reports which has or is being implemented. The recommendations set out at Section 6 are designed to further enhance the safeguarding response provided by Shropshire services to children of separated parents where contact and residency are decided by the Court. 31 | P a g e 5.1.14 In concluding, professionals working with children of separated parents, where contact and residency are decided by the Court should be supported to: Practice with objectivity; Engage with both parents and explore their perspectives; Have a healthy level of professional scepticism and be open to considering what a parent is saying might be true (as opposed to viewing allegations of abuse or neglect as a feature of parental separation/conflict); Recognise and address the emotional impact of parental separation and private law proceedings on children’s emotional well-being; Respond to any safeguarding concerns as they would for a child who is not involved in private law proceedings. These actions will serve to place children of separated parents at the centre of the professional response. 32 | P a g e Section 6: Recommendations a) SSCB to clarify, and subsequently audit the application of the referral pathway and decision-making process for referrals to Early Help and Children’s Social Care. This should include the use and quality of written referral forms and feedback to referrers. b) SSCB to seek regular assurance that: i) Professionals understand how to refer urgent concerns in respect of cases open to Children’s Social Care; ii) Children’s Social Care provide a timely and child centred response to this information. c) SSCB to provide the multi-agency workforce with the knowledge and understanding of i) the impact of protracted private law proceedings on children’s emotional wellbeing; ii) the factors to be considered and assessed in circumstances whereby separated parents make allegations about the welfare of their children iii) the features of filicide cases. d) To test the impact of recommendation (c) SSCB to conduct a multi-agency audit of the services provided to children referred to Children’s Social Care whose parents are separated and where private law proceedings have taken place. The audit should consider the completion of whole family assessments and the response to safeguarding concerns and allegations of domestic abuse. e) SSCB to work with Local Family Justice Board (LFJB) and CAFCASS to review the notification process for Section 37 reports to ensure timely and consistent arrangements. f) CAFCASS to update their Child Protection Policy to include when and how safeguarding referrals (child in need) should be made. g) SSCB to engage with multi-agency frontline staff as well as parents/carers to explore their experiences, and any barriers, to working with fathers. The findings of this work should be considered and acted on by SSCB. h) SSCB to create learning opportunities for the multi-agency workforce to come together and reflect on their approach to providing a whole family focus; including how they consider the impact of parenting capacity on children. Liz Murphy Independent Safeguarding Consultant October 2018 33 | P a g e Acknowledgements The reviewer wishes to acknowledge the support and significant contribution of the SSCB Development Officer in coordinating the review process as well as gathering additional information requested during the review process |
NC52350 | Significant neglect of two children aged 7-years-old and 22-months-old. Learning is embedded within the recommendations. Recommendations include: NHS England considers the feasibility of a system for raising alerts on children not registered with a GP for longer than three months; the local NHS Trust provides guidance to midwifery staff requiring that all women receive a post-natal visit at their normal address; the county council provides assurances on the capacity and workload pressures experienced by the health visiting service, addressing whether the practice of only visiting by prior appointment is universal or specific to a particular team; the county council establishes a multiagency working group to develop guidance regarding responsibilities for school attendance; agencies provide assurance that their assessment processes enable the effective involvement of fathers, partners and other men within the household; agencies obtain independent verification of information rather than relying on self-reporting from service users.
| Title: Serious case review of Family S: learning briefing. LSCB: East Sussex Local Safeguarding Children Board Author: East Sussex Local Safeguarding Children Board Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 www.eastsussexlscb.org.uk twitter.com/eastsussexLSCB Introduction: The East Sussex Local Safeguarding Children Board undertook a Serious Case Review (SCR) of Family ‘S’ concerning two children – aged 7 and 22 months – who experienced significant neglect. The children were living with their mother in a privately rented flat where the home conditions were so poor that when professionals gained access to the accommodation it was deemed unfit for human habitation. Additionally, the older child was found to have a significant disability which had not been addressed and therefore means there will be a need for lifelong medical treatment. A significant feature of this serious case review was the low level of contact that professionals had with the mother and children. Key features of the case: The conditions in which the children were found to be living were truly awful and yet, even with hindsight, no professional could identify any evidence that would have suggested that their home was out of the ordinary. In part this is because the parents were very adept at preventing professionals visiting the family home. It is also likely that the children spent time staying with their grandparents. The Review Team did investigate closely whether there were any indicators present that should have required a more proactive response by professionals however, despite some weaknesses in the safeguarding system being identified, there were no obvious interventions that would have highlighted these children’s predicament. Despite best efforts to engage the parents in the review work, it was not possible to meet with either parent or the grandparents. This has meant that the Review Team are still not clear why the adults allowed their physical environment to reach the level of neglect that it did and what factors might have influenced this. Serious Case Review of Family S Learning Briefing What is a Serious Case Review? A Serious Case Review (SCR) is a locally conducted multi-agency review in circumstances where a child has been abused or neglected, resulting in serious harm or death and there is cause for concern as to the way in which the relevant agency or agencies have worked together to safeguard the child. The purpose of a Serious Case Review is to establish whether there are lessons to be learned from the case about the way in which local professionals and organisations work together to safeguard children, identify what needs to be changed and, as a consequence, improve inter-agency working to better safeguard and promote the welfare of children. 2 www.eastsussexlscb.org.uk twitter.com/eastsussexLSCB As with all reviews, the review has identified some areas where safeguarding arrangements could be improved. A significant feature was the absence of routine health contact with both children. Child 1 was not seen by any health professional for over four years despite having a significant congenital health problem that was treatable, and Child 2 also had minimal contact with community health professionals. It is known from information provided by professionals currently involved with Mother that she considers herself to be a victim of domestic abuse and it is probable that substance misuse by the parents is also relevant. There was some information known about the substance misuse issue at the midwifery stage but this did not lead to a more detailed assessment/additional support. Recommendations: This SCR identified seven recommendations to strengthen safeguarding practice. These included: 1) CCG and NHS England to consider the feasibility of a system for raising alerts on children not registered with a GP for longer than three months. 2) East Sussex NHS Trust to provide assurance that the Midwifery Additional Support Form (ASF) is fit for purpose and is being used consistently with women who meet the criteria for its use. 3) East Sussex NHS Trust provide guidance to midwifery staff requiring that all women receive a post-natal visit at their normal address 4) East Sussex County Council, to provide assurances on the capacity and workload pressures experienced by the Health Visiting service. This report to address whether the practice of only visiting by prior appointment is universal or specific to that team. 5) East Sussex County Council to review the impact of the past IT difficulties within the health visiting service and report any actions needed to resolve the safeguarding concerns. 6) East Sussex County Council to establish a multi-agency working group to develop guidance regarding responsibilities for school attendance. 7) All agencies to provide assurance that their assessment processes enable the effective involvement of fathers, partners and other men within the household. And, where possible obtain independent verification of information rather than relying on self-report from service users. Action taken since the review: Some of the systemic problems identified have already been addressed (e.g. changes to notifications of late starters at school) however some are likely to remain without changes in practice. To that end the Review Team has included some recommendations for action to be taken, either to reassure that practice has changed, or to achieve changes in systems to enable children to be better protected in the future. 3 www.eastsussexlscb.org.uk twitter.com/eastsussexLSCB Action already taken includes: The Health Visiting Service has reconfirmed that visits should not always be by routine appointments. LSCB Independent Chair wrote to NHS England raising concern about lack of national alert system for when children are not registered with a GP. Updated guidance issued to schools relating to link between school attendance and safeguarding issues. A process for regular documented clinical supervision for Health Visitors is in place, this includes a system to monitor compliance with Health Visitor visits Further Reading and Useful Links: Neglect toolkit The East Sussex Neglect Strategy and Operational Practice Guidance (Sept 2017) and Neglect Toolkit and Matrix helps assist practitioners in identifying and assessing children and young people at risk of neglect. This guidance lays out identifying and responding to neglect across the Continuum of Need, assessment and care planning guidance, and threshold for step up. It provides guidance on the use of chronologies and discusses culturally competent practice. LSCB Multi-Agency Training on Neglect The LSCB runs training for multi-agency professionals on neglect. The next one day course is running in November 2018. More details can be found on the East Sussex Learning Portal: www.eastsussexlearningportal.org.uk Pan Sussex Safeguarding and Child Protection Procedures When was the last time you used the Pan Sussex Child Protection and Procedures Manual? Why don’t you refresh yourself! If you want to sign up for alerts when the procedures are updated please add your details on the website. http://sussexchildprotection.procedures.org.uk Serious Case Review Briefings The LSCB will be holding briefing sessions on the findings of this serious case review and other local and national reviews later in the year. Contact Us Telephone: 01273 481544 Email: [email protected] Website: www.eastsussexlscb.org.uk If you think a child is being harmed or may be at risk of harm, please contact: SPoA Mon-Friday 8.30am-5pm Phone: 01323 464222 Email: [email protected] or [email protected] If you urgently need help outside of office hours you can contact the Emergency Duty Service for East Sussex and Brighton and Hove. Phone 01273 335905 or 01273 335906. 4 www.eastsussexlscb.org.uk twitter.com/eastsussexLSCB Learning for practice The LSCB invite you to discuss some of the issues raised in this serious case review in your team meetings or during group supervision. We encourage your responses to be included in your team minutes and forwarded to the safeguarding lead within your organisation. Points for discussion: Recognising signs of neglect, including non-registration with GP Effective use of assessment tools to highlight vulnerabilites Visits to the family home Role of fathers, partners and other men school absence and managing safeguarding concerns Signs of neglect What are the signs of neglect that might have been evident in a family like this? How confident are you/your team at recognising neglect? Professional curiosity How are you professionally curious? How might you have been professionally curious with a family like this? What do you think would help you / your team to be more ‘professionally curious’? ‘Hard to engage’ families How easy would it be for a family known to you to keep all professionals away from their home? What do you/your team do to challenge and support parents when their engagement is causing concern? How are concerns about a family’s non-engagement escalated in your team? Applying learning What have you/your team learnt from this case? How might you/your team apply that learning? |
NC52321 | Death of a 5-year-old child in November 2018 due to injuries sustained in a serious and reckless incident at the family home. Learning includes: gathering and analysing family history, which includes history of contact with services, is a core task when working with children and families; it is important that appropriate empathy towards the parents does not cloud professional judgement or challenge; supervisors and managers should consider how busy front-line workers make trade-offs in order to resolve goal conflicts and cope with uncertainty and system pressures, and ensure this does not compromise children's welfare and safety; the language used to describe services, forms, tasks and activities carries weight and can create expectations; professional curiosity is the ability to think, and communicate, in a way that explores what is happening rather than making assumptions or accepting things at face value; exploring and reconciling differing perspectives about the risks a child or family is experiencing is a necessary task when operating in a multidisciplinary context; when working with parents who are, or become, resistant it is important that expectations are transparent about the professional response to such resistance and that these are clearly stated from the outset; when new, and potentially serious information emerges about risk to children the response should be measured and match the level of seriousness; when undertaking assessment work, professionals should be alert to all risks that children may face, and not make assumptions about mothers naturally being protective. Recommendations include: to ensure the learning is disseminated across the multi-agency safeguarding partnership.
| Serious Case Review No: 2022/C9362 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. OFFICIAL - Sensitive Serious Case Review Family M Date: 19/02/2022 Lead Reviewer: Kevin Ball OFFICIAL - Sensitive CONTENTS Section Page 1.Introduction to the case under review & synopsis of findings 1 2. Process for conducting the review 1 3. Family structure & contribution to the review 2 4. Synopsis of relevant case history 3 5. Findings & analysis 5.1. The use of case history to inform assessments & decision making 5.2. Considerations about thresholds for intervention, including step-up & step-down arrangements 5.3. The quality & effectiveness of safeguarding supervision and/or management oversight & scrutiny 5.4. The extent of professional curiosity, challenge and escalation 5.5. The consideration of risk posed by other adults who had contact/lived with the family 5 6. Good practice 16 7. Conclusion 16 8. Recommendations 17 1 OFFICIAL - Sensitive 1. Introduction to the case under review & synopsis of findings 1.1. This Serious Case Review examines the circumstances of agency contact and involvement with four children that lived together in a family home. The children, aged between 11½ years and 5 years, lived with their mother. In November 2018 a serious and reckless incident occurred at the family home. As a result of the incident and the significant injuries suffered the youngest child later died. The children had been known to services since 2008 and at the time of the death were subject to a support plan via the local authority Strengthening Families Service. 1.2. As a result of the Rapid Review process undertaken by the Local Safeguarding Children Board (LSCB) in January 2019 information emerged that at the time of the serious incident an adult male (to be known as Adult 1) was in a relationship with the mother, and living at the family home. This adult male was of concern given his history of violence against women. Despite services being involved with the family, the adult male’s presence was not known about at the time. 1.3. The decision to conduct a Serious Case Review has been based on the fact that a child suffered serious harm (potentially through abuse and neglect), and then death, and there was cause for concern about the way in which agencies had worked together to safeguard children. Whilst the serious harm, and death, was not directly attributable to abuse or neglect as may be the case in other such case reviews, the concern about the way in which agencies worked together remains, particularly so, given the lack of knowledge about the adult male’s presence in the family home. 1.4. The outcome of a Police investigation and trial in a criminal Court resulted in no convictions. Both Adult 1 and the children’s mother were present at the time of the serious incident and each carry some culpability for events. Children’s Services remain involved with the surviving children offering support. 1.5. By way of a summary, the following findings have emerged from this case review; - Despite being known about, family history and previous involvement with services, was not fully evaluated and not consistently used by professionals to inform assessments and decision making by some agencies involved. - A small number of professionals were determined in their efforts to raise the profile of the concerns they had about the children, particularly the eldest child. Their efforts to raise the threshold of concern with the Multi-Agency Safeguarding Hub (MASH) were mostly unsuccessful due to systemic pressures the Hub was experiencing but also a degree of sympathy being expressed for the mother’s situation; decisions made as a result of these issues were not in the children’s best interest. - Contextual safeguarding issues which were of concern about the eldest child were not recognised, explored or responded to. - Professionals became aware of the presence of an adult male in the family home prior to the incident; this adult presented a risk to children and adults. Information was not best used to assess for any risks he may have posed. 2. Process for conducting the review 2.1. The Board commissioned Kevin Ball as the Independent Reviewer1. The approach taken has complied with the expectations as set out in statutory guidance2 and has provided a way of looking at and analysing frontline practice as well as organisational structures and learning. A Soft Systems Methodology3 has been adopted allowing system 1 Kevin Ball is an independent and experienced safeguarding consultant, with specific experience of chairing and authoring case reviews. 2 Working together to safeguard children, 2015, HM Government. 3 i) Soft Systems Methodology by Checkland, P., & Poulter, J., in Systems Approaches to Managing Change: A Practical Guide, Reynolds, M., & Holwell, S., Open University, 2010, and ii) Soft systems methodology in action, Checkland, P., & Scholes, J., 2003, Wiley. 2 OFFICIAL - Sensitive thinking ideas to be applied, enabling the review to capture and identify opportunities for professionals and organisations to learn and improve safeguarding practices from a whole safeguarding system perspective. 2.2. The decision to initiate a Serious Case Review was taken in January 2019 by the Independent Chair of the Board following a Rapid Review of agency contact with the children. Following the appointment of the Independent Reviewer an initial scoping meeting was held at the end of April 2019. At this point the following steps were taken; - Single agency reports4 and chronology were requested and submitted in May 2019, which in turn generated a combined chronology of agency involvement. This process provided each agency with the opportunity to reflect on their involvement with the children. As a result, agencies have been able to consider actions required of themselves in order to make improvements to practice early on in the process, - A facilitated multi-agency workshop was convened in early July 2019 involving practitioners who had come into contact with the children, - Following the conclusion of the Police investigation and criminal trial, the Independent Reviewer spoke with a close member of the children’s family; the mother declined the opportunity to contribute to the review. - Due to the Police investigation and criminal trial, it was not possible to finalise the review until these parallel processes had concluded; as such, the review process from start to finish took 29 months to complete. The report was accepted by the LSCB’s Review Subgroup Group in September 2021 and the LSCB’s Safeguarding’s Executive Board in November 2021. The Covid-19 pandemic and associated restrictions were also a contributory factor to the pace of the parallel processes. 2.3. The timeframe under review was from August 2015 to December 2018. Relevant information prior to this period has been included as necessary. 3. Family structure & contribution to the review 3.1. For the purpose of conducting this review the following individuals are relevant; Child A (youngest), Child B, Child C and Child D (eldest) with ages ranging from 5 to 11 years – all of whom lived with their mother at the time of the incident. Also, at the time of the incident, Adult 1 was spending a considerable amount of time in the family home. The children’s father died some three years prior to the incident. 3.2. Seeking the contribution of family members has been an important consideration. The mother was offered the opportunity to contribute to the review; this was declined. The Independent Reviewer spoke with a close family member once the criminal trial had concluded. The family member described a number of incidents over many years where it was known that the children were witnessing domestic abuse or being on the receiving end of abusive and emotionally harmful behaviour. Despite concerns being shared the family member felt that little changed. 3.3. Given the children’s circumstances, their age and trauma they had experienced, a decision was made to not offer them the opportunity to contribute to the review. 4 Single agency reports were submitted from the following agencies; - Borough Council in the local authority area - School 1 - Strengthening Families Service - Local Hospital - Community Rehabilitation Company - Children’s Services - NHS Foundation Trust - Adult Social Care - School Health & Wellbeing Service - University Hospitals NHS Trust - Clinical Commissioning Group - National Probation Service - Police - Specialist Secondary School 1 3 OFFICIAL - Sensitive 4. Synopsis of relevant case history 4.1. Relevant history of note, prior to the timeframe under review shows that the family were known to Children’s Services, the Health Visiting Service and the Police. Children’s Services conducted a number of Initial Assessments5; - December 2008: Initial Assessment - concerns related to domestic violence. Following assessment, the case was closed to Children’s Services with no further action. - March 2009: Initial Assessment - concerns related to domestic disputes, the cultivation of cannabis in the family home, the children living in poor conditions, domestic abuse. Following assessment, the case was closed with no further role for Children’s Services. - September 2009: Initial Assessment - concerns related to a domestic dispute and the children being heard screaming by passing Police officers. A further assessment was completed based on the history resulting in the concerns not being substantiated and no further role for Children’s Services. - September 2010: Initial Assessment - Police attended the property with a drugs warrant. Traces of cannabis were found along with drug paraphernalia. No-one was present in the property at the time of the Police visit, the house was in a poor state of repair and considered dangerous for young children, the bedrooms smelt of urine, there was no bedding, few toys, the environment was unsafe and unhygienic and there was little food in the house. Records indicate that once the Initial Assessment was completed no further work was undertaken although the mother and father agreed to attend a Family Centre. The findings of the Initial Assessment refer to the housing and conditions being clean and tidy, make no reference to drugs or the conditions of the property as discovered by the Police. The summary of the account by the Police does not match with the summary of the assessment by Children’s Services. - July 2011: Initial Assessment - concerns were raised by MARAC6 and related to the mother not engaging with the local domestic violence support service, concerns she was taking anti-depressants and struggling, and concerns about Child D’s behaviours towards other children are home and school. The decision was that there was no further role for Children’s Services and the case was closed. 4.2. The father moved out of the family home in February 2011 but saw the children on a daily basis. In January 2013 the Police referred information to the Children’s Services locality team regarding a strong smell of cannabis from the family home, and banging and shouting being heard. This resulted in Children’s Services sending a letter to the family with advice and then no further action. 4.3. In August 2016 the family experienced an unexpected significant bereavement. This event was referred to the MASH. The outcome was that the Health Visitor would provide support to the family and the matter would be closed to the MASH. In September 2016 information was sent to the MASH that the children were found in the local park in the evening by a local Council worker; the worker knew the children from school noting that that they had not been seen in the park before, therefore making it unusual behaviour. 4.4. In March 2017 there was a further Contact & Referral to the MASH made by School 1, stating that Child A had arrived at Nursery crying saying that the mother had smacked him. Bruising was seen on Child A’s legs. This resulted 5 An Initial Assessment was described by statutory guidance at the time as a ‘… brief assessment of each child referred to a local authority children’s social care, in which it is necessary to determine whether the child is in need, the nature of any services required, and whether a further, more detailed core assessment should be undertaken …’, Working together to safeguard children, HM Government, 2006 & 2010. 6 MARAC – Multi-agency risk assessment conference, held in relation to domestic abuse. 4 OFFICIAL - Sensitive in a Strategy discussion7 taking place and further enquires and assessment being conducted. The outcome was a support plan being offered, via Family Support workers. 4.5. In December 2017 a single assessment was conducted following a CAMHS referral to the MASH about the mother’s ability to keep Child D safe due to his behaviour. He was involved with older youths who were affiliated with gangs, criminal activity, vandalism, drugs and dangerous behaviour. At the time Child D was attending School 1 two afternoons per week due to his aggressive behaviour. School 1 were trying to support the mother however she had refused to work with the allocated worker. The outcome of the Initial Assessment was that the family should be supported by Family Support workers. The Police were informed of this referral however no further enquiry or action was taken by them. 4.6. In March 2018 a single assessment was completed following information from CAMHS that Child D and siblings, who were being supported via the Strengthening Families Service, due to Child D not accessing the bereavement support available. No safeguarding concerns were identified and the recommendation was that the Strengthening Families Service should continue to work with the family. 4.7. In May 2018 there was a Contact & Referral made by the Family Support worker who referred concerns about the mother struggling, trying to support Child D’s return to full time education and offering parenting support to the mother following the family bereavement. A full history was included in the referral documentation. The referral noted ‘… Early Help have been involved with the family for about 18 months now with little or no improvement, this is a very long time for Early Help to be open …’8. The decision from this referral by the MASH was that Strengthening Families Service should continue their involvement. 4.8. The National Probation Service became aware that Adult 1 may have formed a relationship with the mother in August 2018. This information was swiftly shared with Children’s Services and the Police. There was further follow up by the Strengthening Families Service with the mother about this possible relationship; which the mother strongly denied. 4.9. In August 2018 there was agreement by the Family Support Worker about needing to review the support offered to the family at the next meeting, scheduled in September. This next scheduled meeting did not take place and no additional review meetings were ever scheduled until the serious incident. This meant that in the interim there was no active oversight or management of the case. Records do however show that Child D had recently started attending Specialist Secondary School 1 (although records highlight this was not without a number of incidents being noted), Siblings A, B & C were reportedly doing well at school, and the mother reported being pleased with progress. 4.10. In October 2018 there was a Contact & Referral made from the Family Support Worker concerned about Child D’s behaviours which appeared to be escalating, but also citing concerns about potential radicalisation. This particular issue was reported as being monitored by School 1 and there being support from Prevent9 discussed. A full history was provided in the referral documentation. The outcome of this referral was that the threshold for Children’s Services involvement was not judged to be met and that the family should continue to work with the Strengthening Families Service. The case was closed to the MASH. 4.11. In November 2018 a Contact & Referral was received following the serious incident. The mother and Adult 1 were implicated in the incident. A Strategy discussion took place, followed by an Initial Child Protection Conference. 7 Strategy discussion is convened under Section 47, Children Act 1989; where a local authority has reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm, the authority shall make such enquiries as they consider necessary to enable to them to decide whether they should take any action to safeguard or promote the child’s welfare. 8 Local authority area contact & referral record, May 2018, submitted to the review. 9 Prevent is a Government strategy to prevent people being drawn into extremism, Prevent duty guidance 5 OFFICIAL - Sensitive This resulted in all four children being made subject to Child Protection Plans under the category of emotional harm. Child A died some weeks later due to the significant injuries suffered. 5. Findings & analysis 1. Having mapped the professional and agency contact with the children over the timeframe under review there are a number of features that stand out that help us understand what happened, and why events occurred as they did. These features are relevant from a multi-agency safeguarding system and practice perspective and, as such, provide us with the greatest insight into the quality and effectiveness of the response to the children at the time. Where possible, an explanation of why events occurred as they did, has been provided. Learning points for use by all professionals and trainers have been emphasised. The following area are explored; - The use of case history to inform assessments & decision making. - Considerations about thresholds for intervention, including step-up & step-down arrangements. - The quality & effectiveness of safeguarding supervision and/or management oversight & scrutiny. - The extent of professional curiosity, challenge and escalation. - The consideration of risk posed by other adults who had contact/lived with the family. 5.1. The use of case history to inform assessments & decision making 5.1.1. Statutory guidance10 in place at the time stated ‘… Assessment is a dynamic and continuous process which should build upon the history of every individual case, responding to the impact of any previous services and analysing what further action might be needed. Social Workers should build on this with help from other professionals from the moment that a need is identified …’. 5.1.2. A defining moment occurred for this family in August 2016 when the family experienced an unexpected and significant bereavement. This significant incident provided the professional network with an opportunity to reflect on the impact of this experience for the children against the known case history and what support the mother and children might need. 5.1.3. In this context family history not only includes historical information from 2008 but should also be viewed as taking account of chronological information gathered over the course of single, or multi-agency, involvement. An event that happened yesterday may be as relevant as something that happened last month or some years ago, and forms a chronological account of professional contact with a child and family. It is the accumulation of information that forms history and which needs to inform assessment and decision making. 5.1.4. When assessing risk from a safeguarding and child protection perspective, risk can be categorised into those factors that are currently presenting themselves as a concern, for which it may be possible to manage i.e., situational risks, and those where there is less likelihood of effecting change and which occurred prior to the current circumstances i.e., pre-disposing risks. In this case there were a number of pre-disposing risk factors that were known, and knowable, by the professional network at the time of the family experiencing the unexpected and significant bereavement which justified consideration. These included; - The Initial Assessments conducted between 2008 and 2011 which highlighted a range of worrying issues, indicative of concerns reaching a sufficient threshold to warrant an assessment by Children’s Services. - There was historical evidence of parental domestic abuse. - The parents using cannabis and misusing alcohol, and the impact this may have had on the children. - The children living in neglectful home conditions. - The mother experiencing post-natal depression following the birth of the eldest child. 10 Working together to safeguard children, p., 24, HM Government, 2015. 6 OFFICIAL - Sensitive - The father’s criminal activity relating to drugs, violence and theft, and the impact of this on the children. - The father’s attendance at appointments with the Community Rehabilitation Company11 (CRC) was poor, resulting in work with him being ineffective and him being breached in November 2015. - The mother’s lack of engagement with professionals, with the exception of the Health Visiting Service. - School 1 expressing concerns in 2015 – 2016 about the children smelling of cannabis, and the uncle that was collecting them from school smelling of cannabis, plus Child D becoming increasingly challenging in school. - Child D receiving a fixed term exclusion from School 1 due to an attack on another pupil in July 2016. 5.1.5. Information about the unexpected significant family bereavement was referred to the MASH by the Ambulance Service at the time. Evidence indicates that the outcome of this referral was that the Health Visiting would make attempts to contact the family the following month to offer support. Attempts by the MASH to contact the mother were unsuccessful resulting in a letter of advice being sent advising that she could access support via the Health Visiting Service, school or GP. Records indicate that the mother did meet with the GP during this period. Arguably, this was a missed opportunity. 5.1.6. There is limited evidence to indicate that the considerable pre-disposing information and historical contact with Children’s Services was considered as a repeating pattern, and no evidence to indicate that School 1 was contacted once the summer holiday period was over to gain a better understanding about the children’s welfare or whether they might need additional support. Matters were processed by the MASH with an onward expectation that an Initial Assessment would be completed by the Children’s Services Locality Team; whilst these assessments were completed the quality is variable and inconsistent. This is a pattern that is repeated throughout the remainder of the timeframe under review, up until the Initial Child Protection Conference in November 2018 following the serious incident. 5.1.7. Following the unexpected and significant family bereavement it is possible to see the emergence of other situational risk factors, against a background of significant pre-disposing risks. The recognition of these situational risk factors mostly appears to originate from School 1. - Child D’s behaviour becoming more challenging in School 1 during the 2016/2017 academic year resulting in him receiving seven fixed term exclusions, requiring extensive pastoral support to help manage his behaviours and a bespoke reintegration programme on, and off, site. Alongside this the school recognised concerns about the family and made a series of referrals to the MASH. - January 2017: further concerns about the smell of substances/cannabis from the children’s clothes and bags. - March 2017: Child A disclosing being smacked by the mother. This resulted in Strategy discussion and a joint visit by the Police and Children’s Services. There was no consideration of the case history in the single assessment that followed. - July 2017: general concerns expressed by the school having received information from agency staff who provided sporting activities, other parents and neighbours about the children’s welfare. - October 2017: Sport agency staff witnessed incidents of concern outside of school hours and passed their concerns to the school. 5.1.8. The emerging concerns outlined above show an accumulation of factors which, when coupled with the other known history, justified a level of professional curiosity. As cited above, there is no evidence to indicate that there was any multi-agency reflection following the unexpected significant family bereavement in August 2016. With the steady stream of additional and concerning information from School 1 over the 12 months following the family bereavement up to the autumn months of 2017, it would not be unreasonable to expect wider professional curiosity and collective 11 CRC is a criminal justice agency tasked with managing low to medium risk offenders sentenced to community orders or imprisonment. To protect the public, probation staff assess and manage the risks that offenders pose to the community. They help to rehabilitate these individuals by dealing with problems such as anger, drug and alcohol misuse and lack of employment or housing, to reduce the prospect of reoffending. They monitor whether individuals are complying with court requirements, to make sure that they abide by their sentence. If offenders fail to comply, probation staff enforce order through the court or request recall to prison. 7 OFFICIAL - Sensitive interest beyond the school’s involvement. This could have included the Health Visiting Service, GP, School and Children’s Services. 5.1.9. Children’s Services have reflected on this noting ‘… a lot of the single assessments did not properly consider the history, make sense of this, and then compare this to current concerns. There was a lack of checking information with partner agencies, for example School 1 and CAMHS … a number of single assessments were completed by a newly qualified social worker … but no evidence of challenge from the team manager and instead a focus on completing the assessment quickly …’12. Learning point: Gathering and analysing family history, which includes history of contact with services, is a core task when working with children and families. This allows professionals to identify possible patterns of behaviour, and how the parents might respond to offers of support. Failing to do this can result in workers becoming caught in a thinking trap of having to start again, each time the family come into contact with services. 5.1.10. The above accounts reveal a clear pattern of case history not being considered in assessments and decision making. The reasons for this will be further examined in the following sections. 5.2. Considerations about thresholds for intervention, including step-up & step-down arrangements 5.2.1. Statutory guidance13 in place at the time noted ‘… the provision of early help services should form part of a continuum of help and support to the different levels of need of individual children and families … having clear thresholds for action which are understood by all professionals, and applied consistently … should ensure that … the right helps is given to the child at the right time …’. 5.2.2. An underlying pattern which has emerged is a difference in perception, with conflicting views, about thresholds for intervention by Children’s Services; this is particularly so from School 1’s perspective who were identifying concerns in relation to Child D yet did not see a shift in response. 5.2.3. School 1 demonstrated tenacity and persistence in recognising concerns and referring them to the MASH. School 1’s frustration was that this was not matched by a suitably robust and effective response by the MASH/Children’s Services. This was compounded by the knowledge that when Child D had moved on to a secondary school, Child A sometimes attended School 1 upset describing that Child D ‘… goes mad at people …’ and had ‘… smashed up my room …’ (October 2018) highlighting continued problems for the children which, it seemed, were still not effectively being dealt with or listened to. School 1’s view was that an Early Help Plan was not a suitably robust mechanism to deal with the weight of issues the children were experiencing. Prior to this there is only one recorded Strategy discussion taking place in March 2017 as a result of Child A reporting being smacked; at no other point do concerns appear to be judged as reaching a threshold of actual, or likely, significant harm or even as a Child in Need14. The involvement and contributions of the Strengthening Families Family Support Worker failed to add weight to any views expressed by School 1. 5.2.4. As noted above, an Early Help Plan was developed in December 2017 despite earlier attempts being dismissed by the mother. Review of the Early Help Plan highlights a recording format that is not reader friendly and with no specific section that confirms who will be responsible for which actions nor which professionals might be involved with 12 Children’s Services, submission to the review. 13 Working together to safeguard children, p. 15, 2015, HM Government. 14 Child in Need - Section 17 of the Children Act 1989 imposes a general duty on the Local Authority to safeguard and promote the welfare of children who are ‘in need’ and to promote the upbringing of children in need by their families by providing a range and level of services to meet those children’s needs. A child in need is defined as a child: i) who is unlikely to achieve or maintain, or to have the opportunity of achieving or maintaining, a reasonable standard of health or development without the provision of services; ii) or a child whose health or development is likely to be significantly impaired, or further impaired, without the provision of services; iii) or a child who is disabled. 8 OFFICIAL - Sensitive the plan. The content within the documents in relation to the actual case management changes little over the duration of the Service’s involvement and there is no indication of progress made. 5.2.5. The implementation of this Early Help Plan was not without problems, which have to be seen alongside concerns about Child D not diminishing. Complicating factors included; - The mother’s engagement was problematic and often focused on her own needs rather than those of her children. This included a focus on the mother’s mental health and bereavement issues over the course of five home visits between April and May 2018. - The mother was reluctant to engage in parenting work, yet continued to struggle with Child D’s behaviour. - Five home visits scheduled between June and November 2018 were cancelled by the mother and she displayed inconsistency in her engagement. The impact of this was that neither the children nor the home environment was seen on a regular basis. During successful visits age-appropriate toys and a clean, tidy home environment were observed. The children were also observed to be clean and wearing clean clothes. There was no obvious reason for the Family Support Worker to be concerned about the children’s safety and welfare. - There is evidence of some mitigating factors that would complicate a decision to increase intervention. Factors included Child A, B & C usually presenting well in school, being compliant with the uniform code and other expectations. The children were also able to achieve age-appropriate educational expectations and their attendance, although not ideal, was not a major concern. These factors are indicative of children that are receiving an adequate level of physical parenting with routines and standards. Whilst the mother did not engage with events relating to educational matters for the children e.g., parents’ evenings, she did attend summer fayre’s, sports events and school performances. These inconsistencies complicated decision making. 5.2.6. However, these factors have to be balanced alongside the knowledge about concerns for Child D continuing to emerge, such as; - School 1 reported concerns that Child D carried a knife, although this was not substantiated. - Concerns about Child D accessing inappropriate material online including extremism and radicalisation. - In October 2018 Child D had moved out of the family home to stay with a relative. 5.2.7. The further referral in May 2018 from the Strengthening Families Service resulted in a decision from the MASH which concluded by stating ‘… the social care history illustrates that the family have had significant input, having been through seven single assessments since 2008. Four of these … have been since the beginning of 2017. There are therefore legitimate concern around the family bouncing between Early Help and Child in Need, and therefore [we should] ... not … encourage statutory involvement unless necessary, in order to prevent the family being passed back and forth unnecessarily … it was identified that [current work] appears to be having a positive impact and that positive change can only be sustained if [the mother] continues with it … it is felt unfair, and arguably oppressive, to not provide the mother with the opportunity to implement positive change. As there has been recognised improvement in the last fortnight, it is felt it may be beneficial for the work to be given a fairer chance to further improve the family’s situation … give it a chance for a few more weeks; then the option to re-refer in the future remains … it is therefore recommended that the case close to MASH …’15. This advice/recommendation which received management endorsement reflects a number of issues; - The ‘… significant …’ level of input provided since 2008 which is mentioned, is not evidenced in the referring information; basing a decision to continue with a Strengthening Families Service offer therefore appears to be made without knowing what level of input the family had actually received since 2008 and was therefore flawed as a decision. The evidenced chronology held on file did not drive a reasoned threshold decision. 15 Local authority contact & referral record, May 2018, submitted to the review. 9 OFFICIAL - Sensitive - There is no reflection or analysis about the ‘… family bouncing between Early Help and Child in Need …’ and what this might mean in terms of the system’s ability to respond to welfare concerns for the children. Alongside this, not wishing to ‘… encourage statutory involvement unless necessary …’ fails to recognise the growing body of concern which had been re-referred and that applying a different threshold to the situation may have been a justifiable option and pathway worth pursuing. - The hope that the current work would have a positive impact failed to consider case history, re-referrals and instead focused on the immediate and presenting issues. This was over-optimistic and is indicative of a mind-set which seeks short term fixes for situations that are more embedded. - The rationale of basing the decision on ‘… it being unfair and … oppressive to not provide the mother with the opportunity to implement positive change …’, suggests of a degree of sympathy for the mother and her situation and is not child focused; it was not based on the weight of evidence from the Family Support Worker and School 1 that the plan for Child D was failing and concerns were not reducing. The daily experiences for the children, especially Child D, were not shifting. Learning point: Research16 into other Serious Case Reviews highlights ‘… the quality of empathy embraces considering both the voice of the child and the needs of the family. It must be grounded in the centrality of the rights and needs of the child, while being sensitive but not colluding with the needs and views of the parents … it is important that appropriate empathy towards the parents does not cloud professional judgement or challenge …’. 5.2.8. The information set out above leads to a conclusion that there were some problems with the quality and effectiveness of the decision making and the application of thresholds at the MASH, at this time and on this case. Evidence reflects over-optimistic gatekeeping at the MASH and over optimism about the extent to which the Strengthening Families Service could intervene given the voluntary and consent driven principles behind any early help offer. Those attending the workshop for this case review almost unanimously reflected this view and that with the benefit of hindsight different decisions could have been made. 5.2.9. The Strengthening Families Service have reflected on their involvement during this timeframe and noted that ‘… the … presenting and escalating concerns during our involvement indicated that in our professional opinion that the threshold for Early Help was exceeded and in May 2018, August 2018 and October, resulting in MASH referrals from Specialist Intervention Team Family Support Worker [being] made. The outcome of all the referrals from our service to the MASH recommended that the support should be met by Early Help support and signposting to counselling support ... The repeated view was that the case did not meet threshold for Child in Need or Child Protection and did not require further assessment from statutory services …’. The Service has further reflected their analysis ‘… throughout our involvement and our three MASH referrals there was a lack of consistency in the analysis by the MASH and Assessment and Intervention Team of the information and consideration that statutory service maybe required. ... We did not use the escalation process following the outcome of these referrals …’17. 5.2.10. Two clear reasons why decisions were made at the time have been captured through documentary review and discussion with practitioners. 5.2.11. Firstly, there was a need to prioritise cases and other children judged as being in higher risk situations; this viewpoint can be justified given some of the complicating and mitigating factors outlined above which are likely to have provided a degree of reassurance. From a system thinking perspective the prioritisation of cases in such scenarios 16 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014, p. 202, University of Warwick & University of East Anglia, May 2016 17 Strengthening Families Service, submission to the review. 10 OFFICIAL - Sensitive can be described as a trade-off. Trade-offs18 are a system thinking concept. Work in complex systems is impossible to assign, predict and prescribe completely. Demand fluctuates, resources are often limited and goals often conflict. Frequently, the choices available to us are not ideal and we are forced to prioritise. Trade-offs, such as these, help us understand behaviour and system outcomes. At the time around 2018 the MASH triaged referrals and information, then passing any further work required to the district-based Assessment & Intervention teams or Strengthening Families Service. In this case, the MASH relied on the assessments and judgements of the Strengthening Families Service that had been involved with the family and had been swayed by the mother’s intentions of continued engagement with the Service (which whilst not ideal, her engagement was seen as sufficient). This triage activity was viewed with a level of bias, with no scepticism about what other assessment work might be useful to dig deeper into what might be happening for Child D and the family. This appears to have been driven by the system demands and pressures. Additionally, the district-based teams had difficulties recruiting staff and were forced to place some inappropriate expectations on newly qualified staff, alongside experiencing management absences. On this basis, decisions were unwittingly made about prioritising workload. The trade-off in this situation was an assessment and decision-making process that moved the work through the system, but which offered limited reflection about what might actually be happening and what the children’s day to day experiences might be. The findings of an Ofsted inspection confirm that system pressures were causing difficulty at the time and it is reasonable to conclude that those pressures were contributing to the way in which this case was managed. Those system pressures included; there being a high demand on the MASH, inconsistency in decision making and the application of thresholds, particularly in relation to cases that are stepped up and down across the continuum of services, and some cases not being responded to with the right level of service and in a timely manner. Learning point: The need to prioritise an inevitable consequence of a system and process managed by people – especially prioritising efficiency against thoroughness. For supervisors and managers, it may be worthwhile considering how busy front-line workers make trade-offs in order to resolve goal conflicts and cope with uncertainty and system pressures, explore how they balance efficiency and thoroughness in light of the conditions and environment in which they operate; and ensure this does not compromise children’s welfare and safety. 5.2.12. Secondly, there was a lack of challenge and escalation due to, what has been described by some practitioners as, ‘referral fatigue’ inasmuch as the case had been re-referred on at least two occasions by the Strengthening Families Service with the same outcome; the decision each time creating a sense of hopelessness. Also, there was no challenge and escalation by the MASH upon re-referrals coming in on the family; the MASH could have challenged the district-based teams’ assessment and intervention in an attempt to reduce the likelihood of further re-referrals. The lack of escalation can be indicative of issues such as; differences in perception and thresholds being applied, system demand and human factors. The escalation process was also described by a small number of professionals outside of Children’s Services as time consuming and not a lean process, thereby adding to the burden of trying to raise concerns about a child’s welfare. Developments have been made to the way re-referrals received in the MASH are viewed. Learning point: Using the escalation and professional differences procedure is an acceptable course of action to take if you are dissatisfied with the response to the concerns you raise about a child’s safety and welfare. Informal resolution should always be the starting point and having robust and clear communication with professional colleagues should be seen as the norm within a healthy and well-functioning safeguarding partnership. 5.2.13. There is also a third point that has been highlighted and which provides rich learning for the Partnership. The phrase 'early help' is broad and has the potential to create confusion between agencies and practitioners. The local authority area implemented the Common Assessment Framework (CAF) and the associated Lead Professional process from 2007 and it was well established across the county and used widely until late 2016. At that time, terminology changed so that what had been the CAF became an Early Help Single Assessment (EHSA), based on the principle of 18 a) Learning into Practice: improving the quality and use of serious case reviews, Masterclass 2: Systems thinking, SCIE & NSPCC, 2016 and b) Systems thinking for safety: Ten principles – A White Paper, Eurocontrol, 2014. 11 OFFICIAL - Sensitive creating one consistent assessment framework that could be used by all agencies at all levels of assessment, i.e., the EHSA framework was identical to the Single Assessment tool used by Children's Services. 5.2.14. There has never been an 'Early Help service' as such in the local authority area and yet professionals involved in this review and agency submissions consistently refer to such a service. Indeed, the ‘Early Help Single Assessment’ phrase, in itself, suggests an ‘Early Help Service’ and has existed for several years; also, the work plan for this family was titled ‘Early Help Work Plan’. Since 2007 there has been a team of Network Support Officers, later known as CAF Officers, whose job was and is to train, offer advice and support frontline practitioners in universal services when using the CAF/EHSA process and acting as lead professionals. That team is still in place. It has never been referred to as a service because the CAF Officers have never delivered direct services to children or their families - their role is facilitative, not operational. However, a team of CAF Family Support workers was recruited around 2009, working directly with parents to improve outcomes for children directly as an outcome of CAF/EHSAs. This family had contact with the Family Support workers up until around the end of 2017. That team then became part of the Strengthening Families Service from early 2018, providing support to families that did not reach threshold for social work intervention either in response to EHSAs or Child in Need referrals. The model is direct intervention by Family Support Workers, who have access to a qualified social worker for consultation. The team is managed and supervised by a qualified social worker. This family were in receipt of services from this team as part of the Strengthening Families Service. 5.2.15. In this case it is clear that the family’s contact with the Family Support worker spanned a period of time when the service was in transition. From an organisational and system thinking perspective transitions can create risk to service delivery, but also confusion about the application of thresholds. Whilst the Strengthening Families Service have demonstrated a grasp of what risks the children were facing in this family and made attempts to escalate their concerns via the MASH, it is evident that this perspective was not shared by the receiving MASH. Not only was the decision making flawed, but the concept of what an ‘early help’ offer might look like was also misinterpreted by the MASH. Learning point: The language used to describe services, forms, tasks and activities carries weight and can create expectations. Being accurate and describing details as they are, is important. 5.2.16. The Police had been involved with the family on 14 occasions during the timeframe under review, 3 of these were from a child protection perspective and others relating to allegations that Child D was engaged in criminal behaviour and criminal activity. During the timeframe under review Child D would have been aged between 8 and 11 years of age. The Police have reflected on their response to these contacts and judged them to be in line with procedural expectations. 5.2.17. Child D is recorded as being accused of committing five assaults, including causing criminal damage, racism and associating with older youths who were engaged in criminal activity. On these occasions no formal action was taken by the Police, which given his age, was a proportionate and reasonable decision. However, there are two learning points to emerge from the Police’s contact and involvement with Child D and the family. Firstly, not all of the incidents that Child D was involved in were referred to the Police’s Harm Assessment Unit meaning that there was no onward notification to Children’s Services about his worsening behaviours. Secondly, there is a sense of the Police operating in isolation of other agencies to consider the risks to a child (aged between 8 – 11 years), but also what might be happening in the child’s family. Whilst the three ‘child protection’ incidents were appropriately screened and investigated by the Police it reflects narrow thinking about the wider circumstances of the family, and fails to consider safeguarding from a broader perspective. Learning point: Statutory guidance19 refers to contextual safeguarding and notes ‘… As well as threats to the welfare of children from within their families, children may be vulnerable to abuse or exploitation from outside their families. 19 Working together to safeguard children, p. 23, 2018, HM Government. 12 OFFICIAL - Sensitive These extra-familial threats might arise at School 1 and other educational establishments, from with peer groups, or more widely from within the wider community and/or online …’. 5.2.18. The local Borough Council had contact with the family and Child D through involvement with a local youth & sports facility, community safety officers, and housing services. Due to anti-social behaviours the Community Safety Team issued an Acceptable Behaviour Order in October 2017 and then updated it in June 2018 due to persisting anti-social behaviours. Whilst referrals were sent to the MASH by the youth & sports facility in September 2016 and October 2017 there is no evidence to indicate this made any difference to the threshold decisions taken to maintain the family at an early help level. 5.2.19. The NHS Foundation Trust, responsible for Health Visiting Services had contact with the mother and children. However, records and discussions confirm that the Health Visitor was not aware of, or involved in, any early help meetings or any actions relating to the Plan. This reflects silo working by the Strengthening Families Service; the reasons for this have been discussed above. 5.2.20. Records indicate discussion about Child D being considered under the Prevent duty given his behaviours. In practice this could have led to a referral to the local Channel Panel20. There is no evidence that this ever happened and the idea that this might have been a source of support, guidance or education for Child D was never put into action because it was felt that the behaviours could be managed via the school and Strengthening Families intervention. 5.3. The quality & effectiveness of safeguarding supervision and/or management oversight & scrutiny. 5.3.1. Research21 notes ‘… All those working with children in need or at risk of significant harm, whatever their agency or role, need someone who is not directly involved in the case to help them deal with the complexities and challenges of the work and to make sense of what they are seeing, hearing and feeling. Supervision can provide a much-needed space for reflection, critical review and for probing, thinking and analysis …’. 5.3.2. The Strengthening Families Service has confirmed case discussion and management oversight between worker and manager. This is also evidenced by the frequency with which the case is re-referred to the MASH. The use of further challenge and escalation beyond this is absent, as is discussion between the Team Manager and the Operations Manager within the MASH. Reasons for these deficits have already been highlighted above. 5.3.3. The Police have noted that the single child protection investigation in relation to Child A’s disclosure and bruising was appropriately overseen and supervised in accordance with expected policy. 5.3.4. School 1 have highlighted that their Pastoral Manager was fully engaged in the early help process and liaised with the Family Support Worker on a regular basis. 5.3.5. Children’s Services have noted that there was no supervision whilst the family were being managed by the district-based team, which was in operation prior to the MASH becoming operational. Following on from this there is evidence of management oversight for the single assessments completed in April and October 2017 and January and November 2018. 5.3.6. The NHS Foundation Trust, responsible for Health Visiting, have confirmed that there is no evidence that safeguarding supervision was accessed. As stated above, because the Health Visitor was not involved with the early help offer of support there was no reason for them to be any more worried and seek 1:1 supervision to discuss safeguarding issues; from the Health Visiting perspective there were no issues that reached a threshold above other issues needing to be dealt with on their caseload. 20 Prevent: a Government strategy implemented at a local level to identify and prevent individual’s being drawn into extremism. 21 Gordon, R., & Hendry, E., Supervising assessment of children and families: the role of the front-line manager, p. 141, in Horwath, J., The Child’s World, second edition, 2001, Jessica Kingsley. 13 OFFICIAL - Sensitive 5.4. The extent of professional curiosity, challenge & escalation. 5.4.1. Research into other Serious Case Reviews22 states ‘… without professional curiosity professionals fail to recognise risks, downplay them, or focus on parents’ needs to the detriment of the child’s … professional curiosity requires professionals to think ‘outside the box’ …’. Learning point: Professional curiosity is the ability to think, and communicate, with children, families and professionals in a way that explores what is happening rather than making assumptions or accepting things at face value. Sometimes it can be described as ‘respectful uncertainty’ – applying critical thinking skills to information received and maintaining an open mind. 5.4.2. The Strengthening Families Service has demonstrated a level of professional curiosity in their dealings with the family. In the information set out in the preceding sections there is reference to the Strengthening Families Service’s attempts to challenge and escalate, although these could have been more robust. 5.4.3. As referred to in section 3, the contributions of the Family Support Worker appeared to add little weight to the referrals made. The status of the worker making a referral to the MASH was discussed by practitioners involved in this case. There was concern that some professionals’ views were not given the same weight as others, and that the culture at the time was one of there being disconnect between the MASH, early help referrals and the status attached to professionals’ roles. The Strengthening Families Service have noted ‘… At the time there was a common view within the family support work team that a family support workers professional opinion was not as valid as a social workers opinion. This was based on a number of MASH referrals that had been made on a number of cases where the outcome had been to remain at Early Help without full consideration of family support workers professional assessment and intervention. This led to Family Support Worker’s feeling frustrated and a perception that thresholds were high and that we were not clear on what would warrant a Child in Need Assessment or Plan …’23. This is relevant system and contextual information, especially from the perspective of workers being asked to be increasingly curious, to challenge and escalate decisions where there is disagreement or dissatisfaction. Whilst all workers can be as curious as we hope them to be, if their rank and professional opinion is not valued or afforded an equal status, curiosity will go no-where. Contributory factors have already been discussed above in respect of the pressures the MASH was experiencing at the time. The Safeguarding Partnership will wish to assure itself that all referrals are treated equally and that regardless of professional status, the welfare of children remains the driving principle behind assessment and decision making. Learning point: The quality of professional relationships and the extent to which professionals trust one another is an important consideration when working in child protection. Exploring and reconciling differing perspectives about the risks a child or family is experiencing is a necessary task when operating in a multi-disciplinary context. All views are valid and bringing them together, alongside examining the case history is a core requirement for timely and effective assessment and decision making. Managers and designated post-holders have a role in facilitating this.24 5.4.4. From a Police perspective it is evident that on those occasions when information was not shared with their Harm Assessment Unit about Child D’s criminal behaviour, thereby preventing the incidents being looked at from a child protection angle, Officers did not exercise professional curiosity about the impact of such events on the children’s safety. There was also no consideration or curiosity about contextual safeguarding issues and the use of local intelligence to inform safety planning or risk management. 22 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014, p. 159, University of Warwick & University of East Anglia, May 2016 23 Strengthening Families Service, submission to the review. 24 Heasman, P., Dimensions of risk: Professionals tipping the balance, in Calder, M., Contemporary risk assessment in safeguarding children, 2008, Russell House Publishing. 14 OFFICIAL - Sensitive 5.4.5. School 1 exercised curiosity and persistence in the attempts to escalate their concerns however have recognised that they could have used the formal escalation procedure rather than relying on verbal challenge and escalation and the efforts of the Strengthening Families Family Support Worker. 5.4.6. The local Borough Council Housing Service were curious and challenging of the initial decision to not re-house the family following the unexpected and significant family bereavement. This led to helpful exchanges, some discretion being applied to the situation and ultimately facilitated a house move. 5.4.7. The NHS Foundation Trust, responsible for Health Visiting Services, report that the Health Visitor challenged the parents about their use of cannabis during the early timeframe under review, but that a Nursery Nurse was less curious about the identity of an unknown male in the household during one visit in November 2015. Records indicate no details about the home conditions, the presentation of the children or the interaction between the parents and children. 5.4.8. There is no evidence of professionals challenging the mother about her inconsistent levels of engagement with services; the over-riding pattern is one of acceptance regardless of the impact this may have on the children’s safety and welfare. The mother partially engaged by having discussions, agreeing to assessments and taking phone calls but then fails to follow through with any consistency. This has the effect of complicating the professional assessment of the situation; on the one hand potentially reflecting her desire to enter into a working relationship with professionals because of her struggles and on the other, appearing to be dismissive of the need for support. As the case remained at an early help level, all activity and contact by professionals would have been based on a universal level of service and consent driven. This style and pattern of engagement was knowable given the historical information held by Children’s Services however it is not considered as a risk factor following the more recent referrals made. It is likely that the sympathy bias discussed above accounts for this lack of challenge. Some practitioners have referred to the mother’s behaviour as disguised compliance. This can be defined as ‘… patterns of ‘closure’ or ‘flight’ when families need to reduce their contact with the external world in an attempt to regain control by shutting out professionals. Often when professionals took a more controlling stance, this was defused by apparent co-operation of the family, the effect of which was to ‘neutralise the professional’s authority and return the relationship to … the previous status quo …’25. Research26 into other case reviews notes ‘… once families are in the child protection system or child in need ‘system’, their engagement with plans can be difficult for professionals to manage. Professionals may be tempted to … close the case when there is poor engagement, further compromising child safety. Making clear plans from the outset … and reviewing concerns if non-engagement arises could lead to more effective working …’. The mother’s style of engagement was clearly a distraction for the assessment and decision making by the MASH and Children’s Services. Learning point: When working with parents who are, or become, resistant it is important that expectations are transparent about the professional response to such resistance and that these are clearly stated from the outset. Ensuring good quality and regular reflective supervision will assist the worker, as will creating a combined chronology of agency contact in order to build a holistic account of what the impact of parental resistance might be on the child. Learning point: Ensuring those professionals who are more likely to be making referrals have a shared, and agreed, understanding about what is meant by ‘early help’ and what a reasonable set of expectations might look like (expectations of professional and parents/carers) is an important step to creating an equitable safeguarding system. 5.5. The consideration of risk posed by other adults who had contact/lived with the family 5.5.1. As a result of the investigations into the serious incident it has emerged that at the time of the incident Adult 1 was at the family home. Due to the information gathering process connected to the decision to initiate a case review, information from agencies has confirmed that Adult 1 was of interest because of his history; being a dangerous 25 Pearson, R., 2013, Guide to working with disguised compliance, Community Care On-line, based on work by Reder, P., Duncan, S., & Gray, M., Beyond blame: Child abuse tragedies revisited, 1983, Routledge. 26 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014, p. 144, University of Warwick & University of East Anglia, May 2016 15 OFFICIAL - Sensitive offender with a history of violent offences, being a perpetrator of serious domestic abuse and posing a high risk of harm to children and adult partners. It is therefore appropriate for this case review to consider whether the involvement of Adult 1 with the children and mother was a contributory factor to the circumstances at the time, potentially increasing the likelihood of abuse or neglect and which may have a causal link to Child A’s death. 5.5.2. Reports submitted to the review indicates that Adult 1 was effectively managed by the National Probation Service in relation to other known relationships he may have had with adult females who also had children, but also Adult 1’s contact with his own children. At the point that the National Probation Service became aware of a possible relationship between Adult 1 and the mother in August 2018, the information was shared the same day with Children’s Services and the Police. At the time the Adult 1 was not subject to active supervision by the National Probation Service – the information came to their attention via a third-party source, but nonetheless despite them not working with him the information was shared. The National Probation Service has reflected on their actions and found that, although they shared information immediately with the relevant authorities about the possible relationship, they did not submit a full referral to the MASH. Had this been actioned, it would have strengthened their information sharing practices albeit based on the limited information they had about the mother and her four children. 5.5.3. The mother strongly denied this relationship when questioned by the Strengthening Families Service 18 working days after the information was received. Although taking 18 days, records clearly indicate some pace with attempts to liaise with others and make contact with the mother. When seeking clarification about the relationship, the Family Support worker could have been accompanied Adult 1’s allocated Social Worker – thereby increasing the strength of questioning. 5.5.4. There is no information to indicate that the Police took any action on the receipt of the information being passed to them by the National Probation Service other than passing the information to Children’s Services and the Integrated Offender Manager coordinator. The Police have confirmed that given there were potential discrepancies with the accounts given and the source of the intelligence was not wholly reliable, this would be their routine action taken in such circumstances. 5.5.5. There is no further evidence to indicate that the mother was asked again about the possible relationship, but also no known information to indicate that the mother was actually in a relationship with Adult 1 until the serious incident in November 2018. This has been confirmed by all agencies involved in this case review. Learning point: When new, and potentially serious information emerges about risk to children the response should be measured and match the level of seriousness. Learning point: When undertaking an assessment work, all professionals should be alert to any, and all risks that children may face, and not make assumptions about mothers naturally being protective. 5.5.6. In terms of future multi-agency sharing of information about adults that may pose a risk to children it is worth noting that Adult 1 presented to A&E (University Hospitals NHS Trust) on two separate occasions (May and July 2018). One presentation related to being stabbed – an incident which would ordinarily arouse some degree of curiosity. This was reported and known about by those agencies involved with Adult 1 at the time. Also, at the time University Hospitals NHS Trust did not share information with the local MARAC Co-ordinator; since August 2018 this has now changed and an alert is added to the victim’s medical records along with any associations with children. At the time it would not have made a difference to this case as Adult 1’s relationship with the mother was not known about. However, the implementation of this information sharing mechanism has the potential to improve joint working and risk management. 6. Good practice 6.1. This Review has identified a number of areas which can be highlighted as good practice. It is important that good practice is recognised and shared. These areas include; 16 OFFICIAL - Sensitive - The Health Visitor sought and shared information with other professionals despite the age of the child being beyond the service’s remit. - School 1’s persisting attempts to raise the profile of their concerns about the family and Child D. - The Strengthening Families Family Support Worker’s attempts to elicit a change in threshold decision from the MASH. - The Strengthening Families Family Support Worker’s attempts to engage the mother in bringing about change for the children. - Children’s Services, Educational Psychology Service, School 1, and the Strengthening Families Service contributing to the decision to support a house move for the family. 7. Conclusion 7.1. This Serious Case Review has examined the circumstances around the involvement of agencies and professionals with a family where there were concerns about abuse and neglect. The review was prompted following a serious incident at the family home, in which the youngest child died as a result of injuries suffered. A Police investigation and subsequent criminal trial did not result in any convictions. 7.2. The review has gathered and analysed documentary information from all of the agencies involved over a period of nearly three years, whilst also recognising relevant background information. It has benefitted from the involvement of many of the practitioners involved with the children and gained their perspectives about what happened, and why events may have occurred as they did. The review has benefitted from the views of a close family member, although the children’s mother declined the opportunity to contribute. 7.3. The review has made a number of findings, which should be used as a platform to learn and improve practice. These include: - The family history and contact with professionals was not consistently used to inform assessment and decision making by all professionals involved. - Attempts to raise the profile of concerns about the children’s safety and welfare were mostly unsuccessful when referred to the Multi-Agency Safeguarding Hub but also followed through by the locality Children’s Services Team where decisions were made; system pressures, new ways of working and a degree of sympathy for the mother contributed to decisions being made that were not in the children’s best interests. - Whilst some professionals demonstrated tenacity in their attempts to raise concerns, this was not matched by all professionals involved resulting in decisions that frustrated attempts to safeguard the children. - Contextual safeguarding in respect of Child D were not recognised; consequently, opportunities were missed to assess and potentially intervene. - Risk posed by Adult 1 were not fully assessed and information sharing was not as effective as it needed to be. 7.4 The review has captured learning points for use by practitioners, managers and trainers. As a result of this review agencies that have contributed have been able to identify learning that can be taken forward internally. Action plans have been provided by each agency involved, and where relevant and appropriate to do so, improvements have been initiated. It is the role and responsibility of the Safeguarding Partnership to monitor, scrutinise and challenge progress against single agency action plans. The report concludes with a number of recommendations for the multi-agency Safeguarding Partnership which may strengthen practice. 8. Recommendations 8.1. As noted in section 2, this review began in early 2019 but has taken over two years to draw to a conclusion due to parallel legal processes. At the outset, agencies were asked to identify their own learning from review of information 17 OFFICIAL - Sensitive held, and take this forward following the submission of their respective single agency action plans in May 2019. However, given the passage of time from the review being initiated to its conclusion, actions and practice has changed – as a result of targeted improvement activity but also within an overall programme of development. In September 2019, with the submission of version one of this report, a series of recommendations were made for the Safeguarding Partnership, prior to the review being placed on hold pending the outcome of parallel processes. These included; 1. To ensure the learning from this Review is disseminated across the multi-agency safeguarding partnership to practitioners and managers. 2. To seek assurance that the actions identified by each partner agency, as a result of this Review, have been managed, implemented and embedded in a timely manner. 3. The Safeguarding Partnership should review the professional escalation procedure and ensure it is fit for purpose, and user friendly. Following review, professionals across the safeguarding partnership should be reminded about where to find it, how to use it, and expectations. 4. Children’s Services to review the effectiveness of the Early Help Plan document to ensure that the format is fit for purpose, contains a section which names who has responsibility for tasks/activities, and is user friendly. When reviewing the format, and given the findings of this review, there should be an expectation that it will naturally lead to reviewing the quality of current Early Help Plans for children and the effectiveness of the multi-agency contributions to such plans. 5. Based on the perspectives articulated in section 5.4.3. the Safeguarding Partnership may wish to seek assurance that referrals to the MASH, particularly re-referrals, are not discriminated or screened based on the status of the person referring, but based on the actual or likely risks to children. This may be best conducted via a focused audit exercise covering a defined and recent timeframe. 6. The Safeguarding Partnership to consider the findings of this review alongside the findings from another recent review (yet to be finalised and published) in relation to contextual safeguarding and be assured those local arrangements are efficient and effective. This should include the use of intelligence about youth crime, deviant behaviour and exploitation from Boroughs/Districts and that it is used at a tactical level to inform operational safeguarding activity. 7. The Safeguarding Partnership to review their thresholds document to ensure it is fit for purpose and provides clarity about the differences in what to expect at each level. The Partnership should then ensure that the document and framework is widely publicised with consistent messaging that reduces the likelihood of different perceptions emerging about how thresholds might be interpreted. 8.2. It is the role and responsibility of the Safeguarding Partnership to scrutinise and seek assurance about not only progress with the single agency action plans, but also the above recommendations since they were first made. Those agencies, as well as the Partnership, will wish to test and evaluate the effectiveness of how well changes and improvement activity has been implemented and hopefully become embedded. |
NC50712 | Thematic review into sexual abuse by foster carers between January 1994 and September 2014. In February 2012, a police investigation resulted in a male foster carer being convicted of 18 offences of historical sexual abuse. He had been a registered foster carer from the early 1970's until 2003 with Hampshire County Council and later Southampton City Council. In September 2013, a female disclosed that her uncle had indecently assaulted her when she was 13 and 15 years of age. He had been a foster carer for Southampton City Council between 1994 and 2008. Ethnicity or nationality not stated. Learning includes: there may still be barriers ensuring that the children's `voice' whether through behaviour or non-verbal communication is heard; understanding the significance of accumulating concerns and complaints is key to keeping children safe in foster care. Recommendations include: consider the most effective way to maintain a whole family approach for children in foster care; Southampton children's social care to provide evidence that the system in place for assuring the quality of foster care practice is focused on the needs of the child, and that social workers are equipped with the skills, support and supervision to enable them to challenge poor practice; bring to the attention of the Department for Education the apparent gap in the system whereby concerns about the behaviour of foster carers is made available should they wish to work with children; seek assurance that children in care are not disadvantaged where an allegation is made regarding potential abuse.
| Title: Serious case review: allegations against foster carers and the abuse of children in foster care. LSCB: Southampton Safeguarding Children Board Author: Jane Wonnacott Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Southampton Safeguarding Children Board Serious Case Review Allegations Against Foster Carers and the Abuse of Children in Foster Care Report Author Jane Wonnacott MSc MPhil CQSW AASW Director, Jane Wonnacott Safeguarding Consultancy Ltd Serious Case Review Final 10.9.18 Page 2 of 31 Contents 1 BACKGROUND TO THIS REVIEW .............................................................................. 3 2 REVIEW PROCESS ...................................................................................................... 5 3 THE CONTEXT: LEGISLATION, REGULATIONS AND PRACTICE ........................... 7 4 NON-RECENT PRACTICE ........................................................................................... 9 5 ACTION TAKEN 2012-2016 ....................................................................................... 17 6 WHAT DO CHILDREN AND YOUNG PEOPLE TELL US? ....................................... 19 7 REVIEW FINDINGS .................................................................................................... 20 8 SUMMARY OF RECOMMENDATIONS ..................................................................... 30 Serious Case Review Final 10.9.18 Page 3 of 31 1 BACKGROUND TO THIS REVIEW 1.1 In February 2012, a police investigation (Operation Z) resulted in a male foster carer (known throughout this report as Perpetrator 1) being convicted of 18 offences of historical sexual abuse. Perpetrator 1 had been a registered foster carer from the early 1970’s until 2003 and fostered children for Hampshire County Council until 1997 and after that date for the newly formed Southampton City Council. 1.2 As a result of this conviction, in March 2012 Southampton Safeguarding Children Board serious case review committee commissioned a partnership review1 focusing on the work of Police and Children’s Services in order to understand the circumstances that had resulted in children in care being sexually abused by Perpetrator 1. 1.3 Following consideration of the issues arising from the partnership review, the chair of Southampton Safeguarding Children Board decided on 26th November 2013 that the case met the criteria for a serious case review as set out in Regulation 5 of the Local Safeguarding Children Boards Regulations 2006. The reason for this decision was the children and been seriously harmed and there were concerns as to the way in which the authority, their Board partners or other relevant persons had worked together to safeguard the children concerned. 1.4 At the point that a decision was made to conduct a serious case review, it was also known that in September 2013, a female had disclosed that her uncle had indecently assaulted her when she was 13 and 15 years of age. It was identified that the uncle (Perpetrator 2) had been a foster carer for Southampton City Council between 1994 and 2008. These allegations were being investigated by Hampshire Police (Operation A). Serious Case Review Phase 1 1.5 An independent chair and overview author were appointed to lead the serious case review supported by a panel of senior professionals from agencies with responsibility for children in care. It was agreed that the aim of the serious case review would be to “examine the multi-agency response to two individuals who were registered foster carers in Southampton and have subsequently been convicted of offences or are currently being investigated for offences against children”. The period under review was agreed as being from January 1994 – September 2013. Since prior to April 1997, the responsibility for the fostering service covering Southampton sat with Hampshire County Council, and a representative from Hampshire was invited to join the panel. 1 A partnership review is a local learning review where a case is not deemed to meet the criteria for a serious case review. Serious Case Review Final 10.9.18 Page 4 of 31 1.6 Due to the ongoing police inquiries relating to Perpetrator 2, the serious case review initially focused on Perpetrator 1. The partnership review was revisited, the fostering file for Perpetrator 1 was re reviewed and a narrative of children’s social care involvement with Perpetrator 1 was produced. Interviews took place with children’s social care staff still in post. A list of victims was compiled and the panel chair and overview author completed one victim interview. 1.7 During this phase of the review in January 2015, further potential offences involving Perpetrator 1 came to light and the serious case review was suspended due to ongoing police investigations. Events following phase one of the serious case review. 1.8 As a result of further intelligence, the Police operation was widened to cover other non-recent child abuse. This included consideration of allegations made against foster carers. On 16th May 2016 Perpetrator 1 was convicted of further offences and given an extra four years in prison. 1.9 Perpetrator 2 had admitted downloading images of children but as a result of Operation A he was indicted for a total of 13 offences: 2 x rape of a foster child 1 x rape of a family member 1 x indecent assault of a foster child 7 x indecent assault of a family member (1) 2 x indecent assault of a family member (2) 1.10 At court he was found guilty for all four counts against family member 2 but was not found guilty of the rape of another family member. 1.11 In May 2016 Hampshire police confirmed that the serious case review could re-commence and a new panel and lead reviewer were appointed. 1.12 Southampton LSCB agreed to lead the review with Hampshire County Council being represented on the panel. The chair of Southampton Safeguarding Children Board discussed the proposed terms of reference with the lead reviewer and members of the serious case review subcommittee. It was agreed that a proportionate approach should be taken and that it was not feasible to review all the past records of children who had been placed with the foster carers in question. The file review should focus on the selection, recruitment and monitoring of the carers concerned, young people known to be affected (now adults) should be offered an opportunity to contribute their views to the review and the focus of the final report should be on analysing progress since the abuse came to the attention of the local authorities concerned. Serious Case Review Final 10.9.18 Page 5 of 31 Serious case review phase two 1.13 The detailed terms of reference and methodology were agreed at the first panel meeting on 3rd August 2016. The review purpose was agreed as: The overarching purpose of this review is to identify lessons that can be learnt both locally and nationally to improve the safety of children and young people in foster care. This review does not aim to review in detail the circumstances surrounding the abuse of the individual young people who were the victims or alleged victim of Perpetrator 1 and 2. It does aim to: 1. Review practice by agencies during the period during which the abuse took place and identify areas for improvement. In particular, practice in relation to: Foster carer recruitment, quality assurance and support (including the role of health professionals in the recruitment process) Monitoring and managing staff performance within the foster care service of the local authority. Opportunities to hear the “voice” of children and young people and recognise indicators of abuse (including the role of health checks). 2. Consider the response by agencies after the abuse came to light and actions taken to improve safeguarding arrangements relating to children in foster care. This will include responses to national changes to legislation and guidance. 3. Review current safeguarding arrangements for children in foster care in Hampshire and Southampton in the light of 1 and 2 above. 2 REVIEW PROCESS 2.1 It was agreed that the review process would include: A review by Southampton Children’s Services, of the records of foster carers where convictions or serious allegations of abuse were known to Hampshire Police, or other partner agencies. This meant that as the first stage of the review had involved a review of Perpetrator 1’s fostering file, the task for Southampton Children’s Services was to complete a similar review of Perpetrator 2’s file and the files of two foster carers who had been identified via Hampshire Police operations but had not been charged with any offence. A review of information from Hampshire and Southampton Children’s Services about action taken between 2012 and 2016 to improve the safety of children in foster care. Offering known survivors of abuse in foster care an opportunity to contribute to the review. Serious Case Review Final 10.9.18 Page 6 of 31 Speaking to practitioners from all partner agencies about their perceptions of current practice as it relates to keeping children safe in foster care. Speaking to children currently or recently in care about their experience and thoughts about how children in foster care can be kept safe from harm. Offering known perpetrators an opportunity to contribute to the review. 2.2 In order to progress this stage of the review reference group meetings were held with the following groups from across Southampton and Hampshire. Children in Care Social Workers Fostering Social Workers Education staff Health Staff Foster carers IROs/ LADOs/police investigators 2.3 These groups considered current strengths, weaknesses, opportunities and threats in relation to: Foster carer recruitment, quality assurance and support Hearing the voice of the child in foster care Monitoring and managing staff performance 2.4 Although the review has not focused in detail on individual children, it has always been the intention of the review to hear from abuse survivors and other people who had been in the care of known perpetrators. During the first stage of the review known victims of Perpetrator 1 were contacted and one mother and daughter came forward wishing to speak. They were seen by the chair and first lead reviewer. During the second stage of the review a comprehensive list of all those who made complaints resulting in charges against Perpetrator 1 and 2 was compiled. This resulted in the Hampshire Police representative on the panel: Contacting six victims of Perpetrator 1 in his role as foster carer. One victim agreed to e-mail contact from the lead reviewer but there was no response when this was attempted. Another agreed to contribute to the review and was seen by the lead reviewer. Reviewing information in relation to five victims of Perpetrator 1 who were abused outside foster care. These victims have not been contacted as none of the women were fostered by Perpetrator 1 and the officer in charge of the case advised that due to the trauma experienced by the women they were concerned about opening old wounds. After the final trial the women indicated that this needed to be a closure point for them. Reviewing the four victims whose complaints against Perpetrator 2 resulted in charges. Only one victim had been fostered by him. All alleged victims were sent letters asking if they wished to contribute to the view. Although attempts were made to arrange meetings, for a variety of reasons, these did not take place. Serious Case Review Final 10.9.18 Page 7 of 31 2.5 The two convicted perpetrators were both offered the opportunity to contribute to the review. Perpetrator 1 declined but Perpetrator 2 accepted and was seen by the review chair and the lead reviewer. Where relevant, information from this meeting is included in this report. Delays to the review process 2.6 Over a year after the start of stage 2 the serious case review had not yet received information from Southampton Children’s Services in respect of: Audits and corrective action since 2012 File reviews in respect of Perpetrator 2 and consideration of any learning from a review of files of other foster carers where there had been allegations. 2.7 Delay was also caused by difficulties arranging to meet with the Children in Care Council as a result of changes in the way that their work was commissioned by Southampton City Council. This meeting eventually took place in April 2018. 2.8 A major problem was the LSCB and serious case review panel received a number of assurances that information required by the review would be available by specific dates, but this did not materialise. With hindsight this can now be understood within the context of a service undergoing a number of structural changes and managed by a series of locum service manager. It was only with the appointment of a new permanent service manager responsible for the fostering service that communication improved, and information provided to the review. 3 THE CONTEXT: LEGISLATION, REGULATIONS AND PRACTICE 3.1 This review spans several years during which time there have been significant changes in the way that foster carers are recruited, assessed and monitored. In 1994 (the start of this review period) fostering was regulated by The Boarding Out of Children (Foster Placement) Regulations 1988 which specified that children could only be placed in approved households. The criteria for approval included checking for any criminal convictions relating to people in the household and obtaining two personal references and arranging for those persons to be interviewed. These regulations were superseded by 1991 by a further set of regulations2 which moved from the approval of a household to the approval of an individual foster parent and set out expectations regarding the need for annual reviews. By this time, the children Act 1989 had come into force and the accompanying guidance3 noted that the manner in which foster carer approval was carried out would be a matter for each local authority. Authorities should make known to prospective foster carers the arrangements 2 The foster placement (children) regulations 1991 3 The Children Act Guidance and Regulations Family Placement Vol 3 Serious Case Review Final 10.9.18 Page 8 of 31 for reaching decisions about approval. The arrangements must reflect the importance of the decision and the need for accountability within the authority. Local choice will vary. (3.37) 3.2 During the 1990’s reports4 raised concerns about the protection of children in public care5 and following further research studies commissioned by central government, the Children (Leaving Care) Act 2000 came into force, designed to improve the life chances of young people living in and leaving local authority care. This was followed in National Minimum standards for fostering in 2002 and 2011. In 2013 regulations6 were amended to include a two-stage process of approval allowing some applicants to be filtered out early based on accommodation, references or prior to fostering difficulties. 3.3 Local authorities are therefore required to adhere to minimum standards for fostering but the exact mean by which the approval and monitoring of foster carers takes place has room for flexibility. This is pertinent for this review as due to local authority reorganisation in 1997 Southampton and Hampshire became separate local authorities with their own structure, practice and procedures in relation to fostering. 3.4 Although there are local variations, the standard tool used across the UK for the assessment and approval of foster carers in the “Form F”. This was first developed by BAAF7 and since 2000 this has adopted a competency approach to assessment. There had been criticism that this focus on demonstrating competencies could become a tick box exercise and not focus well enough on relationships or an analysis of the information gathered8. As a result, the Form F was significantly revised tin 2014 and has now removed the competency grid and contains text boxes headed ‘analysis’. 3.5 In relations to care planning for children in care and monitoring the safety of children in foster care, during this review period the primary legislation has been the Children Act 1989 and accompanying guidance. Children in care will have their own social worker responsible for their overall care plan whilst there will also be a supervising social worker responsible for supporting foster carers and monitoring standards within a foster home. In addition, the role of an independent reviewing officer (IRO) was introduced in 2004 by the Adoption and Children Act 2002 s.118. The IRO is independent from the immediate line management of the child’s social worker and is responsible for ensuring that the child has regular reviews, the local authority is fulfilling its duties and functions and that the child’s views are taken into consideration. The Children and Young Persons Act 2008 and accompanying 4 For example Utting (1997) People Like Us: The report of the review of safeguards for children living away from home. London: The Stationary Office 5 Department of Health (1998) Someone Else’s Children. Inspections of Planning and Decision Making for Children Looked after and the Safety of Children Looked after. London: Department of Health 6 Care Panning and Case Review and Fostering Services (Miscellaneous Amendments) Regulations 2013 7 British Association for Adoption and Fostering : now Coram BAAF. 8 Alper,J. & Howe, D (2014) Assessing Adoptive Parents Foster Carers and Kinship Carers: Second Edition. London: JKP Serious Case Review Final 10.9.18 Page 9 of 31 regulations and guidance strengthened the role of the IRO as, in addition to chairing statutory reviews, they became responsible for monitoring cases on an ongoing basis. 3.6 The role of other professionals working with children in care has also adapted to the requirements of the primary childcare legislation and guidance, with a greater involvement of providing information and working with the local authority as part of foster care assessment and review. There are now dedicated health professionals with responsibility for children in care. Health providers take an active role in providing information as part of the foster care and review process and undertake health needs assessments and provide other services for children in care. The Children and Families Act 2014 amended the Children Act 1989 to require local authorities in England to appoint at least one person for the purpose of discharging the local authority’s duty to promote the educational achievement of its looked after children, wherever they live or are educated. That person (the virtual school head) is expected to work together with the child’s social worker and IRO. 3.7 The other key role in relation to the protection of children in foster care is the Local Authority Designated Officer (LADO) who is responsible for overseeing and providing advice and guidance where there is an allegation that a person who works with children may have harmed a child. This includes foster carers. 4 NON-RECENT PRACTICE 4.1 Although fostering practice has changed dramatically during the time period covered by this review, it should not be forgotten that the review came about because children and young people in the care of the local authority experienced abuse at the hands of those given responsibility to care for them. Whilst it may be thought that this abuse is “historic” and will have little relevance for current practice, this review has started from the position of wanting to understand how foster carers came to be in a position of trust where they could abuse, whether there were opportunities to recognise their unsuitability to foster and how the voices of children in their care were heard. 4.2 The following is a brief resume of the fostering history of the foster carers concerned in order to provide a context for the lessons identified by this review. Perpetrator 1 4.3 Perpetrator 1 and his wife were first approved as foster carers by Hampshire County Council in the 1970’s and in 1982 they were approved as carers for the Hampshire teenage family care scheme. Records also note that in 1983 a 14 year old child was fostered by Perpetrator 1’s mother who was living in the household. 4.4 There are several issues on the file that should have informed action and decisions before 1994 (the start of the terms of reference for this review). Of significance are: Serious Case Review Final 10.9.18 Page 10 of 31 Several comments during preparation for fostering interviews regarding inappropriate boundaries including, “he quickly gave the impression of trying to flirt or confuse me or provoke me by flip comments he made”. Delay in informing the local authority that Perpetrator 1 was subject of an assault charge for which he pleaded guilty (1983). In November 1983 there is a file record that Perpetrator 1’s wife slapped a foster child’s face twice and Perpetrator 1 “tanned her backside”. Perpetrator 1’s affair with a married woman he had met in a pub and the fact that they gave up fostering for a few years due to marital difficulties (1984). Perpetrator 1’s brother having been convicted of an indecency charge (1988). Racist comments by Perpetrator 1 (1989). Reluctance to engage with a new review system (1990). 4.5 The recruitment process picked up on Perpetrator 1’s controlling behaviour but failed to address it, thus allowing him early on to gain an inappropriate level of power within the system. There seems to have been an approach which was one of giving the carers the “benefit of the doubt” and engaging with them as colleagues. 4.6 In 1994 Perpetrator 1 and his wife were approved by Hampshire Family Placement Panel as Project Carers. This scheme paid carers an enhanced rate for providing intensive care and support to young people who were deemed to have the most challenging behaviour and needed highly skilled foster care support. This is significant as a theme throughout the fostering file is the view that Perpetrator 1 and his wife were willing to work with young people that other carers had given up on. 4.7 The family were in some financial difficulties and in 1994 Perpetrator 1 started employment as a night superintendent at a school for children with emotional social and mental health needs. 4.8 Perpetrator 1 and his wife quickly became powerful figures who would readily challenge decisions and went on to use the complaints system as one way of controlling the authorities. 4.9 For example, in April 1995 there is a note on the file that a decision had been made not to place a girl with them as she would be with two boys. This decision was challenged by Perpetrator 1’s wife who said that neither she nor her husband were happy with this decision as they felt that this implied they were incompetent. Within two days, the placement of a girl had been agreed. 4.10 A further example is that in 1995 a complaint was made to the fostering team by the head teacher of a school adjacent to Perpetrator 1’s home. There had been an altercation between Perpetrator 1 and some of the pupils during which he grabbed one by the shirt, raising his fist as if to punch him. A support assistant broke up the fight and sustained bruising, whilst the boy involved had marks on his upper body. The head teacher said that this was not the first occasion that Perpetrator 1 had crossed the fence and threatened the children. On receiving this information, the Serious Case Review Final 10.9.18 Page 11 of 31 fostering team notified the social workers of children placed with Perpetrator 1 which resulted in him saying that he felt unsupported and that he was packing the children’s cases. He refused to attend a subsequent household review and threatened to make an official complaint against a member of staff at the school. The decision of the review was to undertake an assessment using “Form F” which was completed and noted that “I expect Perpetrator 1’s bark is worse than his bite but sometimes it can create the wrong impression.” 4.11 Other concerns were raised about Perpetrator 1’s behaviour including failing to work with the department and discriminatory remarks. Raising these concerns led to a formal complaint by Perpetrator 1 and his wife which was independently investigated and not upheld. 4.12 During the time that the complaint was being investigated, Perpetrator 1 was suspended from work. At this time, he was working in a supported hostel in the Hampshire area and was suspended for five days after an allegation of sexual harassment by a 17-year-old girl. The outcome of a police investigation was that there would be no further action and Perpetrator 1 was re-instated. During the episode the file indicated that the fostering team’s position was clearly one of support with a file note: “Rang [wife] to support. No news re. concerns re. children. Told her they were in our thoughts.” 4.13 A further complaint was made by Perpetrator 1 in 1996 about the actions of social workers, followed by a complaint to the ombudsman in February 1997 saying that social workers had made serious allegations against him that were untrue; he had no letter of apology; all letters about the issue should be removed from his file; those responsible for causing distress should be disciplined. The reply from the investigator in ombudsman’s office concluded that “I do not think I would be justified in pursuing your complaint further.” 4.14 In April 1997 due to Local Government Reorganisation responsibility for Perpetrator 1 passed to the newly formed Southampton City Council. 4.15 One theme throughout the fostering file is that Perpetrator 1 and his wife would be quick to point out to social workers “sexualised behaviour” exhibited by children placed with them. 4.16 One child whose “sexualised behaviour and language” had been set out in a letter from Perpetrator 1 to children’s services was removed. She had been taken in by Perpetrator 1 and his wife as a result of a continuing relationship with her mother (an ex foster child). This informal placement had meant the family were over numbers. 4.17 After her move the new foster carers raised concerns about the actions of Perpetrator 1 including several disclosures of sexual abuse. Two joint interviews took place with Hampshire Police and as no further disclosures were made during formal interviews and no further action was taken in respect of Perpetrator 1 and his wife who continued to foster. After more disclosures by the same child a strategy Serious Case Review Final 10.9.18 Page 12 of 31 meeting was held which concluded that there was insufficient evidence to follow child protection investigation and no evidence of current harm to young people. 4.18 The first fostering review with Southampton City Council was positive but the theme of Perpetrator 1’s controlling behaviour continued with a note that he would refuse to have one reviewing officer in his home. Tensions also continued relating to payment of expenses for damage to the home and there were further complaints from a foster child to his grandmother about his treatment in the foster home. 4.19 In December 1998 the fostering service was notified that Perpetrator 1 had been suspended and then sacked from his job in the hostel due to a number of boundary violations and inappropriate behaviour with a 17-year-old girl. The decision was that no placements should be disrupted but that the fostering service would carry out enquiries. An independent review was commissioned which included a psychiatric report. The conclusion of the psychiatrist and the review was that no further placements should be made, and Perpetrator 1 and his wife should be deregistered. A fostering review in February 1999 recommended that they would cease to be approved as foster carers once the two young people with them had ended their “care lives”. Deregistration did not take place until August 2003. 4.20 Meanwhile, further specific allegations of sexual abuse by Perpetrator 1 towards her and other children were made by the foster child who had made the previous allegations. Police made some initial inquiries but due to an error in the investigation did not have sufficient evidence to arrest Perpetrator 1. A strategy meeting did not take place for two months and all enquiries were negative and no further action was taken. 4.21 In March 2007 a further allegation of sexual abuse was made against Perpetrator 1 by an adult who had stayed with him as a young person. These were denied by Perpetrator 1. Later that year another adult logged a compensation claim alleging sexual abuse by Perpetrator 1. A strategy meeting in November 2007 noted that there was significant indication that Perpetrator 1’s sexual behaviour was of concern and agreed that attempts would be made to contact other children who had been cared for by him. By the time of the next strategy meeting in January 2008 the police did not attend as they had stepped aside from any enquiries as no one was willing to make a formal complaint. The meeting concluded that Perpetrator 1 and his wife should be made aware of the concerns and should not have unsupervised contact with young girls or take any role as foster carers. There followed a joint visit by police and social care in February 2008 to Perpetrator 1. The concerns were discussed informally rather than this being part of any formal child protection process. 4.22 A further allegation in August 2010 resulted in a police investigation and the eventual conviction of Perpetrator 1. Perpetrator 2 Serious Case Review Final 10.9.18 Page 13 of 31 4.23 Perpetrator 2 and his wife were approved as foster carers by Hampshire County Council in 1994. They had raised four children, all boys who were teenagers at that time. The fostering assessment (Form F) is probably representative of assessments at the time in that it relied on self-reported information with very little analysis or challenge. For example, Perpetrator 2’s wife described an unhappy childhood but there was little exploration of how this might affect her own parenting. The assessment noted some marital discord without detailed exploration and Perpetrator 2’s wife talked about resenting the involvement of health visitors, GPs and other professionals, when her children were young telling her how to look after her children. 4.24 References were taken up both of which were negative. One reference wondered how they would cope with fostering as they were not very organised and would not seek help if needed and the other thought that Perpetrator 2 was a “Peter Pan” figure who preferred the company of young people and his wife was unsure of herself. Instead of exploring the issues raised further two more references were sought which provided positive comments. 4.25 A child (Child A) was placed the day after approval and when returned home to her mother spoke of being smacked at the foster home. This was denied by the carers. The same child returned to their care at her mother’s request in September 1995 and was eventually adopted by Perpetrator 2 and his wife in 1999. 4.26 In January 1995 a second child (Child B) was placed and by Spring 1995 Perpetrator 2 and his wife were pushing to be approved as project carers (or paid project care rates) for this child. The theme of pushing to become project carers continued until 1999 when they were approved. 4.27 Although Local Government reorganisation did not take place until 1997, the supervision of Perpetrator 2 and his wife was transferred to the Southampton area in 1995. 4.28 There were ongoing concerns noted about the care of Child B mostly in relation to whether Child A was receiving preferential treatment. By August 1996 Child B’s placement was breaking down, she said she wanted to leave and “knew something about Perpetrator 2 that meant they would never foster again”. 4.29 In May 1998 Child A (age 6) told her school that she walked home alone from the school bus and mummy was not at home when she got in. It seems that following discussions it was accepted that one of the teenage sons was in the house if neither Perpetrator 2 nor his wife were at home. 4.30 There is evidence of Perpetrator 2 and his wife resisting challenge and exerting a degree of control over decisions as, after the adoption order, they threatened to transfer elsewhere if the local authority insisted on them having a break from fostering for six months after the adoption order was made for Child A. The local authority retracted their decision and the half siblings of Child B (Child C and Child D) were placed in August 1998. Serious Case Review Final 10.9.18 Page 14 of 31 4.31 The parents of Child C and D made a referral in November 2000 criticising the care of the children. Perpetrator 2 and his wife denied all the allegations and this was accepted. This referral was within the context of a difficult relationship with the children’s parents and Perpetrator 2 (unusually) gave evidence in court against them in around 2000. Subsequent allegations were understood in this light and seen as intimidatory behaviour by the parents concerned. 4.32 Child C’s school noticed that her personal hygiene was deteriorating and she had missed an event at school because of something wrong at home. This information was passed to the medical advisor who informed Children’s Services when a medical appointment for the children was cancelled by the foster carers. The fostering file noted that this was followed up and the wife of Perpetrator 2 was offended by the comments. 4.33 In February 2001 there is evidence of tensions between the social worker for Child C and D and the supervising social worker (responsible for the foster carers). It was the view of the supervising social worker that there had been insufficient support in relation to Child C’s deteriorating behaviour. The same month, Child C and D’s school referred information that the children were not collected from school and walked home with a dinner lady and let themselves into an empty house. The explanation from the carers to the supervising social worker was that their youngest son was “usually” at home and this appears to have been accepted without further exploration. 4.34 In March 2001 at Child D’s annual health assessment, what looked like fingertip bruising was noticed on her back and Perpetrator 2’s explanation that this was caused whilst they were playing on their bunk beds was accepted. In February 2002 the LAC nurse wrote to Children’s Services (belatedly) about Child C arriving at a community event without any lunch and having had no breakfast. 4.35 In May 2002 Child B alleged that Perpetrator 2 had sexually abused her when she was in placement. This resulted in a child protection investigation which involved two strategy meetings in August and October 2002 and the arrest Perpetrator 2. He disputed whether the offence could have taken place at the time and place alleged by Child B and the conclusion of the investigation was no further action. It seems that Child B’s allegation may have been discredited on the basis that she had made an allegation9 about a carer in a placement that she had moved to after leaving Perpetrator 2. 4.36 By July 2003 the plan was for Child C and D to remain with Perpetrator 2 and his wife “into adulthood”. 4.37 In July 2004 Child C made an allegation of sexual abuse by Perpetrator 2. Child C stayed with her parents for the summer holidays and Perpetrator 2 was advised not to be alone with Child A and D. During the period that the allegation was being investigated Perpetrator 2 and his wife raised concerns about a plan for Child D to 9 From the fostering file this allegation was thought to be credible Serious Case Review Final 10.9.18 Page 15 of 31 see her social worker outside the family home at a family centre. There is a note on file that the social worker told a strategy meeting that if she met Child D in the foster home Perpetrator 2 and his wife would listen at the door and question them both about what had been discussed and when she was seen. 4.38 A file note in October 2004 noted that the allegation was “ongoing” and Perpetrator 2 and his wife were needing “lots of support +++” The allegation was closed down with no further action and Child C did not return to the placement and stayed with her parents. The “stress caused by the allegation” was discussed at the next household review in January 2005 and at the same meeting problems with Child C’s behaviour was seen as the cause of other children in the household missing out. 4.39 The parents of Child C and D made a complaint about the investigation of Child C’s allegation of abuse in April 2005 and asked for Child D to be moved. 4.40 A further child (Child E) was placed in July 2005. During 2005 Perpetrator 2 was on a steering group for the recruitment and retention of foster carers and his wife was training as a child play therapist. By 2006 Perpetrator 2 was buddying two prospective foster carers and was providing day care for a child who had a history of making allegations against carers. 4.41 In July 2007 Child C made a further allegation that she had been sexually abused by Perpetrator 2 and again the outcome of this investigation was no further action. 4.42 Also, in July 2007 a close family member of Perpetrator 2 alleged that he had sexually abused her as a child. He denied the allegation. 4.43 Child D’s placement ended in May 2008 after eight years. This was as a result of Perpetrator 2’s wife saying that she could not continue caring for her if she insisted on having contact with her birth family. During this period Child D made a number of allegations about poor care in the foster home and that she did not feel safe there. 4.44 A competencies report on the foster carers in June 2008 noted three key deficit areas: An unwillingness to work to support contact with families An unwillingness to listen to children placed Not working in Partnership with professionals. 4.45 There was a formal meeting to discuss practice issues and the primary focus was on the breakdown of Child D’s placement. There were no actions from the meeting and Perpetrator 2 was reassured that he would be placed back on the emergency fostering list for the out of hours service. 4.46 Three weeks later Perpetrator 2 and his wife were suspended. Four reasons were given: The disclosure of abuse by the close family member An incident when Perpetrator 2 filmed Child C and D after their placements had ended. This related to an incident where he filmed them apparently Serious Case Review Final 10.9.18 Page 16 of 31 swearing and gesticulating at him and, in his view, this was justified to illustrate the level of hostility from their family. Reports that Child D was frequently staying overnight with other family members and Child D’s social worker was unaware A report that Perpetrator 2 had discussed his case with others (this related to Perpetrator 2 talking to the mother of Child E and asking her to write a letter of support). 4.47 An independent report was written by a social worker not involved in the case which recommended deregistration and this was also the recommendation of the household review in September 2009. Deregistration was then recommended by the fostering panel and approved by the Decision Maker on 19th November 2009. 4.48 Nearly four years later in October 2013, Police informed children's social care that indecent images were being downloaded from a computer at the address of Perpetrator 2. Themes from non-recent practice 4.49 One important feature that stands out from the file reviews is that on several occasions, children and young people did say what was happening. There were clear allegations that were not handled appropriately and the message to the young people concerned must have been that either they were not believed or that no one was willing to listen to them. Some young people had important advocates in their birth families and social workers but there were still unacceptable delays in bringing the perpetrators to justice. Where there are no criminal convictions this could remain an outstanding issue for many young people. 4.50 Although much of the day to day practice will have changed particularly in the recruitment process and response to specific allegations of abuse, there are a number of factors that are apparent from the file reviews which need to be taken into consideration in reflecting more generally on the safety of children in foster care. These factors outlined below are picked up in the findings from this review. 4.51 The carers concerned were seen as a useful resource as they were willing to look after children whose behaviour was deemed to be challenging. The focus on the challenging behaviour which at times included the child’s history of making allegations meant that too often the problem became the child’s, rather than being seen as potentially caused by the care they were receiving in placement. 4.52 There is a pattern of controlling behaviour on the part of the carers which was not addressed and allowed, particularly Perpetrators 1 and 2, to gain an inappropriate level of power within the system. There seems to have been an approach which was one of giving them the “benefit of the doubt” and engaging with them as colleagues, which meant that unacceptable behaviours were not dealt with. This Serious Case Review Final 10.9.18 Page 17 of 31 may have been fuelled by the knowledge that foster carers are a limited resource and the need to recruit as many as possible. 4.53 Overall, the focus was on supporting foster carers rather than challenging their behaviour. Whilst providing support to foster carers is crucial this needs to be balanced with effective supervision and challenge. Fostering social workers need to develop skills in balancing these two aspects of their role and organisations need to support and monitor this aspect of their practice. 4.54 There are several instances where supervising (fostering) social workers and the social workers for the child were in conflict and this split between the two social work teams was clearly identified by Perpetrator 2 when interviewed for this review. Whilst challenge is helpful in these cases the antagonism allowed foster carers to “divide and rule” rather than the focus remaining firmly on the needs of the child. 4.55 The accumulation of concerns was not recognised and patterns of behaviour such as using the complaints system to deflect attention away from challenges to their behaviour was not understood sufficiently as a cause for concern. 4.56 One final issue relates to situations where there is no police investigation but foster carers are removed (or resign) from the foster carers register following concerns about their behaviour. There is no requirement to notify the disclosure and barring service and there is nothing to stop them from applying to other jobs or volunteering in roles which involve close contact with children and young people. 5 ACTION TAKEN 2012-2016 Practice audit by Hampshire Children’s Services 5.1 As a result of the emerging concerns about abuse within foster care in 2012, Southampton and Hampshire Children’s Services agreed a tool for auditing foster carers who had been approved pre the Foster Placement (Children) regulations 1991. 5.2 Hampshire audited 25 foster carers and found five cases where there were concerns about the way in which complaints had been handled. One key issue was the way in which complaints had been managed in relation to the identification of patterns of behaviour and concerns. This audit resulted in a 17 point action plan and a further audit (using the same tool) was carried out of all foster carers who were approved from 2011 onwards and had received level two or three complaints. 5.3 The audit activity identified possible barriers to responding to patterns and complaints as well as potential actions. These are discussed further in finding four below. Internal case review by Southampton Children’s Services Serious Case Review Final 10.9.18 Page 18 of 31 5.4 Another case involving foster care practice came to the attention of Southampton LSCB who asked for information from Southampton Children’s Services in December 2016. This case is relevant to this review since it highlights a number of more recent issues relating to work with foster carers that have similarities to some of the historical concerns raised throughout this serious case review. 5.5 Pertinent issues in the case are: A child sustained significant injuries whilst in the care of his foster carers and children’s services reported that two other incidents relating to a different child had previously been raised regarding injuries sustained whilst in the care of the same foster carers. Both were investigated and deemed to be accidental, although in relation to one of these incidents there was a query regarding the explanation of the foster carers and the injury sustained but no record this was addressed any further. There was an emerging picture of practice concerns and issues relating to the foster carers There was no medical examination at the time of the injury and no referral to the LADO as would have been expected practice Little was known about the role of the foster carer’s birth son within the household including whether he had any caring responsibilities. 5.6 The case resulted in an action plan (for completion March /April 2017) by children’s services linked to the following recommendations: Clear recording is needed to evidence detailed discussion with applicants and their children during the fostering assessment and as part of the annual review process is needed regarding the expectation that birth children in the household do not provide any caring responsibility for children placed. The fostering service needs to consider how it monitors and tracks issues and concerns regarding foster carers to identify emergent and ongoing practice issues to inform the annual review process and, outside of this, enable patterns to be identified and addressed. All relevant staff and managers are aware that medical examination is sought for injuries to the face or head to inform the health needs of a child and confirm the assertion of an accidental injury or otherwise. All relevant staff and managers are aware that the need to use formal child protection procedures may arise, when children are in the care of the local authority. Where a child has sustained an injury and there is any concern regarding the account provided as to how the injury was caused a Strategy Discussion under s47 of the Children Act 1989 takes place and investigations and assessments are conducted without delay and meet all procedural and good practice requirements to include: being consistently directed by a manager the child is seen alone within 24 hours consulting with those who have parental responsibility making thorough agency checks Serious Case Review Final 10.9.18 Page 19 of 31 specialist assessment or advice is sought key decisions, including a decision to take no further action, are clearly recorded and authorised by a manager. All relevant staff and managers are aware of the need to refer to the LADO (Local Authority Designated Officer) to inform decisions relating to child protection procedures. 5.7 The action plan from this audit is being monitored by the Southampton Safeguarding Children Board serious case review sub group. Audit activity undertaken by Southampton City Council 5.8 Although there was some delay due to changes in senior personnel, audit activity relating to foster care services has now taken place in Southampton. There was a review of the fostering service in the summer of 2017 with an action plan produced which informed the improvement plan for the service. Staff from the internal audit unit undertook an audit in December 2017 with the outcome of “Reasonable Assurance”. A safeguarding audit has been commissioned undertaken by an independent social worker with knowledge and experience of the issues being considered by the serious case review and this commenced in February 2018.The draft report has been received and, at the time of writing, is being reviewed by senior management. Outcomes are being aligned with existing improvement activity; which is monitored by the Children's Social Care management team, with input from the Quality Assurance Unit. 5.9 A current audit is underway, commissioned from the Quality Assurance department, auditing 15 carers who have been approved pre the Foster Placement (Children) regulations 1991.This was commissioned to bring Southampton in line with the work undertaken in Hampshire. The results of this are not yet available but there will be an action plan and continued work undertaken as a result of the findings of this audit 5.10 The serious case review had been informed that the fostering service remains under a high level of scrutiny internally to support the development of a continually improving service and the delivery of a robust service. The Southampton Local Safeguarding Children Board will need to be assured that all actions from audit and improvement work are sustained and contribute to the safety and wellbeing of children and young people in foster care. 6 WHAT DO CHILDREN AND YOUNG PEOPLE TELL US? 6.1 Two young people seen individually and the Children in Care Council both helped this review to think about what might help or hinder keeping children safe in foster care. The review would like to thank them for their time and their very thoughtful comments. Serious Case Review Final 10.9.18 Page 20 of 31 6.2 The routes to obtaining support and telling people about anything that may be bothering them in foster care will vary from individual to individual. Some young people feel strongly that staff at school would be first port of call, where others do not. Some would always call their friends. Some would talk to social workers whereas others would not. 6.3 What is clear, is that trust and a feeling that they will be listened to is vital and this will be built up over time in a variety of ways. Where children and young people have had a bad experience with any one person this makes it highly unlikely that they would go to them when they were in any kind of trouble. 6.4 Young people gave the example of feeling that social workers were not always honest (e.g. by saying they would return to parents when this did not happen) and this meant that they would not trust them with other aspects of their lives. They also were wary of social workers who spoke to foster carers about their behaviour (such as self-harm) without speaking to them first about why they were unhappy. 6.5 Within schools some young people felt that their confidentiality was not always maintained with teachers talking about them being in care in front of groups. This behaviour would not encourage them to talk to staff at school about any personal matters including worries about their foster placement. 6.6 There were some specific issues that would help children and young people such as being allowed to talk and confide to friends on line and the challenge for the system is to make sure that this can be achieved safely. 6.7 Southampton children’s services are now engaging with the Coram BAAF Bright Spots project10 which includes using an on-line survey with children in care in order to hear their views on their experiences within the care system. Findings from this survey will contribute to developing a system which provides a range of opportunities for children in foster care to talk about their experiences both positive and negative. 7 REVIEW FINDINGS Finding One The split between social workers responsible for fostering and practitioners responsible for individual children in care can lead to a fragmented, rather than a “whole family” approach to working with the child within the family. 7.1 Whilst the individual roles of the social worker responsible for the foster parents (known as the supervising social worker) and social workers for children in care has developed for good reasons, one issue that has emerged from many of the discussions, is the interface between social workers whose prime “client” is the foster family and social workers responsible for the child. This is not new and was 10 http://www.coramvoice.org.uk/brightspots Serious Case Review Final 10.9.18 Page 21 of 31 identified by the inquiry in 2007 in Wakefield into the sexual abuse of children in foster care11. In that case it was noted that the social workers responsible for the foster carers could not hear negative information about the carers from others including the children’s social workers. This was also an issue in the recent serious case review within Croydon12 and is likely to be even greater where foster carers are provided by an organisation outside the local authority. Relevant points are: Supervising social workers might be aware of stresses in the family and may not be shared with children in care social workers. The systems that are in place do not easily facilitate this; for example, children in care social workers do not always contribute to household reviews and similarly do not routinely receive feedback from the reviews. No one worker is maintaining a “whole family” approach and understanding the dynamics of the family as a whole. Foster carers who are abusing children may “divide and rule”. Perpetrator 2 for example, noted that the fostering social worker was likely to support the carer whereas the children’s social worker would not. 7.2 A literature review of research into the role of the supervising social worker in foster care13 identified similar issues in relation to the need for all those surrounding the child to work effectively together. This is necessary for ensuring foster carers can meet the child’s needs and the literature review notes the desire of foster carers to be part of the team around the child. It recommends “Public and independent fostering services need to consider ways of enhancing the working relationships between supervising social workers, foster children’s social workers and foster carers, by the use of such concrete activities as joint training”. It also explores the tensions inherent in the foster carer role as being both “client” and “colleague”. This is particularly significant in relation to keeping children safe as both the supervising social worker and the social workers for children placed in the home need to understand the evolving dynamics of the household and any factors that might impact on parenting capacity. Communication should be designed to serve the purpose of supporting the carers to meet the child’s needs but also continually assess any support or other action needed to keep the child safe in the home. Perpetrator 1 and his wife for example had a number of problems but it is not clear that these were known to social workers placing children. 7.3 Although not necessarily a direct result of the fragmentation between social worker teams, the information gathered for the review suggests that the lack of a whole family approach includes, at times, limited understanding of the role of men in the family. Men are very involved in the recruitment phase but from then on may become invisible and are generally not present for supervision sessions or even 11 Parrot, B., McIver, A. & Thoburn J. (2007). Independent inquiry report into the circumstances of child sexual abuse by two foster carers in Wakefield, Wakefield Metropolitan District Council 12 Croydon LSCB (2017) Serious Case Review “Claire” 13 Cosis. H., Brown,J., Sebba J., & Luke, N. The role of the supervising social worker in foster care An international literature review Rees Centre University of Oxford. http://reescentre.education.ox.ac.uk/research/publications/role-of-the-supervising-social-worker-in-foster-care/ Serious Case Review Final 10.9.18 Page 22 of 31 household reviews. Women are likely to be seen as the main carer and more available in working hours when the fostering social workers visit; although Hampshire have now implemented a standard stating that it is expected practice for both carers to be present at the annual review and every second supervision visit. A similar standard has recently been developed within Southampton. 7.4 At the other end of the spectrum men (or women) may exert a great deal of power and influence. In relation to Perpetrator 1 and 2, both men were very involved in the whole fostering process and Perpetrator 1 was described variously as controlling and volatile and both he and his wife were known to frequently use the complaints system to control social work decision making. Perpetrator 2 did not work, having taken early retirement and became influential through his work with various foster carer groups. This would seem to suggest that there is a need to aim for a balanced approach whereby no one person is either excluded from ongoing monitoring and review or exerts inappropriate influence on others in the system. 7.5 A whole family approach will take proper account, from recruitment onwards, of the role of siblings within the family. There is little evidence of consideration being given to the role that that the son of Perpetrator 1 had within the family and a survivor has now referred to him as “creepy” and a “risk to other people”. This may also be relevant in the context of today’s practice as the recent internal review noted that although there is no evidence that the carer’s son posed a risk to children, it remains unclear how effectively the recruitment process addressed the potential implications of his learning difficulties within the household. All children will change and develop over time and household reviews will need to consider the evolving dynamics between foster carer’s children and children in care and share any relevant information with the children in care social worker. Recommendation One Hampshire and Southampton Children’s Services should consider the most effective way to maintain a whole family approach for children in foster care which includes joint working between the social worker for the carers and the social worker for the child. Consideration should be given to arrangements for joint supervision of social workers where a child is in a long-term foster placement. Recommendation Two Southampton Children’s Services should provide evidence to the Safeguarding Children Board that the newly developed approach to involving men/partners in foster care is effectively implemented, in order to ensure that, as a minimum, all members of the family are involved in household reviews. Finding Two Although recruitment and quality assurance processes have developed over time, practice will be enhanced where: Serious Case Review Final 10.9.18 Page 23 of 31 relevant information from other agencies about foster carers is routinely shared with Children’s Services social workers are trained and supported by their organisation to challenge foster carers where there are concerns about their practice relevant information regarding foster carers who are removed from the register or resign following concerns about behaviour are shared if they seek other roles working with children and young people. 7.6 Recruitment procedures are now much tighter than they were when Perpetrator 1 was approved and current foster carers told the review that no area of their life is left unexplored. The results of the “Form F” assessment are presented to an independent fostering panel for review. Fostering panels consist of members who have relevant personal and/or professional experience or expertise in looking after children and they review the written report and ask relevant questions to enable them to make a recommendation. The recommendation of the panel is sent to the Agency Decision Maker who has the final decision on approval of foster carers. 7.7 One potential gap may be in the health information to the fostering panel if GPs are not aware of the significance of information within their records or the records have not been coded to make the identification of vulnerabilities easy. Unless the patient record is clearly coded, a GP may not be aware that a patient with a condition that may affect parenting capacity is in fact a foster carer. This has been recognised as a potential issue within Hampshire and training for GP practices is being rolled out locally to address this. Within Southampton there are current discussions between health organisations and the local authority regarding a process for making sure that GPs are aware when one of their patients has been approved as a foster carer. 7.8 Although foster carers believe that they are heavily scrutinised, the file reviews and discussions with current practitioners highlight the skills needed to manage and work with articulate people. Some practitioners report not feeling confident to challenge powerful individuals particularly in long term placements where the message from others in the system might be “do not rock the boat.” This is significant as evidence from research shows that in cases of substantiated concerns most carers had been fostering for a substantial period of time; over half for more than five years.14 The same research noted a case where carers were openly rude and uncooperative to work with, yet it appears that professionals had not challenged them sufficiently. 7.9 The issue regarding foster carers who are de-registered or resign following concerns about behaviour and there has been no police investigation and/or criminal conviction had been noted earlier in this report. In such situations a referral would not be made to the disclosure and barring service (DBS) and it would not be impossible for carers to apply to foster in a different area or obtain paid or voluntary work with children without their fostering history being revealed. This appears to be 14 Biehal B. Cusworth L.,Wade J. with Clarke S.(2014) Keeping Children Safe: Allegations Concerning the Abuse or Neglect of Children in Care. Final Report. University of York and NSPCC. Page 84 Serious Case Review Final 10.9.18 Page 24 of 31 a gap in the system whereby serious concerns about a person’s capacity to work with children may not be known to subsequent employers. Recommendation Three Southampton LSCB should ask Southampton children's social care to provide evidence that the system in place for assuring the quality of foster care practice is focused on the needs of the child and that social workers are equipped with the skills, support and supervision to enable them to challenge poor practice. Recommendation Four Southampton LSCB should ensure that a system is in place for GPs to be made aware when a Foster Carer is approved. They should also seek assurance that any health concerns that may impact on a patient’s capacity to foster are shared with Children’s Services. Recommendation Five Southampton LSCB should bring to the attention of the Department for Education the apparent gap in the system whereby concerns regarding the behaviour of a foster carers is made available should they wish to work with children in a paid or voluntary capacity. Finding Three Although there is common understanding about the importance of hearing the voice of the child there may still be barriers ensuring that the children’s “voice” whether through behaviour or verbal communication is heard. 7.10 Evidence suggests15 that children placed in foster care are likely to face a number of obstacles to reporting abuse. They may be silenced by the carers who tell them that they should not speak about the abuse, they may have several changes of workers and in the worst cases, their expressions of unhappiness about a placement may be ignored. In seven of the 10 reported cases of sexual abuse in the research sample, the abuse was not disclosed until a considerable time after the child left placement. 7.11 The situation of children placed in foster care can be compromised by the meaning professionals ascribe to their behaviour, as well as the opportunity to speak freely outside the foster home to a trusted adult. It is likely that the previous life experiences of children in care may lead to a range of behaviours which all too 15 Biehal B. Cusworth L.,Wade J. with Clarke S.(2014) Keeping Children Safe: Allegations Concerning the Abuse or Neglect of Children in Care. Final Report. University of York and NSPCC. Page 96-7 Serious Case Review Final 10.9.18 Page 25 of 31 easily label them as “difficult” or “hard to place”. Both Perpetrator 1 and 2 were known to be willing to take such children and were payed an enhanced rate as “project carers”. Children’s “difficult” behaviour in placement was too easily understood as either their problem or (sometimes) resulting from their past experiences. The foster carers were praised for being able to manage this when others could not and there was too little attention paid to whether the behaviour might be resulting from current distress. 7.12 There are examples of children speaking out either at the time or afterwards, but these allegations were not responded to appropriately. It is ironic that one victim commented that due to previous abuse she could easily “spot a perpetrator” but this was not taken into account when she tried to warn her social worker about the foster carer as she was leaving the placement. 7.13 A victim has spoken about the importance of regular visits from social workers but social workers are currently limited in the time they can devote to seeing the child. Practitioners spoke of lack of time to see a child outside of placement as statutory visits have to be in the home and they have to see the child’s bedroom. Social workers also have described lacking the skills in direct work that they need to communicate effectively with children and young people. Despite this many practitioners in agencies other than children’s social care assume that the social worker is the person who will be key in hearing the voice of the child. 7.14 From one victim’s perspective, children will be most likely to share with social workers who “accept me for me”. The best social workers were described as warm and kind and really care about the children they are working with. They also need training and to feel confident, as this victim did speak to the “best social worker I ever had” about sexual abuse in a residential home but she was newly qualified and did not know what to do. It has meant a lot to this victim that the social worker has since called her to apologise. Another young person told the review that his experience of social workers varied but currently they would talk to their current social worker as they were reliable and “really tries to get to know you”. 7.15 Forums such as contact with school staff and discussions with children in care nurses at annual health checks may also provide important opportunities for children to speak and two young people told the review that they would speak to staff at school if they were worried. 7.16 However, there can be limitations in the systems in place to gain the views of the child. The paperwork for formal reviews inviting a contribution from the child may be filled in with the assistance of the foster carer and there are particular issues where a child is placed outside the local area. For these children health assessments may be delayed whilst a local provider is found and in some areas health checks are not provided for out of area children. There are advantages and disadvantages to both scenarios. Children seen locally may be more likely to be linked in with local services but, conversely, where the home authority maintains responsibility consistent relationships are more likely to be maintained over time. The problem is Serious Case Review Final 10.9.18 Page 26 of 31 that systems vary from area to area. In some locations there is a lack of capacity to offer out of area assessments and because of the variations children may fall down between different approaches in different areas. 7.17 The review has heard that within schools, as in other settings, there may be confusion in understanding that challenging behaviour may be a result of current abuse and not just past abuse. However, schools can be a positive place where children’s voices can be heard and the role of schools work best where designated teachers for children in care have the authority within the staff team to make sure their needs are met through working closely with the head of year and pastoral team. The concerns of young people outlined in section five of this report need to be heard and thought given to ensuring the privacy of children in care in order to provide a culture where they feel they can talk about personal matters and confidentiality will be maintained. Recommendation Six All partner agencies should provide Southampton and Hampshire Safeguarding Children Board with evidence that staff working day to day with children in care have knowledge and skills to understand the meaning of children’s behaviour and recognise when this may be communicating distress or information about abuse. Recommendation Seven Southampton LSCB should ask children's social care to provide evidence that social workers and relevant others are spending time with children in care both inside and outside the foster home in order to provide sufficient opportunities for effective communication. Recommendation Eight Southampton LSCB should bring to the attention of the Department for Education and the Department of Health the lack of a national policy regarding the provision of health checks for children in care placed away from home. Finding Four Understanding the significance of accumulating concerns and complaints is key to keeping children safe in foster care. 7.18 From the review of the perpetrators and alleged perpetrators files it is clear that insufficient attention was paid to accumulating concerns over time and there was a lack of recognition of patterns of behaviour that may cause concern. This chimes with research which found that in cases where allegations of abuse by foster carers Serious Case Review Final 10.9.18 Page 27 of 31 had been substantiated16, 43% had been the subject of earlier allegations and in some cases there had been a string of low level complaints over the period of time that the carers had been fostering17. The research also found that where the accumulation of complaints had been recognised it was more likely that a particular allegation would result in deregistration and/or criminal prosecution. 7.19 The internal audits carried out by Hampshire Children’s Services indicated that further work was needed to ensure that all staff recognised the significance of concerns and complaints and considered what these might mean. The findings from the audit were discussed with practitioners at a fostering services workshop in November 2016 and included in full here as a good example of proactive action that has taken place with one local authority since the abuse by Perpetrator 1 came to light. 7.20 Possible barriers identified by auditors were: Work pressure Poor working relationships Not taking complaints seriously or believing the allegation Difficulties in challenging foster carer Lack of chronologies or using those that were available Understand what a recurring pattern might look like. The actions to consider from the audit were: The possibility of an independent worker managing the complaint An independent worker completing unannounced visits Group supervision using case studies to develop consistent practice A chronology workshop refresher A chronology prompt template for supervision Sharing chronologies with carers more openly and regularly to discuss patterns Using the child’s ICS number in case records Having a workshop on the new complaints and allegations policy Peer inspection Using titles in recording to identify common themes Having a clear process of consequences in response to foster carer patterns and behaviour. 7.21 The results of internal audit work in Southampton will also be needed in order to inform the final recommendations from this serious case review. 16 This related to all forms of abuse; not just sexual abuse 17 Biehal B. Cusworth L.,Wade J. with Clarke S.(2014) Keeping Children Safe: Allegations Concerning the Abuse or Neglect of Children in Care. Final Report. University of York and NSPCC. Serious Case Review Final 10.9.18 Page 28 of 31 Recommendation Nine Hampshire Safeguarding Children Board should ask children's social care to provide information regarding actions taken as a result of their foster care audit activity and the impact of these actions on practice. Recommendation Ten Southampton LSCB should requite children's social care to provide a summary report on the findings of all recent audit and quality assurance activity relating to children in foster care and include progress against actions identified. Finding Five Although investigations into allegations about abuse in foster care have improved during the time period covered by this review, all partner agencies need to consider whether children in care receive the same quality of response as children not in the care of the local authority. 7.22 Historically it is clear that the investigation process failed to keep children safe but police investigators have described to the review a change in culture over the last 15 years. Previously any 1:1 allegations did not result in action whereas now it is possible to explain to the alleged victim that it is possible that they are not the only one and to look for other potential victims. This was previously seen as an inadvisable “fishing trip” that could harm a prosecution. The change has come via a changed approach within the Crown Prosecution Service stemming from changed guidance from the Director of Public Prosecutions18. 7.23 In Southampton, until recently there were issues within the investigation system linking to whether the allegation was from a child already known to children's social care. A referral for a child not known is reviewed via the MASH system which will include an immediate sharing of information and a strategy discussion. Where a child is known (and by definition this will include foster children) the allegation went to the children in care team who then considered who to involve; there was no mechanism for instant sharing of information. This caused delay and there are indications that the focus of attention became wider issues to do with the placement rather than a standalone risk to the child who might need urgent medical assessment. This system effectively disadvantaged children in care. The review has been informed that now, all allegations are considered by MASH and the LSCB will need to be assured that this system is embedded and working well. 18 https://www.app.college.police.uk/app-content/major-investigation-and-public-protection/child-abuse/complex-investigations Serious Case Review Final 10.9.18 Page 29 of 31 7.24 The role of the Local Authority Designated Officer (usually referred to as the LADO) is significant and the recent internal review of a child in Southampton has shown that social workers are not always clear when to inform them of concerns about a person caring for a child. In addition, there appears to be some confusion about boundaries of the LADO role. The Southampton LADO described being responsible for oversight of all allegations made against carers working for organisations whose head office is in the Southampton area. This may include allegations investigated by police forces some distance away. This may be problematic and it appears there is no national consensus as to how boundaries function in these circumstances. 7.25 Both police investigations and the serious case review have been hampered by poor record keeping on file and problems in locating the files themselves. Whilst it must be acknowledged that historically record keeping was often handwritten, hard to read and not on standardised documentation, local authorities do have a responsibility to keep a child’s records safe and accessible and this has not been achieved within the local area. A victim told this review that she was very concerned to find that there were chunks of her record apparently missing. Recommendation Eleven Southampton LSCB should seek assurance that children in care are not disadvantaged where an allegation is made regarding potential abuse. The process of investigation should be the same as for all children. Serious Case Review Final 10.9.18 Page 30 of 31 8 SUMMARY OF RECOMMENDATIONS Recommendation One Hampshire and Southampton Children’s Services should consider the most effective way to maintain a whole family approach for children in foster care which includes joint working between the social worker for the carers and the social worker for the child. Consideration should be given to arrangements for joint supervision of social workers where a child is in a long-term foster placement. Recommendation Two Southampton Children’s Services should provide evidence to the Safeguarding Children Board that the newly developed approach to involving men/partners in foster care is effectively implemented, in order to ensure that, as a minimum, all members of the family are involved in household reviews. Recommendation Three Southampton LSCB should ask Southampton children's social care to provide evidence that the system in place for assuring the quality of foster care practice is focused on the needs of the child and that social workers are equipped with the skills, support and supervision to enable them to challenge poor practice. Recommendation Four Southampton LSCB should ensure that a system is in place for GPs to be made aware when a Foster Carer is approved. They should also seek assurance that any health concerns that may impact on a patient’s capacity to foster are shared with Children’s Services. Recommendation Five Southampton LSCB should bring to the attention of the Department for Education the apparent gap in the system whereby concerns regarding the behaviour of a foster carers is made available should they wish to work with children in a paid or voluntary capacity. Recommendation Six All partner agencies should provide Southampton and Hampshire Safeguarding Children Board with evidence that staff working day to day with children in care have knowledge and skills to understand the meaning of children’s behaviour and recognise when this may be communicating distress or information about abuse. Recommendation Seven Southampton LSCB should ask children's social care to provide evidence that social workers and relevant others are spending time with children in care both inside and Serious Case Review Final 10.9.18 Page 31 of 31 outside the foster home in order to provide sufficient opportunities for effective communication. Recommendation Eight Southampton LSCB should bring to the attention of the Department for Education and the Department of Health the lack of a national policy regarding the provision of health checks for children in care placed away from home. Recommendation Nine Hampshire Safeguarding Children Board should ask children's social care to provide information regarding actions taken as a result of their foster care audit activity and the impact of these actions on practice. Recommendation Ten Southampton LSCB should requite children's social care to provide a summary report on the findings of all recent audit and quality assurance activity relating to children in foster care and include progress against actions identified. Recommendation Eleven Southampton LSCB should seek assurance that children in care are not disadvantaged where an allegation is made regarding potential abuse. The process of investigation should be the same as for all children. |
NC047201 | Death of a 9-month-old in September 2012 after being found face down in a baby bath. Child Z had briefly been left unattended by father while in the bath with older sibling, 20-months-old. After Z's death, a large cannabis factory was found in the home and there were visible signs of child neglect. Charges of child cruelty against parents were dropped in December 2014. Family had a high level of involvement with the Family Nurse Partnership programme (FNP) throughout mother's pregnancy with Z's sibling and enhanced support through the Healthy Child Programme with Child Z. Both parents had experienced traumatic/abusive childhoods. Father had a history of mental health and substance misuse problems, criminal behaviour, and domestic abuse perpetration. Children's Services had previously been involved with the family concerning domestic violence, neglect and bruising to Z's sibling. Uses elements of the SCIE framework to highlight issues for consideration. Learning highlighted includes: effective and informed assessments require access to and understanding of family and parental history; families living at the margins of their community may be suspicious of professional intervention and motivated to resist and misdirect; adults with complex histories and chaotic lifestyles can overwhelm practitioners; a perceived toleration of drugs such as cannabis underestimates the impact of such behaviour on parenting capacity; and misplaced assumptions about the roles of different services can undermine decision-making.
| Title: Serious case review: Child Z: Overview report. LSCB: Manchester Safeguarding Children Board Author: Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Child Z SCR Overview Report published 051015 Manchester Safeguarding Children Board A Serious Case Review ‘Child Z’ The Overview Report September 2013 This report has been commissioned and prepared on behalf of Manchester Safeguarding Children Board and is available for publication on the 5th October 2015 Child Z SCR Overview Report published 051015 Index 1 Introduction and context of the Serious Case Review..............................................1 1.1 Rationale for conducting a Serious Case Review ..................................... 4 1.2 The methodology of the Serious Case Review......................................... 4 1.3 Reasons for the review and terms of reference....................................... 6 1.4 The scope of the Serious Case Review .................................................... 6 1.5 The terms of reference in national guidance........................................... 8 1.6 Particular issues identified by the SCR Panel for further investigation by the Individual Management Reviews................................................................. 9 1.7 Membership of the Case Review Panel and access to expert advice.......10 1.8 Independent Author of the Overview Report and Independent Chair of the Serious Case Review Panel .........................................................................11 1.9 Parental and family contribution to the Serious Case Review.................11 1.10 Timescale for completing the Serious Case Review ................................12 1.11 Status and ownership of the Overview Report.......................................13 1.12 Previous Serious Case Reviews..............................................................13 1.13 Inspections of services for children in Manchester.................................14 1.14 Summary conclusion of the Review Panel..............................................15 1.15 The family and other significant people and including relevant history ..20 1.16 Cultural, ethnic, linguistic and religious identity of the family................22 2 Synopsis of agency involvement ...........................................................................25 The critical reflection and analysis from the Individual Management Reviews. .............44 2.1 Summary ..............................................................................................44 2.2 Significant themes for learning that emerge from examining the IMRs ..44 2.3 Good practice identified through the review .........................................45 TOR 1 Recognition and response to need and indicators of risk.........................46 TOR 2 Quality of parenting assessments...........................................................53 TOR 3 Multi-agency recognition and response to neglect..................................58 TOR 4 Quality of communication and working in partnership ...........................61 TOR 5 Quality of inter-agency response to specific incidents or information of concern............................................................................................................63 TOR 6 How information about the family’s more general circumstances was considered .......................................................................................................64 3 Analysis of key themes for learning from the case and recommendations.............66 3.1 Learning from Previous Serious Case Reviews........................................67 3.2 Innate Human Biases (cognitive and emotional) ....................................67 3.3 Responses to incidents or information ..................................................69 3.4 Longer term work .................................................................................71 3.5 Tools.....................................................................................................72 3.6 Management systems ...........................................................................74 3.7 Issues for national policy.......................................................................75 4 APPENDICES.........................................................................................................77 The recommendations of the individual agencies and the Health Commissioning Overview Report..........................................................................................................77 Single Agency Recommendations.................................................................................77 Appendix 1 - Procedures and guidance relevant to this Serious Case Review.....81 Child Z SCR Overview Report published 051015 Legislation........................................................................................................81 The Children Act 1989 ......................................................................................81 The Children Act 2004..........................................................................................81 Safeguarding Procedures..................................................................................82 The local safeguarding children procedures........................................................82 Other local procedures relevant to this serious case review ..............................82 National guidance ............................................................................................82 Working Together to Safeguard Children 2013...................................................82 Framework for the Assessment of Children in Need and their Families 2001....82 Glossary...........................................................................................................84 Page 1 of 84 Child Z SCR Overview Report published 051015 1 Introduction and context of the Serious Case Review 1. In late September 2012 the regional ambulance service received an emergency telephone request to attend at Child Z’s home; it was mid-morning. Upon arrival the paramedics found Child Z aged nine months to be in cardiac arrest with no response or cardiac output. The paramedics commenced CPR (cardiopulmonary resuscitation) and Child Z was immediately taken by ambulance to the hospital where Child Z was formally certified as having died. 2. The parents provided an account of what had occurred; this summary does not take account of any other information provided in the parallel criminal proceedings and the Coroner’s enquiry. 3. Child Z had been ill and had vomited at around 10.00; this had followed loose stools, which had occurred on and off for the previous week. Child Z had however been eating and drinking well and had no fever. 4. Mother (MZ) had taken both of her children up to the bathroom and put Child Z in the bath at the higher end of the bath and filled up the main bath with water, overflowing into the baby bath. Child Z was then put into the baby bath and the older sibling aged 20 months was put into the main bath nearest the taps. This was around 10.30am. 5. MZ had gone downstairs and swapped over parenting tasks with Father (FZ) and then went to a neighbouring house. FZ stayed with his children in the bathroom and played with them for about ten to fifteen minutes. FZ’s account was that he had then left both of them playing in the bath and went downstairs to get two nappies and a towel. FZ stated that this had taken approximately two minutes and when he returned to the bathroom Child Z was face down in the water of the main bath. The older sibling had their back to Child Z. 6. FZ pulled Child Z out of the bath who was described as blue and unresponsive. He commenced CPR and Child Z vomited and produced a lot of water out of the mouth. There was then a knock on the front door and he ran downstairs to let MZ in. He put Child Z on the floor and restarted CPR and then a neighbour came to the house and took over. A neighbour had called for an ambulance and CPR was continued with telephone instruction and support from the ambulance dispatcher dealing with the emergency call until a solo paramedic arrived within five minutes followed shortly afterwards by a fully crewed ambulance who immediately transferred Child Z to the local hospital where determined and prolonged effort was made to resuscitate Child Z without success. 7. A post mortem examination concluded that Child Z appeared to be well grown and the state of nutrition looked good. Child Z was generally clean although with some dirt under the finger nails. No signs of injuries were found. Page 2 of 84 Child Z SCR Overview Report published 051015 8. The last visit to the family home had been by a community health professional five days previously; this professional had not found anything untoward describing the visit as ‘happy’. Both children had been seen and no concerns had been noted about their health and presentation or the house during that home visit. 9. After Child Z’s death the family’s home was visited later the same day by a Paediatrician, Police Officers and a Social Work Manager. On entering the property there was an immediate and powerful smell of cannabis. A large ‘cannabis farm’ was found in the back bedroom; the Police have estimated that the street value was substantial amounting to several thousand pounds worth. The room in which the plants were located had extractor fans rigged to subdue the smell although these were switched off and may explain why the health professional who visited a week earlier had not reported any smell of cannabis. When the independent reviewers met the parents in February 2015 after the completion of the criminal court proceedings, FZ confirmed that he had been careful to seal the room and prevent the smell of cannabis being detected by visitors to the house. 10. As part of the routine procedure a comprehensive photographic record was taken of the condition and circumstances of the house. The panel and the Overview Author have viewed some of the pictures that provide graphic evidence of neglect. The house was filthy with dirty clothes and nappies, used and clean, evident on the floors in many of the rooms as well as on a kitchen work surface. The bedding in Child Z’s cot was very dirty and contained a large pillow. There was a cricket bat on the stairs and an axe handle/cosh was upstairs. Child Z’s feeding chair was covered in food residue and was extremely unhygienic. There were bare floor boards in several rooms and the stairs had no covering and were showing signs of splintering. There were holes in some internal walls. The bath revealed a baby bath 80 cm in length in the shallow end of the bath. This was brim full with water; the main bath itself was empty of water. 11. The parents were arrested on suspicion of the ill-treatment of a child and the production of cannabis and remained on police bail. They were both charged with child cruelty. FZ was charged with the production of cannabis and MZ was charged with allowing the production. The parents were acquitted of the charges of child cruelty in December 2014. FZ was convicted of growing cannabis and was given a six month community order with a condition that he complete 42 hours unpaid work. MZ was conditionally discharged for six months for allowing cannabis to be grown in their home. 12. The Police used their Police Powers of Protection (PPOP) to prevent Child Z’s older sibling remaining with the parents and was placed with foster carers and care proceedings were initiated by the local authority. The placement with foster carers was achieved through the parents giving their consent to the arrangement. The local authority subsequently began care proceedings and after they were granted an Interim Care Order (ICO) and this conferred shared parental responsibility for determining arrangements for Sibling 1. Page 3 of 84 Child Z SCR Overview Report published 051015 13. There had been a high level of involvement with this family through the Family Nurse Partnership Programme1 (FNP) which started during the pregnancy with the elder Sibling 1. The Family Nurse (FN1) provided an enhanced level of support during the second pregnancy (Child Z) through the Healthy Child Programme. FNP is a preventative maternal and public health programme providing targeted and specialised support to vulnerable first time young parents under 20 years of age. 14. Families are not referred onto the programme due to particular identified vulnerability need. It is a voluntary, but targeted programme. In this instance, the family were introduced to the programme as part of a national randomised control trial. The programme is led nationally by the FNP National Unit that provides extensive implementation guidance to local sites, who in turn have responsibility for local implementation and integration of the service with others in the locality. The Family Nurse contact involved 36 visits to Child Z’s older sibling and 15 of these occurred after Child Z’s birth. Family members had also received services, and had contact with a number of other agencies during this time. 15. The Health Overview Report (HOR) provided an opportunity for the authors to review the medical records of both parents and highlights for example that MZ, who was the youngest of six siblings, had grown up in a home where there were longstanding concerns about cleanliness and risk for the children. There was a history of mental illness for one of MZ’s parents, domestic abuse and ‘marital disharmony’ (suggestive of domestic abuse). This information about MZ’s childhood contained in the records of the GP was not accessed and therefore was not known when MZ became pregnant and became a parent. 16. In November 2009 MZ had attended North Manchester General Hospital A & E department following an alleged overdose; she had been reluctant to wait however and left without receiving treatment. The police were subsequently asked to carry out a ‘welfare check’, which they did. MZ was found to be at her mother’s and agreed to attend at A & E later that day. 17. FZ has a history of mental health and substance misuse dating back to 2009 involving self harm and attempted suicide. There were four referrals to Children’s Services 1 FNP is a national and licensed programme across England that has three aims: to improve pregnancy outcomes, improve child health and development and to improve parents’ economic self-sufficiency. FNP is a voluntary, preventive programme for vulnerable young first time mothers. It offers intensive and structured home visiting, delivered by specially trained nurses, from early pregnancy until age two. FNP uses in-depth methods to work with young parents, on attachment, relationships and psychological preparation for parenthood. Family nurses aim to build trusting and supportive relationships with families, guide first-time young parents and use behaviour change methods so that they adopt healthier lifestyles for themselves and for their babies, to provide good care for their babies and toddlers, and to plan their futures. The Healthy Child Programme for the early life stages focuses on a universal preventative service, providing families with a programme of screening, immunisation, health and development reviews, supplemented by advice around health, wellbeing and parenting. Family Nurses are trained nurses with post registration specialist training and can hold a Health Visitor /, Midwifery or other nursing qualifications The Family Nurse Partnership (FNP) is a preventative programme for vulnerable, young, first time mothers. It offers intensive and structured visits delivered by specially training nurses from early pregnancy until a child is two years old (The Evidence Base for Family Nurse Partnership, undated). This programme began in England in 2007 with testing in 10 sites and with over 91 local areas sites across England offering places to up 11,500 families (The Evidence Base for Family Nurse Partnership, undated). FNP was implemented in Manchester in 2007 and was one of the initial test sites. FNP Wave 2, which contains a second team of Family Nurses (FN) commenced in January 2009. and has contributed to the randomised controlled trial of the partnership Page 4 of 84 Child Z SCR Overview Report published 051015 between November 2010 and June 2012. These referrals indicated concerns about domestic violence, neglect and one report of a bruise to the older sibling. 18. FZ was subject of a Child Protection Plan when he was a child. In 1992 he was on the Child Protection Register (replaced by Child Protection Plans in England from April 2008 following the Laming Inquiry) for eight months as a result of physical abuse after sustaining an injury during an argument between his parents. The information about FZ’s childhood history was also not accessed and therefore known when MZ became pregnant and the two children were born. 19. FZ also has a domestic abuse history involving previous as well as his current partner since 2003. He also has a criminal history between 2003 and 2010 involving offences of criminal damage, burglary, affray, assault, racially aggravated damage, robbery, offensive weapon, racially aggravated public order and theft. FZ was injured in an assault from an air rifle in 2010. 1.1 Rationale for conducting a Serious Case Review 20. Regulation 5 of the Local Safeguarding Children Board Regulations 2006 requires a Local Safeguarding Children Board (LSCB) to undertake a review of a serious case in accordance with the procedures that were set out in chapter 8 of Working Together to Safeguard Children (2010) but now amended and found in chapter four of Working Together to Safeguard Children (2013) issued in April 2013. 21. The LSCB should always undertake a Serious Case Review when a child dies and abuse or neglect is either known or is suspected to be a factor in their death. 1.2 The methodology of the Serious Case Review 22. A Serious Case Review Panel was convened of senior and specialist agency representatives to oversee the conduct and outcomes of the review. The panel was chaired by an independent and suitably experienced person. 23. Work began on compiling a chronology in December 2012, which coincided with the appointment of the Independent Chair of the Serious Case Review Panel and of the Independent Author of this Overview Report. Neither the Chair nor the Overview Author has worked for any of the services contributing to this Serious Case Review. Further information about their relevant experience and knowledge is provided in section 1.8. 24. This Serious Case Review was completed using the methodology and requirements set out in current government national guidance that applied at the time of the review being commissioned and completed. That guidance has been extensively Page 5 of 84 Child Z SCR Overview Report published 051015 revised in the latest edition of Working Together 2013 following the publication of the Munro Review’s final report and recommendations in 2011. 25. The LSCB in Manchester was already working on how future serious case reviews could be developed in order to provide a more productive window into the local systems for safeguarding and protecting children2 using system learning within serious case reviews such as developed by SCIE (Social Care Institute for Excellence). 26. The analysis in the final chapter of this report uses some of the framework developed by SCIE to present the key learning within the context of the local systems. This also takes account of recent work that suggests that an approach of developing over prescriptive and SMART recommendations have limited impact and value in complex work such as safeguarding children3. The final chapter of the review for example explores the influence of family and professional interactions, the responses to incidents and the tools that are used by professionals to help inform their judgments and decisions. 27. It is important to state that although the SCR panel has sought to place the learning from the review into a framework of systems learning this is not a SCIE review that has entirely used systems methodology to collect and analyse information from the people directly involved with the family. The evidence explores how the local systems both promote and in some circumstances inhibit professional practice and decision making. 28. The panel agreed case specific terms of reference that provided the key lines of enquiry for the review and were additional to the terms of reference described in national guidance. The panel established the identity of services in contact with the family during the time frame agreed for the review. For services that had significant involvement they were required to provide an independent management review (and are listed in section 1.4). These reports were completed by senior people who had no direct involvement or responsibility for the services provided to the children and their parents. 29. An overview of the health agencies was provided in a Health Overview Report provided by the Designated Doctor for NHS Manchester. 2 Analysis of clinical incidents; providing a window on the system not a search for root causes. CA Vincent; Quality and Safety in Health Care, 2004; The article argues that incident reports by themselves tell comparatively little about causes and prevention, a fact which has long been understood in aviation for example and is the basis of developing a systems learning approach to serious case reviews in England. 3 A study of recommendations arising from serious case reviews 2009-2010, Brandon, M et al, Department of Education, September 2011 The study calls for a curbing of ‘self perpetuating and proliferation’ of recommendations. Current debate about how the learning from serious case reviews can be most effectively achieved is encouraging a lighter touch on making recommendations for implementation through over complex action plans Page 6 of 84 Child Z SCR Overview Report published 051015 1.3 Reasons for the review and terms of reference 30. The reason for undertaking this review is that Child Z may have died as a result of neglectful parental care. The death was reported to the Manchester Safeguarding Children Board (MSCB) and was reviewed by the Serious Case Review Sub-Group on the 7th November 2012 who recommended to the Independent Chair of the LSCB that the circumstances of Child Z’s death met the criteria for a mandatory Serious Case Review. 31. The review was commissioned by Ian Rush, the Independent Chair of the Manchester Safeguarding Children Board (MSCB) on the 19th November 2012. The delay in making the formal decision was to allow clarification regarding the persistence of neglect in the case. A Serious Case Review panel was convened. 32. The Serious Case Review panel at their first meeting on the 12th February 2013 confirmed the scope and terms of reference for the SCR. These were routinely discussed and updated at subsequent panel meetings to take account of any new or emerging information and reflection. 33. The purpose of the review is to establish what lessons are learned from the case through a detailed examination of events, decision-making and action. In identifying what those lessons are, to improve inter-agency working and better safeguard and promote the welfare of children in Manchester. 1.4 The scope of the Serious Case Review 34. The period under review is from the 17th July 2010 when MZ was subject of a domestic assault at 14 weeks into her pregnancy with the older sibling until the day after the death of Child Z in September 2012 in order to capture the paediatric response at the hospital and the post mortem examination and analysis of how Sibling 1 was safeguarded. 35. There is significant earlier involvement by some universal and specialist agencies in the lives of the parents. Therefore organisations were asked to include any earlier information about both parents, especially where it had a bearing on understanding their capacity as parents, including any evidence of violent or sexual behaviour, mental ill health or substance misuse. 36. All information known to a service providing an IMR was reviewed. Any information regarding involvement prior to the period of the detailed chronology and analysis was summarised in the IMR and the Health Overview Report. 37. All agency chronologies included detailed information about when the child was seen or observations were made about them. Page 7 of 84 Child Z SCR Overview Report published 051015 38. Agencies that identified significant background histories on family members pre-dating the scope of the review provided a brief summary account of that significant history. 39. Reviews of all records and materials were considered including: • Electronic records • Paper records and files • Patient or family held records. 40. Individual management reviews were completed using the template provided by the Manchester Safeguarding Children Board (MSCB), and were quality assured and approved by the most senior officer of the reviewing agency. 41. The following agencies have provided an individual management review that was to be completed in accordance with Working Together to Safeguard Children (2010), Chapter 8 and the associated LSCB guidance and relevant procedures. � Health services in the Greater Manchester area that include: o Central Manchester University Hospitals NHS Foundation Trust (provided the Family Nurse Partnership service that had extensive contact from the birth of Sibling 1 until the death of Child Z; because there was intensive FNP support there was no health visitor contact); o Pennine Acute Hospitals NHS Trust (provided midwifery services during both pregnancies; the specialist midwife referred MZ to the Family Nurse Partnership managed by the CMFT); o Manchester NHS General Practitioner (FZ and MZ were registered with different GP practices until November 2011; the GP practice had neither as patients until MZ had first registered in January 2011 after MZ’s previous GP practice closed due to the death of the GP in early 2011); the family also used walk-in medical services; o North West Ambulance Service (made one referral to CSC in regard to suspected neglect observed when called to transport MZ to hospital in June 2012 and provided the emergency paramedic and ambulance response when Child Z had been found in the bath); � Greater Manchester Police Service (extensive involvement with FZ in respect of crime detection and dealt with one recorded incident of domestic abuse between FZ and MZ); � Manchester Children’s Social Care4 � Northwards Housing (the provider of housing from June 2011; prior to this date MZ and FZ had lived in privately rented property); 4 The first referral to CSC in regard to Child Z or Sibling 1 was at the end of November 2010 from the trainee probation officer requesting a pre-birth and parenting assessment to be completed in regard to Sibling 1. Page 8 of 84 Child Z SCR Overview Report published 051015 � Greater Manchester Probation Trust (FZ was subject to a community supervision order; although MZ occasionally attended at Probation with FZ there was no formal involvement with MZ); � Sure Start and Early Years Service (registered from 2009 although MZ was an infrequent user of the services). 42. Information was sought from other services although these agencies were not required to provide an IMR: � Connexions who had contact with MZ as a school leaver and who sought help from that service when she was told to leave her family’s home when she was three months pregnant; � Family Action (a national charity providing support to children and families through approximately a 100 projects across the UK) who had two contacts with MZ in Manchester; one of those was with the Credit Union and the second was a large open access activity; � Greater Manchester West Mental Health NHS Foundation Trust (GMWMHT) had limited historical involvement with FZ in 2010 when he was referred for psychiatric assessment by the probation service in relation to self-harm; a self-inflicted stab wound and had taken an overdose in November 2009; � University Hospital of South Manchester NHS Foundation Trust (UHSM) provided surgical care when FZ injured his hand in March 2011; � Manchester College in regard to courses attended by MZ. 43. There were additional discussions with the FNP National Unit and the Chair of the panel and the Designated Nurse panel member to explore and clarify issues to support the learning from the review. These focussed on discussing the mismatch between the evidence of neglect and disengagement that became apparent in the information collated by the panel and the generally optimistic accounts from the local FNP service provider in particular that was influential in some aspects of multi-agency contact. The FNP National Unit was able to clarify that the strength based approach should be balanced with a sophisticated and on-going assessment of the families’ ability to make use of the programme and institute change. There are a number of approaches, national guidance and tools within the programme to facilitate this. Discussions also included the extent of the application of the FNP National Guidance within the local context. This is discussed within the analysis provided in later sections of this report. 44. Information was also sought from the family and is described in section 1.9. 1.5 The terms of reference in national guidance a) Keep under consideration if further information becomes available as work is undertaken that indicates other agencies should carry out Individual Management Reviews; b) To establish a factual chronology of the action taken by each agency; Page 9 of 84 Child Z SCR Overview Report published 051015 c) Assess whether decisions and action taken in the case comply with the policy and procedures of the Manchester Safeguarding Children Board; d) To determine whether appropriate services were provided in relation to the decisions and actions in the case; e) To recommend appropriate inter-agency action in light of the findings; f) To assess whether other action is needed in any agency; g) To examine inter-agency working and service provision for the children; h) To establish whether interagency and single agency policies adequately supported the management of this case; i) Consider how and what contribution is sought from the family members; j) To develop a clear multi agency action plan from the Overview Report. 1.6 Particular issues identified by the SCR Panel for further investigation by the Individual Management Reviews5 45. In addition to analysing individual and organisational practice, the Individual Management Reviews should focus on: a) Analyse agencies recognition and response to needs and risk identified during the antenatal periods of Child Z and Sibling 1; b) Consideration as to how the assessments of parenting took into account the following risk factors and how this informed the safeguarding of both children: i. Teenaged parents ii. Parents with learning difficulties iii. Offending history iv. Domestic abuse v. Self-harm vi. Housing vii. Substance Misuse viii. Mental Health ix. Engagement with services; 5 These are the detailed issues that are analysed by the IMRs and in the detailed analysis. Page 10 of 84 Child Z SCR Overview Report published 051015 c) The effectiveness of agencies recognition and response to indicators of neglect and their potential impact on the wellbeing of the children and analyse whether there was tolerance of neglect; d) To what extent, if any, did agencies communicate effectively and work together to safeguard and promote the continued well-being of both children. Examine whether partnership working was affected by assumptions in relation to the services provided by other agencies; e) During the time frame of this review, there were episodes of concern. Analyse the effectiveness of agencies response to these incidents in relation to child protection procedures; f) To what extent did agencies and services take account of issues such as lifestyle, economic status, community integration, race and culture, language, age, disability, faith, gender and sexuality and how did this impact upon agencies assessment and service delivery? 1.7 Membership of the Case Review Panel and access to expert advice 46. The Serious Case Review panel that oversaw this review comprised the following people and organisations: Position Organisation Valerie Charles Independent Chair Peter Maddocks Independent Author Interim Head, Safeguarding and Improvement Unit Manchester Children’s Social Care Designated Doctor (and Author of the Health Overview Report) NHS Manchester Partnership Manager Greater Manchester Probation Trust Head of Business Effectiveness and Communications Northwards Housing Detective Sergeant Greater Manchester Police District Head of Centre Sure Start and Early Years Services Assistant Director Barnardo’s Business Support Officer MSCB Business and Performance Manager MSCB Consultant/Designated Nurse NHS Manchester 47. The Independent Author of the Overview Report attended every meeting of the panel. Page 11 of 84 Child Z SCR Overview Report published 051015 48. The panel had access to legal advice from a Solicitor in the council’s legal service. The panel also had access to other specialist advice if it had been required. 49. Written minutes of the panel meeting discussions and decisions were recorded by a member of the LSCB staff team in Manchester. 1.8 Independent Author of the Overview Report and Independent Chair of the Serious Case Review Panel 50. The Independent Chair of the Serious Case Review panel was Valerie Charles. She works as an Independent Consultant and is registered with the Health and Care Professions Council. Valerie has been qualified since 1991 and has a professional social work qualification and MA. She has extensive experience of working in children’s services in both the local authority and voluntary sector. She was a senior manager for NSPCC from 2006 to 2012. Valerie has worked in different roles within Local Safeguarding Children Boards, including chairing serious case reviews and has experience in systems methodology case reviews. 51. Peter Maddocks was commissioned in December 2012 as the Independent Author for this Overview Report. He has over thirty-five years’ experience of social care services the majority of which has been concerned with services for children and families. He has experience of working as a practitioner and senior manager in local and national government services and the voluntary sector. He has a professional social work qualification and MA and is registered with the Health and Care Professions Council (HCPC). He undertakes work throughout the United Kingdom as an Independent Consultant and Trainer and has led or contributed to several service reviews and inspections in relation to safeguarding children. He has undertaken agency reviews and has provided overview reports to several LSCBs in England and Wales as well as work on Domestic Homicide Reviews. He has undertaken work as an Overview Author on two previous Serious Case Reviews in Manchester. Apart from this, he has not worked for any of the services contributing to this Serious Case Review. He has also participated in training for overview authors including the application of systems learning. 1.9 Parental and family contribution to the Serious Case Review 52. In view of the separate investigation by the Police as well as the Coroner’s enquiry the Serious Case Review panel had to ensure that all contact with the family was the subject of appropriate consultation and advice. The panel used the national guidance agreed between Chief Police Officers, the Crown Prosecution Service and the Directors of Children’s Services in England6. 6 A Guide for the Police and the Crown Prosecution Service and Local Safeguarding Children Boards to assist with liaison and the exchange of information when there are simultaneous chapter 8 serious case reviews and criminal proceedings; April 2011 Page 12 of 84 Child Z SCR Overview Report published 051015 53. The parents were made aware of the Serious Case Review when it was commissioned, in a letter sent on the 22nd February 2013. Further contact with the family had to be postponed until the criminal investigation and prosecution had been concluded. 54. The parents subsequently agreed to meet the independent reviewers in February 2015. They acknowledged that they had withheld information from professionals. FZ said that he had not understood the seriousness of some of his lifestyle in terms of implications for a young child; this included his habitual use of cannabis that he had used since early adolescence. He says that he has now stopped using cannabis for several months. 55. The parents also discussed how their lifestyle had not been much different to a lot of other people living in their neighbourhood at the time. For example the use of drugs; MZ says she has never used drugs. 56. Both parents felt that professionals had readily accepted what they told them without sufficient challenge or scepticism. They acknowledged that they did not ask for help and support when they needed it for fear of what they perceived as potential consequences (potential removal of their children). 57. Both parents recognised that they both had difficult childhoods and that their family backgrounds and isolation from family support did not appear to be sufficiently considered by professionals working with them. 58. Both parents spoke positively about the work being done by the current group of professionals. 59. FZ and MZ acknowledged some of the difficulties faced by parents, particularly young parents, who are not sufficiently aware of risks and that this is a possible area that they felt could be further improved upon in the future such as raising awareness of risks associated with bathing and co-sleeping. 60. It was notable that the property the couple were living in when the independent reviewers met them in February 2015 was in positive contrast to the photographs of their previous property. 1.10 Timescale for completing the Serious Case Review 61. The Serious Case Review panel met on five occasions between February 2013 and June 2013. The initial chronology of services involvement was completed by January 2013. The first draft agency reviews were completed in late January 2013. Individual discussions also took place with agencies providing an IMR with the Chair and members of the panel, the Independent Author and MSCB Business and Performance Page 13 of 84 Child Z SCR Overview Report published 051015 Manager. The first draft of the Health Overview Report was completed in May 2013. This Overview Report was presented to a meeting of the MSCB in August 2013. 1.11 Status and ownership of the Overview Report 62. The Overview Report is the property of the Manchester Safeguarding Children Board (MSCB) as the commissioning board. 63. Since June 2010, all overview reports provided to LSCBs in England have to be published in full. This Overview Report provides the detailed account of the key events and the analysis of professional involvement and decision making in relation to Child Z and the family. 64. The report has to balance maintaining the confidentiality of the family and other parties who are involved whilst providing sufficient information to support the best possible level of learning. 65. In reading this report, it is important to remain clear about the purpose of the overall review and of this overview report in particular. The review examines with the benefit of hindsight, if it possible to identify whether alternative judgments and decisions could or should have been taken, and whether different outcomes might have been achieved for Child Z. The review does not investigate the circumstances of Child Z’s death. That is a matter for the coroner and for the police. 66. The review aims to be very challenging of all services for the purpose of building on the considerable knowledge and expertise that has developed in relation to the safeguarding of children in the UK. In doing this work, the panel are mindful about how complex or unclear some of the information and events may have looked to practitioners at the time of events. 67. An Executive Summary was provided at the conclusion of the review. This provides a brief summary of events and the most significant points of learning identified as a result of the review. The LSCB will determine how and what further information is provided to the family at the conclusion of the review and following the submission of the Overview Report and Executive Summary to the Department of Education7. 1.12 Previous Serious Case Reviews 68. The LSCB in Manchester had undertaken ten previous Serious Case Reviews between 2009 and 20128. 7 In England, Ofsted have the responsibility for evaluating the thoroughness of the serious case review. The executive summary includes a statement about that evaluation. 8 The coalition government’s notice issued on the 10th June 2010 under section 16(2) of the Children Act 2004 which amended the previous national guidance in Working Together to Safeguard Children requires that both the executive summary and the overview report with suitable redaction to provide confidentiality are published. The coalition government ended the formal evaluation of SCRs from the 5th July 2012. Page 14 of 84 Child Z SCR Overview Report published 051015 69. Reference is made by several IMR authors to some of these and other previous Serious Case Reviews completed in other parts of the country and is also referenced where relevant in this Overview Report. The purpose of this is to highlight where similar issues or themes have been identified in previous reviews. This ensures that action already recommended is not unnecessarily repeated. 70. Subsequent chapters of this review describe in greater detail the specific lessons to emerge from a detailed analysis of this Serious Case Review and include comments on how learning from previous reviews has been used. 1.13 Inspections of services for children in Manchester 71. All children’s services in England are subject to inspections. Manchester’s annual children’s services assessment in November 2011 judged that Children’s Services were adequate. This means that services were meeting minimum national standards. 72. In late 2010 there was a statutory inspection of safeguarding and looked after arrangements in Manchester9. This evaluated safeguarding arrangements as adequate in Manchester with a good capacity for improvement; Child Z was not the subject of any child protection plan. The inspectors recommended that improvements to the quality of assessments and the workload of social workers should be accelerated and this required an action plan to be implemented. 73. An unannounced inspection of contact, referral and assessment services in August 2011 found that some assessments lacked ‘rigour and offer insufficient analysis, resulting in a lack of clarity of children’s needs and vulnerabilities on which to base the provision of services’. This had been an area for development at the previous inspection and was reflected in this case. 74. The Common Assessment Framework (CAF) was underdeveloped as a process for identifying children’s needs and it was not sufficiently embedded with partner agencies. This had a negative impact on early intervention and resulted in high levels of re-referral to social care services. Senior managers were aware of this issue and had plans in place to address it. This had been an area for development at the previous inspection. The CAF was not used in this case and is highlighted as one of the themes for the review. 75. Some caseloads were high and this was leading in certain instances to delays in information being recorded on the electronic recording system. Some staff reported 9 The inspection was carried out under section 138 of the Education and Inspections Act 2006. It contributes to Ofsted’s annual review of the performance of the authority’s children’s services, for which Ofsted will award a rating later in the year, subject to any changes that the coalition government may introduce. The inspections are part of a national programme of enhanced inspection of children’s services introduced in 2009 following the death of Peter Connolly (Baby P) and the two subsequent serious case reviews in Haringey. Page 15 of 84 Child Z SCR Overview Report published 051015 working excessive hours in order to meet the deadlines required to safeguard children and additional posts had been created to address this issue. This had been an area for development at the previous inspection. The panel had insufficient information about workload of the practitioners involved with Child Z although issues in regard to accessing historical information and recording were themes in this case. 1.14 Summary conclusion of the Review Panel 76. The purpose of conducting a Serious Case Review is to undertake a detailed examination of the events within the context of understanding how the judgements, decisions and actions were taken by the various professionals involved with Child Z and the family for the purpose of drawing out learning to inform future policy, service development and individual practice. 77. The Munro Review commissioned by the coalition government in 2010 emphasised the importance for learning and improving services and practice by looking at information within the context of people’s professional and organisational arrangements and the information they knew at the time of events. Hindsight can distort and mislead the quality of analysis and cause the focus to fall on how individuals behave and act rather than understanding how they are influenced by a range of contributory factors. 78. The influences on practitioners doing their work effectively include the stability of the organisation they work in, their personal workload and more generally of their services, the quality of their training and knowledge, their use of tools for assessing need and risk, the clarity of working arrangements in matters such as recording and sharing essential information as well as their cognitive functioning (how they are processing and analysing information). These were all important in understanding this case. 79. In order to extract the best level of learning from the review the panel have looked for the most significant episodes of practice. In doing this, the panel are looking for the various factors that shaped how judgments and decisions were made at the time. As with all complex human interaction and with the benefit of hindsight and detailed collation of information, it is possible to identify the options that could have been explored. The purpose in all of this is to keep on adding to and developing the collective knowledge and expertise in regard to the identification of children who maybe vulnerable. 80. The panel have not identified any single agency or individual practitioner who could have prevented the tragic death of Child Z. The panel have identified opportunities for managing the response to Child Z’s family differently that would probably have reflected a more assertive style of engagement and with clearer leadership for that involvement. The panel believe that neglect was a significant factor in this case but was not recognised at the time by the professionals who had the most extensive involvement with the family. Page 16 of 84 Child Z SCR Overview Report published 051015 81. There appeared to be a high reliance for example on the Family Nurse Partnership programme being able to deliver positive outcomes for the children. There is good research evidence that such strengths based support can work very well with many families living in circumstances similar to Child Z. In this instance of delivering the local programme, there was an inability to identify and give enough attention to indicators of risk. 82. Those indicators included the underlying reluctance of both parents to commit with enough openness and resolve to the support that was available from different services; there was evidence of underlying abuse in the relationship between the parents; the physical conditions in the home were at best inconsistent and in probability never good enough for the appropriate care and safety of very young children. 83. The age of MZ, the fact that she became pregnant very quickly after the birth of her first child, the absence of appropriate housing for a significant period of time and the apparent isolation from positive sources of help and support were indicators of vulnerability that were not given sufficient inference; part of this may be due to the fact that they are characteristics shared by many other young parents in the same area. It may also have been partly a product of the intensive support that was in place and the associated research evidence that encouraged a belief in good outcomes being achieved. 84. There was evidence of significant substance misuse that never really attracted the level of inquiry required; the panel retain a belief that some professionals may have taken a tolerant approach to aspects of behaviour that may have been different if it had been exhibited in a different part of the city; in other words a process of ‘cultural relativism’ applied to some judgments in matters such as household cleanliness and cannabis use for example. 85. This should not be taken as direct criticism of professionals who have to reconcile difficult dilemmas. For example, when faced with adults who avoid and withdraw from contact, they have to try and find ways to develop sufficient trust or alternatively have sufficient evidence to take a more authoritative and assertive approach if it is seen as necessary to ensure a child’s needs are being given sufficient attention. The emotional impact on professionals working with families facing high levels of need is also a factor examined by the review and is a factor identified in national research and evaluation. 86. Significant influences on how the case was managed included insufficient collation of historical information about either of the parents or their respective extended families; for example they had both experienced levels of childhood trauma and abuse. A significant contributing factor were the gaps in electronic data systems being able to identify archived and historical information in CSC that was only accessed as a result of the strategy meetings held after Child Z had died and was provided by other services. Page 17 of 84 Child Z SCR Overview Report published 051015 87. If the assessment had involved more rigorous inquiry with services such as the GP it would have provided an opportunity to identify the significant and relevant history for both parents. Both parents have some learning difficulties which were not identified until the start of the criminal investigation; MZ was diagnosed with moderate learning difficulties as a child and at the age of nine was about four years behind her peers. The probation service and police recognised that FZ had unspecified learning difficulties. 88. There was not enough attention given to the history of the relationship between the parents, the circumstances and attitude to the pregnancies or their use of support. FZ has an extensive history of substance misuse and violence and had been unwilling to acknowledge his need for help in regard to mental health and educational or employment support. His lifestyle has represented risk to himself and to members of a household where very young children were living. He has been subject of assaults as well as being involved in assaults on others. There was evidence in the house for example of objects such as bats that could be used as weapons which with the exception of the police do not appear to have aroused any particular curiosity. 89. The absence of historical information may have contributed to an apparent down playing of information about the parents’ current circumstances and lifestyle. Both parents have difficulties associated with their mental health and substance misuse although largely denied these problems. This led to misdirection when some professionals used self-reporting and disclosure tools with the parents upon which they subsequently made important judgments. 90. There was evidence of domestic abuse which apart from one occasion in 2010 when MZ contacted the police, was largely denied and hidden. There are well known factors associated with why domestic abuse is very often hidden that are described in later sections of the report. There was an apparent absence of knowledge and curiosity displayed by many of the professionals who generally relied on the positive interpretation that MZ in particular provided when confronted occasionally on issues such as dirt or chaos. 91. There is clear evidence of misdirection occurring in the case. There was a belief that the parents were open to and willing to accept help and support. In reality, there was an underlying pattern of missed appointments, behaviour that did not put the children’s needs foremost (for example in MZ self-discharging from hospital after the first birth), and a reliance on parents saying they would make required changes without enough evidence of what was actually achieved. 92. Some of this reflects a misplaced empathy with parents being seen to overcome a range of personal difficulties, possibly an over confidence in the ability of a particular model of working being able to overcome and deliver improved outcomes, some professionals being under significant workload pressures and competing demands, not enough organised collation of information that could have highlighted important Page 18 of 84 Child Z SCR Overview Report published 051015 historical information as well as identifying for example behaviour that was indicative of disguised compliance. 93. The HOR for example highlights that during the ante natal care of Sibling 1, MZ missed eight appointments one of which was a joint appointment with the midwife and the FNP. The HOR points out that three of the appointments were during the later stages of pregnancy and therefore increased the level of risk for the unborn child as well as for the mother. 94. This pattern of missed appointments resulted in very concerted efforts especially by the FNP to secure improved contact and it may have led to a defensive rather than assertive approach being taken. Although there is evidence that there was an improved level of contact, FZ became less available and involved from late 2011. 95. The panel had identified five particular events that are significant for learning lessons: a) The referral in June 2010 by the midwife to the FNP was not the result of identified need or vulnerability; MZ was not seen as being particularly vulnerable as a pregnant teenager partly because there was insufficient knowledge about FZ; b) The contact by the police in July 2010 to deal with MZ’s disclosures of domestic abuse over several months was not reported to CSC who therefore remained unaware of that information; the systems that applied at the time relied on the use of fax information that did not log and allocate responsibility to specific people in different services; this practice has already changed; c) In November 2010 the unqualified probation officer (PO1) who was undertaking professional training made a referral to CSC outlining concerns about the history of FZ and the pregnancy of a teenage partner; in the absence of other historical information or making sufficient and completed enquiries the information was passed to the midwifery service without direct conversation; a misplaced assumption was made by CSC that a targeted service through the Vulnerable Babies Service (VBS)10 would be offered and the midwifery service knew that FNP were becoming involved (neither of the services addressed specific risks identified in the referral); in the absence of any specific concerns specific to the child; no further action was considered necessary; 10 The VBS was set up in 2004 to tackle infant mortality in Manchester, in particular sudden unexplained death of infants (SUDI). The VBS also plays a public health role in preventative practices; leading on safe sleeping policies across the city and strategically informing practice to improve outcomes for infants. Page 19 of 84 Child Z SCR Overview Report published 051015 d) In June 2011 the ambulance service made a referral to CSC describing concerns about the neglect in the home and in the care of Sibling 1; no assessment took place following a discussion with FN1 who believed that the parents were coping adequately and were accepting of help and advice; with hindsight this was an example of a judgment that relied too much on what the parents said they intended to do rather than what they were actually doing; the review highlights in later sections for example that in spite of sessions in regard to issues such as hygiene and home safety there was evidence of this advice not being taken seriously; for example, at the time Child Z died there was an electric kettle in the bathroom on an extension lead and filthy baby equipment as well as the overall evidence of neglect described in the introduction to this report; e) In June 2012 a referral was made from the duty nurse at the hospital emergency department; the referral contained reference to the neglected condition of Sibling 1, a report of a bruise to the child and information about FZ’s odd presentation of information. Although this was followed up with a joint visit that involved FN1 it seems that a prevailing mindset was unable to overcome MZ’s ability to rationalise and explain away information; in the opinion of the panel this was the clearest opportunity to have completed a more rigorous assessment about the needs and risks in regard to the children; it is highly unlikely that either child would have been removed from their parents care although there should have been a formal and structured multi agency enquiry and assessment and sharing of information; f) The strategy meeting held promptly after the death of Child Z did not result in any recorded decisions being made in regard to Child Z’s sibling or any other action in regard to the joint enquiries following the sudden death of Child Z. Information about the paternal family’s history was not identified or discussed until the second strategy meeting the following day when both parents were in police custody. Although the police had agreed to use their police powers of protection to keep Sibling 1 safe this did not extend beyond the immediate need to place Sibling 1 who had been apparently left with the paternal family. The reliance on a voluntary agreement with MZ and FZ for Sibling 1 to be looked after meant that the local authority did not acquire any shared parental responsibility for Sibling 1 in making arrangements. 96. The last referral in June 2012 was probably sufficient, given the evidence of neglect and a physical injury, for conducting formal S47 safeguarding enquiries. If this had resulted in a Child Protection Conference (CPC) there would have been opportunity to have shared the information more fully. If there had been a CPC and it had agreed a Child Protection Plan (or Child In Need Plan) was required, it would have meant that the case would have been subject to more explicit arrangements for sharing Page 20 of 84 Child Z SCR Overview Report published 051015 information and coordinating professional involvement. It would not have meant that Child Z or Sibling 1 would have been removed from their parents care. 97. There were opportunities for using the Common Assessment Framework (CAF) to coordinate information; this had been planned to take place as early as 2011 but was never done, initially being overtaken by the late birth of Sibling 1 and not being followed through because the concerns had been lost and FNP thought she could address the issues. 1.15 The family and other significant people and including relevant history 98. Child Z lived with MZ, aged 20 years; FZ who was aged 23 years and the 20 month old sibling (Sibling 1). Both parents had been known to different services. 99. MZ is one of six siblings. She had been known to children’s services during her childhood and had a history of interrupted education. She had experienced significant childhood trauma involving a house fire that destroyed all of the family’s possessions. According to the HOR one of her older siblings was the subject of a child protection concerns in 1990 because of physical abuse, but although this was taken to a child protection conference there was no child protection plan. 100. MZ had previously allegedly taken an overdose of prescription drugs and alcohol (50 beta-blockers and vodka) in November 2009 but had left hospital before a psychiatric assessment was carried out. MZ had also sought medical attention on two other occasions for a physical injury sustained during domestic arguments; in May 2010, MZ had punched a wall with her right hand, and in early June 2010 she had sustained an injury to her left foot from kicking her brother. MZ also has a medical history of childhood migraine and asthma. 101. FZ has a history of mental health and alcohol issues dating back to 2009 involving self-harm and attempted suicide. FZ was physically and emotionally abused as a child and was subject to a Child Protection Plan for eight months in 1992 when he was aged two years old following an injury as a result of domestic violence between his parents (paternal grandparents). When older, he suffered depression and low self-esteem and he also became known to the criminal justice services and was homeless for a period. 102. FZ has a domestic abuse history as a perpetrator between July 2003 and October 2009. In March 2008, there was an allegation that FZ had thrown a brick at a previous partner whilst she was pushing their child in a pram; no injuries were sustained and no further action was taken. In July 2010, MZ alleged an assault by FZ but was unwilling to formally complain. No action was taken. In May 2011, FZ and MZ were both warned under the Harassment Act not to cause harassment to his previous partner and family. Page 21 of 84 Child Z SCR Overview Report published 051015 103. FZ also has a criminal history between 2003 and 2010 involving offences of criminal damage, burglary, affray, assault, racially aggravated damage, robbery, offensive weapon, racially aggravated public order and theft. 104. Both parents have had some contact with mental health services although some of that support was disrupted for example because FZ was at times not registered with a GP; FZ was deregistered from the GP in late 2012 after he had failed to keep three medical appointments. There are also some gaps in information how information was recorded and summarised in regard to family history and the involvement of different services such as the Family Nurse Partnership (FNP). 105. FZ received treatment for a self-inflicted stab wound in March 2010 that had occurred following an argument, as well as longer term for his use of alcohol, drugs and depression; he was prosecuted for having a bladed article in a public place and was subsequently made subject to a 12 month community order with supervision by a probation officer in April 2010. 106. During one of his early supervision discussions he disclosed that he was using £20 of ‘skunk’ cannabis a day11 and in later sessions it seems clear that FZ was using the cannabis to ‘self-medicate’ and ameliorate his symptoms of depression and to try and reduce his reliance on alcohol; his effort to reduce alcohol may also have been influenced by knowledge that MZ was in the early stages of her pregnancy. He resisted advice and suggestions to accept a referral to mental health services to help with the depression. He did attend six sessions of ADS (Addiction Dependency Solutions) extended brief interventions for probation clients experiencing problematic substance misuse (alcohol and drugs) which lasted until June 2010. 107. In May 2010 he had told the Substance Misuse Practitioner (SMP) at the Addiction Dependency Service (ADS) that he had reduced his consumption now that his partner (MZ) was pregnant. 108. In May 2010 he was shot with an air rifle and wounded. He declined medical treatment and was reluctant to speak with the police. FZ was extremely agitated and angry and made threats to those who had inflicted the injury. The probation IMR discusses the implied risk of ongoing conflict resulting from the incident and with better reflection should have been more explicitly risk assessed at the time in consultation with other services. Further comment is provided in later sections of the report. CSC for example was not aware of this incident until this SCR. 109. It is unclear from records where Child Z’s parents had first met although it is known that they had both received treatment in regard to their use of alcohol and drugs. In November 2009 MZ had attended North Manchester General Hospital A & E department following an alleged overdose, she was reluctant to wait however and 11 Skunk is the generic name often used to describe a potent form of the cannabis plant. Skunk is only one of 100 or so varieties of cannabis plant which have high levels of tetrahydrocannabinol (THC). There is evidence that users are more likely to develop psychotic illnesses and exacerbate pre-existing mental health difficulties. Page 22 of 84 Child Z SCR Overview Report published 051015 left without receiving treatment. The police were subsequently asked to carry out a ‘welfare check’, which they did. MZ was found to at her mother’s home and she agreed to attend at the hospital A & E service later that day. 110. Both MZ and FZ were patients at Hospital 1 in early December 2009 following an overdose although it is not clear they knew each other although at least one of the IMRs thinks that they probably did know each other, at this time. Their first child was born 13 months later. In May 2010 MZ received treatment at a NHS Walk in Clinic for an injury to her right hand sustained by hitting a wall; there are no further records about the incident or regarding the location or circumstances. Such injuries have an association with incidents of domestic abuse; pregnancy is also a time when domestic abuse can become evident. 111. It was around this time that FZ was informing his probation officer about the pregnancy and was trying to reduce his use of skunk cannabis. In June 2010 MZ was treated for a displaced fracture to her foot following an argument with her brother. It was in June 2010 that the first record of the parents living together was made. 112. There is a brief history of four previous referrals12 to children’s services (CSC). In November 2010 there was a referral from the Probation service regarding MZ who was due to give birth in January 2011; and there was a request for a pre-birth parenting assessment of both parents ability to care for Sibling 1 owing to MZ’s perceived lack of compliance with ante natal appointments and her ability to keep herself safe due to a history of domestic abuse between the couple. The PO1 also described FZ’s history of offending and substance misuse. The information was reported to the community midwife service with the intention of offering MZ involvement in the Vulnerable Babies Service which had a focus on reducing the incidence of sudden unexpected infant deaths through promoting for example safe sleeping practices; she had declined this and there was no direct conversation between FRT and the midwifery service. Further information and analysis is provided in later sections of the report. 113. In terms of the home conditions various health and housing services had been assisting to ensure that adequate repairs and support including access to facilities were put in place. There was a problem with the shower (that took several weeks to resolve during 2012). There was clutter in the house and the floor in the living room was dirty. There were no floor coverings in most of the house. The children’s bedrooms were checked and found to have adequate beds and bedding. Further information about the visit and assessment is provided in later sections of this report. 1.16 Cultural, ethnic, linguistic and religious identity of the family 12 The issue of whether the four occasions were referrals is considered in more detail in later sections of this report along with the action that was taken. Page 23 of 84 Child Z SCR Overview Report published 051015 114. Child Z’s maternal and paternal families are white British. Their first and only language is English and there is no recorded physical or learning disability by the services involved with Sibling 1 or Child Z until the first strategy meeting after the death of Child Z when there is reference to the parents having unspecific learning difficulties. 115. Child Z was living with both parents and the older sibling in rented accommodation at the time of the death in an area of Manchester that is amongst the ten per cent of the most deprived areas in England. Both parents were and remain unemployed. 116. The area has a higher concentration of white British people compared to the city’s overall population profile. The area has higher levels of children living in poverty, with ill health and experiencing crime. The area has a higher concentration of adults who have no educational qualifications. 117. Although the particular ward that Child Z lived in is not the most deprived district in Manchester it is an area which is one of the most deprived areas in England. In spite of the social challenges in the area, it is a place that appears to be one where people are relatively settled based on factors such as tenancy turnover, transfer requests and length of time people remain in their homes and living in the area. 118. There is evidence that Child Z’s family were part of an informal community that provided support and practical help and for example shared or swapped items of household and baby equipment. The FN1 had not seen the filthy baby chair found in the house on the day that Child Z had died. 119. The North West of England has a higher rate of teenage pregnancies; there are also higher concentrations of families living in social housing and a lower proportion of children are living in two parent households. 120. There are 115,910 children and young people aged 0-19 years living in Manchester according to the 2009 mid-year population estimate. This accounts for 24 per cent of the city’s total population of 483,830. Manchester has been growing at over 1 per cent a year since 2001, twice the average rate of growth in England and Wales. The number of children aged five to 14 years has decreased during this period, but there has been an increase of over 20 per cent in the number of children aged under five. 121. The 2007 Index of Multiple Deprivation ranked Manchester as the fourth most deprived local authority area in England. In 2009, 77 per cent of pupils lived in one of the 20 per cent most deprived areas in England. The area in which Child Z lived is one of the 10 per cent most deprived areas in England. In 2010, 37 per cent of primary school pupils and 34 per cent of secondary school pupils were eligible for free school meals, significantly more than nationally. In the 2001 census, 31 per cent of children and young people aged 0 to 19 years were from minority ethnic groups compared with 26 per cent for the total population. According to the January 2010 school census, 35 per cent of primary school pupils and 30 per cent of secondary school Page 24 of 84 Child Z SCR Overview Report published 051015 pupils spoke English as an additional language, well above other areas of the country. Over 170 languages are spoken across schools in Manchester. Page 25 of 84 Child Z SCR Overview Report published 051015 2 Synopsis of agency involvement 122. This narrative summary of professional contact with Child Z provides an account of the most significant events and decisions from the different services involved with Child Z during the timeframe established for the review. It does not give an account of every contact with an individual professional or service. 123. For example both parents had routine consultations with the GP that are not included in detail in this chapter; this includes detail about the missed appointments in regard to MZ for ante natal care. There were 46 individual contacts by the FN1. The Probation service arranged six sessions of brief intervention treatment at the Addiction Dependency Solutions service for FZ that are not all recorded in this narrative as well as the other work related support for example at the Achieve service on helping FZ improve his employment prospects through work skills assessment and development. 124. Similarly there was a high level of contact by the housing provider in regard to repairs at the third and final address, some of which are described when relevant to this summary of key events. MZ was registered with the local Sure Start service from early February 2009 up to January 2012 but was an infrequent user of those activities. 125. This summary, and indeed the whole Overview Report, has to strike a balance between protecting the confidentiality of the children, their family and the various people who were in contact with them whilst providing a sufficiently detailed account of events in order to draw out the points for learning and development in the later chapters. It is also the first time that the overall story of Child Z and the family has been collated as a result of the detailed work for this SCR. 126. The pregnancy with Sibling 1 was formally booked at 15 weeks into the pregnancy in June 2010; a first ante natal check is usually between eight and twelve weeks. A specialist Teenage Pregnancy Midwife (TPM) identified that MZ had received historical support from a social worker and had a history of some depression in the past; referrals were made to Connexions and to the Family Nurse Partnership (FNP)13. The referral to the FNP was subject to some delay before the Specialist Nurse (FN1) saw MZ that was attributed to allocation methods that existed at the time and a period of illness between early March and early July 2010. 127. MZ had been living with her family but she was told to leave in June 2010. It is not known if the pregnancy, which by this stage was confirmed, was the catalyst for this. MZ sought help from Connexions to address her homelessness. 128. Around the time the pregnancy was confirmed and a referral was made to the FNP, FZ was formally warned about missing a scheduled activity under the terms of 13 The FPN was being established at the time and was the subject of a formal programme of research and evaluation designed to collate empirical evidence to help inform further development to of the service model and practice at local and national levels. Page 26 of 84 Child Z SCR Overview Report published 051015 his community order; up until that point he had been complying well with the order which was in marked contrast to his response following previous offences. He had been using supervision sessions to discuss his current circumstances including his use of cannabis and the fact that his girlfriend was pregnant. He talked about his abuse as a child and apparently the relationship with the paternal grandfather was still an abusive relationship. In later sessions in July 2010 it became evident from the recording that FZ was resisting any advice in regard to drugs, health or employment; he superficially complied by turning up for supervised appointments and engaging in discussion but showed very little motivation or determination to address his areas of difficulty in spite of the fact that he was due to become a father. 129. In mid-July 2010 MZ made an emergency telephone call to the police asking for assistance to deal with a domestic argument that was ongoing with FZ. A uniformed police officer arrived within three minutes although FZ had already left the property. MZ said that she had been in a relationship with FZ for about a year and although there had been previous arguments this had escalated to physical violence. 130. MZ informed PC3 that she had been in an ‘on/off relationship’ with FZ for approximately a year and that they had been arguing all day in relation to splitting up. MZ stated that although they often argued she had never called the police before. It had escalated when MZ had intervened in preventing FZ from taking MZ’s brother’s computer X-Box from the property14. MZ told the officer that she was pregnant although declined to confirm who the father was. MZ declined to make a formal written statement because she did not want to get FZ into further trouble. 131. A report of the crime was submitted and an application for special measures was also completed; all of this information was given to MZ with the objective of ensuring that she received reassurance that the police were treating the domestic violence as a serious matter for her and for the baby. 132. A referral was made via the police Domestic Violence Unit (DVU) to the Health Visitor although there is no record of this being received in the health records. Attempts were made to achieve an early arrest of FZ which is consistent with a proactive and positive action policy towards domestic violence although as part of that effort a voicemail message was placed on FZ’s mobile phone to inform him that the police wished to speak with him. This was naïve as it could have increased the risk of further violence towards MZ. Further analysis is provided later in this report as well as in the police IMR regarding the management of domestic abuse and the common difficulties associated with investigation and prosecution and in particular when responding to families who may feel suspicious and wary of services such as the police. 133. During this police response to deal with the domestic violence, potential weapons were observed hanging from nails in the living room wall. These included a wooden 14 Although the IMRs do not state any further information in regard to why the attempted theft was being made it is probably relevant that FZ was still using significant quantities of cannabis and was unemployed. Page 27 of 84 Child Z SCR Overview Report published 051015 rounder’s bat, a large piece of plastic and metal gas piping, a metal coping saw and an axe with a wooden handle. MZ claimed that all of the weapons had been placed in the room by FZ and she handed them over to police for their destruction. No more weapons were on visible show although there were numerous pairs of large sharp scissors around the house which could be used as a weapon. This information about weapons was logged for police intelligence purpose although it is less clear whether it was included in the information provided to the Health Visitor which was never apparently received. 134. Given the information in regard to the domestic violence involving a pregnant woman and evidence of weapons in the house it would be expected practice for a safeguarding referral to be generated from the police to CSC. This was not done and it remains unclear what factors caused this. 135. In late July 2010 MZ missed a planned ante natal appointment. This was reported to the TPM who subsequently followed it up by a home visit from FN1 to see MZ the following day. MZ was out but she subsequently contacted FN1 and apologised and spoke positively about the pregnancy and was generally talkative. Commitments were made to complete relevant paperwork for a support session and an agreement for a follow up home visit to be made a week later in early August 2010. 136. The IMR author comments about a previous SCR having introduced a requirement for the specialist health practitioners to check historical archived health records for teenagers who are pregnant which was not done in this case; it was a recent action and just being introduced at the time. The same IMR also points to the effort given to establishing a positive relationship with MZ at the outset and working to overcome any initial resistance; this is important and sensitive practice especially in relation to young mothers who may have very poor experiences of statutory services that leaves them fearful and unwilling to have contact and ongoing help. This is explored further in later analysis in the report. 137. In late July 2010 a police intelligence report identified that FZ and his brother, BFZ, who was living with FZ and MZ, might be responsible for a physical assault on two teenage boys (13 and 16 years old). Although the police IMR confirms that the information was managed in compliance with the police service standards there does not appear to have been any cross reference to the incident of domestic violence that the service had responded to less than two weeks previously and the information in regard to FZ having a history of violence and was living with a pregnant and young partner. 138. In mid-August 2010 the FN1 completed a national monitoring form during a home visit to MZ which provided a structured collection of relevant information associated with the pregnancy. The form asked for information in regard to lifestyle such as diet and smoking by both of the parents, explored MZ’s emotional and psychological as well as physical health as well as seeking information about evidence of domestic abuse. Page 28 of 84 Child Z SCR Overview Report published 051015 139. The questions were all answered in such a way as to provide a positive picture about the pregnancy but were not necessarily true. For example MZ said there was no domestic violence in spite of the request for police help in July 2010 and the disclosure that there had been previous arguments including with her brother that had resulted in her being injured in June 2010. 140. Although MZ did disclose domestic abuse this was attributed to the maternal grandmother. There was no reference to the use of cannabis. Further analysis is provided in the IMR and in later sections for this report in regard to the difficulties facing professionals relying on such self-disclosed information from parents. 141. MZ was admitted to a hospital gynaecology ward on two occasions during August 2010. There is no reference to any screening for domestic violence and it is not apparent that the hospital was aware of the incident in June or July 2010 or the general history of FZ. 142. In late August 2010 the Probation service completed the four monthly review OASys assessment. The review highlighted some ongoing accommodation issues but was otherwise positive; this is also based primarily on self-reported information; FZ has reported that he was feeling more positive through an improved lifestyle and an improvement in his relationship with his Father (FFZ). The IMR highlighted the absence of any reference to the shooting incident and the risk management plan was ‘vague’. 143. The home visit by the FN1 at the beginning of September 2010 includes reference to the house ‘falling down’ and the family having to move out by the end of the week. This is the first reference to the physical condition of the house which appeared to be unsatisfactory for habitation by a young child; neither of the parents were tenants of the property which appeared to have been rented by FZ’s brother. The IMR notes that the family did not meet the thresholds for the Vulnerable Babies Project (apart from being homeless) but would have if other vulnerabilities had been known. The FN1 also refers to the inability to have her phone call to the homeless families service answered. 144. A further home visit two days later found MZ in a ‘brighter mood’ with plans to return to college. She completed the HAD15 questionnaire that identified some milder depression (four) and anxiety (ten) but included no information about MZ. The IMR explains that a combined total of ten or more is moderately high indicating some follow up but not for more urgent help. 145. In September 2010 the GP was made aware that MZ had contracted an infection during pregnancy. This represented some enhanced risk to MZ’s baby and for a premature birth. The GP was told that MZ had not attended for treatment on four occasions. 15 The Hospital Anxiety and Depression Scale is a screening tool validated for use in health services. Page 29 of 84 Child Z SCR Overview Report published 051015 146. On the 10th September 2010 the FN1 found the family home front door boarded up. She attempted unsuccessfully to contact MZ by phone. The FN1 had no alternative contact details. There followed two failures to attend antenatal appointments until FN1 was able to arrange to meet MZ in a car park on the 24th September 2010. MZ agreed to meet at the car park again on the 28th September to take FN1 to the new house as it ‘was difficult to find’. Although this might appear naïve it was another example of the dilemmas that face health and other professionals trying to establish and sustain a relationship with young vulnerable adults. Further analysis is provided in later sections of the report. 147. The planned follow up meeting in the car park did not take place; FN1 tried to contact MZ by mobile without success. The TPM spoke with FZ on the 5th October 2010 who said that MZ was at college and would contact TPM as soon as possible. An arranged visit was achieved on the 26th October 2010. 148. On the 5th October 2010 the Probation service withdrew a warning letter to FZ for his non-attendance when the Probation Officer was told that FZ had been moving house on the day in question. The following day the Probation service put a Child in Need (CIN) ‘flag’ on the electronic records; this appears to have followed receipt of information about the domestic violence incident in July 2010 and ‘other information received from other agencies including DV unit and social services’. 149. The IMR author is unsure of why the CIN flag was inserted and identifies some confusion in regard to the Trainee Probation Officer’s understanding about the process. This is explored in later sections of the report; the significance here is not so much whether a procedure was sufficiently understood and complied with but rather the degree of insight and understanding about the significance of CIN indicating a child who may be prevented from appropriate development as a precursor to more serious concerns about significant harm; in this case Child Z had yet to be born and therefore there was no child to be the subject of any process. 150. On the 6th October 2010 there was consultation with a Senior Probation Manager regarding the case that included the police service’s interest in arresting FZ in regard to the domestic violence and other issues. Advice was provided to check whether children’s services were aware of MZ and to consider making a referral and to also consider whether a MARAC16 was required. The referral was not made to CSC until the 29th November 2010. 151. FZ attended with MZ at a police station on the 11th October 2010 and was arrested in regard to the domestic violence in July 2010 and the alleged assault on the two adolescents. He was interviewed by the police and provided a different account of the circumstances of the incident of domestic abuse with MZ in July 2010; he attributed it to MZ being jealous. MZ made a statement of retraction. No charges were made in regard to any of the assaults due to absence of witness evidence. MZ and FZ were staying with the maternal grandmother. Further analysis about the 16 Multi agency risk assessment conference Page 30 of 84 Child Z SCR Overview Report published 051015 detection and investigation of domestic violence and working with reluctant witnesses is provided in later sections of this report. 152. The following day FZ told his Probation Officer that he had been to the police who were dropping their interest in the domestic violence which he did not wish to discuss. He also said that he was living at his father’s home with MZ in contrast to the information provided to the police. The Probation IMR identifies concerns that the information about MZ sharing a house with FFZ was not regarded as significant given the known history of abuse and violence and the implication it had for the parents and the unborn baby. The probation officer emailed the police DVU asking for further information about the domestic violence although did not have a date for the incident. 153. The IMR from Probation comments that the information about domestic violence should have resulted in a re-categorisation of the case to a higher level; the significance would have been for the officer’s workload. A re-categorisation could have resulted in the individual workload being adjusted to allow improved capacity to undertake relevant work related to the domestic violence. 154. On the 28th October 2010 FZ was issued with a third warning about his failure to keep to an appointment with his probation officer; he claimed confusion again about arrangements this time in relation to the job centre. The Probation IMR explains that three warnings require a referral to a manager which did not take place in this case. This pattern of missing appointments that is not apparent to the individual practitioners at the time and offering a plausible explanation is an underlying pattern familiar in reviews; it is sometime symptomatic of disguised compliance that is a theme relevant to this case and is explored in later sections. 155. In early November 2010 MZ accompanied FZ for an appointment with the Probation Officer. She was talkative and communicative and both seem agreeable to FZ being referred again to Achieve to help with work related skills and self-esteem and confidence. The Probation IMR comments that all of this was very relevant given the family’s circumstances and the need to keep FZ occupied. MZ was asked about the midwife’s details; a first name was provided based at a local clinic indicating some reticence in sharing too much information. 156. The following day the Probation Officer (PO1) consulted the Probation MARAC17 representative to inquire whether there are any referrals to the panel pending in respect of MZ. There are not and PO1 is advised that a referral can be made if it is considered appropriate but the deadline for the next panel was the next day. PO1 was told that the police had made a referral to social services and health due to the pregnancy. 17 The Multi Agency Risk Assessment Conference, or MARAC, is a regular, multi-agency meeting to support high risk victims of domestic violence and abuse. Page 31 of 84 Child Z SCR Overview Report published 051015 157. On the 15th November 2010 FN1 made contact with MZ who apologised for not being in touch; she had changed mobile number, had been on holiday, her nephew had died and MZ provided the new address. FN1 gave condolences and arranged to meet on 22nd November 2010. The IMR comments that MZ had been disengaged from support for six weeks. 158. The following day FN1 has a supervised discussion with FN2. Key issues for the baby were identified as MZ having recently moved in with her boyfriend (FZ); MZ appeared to be attached to baby, she had been doing work prior to moving and then losing contact (rather than being seen as disengagement), was living in an area of significant deprivation, had engaged initially but then moved, had lost contact and had changed her phone. FN1 had managed to find MZ who had an appointment to restart the programme. The recorded summary of documented analysis was a history of family abuse with a poor attachment to her MGM. Protective factors that were identified included MZ being in college, she enjoyed the FNP work, had a stable relationship with her boyfriend, and had been re-housed via homeless services. 159. Further analysis is provided in later sections of this report in regard to some of the misdirection that had taken place inadvertently and in spite of the structured analysis it was highly reliant on self-reported information and short episodes of observed behaviour. This is not to criticise FN1 or other colleagues who were showing persistence in overcoming obstacles to MZ being accepting of help and support and were working with a framework of collating information and subjecting it to critical dialogue and analysis. 160. On the 18th November 2010 MZ again accompanied FZ to Probation and was again talkative and open in her communication. She discussed the fact that because she was a pregnant teenager she was having support from a specialist midwife. It was agreed that a referral would be made to CSC although there is no explicit record of this being discussed with MZ or FZ. The referral was not made until the 29th November 2010. A telephone call was made to CSC and a telephone discussion between PO1 and a social worker established that MZ was known to CSC as recently as 2009 although it was ‘through her mum’. 161. There is no clarity about what this means in the discussion or in recorded log of the call. The enquiry confirmed that a referral to CSC was required. The Probation IMR acknowledges that it was a good example of multi-agency information sharing although the referral is not made for ten more days. This could be a reflection of several different factors such as other tasks that PO1 was simultaneously involved with but are not described or analysed. 162. A home visit on the 22nd November 2010 by FN1 provided an opportunity for discussion with MZ and FZ about preparing for the birth; MZ was eating and sleeping well and both parents were agreeable to looking at material including DVDs as part of their preparation for the baby’s birth in January 2011. MZ missed a scheduled ante–natal appointment a week later on the 29th November 2010. Page 32 of 84 Child Z SCR Overview Report published 051015 163. The referral to CSC from PO1 on the 29th November 2010 provided a summary of information known to PO1 and asked for a pre-birth assessment to be undertaken by CSC; there had not been a home visit by PO1 and there never was during the entire length of the community sentence. 164. The information included the following; under 18 pregnancy; difficulties in contacting Midwives and Health Visitor; MZ had been previously known to social care services in 2009; there had been a domestic violence incident in July 2010; she was currently sharing a property with a close relative of FZ who was a known domestic abuse perpetrator and has also been flagged by the probation service as a “risk to staff”; FZ’s mental health and self-harm issues, previous hospitalisation for depression and self-harm in 2009, current offence of possession of bladed article which involved FZ stabbing himself. 165. The referral requested that children’s services should conduct an assessment of FZ and MZ’s parenting abilities and their compliance with pre-natal appointments and advice; MZ’s ability to keep herself and the unborn child safe; the suitability of the current address given concerns regarding FZ’s relationship with FFZ and his history of abusive behaviour. The referral also requested to know the contact details of the Midwife and Health Visitor and any inter-agency working agreements. 166. A health habits form completed by MZ in early December 2010 again presents a positive lifestyle response in relation to diet and issues such as ingestion of alcohol or drugs as well as stating here was no domestic abuse; the form again does not include information specifically about FZ. 167. On the 2nd December 2010 CSC sent a fax to the midwifery service confirming that they had received a referral from PO1. The fax incorrectly suggested that MZ may have had another child who was in local authority care; it is not clear whether PO1 or CSC had added this detail. The fax asked whether this was a case for the Vulnerable Babies Service (VBS) and stated that CSC would not take any further action until they had a response. 168. The role of VBS is to reduce sudden death of babies through promoting good practice in regard to leading on issues such as safe sleeping. Although the VBS would almost certainly have accepted a referral if all the risk factors had been known, there was insufficient information provided to prioritise such a referral and therefore VBS did not become involved. 169. Further analysis is provided in later sections of the report in regard to how the enquiries by CSC were handled and the circumstance under which the responsibility for an initial assessment of MZ’s circumstances were being delegated. 170. CSC contacted PO1 who confirmed the details of the midwife involved with MZ. The duty worker advised PO1 that CSC would close the case. A significant factor recorded on the probation log of the conversation appeared to be the belief by CSC that there were already a sufficient number of professionals already involved. Page 33 of 84 Child Z SCR Overview Report published 051015 171. Given the overall workload pressures on the service and the known potential for families to become overwhelmed by too much contact with too many different professionals this was not an entirely unreasonable judgment. However, neither service had addressed the risk factors that had been set out in the referral from PO1 to CSC. 172. Although the CSC recorded that details of the situation were explored with relevant agencies the only evidence of any contact is the fax to the midwifery service and the telephone discussion with PO1. The referral was signed off as NFA (no further action) by the appropriate manager. A letter was sent to PO1 confirming the outcome. 173. On the 8th December 2010 and after a further failed appointment by MZ the previous day with the TPM, she had a telephone discussion with FN1 to discuss the information that had been sent from PO1 together with the information of missed appointments. Although they record that a plan was agreed it is unclear what specific actions were to take place and by whom. 174. For example they discussed whether a CAF was appropriate. They considered the vulnerable baby project but that was considered as not available because the family were no longer homeless (although they did not have their own tenancy). The CAF was the ‘expected plan’ due to the additional needs being identified. The conversation did not appear to identify and discuss any of the indicators of risk. 175. On the 10th December 2010 the TPM made a home visit and saw MZ and voiced her concerns about her ‘lack of engagement with antenatal care’. The ‘lack of engagement’ may have been expressed more explicitly in person and during the conversation with MZ but the use of quite abstract language especially with a young parent who seems nervous and resistant to services and did not complete her education is fraught with the potential for miscommunication and misunderstanding. 176. Two days later on the 12th December 2010 the TPM completed a Special Circumstances Form (SCF)18. The SCF has some significant and misunderstood information and does not include evidence of risk from facts such as a history of violence in this and previous relationships. The SCF states MZ has not attended all of her antenatal clinic appointments, that FZ was (rather than is currently) known to a ‘Parole Officer’ (rather than a Probation Officer subject to a community sentence) due to anti-social behaviour. The SCF refers to the ‘Parole Officer’ having raised concerns about MZ and FZ’s ability to parent. Children’s Social Care (CSC) were contacted with the concerns however, TPM was informed that no further action was necessary. Family Nurse Partnership (FNP) Nurse had been contacted and she had stated that initially MZ was difficult to contact, however she felt that MZ’s ability to parent was acceptable. 18 The SCF is a record of concerns / actions that is sent to the safeguarding team, community midwives and health visitors with a copy placed within the patient notes to ensure all staff are aware of the concerns Page 34 of 84 Child Z SCR Overview Report published 051015 177. There was no information recorded about how the judgments being expressed and recorded were evidenced. The SCF states that a referral to the Vulnerable Babies Service was offered and had been refused. An assessment and plan using the Common Assessment Framework (CAF) had been discussed and MZ had consented to this assessment. The plan was to re-visit MZ and complete the CAF in conjunction with the FNP on the 16th December 2010. Further analysis is provided in later sections and in the IMR. 178. A supervision session for FN1 on the 13th December 2010 discussed the information. The focus was on whether the parents could be good enough parents; there was no explicit discussion about the evidence of risk factors and it was acknowledged that the history of both parents was incomplete. 179. The planned visit to MZ on the 13th December 2010 by the TPM and FN1 was cancelled due to MZ not being in. The visit had been prearranged with the purpose of discussing the pattern of missed appointments and to talk about the planned CAF. The IMR acknowledges that the cancellation probably contributed to concerns becoming lost. There were two further missed appointments before Christmas although MZ did attend for an obstetrics appointment at hospital. 180. The updated OASys in December 2010 identified that FZ continued to be assessed as at “high” risk of reoffending and at a “Medium” risk of serious harm. During a telephone discussion at the end of December between PO1 and the TPM agreement was made to undertake the CAF in January 2011. 181. A visit by FZ to the probation office in early January 2011 made clear that FZ was unhappy that information about domestic violence had been shared with the TPM. 182. Two days later Child Z’s older sibling was born at 41 weeks gestation and weighing 3240g and was physically well baby. MZ had been admitted via ambulance; she denied having missed any antenatal care although the SCF completed by the TPM was available to the hospital. 183. A midwife at North Manchester General Hospital contacted CSC through the Emergency Duty Service (EDS) informing that MZ had given birth to Sibling 1 and highlighting concerns that she had not accessed ante natal care, had frequently moved home and had declined support from the vulnerable babies’ service. FZ was also known to the probation service that had concerns that he was known for weapons, homelessness, alcohol problems and previous incidence of domestic abuse. FZ smelt of cannabis and MZ appeared drowsy. 184. EDS requested that MZ was not to be allowed home with the baby although the hospital stated they had no grounds upon which to prevent her leaving. Although MZ had initially agreed to stay in hospital for 48 hours, she self-discharged against medical advice the day after the birth; she had raised blood pressure which had some significant risk to MZ’s health associated with pre-eclampsia. Page 35 of 84 Child Z SCR Overview Report published 051015 185. The TPM visited the day after discharge. The CAF checklist was not completed. CSC was told that MZ had discharged herself. FN1 made a home visit two days later and observed both parents caring for and interacting with their baby positively; she recorded that there was evidence that this was ‘a much wanted baby’. The significance and meaning of babies for new parents is seen as an increasingly important area for professional assessment when working with new born and very young children and is explored in later sections of this report. 186. On the 21st January 2011 the TPM discussed undertaking a CAF with the FN1. FN1 felt that a CAF was not required as MZ was coping well with the support of the FN1. 187. At the end of January 2011 MZ transferred to a new GP practice. Although no reason is recorded in the patient records the IMR believes that the transfer was caused by the previous practice closing due to the death of the GP. 188. In early February 2011 FZ and MZ were warned by the police under the Harassment Act 1998. This had followed a confrontation on a street in Manchester involving FZ’s previous partner; FZ was reported for threatening to smash windows on a motor vehicle and MZ was also reported to have used threatening words to the ex-partner; the relationship with FZ had apparently ended over three years previously. The warning was administered in mid-February and an entry made on the harassment register. This information was not shared with any other service and there is no information about the circumstances of how the confrontation occurred. 189. In mid-March 2011 FZ received treatment for an injury to his hand; he had fallen in the street as he walked home from the pub in the mid evening. Five days later the police dealt with a domestic incident that was phoned in by an anonymous caller who was overhearing FZ and MZ screaming at each other with sounds of a distressed child in the background. Two uniformed police officers attended within six minutes although found no domestic incident to be evident; FZ had reported shouting up the stairs to MZ who had just woken. The call was logged as being with ‘good intent’. 190. In early April 2011 FZ completed his community sentence and supervision by PO1 came to an end. FZ had missed two appointments during the first four months of 2011. The closing assessment concluded that FZ had improved stability in his life and that all sentencing objectives had been met. 191. In May 2011 MZ was confirmed to be nine weeks pregnant with Child Z. The booking included a routine screening for domestic violence (a negative and misleading response was provided from MZ) and noted a history of some depression; MZ also said that she had never had social work support. The booking noted that MZ had been supported by the FNP; it also recorded brief details about FZ being unemployed. 192. The midwife history taking in relation to the pregnancy with Child Z revealed a significant history of childhood death in MZ’s family. The circumstances of the deaths Page 36 of 84 Child Z SCR Overview Report published 051015 were not apparently enquired into. It is not clear if the information was known to the GP. 193. In June 2011 the family were offered their own tenancy. In mid June 2011 MZ was taken by ambulance to hospital having been vomiting. A referral was made by the ambulance crew to CSC; they were concerned about conditions in the home; they reported the house to have rubbish thrown on the floor, dirty nappies on the floor, smell of faeces. Sibling 1 was described as being propped up with a cushion; the child was dirty and wrapped in blankets even though it was a warm day. Sibling 1 became upset and the crew noted that the child was not acknowledged by either parent. 194. SW1 in CSC contacted health services, who reported that FN1 was routinely involved with the family. FN1 was contacted and reported positively on MZ’s level of care and stimulation, and she felt that MZ would be upset if contacted by CSC. FN1 agreed to visit and discuss with MZ in the first week of July (two weeks after the referral). The family was due to move house the following week. CSC informed the regional ambulance service of the outcome to their referral. 195. FN1 made the agreed home visit and discussed the referral. Sibling 1 was seen to be very happy, to smile and was ‘interactive’. FN1 discussed introducing different foods, finger foods, floor time, to encourage rolling and use of upper body to promote crawling. Sibling 1 was seen sitting with parents, happy, smiling and sociable. MZ informed of the concerns raised by ambulance crew which was recognised. The issue of ‘clutter’ was not apparently addressed according to the IMR. 196. The following week MZ contacted the police to report that she had been forced out of her property by the landlord over a dispute regarding payment of the rent. The landlord had refused to allow MZ to get her belongings out of the house. Whilst she was on the phone the landlord had returned and had allowed access to the property to recover her property. MZ confirmed she did not require police assistance and that she had an address to move to. Details were not taken. Information was not shared with any other service. 197. In mid-July 2011 Sibling 1 was diagnosed with oral thrush; the IMR comments that the indication of poor hygiene was a significant factor. 198. In August the demographic update on the Infant Care Form records that Sibling 1 was not fully immunised and MZ was no longer at college. No information was recorded about FZ; the IMR comments that this was a limitation of the data collection form that was used at the time. Sibling 1 was seen in clinic and was putting on weight appropriately and appeared to be developing and was in good health. 199. At the end of August 2011 complaints were made about anti – social behaviour at or around the house. This included noise, groups of people gathering and rubbish being thrown in the street. MZ attended an interview with the housing officer; during Page 37 of 84 Child Z SCR Overview Report published 051015 the interview MZ said that FZ was not a member of the household; she suggested he was there on a daily basis but left mid evening. 200. In early September 2011 it was noted that MZ had missed several ante-natal appointments. The community midwife made a home visit to follow up; MZ put the missed appointments down to moving house. 201. From late October 2011 FZ was less involved in visits and contact by FN1; the IMR from CMFT comments that up until this point FZ is not involved in the Partners in Parenting Education (PIPE) and was not present at visits from this stage onwards which was unusual19. There are times when he was in the home but did not fully engage in the activity as he had previously. FN1 had stated that FZ had shown great involvement in the programme and this could have prompted further exploration at the time. The key issues summary completed in early November stated that FZ and MZ were both engaging well which reflected the established pattern up to this point. The same summary also refers to an improvement in the clutter observed in the house although is non-specific and includes no indication as to whether conditions were regarded as satisfactory. 202. In mid-November 2011 FZ registered with a new GP who was the GP that MZ was already registered with. 203. In mid-December Sibling 1 was taken to A&E by MZ in the early hours; the child had been generally unwell for about a week. MZ reported having seen the GP and Sibling 1 being prescribed an antibiotic; there is no record of a consultation being sought with the GP apart from a consultation for MZ about a sore throat. The HOR comments that it raises the possibility that Sibling 1 had been given the antibiotics that had been prescribed for MZ. After two hours MZ said that Sibling 1 was much better and left the hospital. MZ did not make an appointment with the GP the following day as agreed in the discharge paediatric letter. 204. The demographic update form that was completed at the end of December provided a positive summary of the parents’ relationship and their care of Sibling 1. The IMR comments that there was no evidence that information was collected from FZ and there is no reference to FZ’s use of cannabis or to the previous involvement of probation and safeguarding concerns. This information was collated just prior to Child Z being born at the end of December 2011 at 40 weeks gestation and a birth weight of 3360g. 205. MZ and Child Z were discharged on the day of the birth and it was recorded that they were living at the grandmother’s home although no indication as to whether this was the paternal or maternal grandparent. 19 PIPE provides a major component of the FNP programme’s approach to the development of competent parenting and aims to develop the understanding and skilfulness of the clients in relation to their care giving role, in order that their babies receive the responsive and sensitive care that will enhance their development and the caregiver/infant relationship. Page 38 of 84 Child Z SCR Overview Report published 051015 206. The health IMR comments that the GP was notified about the birth but was unaware of the involvement of FN1; the midwifery service also appeared to be unaware of the FN1’s Involvement. FN1 made a home visit two weeks after the birth and support was agreed with MZ through the Healthy Baby Programme. FZ was in the home but he continued to be unavailable to professional contact as commented previously. 207. MZ was observed to interact well with Child Z during routine contacts and clinic visits. Child Z was feeding well and putting on weight. MZ was on one occasion described as reading ‘beautifully’ to Child Z by the end of January 2012; there is no reference to clutter. 208. By the end of February 2012 it was observed that there had been missed appointments and immunisations were required. 209. In March 2012 the family had rent arrears and MZ made enquiries about having a bath fitted to the property rather than relying on a leaking shower. 210. There was an attempted break in to the property while MZ was in the garden that had resulted in the front door being damaged. The police were called. No entry had been gained and no witnesses were identified and house to house enquiries proved negative. A crime scene investigator later attended and took photographs and a gel lift of the foot mark on the front door. MZ was contacted by telephone by the crime reduction unit and a standard victim letter was sent to her. In addition, a reassurance visit by a uniformed patrol was conducted together with cocooning in the immediate area of the address. The police IMR author explains that this is a reactive police strategy to protect against residential burglary that can be employed following a ‘spike’ in residential burglaries within a certain area. 211. The argument about a bath continued over several weeks with the landlord declining to fit a bath as MZ had been aware of the absence of a bath when she had accepted the tenancy. For MZ, this did not address the issue of whether the property was suitable particularly now that MZ had a second baby. Further analysis and comment is provided in the IMR and in later sections of this report. 212. By the end of March MZ was becoming increasingly upset by the problems with the bathroom; she was washing herself and the children in a bowl due to the shower not working. There were ongoing problems in regard to repairs to the bathroom and front door that continued through to the summer. 213. In mid-April 2012 FZ was again facing criminal prosecution and a pre-sentence report was required. PO1, the Offender Manager who had provided the previous supervision, was again assigned to FZ. Discussion during the initial session focused on identifying what FZ regarded to be the most important factors to be addressed on the new order. The discussion revealed a contrasting picture of problems that do not Page 39 of 84 Child Z SCR Overview Report published 051015 appear to have been apparent to other professionals such as FN1 who was optimistic about the family’s circumstances and capacity. 214. Issues highlighted by PO1 during the discussion with FZ include his mental health, use of alcohol, not having his own accommodation (disguised homelessness) and building family ties. FZ considered his use of alcohol to be the most important factor to reduce the likelihood of reoffending and PO1 explained that she would make a referral to Addiction Dependency Solutions (ADS) for assessment and on-going intervention; FZ had previously been helped by the service. 215. The family’s need for accommodation was explored. FZ was living with MZ and her mother. PO1 had verified with MZ’s mother that she was happy for FZ to reside there. All seemed fine. FZ’s mental health was explored. FZ had been referred to the community health services by his GP. FZ was not currently on medication as this made him feel worse than previously. FZ had been previously hospitalised as a result of self-harm and an overdose of painkillers and alcohol in December 2009. FZ admitted he could act irrationally and suffered from black-outs. 216. PO1 discussed referral to the Manchester Offenders Diversion Engagement Liaison (MO:DEL) Team20 for support with these mental health concerns. FZ refused to allow this referral as he felt the issues had already been dealt with by his GP. MZ’s relationship status was explored. FZ disclosed that MZ was 17 years old and attended college; she in fact had not been attending for some months. He stated that she did not drink or smoke; she in fact did smoke. 217. In mid-April 2012 MZ reported to FN1 that Sibling 1 had fallen in the shower causing a cut to the head. Work was being undertaken in the bathroom by contractors that had required the removal of some tiling in the shower. It was apparently assumed that Sibling 1 was in the shower with a parent when she fell though this is not detailed in the records. The IMR from CMFT comments that a CAF should have been suggested at this stage due to the housing issues, maternal mental health needs and the impact on child safety. It is apparent from the information revealed during PO1’s initial assessment interview with FZ that there were other significant needs that were not being recognised at the time. 218. The OASys assessment that was completed in April 2012 for the pre-sentence report concluded that there was a high risk of re-offending by FZ and that he represented a medium level of risk of harming somebody known to him (low in regard to the general public). The risk of serious harm summary mentioned concerns relating to potential risks to MZ and to MZ’s father but little detail were provided about what evidence this was based upon. 219. The sentence plan included objectives to address self-harm and alcohol misuse and the need for acquiring more stable and long-term accommodation. The probation 20 MO:DEL has won awards for the provision of a multi disciplinary service to work with offenders who have co-morbid mental health needs, learning disabilities or other complex health needs that included substance misuse, homelessness and difficulties in relationships. Page 40 of 84 Child Z SCR Overview Report published 051015 IMR comments that although the assessment had met generally expected standards for anybody assessed as posing a “Medium” risk of causing serious harm required a full and thorough risk management plan detailing exactly how the risks would be managed and contained. In this instance the plan was vague about how the risks to FZ’s partner and to her father might be managed and by whom. 220. In mid May 2012 FN2 completed the on-going key issues summary that there was no bath and the shower was broken (actually an uncompleted repair). No concerns were highlighted in regard to either Child Z or Sibling 1 though if MZ’s mood deteriorated due to the bath/shower this would have an impact on her children. Some tension with the housing association was noted. FN1 had noticed a mood change and felt that MZ would deal with this inappropriately and would have more problems. The IMR Author comments that this could have been an opportunity to organise a CAF but that did not take place. There is no reference to FZ’s offending or any of the issues highlighted for example by PO1’s OASys assessment. 221. At the end of May 2012 MZ had invoked the housing pre-action disrepair protocol with the help of Shelter having become stressed about the lack of progress in resolving the issue of the shower repair; the involvement of Shelter appeared to indicate an intention to seek legal remedy to the issue of repairs to the shower. In early June 2012 MZ contacted the local credit union to discuss the options for finance to install a bath herself. 222. In mid June 2012 Sibling 1 was presented at A&E. Sibling 1 had a three day history of vomiting at night. Sibling 1 was observed to have a small bruise near an eye and FZ stated that Sibling 1 had fallen down three stairs at the grandmother’s house three days previously. When questioned by staff FZ stated that he was not present at the time of the accident and MZ would have brought Sibling 1 at the time if Sibling 1 had lost consciousness. Staff in A&E tried to contact MZ to clarify events, but to no avail. 223. On examination Sibling 1 was observed not to have an obvious head injury; there was a bruise to one eye area and the doctor diagnosed a possible viral illness. Whilst in the department EDN3 contacted CSC and established that Sibling 1 was known to them. EDN1 completed an electronic referral form which identified that Sibling 1 had an unexplained bruise to the face; Sibling 1 appeared unkempt and was wearing dirty clothing. EDN1 requested that there was a home visit to ensure the safety of the children. This information was also sent to the Health Visitor (HV). 224. A joint home visit was undertaken two days later by FN1 and a Social Worker (NSW1) who saw MZ, FZ, Sibling 1 and Child Z. The house was described as ‘messy’. They discussed hygiene. MZ reported that Sibling 1 had fallen whilst going up steps (rather than down as reported by the hospital). Sibling 1 had tripped and banged a cheek, had a bruise which was not present at the time of this visit. Sibling 1 had then vomited 2-3 days later. Following the fall Sibling 1 was well. FN1 assessed that MZ was appropriate in her decision making. Issues discussed included hygiene and thorough hand-washing to reduce the risk of gastro-enteritis. NSW1 checked the Page 41 of 84 Child Z SCR Overview Report published 051015 rooms (although no further detail was recorded by either worker). The interaction with both children during the visit was recorded as being good. NSW1 was made aware of the housing problem regarding the shower and how this impacted on MZ’s mood and that she could not bath the children. 225. The initial assessment by CSC resulted in the case being closed; reliance was given to the fact that FZ had taken Sibling 1 to hospital and both children ‘appeared to be fine’. The IMR author comments that the standard and range of recording appears limited and incomplete. The summary of background information and past history was not recorded and left blank; there was no evidence that any previous history was considered in the context of the current situation or measured against previous information or concerns. 226. FZ was not seen or spoken to as part of this initial assessment in spite of the fact that the referral form referred to his confusion and his ‘odd answers’ during the history taken at the hospital. 227. The timescale and context of the apparent housing problems alongside the reported neglect at home appear not to have been explored or challenged by NSW1 with MZ or indeed by FN1. There was no description of the children, or their clothing. Also they did not appear to have been spoken to and engaged in the initial assessment, nor had NSW1 offered any view on them, their development, or the standard of parenting being provided. 228. The CMFT IMR Author comments that given the information that had emerged during June including the referral to CSC, it would have been appropriate to have discussed the case within the health trust’s safeguarding children framework which relies on practitioners to highlight concerns. It did not happen in this case and is explored in later sections. 229. About a week after the hospital visit the GP out of hour’s service at a Walk in Centre (WIC) was used by the parents to present Sibling 1 with a vomiting illness. There was no unusual temperature. The IMR Author highlights that the detailed entry about this and some previous health contacts was made on MZ’s health records rather than of Sibling 1. This has significance in terms of keeping information attached to the individual history of a child and is explored in later sections. 230. In July 2012 a bath had been fitted. This had followed the previous shower repair being designated uneconomic for the landlord and agreeing to install a bath as the replacement. During the rest of the summer there continued to be regular and routine contact with the family by health professionals. No concerns were noted. 231. In the early afternoon of the 12th August 2012 the police received a 999 call from the landline at the home address of MZ during which the caller requested the police. The police immediately recalled the originating landline number that was linked to the home address of MZ and the operator spoke to a female who gave her name as MZ and provided her date of birth. At the time of recalling the landline number a Page 42 of 84 Child Z SCR Overview Report published 051015 baby could be heard crying. MZ stated that the crying baby was Child Z and she provided the child’s date of birth. 232. MZ stated that the call to the police was the result of a female friend messing about because she was drunk. MZ provided the forename of the female friend but no further personal information. The GMP incident log was closed with a closing code of hoax calls to emergency services and no further action was taken. The police had taken a silent 999 call from the property in early June 2012 although the IMR explains that on that it had been established that it was unlikely to be linked to MZ on that occasion. 233. The last visit to the home before Child Z died was five days before the admission to A&E by the FN1. No concerns were noted; both children were seen and were well. Developmental checks were done. 234. In late September 2012 Child Z was taken to A&E. The regional ambulance service had received an emergency 999 call from a neighbour at 10.39. The dispatcher took details that identified a baby not breathing and coded the response as red and transmitted the information electronically to a fast response paramedic; this was then upgraded to ‘Government Code Red 1’ indicating the highest priority response with a required response time of less than eight minutes. A crewed ambulance was also redirected from another call (Crew 2 and Crew 3). The paramedic (Crew 1) was on the scene by 10.41. The dispatcher had been providing verbal instruction on CPR for FZ who was administering it to Child Z. Crew 1 immediately took over CPR on arrival at the scene using a bag-valve mask resuscitator and oxygen. He inserted a nasopharyngeal airway and requested back-up. Crew 2 and Crew 3 arrived on the scene at 10.45. The ambulance left the scene at 10.49 with Crew 1 also on board who with assistance from Crew 2 continued to administer CPR. There was no response and no output and Child Z’s condition did not change. 235. On arrival at the hospital at 10.56 the medical care was transferred over to the hospital that had been pre-alerted and who continued to administer resuscitation which was halted at 12.40. 236. The Sudden Unexpected Death of Children (SUDC) Protocol was invoked and CSC, the police and Health Visitor were all notified of the death of Child Z. The police attended the A&E and arrested the parents. 237. Two strategy meetings took place the same day with representatives from Police, CSC, and the head of safeguarding at Hospital 1, the Consultant Paediatrician, FN1 and NN2. An account was initially shared of the circumstances which led to the death of Child Z with the second meeting providing further information after the parents had been initially interviewed and a visit to the home address had been completed. This information was summarised in the introduction to this report. 238. The police together with the Consultant Paediatrician and CSC Manager had visited the house and had found the house in a very neglected condition; it was described as Page 43 of 84 Child Z SCR Overview Report published 051015 unhygienic, untidy and as not fit for human habitation, the living room was in a state of chaos, the kitchen was the same and was untidy, there were seven used nappies under the chairs, a hole was found in a wall which someone may have aggressively punched, a cricket bat was in evidence, the stairs were cluttered making access difficult with the consultant paediatrician almost falling whilst attempting to walk upstairs. There was no bedding on the parent’s bed. The baby cot was untidy; it was unhygienic and contained a large adult pillow. There was a drawer where milk was prepared which was unhygienic and had the potential to cause health problems. One of the bedrooms contained cannabis plants with a street value of several thousands of pounds. 239. The Consultant Paediatrician shared details that FZ had a medical and criminal history (and this information would be shared at a later date), Hospital 1 had records which doubted FZ’s ability to parent following information from the Probation service, MZ had a learning difficulty and the extent was unknown, the house had been photographed and the police agreed to forward to NN2. Sibling 1 was subject to Police Powers of Protection (PPOP) and a Section 20; Children Act would be requested to safeguard the sibling. Sibling 1 was to have a child protection medical examination the following day. Post mortem results were to be shared when available. A Bereavement Support Leaflet was given to FN1 from the Consultant Paediatrician for the parents. 240. Although a detailed plan had been agreed this was not written, signed and shared at the time. Page 44 of 84 Child Z SCR Overview Report published 051015 The critical reflection and analysis from the Individual Management Reviews. 2.1 Summary 241. All of the Individual Management Reviews (IMR) were completed using Working Together to Safeguard Children (2010) which was also supported with additional local guidance provided on behalf of the LSCB. The IMRs include action plans for implementing recommendations. All the IMRs are countersigned by the senior manager for the individual commissioning agency. 242. Many of the services have already taken action or initiated action in response to improvements or areas of development identified through their individual review. 243. For some of the authors, they were simultaneously working on other IMRs for other serious case reviews. All of the authors were also undertaking their usual range of professional roles and responsibilities. 2.2 Significant themes for learning that emerge from examining the IMRs 244. The agency reviews identify themes that have implications for policy development and staff training that applies to all services working with children. In the summary of the review’s findings provided in chapter one there is acknowledgement that some of the issues to come out of this review are reflected in the finding of national evaluation and research. Important messages for learning from this review include: a) Effective and informed assessment of risk and need in regard to children requires access to and understanding of significant family and parental history; b) Assessment at any level relies on appropriate triangulation of information and data from observation, collating what is declared or reported by the adults (and children) and checking historical and third party information and looking for underlying patterns and inconsistencies; c) Families living at the margins of their community or general society will be suspicious and resentful of intervention from social and criminal justice welfare services and will be motivated to resist and misdirect; d) Adults with complex histories, attitudes and behaviour with chaotic lifestyles can be overwhelming for individual practitioners and especially if the practitioner is relatively inexperienced or not sufficiently knowledgeable; e) Strengths based help and support can be very effective in helping many families but is liable to be less attuned to the misdirection that can come from disguised compliance or other obstruction; Page 45 of 84 Child Z SCR Overview Report published 051015 f) The use of drugs and or alcohol deserves careful attention especially when combined with evidence of poor mental health or other difficulties; a perceived toleration of drugs such as cannabis represents risk to the child and is a misunderstanding about the impact of such behaviour on the emotional, physical and mental health and capacity of a parent; g) Cognitive and learning difficulties can be an additional barrier to effective communication and understanding in the interaction between professionals and parents; if it is not looked for or recognised, incorrect assumptions can be made in regard to the level of understanding and insight available to the parents or other significant adults; h) Misplaced assumptions about the roles of different services can undermine judgment and decision making; in this case there was more than one occasion when assumptions were made that services such as the vulnerable babies service or the FNP would address issues highlighted in referrals; i) Arrangements such as CAF should be used to provide the opportunity to collate information about children who may be vulnerable but are not seen to meet the thresholds of specialist and high tier services such as CSC; it is an opportunity to get a wider perspective that is not available in single agency ‘silos’. 245. It is important that constructive feedback and reflection is provided to all the practitioners involved in this case to give them the appropriate positive encouragement for their continued professional development and retention in the workforce. 246. The remainder of this chapter summarises key evidence relating to the terms of reference established for the IMRs. 2.3 Good practice identified through the review 247. To support the learning from the review the panel looked for examples of good practice. To constitute good practice, the panel looked for action or decision making that went beyond compliance with local and national policy, procedures and guidance. 248. Examples of good practice identified by the review include: a) The detail of information contained in the referral from PO1 was of good quality; b) The police officers who dealt with the assault on MZ by FZ showed sensitivity and persistence in securing information about the incident and initiating the domestic abuse protocols; Page 46 of 84 Child Z SCR Overview Report published 051015 c) FN1 showed great persistence and resilience in maintaining a relationship with MZ; d) The allocation of the paramedic to accompany the crewed ambulance on the journey to hospital provided additional support to Child Z; e) The allocation of PO1 to provide the second pre-sentence report provided consistency. 249. The remaining sections of this chapter summarise the most significant learning from the IMRs against each of the case specific terms of reference. TOR 1 Recognition and response to need and indicators of risk Analyse agencies recognition and response to needs and risk identified during the antenatal periods of Child Z and Sibling 1 250. The Munro Review emphasises the importance of early recognition of need and echoes the work of other reviews that have included Frank Field MP (2010), Graham Allen MP (2011) and Dame Clare Tickell (2011). The recognition that MZ had additional vulnerability by virtue of becoming pregnant as a teenager and therefore allocated to a specialist midwife occurred at an early stage. The lack of engagement with appointments did not attract sufficient attention and especially during the critical latter weeks of the pregnancy that represents risk to the baby and the mother. 251. The involvement of FNP arose from the fact that MZ had additional vulnerabilities by virtue of becoming pregnant as a teenager (FNP is a targeted service for vulnerable first time young parents under 20 years of age), but was not based on an explicitly defined enhanced level of need or risk that has been described in the earlier sections of the report. It is possible that the fact that services such as FNP had been allocated and were working hard to be involved with MZ contributed to other services assuming that the level of need and risk had been addressed without the need for more persistent enquiry. It is a fact that FN1 was influential in how CSC managed aspects of their enquiries and assessment. 252. PO1 who was supervising FZ became aware of the pregnancy and because of knowledge about FZ’s history and the age of MZ was sufficiently concerned to make a referral to CSC recommending a pre-birth assessment. The IMR acknowledges that this could have equally have been an opportunity for PO1 to have initiated a CAF. The referral to CSC resulted in that service trying to contact the midwifery service and in absence of any direct conversation with either PO1 or the midwives CSC suggested that the Vulnerable Babies Service might be an appropriate response. 253. There may have been a misunderstanding in CSC about the VBS being a targeted service which required evidence that a child was at higher risk in order to allocate Page 47 of 84 Child Z SCR Overview Report published 051015 any resource, being primarily a preventative service aimed at leading on practices that reduced the risk of sudden infant mortality with higher risk children. If the risk factors had been collated and described in a referral to VBS it would probably have resulted in VBS becoming involved. 254. The CSC IMR also describes the problems that had confronted the service in regard to the implementation of new information systems that had not been thoroughly integrated with historical and archived records. This meant that in this case, historical information about the parents’ childhoods was not identified as part of the initial enquiry or subsequent assessments. 255. This left CSC more reliant on current information being reported to them from other services such as PO1. In the absence of any current and identifiable risk to a child, there was no compelling reason to undertake more comprehensive assessment. Such decisions also have to be seen within the context of a service that is receiving over 1300 contacts about children each month. 256. Although there was a subsequent plan to complete a CAF this was not achieved on this or any other occasion. The significance in this case is that individual professionals never took an opportunity to share information and intelligence about their interaction with the family. Therefore, the patterns that have become clear during this review such as the avoidance of contact were not as apparent to individual practitioners with the possible exception of PO1 and of FN1 who showed personal persistence in maintaining contact with MZ in particular. None of the services had any historical information to inform their current understanding and observations. The family was largely not regarded as being particularly more vulnerable than many other families in similar circumstances. 257. The identification of vulnerable families and babies and delivering early help and support is recognised as an important aspect of preventing a range of problems developing for a child over subsequent years. It is for this reason that considerable effort is made in trying to identify needs and risk at an early stage that begins with ante natal care. 258. For such strategies to be effective it requires the collective co-ordination of information and behaviour across different services and individual professionals. It relies on relevant information being identified for example by GPs who may have significant information to share and contribute to early identification about domestic violence or lifestyle issues for example; it relies on the midwifery services being able to encourage pregnant women who may have had poor experience of contact with statutory services or feel they live on the margins of their community, to disclose relevant information about sensitive areas of their lives such as the quality of the relationship with their partner, their experience of abuse and their lifestyle as it might effect their children in regard to substance misuse for example. 259. In this case there were challenges facing professionals such as the GP in identifying MZ as a pregnant woman who might be in need of additional help over and above Page 48 of 84 Child Z SCR Overview Report published 051015 only being 17 years old when she became pregnant on the first occasion with Sibling 1. MZ had to move to another GP when her original GP died. Although the new GP practice employs a person to specifically provide a summary of historical information it did not happen on this occasion and coincided with several other patients joining the practice at the same time. MZ transferred into the second GP practice from the first practice that had no knowledge of FZ who was apparently not registered with a GP for an unknown period in 2010 and the second GP practice only had information about FZ when he transferred to the same practice as MZ several months afterwards in late 2011. 260. The initial confirmation of pregnancy by the GP did not acquire very much information about FZ or the circumstances for the pregnancy. This is not unusual in terms of the practice of GPs across the UK. The focus is primarily on the health of the pregnant teenager in this case and ensuring that MZ was booked with the midwifery service who would provide oversight and support through to the birth and handover to the community health visiting service. 261. The midwifery service have developed expertise in identifying pregnant women who may require additional support and have access to a range of services some of which operate within the primary health community whilst other are located in the local authority or third sector. 262. There are services such as the children’s centres that provide a wide range of activities and help for pre-school children and parents. More information is provided at a later stage about some of these services and their contact with MZ and the family. 263. At the ante natal stage the main need that was identified was MZ’s age; she was a teenager expecting her first baby and she was also without a secure home of her own. She was booked for maternity care 15 weeks into her pregnancy with Sibling 1. It was identified that MZ had had a social worker in the past due to school problems and that she had suffered depression in the past. A referral was made to Connexions and to the Family Nurse Partnership by the Specialist Midwife (TPM) who took over the coordination of ante-natal support from August 2009. 264. The Pennine Acute Trust IMR explains that the referral to the FNP by TPM was achieved as a result of the local maternity services participation in the ‘building blocks research project’ that routinely sought permission from a young mother for her details to be passed to the FNP and then a computer programme randomly selected a family for allocation to the FNP service21. 265. The significance is that allocation to the FNP was not based on identification of significant needs over and above being a teenaged mother but was a randomised trial of a programme designed to achieve enhanced outcomes for children. The TPM 21 The local FNP team were participating in the study to test the effectiveness of the FNP intervention; eligible clients were randomly assigned to receive the programme. Page 49 of 84 Child Z SCR Overview Report published 051015 offered the FNP to all pregnant teenagers and was then informed which of those had been allocated to the FNP. MZ had missed her first ante natal appointment and missed several more throughout her ante-natal care. She attended at the hospital emergency service with vomiting and bleeding at 18 weeks and was admitted onto the gynaecological ward. 266. In late summer 2010 MZ was routinely screened for anxiety and depression by FN1 that identified high levels of anxiety and moderate depression. This in part reflected the insecure housing that MZ had at the time; the house was described as falling down and in September 2010 MZ left that address. She was out of contact for a period of weeks. The IMR author for the FNP reflects on the importance of anticipating some of the chaotic arrangements that can arise when a parent or family change mobile phones and move house at short notice and there has been insufficient attention to acquiring alternative contact details. The absence of a comprehensive family and social history in health or social care had not captured information about family members and identifying alternative contacts. 267. MZ re-established contact after six weeks and initially met in a car park due to MZ asserting that the new house was difficult to locate. Given the history of missed appointments and keeping services at a distance this appears to have been another form of controlling of contact with professionals by MZ. 268. This was not how it was viewed by FN1 and who continued to be very persistent and diligent in keeping contact with MZ. This is a common dilemma facing professionals working with young adults who are suspicious of and reluctant to accept involvement from professional sources. Families living on the fringes of their community can be reluctant to allow too much information to be disclosed for fear of further intrusion and more far reaching consequences from criminal justice or social welfare agencies. 269. It is these types of dilemma that should be presented in formal supervision and case discussion to prevent inappropriate misdirection of the practitioner’s focus. 270. PO1’s referral to CSC in November 2010 followed an initial telephone call to the service to establish whether CSC knew the family given the fact that PO1 had become aware that FZ was living with MZ who was pregnant and that FZ had a history of violence and substance misuse. It was for this reason that PO1 wanted a pre-birth assessment to be completed. PO1 could have initiated a CAF which would have provided an opportunity for further information to have been collated prior to the referral but did not. The referral to FRT resulted in a social worker trying to speak with the midwifery service and when that was not possible by telephone, information was faxed to the midwifery service suggesting that the Vulnerable Babies Service might be appropriate and confirming that FRT planned to take no further action. There was no discussion with PO1 regarding the risk factors and concerns that had prompted the referral (although there had been a previous conversation when PO1 wanted to check whether there was any social work involvement) and there was no check of historical information on either of the parents and their families. Page 50 of 84 Child Z SCR Overview Report published 051015 271. The TPM was made aware of the information from FRT which coincided with several missed ante-natal appointments. The TPM recognised that there was an emerging picture of need and potential risk when she opened the Special Circumstances Form (SCF) so that information was available to other health professionals who came into contact with MZ. 272. This recorded the fact that there had been missed ante-natal appointments, there was involvement by the probation service (although was non-specific about the circumstances over and above anti-social behaviour), there were concerns about the parents ability to parent raised but that CSC were taking no further action; the fact that CSC were not taking action may have been interpreted as signifying there were no substantial concerns. 273. An offer for support through the Vulnerable Babies Service had been declined although the FNP were involved and FN1 felt that MZ’s ability to parent was acceptable; it is not apparent that FN1 was aware of the information provided by PO1 or the history in both families that even at the time of the SCR remained largely unknown to people currently involved with the family. 274. The TPM agreed to complete a CAF in consultation with the FN1 in mid-December 2010. This could have provided an opportunity to collate further information from the parents and to consult other people with knowledge of the family. In the event MZ did not attend for the scheduled appointment at the hospital or at the day unit two days later. When the TPM tried to make a home visit just prior to Sibling 1’s birth MZ was out. By this stage MZ was overdue for delivery of her baby and focus appears to have moved to discussion about possible induction to ensure the safety of MZ and her baby. Although there was a discussion with PO1 who asked to be included in the CAF which was postponed until the New Year. 275. In the event, MZ went into labour in early January 2011 just prior to the planned induction. The Special Circumstances Form that was now part of MZ’s patient records alerted the hospital to the concerns and issues recorded by the TPM and a telephone check was made with CSC in regard to any plans for MZ and her baby. 276. The Emergency Duty Team (EDT) advised that MZ should not be allowed to go home (the reason is unrecorded and CSC had no direct information about MZ and her circumstances); the hospital recorded that they had no reason to delay MZ going home. There was also a record made of FZ coming to the hospital smelling strongly of cannabis. This information does not appear to have been shared with the TPM, FRT or with PO1. The recording about smelling of cannabis does not identify who saw FZ and smelt the cannabis. 277. MZ looked after Sibling 1 whilst she was in hospital for one day without any concerns being observed; her care and response to Sibling 1 was appropriate. There is no record of when FZ visited or his care of his baby. MZ discharged herself against the advice of medical staff; she had raised blood pressure and remained at risk of a Page 51 of 84 Child Z SCR Overview Report published 051015 condition such as preeclampsia. CSC was advised that MZ had discharged herself from hospital. 278. Less than two weeks later FZ received treatment at the same hospital after he fell and cut his hand when returning home from the pub whilst under the influence of alcohol and possibly cannabis or other substance. The IMR for Pennine Acute comments that he was not asked about any caring responsibility for children and this visit to the emergency department was not known about to other services. 279. Becoming pregnant and caring for a very young child represents considerable emotional and physical demands especially for any young first time parent. The first months of a child’s life are an important stage in the development of emotional bonds and creating the conditions for successful attachment for example. MZ had become pregnant again by early March 2011 and was booked for ante natal care seven weeks into her pregnancy with Child Z in mid May 2011. MZ was routinely screened for domestic abuse during the booking for Child Z; she indicated that she had never experienced violence in the relationship; this was not true although this is an example of how self-reported evidence can provide misleading information for practitioners to make judgments and decisions; similar problems face people such as probation officers as evidenced in this case. MZ was equally unforthcoming with the FN1 during the screening and monitoring used on the FNP programme that follows a structured process of enquiry and work with parents. 280. The police had dealt with a clear incident of domestic violence in July 2010 (concerning the argument over the computer X-box) and during which she had told the police that her relationship with FZ was ‘on and off’, that they often argued and that “FZ drank frequently and was aggressive when drunk.” The absence of a statutory assessment by CSC during the ante-natal period for either child and the absence of routine checks with agencies meant that the information held by the police (and which included evidence of involvement in crime) was not accessed to be considered alongside the other information that had been provided by PO1 and the ambulance service. 281. The police were initially proactive in dealing with the incident of domestic violence which included a warrant to arrest FZ but did not process the information as a safeguarding referral through the PPU. 282. The notification by mobile telephone to FZ potentially increased the risk for MZ and made her vulnerable to coercion and possibly influenced the outcome of the episode when FZ eventually responded when he went to a police station in the company of MZ who declined to make a formal complaint about FZ’s behaviour and did not want to cooperate further. This led to no further action in the absence of independent witnesses or forensic evidence. FZ’s presentation of a different version of events that sought to place responsibility on MZ and her mother was significant. Page 52 of 84 Child Z SCR Overview Report published 051015 283. PO1 was aware of the domestic violence incident but it was not followed up in the context of the supervisory discussion with FZ; the IMR author highlights this as unsatisfactory. 284. In June 2011 during the second pregnancy MZ had called the ambulance service when she had severe vomiting 13 weeks into her pregnancy. The crew that responded made a referral to FRT reporting that the house was filthy with clean and dirty nappies ‘strewn’ on the floor and the house smelt of faeces. The crew also reported that Sibling 1 was seen with a feeding bottle hanging from the mouth propped on a chair on a cushion; the child was described as filthy and wrapped in blankets despite it being a warm day and was ignored by both parents despite being distressed22; the presence of uniformed strangers in the house would have been an upsetting and unsettling experience for a young child. 285. This was a clear report of neglect that deserved further exploration and if it had been combined with the other information reported by PO1 in late 2010 it should have prompted at the very least multi agency discussion and assessment as a child in need. The historical information about abuse in both parents’ childhoods was significant information that apparently remained unknown until this review. CSC had established that a Specialist Midwife from the Family Nurse Partnership was visiting the family every two weeks and no further assessment was judged necessary. 286. MZ missed a series of ante-natal appointments and required persistent follow up throughout both pregnancies. MZ had one further presentation at the hospital emergency service in September 2011. Care was handed over from the TPM to FN1 following the birth of Sibling 1. The TPM was not involved in the ante-natal arrangements for Child Z; in part this appears to have reflected the fact that intensive contact was taking place with the FNP. 287. In June 2012 Sibling 1 had been taken to the emergency department at the hospital with a bruise to the cheek. Sibling 1 was described as being dirty and dishevelled by the Emergency Department Nurse (EDN3) who made a referral to the First Response Team (FRT) in CSC; this detail was lost in the subsequent handover to the neighbourhood team that completed an initial assessment. 288. There were concerns about the way that FZ had answered questions regarding the history of vomiting and circumstances of the bruise, which ‘seemed odd’. There was a subsequent joint visit by a social worker and the FN1 to complete an initial assessment; they were not fully aware of all the information reported by the EDN. There were several concerns about the home conditions. Parents provided an explanation that the sibling had tripped and fallen over striking a cheek on a stair, which was accepted. 22 The information about bottle feeding and ignoring Sibling 1’s need for comfort and reassurance is significant evidence that the information about the condition of the house is indicative of neglect; prop bottle feeding has physical risk for the child and is also poor nurturing of a young child who should be getting close physical contact and emotional reassurance from an adult during the feeding. Page 53 of 84 Child Z SCR Overview Report published 051015 TOR 2 Quality of parenting assessments Consideration as to how the assessments of parenting took into account the various risk factors and how this informed the safeguarding of both children. 289. A consistent theme to come from serious case reviews and the inspection of safeguarding work is the challenge of achieving assessment practice that reflects the needs and circumstances of children living in families that face a wide range of persistent challenges and difficulties. It is a recurring conundrum that assessment is often distracted by the problems and needs of adults and is therefore unable to analyse the implications for parenting of very young children in particular. Analysis is also compromised by insufficient discussion between different professionals. A consistent theme in this and other serious case reviews is the degree to which the information held by GPs in particular is not accessed. 290. PO1 identified a need to have a parenting assessment completed at an early stage in the first pregnancy. No assessment was completed in response to that referral. CSC were not persuaded that a pre-birth assessment was necessary based on the information they received; that judgment relied on partial information that did not achieve direct conversation with other relevant services and did not identify the history about the childhood abuse of both parents. 291. The historical checks were impeded by difficulties in the functionality of the electronic information systems to identify historical information from as late as 2008 and accessing archived records. FN1 was also influential in how CSC managed aspects of the referral and assessment. 292. The involvement of the family nurse in this case involved a degree of assessment with the focus on a structured strengths based and motivational model of engagement with MZ through a structured visiting programme. Clinical record keeping includes supervision documentation and focuses on both strengths and risks within the household across a number of domains, especially in relation to safeguarding the child. FNP is a behaviour change programme identifying strengths in order to build positive, sustainable behaviour change. The programme also has an expectation that practitioners will assess for and identify risks, agree actions with clients and continually monitor progress ,so that risks are addressed, including ensuring protective factors are in place to keep a child safe. 293. Local implementation of the FNP model is supported by a detailed management manual, which informs and guides local areas in what they need to do to set up, sustain and continually improve the FNP programme locally. The guidance in the manual is then backed up by a range of national clinical guidance documents, which are continually reviewed and updated in light of national and local learning. All local areas are advised to implement the clinical guidance within the requirements of their local frameworks and to ensure that the national guidance is understood locally. Page 54 of 84 Child Z SCR Overview Report published 051015 294. The model has been validated through research evidence to produce improved outcomes for maternal health and child development. Not unreasonably, the use of such validated approaches can infer a high level of confidence that good outcomes will follow in all circumstances; this is not a comment intended to be restricted to FNP and certainly does not argue against the implementation of validated and structured approaches that are supported with good research evidence such as FNP. This is an area of refection and challenge in the final chapter of this report. 295. FN1 had assessed that MZ had been happy about both pregnancies and there was good attachment with both children. As will be clear from the previous sections, there was evidence that suggested that attachment practice was not as positive as had been inferred. What is clear is that FN1 had secured MZ’s confidence and that MZ re-established the contact after six weeks when she had withdrawn from midwifery services. 296. The other assessment that was undertaken was the initial assessment in June 2012 that followed the referral from the hospital Emergency Department Nurse after FZ had presented Sibling 1 with a history of three days vomiting. The presence of a bruise and Siblings 1’s dirty and dishevelled condition combined with FZ’s ‘odd’ answers had caused the nurse to make a referral. This was the clearest opportunity for an s47 enquiry and assessment to have been completed and should have been. If the information had been correctly defined as a child protection referral there would have been a medical examination of the children and a multi-agency strategy discussion that may have moved on to a core assessment. This does not mean that the tragic death of Child Z would have necessarily been prevented but it would have created the conditions for a much clearer level of insight and understanding about what the children’s circumstances were. 297. The CSC IMR explains the system of referrals as requiring an initial response from FRT but the assessment was then allocated to a neighbourhood social work team. In this case there was an important loss of detail in information between the hospital and the area. For example the information about Sibling 1’s physical presentation at hospital was not included. There was no discussion between the emergency department nurse and the Social Worker who had responsibility for the home visit and completion of the assessment. The system also has implications for how the team manager was able to quality assure a response to contacts and referrals; in being able to assess the rigour and appropriateness of decision making the manager has to have a sufficiently detailed knowledge about what the originating issues and concerns were. 298. A home visit took place involving FN1 and the Social Worker; FN1 had discouraged an assessment following the referral from the ambulance service because it would upset MZ and FN1 clearly still felt that MZ was capable of parenting her children adequately. The mindset that was carried into the process of assessment is an influence that is increasingly understood in a range of different settings; how to ensure that the person making the enquiry is not just looking for evidence and information that they expect to find to reinforce their pre-existing judgement about Page 55 of 84 Child Z SCR Overview Report published 051015 the person or situation. It is especially important in this type of assessment that involves children who have yet to develop sufficient language and other skills to convey their own feelings; it is also important when trying to identify underlying patterns of neglect that do not usually involve one defining act of abuse or maltreatment but rather represents an accumulation of inappropriate emotional and physical care that has a negative cumulative impact on the child’s development and possible safety. 299. The Munro Review was very critical of the national assessment frameworks and practice in place until April 2013 and this has informed the revised national guidance for how local areas develop their own assessment frameworks. In a well-intentioned effort to create greater consistency and thoroughness, the system of national standards had largely created the conditions for assessment to be treated as an essentially administrative task of completing forms. 300. These forms have inherent weaknesses such as providing little scope for developing the narrative story of a child and how they are affected by the behaviour or lifestyle of parents or other adults as well as being weak on identifying risk or understanding need. However, there are parts of the form that should be useful that include for example capturing information about family and some of their history. This was not completed in this case. If the history had been known, it is more likely that a different inference would have been given to the current information reported in relation to the children of MZ and FZ. 301. By the time the initial assessment was completed there had already been prior referrals from probation and midwifery services that included concerns about domestic violence and use of drugs. Additionally, if historical checks had been completed there was a relevant history of childhood abuse and trauma in both parents’ childhoods available in archived paper records rather than stored in the current electronic systems, and aspects of their current lifestyle that also deserved more detailed, reflective and sceptical exploration. It was the second strategy meeting after the death of Child Z that identified learning difficulties, the history of self-harm by both parents and the level of offending by FZ both historically and recently. 302. The records were not checked and the consequence was that FN1 (who was already convinced MZ could parent) and the social worker (who considered this was a case that did not involve an identifiable risk of injury and significant harm because the main presenting issue in the information passed through focussed on the delay in seeking medical attention for Sibling 1) were more reliant on what MZ wanted them to hear or discover through the assessment. 303. MZ was motivated to minimise any reason for concern and therefore continuing involvement by a service such as CSC. Therefore she was allowed to offer reassurance for example on why the house was in the condition it was because she had been ill and ‘was a bit behind’. MZ had the motivation to divert attention and the professional mindset was such that it lacked enough sceptical curiosity and challenge Page 56 of 84 Child Z SCR Overview Report published 051015 to see behind the information being presented in words and behaviour. FN1 was also clearly working hard to maintain a relationship with MZ and in retrospect this probably deserved more exploration in professional supervision. 304. The CSC IMR identifies a number of learning points from their examination of the assessment for the serious case review. This included the absence of historical checks, not recognising the indicators of inappropriate care such MZ’s reference to allowing Sibling 1 to go up and down stairs and playing on their own in their bedroom and the physical conditions throughout the house. 305. There is a phrase that is often used in multi-agency discussion that centres on trying to understand what is ‘good enough parenting’. Consideration has also been given to the fact that MZ and FZ lived in a community where some aspects of their lifestyle were not unusual in matters such as a toleration of substance use. Difficult judgements also need to distinguish between people trying to overcome poverty and the contrast with behaviour that is neglectful and abusive to children. 306. In this case it is known that FN1 believed that MZ was capable of providing good enough parenting and had been influential in how an earlier referral had been managed and persuading CSC that an initial assessment would be unhelpful. It seems clear that a great deal of this judgement was a reflection as to how MZ responded to the FNP structure which was not risk based. 307. FZ was not present for the assessment interview; no tools were used to explore issues such as the use of drugs or the quality of emotional care and attachment process with the children. The result of the assessment was that no further action was required; the reasoning was that there had been no previous CSC involvement (which was not correct as far as historical childhood contact with MZ and FZ was concerned); that other services such as the FNP were already involved and reassurance had been taken from the way MZ had responded during the single visit. MZ did not want further help and involvement and both professionals identified no reason to take a more assertive approach. There was little recorded about the interaction between MZ and her children although tellingly one of the children was only dressed in a nappy during the visit. 308. Although there are clear and validated reasons about why early years, health and social care professionals in particular should give sufficient attention to historical information about families where pregnancy and young children are concerned, this continues to be an area of practice that is highlighted frequently in child deaths and serious case reviews as requiring more development. 309. The serious injury and killing of children is rarely a predictable event. There are factors that can indicate a child might be more vulnerable to neglect or significant harm through the interplay of underlying and often overlooked factors that have their origins in personal and family history. This does not mean that where such factors are recognised it should lead to parents being suspected or accused of harming their children but rather should alert and provoke a higher level of informed Page 57 of 84 Child Z SCR Overview Report published 051015 and sceptical curiosity that is respectful and persistent. This is difficult when individual professionals are managing complex workloads and need to prioritise according to what they see to be the more urgent situations. 310. The factors that are identified in research as being likely to be found in the maltreatment of children rely on sufficient attention being paid to history rather than waiting for a defining event to occur such as an injury to the child. The factors relevant to this case include the following: a) Isolated parents who have little or no extended family capable of providing good emotional and practical support or have other forms of support available for example from a community or faith based group; in this case FZ had very limited family support which was characterised by violence and some professionals may have been over optimistic about the quality of family support that was available to MZ; b) A history of being abused or rejected as children or having multiple changes of carers; FZ’s history is especially relevant and there are gaps in regard to MZ; there is a dearth of family and social history although the initial assessment established that neither parent was close to their respective families despite living nearby and appeared to be socially isolated; c) Mental illness, personality disorder and/or a learning disability/difficulties; these are often not recognised or diagnosed and in this case there was no evidence of information being sought from the parents or elsewhere; the education history in respect of both being young parents (and therefore had left school relatively recently) was not sought to establish if there was any evidence of special educational needs when they were at school; d) Particular vulnerability if there is no other parent or extended family member available to share parenting (that becomes exacerbated if a child is hard to parent which does not appear to been the case for Child Z or Sibling 1); it was unclear to what extent FZ was a member of the household for several months; MZ had the sole tenancy on properties and after Child Z had died FZ was said to be still living at a different address (Address 5); e) There is reliance on alcohol or drugs and the parents do not accept they need to control it; FZ had a historical and problematic use of alcohol and drugs and continued to use skunk cannabis; there is no evidence of enquiry about his use of substances except by PO1 and similarly no enquiry regarding MZ; this is an area of practice that is frequently not managed well by any professional group outside of specialist services and was a theme in recent serious cases in other areas; Page 58 of 84 Child Z SCR Overview Report published 051015 f) There is a history of aggressive outbursts and a record of violence including intimate partner violence; FZ’s record of violence was known to PO1 and was included in the first referral to CSC; no inquiries were made with the police who had information about violence in the relationship between FZ and MZ which had not been shared with CSC in spite of it occurring when MZ was pregnant; g) There is a history of obsession/very controlling personalities often associated with low self-esteem; FZ’s history and his childhood trauma of maternal death were all factors that were not looked at and the implications for his sense of identity and self-worth; h) There is fear of stigma or suspicion about statutory services; this is a frequent and unrecognised factor in interaction between professionals and families and in this case there was clear evidence for example in the response from FN1 to the first referral to CSC and her expressed concerns of involving services such as CSC; it has implications for how parents will seek to present themselves and want to manage information that minimises the motivation and reasons for key professionals to become more curious and further involved when it is not welcomed. 311. It is apparent that these factors to varying degrees were present in this case but either went unrecognised or individual practitioners were misdirected by a false sense of reassurance. On two occasions MZ had scored towards the higher end of the Hospital Anxiety and Depression Scale (HADS) but this was not followed up. The injury to FZ’s hand in March 2011 required specialist plastic surgery indicating a significant injury that was also not enquired into. A similar lack of curiosity applied in respect of evidence of cannabis use and domestic abuse. 312. In addition to these factors that are indicators for enhanced historical curiosity, there are specific areas that a competent parenting assessment would give attention to and requires sufficient historical inquiry; this includes for example the style of attachment experience that parents had as a child and therefore bring to their own parenting. In services that were busy and professionals have busy and challenging workloads, there was insufficient attention to challenging an over reliance on observed behaviour to make important judgments and decisions. TOR 3 Multi-agency recognition and response to neglect The effectiveness of agencies recognition and response to indicators of neglect and their potential impact on the wellbeing of the children and analyse whether there was tolerance of neglect. 313. The HOR comments that there was evidence of potential neglect from the first pregnancy when there were several missed appointments for antenatal care. The Page 59 of 84 Child Z SCR Overview Report published 051015 author of the HOR and of this overview report was struck by how the IMRs give an impression of key professionals ‘treading softly’ in trying to encourage a better level of engagement by a young parent and were cautious about adopting a more assertive strategy that focussed on the implications for the unborn child. 314. This is a theme explored in the final chapter of this report; it is an area of practice that represents a challenge for most professionals who will be mindful that the greatest potential for effective help is developing a relationship that encourages trust and openness. In this particular case there was an improved level of engagement after the birth of Sibling 1 which was regarded as progress particularly by FNP1. 315. It is not apparent that the health and social care professionals anticipated that neglect might be a factor in this family. The absence of such anticipation or hypothesis means that the patterns of cumulative concerns are less likely to be identified. The family were regarded as having money problems and clearly there was a toleration of dirty and chaotic domestic conditions. Neglect is a pattern of behaviour which by its nature may not look significant unless underlying patterns are identified and there is sufficient focus and understanding about how severe neglect has adverse effects on for example children’s ability to form attachments and can significantly impair physical growth and intellectual development. 316. The impact of physical and emotional neglect has only recently become much more understood especially in relation to preschool children. Physical and emotional neglect has profound risk for issues such as brain development, physical growth and health and the development of cognitive and language skills of children. These have short and longer term implications for children. 317. The recognition and assessment of neglect has been problematic for professional practice across all disciplines and is one of the single greatest challenges for single and multi-agency work. There are problems in arriving at working frameworks of definition that can help professionals from different backgrounds to communicate meaningfully. For example, a health professional may have a very clear theoretical and clinical understanding about the future implications of neglectful care that is not as well understood by other professionals or it may be that professionals have different views about what constitutes harmful neglect. 318. There are profound ethical dilemmas and conflicts that confront professionals; for example wanting to avoid discriminatory practice that penalises a family living in poverty especially in communities that are dealing with widespread deprivation and social challenges. Distinction has to made between material poverty and disadvantage for example, and evidence of emotional neglect. Additionally, neglect relies on being able to discover the patterns associated with neglectful parenting behaviour and giving proper inference to issues of lifestyle. 319. It is also about understanding the significance of adult behaviour for the well-being of the children. The HOR highlights for example how MZ’s decision to take her own discharge from hospital after the birth of Sibling 1 was an example of putting her own Page 60 of 84 Child Z SCR Overview Report published 051015 needs ahead of her baby’s. There were other examples of similar behaviour in regard to missed appointments and waiting for treatment. 320. The fact that the regional ambulance service made one of the referrals about the evidence of neglect when they went to the house in June 2011 prompted particular reflection by the panel. It is relatively unusual for the ambulance service to make a referral and by inference suggested there was a significant set of issues to be explored. 321. There were specific challenges facing this family for example in regard to their housing. It remained unclear when and whether FZ and MZ were sharing a household. MZ lived in two properties that had problems. In the last but one property that was privately owned the property was in a state of considerable disrepair and from evidence in the police records MZ had difficulties with the landlord. 322. The identification of neglect requires a good deal of self-confidence on the part of practitioners working with families living in very challenging circumstances who have the capacity and time to spend with parents and children. They also need to have access to and an understanding of relevant tools and analytical techniques or frameworks that can give greater confidence in distinguishing between what might be isolated patterns of inadequate emotional or physical care and the more damaging and persistent underlying patterns associated with neglect. It requires a clear and consistent focus on what is happening to the child in terms of their emotional and physical development and can also develop an understanding about the particular resilience of specific children and their families. Working with neglect is not about the application of a restrictive template of standards although it has to recognise that children have essential rights to a minimum level of care and nurturing. 323. The barriers that confront effective interaction between professionals and parents and their children are becoming better understood. It is not good enough to rely on the observed behaviour of a parent during short interviews or other activity or on their asserted intentions of behaving differently when confronted over individual episodes of inappropriate behaviour. In this case, FZ was never interviewed in regard to his role as a parent or the risks that his history and lifestyle represented to his children. That risk came from his capacity for violence as well as the implied violence to be inferred from the reports of attempted break in to the property and the discovery of weapons in the house. 324. None of the IMR authors described any recognisable tools or frameworks for collating information about neglect or arrangements for inferring and analysing the significance for the children. The only tool or framework that is described related to FNP that had a distinct and different purpose in motivating and reinforcing the strengths based approach to working with parents. In this case, it was unable to recognise emerging patterns that required consideration as to whether the approach was sufficient. Page 61 of 84 Child Z SCR Overview Report published 051015 325. Care is needed in being overly critical, recent national studies describe the problems of developing such material and ascribing too much reliability. It is not the tools that can produce the right judgments; it is the training and emotional intelligence and aptitude of the practitioners applying themselves to more structured and analytical supervision and multi-agency discussion that is more likely to minimise the reliance on simply trying to guess what might be important. It also creates the conditions in which the resolve, motivation and capability of an adult to parents is more likely to occur; asking and exploring for example what the significance of the children were to both MZ and to FZ. TOR 4 Quality of communication and working in partnership To what extent, if any, did agencies communicate effectively and work together to safeguard and promote the continued well-being of both children. Examine whether partnership working was affected by assumptions in relation to the services provided by other agencies. 326. This section of the report invites reflection as to whether communication was good enough to encourage the well-being of both children and the extent to which assumptions were made about the role of different services. Comment has already been made about the influence of mind-set and relying on what MZ in particular was saying rather than paying more attention and inference to other evidence contained in referrals, historical records if they had been checked as well as the observation of physical standards and care. 327. The quality of information sharing and communication are frequently an area of particular difficulty identified in serious case reviews, it would therefore be surprising if there was not learning to be examined in this case about how different people processed information as it was transferred between different services and work locations. 328. The importance of early identification of vulnerability in relation to new parents in particular has been commented upon in previous sections. There will be opportunities for discrete professional groups such as GPs and midwifery services to revisit the expectations and accepted practice that applies for example in the very early stages of pregnancy to gather enough information at the outset about the circumstances of the pregnancy and the parents. 329. In this particular case, very little information was gathered about FZ at the outset and he remained largely invisible throughout the time period examined by this review. It is significant that the GP practice was not aware of the involvement of the FNP. The practice had been sent a letter when MZ first enrolled on the programme. This information was lost when she changed GP and there was no further attempt to communicate with the GP. Page 62 of 84 Child Z SCR Overview Report published 051015 330. The HOR comments that that it was notable that there was a lack of important information sharing within the health community as well as between health and other services. In particular, the GP had significant information, historical and current, that was not accessed by other services during enquiries and assessment, and FN1 generally worked in isolation from other services that included the GP. 331. PO1 was the first professional to query whether there were risks associated with FZ in particular. PO1 appropriately checked with FRT to establish whether there was any current CSC involvement with the family. When it was established there was none, the response was to make a referral for a pre-birth assessment. The request for a pre-birth assessment has to be placed within some organisational context; in Manchester the FRT are dealing with in excess of 16,000 contacts each year. Inevitably, the service will be applying a risk assessed approach to that volume of enquiry and this will be reliant on the information provided from the person making the referral as well as completing sufficient checks to each individual contact. 332. A further important distinction is that for FRT and CSC generally, the decision as to whether information coming into the service is a contact (providing information for example) or a referral rests with FRT. It is FRT who decide that the information is being managed as a referral and therefore requires further enquiry and assessment. 333. For the probation service there are two main areas for learning identified. The first is that a CAF could have strengthened the range of information that could have been included in a referral to FRT if efforts to deliver support had proved insufficient. It would have been a vehicle for sharing information from the criminal justice system and primary and midwifery services and given a more informed picture of the range of need and risk associated with the family. 334. Secondly, the fact that PO1 was not yet qualified and there was a lack of supervisory oversight are other contributory factors identified by the IMR rather than a lack of capacity or will for the service to engage with the CAF process. When a decision to compete a CAF in late 2010 was made, the opportunity was lost when MZ effectively withdrew from contact with services. When contact was re-established, the plan was not followed through possibly arising through a concern that it would discourage MZ from engaging with the FNP In particular. 335. The fact that PO1 did not follow up with any challenge to the absence of further assessment by FRT was probably a reflection that reassurance was taken by both PO1 and FRT that the midwifery service would alert CSC if there were any cause for additional concern. This is not an unusual approach in cases that do not have a compelling and visible level of risk needing to be addressed. 336. The referral in June 2011 from the North West Ambulance Service(NWAS) to FRT raised concerns about the physical conditions in the home and the emotional care of Sibling 1. The discussion with FN1 provided reassurance that MZ was engaging with the FNP and her concerns if CSC visited reflected a range of assumptions on the part of both services; that FN1 was in a position to objectively comment about evidence Page 63 of 84 Child Z SCR Overview Report published 051015 of neglect and the assumption that CSC did not have the capacity to respond to MZ’s anxieties and concerns. 337. The response in June 2012 following the referral from the EDN following FZ’s presentation in the hospital emergency service with Sibling 1 resulted in the initial assessment that recommended no further action by CSC. It is explicitly recorded that one of the reasons for no further action was the involvement of other services although this relied on MZ both continuing to allow contact by FN1 in particular and that the contact was addressing the indicators of neglect and risk. This was not happening and because of the manner in which the assessment was completed these factors were not identified and therefore recognised. 338. The family faced considerable practical difficulties in regard to their housing and in particular the issue in respect of the malfunctioning shower. There was a considerable level of communication by phone, letter and email from different professionals about this although it was some months before the matter was resolved. 339. Although the housing provider accurately describes the legal position whereby MZ took on a tenancy knowing for example about the absence of a bath, there appeared to be reluctance to acknowledge her desperation at the time to secure a home and that her circumstances had changed with the birth of Child Z and practical problems that confronted MZ in bathing her two very young children; this did not help a situation where the standards of cleanliness in the house were clearly an issue. The matter was only resolved when the surveyor condemned the condition of the shower as being uneconomic to repair. TOR 5 Quality of inter-agency response to specific incidents or information of concern During the time frame of this review, there were episodes of concern. Analyse the effectiveness of agencies response to these incidents in relation to child protection procedures. 340. The episodes of concern that were identified during the timeframe for the review were never considered within the framework of the child protection procedures. The reasons for this have been described and analysed in other sections of the report. 341. PO1 had thought a pre-birth assessment was required when MZ was pregnant with Sibling 1 but this was not seen to be necessary by other services. When MZ told Connexions that she had become homeless when her family told her to leave when she was three months pregnant this did not result in contact or referral to CSC or the completion of a Connexions assessment. This was a departure from agency standards and practice. 342. Referrals from the ambulance service and the hospital emergency department were not escalated and the police did not make any referral to CSC in regard to the Page 64 of 84 Child Z SCR Overview Report published 051015 domestic violence. The single most significant consequence is that information was never collated in any form of multi-agency discussion and analysis. 343. Although it is correct to assert that keeping children safe does not just rely on the application of the specific protocols developed by the MSCB and in current national guidance and standards, the significance of framing concerns as having the potential to cause significant harm for children provides a focus on identifying the significance of different information and ensuring that all services contribute and share information. 344. The single largest gap in the case is that it was not until the death of Child Z and the convening of a strategy meeting under the MSCB protocols that there had been any multi agency meeting to share and consider the significance of different information. Until that point, although information was being shared, the outcomes were largely reliant upon the decision making within single agencies and often relied on the inference and interpretation given by professionals working within the silos of their own discipline in too much isolation from each other’s sources of information and analytical perspective. 345. The consequence was that any gaps or misdirection in the information was not identified until this review began collating information and subjecting it to analysis by the review panel. 346. Although the serious injury and killing of children is rarely a predictable event, there are factors that can indicate a child might be vulnerable to neglect or significant harm through the interplay of underlying and often overlooked factors that have their origins in personal and family history. 347. This does not mean that where such factors are recognised it should lead to parents being suspected or accused of harming their children but rather should alert and provoke a higher level of informed and sceptical curiosity that is appropriately persistent. This is more likely to occur if there has been an opportunity to share information and to provide respectful and informed challenge. It is especially important when services and people feel under pressure and are having to manage difficult workload demands. TOR 6 How information about the family’s more general circumstances was considered The extent to which agencies and services take account of issues such as lifestyle, economic status, community integration, race and culture, language, age, disability, faith, gender and sexuality and the impact upon agencies assessment and service delivery 348. The IMRs generally acknowledge that although individual professionals were appropriately sensitive and respectful to MZ who was the main point of contact, there was less attention given to the fact that MZ and FZ were relatively isolated from their families and within their community. Page 65 of 84 Child Z SCR Overview Report published 051015 349. It has become more apparent that learning difficulties were a factor; the police recognised this at an early stage in the criminal investigation by arranging for appropriate adults to be part of the interviews with both parents. Only PO1 identified any degree of difficulty when FZ’s dyslexia was recognised and had implications for FZ’s self-confidence and willingness to commit to support from other services trying to help him gain employment and to address his difficulties in relation to his use of alcohol and drugs. 350. The risk factors associated with aspects of FZ’s lifestyle in particular did not attract sufficient attention; the continuing evidence of cannabis use, his capacity for violence in and outside the household and the implications of his criminal activity on the safety of the household were not sufficiently recognised at the time. 351. Issues such as illicit substance misuse can present ethical and professional dilemmas for individual practitioners. An implied tolerance of issues such as cannabis use can reflect an individual professional feeling empathetic to the difficulties facing an adult and a misunderstanding about the potential risks for example to the care of very young children. There will also be additional concerns for example in wanting to establish and sustain relationship with adults who have shown a reluctance to maintain contact. A health or social care professional will know that establishing the trust and confidence of a parent is the foundation for developing a more open line of communication where the adult is willing to disclose and talk about the real concerns and troubles that they want to keep hidden. Page 66 of 84 Child Z SCR Overview Report published 051015 3 Analysis of key themes for learning from the case and recommendations 352. This report begins with an acknowledgment of the imminent changes that will take place over the forthcoming months in the conduct of serious case reviews throughout England. These changes are driven by the recognition that for any meaningful analysis of the complex human interactions and decision making processes that are involved in multiagency work with vulnerable families has to understand why things happen and the extent to which the local systems (people, processes, organisations) help or hinder effective work within ‘the tunnel’23. 353. In this chapter the panel set out key findings that are designed to offer challenge and reflection for the LSCB and partners. The emphasis is not on the more traditional articulation of SMART recommendations. The key findings are framed using a systems based typology developed by SCIE. Although this serious case review has not used systems learning to collate evidence there is value in using the following framework to identify some of the underlying patterns that appear to be significant for local practice in Manchester whilst accepting there are some limitations and mismatch between how the evidence has been collated and this form of presenting the key findings: a) Innate human biases (cognitive and emotional) b) Family-professional interaction c) Responses to incidents d) Longer term work e) Tools f) Management systems. 354. The remainder of this report aims to use this particular case, and to reflect on what this reveals about gaps and inadequacies in the local child protection system and use it as a limited window into the local systems. 355. In providing the reflections and challenges to the LSCB there is an expectation that the Board will provide a response to each of the key findings as well as to the recommendations and action plans that are described in the IMRs. As far as the key findings described in the remainder of this chapter it is anticipated that the Board will take the following action: LSCB response: a) Does the Board accept the finding? b) How is the Board to take this forward? If not, please explain why. 23 View in the Tunnel is explained by Dekker (2002) as reconstructing how different professionals saw the case as it unfolded; understanding other people’s assessments and actions, the review team try to attain the perspective of the people who were there at the time, their decisions were based on what they saw on the inside of the tunnel; not on what happens to be known today through the benefit of hindsight. Page 67 of 84 Child Z SCR Overview Report published 051015 c) Who is best placed to do this? d) What are the timescales for response? e) How and when will it be reported? 356. The LSCB will determine how this information is managed and communicated to relevant stakeholders. This report recommends that the LSCB discuss the key findings and make a formal response that is also published. 3.1 Learning from Previous Serious Case Reviews 357. The LSCB in Manchester had undertaken ten serious case reviews between 2007 and 2010. 358. Reference to the evidence from serious case reviews has been made throughout the IMRs, the Health Overview Report (HOR) and this Overview Report. 3.2 Innate Human Biases (cognitive and emotional) Human empathy for helping families overcome personal and social disadvantage has to be balanced with appropriate levels of sceptical and knowledgeable curiosity to prevent the development of collusion and over reliance on self-reported information and intentions. 359. The circumstances of MZ in particular provoked an empathetic response in the professionals working with her and were most evident for the individuals who had very extensive contact and personal commitment to helping the family. The importance of making an emotional connection between the people needing help and the person providing support is very well understood as a foundation for developing a relationship of trust and was in evidence for example in how FN1 worked with the family and MZ especially. 360. It is part of the emotional foundation described by Ferguson24 for exercising good authority. He describes the complexity of cognitive influences, systems and processes and understanding the significance of the factors that are linked to increased harm; recognising the families who through their history as well as immediate circumstances, are likely to have less resilience to face events that can derail them; how this relies on professionals having the capacity and aptitude to develop appropriate relationships with the family that goes beyond relying on empathetic support. 361. There were several examples of individual professionals wanting to help MZ and FZ translate their stated intentions to create better childhoods for their children than 24 Child Protection Practice; Palgrave Macmillan; 2011. Page 68 of 84 Child Z SCR Overview Report published 051015 had been possible for them although they faced considerable difficulty in seeing the intention translated into tangible outcomes. 362. A common thread through this case is that none of the individual professionals had an entirely satisfactory knowledge of either parent’s history. This inevitably made the professionals more reliant on processing information from their direct observation and contact on the basis of what either parent told them. The report has highlighted in previous sections how information was minimised, omitted or simply not factually correct on regular occasions with the apparent intent to redirect professional attention. This is behaviour that is identified very often in reviews such as this. 363. The only professional who had a better level of historical information as it related to FZ was PO1 who initially asked for a pre-birth assessment to be completed. This did not happen and neither did a CAF take place. Contributory factors to that particular aspect of the case included the fact that PO1 was in training and therefore did not have the status and confidence that could be expected from a fully qualified practitioner. The case coincided with a period when the probation service was under significant local organisational stress and the availability of supervision and management oversight was not as clear as would more normally be achieved. 364. The most significant professional involved with the family was FN1 who clearly worked with great persistence and dedication to develop a relationship and implement a validated programme of support and parent training that had the potential to secure improved outcomes for Child Z and Sibling 1. 365. In developing that relationship and implementing that programme it appears that a prevailing mind-set had developed that believed MZ and FZ had the capacity to parent their children to a good enough standard. Influential in that judgment was how MZ in particular interacted with FN1. For example, FN1 did not contradict concerns directly on the occasions that were raised, for example in regard to the referral from the hospital, but instead were subjected to an acknowledgment of the issue, an explanation about why standards had not been achieved for example in regard to aspects of cleaning and a commitment to do better and to get on top of things. FN1 believed that MZ and FZ could make their parenting better than they had experienced as children. 366. With hindsight it is possible to query the foundation of evidence that was available to the professionals who had the most influential roles in the case. This is not to personalise around single professionals but was a general theme. 367. There is evidence that professionals for a variety of reasons tolerated or overlooked aspects of lifestyle and behaviour. The FN1 was influential in how other services such as CSC conducted their enquiries; for example expressing concerns about the impact on MZ of involvement by CSC; both services missed evidence of neglectful parenting and did not provide enough challenge about the chaos and dirt in the house. Some of the practitioners were shown copies of the photographs that were taken in the house on the day that Child Z had died; some dispute that the Page 69 of 84 Child Z SCR Overview Report published 051015 conditions were as poor during their visits to the home although the panel retain a more sceptical view that the conditions were representative of longer term difficulties. 368. Some professionals knew that FZ was a habitual user of cannabis although with some exceptions, very little enquiry or challenge was made regarding his use. Some of that probably reflects the fact that in some areas the use of substances such as cannabis is part of the routine background to daily life. Issues for consideration by the LSCB 1. To what extent are professionals helped to develop the appropriate emotional and mental skills that can balance empathy with the right degree of knowledgeable sceptism and professional assertiveness? 2. Is the MSCB satisfied that professionals have a sufficiently clear framework of personal and professional standards that can prevent inappropriate normalisation of behaviours such as substance misuse and neglectful behaviour? 3. Is assessment of risk to children sufficiently focussed on lifestyle issues such as substance misuse and is there a good enough understanding about the risk associated with substances such as cannabis in adults caring for very young children in particular and especially where mental health is an additional factor? 3.3 Responses to incidents or information Effective enquiries and management of information have to identify the relevant underlying patterns of behaviour, inconsistencies and inherent factors of vulnerability of risk. 369. The first chapter of this report identified five episodes that the panel have examined in particular for the purpose of looking for learning opportunities from this case; four episodes concern referrals that could have been opportunities for more effective enquiry that could have included the use of CAF. 370. The first was a request for a pre-birth assessment that was diverted to the midwifery service as a case for the Vulnerable Babies Service; it did not address the underlying reasons for the concerns being raised. The report has also highlighted that a CAF could have provided an opportunity for enquiry and sharing of information. The report has highlighted that a combination of factors had an impact on that first occasion that included the inability of the FRT electronic system at the time to identify historical archived information, through to the relative inexperience of PO1 who was working with reduced levels of supervision support and oversight due to organisational problems at the time. Page 70 of 84 Child Z SCR Overview Report published 051015 371. The second episode that involved the police having a disclosure of domestic abuse over several months and involving a pregnant teenager was not referred to CSC. There was a mistaken belief that information just went to health and at the time was transmitted via a fax that left no audit trail of who actually received the information or what was done with it. The incident represented a safeguarding concern for both MZ and the unborn child and about which CSC remained unaware until this SCR. The Police Officer who dealt with the incident displayed an appropriate concern and focus on offering protection to MZ who declined to make a formal criminal complaint against her partner. As on the first occasion an opportunity to identify significant underlying patterns of concerns was missed by systems of information sharing not working effectively. Matters were compounded by incomplete checks and enquiries with other services. 372. In June 2011 when the ambulance service made a referral in relation to neglect was a third opportunity to make formal enquiries. Although this did result in a home visit taking place it did not involve CSC who were persuaded perhaps too readily that FN1 could follow this up. Analysis in regard to the cognitive and mindset influences has identified the conditions within which the information provided by the ambulance crew was downgraded rather than being seen as an unusual source of referral. 373. The fourth occasion was the referral from the hospital emergency department that was also indicating neglect as well as for the time describing a physical injury to one of the children. Although the referral was followed up through a joint visit to the home, the visit lacked sufficient focus on the information provided. Again this was for a number of different reasons that included some aspects of the referral not being made clear in the transfer of information from FRT to the neighbourhood team; assumptions being made that the child had been subject of a medical examination and by implication in the absence of any diagnosis of abuse there was a lower level of concern; and the interaction between MZ and a more trusted professional who had confidence and belief in the capacity of the parents to look after their children. 374. The influence of hindsight that can have an impact on a review such as this can make this sequence of opportunities look more obvious than they were in reality at the time for the people dealing with information and events. Although PO1 had felt there was a degree of concern to justify a pre-birth assessment this was on the basis of wanting to discover more information rather than being certain and definite about the degree of risk or otherwise to the unborn baby. 375. This could have been addressed through a CAF and would have been the basis of more information for further contact with services such as CSC. The involvement of services such as the FNP apparently provided a good deal of reassurance to several people. The ambulance referral was not regarded as being a significant concern. 376. All of this reflects the lessons that come through often, that it is not individual incidents or events that are significant but rather the ability to place them within a context. That context has to include sufficient knowledge about the history of parents or significant adults as well as linking current and recent events in a Page 71 of 84 Child Z SCR Overview Report published 051015 meaningful chronology and narrative that focuses on what the implications are for the child. 377. It requires triangulation of direct observation of attitude, behaviour and lifestyle, checking for relevant historical information within which to place current information and analysis, together with appropriate and proportionate discussion with third party professionals in respect of information and perspectives they may have. Issues for consideration by the LSCB 1) To what extent is the absence of an adequate family history by the health and social care professionals who had significant contact with Child Z and parents a representative example of current practice? 2) To what extent do agencies secure a good enough chronology and narrative to support adequate analysis of information? 3) To what extent are there barriers that prevent professionals using the CAF and to what extent are they understood? 3.4 Longer term work The impact of environmental factors associated with long term substance misuse, mental health and domestic violence have implications for longer term support and involvement by individual practitioners and services. 378. The influence of empathy that is highlighted in regard to the emotional response to MZ and FZ’s circumstances have implications for longer term work with parents with longstanding challenges that arise from health, lifestyle and social circumstances. 379. For the professionals working with families facing high levels of complex needs and difficulty it can be the case that the problems of the family overwhelm everybody. This can be a reason why families can believe there is no point reopening a discussion about particular problems such as anger management or domestic abuse for example, as much as the professionals wanting to believe optimistic statements that previous interventions have addressed problems. In this case, there was reference to FZ having done work in relation to anger management although little detail was sought in regard to what had actually been achieved or to meaningfully understand whether it had been successful. 380. There were several longer term issues that were apparently given cursory attention. This included the evidence of very poor home conditions; the panel were generally dismayed by the photographic evidence of the house on the day that Child Z died and had difficulty reconciling this with the information provided through IMRs that acknowledged clutter and some lack of cleanliness but did not resonate with the evidence of long term squalor and neglect represented in the photographic evidence. 381. Because of the current methodology of reviews there is some limitation on how far a report such as this can truly understand the systemic influences operating on Page 72 of 84 Child Z SCR Overview Report published 051015 practitioners and families such as Child Z. It is possible to say that evidence from this and other reviews do identify how long term and chronic problems and needs represent a challenge to the professionals achieving and sustaining an effective role and influence. 382. Other factors such as the long term substance misuse, offending and the evidence of weapons in the home were not identified as factors to be addressed. In this particular case, there was the additional factor of a specific model of intervention through the FNP and the perception that other services had of this, that probably had an influence in how these aspects of case management were handled. Issue for consideration by the LSCB 1. Is the evidence from this case in regard to the management of complex long term need representative of models of local help and support? 3.5 Tools The use of tools are not sufficiently utilised to explore the historical context and circumstances of the family and identify and analyse indicators of risk from issues such as neglect as they relate to children’s emotional, physical and psychological safety and rely too much on self-reported information and disclosure. 383. An important aspect of this particular review is the use of the FNP and some of the possibly unintended consequences that have applied. The FNP and probation service used tools to underpin their ongoing work and were primarily focussed on current circumstances. In Probation there was an assessment of risk presented by FZ which supported the initial referral to CSC. The FNP deployed a framework designed to strengthen the parenting capacity and capability of MZ in particular but was not rooted in any knowledge about the history and experience of either parent. 384. The FNP is an important aspect of the local frameworks of services that are being implemented across health and social care services in Manchester and England more generally. 385. The report has described some of the incorrect inferences that were applied to the FNP and to other programmes such as the Vulnerable Babies Service. There has been a degree of reassurance taken from the fact that the FNP had been apparently accepted by the family and that it was going to be addressing the issues being highlighted in referrals and contacts with services such as CSC. 386. In reality there was some doubt about the extent to which the FNP was accepted by the family in spite of the very considerable effort by FN1 to achieve this. The panel have noted that FN1 showed persistence in keeping contact with MZ in particular. FN1 was successful in being allowed to resume contact with MZ after she moved although may have developed a misplaced confidence that the parents were accepting of the contact. Much of this appears to have relied on the parents (MZ in Page 73 of 84 Child Z SCR Overview Report published 051015 particular) expressing a commitment to follow up advice such as improving the standards of hygiene. In reality, there is evidence that very little of the advice appeared to be effective in changing conditions. 387. The FNP follows a structured programme which did not appear to be sufficiently adapted in this instance to a family that was experiencing high levels of disruption and chaos. The insecurity of the family’s housing, the difficulties of the broken shower in addition to the other problems discussed in previous sections were not directly inquired into and assessed in terms of risk for the children. 388. The clarification through the review that the allocation of FNP had never reflected a particular assessment of level of need within this family, over and above the fact that MZ was a first time teenage mother at the time of referral, provided a stark contrast to the assumptions that had apparently been made by various professionals. 389. A lesson from this review is that the use of a strengths based approach to increasing the quality and capacity of parenting skills in particular families has to give some cognisance to the circumstances, motivation and ability of the family to use such an approach. It also has to ensure that the effectiveness of the programme is being examined in respect of benefits and outcomes for the child. 390. In regard to the statutory assessment it is not apparent that any other tools or frameworks were used to analyse issues such as the parenting capacity of MZ and FZ (possibly because it was assumed this was being done by the FNP), there was no recognition and therefore analysis about the quality of emotional as well physical care of the children. There was no evidence of any common framework or tool such as the graded care profile to help collate and analyse information about neglect. Issues for consideration by the LSCB 1. How are the lessons identified in this review to inform how preventative programmes are developed and implemented with families with more complex levels of need? 2. Do professionals have access to and encouragement to use relevant tools or frameworks to help collate and analyse information about emotional and physical neglect? 3. Can health and social care practitioners in particular be encouraged to rely less exclusively on direct observation and triangulate information from third party and historical information? Page 74 of 84 Child Z SCR Overview Report published 051015 3.6 Management systems The implementation of new or revised working arrangements and information systems can represent additional barriers to effective information searches, collation and analysis. 391. This review has highlighted the extent to which the performance and decision making of professionals can be adversely affected by the functioning of other systems and organisational arrangements around them. 392. The response by FRT in respect of contacts from PO1, the ambulance service and the hospital emergency department were all unable to identify that there had been relevant historical involvement. Access to supervision and oversight for PO1 had been affected by organisational workforce problems and the sharing of information by the Police in regard to the domestic abuse was hindered by working practices that have since been changed. 393. A significant part of this final chapter of the report has reflected upon the challenge of implementing new programmes and ensuring that they do not misdirect practitioners and their purpose is sufficiently well understood by the relevant services. False assumptions were made about the FNP and the Vulnerable Babies Service. Issue for consideration by the LSCB 1) Does the MSCB feel sufficiently well informed about the implementation of revised working arrangements and management of new services and the possible implications for safeguarding arrangements? Supervision and semi-structured peer discussion does not yet provide sufficient opportunity to deal with the ethical and legal complexities associated with more marginal lifestyles. 394. The panel were concerned that this case appears to indicate a degree of tolerance being exhibited in issues such as the use of cannabis and the degree of cleanliness. 395. The reality for many of the professionals in this case is that they will be working with families in some of the most challenging of social and economic circumstances. Listening to adults who want to overcome their problems can invoke a mindset that is less challenging of contradictory evidence or aspects of lifestyle such as the use of cannabis and alcohol. 396. For practitioners who are trying to work on the longer term achievement of change with families, they face the juxtaposition of trying to gain the engagement and confidence of adults who through their personal history and circumstances are mistrustful and at the same time have to confront behaviours and lifestyles that are detrimental to children. Page 75 of 84 Child Z SCR Overview Report published 051015 397. Knowing when and how to respond comes with experience and professional self-confidence. It is less developed in professionals who are not so established in their professional roles. 398. Practitioners have access to and be required to participate in supervision and discussion that can offer the degree of critical challenge and purposeful reflection that goes beyond compliance with protocol and develops greater resilience and resistance to the dangers of normalising or minimising evidence and information. Issue for consideration by the LSCB 1) Is it reasonable to expect practitioners to be able to identify for themselves the ethical and legal issues that require challenge and reflection in professional supervision? 3.7 Issues for national policy 399. The development of the Family Nurse Partnership is an important aspect of national policy. On the 4th April 2013 the Health Minister announced that 16,000 of the most disadvantaged new parents in the country will be offered tailored help and support from a specialist nurse by 2015. This means many more vulnerable children across the country will get early support for a better start in life. Initial research in England has found that mothers who receive support from family nurses show positive results. 400. This review has highlighted the importance of local areas developing a robust understanding of FNP and giving clear consideration, through the recommended FNP Advisory Boards, of the ways in which they will integrate national implementation and clinical guidance within local policy and practice. This includes initiatives such as the FNP being linked effectively with other local services and ensuring that practitioners have a clear understanding about when to consult and make referrals to other services. 401. The review also raises a challenge in how the methodology and evaluation of such programmes is understood. A simplistic, deterministic belief in the veracity of a proven framework can encourage misdirection away from evidence of need or an inadequate assessment of the extent to which risk factors are being addressed through change or improvements in the family. This has implications for the level of information that is exchanged between agencies in regard to issues such as personal and family history, the continual development of a supervision model within the programme which encourages critical reflections and an implementation context which ensures that local processes support expert practice. This should ensure that practitioners are able to continue to have an approach of respectful curiosity in regard to all aspects of the family’s life and keep the child at the centre of their work. Page 76 of 84 Child Z SCR Overview Report published 051015 Peter Maddocks, CQSW, MA. Independent author August 2013 Signed Ian Rush | Independent Chair of the MSCB 20th August 2013 Child Z SCR Overview Report published 051015 Page 77 of 84 4 APPENDICES The recommendations of the individual agencies and the Health Commissioning Overview Report. Single Agency Recommendations Children’s Social Care 1. Background system checks will be made within MiCARE which now include POCC records, and identify when there is a SCi record. The names of all known family members will be checked, which will highlight a known Social Work History in the Family. The historic Child Protection database can also be checked. 2. Additional guidance to staff when undertaking assessments to ensure that they have checked all necessary background information, and evidence that this is analysed in their assessment and recommendations. 3. Where an assessment has been requested, then one should be carried out, unless there is a subsequent discussion following which the referrer agrees that one is not required. 4. An annual workshop to be considered for front line management to reinforce and support skills around analysis, reflection, and quality assurance in their role. 5. Practice workshops with practitioners and managers to be planned to improve reflection re the analysis and the conclusions in casework documents. 6. Where a child has been seen by a medical professional, and a referral received, the worker should obtain details of that contact in order to be able to discuss any concerns fully and clarify any information required. 7. Contact Centre management continue to ensure timeliness for incoming referrals/faxes to be passed to First Response Team. Central Manchester Foundation Trust 1. It is recommended that when any ‘additional needs’ are identified; a MCAF should be implemented by the FN’s. There is a sharper focus on CAF and the Family Nurse Supervisors discuss with FN’s the reasons why a professional decision has been made not to undertake a MCAF when additional needs have been identified. 2. It is recommended that FNP National Record Keeping Guidance (2011) with regards to father’s health needs and other household residents is reviewed and is Child Z SCR Overview Report published 051015 Page 78 of 84 fully implemented across the service by the FNP. There will be a requirement to ensure that this is achieved and therefore an audit of records will be required. 3. It is recommended that the CMFT Children’s Community Services Directorate ensures that all assessment or contacts with a child /family detail within the records clearly what the daily lived experience feels like. Greater Manchester Police The Greater Manchester Police IMR Author stated “There are no recommendations or single agency action plan arising out of this review.” Northwards Housing Trust 1. Officers from Northwards Housing should ensure that, when other agencies contact us on a tenant’s behalf, we ask appropriate questions about the nature of their involvement with the tenant. This will ensure that we have access to all relevant information in order to work most effectively together to protect children living in or visiting the homes we manage. This will be incorporated into Northwards' safeguarding policy and procedure and reflected in staff training. North West Ambulance Service 1. Update and reiterate in the Sudden Unexpected Death of Children Procedures that during any Acute Life Threatening Event (ALTE) or sudden unexpected death of a child, the police must be notified by the relevant Emergency Operations Centre EMD. 2. Further develop the Address Flagging Procedure to include flags for sharing information about vulnerable children and adults. 3. Lessons from this review are communicated to Senior Managers within the Trust NHS Manchester 1. GP practices to consider making enquiring as to the presence of children and any safeguarding risk factors before removing an adult who is a parent or legal guardian from the practice register. 2. GP practices to ensure that if they aware of women enrolled onto the family nurse partnership programme, there should be active two way information sharing and a method of highlighting this involvement, for example using alerts on the electronic records. Child Z SCR Overview Report published 051015 Page 79 of 84 Pennine Acute Hospitals Trust 1. The Trust safeguarding team will undertake a record keeping audit to measure compliance with the Trust policy re: documentation standards and mandatory questions about patients’ caring responsibilities. 2. An improved electronic information sharing system will be developed to improve the quality of information sharing between hospital and community staff. Greater Manchester Probation Trust 1. For Greater Manchester Probation Trust in the City of Manchester to assess the quality and timeliness of supervision provided to Probation Service Officers taking into consideration whether opportunities are provided to examine cases where risk of serious harm might be escalating, particularly in relation to domestic abuse and child safeguarding concerns. 2. For Greater Manchester Probation Trust in the City of Manchester to commission a piece of work to examine whether Probation Service Officer staff are holding domestic abuse cases and assess whether these are appropriately allocated to this grade of staff, in line with the Domestic Abuse Policy and Practice Directions. 3. For Greater Manchester Probation Trust to examine the use of home visiting across the Trust to assess whether they are being used effectively to aid risk assessment, management and decision making where child safeguarding concerns exist. 4. For Probation Operations Managers and Probation Service Officer staff to be reminded of the Domestic Abuse Practice Direction which states that domestic abuse cases must be allocated to Probation Officer grade staff unless a manager’s approval is granted and recorded on the case file. 5. For Greater Manchester Probation Trust to issue updated Safeguarding Children Policy and Practice Directions that will make explicit reference to children and unborn babies. Child Z SCR Overview Report published 051015 Page 80 of 84 Health Commissioning Overview Report Recommendations 1. When a family is enrolled with the FNP there should be a trawl of all agencies for information about the family and this should always include the GP. 2. When FNP is working with a family, there should be ongoing two way liaison with other involved agencies. 3. FNP supervisors should receive specialist training on “The Ten Pitfalls” document and should use the additional knowledge when supervising practitioners. 4. All families enrolled in the FNP should be discussed regularly in supervision. 5. If another agency raises concerns about a family enrolled with FNP this should automatically trigger: i) discussion with the named nurse for safeguarding ii) a joint visit with the FNP supervisor iii) a “team around the child” or case planning meeting. 6. The FNP Board should oversee ongoing FNP work and ensure governance. Child Z SCR Overview Report published 051015 Page 81 of 84 Appendix 1 - Procedures and guidance relevant to this Serious Case Review Legislation The Children Act 1989 Section 11 of the Children Act 2004 places a duty on the key people and bodies described in the Act25 to make arrangements to ensure that their functions are discharged with regard to the need to safeguard and promote the welfare of children. The application of this duty varies according to the nature of each agency and its particular functions. The Section 11 duty means that these key people and bodies must make arrangements to ensure that their functions are discharged having regard to the need to safeguard and promote the welfare of children and this includes any services that they contract out to others. Section 17 imposes a duty upon local authorities to safeguard and promote the welfare of children in need. Section 47 requires a local authority to make enquiries they consider necessary to decide whether they need to take action to safeguard a child or promote their welfare when they have reasonable cause to suspect that a child is suffering, or is likely to suffer significant harm. These enquiries should start within 48 hours. The local authority is required to consider whether legal action is required and this includes exercising any powers including those in section 11 of the Crime and Disorder Act 1998 (Child Safety Orders) or when a child / young person has contravened a ban imposed by a Curfew Notice within the meaning of chapter I of Part I of the Crime and Disorder Act 1998. Section 46 provides the Police with Powers of Protection to take children into police protection where a police officer has reasonable cause to believe that a child would otherwise be likely to suffer significant harm. The Children Act 2004 Section 10 requires each local authority to make arrangements to promote co-operation between it, each of its relevant partners and such other persons or bodies, working with children in the authority’s area, as the authority consider appropriate. The arrangements are to be made with a view to improving the wellbeing of children in the authority’s area – which includes protection from harm or neglect alongside other outcomes. This section is the legislative basis for children’s trusts arrangements. Section 11 of the Children Act 2004 places a duty on the key people and bodies described in the Act26 to make arrangements to ensure that their functions are discharged with regard to 25 Local Authorities, including District Councils, the Police, National Offender Management Service, NHS bodies, Youth Offending Teams, Governors/Directors of Prisons and Young Offenders Institution, Directors of Secure Training 26 Local Authorities, including District Councils, the Police, National Offender Management Service, NHS bodies, Youth Offending Teams, Governors/Directors of Prisons and Young Offenders Institution, Directors of Secure Training Centres. Child Z SCR Overview Report published 051015 Page 82 of 84 the need to safeguard and promote the welfare of children. The application of this duty varies according to the nature of each agency and its particular functions. The Section 11 duty means that these key people and bodies must make arrangements to ensure that their functions are discharged having regard to the need to safeguard and promote the welfare of children and this includes any services that they contract out to others. Safeguarding Procedures The local safeguarding children procedures The procedures provide advice and guidance on the recognition and referral arrangements for children suffering abuse. This includes emotional abuse that involves causing children to feel frightened or in danger. The procedures also cover physical abuse of children. The procedures also describe abuse involving the neglect of children that includes failing to protect children from physical harm or danger or the failure to ensure access to appropriate medical care or treatment. This includes describing distinct action to be taken when professionals have concerns about a child, arrangements for making a referral, and the action to be taken. The procedures cover arrangements for the ACPC (now superseded by LSCB) to ensure there are effective arrangements that promote good interagency working and sharing of information and training. The procedures describe specific responsibilities for all agencies contributing to this serious case review. Other local procedures relevant to this serious case review National guidance27 Working Together to Safeguard Children 2013 The national guidance to interagency working to protect children is set out in Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. The guidance includes safeguarding and promoting the welfare of children who may be particularly vulnerable. Framework for the Assessment of Children in Need and their Families 2001 The guidance in respect of the Framework for the Assessment of Children in Need and their Families is issued under section 7 of the Local Authority Social Services Act 1970 and is therefore mandatory. The framework sets out the framework for ensuring a timely response and effective provision of services to children in need. It makes clear the importance of achieving improved outcomes for children through effective collaboration between practitioners and agencies. The framework sets out clear timescales for key activities. This includes making decisions on referrals within one working day, completing initial assessments within seven 27 The election of a coalition government in May 2010 may result in changes to guidance and policy developed by the previous government. Child Z SCR Overview Report published 051015 Page 83 of 84 working days and core assessments within 35 working days. As part of an initial assessment children should be seen and spoken with to ensure their feelings and wishes contribute to understanding how they are affected. If concerns regarding significant harm are identified they must be subject of a strategy discussion to co-ordinate information and plan enquiries. Child protection procedures must be followed. Assessments should be centred on the child, be rooted in child development that requires children being assessed within the context of their environment and surroundings. It should be a continuing process and not a single or administrative event or task. They should involve other relevant professionals. The outcome of the assessment should be a clear analysis of the needs of the child and their parents or carers capacity to meet their needs and keep them safe. The assessment should identify whether intervention is required to secure the well – being of the child. Such intervention should be described in clear plans that include the services being provided, the people responsible for specific action and describe a process for review. Common Assessment Framework (CAF) The CAF is a key part of delivering direct services to children that are integrated and focused around the needs of children and young people. The CAF is a standardised approach to conducting assessments of children’s additional needs and deciding how these should be met. It can be used by practitioners across children's services in England. The CAF promotes more effective, earlier identification of additional needs, particularly in universal services. It aims to provide a simple process for a holistic assessment of children's needs and strengths; taking account of the roles of parents, carers and environmental factors on their development. Practitioners are then better placed to agree with children and families about appropriate modes of support. The CAF also aims to improve integrated working by promoting coordinated service provisions. All areas were expected to implement the CAF, along with the lead professional role and information sharing, between April 2006 and March 2008. Child Z SCR Overview Report published 051015 Page 84 of 84 Glossary A&E Accident and Emergency ADS Addiction Dependency Solutions CAF Common Assessment Framework CIN Child in Need CSC Children’s Social Care CPP Child Protection Plan CPR Cardiopulmonary Resuscitation CMFT Central Manchester Foundation Trust CPC Child Protection Conference DVU Domestic Violence Unit EDN Emergency Department Nurse EDS / T Emergency Duty Service / Team FNP Family Nurse Partnership FRT First Response Team (part of CSC) GP General Practitioner GMWHMT Greater Manchester West Mental Health Trust HADQ/S Hospital anxiety and depression questionnaire/Scale HCPC Health Care Profession Council HOR Health Overview Report ICO Interim Care Order IMR Individual Management Review (report) LSCB Local Safeguarding Children Board MARAC Multi Agency Risk Assessment Checklist MSCB Manchester Safeguarding Children Board NFA No further Action NHS National Health Service NSPCC National Society of the Prevention of Cruelty to Children NWAS North West Ambulance Service OASys Offender Assessment System (Probation) PPOP Police powers of protection PPU Police Protection Unit PIPE Partners In Parenting Education SCIE Social Care Institute for Excellence SNF/SCF Special Needs or Circumstances Form SMART Specific, Measurable, Achievable, Realistic, Timely SUDC Sudden Unexpected Death of Children TPM Teenage Pregnancy Midwife UHSM University Hospital South Manchester VBS Vulnerable Babies Service WIC Walk in Centre |
NC52388 | Death of a 14-month-old girl in August 2019. Isabella's mother found her unresponsive at home and she was transferred to hospital by ambulance but died after resuscitation failed. Isabella had complex medical needs and global developmental delay. Parents were known to children's services. Mother had been subject to a child protection plan and there were concerns for her around child sexual exploitation. These increased when her relationship with Father became known when she was 16 and he was 21-years-old. Father had issues with alcohol misuse. Isabella was born prematurely and spent 13 weeks in neonatal intensive care, under the care of several consultants with different medical expertise. Concerns were raised about parents' parenting capacity due in part to their young age and missed medical appointments, lack of support, and home environment. Mother gave birth to Isabella's sibling in July 2019. Learning includes: considerations should be given as to how professionals engage with fathers. If a father has not engaged, it should be clearly recorded that he remains an unassessed risk; if a parent does not consent to Local Authority support for a Child in Need (CIN), careful consideration should be given to escalating the protection provided; information about avoidant behaviour should be shared with all other professionals involved. Ethnicity and nationality not stated. Recommendations include: ensure that the language change - 'Was Not Brought' is reinforced across partner agencies and make certain that practitioners are trained to realise 'medical neglect' and recognise missed appointments as an indicator.
| Title: Serious case review: Isabella. LSCB: Bury Safeguarding Children Board Author: Allison Sandiford Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Allison Sandiford LLB (Hons) Independent Reviewer SERIOUS CASE REVIEW ISABELLA 1 Contents 1. Introduction .............................................................................................................................................................. 2 2. Brief Synopsis of Events ............................................................................................................................................ 4 3. Family Views ............................................................................................................................................................. 7 4. Practitioners’ Views / Actions ................................................................................................................................... 8 5. Analysis of the Key Lines of Enquiry ........................................................................................................................ 10 6. Good Practice Identified ......................................................................................................................................... 19 7. Recommendations .................................................................................................................................................. 20 2 1. Introduction Initiation of the Serious Case Review 1.1. This Serious Case Review (SCR) was commissioned in September 2019 by Bury Safeguarding Children Board (BSCB). The matter under review is the unexpected tragic death of a young child (Child Isabella1). 1.2. Isabella had complex medical needs and global developmental delay. At the time of death Isabella was supported by a Child in Need (CIN) plan. When Isabella was 14 months old, her Mother found her unresponsive at the home address. Isabella was transported to hospital by ambulance under respiratory arrest but sadly died after attempts to resuscitate failed. 1.3. The BSCB concluded that the circumstances of this case meet the criteria for a SCR as per statutory guidance2. 1.4. In 2018, the government announced that all local authorities would be required to replace their Local Safeguarding Children Boards with a team of Safeguarding Partners, who will work as a group to strengthen the child protection and safeguarding system. Consequently, on 30th September 2019 the BSCB was replaced by the Bury Integrated Safeguarding Partnership (BISP) and will be referred to as this thereafter throughout this report. Methodology and Agency Involvement 1.5. The review was managed by a review panel (known as the Panel) which included representation from relevant organisations within Health, Children’s Social Care (CSC), the Police and BISP. Allison Sandiford, an independent reviewer (the Reviewer) was commissioned to work with the Panel and to undertake the Review. 1.6. Individual report templates were distributed to agencies which requested a timeline of significant events and consideration and analysis of their involvement with Isabella and family. Following completion of the reports the timelines were merged and carefully analysed by the Reviewer. Key practitioners, managers and safeguarding leads then attended a one-day Learning Workshop, facilitated by the Reviewer, which provided the opportunity for individuals to discuss the detail of agency practice. The reports and discussions formed the foundation of this report. The Panel then reconvened to consider a draft report and all members made an invaluable contribution to the process and learning of the Review. 1.7. The Panel convened on a further occasion to consider recommendations and how learning could be shared with relevant practitioners and agencies. A final draft report was shared electronically and considered by all in advance of the extraordinary meeting with the BISP Strategy Group in February 2020 where the Review was presented. The Purpose of this Review 1.8. The purpose of this Review is to consider what lessons can be learned to guide better future practice. This Review is understanding of the increasing pressures placed upon agencies that too often results in overwhelming workloads for very capable individuals. It is therefore necessary to reiterate that it is not the purpose of this Review to scrutinise the actions of, or apportion blame to, agencies or individuals. 1 It is important to protect the identity of the child and family; the name Isabella has been chosen for the review and is not the child’s name. 2 Working Together to Safeguard Children, 2015, HM Government 3 1.9. Nor is it the purpose of this Review to make a judgment as to whether Isabella’s death was predictable or preventable. 1.10. The Review process has unavoidably been worked with the benefit of hindsight, but the report has attempted to minimise any influence of outcome bias. Period under Review 1.11. The Review period commences from when the pregnancy becomes known and ends with the tragic death of Isabella. The Review sought to understand the following Key Lines 1.12. Whether there was enough assessment of, and whether concluded assessments had considered the pre-existing vulnerabilities of parents such as; Mother’s young age Parents’ own childhood experiences Any history of domestic abuse and/or sexual abuse 1.13. Whether practitioners were confident of Mother’s ability to meet the health needs of Isabella and whether a sufficient support package was in place. 1.14. Whether there was enough knowledge of and involvement of Father and whether his information was shared and communicated effectively between workers/agencies. 1.15. Whether the case was managed effectually at Child in Need and whether the plan was maintained, reviewed and progressed as necessary, taking all of the needs of Isabella into consideration. 1.16. Whether the multi-agency meetings were clarified and focused, and whether communication regarding the management of risk was effective, in particular with regards to any non-engagement from parents. 1.17. Whether consideration was given to the effect a new baby would have on parents’ ability to manage the needs of Isabella and whether there was any new subsequent impact on risk. Parallel Processes 1.18. The Review, although an independent process undertaken on behalf of BISP, was thoughtful of the ongoing Sudden and Unexpected Deaths in Childhood (SUDC) procedure in relation to Child Isabella’s death. Family Involvement 1.19. In line with the principles laid down in Working Together, parents were invited to contribute to the Review. Their contributions are included in section 3 of this document. 4 2. Brief Synopsis of Events Background 2.1. Prior to Isabella, both parents had been known to CSC. Mother’s parents (hereafter referred to as maternal grandmother (MGM) and maternal grandfather (MGF)) separated when Mother was young, but she maintained contact with both parents and her siblings. Professional records report a lack of structure, guidance and boundaries for Mother within her childhood which accumulated in her becoming subject to a Child Protection Plan3 (CPP) for a period of time. There were also concerns for Mother in respect of Child Sexual Exploitation (CSE) and these increased when her relationship with Father became known when she was 16 and he was 21. Mother undertook some work around CSE and over time the risk was thought to have lessened as it appeared that the relationship had ended. However, the concerns, coupled with a dip in home conditions at MGM’s address, resulted in Mother becoming recognised as a CIN. 2.2. As a child Father lived with his parents (hereafter referred to as paternal grandmother (PGM) and paternal grandfather (PGF)) and siblings. Pregnancy 2.3. Mother moved out of the area to live with her grandparents around the same time that she discovered she was pregnant. She engaged with midwifery services and a pre-birth assessment. Father did not attend midwifery appointments and his engagement with the assessment was minimal. As a result of the assessment CSC offered Mother support but she did not consent and as there was no statutory role for CSC, the case was closed. The assessment recognised issues in relation to parent’s relationship when Father was under the influence of alcohol. With the exception of PGM, the paternal family were unaware of the pregnancy. The assessment reported that Mother had no intention to live with Father and that she wished to remain with her grandparents in a supportive environment. 2.4. In the last trimester of the pregnancy, a verbal domestic incident occurred between parents whilst Father was under the influence of alcohol. Birth 2.5. Isabella was born prematurely and admitted to the Neonatal Intensive Care Unit (NICU). Mother was discharged from hospital 4 days later, but Isabella remained for just under 13 weeks. Health 2.6. During her lifetime Isabella was under the care of several consultants whose expertise lay in different areas of medicine. Appointments were frequent and attendance of Isabella was needed at a variety of appointments in several locations across 3 different hospitals. It is acknowledged that Isabella’s health needs were so great that she would require additional intervention and care, above and beyond what is expected for a new-born and that if her health was not monitored regularly, she would be at risk of becoming very ill quickly. Subsequently the health information submitted for this review was extensive and this report is not inclusive of all of the professional medical involvement. 2.7. The Review acknowledges that it was Mother who cared for Isabella on a daily basis and that Isabella’s needs would have made this a demanding job. The involvement that Isabella required from a range of professionals would have proved difficult for any parent to coordinate and manage. Furthermore, it is acknowledged that the medical care was disjointed across a variety of locations and this would have been an added burden for Mother due to financial circumstances and limited support from Father and extended family. 3 Child Protection Plan – A multi-agency plan created in situations where a child has been deemed as suffering, or likely to suffer, significant harm. 5 Discharge 2.8. During Isabella’s time in hospital there were instances reported of irregular visiting from Mother and a lack of clean clothes and nappies being provided but education for Mother regarding medication and safe care was ongoing. Prior to discharge Mother had a period of ‘rooming-in’4 during which time it was recorded that Mother had asked for Isabella to be returned to the unit as she was tired and couldn’t cope with her. It was noted that Mother managed much better when MGM accompanied her rooming-in, but that Father had appeared disinterested. The concerns were shared at the discharge planning meetings and a competency folder was made and given to Mother upon discharge so that all of the information could be shared with the Outreach Team5. 2.9. Upon discharge, Mother had decided to leave her Grandparents address and had returned to live with her father (MGF). Father continued to live elsewhere. Home 2.10. During the timeframe under review following Isabella’s discharge from hospital, the chronology and agency reports reveal a developing picture of inconsistent and sporadic engagement with professionals by Mother. Many health appointments were either cancelled or not attended and strategy meetings6 were convened as a consequence. 2.11. The Health Visitor (HV) worked hard to co-ordinate appointments in an attempt to monitor and improve Mother’s engagement with services but by December 2018 professionals had deemed that Isabella was a CIN. The CIN plan centred around Isabella’s health needs but Mother’s engagement remained sporadic and health appointments continued to be missed resulting in CSC having a case discussion with a Child Protection Conference Chair who advised that the case should continue at CIN but be escalated if non-engagement continued. 2.12. Around the same time that CIN commenced Mother discovered that she was pregnant again. 2.13. A number of concerns were reported by professionals over the following months including an occasion whereby Mother had attended the GP for a routine visit regarding her own health needs and the GP observed Isabella to be so unwell that an ambulance was called. Isabella was admitted into hospital and during this admittance, staff at the hospital shared concerns about Mother’s ability to manage Isabella’s needs. There were also 2 separate safeguarding referrals made by North West Ambulance Service (NWAS) due to the home environment at MGF’s address and a lack of support for Mother from Father and extended family. However, on a positive note a Family Support Worker (FSW) was appointed to work with Mother and Mother appeared to work well with her, putting appointments into a diary to create order and addressing housing and financial needs. But by May 2019 concerns regarding missed health appointments were high again and a strategy meeting convened where it was decided that it was necessary to escalate the case to an Initial Child Protection Conference (ICPC). Following discussion with a Conference Chair a conference was provisionally booked but the case never progressed. 2.14. In July 2019 Mother gave birth to Isabella’s sibling. 4 ‘Rooming-in’ means that mother and baby remain in hospital but are unsupervised in a room separate from the Neonatal intensive care unit. Mother would be expected to carry out all cares. 5 The Outreach Service aims to support parents and carers with the care of their children to provide support for the families within the home environment and within their local communities 6 Strategy meetings are convened under section 47 of the Children Act 1989 where there is reasonable cause to suspect a child is suffering, or likely to suffer, significant harm. 6 Response to Being Unwell 2.15. In August 2019 Mother called an ambulance after finding Isabella unresponsive. The ambulance crew transported Isabella to hospital under respiratory arrest. Following further cardiac arrests, Isabella sadly died after all attempts at resuscitation had failed. 2.16. Mother reported that Isabella had been poorly for 2-3 days and had been vomiting. 7 3. Family Views 3.1. Mother met with the Reviewer and provided her experience of the support and services received by Isabella and herself. Her contribution has proven invaluable and the Reviewer would like to offer Mother and all of Isabella’s family sincere condolences. 3.2. BISP has contacted Father and invited him to meet with the Reviewer and contribute to the Review but has not received any response. 3.3. It is clear from discussions with Mother that Isabella was very much loved. Mother was happy to be pregnant and understood the initial reasons for CSC becoming involved and conducting the pre-birth assessment. She admitted that she was wary of Social Workers (SW’s) due to her own past experiences of them when she was younger and that of others whom she had spoken to. 3.4. Mother had mixed emotions about the time that Isabella spent in hospital following her birth. Mother said that some of the staff were very helpful and nice, but others didn’t explain things very well and she felt as if they were looking down their noses at her. Mother said that sometimes staff would offer to help her with Isabella but when she accepted help it would later be used against her with staff reporting that she couldn’t manage on her own. She also said that she would have appreciated doctors and nurses spending more time with her explaining the condition and why it might have happened. This question still remains unanswered. 3.5. Mother was pleased when Isabella was allowed to come home and overall, she was happy with the support that she got from professionals that supplemented the help that she got from her parents and Isabella’s father. However, as time went on there were instances when professionals would contradict one another with their instructions regarding medication and care and Mother found this confusing. She talked of different medical practitioners stating different dosages for some of Isabella‘s medication and of times when she had asked for Isabella to be admitted to hospital due to sickness, as instructed, but was told not to attend. Mother said she felt able to phone hospitals for advice and often did, but there were some occasions when she felt as if professionals were talking about her behind her back; she found comments about not bonding and not meeting Isabella’s health needs hurtful, and in her opinion, untrue. Mother also remembered that one consultant had accused her of not giving Isabella her medication when she had, and she had found this to be very upsetting. 3.6. Mother admitted that she did miss some of Isabella’s health appointments but felt that she always had a valid reason for doing so. There were times when either she or Isabella was too unwell to travel and other times when appointments clashed. Transport was sometimes a problem and she had been told to call an ambulance which she understood to mean calling 999, and she wasn’t comfortable doing this when it wasn’t an emergency. 3.7. Mother didn’t really have any particular memories of the CIN plan. However, she remembered that she was unhappy when she heard that Isabella was going to be subject to a Child Protection Conference. Mother felt that this was unfair as she hadn’t had a SW for many weeks at this time and the FSW had also ceased her visits. 3.8. When Mother discovered that she was pregnant again she was happy. She said that she has always wanted to have a family and she is at her happiest when at home with the children. She was not worried about caring for 2 children and managing their needs. 3.9. In summary Mother was happy with much of the support that she and Isabella received but felt as if there were times when she received conflicting information and times when she wasn’t kept in the loop. For example, she didn’t receive the results of an MRI scan that Isabella had undergone for 6 months, by which time Isabella had passed. There were also problems with professionals not always keeping their own records up to date with medication and Mother was frustrated with the many changes of SW. 8 4. Practitioners’ Views / Actions The following observations and considerations have come from agency reports and the Practitioners who attended the learning workshop. 4.1. Practitioners all agreed that the cornerstone of this case was the recognition of any medical neglect. Medical neglect can result if a carer fails to ensure that a child in their care is receiving adequate medical care. According to a clinical report by the American Academy of Paediatrics7 the following factors are considered necessary for the diagnosis of medical neglect: A child is harmed or is at risk of harm because of lack of health care. The recommended health care offers significant net benefit to the child. The anticipated benefit of the treatment is significantly greater than its morbidity, so that reasonable caregivers would choose treatment over nontreatment. It can be demonstrated that access to health care is available and not used, and The caregiver understands the medical advice given. It was the collective task of the professionals involved with Isabella to assess whether medical neglect was a factor and how best to safeguard her. CIN was a correct environment to consider this after initial concerns had been raised. Professionals needed to first, wholly understand Isabella’s needs and second, establish the efforts that Mother had made to meet these needs whilst taking into consideration, her means (financial, physical and emotional) to do so. This required a good working relationship between Mother and practitioners with a good level of honesty and communication that could only be achieved by overcoming any distrust Mother may have had of agency support. 4.2. As medical neglect was discussed at the learning workshop the importance of having an accurate recording system of non-attended medical appointments became clear. As did the importance of parents and carers understanding that the onus of attendance was on them. An article in The British Journal of General Practice8 has made two suggestions regarding non-attendances of paediatric appointments that addresses both of these points; The first suggestion is that it is probably no longer appropriate to use the term ‘Did Not Attend’ (DNA) when describing a child’s non-attendance at a clinic because it is not a child’s responsibility to attend clinic (it is their parent’s responsibility to take them). It would therefore be more appropriate to say that the child ‘Was Not Brought’ to an appointment. This method of recording is already being utilised within the Bury area but not everyone at the workshop was aware of it, despite an expectation of staff who are mandatorily required to attend the safeguarding training course to cascade it to other staff. The second suggestion discusses the importance of GP practices to have policies and procedures in place that clarify what they should do if a child is not brought to an appointment. Such a non-attendance should not only be coded correctly but also trigger an appropriate response, perhaps a follow-up phone call from a receptionist or GP. Of course, this guidance should also apply to hospitals who should be clear on what action to take if a child is not brought. Health practitioners confirmed that there is such a policy in place within the acute setting involved with Isabella. This policy states that if a child has not been brought to an appointment or has had appointments repeatedly cancelled or re-arranged, then the Consultant should review the case notes. Whether the Consultant decides that the child can be discharged or that a further hospital appointment is required, the Secretary should be asked to write to the Choose and Book System and copies of this letter should be sent to the GP, person(s) with parental responsibility and community health services. Effectively the policy means that the GP, community health services and Mother should all have been aware of all of the missed appointments. 4.3. It has been confirmed to the Review that all of the GP practices in the area are expected to follow up any child who has not been brought to an appointment. However, the GP practice in this case did not have a robust process in place at the time of Isabella’s care. This gap had already been identified and addressed in September 2019 and it became expected that from that time forward a named GP for Safeguarding within the practice would review all of the children subject to CSC who were not brought to an appointment and either 7 Recognizing and Responding to Medical Neglect by Carole Jenny, MD, MBA, and the Committee on Child Abuse and Neglect 8 Child not Brought to Appointment by Jeremy Gibson and Jenny Evennett. British Journal of General Practice 2017; 67 (662): 397 9 the safeguarding GP or another member of staff would follow up with the parents/carers as to why the child was not brought, or review the clinic/hospital letter received to ascertain the future plan of care. However, it is noted that this system relies heavily upon the acute settings following their policy accurately and consistently communicating the missed appointment to the GP. Any omission of this will result in the GP not becoming aware of all of the missed appointments and frustrate their process. 4.4. There was much discussion at the workshop about CSC; what the perception was across social care teams during the timeline of this review, and the subsequent effect that this had on the workings of the case. It was considered that the situation at the time was not conducive to effective practice. Representatives from CSC explained that one team had found itself in an indeterminate state when their manager left and simultaneously there were a number of vacant roles across other teams. The situation was described as unusually chaotic. It was explained that as a result a ‘project team’ had been established using agency workers and this team was allocated cases to relieve other SW’s. However, it was still necessary for practitioners to prioritise work and this is very difficult to do without allowing any cases to drift. The situation also highlighted that when so many people leave their roles simultaneously it is very difficult to conduct formal handovers that follow protocol, and CSC is aware that this needs to improve. 4.5. During the course of this Review similar concerns have been identified by practitioners that have arisen in recent SCR’s examining practice in the area. Most notably these include: A lack of professional curiosity about fathers – it was agreed that all of the assessments should have included consultation with both parents. A lack of professional challenge between practitioners and agencies – practitioners discussed a lack of professional challenge when multi-agency meetings did not copiously address issues or there was disagreement regarding actions and assessments. A lack of focus on the child – the CIN plan focussed on Mother’s abilities to attend appointments as opposed to the effect of missed appointments on Isabella. The lack of a pre-birth assessment – a pre-birth assessment should have been undertaken regarding Mother’s second pregnancy given that a sibling was subject to CIN due to safeguarding concerns. A disregard of Think Family – practitioners forgot to Think Family and consider the needs of all household members upon learning of the second pregnancy. This would suggest that learning and recommendations from previous SCR’s have not been embedded effectively into current practice and may benefit from being revisited. 10 5. Analysis of the Key Lines of Enquiry The analysis is derived from the practitioners who attended the learning workshop, the family and discussions with the Panel. The analysis of practice in no way seeks to apportion blame to professionals but seeks to understand what can be learnt to support professionals to develop better future safeguarding of children. Whether there was enough assessment of, and whether concluded assessments had considered the pre-existing vulnerabilities of parents. 5.1. Isabella was initially subject to a pre-birth assessment. This assessment was completed by a neighbouring CSC team as at the time Mother was staying with her grandparents. As in accordance with procedure, the assessment was initiated by Bury CSC due to the previous concerns around CSE, Mother’s relationship with Father and poor home conditions at MGM’s address. Information was appropriately transferred between bordering authorities and Bury CSC conveyed that Mother had been subject to a CIN plan that had recently been closed in January 2018 when safeguarding concerns had been reduced. 5.2. Mother’s history is clear within the assessment. Her young age is given consideration and it is concluded that although she is mature for her age, she will require support when the baby is born. The assessment acknowledges that she has this support by means of her grandparents who were seen as offering a stable environment. However, the assessment is optimistic and offers no consideration to the event that Mother could return to the care of her own parents with the baby following the birth. Given that there is reference to CSC having had substantial involvement with Mother and her family previously and that she was subject to child protection whilst in their care, the absence of this consideration is a large omission and will have had a significant impact on the level of risk concluded. 5.3. The assessment focuses largely on Mother’s ability to parent as it becomes known that Father will not be living with Mother and the baby following the birth. However, it is important for professionals to preserve an open-minded curiosity when completing pre-birth assessments and include Fathers in all situations where possible. The assessment records that Father did not engage well - there was only one meeting effected with him despite several attempts. Importantly this assessment had cited concerns about Mother and Father’s relationship at the beginning and as such Father and the relationship should have remained high priority with Father’s avoidance to engage only serving to increase concerns. His poor engagement obstructed any understanding of his ability to parent and what support he may offer. There was some successful discussion with PGM who informed of cultural differences proving problematic but there is little knowledge of Father’s personal experiences of being parented himself. The assessment does consider some domestic incidents that have occurred between Father and his first wife and it is noted that although Father acknowledged that they provided cause for concern, he was reluctant to discuss them. Mother said that things were different in their relationship, yet a concerning incident did occur whilst the assessment was being completed. Reassuringly Mother called the police to report the incident with Father, but Father had left prior to officers attending. The DASH9 was completed and a referral was correctly sent to the MASH10 covering the area where Mother was residing, but Mother declined offers of further support stating that she was happy and fine within the relationship. She was advised to consider Clare’s Law but there is no evidence of this ever happening, neither is there evidence of the police speaking directly with Father. Although this incident is referred to within the pre-birth assessment it lacks consideration of the risks that a further incident could present to baby and only includes parent’s acknowledgement that this is not an ideal environment and that contact should be limited when Father has had a drink. 5.4. The pre-birth assessment by nature of Isabella’s health needs being unknown pre-birth could not take into consideration Mother’s ability to parent a baby with considerable health needs. 9 The Domestic Abuse, Stalking and Harassment and Honour Based Violence (DASH 2009) Risk Identification, Assessment and Management Model is to assist the police and partner agencies across the UK to identify and assess risk 10 The Multi-Agency Safeguarding Hub (MASH) is a single point of contact for safeguarding concerns bringing together professionals from services. 11 5.5. Following the birth, it was good practice for the nursing staff to arrange a discharge planning meeting in respect of Isabella and good practice for the hospital to initiate a C&F11 assessment. This assessment noted the current home conditions with MGF (where Mother was now residing) to be good enough and reported that Mother was meeting Isabella’s basic needs. It was learned that Mother had taken Isabella to stay overnight at MGM’s address and given the previous associated risks at this address, this decision was discussed, and advice was given that Isabella did not stay there. Mother engaged with the assessment and said that she was happier now Isabella was home and she was managing well. The SW observed positive attachment and emotional warmth from Mother towards Isabella. Mother made it clear during the course of the assessment that she would not work with the Local Authority on a voluntary level and thus it was concluded that a multi-agency strategy meeting was required to allow professionals to consider up to date information and decide whether it was safe enough to close the case or whether the threshold was met for an a Initial Child Protection Conference to convene. There is verification of managerial oversight at this time which agreed with the conclusion to close the case. However, given the history of the parenting provided to Mother herself as a child; the consideration that Mother was still a child by nature of being 17 years old; and considering that Mother was now reliant on her parents to assist her to parent a child with complex health needs, it is difficult to see how the case could be closed in the absence of a parenting assessment or risk assessment in respect of Father and the other significant adults living within the same address. A refusal by anyone to engage with the assessments should have been seen as further cause for concern to be considered alongside Mother’s ability to manage significant health needs whilst heavily reliant on the support of her parents, which had not yet been tested. Whilst it was acknowledged that Mother had engaged well with some health professionals, it remained that she had already cancelled appointments with the HV and failed to attend some health appointments. Which when coupled with the concerns raised by the hospital at discharge, is further concern as to whether she was able to manage the needs of Isabella in her current environment. 5.6. Within months a second C&F assessment commenced due to concerns that Isabella’s health needs were not being met. Mother had now turned 18 but the assessment rightfully still references her age and experience as an underlying factor. Mother now agreed to work voluntarily with CSC at CIN. 5.7. Both of the C&F assessments that were undertaken with the knowledge of Isabella’s health needs, overlooked the need to consider how, and if, Mother had come to terms with the diagnosis. A parents emotional response is an important component regarding the ability to understand and process the needs of a child with complex needs, and it is reasonable to assume that Mother’s emotional response may have been exacerbated by the fact that she herself was of a young age and that this was her first child. Appropriately both assessments do refer to the challenges faced by Mother within her own upbringing but omit to consider any depth of consideration into how her experiences could impact upon her ability to parent. Research12 has proven that women who have experienced neglect within their childhoods are more than twice as likely as other women to experience depression, more frequently have a teenage pregnancy, and are more likely to be in adult relationships characterised by domestic violence13. Sadly, these matters have a cumulative effect on a young mother who as a consequence may then be less responsive towards her own child. This alone raises the chances of neglect occurring for a child but given Isabella’s complex needs the chances become even higher. With regards to Father, both of the C&F assessments refer to him and acknowledge that he isn’t able to offer much positive support yet neither consider how this, and the domestic incidents that occur between Mother and Father, may further impact Mother’s ability to meet Isabella’s needs and/or how it may affect Mother’s emotional health which is crucial to her parenting. 5.8. A combination of the pre-existing vulnerabilities of parents that were known to professionals all identify as risk factors for child neglect. These include parental history of neglect, parental characteristics of young age and low income, family disorganisation and domestic violence. Couple these with Isabella’s young age and chronic physical illness and it is very apparent that much further research was required. 11 A Child and Family (C&F) Assessment addresses the most important aspects of the needs of a child / young person, and the capacity of his or her parents or care givers to respond appropriately to these needs within the wider family and community context 12 Neglect: research evidence to inform practice Dr Patricia Moran, Action for Children Consultancy Services 13 Bifulco and Moran, 1989, Wednesday’s Child: Research into Women’s Experience of Neglect and Abuse in Childhood and Adult Depression 12 Learning: Ongoing consideration should be given as to how professionals engage with fathers. If a father has not engaged, it should be clearly recorded that he remains an unassessed risk. The effect of significant events in a parent’s life should be considered when assessing their ability to parent. If a parent does not consent to Local Authority support at CIN, careful consideration should be given to escalating the protection provided. Whether practitioners were confident of Mother’s ability to meet the health needs of Isabella and whether a sufficient support package was in place. 5.9. It is clear from professionals’ meetings that health practitioners had some early concerns regarding the capacity of Mother to care for Isabella. These concerns were alleviated by means of a referral to CSC and the use of a competency folder clearly identifying Isabella’s medical needs for Mother to share with the Outreach team. In addition, all follow-up appointments were made prior to discharge to ensure continuity of care and there was a sick-day plan which stated what to do in the event of Isabella becoming acutely unwell. There is reassurance of Mother’s abilities when sometime later, consultants at Northern Care Alliance recorded that Mother presented as aware of Isabella’s health needs at appointments and was able to articulate changes and challenges that had arisen since their last meeting. Their report also evidenced that Mother had reassured some professionals that she had support in the form of MGM and MGM’s attendance at many health appointments backed that this was the case. Mother also presented the idea that Father was supportive when she attended these appointments. This information was taken at face value by professionals. 5.10. The HV saw Isabella and Mother most frequently and as the extent of the care required for Isabella became apparent and the limitations of Father’s and extended family support became clear, she supported Mother with extensive home visits that were over and above what would usually be provided. The HV tried to assist with the organisation of the health appointments and was able to monitor Mother’s engagement with health services to an extent. Subsequently she referred to CSC with concerns that arose. Consequent strategy meetings recognised that Mother was struggling to attend appointments and manage the health needs of Isabella, and this raised concerns. The struggle that Mother had is comprehensible - Horwath14 has found that children who have complex needs are vulnerable to medical neglect - the medical demands can place strain on carers, particularly those living in poverty and without support systems. Horwath’s findings coupled with the growing concerns of practitioners involved with Isabella, would strongly suggest that an updated assessment of Mother’s capability, with contributions being required from all involved professionals, was an essential exercise. However, there is no evidence of such an assessment being undertaken. This assessment could have sought to explore underlying issues regarding Mother’s understanding of the importance of health appointments and any frustrations she had about the care Isabella was receiving. When the FSW was introduced to Mother in March 2019 Isabella’s diagnosis was discussed. It is clear from the discussion that Mother rejected the notion that Isabella was subject to a disability. This point is worthy of further analysis as it would suggest that the impact of Isabella’s needs and the circumstances surrounding her health still hadn’t ever been fully determined with Mother. On hearing Isabella ‘s diagnosis Mother would have likely experienced grief and a host of other emotions and if she didn’t immediately experience a sense of bereavement for the loss of the type of life she had envisaged her and her child living, research suggests that it is predictable that she would have eventually. An article written in 2003, Supporting Parents’ Adaptation to Their Child with Special Needs15 looked at how a parent’s adaptation to their child’s condition can serve as a crucial focus when intervening to improve functioning. It states that ‘In addition to the stress associated with the extra physical demands of raising a child with a chronic condition, parents experience psychological stress and disappointment when their child does not meet their hopes and expectations for a healthy child. From this perspective, many parents go through a process of grieving, although most appear to recover. We believe this recovery is the process of updating, rebuilding, and replacing the hopes and expectations they had prior to their child’s birth 14 Horwath, J., Child Neglect: Identification & Assessment, 2007, Palgrave 15 Building New Dreams. Supporting Parents’ Adaptation to Their Child with Special Needs by Douglas Barnett, PhD; Melissa Clements, PhD; Melissa Kaplan-Estrin, PhD; Janice Fialka, MSW, ACSW. Infants and Young Children Vol. 16, No. 3, pp. 184–200 2003 Lippincott Williams & Wilkins, Inc. 13 with the realities of their child’s actual prognosis’. There is no evidence that this was ever considered post Isabella’s birth or that this issue was given attention when planning support. Yet this was important as this state of mind may have had a direct link to the sporadic attendance of health appointments by means of an unconscious denial of their importance. 5.11. It is irrefutable that any health plan would have proved more effective if one person had been designated to be a lead professional. Despite many agencies and professionals being involved with Isabella there was no suitable lead person identified to co-ordinate appointments and their locations. The HV was initially tasked at the discharge meeting but professionals in attendance at the workshop all agreed that the expertise required was beyond the capabilities of the HV role. A suitable candidate for this holistic role would have been a nurse from the Children’s Community Nursing Team (CCNT) but Mother had refused their support when it had been offered when Isabella was initially discharged home. A further opportunity to engage Mother with this team was sadly missed when, following Isabella suffering a period of illness, Mother did consent to a referral. The referral requested contact be made with Mother and stated that Mother had said that she was struggling at home. Unfortunately, this referral was not actioned due to human error possibly caused by staff shortages, but it should be noted that Mother had always been given open access to CCNT and could have been pro-active in utilising their support that was available to her at any time. 5.12. Lancashire NHS Foundation Trust have recognised the importance of having a lead professional and have developed a role of ‘Safeguarding Health Practitioner’ (SHP) within one of their localities. These roles are filled by trained nurses who have experience of undertaking holistic assessments and multi-agency working. The SHP’s undertake joint work with CSC to assess and support complex health needs and will attend multi-agency meeting (including CIN meetings), undertake home visits and work directly with families whilst liaising with other health professionals. 5.13. It is reasonable to conclude that the support package offered to Mother may have been advantageous to some people finding themselves in her situation. However, Mother clearly struggled to accept help from professionals, and it is not clear how much this was explored with her. Professionals at the workshop discussed Mother’s frequent reassurances that she could cope and her reluctance to accept that by definition of her age alone16 she may require support. Becoming a mother produces considerable challenges for everyone as a number of physical and emotional changes take place including the reorganisation of identity, roles and responsibilities17. For young mothers, the challenges of becoming a parent are particularly heightened and often take place within the background of disadvantage and adverse childhood experiences18. Professionals who have worked closely with Mother report her to be a very proud person who is eager to prove her capabilities. If you consider some of the negative attitudes’ society displays against young mothers, any young mother’s fear of being judged or criticised is understandable. In 2018 Action for Children commissioned researchers from the Institute for Policy Research, University of Bath to carry out a literature review and analysis to find out more about the difficulties young parents can face19. As part of the project they held focus groups and interviews with 21 young parents. When asked why she was reluctant to admit that she needed any support, one expectant mother aged 19, replied: ‘They think that you’re young so you’re not going to do very well, so there’s a lot of pressure to prove everyone wrong.’ With this in mind a deeper exploration as to why Mother didn’t want to accept help may have helped professionals to create a more suitable support package that maintained a sense of autonomy for Mother over the decisions to be made regarding her child. Learning: When there is a large group of professionals involved with a child it is important for there to be a confirmed lead professional who is able to take a holistic view. Children who have complex health needs are particularly vulnerable to neglect and require close and regular monitoring by a skilled lead practitioner. The Clinical Commissioning Group (CCG) must give consideration to 16 Reports tend to use the term ‘young parent’ to denote any person aged under 25 years who is expecting a baby or has a child 17 Knox, 2014; Slade et al., 2005 as cited in Young Mums Together Mental Health Foundation 18 Hillis et al., 2004 as cited in Young Mums Together Mental Health Foundation 19 https://www.rip.org.uk/news-and-views/blog/young-parents/ 14 the absence of such a professional and consider the creation of a position similar to that discussed at 5.12 to assist a family to co-ordinate the health chronology. Parents or carers of children with complex health needs who are themselves subject to vulnerabilities, including by means of young age, may benefit from a professional assisting them to steer the professional system. Practitioners need to consider how to communicate what support is available to parents without any social discrimination and respond to parents who do not feel able to accept support in a positive and understanding way. Whether there was enough knowledge of and involvement of father and whether his information was shared and communicated effectively between workers/agencies 5.14. There has been a lack of consideration about the role of Father throughout this case and the extent of his care and contact with Isabella is unclear. This could be attributed to a lack of professional curiosity, but it is also a factor that Father is difficult to engage and is described by many professionals as being quiet. He is vague in his responses to questions and has been known to say that he cannot recall details such as names and addresses, which has an effect of frustrating further checks. 5.15. Some history of Father was obtained by the SW during the pre-birth assessment and it became known that he had previously been married and that there had been domestic violence within that relationship. By this time Mother had provided his name to midwifery although it appears that he did not attend any of the appointments. There is some mention of Father attending the NICU and rooming-in to support Mother whilst Isabella was in hospital but no evidence of him being involved in the care. There is no evidence of Father being involved in the CIN process. 5.16. Following the birth of Isabella, Father was subject to a Pre-Sentence Report. The National Probation Service (NPS) made safeguarding enquiries with Children’s Services but at this time Mother and Isabella had not returned to the Bury area and the pre-birth assessment in the neighbouring authority had concluded and closed. NPS were therefore told that Isabella was not open to CSC. However, the author of the pre-sentence report being compiled at the time reported that all elements of safeguarding relating to his partner and children would require investigation by his offending manager. For reasons that this Review has been unable to establish, this did not happen. During an assessment 8 months later Father disclosed Isabella during a discussion and it was explained to him that due to the concerns of domestic abuse in his previous relationship, CSC would be contacted, and information would be requested from the police regarding the domestic callouts. Father was described as being uncomfortable about this. It appears that, possibly due to a long-term sickness absence of a staff member, these enquiries were not completed, and a safeguarding referral was not completed. 5.17. All of this lack of information seeking is despite the fact that only 18 months prior to Isabella being born, the relationship between Mother and Father gave professionals cause for concern; a couple of weeks after Mother’s 16th birthday professionals had been concerned that she may be at risk of CSE after a member of the public reported her as presenting as intoxicated in a fast food outlet at 02:45 hours. She was with another young female and an older Asian male whom she later admitted to being Father although she initially said that they were just friends. At this time Father was 21 years old and it was decided that structured work looking at CSE and grooming would prove beneficial to Mother. Mother had initially been assessed as being at high risk of CSE but following sporadic engagement with a social worker and some work being completed, the risk was declared to have reduced - It had been 6 months since the reported incident and Mother was reported to be spending more time at home; had ended the relationship with Father; and had changed her associates. There is nothing in any of the reports provided to the Review that indicates that when Mother presented as pregnant any consideration was given to the previous exploitation concerns within parents’ relationship. The information would have been available from several sources (the police would have had the CSE concerns on record as would Mother’s CIN meeting minutes and CSC would have had a copy of the CSE risk measurement tool) and should have been shared with other agencies during the assessments. Had this information been shared, professionals would have had reason to consider the power balance between Mother and Father’s relationship and any associated risks posed to Isabella as a result. 15 Learning: Professionals must include fathers in all assessments and show additional curiosity when a person attempts to avoid engagement. Information about avoidant behaviour should be shared with all other professionals involved. Historic information from all agencies should be considered and there should be no assumptions about what is known by those involved. Whether the case was managed effectually at Child in Need and whether the plan was maintained, reviewed and progressed as necessary, taking all of the needs of Isabella into consideration. 5.18. Mother has often declined support from agencies and some practitioners who have worked with Mother have struggled to gain her confidence. There appears to have been a distrust of professionals that has created barriers to how effective any support could be. Mother’s subsequent perceived lack of engagement has been a continual source of concern and was a contributing factor to the decision for the case to be held at CIN. However, even when engagement with professionals and attendance at health appointments still did not improve enough, reasons provided by Mother regarding missed appointments were readily accepted. In addition, requests to cancel CIN meetings were respected when in fact, the meetings could have convened in Mother’s absence. Continuing with the meetings regardless would have assisted professionals to collate failed appointments and would assist in ‘evidencing the issue by giving an over-view of co-operation levels and reasons for failed appointments’ as is instructed within the Greater Manchester Procedure for managing non-engagement20. It would also have ensured that meetings had continued to convene within procedural expectations. Eventually the continual non-engagement did correctly lead to further strategy meetings and consideration of a Child Protection Conference. However, the real question should be ‘why’ Mother did not prioritise attendance of CIN meetings. It is possible that the meetings lacked enough impact, and this was discussed when the Reviewer met with her. It was concluded that she may have been more likely to attend if the meeting had offered her a practical solution to her problems such as assisting her to record and plan all of Isabella’s health appointments forthcoming within the next review period and consider transport options. This would have also provided an opportunity for professionals to see what the appointment schedule looked like and become aware of any duplications or opportunities to bundle appointments together by location. This type of planning could have proved effective in helping Mother to gain trust in the professionals around her and start to value their support. The transparency of such a piece of work would also have exampled Mother’s abilities and engagement providing a clearer path towards any escalation of support. 5.19. It is undeniable that case management proved complex largely due to the substantial number of health appointments and that organisation of these was complicated by Mother’s limited engagement. To address the engagement, meetings were often held at Mother’s address as this clearly made it easier for her to attend. Still, it also would have been beneficial to hold at least a fraction of the meetings at hospitals to assist Consultants to attend. Their opinion and expertise regarding the impact of missed appointments for Isabella was crucial in exemplifying any harm Isabella was at risk of suffering and their explanations may have helped Mother to understand the importance of engagement. 5.20. Everyone in attendance at the practitioner’s workshop agreed that there were elements of drift within the CIN process regarding professional involvement. Records indicate that there was at least one occasion where the HV had not been invited to attend (established to be due to an error in the recording of an email address) and the GP was not included in the process. This inconsistent or non-attendance of key professionals rendered it impossible to obtain a full comprehension of how many health appointments had been missed and without this complete information it was impossible to assess or manage Mother’s capacity and ability to improve attendance. A successful plan depends greatly upon the professionals having a clear view of individual review periods and the situation overall - and being reactive. 20 ttps://greatermanchesterscb.proceduresonline.com/chapters/p_deal_uncooperative_fam.html 16 5.21. The following points indicate that the CIN plan was not proving robust enough to address the current circumstances: Health appointments continued to be missed but there is nothing in the reports that evidences sufficient understanding by Mother or the professionals regarding the subsequent harm that could result as a direct consequence and was avoidable. CIN meetings were being cancelled upon the request of Mother. A further domestic incident was reported suggesting that relationship work was not effective. 2 referrals made by NWAS reported ongoing concerns for Mother’s need for more support. 5.22. With the above in mind it would have been beneficial to utilise the Graded Care Profile 2 Tool to objectively measure the quality of care afforded to Isabella in terms of Mother’s commitment. This would have assisted professionals to identify the support required for Isabella and develop the working relationship with Mother. 5.23. It is unanimous within the reports gathered for this review and the discussions had at the learning workshop, that the escalation decision to convene an ICPC was appropriate based on statutory guidance21. There developed a common consensus that Isabella was at risk of suffering significant harm22 if her health needs were not met and this decision recognised that the complex health needs of Isabella should not alter the threshold for escalation of intervention. The first documented recognition of this appears the month after Isabella was discharged from hospital; Police records note that an officer had a strategy discussion with CSC after the HV had raised significant concerns regarding Isabella not being brought to vital health appointments. It is recorded that the discussion concluded that should Mother DNA on any of Isabella’s health appointments then it should be escalated to ICPC. This did not happen immediately but within weeks it had been decided that a CIN plan would be implemented and when concerns remained 2 months later, CSC did have a case discussion with a Child Protection Conference Chair. The advice at this time was to remain at CIN and escalate if non-engagement continued. It was at a strategy meeting 4 months later that the decision to escalate was further concluded and as a result an ICPC was agreed to be booked within timescales. However, due to staff absences this decision was not shared with the necessary administration staff and the meeting was not actioned. Subsequently no invitations were sent to any agencies and professionals remained in the dark as to why the case had not progressed. Discussion was had amongst practitioners at the workshop as to why no other professional had raised any concerns regarding this lapse. It became clear that agencies often allow CSC to take the lead stance on a case and there is a presumption that CSC will have completed certain tasks and addressed the concerns raised within a multi-agency forum. It is important to re-iterate here that any practitioner with serious concerns that a child’s welfare is not being adequately safeguarded should request that a conference be convened23. This was not done in this case, and neither were any concerns escalated to supervision. Use of an escalation policy is not a personal attack on another agency or a colleague but a method to initiate a professional question mark and reflect upon multi-agency work and decision making. The fact that all the professionals at the workshop had been in agreement that the decision to proceed to ICPC was correct, would indicate that this absence of curiosity regarding why the case was not progressed, was not due to any uncertainty about how best to manage the interests of Isabella. It was in fact established to be a reflection, in some cases, as to how confident a practitioner is about discussing such concerns with their supervision. Attendees at the practitioners workshop discussed this in detail and concluded that practitioners should feel comfortable taking a case to supervision that they feel anxious about but often a one-to-one with a manager can feel like a scrutiny of how well you are performing within your role as opposed to a discussion of options. The importance of good quality supervision is evident here and reflective support is essential in such a situation to ensure that practitioners feel able to challenge if a plan is not escalated. 21 Working Together to Safeguard Children, 2018, HM Government 22 The Children Act 1989 describes the concept of significant harm as the threshold that justifies compulsory intervention in family life in the best interests of children. 23 Working Together to Safeguard Children, 2018, HM Government 17 Learning: If a parent or carer continually cancels meetings, professionals should consider convening in their absence to assess risk and reflect upon the impact on the child when parent’s engagement is not good enough. Meetings need to involve all relevant agencies and all professionals must remain alert to any drift of a plan and be empowered to challenge a plan that is not working. Professionals who have made a referral or agreed to an escalation of safeguarding have a statutory duty to follow up their concerns if they are not satisfied with a response and should escalate their concerns in the event that they remain dissatisfied. It is important for professionals to remember to use and to feel confident within the escalation process if they feel that a decision or action is not in the best interest of the child. The Graded Care Profile 2 assessment tool is already used by social workers in the area and all practitioners should remember to give it due consideration. Professional thought processes and decisions must be recorded to support case management in the event of long-term sickness or changeover of staff. CSC should not be viewed as the prime agency. Whether the multi-agency meetings were clarified and focused, and whether communication regarding the management of risk was effective, in particular with regards to any non-engagement from parents. 5.24. In addition to the CIN meetings there have been a number of other multi-agency meetings that have convened throughout this case including strategy meetings and discharge planning meetings. A number of issues have been identified with both their content and in the case of CIN, their frequency. 5.25. The purpose of multi-agency meetings is to present and examine facts and consider subsequent risks to the child. There is no evidence to suggest that in this case, this has always been thorough and practitioners at the workshop did not consider that meetings had always addressed the risk factors that arose from missed health appointments. There was a lack of analysis of any potential impact, for example there is no evidence of discussion as to how the missed appointments could impact Isabella by creating a life-threatening situation to occur that was otherwise potentially avoidable. The overriding focus has been primarily upon Mother’s reasons for non-attendance. 5.26. The meetings were always chaired by experienced SW’s and there was good representative of agencies overall, but it is clear that on occasions key professionals have not been invited to meetings or received any feedback. There is for example, no record of the paediatricians having any minutes or actions from multi agency meetings despite them raising concerns about missed appointments. However, this Review does recognise that professionals all have a responsibility to chase the results of referrals that have been made by themselves. The GP reported to be unaware of meetings and the HV was missed from at least one strategy meeting even though she had vital information about health appointments not attended and a good knowledge of Mother’s parenting. It was discussed in the practitioner workshop that an automatic notification of multi-agency meetings to all agencies, regardless of their involvement, could assist with the issue of professionals being missed from invites or unaware of meetings. 5.27. Over all the meetings do appear to have lacked clarity and this, although wholly recognised by professionals, has gone uncontested. Professional challenge is crucial, and anyone involved in a multi-agency meeting should feel confident to challenge another professional if they consider that concerns have not been addressed. No such challenge is recorded within this case. Learning: Professionals should be confident to challenge and ask questions if a meeting has not addressed the concerns. Professionals who feel that there has been a loss of focus on a child should be professionally curious and able to seek reflective supervision and support to assist with a timely response to any decline in a child’s situation. Any practitioner receiving professional challenge should not be offended. Professionals should chase the results of the referrals they have made. 18 Whether consideration was given to the effect a new baby would have on parent’s ability to manage the needs of Isabella and whether there was any new subsequent impact on risk. 5.28. Upon learning of Mother’s pregnancy CSC should have completed a pre-birth assessment but this was overlooked in a flurry of changing social workers and heavy caseloads. In addition the midwifery team involved with the care of this pregnancy, made an assumption that there were no safeguarding concerns for the older sibling (Isabella),likely presuming that the CIN plan was regarding Isabella’s health needs as opposed to safeguarding, and therefore did not make any referrals. There was no other reason for midwifery to make a referral and seek out other agencies at this time as baby was developing well and Mother was attending all of her ante-natal appointments. This has affected a disjointed approach and has resulted in a definite split down the agencies working with Mother, with some being completely focussed on Isabella and some being wholly centred on unborn baby. No agency appears to have had focus on both and the Think Family approach which promotes the importance of a whole-family attitude appears to have been lost. 5.29. As the pregnancy has developed CIN meetings have diminished due to Mother cancelling, social workers leaving, and the case not being immediately reassigned. The last CIN meeting convened when Mother was approximately 6 months pregnant. A strategy meeting occurred the following month and this concluded that both Isabella and unborn baby would be considered at ICPC. The reasons for this meeting not convening have been discussed previously within this report at 5.23 but had the meeting occurred, a conversation would have been had regarding the safeguarding of both Isabella and the unborn baby. And this would have included any effect that the introduction of a new-born into the family might have had. Learning: The Think Family approach must be considered in all situations. 19 6. Good Practice Identified Many examples of good practice have become apparent during the course of undertaking this review. The following list is not exhaustive. 6.1. The professionals who have completed reports and participated in this review have done so with extraordinary openness, transparency and honesty. All discussion that transpired during the course of the workshop was conducted with respect and opinions and reflections were communicated in a non-disparaging manner. 6.2. The HV has demonstrated an excellent commitment to supporting Mother and Isabella whilst maintaining good communication with other practitioners and agencies. Likewise, the FSW worked well to develop a good relationship with Mother and utilised pragmatic and practical methods of assistance. 6.3. Upon becoming aware of Mother and Isabella’s situation, Housing obtained temporary accommodation promptly and efficiently in an attempt to minimise disruption and reduce any emotional stress. 6.4. The Paediatrician recognised that Mother would benefit from support to manage Isabella‘s health care early in the process and raised concerns with the relevant agencies. 6.5. The NWAS was expeditious in raising their concerns and making the appropriate referrals. 6.6. There was a good understanding of medical neglect by some practitioners who attended the workshop and they shared their knowledge and discussed the matter in a helpful and informative manner. 20 7. Recommendations In order to promote the learning from this case, the review identified the following actions for BISP and its member agencies: 7.1. BISP to review the supervision arrangements within partner agencies, in line with the agencies’ individual roles and competencies, and to be assured of compliance by utilising feedback from supervisors, supervisees and people who use services. BISP should reconsider the use of a multi-agency practice forum to reflect upon group supervision and explore complex multi-agency decisions. Proposed Outcome: BISP will be confident of the multi-agency decision making process and professionals will be empowered to seek supervision and support as necessitated. 7.2. BISP to ensure that the language change – ‘Was Not Brought’ is reinforced across partner agencies and make certain that practitioners are trained to realise ‘medical neglect’ and recognise missed appointments as an indicator. Proposed Outcome: The universal use of the language term will emphasise a parents/carers responsibility to take a child in their care to health appointments and will deliver a clearer marker to identify neglect. 7.3. BISP to confirm that all partner agencies have a rigorous and thorough system in place regarding the management of handing over cases to other practitioners, and verify that each agency has reviewed their system to ensure that teams are managed most effectively and have an inbuilt resilience to cover, in particular, cases of extreme absences. Agencies must be seen to consider introducing new measures, such as a buddy system or business continuity plan, to mitigate the instances of absences. Proposed Outcome: Disruption to service users subject to a change of worker will be minimal and the support provided will be uninterrupted. 7.4. Given the detection of similar concerns raised in previous SCR’s, BISP should seek reassurance that previous learning is embedded within the working environment. BISP must complete their future Serious Case Review learning within reasonable timescales and quality assure practice to evidence that supervision is satisfied that learning has been effective and is being applied. Proposed Outcome: BISP will be confident that learning from reviews is embedded and proving effective. 7.5. The CCG to consider establishing a role within Bury similar to the ‘Safeguarding Health Practitioner’ role which has been successfully introduced to a locality within Lancashire Refer to 5.12. Proposed Outcome: Trained nurses will work jointly with CSC to assess and support complex health needs and work directly with families whilst liaising with other professionals. 7.6. Where a child is diagnosed with complex medical conditions, the CCG should consider appointing a Lead Practitioner to facilitate and support all carer(s) in understanding the condition, and the importance of responding to symptoms promptly and attending all appointments. Proposed Outcome: All carers will be supported to develop a better understanding of a child’s health condition and their treatment plan. |
NC046915 | Death of a 15-year-old girl in spring 2014, by hanging. Alex lived with her mother and step-father, and before her death there was no involvement with services except universal services. Around six months before her death three of her friends had told school staff that Alex had been self-harming. Police investigations following her death found that she had been abused by a distant family member, who was a convicted sex offender. He was arrested and committed suicide whilst on police bail. Identifies learning including: professionals need to be equipped with the knowledge to recognise self-harm and take appropriate action according to their role; students should be supported to know how to respond when they become aware of friends who self-harm or have suicidal thoughts; if a child who is self-harming refuses an offer of support this should be regarded as potentially increasing the child's risk; parents and carers need support in recognising the risks that may be posed by individuals and have strategies available to protect children from that risk; Police services need to be intrusive in their management of registered sex offenders and make use of dynamic risk assessment tools available to them. Makes recommendations for improving practice, including: the local authority should develop model guidance on self-harm for its schools; LSCB guidance on self-harm should be updated and key messages around safeguarding risks should be reviewed to ensure that they are communicated effectively and help parents protect their children; the effectiveness of police management of registered sex offenders should be reviewed.
| Title: A serious case review: NN15 – overview report. LSCB: Nottinghamshire Safeguarding Children Board Author: John Bradley Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Nottinghamshire Safeguarding Children Board A Serious Case Review NN15 - Overview Report 2 Contents 1 Background to the Serious Case Review. ...................................................................... 5 1.1 Events leading to this review ................................................................................... 5 1.2 Decision making process ........................................................................................ 6 1.3 The Independent Author. ........................................................................................ 6 2 Terms of Reference. ...................................................................................................... 7 3 Subjects of the review - Anonymity chart........................................................................ 8 4 Methodology .................................................................................................................. 9 4.1 Contributing Agencies and the SCR Panel .............................................................. 9 4.2 Parental involvement ............................................................................................ 10 4.3 Limitations in the investigation .............................................................................. 10 5 Facts of the case .......................................................................................................... 11 5.1 Culture, ethnicity and disability .............................................................................. 11 5.2 The period prior to Alex’s death ............................................................................ 11 5.3 The period following Alex’s death .......................................................................... 15 5.4 Step Grand Uncle – his criminal record, offender management and contact with Alex ……………………………………………………………………………………………...16 5.5 Step Grand Uncle’s criminal record ....................................................................... 16 5.6 The management of Step Grand Uncle as a registered sex offender .................... 17 5.7 Step Grand Uncle’s contact with Alex’s family ....................................................... 18 5.8 Step Grand Uncle’s arrest and subsequent death ................................................. 19 6 Contextual information: Self-harm and suicide by young people .................................. 20 7 Analysis ....................................................................................................................... 23 7.1 Examine the effectiveness of the management of Step Grand Uncle as a registered sexual offender following his conviction in 2003 .............................................................. 23 7.1.1 The assessment of risk Step Grand Uncle posed and his management......... 23 7.1.2 Compliance with Kent Police policy and MAPPA guidelines in place at the time ………………………………………………………………………………………...27 3 7.1.3 Were those responsible for his offender management aware of any potential risks to Alex, or could have reasonably expected to be aware? ................................... 28 7.1.4 Developments in Kent Police’s management of registered sex offenders ...... 29 7.2 Examine the actions of Alex’s school following the disclosure made to them by her friends that Alex was self-harming ................................................................................... 30 7.2.1 The actions of Alex’s school following the disclosure ..................................... 30 7.2.2 School 1’s learning from these events ........................................................... 34 7.2.3 Using this learning to improve practice across the education sector. ............. 36 7.2.4 What provision did the school have in place for covering e-safety and keeping safe more generally with students, have they reviewed their processes and is there best practice which can be shared across the Education sector? ........................................ 38 7.3 Was there anything which could have been done to support the parents when they became aware of Step Grand Uncle’s offending which would have helped them to protect Alex? ……………………………………………………………………………………………...41 8 Parallel processes ........................................................................................................ 43 9 Good practice identified ............................................................................................... 43 10 Conclusions .............................................................................................................. 43 10.1 The delay in instigating a serious case review ...................................................... 48 11 Recommendations ................................................................................................... 50 4 Anonymisation In order to protect the privacy of the family, this report has been anonymised for publication. At the suggestion of her mother, the young woman who is the subject of the review is referred to by the pseudonym ‘Alex.’ Other family members are referred to in terms of their relationship to Alex, with that name capitalised– Mother, Step-Father, Step Grand Uncle etc. The school Alex attended is not named, in order to protect Alex’s identity. Staff at the school are referred to by a non-specific description of their role e.g. ‘Senior Teacher B.’ References to towns or other locations that could identify Alex or her family have been avoided. Specific dates, such as the date of her death, which could have allowed Alex to be identified have been avoided and instead more approximate dates are used – ‘spring 2014.’ 5 1 Background to the Serious Case Review. 1.1 Events leading to this review Alex, who was 15 years old at the time of her death, lived with her mother and step-father. Prior to her death there was no involvement with services other than universal services. At 8.15 am in spring 2014 she was found dead in her bedroom by her step-father with a scarf tied around her neck. According to parents, the previous evening had been unremarkable and Alex had last been seen by her parents at 9pm when she retired to her room. On examination of her body at the Emergency Department, Police reported 5 faint linear marks on Alex’s left forearm. It subsequently emerged that three of Alex’s friends had approached school staff in October 2013 to report that she had been self-harming. Police investigations commenced and a notebook was found in her bedroom with a note in it which suggested she may have been a victim of abuse. Further forensic work with mobile telephones and laptops indicated Alex had been receiving numerous messages from a man subsequently identified as her Step Grand Uncle, a relative who lived in the south of England. As a result, this man was arrested by Kent Police and indecent images of children, including images of Alex were recovered from his lap top. The man took his own life whilst on Police bail. A subsequent inquest into her death gave a narrative verdict and ruled that ‘Alex took her own life by hanging.’ The Coroner was not able to determine what her intention was at the time she took this action. Since Alex’s death her school have developed excellent policies and guidance on ‘self-harm’ which will be used to improve practice across Nottinghamshire. 6 1.2 Decision making process This case was first considered by the Serious Incident Review sub group on 7th October 2015, when a decision was made to recommend a serious case review (SCR) be carried out. A summary of the recommendation was passed to the independent chair of Nottinghamshire Safeguarding Children Board on 13th October 2015 and following a request for additional information on 5th November the Chair confirmed his decision to carry out an SCR. It was judged that the criteria for undertaking a SCR were met – ‘abuse or neglect of a child is known or suspected and the child has died – including where a child has died through suspected suicide.’ On 17th November 2015 Ofsted and the National Panel of Independent Experts were notified of this decision. There was a delay of 20 months between Alex’s death and the decision to conduct a serious case review in November 2015. This issue is discussed later in the report. The review has been conducted in line with the principles set out in Working Together 2015 and Nottinghamshire Safeguarding Children Board Interagency Procedures to Safeguard Children. The purpose of reviews is to identify improvements that are needed and to consolidate good practice. Reviews look at what happened in a case and why, and what action will be taken to learn from the review findings. 1.3 The Independent Author. The author of this overview report is Dr John Bradley, a consultant educational psychologist with over 35 years experience. He began his career as a teacher, in both mainstream and special schools. He is a former Principal Psychologist who worked for local authorities and the Ministry of Defence. He is now an independent consultant psychologist for The Educational Guidance Service (Halifax.) He has been the author of individual agency reports in six previous serious case reviews and three domestic homicide reviews. He is the author of an investigation undertaken at the request of the Secretary of State for Education into contact by Jimmy Savile with 7 schools. He is registered with the Health and Care Professions Council to practise as an Educational Psychologist having the registration number PYL00157. He holds a Doctorate in Applied Psychology (Educational) awarded by the University of Nottingham and completed his postgraduate clinical training at The Tavistock Clinic, London. He is a published academic author on the topic of young people’s educational decisions and has been a trainer on issues of young people’s emotional health and wellbeing and safeguarding in schools. The author is mindful of the advice of the National Panel of Independent Experts on Serious Case Reviews that the aim is: ‘…to produce a clear and succinct account of what happened and why, and what needs to change to prevent it from happening again.’ 2 Terms of Reference. The following terms of reference were determined by Nottinghamshire Children’s Safeguarding Board. The initial work carried out by the Serious Incident Review Sub-Group to gather information and subsequent follow up enquiries revealed that there had been very little contact with the family by agencies. Two key practice episodes were identified that require further examination. 1) Examine the effectiveness of the management of Step Grand Uncle as a registered sexual offender following his conviction in 2003, a) in particular, • the assessment of the risk he posed, • compliance with Kent Police Policy and MAPPA guidelines in place at the time b) Were those responsible for his offender management aware of any potential risks to Alex, or could have reasonably expected to be aware? 8 2) Examine the actions of Alex’s school following the disclosure made to them by her friends that Alex was self-harming. a) Consider any learning which the school has put in place as a result of this incident. b) Examine this response and best practice from other areas to make recommendations as to how responses to this type of disclosure can be improved across the Education sector. c) What provision did the school have in place for covering e-safety and keeping safe more generally with students, have they reviewed their processes and is there best practice which can be shared across the Education sector? In addition: 3) Was there anything which could have been done to support the parents when they became aware of Step Grand Uncle’s offending which would have helped them to protect Alex? 3 Subjects of the review - Anonymity chart Pseudonym Relationship Alex The subject of the review Mother Mother of Alex Step Father Mother’s partner, Step-Father of Alex Father Father of Alex Step Grand Uncle Paternal Step Grand Uncle of Alex and Uncle of Step Father Step Grandmother Step Grandmother of Alex and Mother of Step Father 9 Step Great Grandmother Step Great Grandmother of Alex and Mother of Step Grand Uncle 4 Methodology The overview author worked closely with the Development Manager of the Nottinghamshire Safeguarding Children Board (NSCB.) His specialist knowledge as a former senior police officer was particularly useful in considering the role of Police in this case. 4.1 Contributing Agencies and the SCR Panel The following local agencies were asked to provide an information report of their contact with Alex and her family: School 1 Nottinghamshire Children’s Social Care Local NHS Foundation Trust Nottingham University NHS Trust Nottinghamshire Healthcare Foundation Trust Alex’s GP Primary Care Centre Nottinghamshire Police Kent Police The author was also provided with detailed minutes of the Initial Case Discussion and Final Case Discussion meetings held to respond to the unexpected death of a child. Three agencies were found to have had a significant involvement in the case: School 1 (Alex’s school); Nottinghamshire Police (who dealt with the local investigation following her death) and Kent Police (who had been responsible for the offender management of Step Grand Uncle and the subsequent investigation into his contact with Alex.) These agencies were asked to conduct an individual management review (IMR) and provide a report signed off for accuracy by a senior responsible officer. 10 A briefing event was held for the agencies asked to provide Individual Management Reviews. This was also attended by the Acting Director Education Standards and Inclusion. A panel was established to oversee the review. This comprised; Manager, Nottinghamshire Safeguarding Children Board (Chair) Development Manager, Nottinghamshire Safeguarding Children Board The overview author Acting Director Education Standards and Inclusion Nottinghamshire County Council The Principal of School 1 The author of the Education IMR The author of the Nottinghamshire Police IMR The author of the Kent Police IMR A representative of the commissioner of Kent Police IMR The Chair of Nottinghamshire Safeguarding Children Board also liaised with the Chair of Kent Safeguarding Children Board. 4.2 Parental involvement Alex’s mother met with the overview author and the NSCB Development Manager on two occasions – at the start and towards the end of the review process. Her views are reported in the body of the report. Alex’s father was invited to meet with the overview author and the NSCB Development Manager but declined. 4.3 Limitations in the investigation The period of 20 months between Alex’s death in 2014 and the decision to conduct a serious case review in November 2015 may mean that some participants’ memories of events are not as clear as they would have been if spoken to sooner. More significantly, a key member of staff at School 1 has now left the school and is no longer in the country. He could therefore not be interviewed. 11 5 Facts of the case 5.1 Culture, ethnicity and disability Alex is described as being of White British heritage. She attended a school where most pupils are also White British1. She had a mild specific learning difficulty that was well managed by her school. It is not known whether religion was a feature in Alex’s life but Police records describe her as ‘Christian.’ 5.2 The period prior to Alex’s death Alex lived with her mother and step-father. Her parents had separated when she was young but she had contact with her father. Alex only had contact with universal services prior to her death. Alex joined Year 7 of School 1, her local secondary school, in September 2009. Her attendance averaged around 94%. Alex’s absences were a mixture of odd days of illness and a family holiday in term time. In November 2012 her mother raised concerns about Alex’s reading. She was struggling to read black text on a white background2 . An in-school assessment identified mild dyslexia and Alex was provided with her work on coloured paper (to reduce contrast) and granted exam dispensations – extra time and the services of a reader and scribe in exams, if requested. Her teachers were provided with advice on supporting Alex’s specific learning difficulty. Alex passed 2 GCSEs at grade C in Year 10 and was posthumously awarded a further 5 GCSEs at grade C or better in Year 11 on the basis of work already submitted. Alex was a Girl Guide and helped at the local Brownie pack. She occasionally played for the school netball team and was working for her Duke of Edinburgh Award. Alex had some limited contact with her GP where she usually attended with her mother. Her GPs have reported that there were no indicators of concern during these 1 Ofsted (2014) Inspection report on The School 1 2 Difficulty reading high contrast text is sometimes associated with Irlen syndrome or ‘visual stress,’ a condition often associated with dyslexia. 12 appointments and no concerns about safeguarding or other issues possibly connected with her death. In School 1’s IMR Alex’s form tutor for Years 10 and 11 is quoted as describing her as follows: ‘I was Alex’s Form Tutor since Alex was in year 10. At the start of year 10 Alex was a popular member of the tutor group, who was always happy and quiet; which was her manner. She was in a relationship with a popular year 10 boy and Alex had grown in confidence due to this, in my opinion. Alex was always well turned out doing her hair and makeup each day. I [did not have contact with her] from Easter 2013 until January 2014. [After] January 2014 I did notice some changes to Alex. She was no longer in a relationship, but was still happy and looking forward to school events that were coming up for her. This included the [school trip] and the school prom. However, Alex did not take as much pride in her appearance as she did in Year 10, as she was wearing less make-up and her hair was not as made up as she had been, when she was in year 10. However she was still the same happy girl, always talking about the prom dress she was going to wear. I had no safeguarding concerns about Alex. I had no knowledge of any self-harm concerns raised about Alex. I felt Alex’s death was completely out of the blue.’ A key event occurred in October 2013. Staff Member 1, a senior non-teaching support member of staff, was approached by three of Alex’s friends who reported that she was self-harming. He sent an email to Senior Teacher B saying: ‘Hi, 3 students have come to me at the end of the day today to report that Alex is self-harming. I will pick it up tomorrow and contact home.’ Senior Teacher B reports that he later met with Staff Member A and advised him of the appropriate next steps - to speak to the Alex’s parents and to Alex herself to see if support was required. There is no record of that discussion and no record or memory of the nature of the self-harm that was reported, or which pupils reported it. 13 Staff Member A is no longer in the country and therefore could not be interviewed about these events. It appears that Staff Member A tried to phone parents but did not get through to them. He appears not to have contacted them later, either by phone or letter. There is no record of any contact with Alex’s parents and School 1 IMR notes: ‘…record keeping of the phone call home was not made at the time of Alex’s reported incident of self-harm. Staff Member A did not record whether he had made actual contact with Alex’s parents, and this information was not placed on the communications log on SIMS (School Information Management System). For if it had been recorded accurately on the day of the self-harm incident Staff member 1 would have known whether he needed to attempt to contact parents again.’ The School 1 IMR goes on to report that at an earlier interview, following Alex’s death: ‘Staff Member A recalled he did speak with Alex and asked her if she needed support with regards to self-harming, Alex was offered both CASY3 counselling and to speak with the School Nurse, but Alex declined having any support in school.’ Again there is no record of this conversation and apart from the very brief email to Senior Teacher B, information about this concern does not appear to have been shared with anyone. The information report from Nottinghamshire Healthcare Trust found no record of school nurses being informed of Alex’s self-harm and her form tutor was not informed. 3 CASY is an independent counselling service commissioned by the School 1 14 There is no record of any further follow up of this disclosure either with Alex or the friends who reported their concern. Senior Teacher B did not follow up the matter with Staff Member 1. When interviewed by Nottinghamshire Police following Alex’s death Staff member 1 was not able to recall which students had reported their concerns to him. Police inquiries identified a student who had reported the self-harm. This student said ‘she had asked Alex about it and she had just said she was ‘not getting on with her family.’ Another student told Police that ‘Alex had cut herself in Year 10 and the student had said to her ‘You can talk to me about anything‘ to which Alex replied ‘Yeah I know I can’ but nothing further was said or disclosed.’ Another student told Police that Alex had received abusive comments from some students after a rumour had circulated that she had an alleged sexual encounter with a boy. Nottinghamshire Police went on to interview eight of Alex’s close friends, including an ex-boyfriend by way of a standardised questionnaire and Nottinghamshire Police IMR reports: ‘They all generally described her as happy and outgoing. There is a suggestion that she was subject to some bullying but no specific details. The boys apparently teased her about her weight but this was behind her back and it isn’t known if she ever knew about it. None of her friends had been asked by Alex to keep secrets for her and she hadn’t disclosed any abuse by anyone. There were rumours that she had had sex with an older boy in a caravan during the summer holidays in 2013 but nothing was confirmed and Alex didn’t disclose any details about it to her friends.’ ‘Generally she was described as confident, outgoing and happy. Some said she could sometimes be moody but those that remember speaking to her the day before she died said she appeared happy.’ Shortly before she died, Alex had been on a school trip. The member of staff looking after the girls on the trip reported: 15 ‘Alex never raised any concerns to me during the trip. She progressed slower than others, with [the activities], but Alex was not alone, as she was with another student of a similar ability… and she had a ‘give it a go’ spirit. In the evening she always got involved with evening activities, socialising with her friends. She was never isolated from the group. She was always well turned out, applying make-up. I had no concerns about Alex during or after the trip.’ 5.3 The period following Alex’s death In spring 2014 at around 8.15 am Alex was found dead in her bedroom by her step-father with a scarf tied around her neck. Nottinghamshire Police and East Midlands Ambulance Service were called to the family’s home. Alex’s parents told police that the previous evening had been unremarkable and Alex had last been seen by her parents at 9pm when she retired to her room. Police report that on examination of her body at the Emergency Department, five faint linear marks on Alex’s left forearm were noted. ‘One looked like it had broken the skin at some point and possibly bled – possibly self-harm marks.’ In my meeting with Mother she told me that she had not seen any signs of self-injury and no signs that Alex was covering up her arms to conceal anything. When Police examined Alex’s room they found handwritten notes suggesting that she was very unhappy about something that was happening to her and wanted to get away from the situation. Nottinghamshire Police examined Alex’s iPhone and found that it had been used extensively to view internet websites on depression. These searches started around 8th February 2014. The police discovered that Alex had posted quotes on her Twitter account suggesting that she was feeling a pain that others could not see. Further examination of Alex’s phone showed repeated contacts from Step Grand Uncle. 16 His messages to Alex included: ‘Think hard Alex. You don’t have to do anything! Just being pleasant and talking to me could get you so much. I already have euros for your trip.’ ‘[Name] says you want money for the weekend. If you text me your bank details I would send you some. No strings. I love you that’s all there is to it xx.’ Nottinghamshire Police concluded: ‘Paternal step-grand uncle may have been grooming her in the form of giving Alex money and buying her presents. All phone contact from him, generally in the form of text messages had been unreciprocated by Alex. The last message was dated [ the day she died.] Enquiries revealed that Step Grand Uncle had previous convictions for distributing indecent images of children and indecency with children. It was also established that although he lived some distance away in another part of the country, he had regular contact with the family and had been on holiday with them. Nottinghamshire Police liaised with Kent Police to pursue enquiries about Step Grand Uncle. 5.4 Step Grand Uncle – his criminal record, offender management and contact with Alex Step Grand Uncle was Step Father’s uncle and so was Alex’s paternal step-grand uncle. Step Grand Uncle lived in Kent but his mother, Step Great Grandmother, lived in Nottinghamshire. 5.5 Step Grand Uncle’s criminal record 17 In June 2003 Step Grand Uncle pleaded guilty to charges of indecent assault on a girl under 16; gross indecency to a child and making indecent images of children. Other offences were left to ‘lie on file.’ The victim was a child known to him who was between 12 and 14 at the time of the offences. He had apparently induced the victim by buying CDs and clothes for her. After committing the offences he made threats to the victim that if she told anyone about it he would post the pictures on the internet. He did later post the pictures on the internet. Step Grand Uncle was sentenced to six months imprisonment and released in September 2003 and was required to sign on the Sex Offenders Register for a period of 7 years. 5.6 The management of Step Grand Uncle as a registered sex offender Shortly before his release in September 2003 Step Grand Uncle was risk assessed by Kent Police using the Violent and Sex Offender Register (ViSOR) matrix. He was assessed as ‘low risk’ – meaning he was judged to show no significant current indicators of risk of harm. The fact that his convictions related to an acquaintance and did not involve physical violence were factors in him being judged ‘low risk.’ As a ‘low risk’ subject he was required to register with the police annually, notify them of any changes of address and other addresses he was likely to visit for more than 7 days in any year and also undergo an annual home visit. Step Grand Uncle was next risk assessed using the Matrix 2000 risk assessment in December 2009. He was again identified as low risk. The Kent Police IMR comments that: ‘There is no record of additional formal risk assessments being carried out between these dates (2003 and 2009) although, no doubt, risk was in the mind of the visiting officers throughout that period but was not recorded as a ‘Risk Assessment’. 18 In February 2008 Step Grand Uncle declared Step Great Grandmother’s address in Nottinghamshire as one that he would attend for more than 7 days a year. However no questions were recorded about access he may have had to children when in Nottinghamshire. It was recorded that he told police his family ‘were aware of his situation’. In 2008 officers became aware that Step Grand Uncle was in a sexual relationship with a married woman. He told officers that the woman’s husband knew about the affair and was not concerned. However when the relationship broke down Step Grand Uncle sent compromising photos of the woman to her husband, apparently by email. This resulted in the husband attending Step Grand Uncle’s house and, following a disturbance, being arrested. Step Grand Uncle was removed from the Sex Offenders Register on 11 May 2010 and the record was archived. 5.7 Step Grand Uncle’s contact with Alex’s family The Nottinghamshire Police IMR gives the following account of what they understand to have been Step Grand Uncle’s contact with the Alex’s family. ‘Mother believes she first met Step Grand Uncle when Alex was around six years old and her youngest daughter had recently been born in 2002… she had heard from Step Grand Uncle’s mother [Step Great Grandmother] that he had been in trouble with the police over something to do with a girl …but believed Step Grand Uncle would not have been capable to do anything due to a heart condition. Mother did not consider Step Grand Uncle’s offending history to be serious but it is not known exactly how much she was told about it by his family. As a family they saw Step Grand Uncle about three times a year when he visited his mother in Nottinghamshire. Mother was aware that Step Grand 19 Uncle’s wife had left him due to what had happened with the girl, and that his own sons no longer spoke with him either. They first went away as a family on holiday with Step Grand Uncle in 2012, having previously met up with him several times in Kent. They had also gone to France for the odd day and he would join them. In 2013 they had 5 days with him in Whitstable and were due to see him in Nottinghamshire again in June 2014 and later on holiday in August 2014… Step Grand Uncle would ring and speak to all the family on occasions and she knew he rang and texted Alex. Step Father knew about Step Grand Uncle’s offending history but again did not think it was serious.’ 5.8 Step Grand Uncle’s arrest and subsequent death On 1st May 2014 Kent Police were contacted by Nottinghamshire Police following the death of Alex. Later that day Kent Police Paedophile Online Investigation Team (POLIT) officers executed a warrant at Step Grand Uncle’s address and arrested him on suspicion of sexual assault. A quantity of computer equipment was seized from the house for analysis. After interview, during which he denied any offences, he was released on bail pending analysis of the computers. He returned on bail and was further questioned about his involvement and some images that had been found on his computer. He answered ‘no comment’ to all questions put to him. He was bailed again to allow further analysis. Under examination a number of indecent images of children were discovered. These included images judged to be levels A, B and C. Level C is the lowest level of illegal images and it covers erotic posing by children. Level B covers sexual activity without penetration. Level A includes instances of penetration and also incidents involving animals or humiliation or torture. 20 Within these images were a large number of personal photographs which on examination included some images of a young girl who appeared between 7 and 10 years old apparently taken in a bedroom. These images fell within the level C category. These images were identified by Alex’s family as pictures of her taken about 2007 or 2008. The bedroom was identified as Alex’s bedroom at her home in Nottinghamshire. Kent Police conclude that the images were taken on Step Grand Uncle’s camera, during the period Step Grand Uncle was subject to sex offender registration. On the day he was due back on bail, 13 November 2014, Step Grand Uncle sent a text message to his legal advisor asking him to inform the investigating officer that he would not be attending the police station that morning. Police attended his home address and found him dead on the bed having apparently consumed a large quantity of tablets. Kent Police report that at Step Grand Uncle’s inquest the coroner returned an ‘Open’ verdict. However the coroner commented that ‘he was satisfied that Step Grand Uncle had fully intended and took the necessary steps to take his own life.’ 6 Contextual information: Self-harm and suicide by young people Before turning to the questions posed in the terms or reference it may be helpful to review briefly what is known about self-harm and suicide by young people. It is very difficult to be sure about the number of deaths that could be described as suicide. The Department of Health4 is aware of this difficulty and recognises that incidence figures are probably an underestimate. Several writers suggest there is reluctance by coroners to label a death as suicide, particularly in the case of young people. It should be remembered that the coroner in Alex’s case did not give a verdict of suicide but rather provided a narrative verdict. With that caveat, the Department of Health reports suicide rates for 15 – 19 year old females as being 4 Department of Health ‘Statistical update on suicide’ February 2015. 21 around 2 per 100,000. This makes it a statistically uncommon event when compared to the most at-risk group, 40-44 year old males, where the incidence is 24 per 100,000. The incidence of self-harm by young people presents a very different picture. Self-harm is defined by National Institute for Clinical Excellence as ‘self-poisoning or injury, irrespective of the apparent purpose of the act.’ The National Child and Adolescent Mental Health Support Service (2011)5 quotes data suggesting a prevalence of self-harm among 11-15 year olds without any diagnosed mental health issues as 1.2% (1,200 per 100,000) this rises to 9.4% (9,400 per 100,000) for young people with an anxiety disorder and 18.8% (18,800 per 100,000) for those with depression. Hawton et al (2000)6 suggest that one in ten UK teenagers deliberately self-harm, and the average age to start self-harming is 13, with the prevalence of self-harming behaviour being three times higher in girls than in boys. The Report of the National Inquiry into Self-harm among Young People7 (Mental Health Foundation, 2006) estimated that one in 15 young people self-harm, with the average age of onset being 12 years old. Public Health England reports even higher levels of self-harm – quoting figures of one in six8. Even when we take in to account uncertainties about these statistics, and the overlapping age groups being reported, it is clear that suicide by young women is a relatively uncommon event while self-harm by young people is much more frequent. The Hawton et al figures, which are midway between the higher and lower estimates, 5 National CAMHS Support Service (2011) Self-harm in children and young people handbook 6 Hawton, K, Rodham, K. Evans, E. & Wetherall, R. (2000). Deliberate self-harm in Adolescents. Oxford: Oxford University Press. 7 Mental Health Foundation (2006). Truth Hurts: Report of the National Inquiry into Self-harm among Young People. London, UK: Mental Health Foundation. 8 Public Health England gives as the source for this claim ‘Health behaviour in school-aged children: world health organization collaborative cross-national survey.’ However the overview author has not been able to find or verify this data. 22 would imply that in every secondary school class of thirty pupils there could be three pupils who would at some point commit self-harm. There is no clear agreement about the links between self-harm and suicide. Some researchers9 view self-harm as being quite a different clinical issue to suicide. From this perspective self-harm is seen as a coping mechanism – a method of relieving stress. As such it is seen as a mechanism to make life bearable rather than to end it. For others however self-harm and suicide should be understood as being part of the same continuum, both being responses to distress10. The University of Oxford Centre for Suicide Research has undertaken large scale studies of suicide by under 25s in England11 12 13. They found that just under half (44.8%) of the young people had a history of previous self-harm. 22% had carried out multiple episodes and 26% had self-harmed within the previous year. The Royal College of Psychiatrists reports that ‘The risk of suicide (by young people) in the first year after self-harm is between 60 to 100 times the risk of suicide in the general population.14 In Alex’s case it seems reasonable to see her self-harming as a precursor to her death by her own hand and to suspect that similar issues were behind both actions. 9 See for example Social Care Institute for Excellence (SCIE) 2005 ‘Deliberate self-harm among children and adolescents: who is at risk and how is it recognised?’ 10 NSPCC (2009) Young people who self-harm: Implications for public health practitioners 11 Hawton, K., Houston, K., Shepperd, R. (1999) Suicide in young people: a study of 174 cases, aged under 25 years, based on coroners' and medical records. British Journal of Psychiatry, 175, 271-276 12 Houston, K., Hawton, K., Shepperd, R. (2001) Suicide in young people aged 15-24: a psychological autopsy study. Journal of Affective Disorders, 63, 159-170 13 Fortune, S., Stewart, A., Yadav, V., Hawton, K. Suicide in adolescents: using life charts to understand the suicidal process. (2007) Journal of Affective Disorders, 100, 199-210 14 Royal College of Psychiatrists (2004) Deliberate self-harm in young people: Factsheet for parents and teachers 23 Research15 suggests an overlapping list of risk factors for both self-harm and suicide. These include: • mental health problems including depression • family issues (criminality. poverty) • disrupted upbringing • physical or sexual abuse • having worries about sexual orientation • family relationship problems • self-harm in a family member • drug use • low self-image and low self-esteem. Other research16 has highlighted the strong links between childhood abuse and self-harm. 7 Analysis This report now considers the questions raised by the safeguarding board in their terms of reference for the review. 7.1 Examine the effectiveness of the management of Step Grand Uncle as a registered sexual offender following his conviction in 2003 7.1.1 The assessment of risk Step Grand Uncle posed and his management On release, Step Grand Uncle was managed as a Registered Sex Offender by Kent Police under the terms of the Multi-Agency Public Protection Arrangements 15 The child and adolescent self - harm in Europe seven year study (2005). National Children’s Bureau 16 Romans, S.E., Martin, J.L., Anderson, J.C., Herbison, G.P. & Mullen, P.E. (1995) Sexual abuse in childhood and deliberate self-harm. American Journal of Psychiatry, 152, 336-342. 24 (MAPPA). The Kent Police IMR author commissioned an evaluation of Step Grand Uncle’s management which concluded ‘that there was an appropriate level of visits and the subject matter discussed at the visits was reasonable.’ However the IMR author also identifies weaknesses in Step Grand Uncle’s management and concludes that ‘records appear to indicate that officers were recording the welfare of the subject and his feelings and wellbeing but could have been more intrusive in their visits.’ The Kent Police IMR author makes some important observations about the episode involving Step Grand Uncle, a married woman with whom he had an affair and her husband. When the relationship broke down Step Grand Uncle sent compromising photos of the woman to her husband, apparently by email. This resulted in the husband going to Step Grand Uncle’s house and, following a disturbance, being arrested. The Kent Police IMR points out that this episode revealed some similarities to his previous method of offending against his previous child victim – the taking of intimate images, then threatening to share them, and then doing so. The report notes that ‘This may be part of his controlling nature and is certainly similar to his actions in 2008.’ This interpretation also raises questions about the nature of his contact and offending with Alex. We know that Step Grand Uncle took indecent images of Alex and it remains a possibility that he used them, as he had done on these earlier occasions, to threaten and exert control over her. The 2008 episode also revealed that Step Grand Uncle had access to the internet at a time when the visit notes by Kent Police officers report that he had no internet access. The Kent Police IMR goes on to identify another weakness in Step Grand Uncle’s management at this time: ‘It was recorded that the woman friend had children and although some questions were asked around access to the children no consideration was made regarding child protection referrals for those children. It is unclear to the Reviewing Officer what level of knowledge the woman friend had with regard 25 to Step Grand Uncle’s convictions. It was recorded on records that ‘she knew of his situation’- this should have been explored further.’ It is worthwhile examining the nature of ‘risk assessment’ in this context. Step Grand Uncle was categorised as ‘low risk’ on the basis of standard assessment tools. The Risk Matrix 2000 (RM2000), used in 2009, is a statistically-derived risk classification process for men who have been convicted of a sex offence. It is an approved tool for use in the MAPPA process. It is what is termed a ‘static’ assessment tool – it uses simple factual information about offenders’ past history to divide them into categories that differ substantially in their rates of reconviction for sexual or other violent offences. The validity and reliability of the tool was tested using a large national sample of offenders who were followed for nearly 20 years after assessment17. 17 Hanson, R.K, and Thornton, D. (2000). Improving Risk Assessment for Sexual Offenders: A Comparison of Three Actuarial Scales. Law and Human Behaviour, 24, 119-136. 26 Thornton (2007)18 examined re-offending rates for sexual offenders assessed using Risk Matrix 2000 with the following results: RM 2000 5 years re-offending rate 15 years re-offending rate Offenders assessed as ‘Low risk’. 8% 11% Offenders assessed as ‘Medium risk’. 25% 29% Offenders assessed as ‘High risk’. 49% 55% Offenders assessed as ‘Very high risk’. 85% 91% Figure 1 The estimated actual re-offending rates of offenders assessed using Matrix 2000. Source: Thornton, D. (2007). ‘Estimating Sexual Recidivism Rates: Observed and Undetected.’ This and other research suggests that while static, statistically derived, risk assessment tools such as RM2000 are very effective in distinguishing between groups with different likelihoods of re-offending, ‘low risk’ should not be misunderstood as meaning ‘no risk.’ More than 1 in 10 low risk offenders are likely to re-offend within 15 years. Given that ‘low risk’ does not mean ‘no risk’, it is important that those managing sex offenders are alert to the significance of continuing sexually coercive and threatening behaviour, such as that shown by Step Grand Uncle in 2008. This event should, at the least, have led to more intrusive enquiries about his contact with children and young people. As more recent MAPPA guidance19 notes: 18 Thornton, D. (2007). ‘Estimating Sexual Recidivism Rates: Observed and Undetected.’ 19 Ministry of Justice 2012 MAPPA Guidance Version 4 27 Risk assessment is a dynamic process which requires ongoing re-evaluation in the context of the offender’s changing circumstances. It should be reviewed regularly. 7.1.2 Compliance with Kent Police policy and MAPPA guidelines in place at the time Kent Police report that they have been unable to locate copies of the earliest MAPPA guidance, issued around 2003. However local Kent Police policies from between 2001 – June 2009 were reviewed and found not to provide any guidance regarding the need to repeat risk assessments. Kent Police go on to report that ‘MAPPA guidance issued in 2007 under Good Practice Standards includes the requirement that all level 1 cases20 are reviewed at least once every four months. This Level 1 review must identify any new information relating to the case which has an effect upon the risk assessment.’ Kent Police go on to note that their local policy was updated in September 2009 to make clear that: ‘…there is a requirement to monitor the risk of the particular offender, identify changes and risk factors and ensure that appropriate action is taken to manage and where necessary review the risk.’ The context in which Kent officers were working was that they had no local guidance on the need to review risk assessments prior to September 2009. However from at least 2007 national MAPPA guidance made clear the need to review their risk assessments in the light of new information. Against this context, the Kent Police IMR identifies some explicit shortcomings in Step Grand Uncle’s management. • Officers did not consider the potential significance of Step Grand Uncle’s use of intimate photographs (and possibly threats as to their use) as part of a sexual relationship 20 Such as Step Grand Uncle 28 • his access to email, as evidenced by the 2008 episode, suggests that he misled officers in saying that he had no internet access. It should have been apparent from the facts of this episode that he did have internet access. • his potential contact with children in Kent was known but not pursued through child protection procedures • his visits to Nottinghamshire and possible contact with children there were not explored in more detail • information about his extended visits to Nottinghamshire were not shared with Nottinghamshire Police. As the Kent Police IMR concludes such issues ‘should have resulted in a revisiting of the Risk Assessment on each occasion. If this was done it is not recorded.’ 7.1.3 Were those responsible for his offender management aware of any potential risks to Alex, or could have reasonably expected to be aware? In February 2008 Step Grand Uncle declared Step Great Grandmother’s address in Nottinghamshire as one that he would be at for more than 7 days a year. Given that he had been on the sex offenders register since 2003 and Mother believes the family first met him in 2002, it raises the question of whether Step Grand Uncle declared his visits to his mother in Nottinghamshire as soon as he should have. The Kent Police IMR reports that there is no record of any questions to Step Grand Uncle about the access he had to children when in Nottinghamshire. It was recorded that Step Grand Uncle told officers that his family ‘were aware of his situation’. It is unclear to the Kent IMR author whether that meant the family knew he had been to prison or the detail of what he had been to prison for. He concludes that ‘This was not recorded as having been probed in sufficient detail. The officers should have explored the subject’s access to children and any details shared with the relevant forces.’ There is no record by either Kent or Nottinghamshire Police of information about Step Grand Uncle’s visits being passed to Nottinghamshire Police. This was a 29 mistake. Nottinghamshire Police should have been informed about his visits so that they could take appropriate steps. The Nottinghamshire Police IMR sets out what would have happened if that notification had taken place. If Nottinghamshire Police had been informed in 2008 when Step Grand Uncle first registered the Nottinghamshire address the following action would have been taken: • The address would have been visited for a risk assessment of Step Grand Uncle’s surroundings by the Management of Sexual and Violent Offenders department. • Any reference to a child having access to that address/familial access would have been referred to Children’s Social Care who would then also have conducted an assessment • An intelligence record of his temporary residence at that address would have been created. • A place of interest marker may have been placed on the address if Step Grand Uncle was felt to be high risk of re-offending 7.1.4 Developments in Kent Police’s management of registered sex offenders Kent Police IMR reports that working practices have improved and more detailed information is now collected from offenders and there is more thorough recording of this information. Kent Police training now focuses on the need to corroborate accounts and reminds officers to be aware that subjects may be controlling in their nature and wish to appear compliant. The Kent Police IMR author concludes that he is assured that if the same circumstances occurred today a revision of the risk assessment would take place. All relevant officers undertake the Management of Sexual Offenders and Violent Offenders course. Local training makes particular emphasis on the grooming of officers by offenders. Kent Police now use the Active Risk Management System (ARMS) to assess risk. This is a dynamic assessment tool and includes an explicit assessment of the extent to which offenders have access to children. 30 If any children are identified as at risk through this process they would be identified in the risk management plan and a child protection referral to the Central Referral Unit for onward dissemination to Social Services would be made. The Kent Police IMR author is content that current training covers any inadequacies that may have been identified in this case. Improvements have clearly been made in Kent Police’s management of registered sex offenders. In the light of the learning from this review, Kent Police will be conducting an audit of how effectively these new arrangements are being implemented. 7.2 Examine the actions of Alex’s school following the disclosure made to them by her friends that Alex was self-harming • Consider any learning which the school has put in place as a result of this incident. • Examine this response and best practice from other areas to make recommendations as to how responses to this type of disclosure can be improved across the education sector. • What provision did the school have in place for covering e-safety and keeping safe more generally with students, have they reviewed their processes and is there best practice which can be shared across the education sector? 7.2.1 The actions of Alex’s school following the disclosure There were failings in the way School 1 responded to the disclosure by friends that Alex was self-harming. The events show both individual mistakes by staff as well as shortcomings in School 1’s systems at the time. The record keeping relating to these events was not in line with the school’s safeguarding policy. In part this was because at the time, self-harm was not explicitly identified as a safeguarding issue within the school’s safeguarding policies. 31 The School 1’s safeguarding procedures in place at the time make no explicit reference to responding to self-harm but they do set out the general procedures for responding to concerns about a pupil: • Any member of staff who has concerns about the safety or potential abuse of a child must report their concerns to Senior Teacher B without delay. When Staff Member A became aware of a risk to Alex’s safety he did the right thing and informed the Designated Member of Staff for Child Protection - Senior Teacher B. However from this point on there was a failure of both Staff Member A and Senior Teacher B to keep any record of the concerns or their actions. This hampered the effectiveness of their work. The School 1 safeguarding policy of the time referred to the need to carefully record ‘abuse’ but did not explicitly extend this to recording other safeguarding concerns such as self-harm. It required that: • Any member of staff receiving a disclosure of abuse from a child or young person, or noticing signs or symptoms of possible abuse in a child or young person, will make notes as soon as possible (within the hour), writing down as exactly as possible using the child’s own words, what was said or seen, putting the scene into context, and giving the time and location. Dates and times of events should be recorded as accurately as possible, together with a note of when the record was made. All records must be signed and dated clearly. Children will not be asked to make a written statement themselves or to sign any records. • All records of a child protection nature (handwritten or typed) will be given to the designated safeguarding lead for safekeeping. This includes child protection conference minutes and written records of any concerns. Access to any records will be on a ‘need to know ‘basis. All records must be securely held, separate from the main student file, and in a secure place. Had this been done, staff would have had a record of what they had been told and by whom and the failure to contact Alex’s parents would have been apparent. 32 Previous serious case reviews in Nottinghamshire have identified the impact of poor record keeping on the effectiveness of school safeguarding. As a response, Nottinghamshire produced a toolkit for governors and managers to audit their school safeguarding record keeping. This material asserted that ‘Good record keeping is not bureaucracy – it is safeguarding.’ The fact that pupils brought their concerns about Alex to a member of staff suggests that they had a raised level of concern about her but also that they had a sense of trust in staff – feeling able to take such issues to them. When information about Alex’s self-harming was given to staff there should have been an assessment of the level of risk this represented in order to guide appropriate responses. There were no school level procedures in place to support staff in doing this but more general guidance on self-harm was available from the safeguarding board. Any assessment of risk there was appears to have been very informal and nothing was recorded. The School 1’s new procedures for self-harm include an explicit process of risk assessment. This is good but needs to be supported by evidence-based guidance on evaluating risk. The safeguarding board’s guidance suggests that self-harm could sometimes prompt more substantial planning: ‘As the child or young person who is self-harming is likely to be experiencing problematic issues in a number of areas in their life the professional should discuss with the child or young person the possibility of undertaking a Common Assessment Framework (CAF) and/or, having a multi-agency meeting to identify the young person’s needs.’ The actions agreed in response to the report of Alex’s self-harm were to inform her parents and speak to Alex. These would have been a reasonable first response, although an initial conversation with Alex should have only been a first step. 33 It appears that Staff Member A did not contact Alex’s parents as he intended to do. Without the benefit of an interview with Staff Member A it is not clear why this was the case. However in the overview author’s experience secondary schools are very busy places and staff dealing with pastoral and behavioural issues are often trying to juggle many important issues. As such it would be reasonable to conclude that a well-intentioned action became lost as other tasks emerged. This is why systems for recording and reviewing actions are important. As School 1’s IMR comments ‘if it had been recorded accurately on the day of the self-harm incident then Staff Member A would have known whether he needed to attempt to contact parents again.’ No notes were made of the meeting between Staff Member A and Senior Teacher B. Similarly there is no record of the Staff Member A talking with Alex about the concern, although he reportedly said that he did speak with her the next day. A conversation with Alex asking if she wanted to access support would have been a good initial response. However Alex’s initial response to decline such help should not have been left at that. Other opportunities for Alex to talk with a trusted adult and consider further the offer of support would have been helpful. The local safeguarding board guidance on self-harm advises that if a young person declines support that should be viewed as something that ‘will potentially increase the level of risk.’ Instead Alex’s refusal of support seems to have been viewed as suggesting matters were not serious. The question of sharing the information about Alex’s self-harm with others should have been discussed. This might have included telling her form tutor or the school nurse. The safeguarding board guidance offers advice on sharing information and in Alex’s case it may have been judged that it was appropriate to share information, even without her consent, in light of the risks to her safety. Having been made aware of the disclosure and advised on next steps, Senior Teacher B did not follow up the matter with Staff Member A to find out what had happened next. There do not appear to have been systems in place at the time to 34 provide a framework to help staff record concerns of this type and monitor follow up actions. The School 1 IMR notes that ‘there was insufficient supervision in place to ensure that all staff were following the framework correctly, so areas such as record keeping were not overseen regularly.’ It also highlights that there was no specific guidance to help staff respond to self-harm – ‘A specific framework/ flow chart was not in place at this time to support specific actions for self- harm.’ Research suggests that many schools have had poor systems for responding to self-harm. The Mental Health Foundation’s report ‘Truth hurts21’ described the views of pupils. They told researchers that: ‘…schools have no real focus on promoting good mental health and emotional well-being – most of the PSHE sessions concentrate more narrowly on drug and alcohol issues, sexual health, peer-pressure and bullying. They expressed particular concerns about needing clear and informed information and advice specific to self-harm. Most said that they had never had any opportunity to discuss or learn about self-harm at school or in any other context.’ 7.2.2 School 1’s learning from these events Following Alex’s death School 1 reviewed and amended its procedures for responding to self-harm. Their IMR describes the new systems now in place: • Model practice for managing self-harm flow diagram; this highlights to frontline staff involved the key procedures that need to be followed in order to ensure the safety of a child with regards to self-harm. This flow diagram takes into account both low level concerns and points of crisis. The 21 Mental Health Foundation (2006). Truth Hurts: Report of the National Inquiry into Self-harm among Young People. London, UK: Mental Health Foundation 35 procedures give a degree of accountability to staff and also provide a clear time line for actions to be completed and checked. • A self-harm incident form; to be used by staff reporting incidents of self-harm with clear follow up actions and time dependent checklists – which is collated and overseen by the Senior Designated Person. • Follow up letter of concern; the letter of concern follows up the telephone call and subsequent conversation previously made to a parent. Also a letter of concern is sent to parents in the unusual situation where the member of staff has failed to make contact with a parent of a student and they have recorded this on the ‘Self-harm Incident Form’. Staff are required to continue to attempt to contact home until they are successful and manage to speak with a parent/carer. • Emergency contacts business card; this is included with the letter of concern providing parents with several key phone numbers for support including; ChildLine, Women’s Aid, Samaritans and the School Principal’s personal phone number. • Parent and Carer fact sheet to explain self-harm; this is a fact sheet explaining what self-harm is with clear guidance for follow up by the parent or carer. • ‘What to do if you are aware of concerns of a student self-harming’ document; this has been issued to all staff as part of the safeguarding training completed regularly in the School 1. • Safeguarding training for students; students are made aware of the safeguarding procedures through the School 1 assembly programme and through themed PSHE days. Key issues of bullying, e-safety, self-harm, CSE are addressed through these days, as well as, assemblies and in tutor times. This new material is of very high quality and could provide a model for other schools. It provides the clear guidance on how to respond that would have been helpful in supporting staff dealing with Alex. The only issues raised by Alex’s case that may not be fully reflected in the new guidance are: 36 • recognising that disclosures about self-harm will quite often come from other students. Therefore students as well as staff need training and guidance on recognising and responding to self-harm • ensuring that the procedures are followed by staff. This will mean auditing practice, including record keeping, regularly • when discussing the sharing of information about a pupil who is self-harming staff should weigh up the possible benefits of sharing information with others. For example the form tutor is likely to see the pupil on daily basis and the school nurse may be able to offer advice to staff • the flow chart of actions includes a point of ‘risk assessment’. It will be important for the staff making this assessment to have an evidence based framework of self-harm risk assessment to guide them. 7.2.3 Using this learning to improve practice across the education sector. The Nottinghamshire Safeguarding Children Board (NSCB) guidance22 on self-harm was published in 2011 and updated in March 2014. It provides clear simple multi-agency guidance on self-harm. However it refers to structures that are no longer in place (Joint Access Teams, Multi-Agency Locality Teams) and frameworks that have changed (Common Assessment Framework.) This guidance is available as a printed document and as a pdf on the NSCB website. The NSCB also provides other information on self-harm and suicide on their website23 and while this advice is broadly similar to the 2014 self-harm guidance document, it follows a different format. The additional website information offers more detailed advice, which would be helpful to staff. NSCB should consider if both pieces of guidance are needed in their current format. It might be appropriate to amalgamate them. While this guidance is clear and helpful it would not be sufficient in itself to provide guidance to schools on how they should respond to self-harm. Schools would need 22 Children and Young People who Self-Harm: Inter-agency practice guidance. Nottinghamshire Safeguarding Children Board and Nottingham City Safeguarding Children Board. March 2014. 23 http://nottinghamshirescb.proceduresonline.com/guides/p_self_harm_suicidal.html 37 more detailed guidance that reflects their own internal structures and the pattern of provision in their area. The Self-Harm Awareness and Resource Project (SHARP) has recently published guidance for secondary schools in Nottingham City24. This provides the more detailed guidance on self-harm that schools in Nottinghamshire would also find helpful if it were adapted to reflect their local circumstances. In 2011 Nottinghamshire Educational Psychology Service produced ‘Self-harm: Guidance Notes’ for schools in collaboration with colleagues from Child and Adolescent Mental Health Services. The service is currently revising and updating that guidance. Other examples of national best practice have been highlighted in the Public Health England report ‘Promoting children and young people’s emotional health and wellbeing. A whole school and college approach.’25 This provides examples of best practice in relation to mental health and self-harm as well as examples of teaching materials. There is an opportunity to use • the learning from this SCR • the school level material developed by School 1 • the material developed by SHARP for Nottingham City secondary schools • the emerging revised EPS guidance • an updating of the safeguarding board guidance • examples of national good practice to develop new guidance for Nottinghamshire schools. 24 Nottingham City Secondary School Self-Harm Guidance May 2015 25 Public Health England (2015) Promoting children and young people’s emotional health and wellbeing. A whole school and college approach.’ PHE publications London 38 When providing safeguarding guidance of this type Nottinghamshire typically develops a ‘model policy’ for schools, which schools are then asked to adapt to reflect their internal structures and local provision. It is recommended that Nottinghamshire commission work to develop such a ‘model policy’ which is then supported with training events for schools. It will be important that this model policy is developed with representatives of schools, health services, children’s social care and the independent and voluntary sector. The views of young people should also be reflected, either by local consultation or by reference to other recent projects that have given expression to their views. 7.2.4 What provision did the school have in place for covering e-safety and keeping safe more generally with students, have they reviewed their processes and is there best practice which can be shared across the Education sector? ‘E-safety is defined as ensuring children and young people are safe whilst using all fixed and mobile technologies that children and young people may encounter, now and in the future, which allows them access to content and communications that could raise e-safety issues or pose risks to their wellbeing and safety’ (British Educational Communications and Technology Agency). When the terms of reference for this review were established it seemed possible that issues of e-safety might emerge from Alex’s case. As such additional questions about e-safety at School 1 and Nottinghamshire schools were posed. In practice electronic communication did play a role in this case, but Step Grand Uncle’s contact with, and access to, Alex was established by non-electronic means. He did however use telephone calls and texts, to her mobile, to maintain his contact with Alex. Alex also used Twitter to express her thoughts, including some that might have given rise to concerns. 7.2.4.1 E-safety and keeping safe at School 1 The School 1 IMR reports that 39 ‘Prior to Alex’s death no audit was in place of how students were kept informed of e-safety and keeping themselves safe. It was planned for and delivered in assemblies, PSHE lessons, tutor time and throughout subject lessons, such as ICT. The Pint Sized Theatre Company also delivered a performance to students based on e-safety and Challenge Days (themed days of focus such as safeguarding) took place.’ The report goes on to say that School 1’s approach to e-safety and keeping safe is now more systematic: • ‘the topic of covering e-safety and keeping safe more generally with students is now shared with students in themed assemblies which are clearly set and calendared throughout the year, in addition to the above. • Display boards now show students key information to keep safe and also sign post students to places and agencies who can help them. • Specific students also receive additional guidance, based on records and referrals.’ The Nottinghamshire lead officer for e-safety has a record showing she provided training to some parents of School 1. The School reports that staff are now trained and made aware of e-safety as part of their safeguarding training. The School keeps records of all staff safeguarding training. 7.2.4.2 Best practice In 2010 26 and 2012 27 Ofsted published reports that described the characteristics of excellent e-safety practice in schools. These features were: • having an active approach • a close relationship between provision and pupils' knowledge and understanding 26 Ofsted (2010) ‘The Safe Use of New Technologies.’ Manchester: Ofsted 27 Ofsted (2012) ‘Inspecting e-safety’ Manchester: Ofsted 40 • well established staff training which was monitored and evaluated • well planned and coordinated curriculum • using 'managed' rather than 'locked down' systems • systematic reviewing and evaluation of e-safety policies • shared responsibility for provision • leaders, governors, staff and families working together to develop a clear strategy • excellent relationships with families • systematic training of staff. The local safeguarding board produced guidance in November 2011 for all agencies working with young people – ‘E-safety: Inter-agency practice guidance.’ Nottinghamshire’s Anti-bullying Co-ordinator is a qualified e-safety trainer and Child Exploitation and Online Protection (CEOP) Ambassador. She provides training to schools and parents on e-safety. Nottinghamshire has published guidance for schools28 on how to develop an e-safety policy and acceptable use policy. This is available on the Schools’ Portal. Nottinghamshire recently commissioned a large scale survey by ‘Youthworks,’ a specialist consultancy in the field of e-safety. Nearly 3,000 Nottinghamshire pupils took part in the survey in the Autumn term 2015. 75% of pupils said they had received teaching about e-safety and those who had, said they were likely to follow it. The anonymous survey revealed disclosures by young people of potentially risky on-line behaviour. For example over 200 12-15 year olds said they had met up in real life with someone they met online and fewer than three-quarters of those told anyone they were going to do it. This new data is being used to inform a new Nottinghamshire programme ‘Tacking Emerging Threats to Children,’ which it is hoped will begin in late 2016. This will share best practice across the education sector. 28 Nottinghamshire County Council (2015) E-safety policies: Advice & guidance to schools 41 Alex was posting worrying material on Twitter prior to her death. It will be important to ensure that e-safety training for parents points out the need to monitor young people’s postings on public spaces such as Facebook and Twitter. 7.3 Was there anything which could have been done to support the parents when they became aware of Step Grand Uncle’s offending which would have helped them to protect Alex? It is not the purpose of this review to consider the actions of Alex’s family. However it is appropriate to consider what might have helped them protect Alex when they became aware of Step Grand Uncle’s history of sexual offending. There is discussion earlier in this report of what information should have been provided by Kent Police to Nottinghamshire Police when it became known in 2008 that Step Grand Uncle was regularly visiting his family in Nottinghamshire. Without that information Alex’s family were reliant on what they had been told informally by Step Grand Uncle’s relatives about his offending. This account apparently minimised his offending and the risk he posed. Nottinghamshire Police provide information about child sex offenders under the terms of the Child Sex Offender Disclosure Scheme, often known as Sarah's Law. The Nottinghamshire Police website has well-presented information on this scheme which the author was able to find quickly with a Google search. The website explains: Child Sex Offender Disclosure Scheme (Sarah's Law.) We operate a scheme that allows anyone concerned about others working, living or in contact with children to raise their concerns with the police. This may include a parent concerned about their new partner or a friend of the family. 42 Once a concern is raised, we will carry out background checks and, where appropriate, inform the person best placed to protect the child or children concerned from harm. Please see the link at the bottom of this page for more information about the scheme. The website takes readers to well written leaflets about the scheme. The first of these explains: The aim of the scheme is to: • To reduce sexual offending against children • To provide parents, carers and guardians with information that will enable them to better safeguard their children • To improve public confidence. If police checks show that the individual has a record for child sexual offences, or other offences that might put the child at risk, the police will consider sharing this information with the person(s) best placed to protect the child, usually the parent, carer or guardian. The leaflet goes on to explain how to request information about a person of concern and how the Police will respond. Nottinghamshire Police, then, have a mechanism for applying Sarah’s Law locally and it is well explained on their public website. This only leaves the question of how well known it is within the local community. Given that the law was introduced in 2011 it may now be an opportune time to refresh the public’s awareness of the law and how it operates in Nottinghamshire. This would remind other parents of the resources available when they are concerned about the possible sexual offending history of someone who has contact with their children. 43 8 Parallel processes The coroner has issued her findings in regard to Alex’s death. Kent police have closed their investigation of Step Grand Uncle. Nottinghamshire Children’s Social Care has closed their involvement with Alex’s family. An inquest in to Step Grand Uncle’s death has been completed. 9 Good practice identified School 1’s work to develop systems and guidance for responding to self-harm is excellent. It should be used as one of the resources for developing a model policy on self-harm for Nottinghamshire schools. The Nottinghamshire Police public website provides excellent, easily understood, guidance on the use of ‘Sarah’s Law.’ 10 Conclusions Alex was 15 years old when she took her own life by hanging. She was a bright girl, doing well at school and was ready to progress to the next stage of her education. Her diary tells us that she had positive hopes and dreams of a life with marriage and children. She was seen by teachers as generally positive and happy. Her friends had a more nuanced picture of her. They knew she could appear cheerful and happy much of the time but some of them also knew that she could be unhappy. They did not know what caused this unhappiness but some of them knew that she harmed herself, probably by cutting herself. We now know that there were good reasons for Alex to be unhappy. In addition to whatever normal adolescent turmoil Alex had to navigate, she was the victim of abuse by Step Grand Uncle, someone trusted by her family. Step Grand Uncle continued to groom and pursue her up until the day of her death. He had taken indecent photographs of her when she was younger. He had previously used indecent images he had taken of women to threaten and control them. It is possible that he was doing the same with Alex. 44 It is not clear how long Alex had been self-harming but one pupil told Police that Alex had been self-harming in Year 10. In Year 11 a group of her friends became sufficiently concerned to disclose the matter to a member of staff. When Alex’s self-harm became known to staff they set out to do the right things – talk with Alex and inform her parents so that they could seek support. Although they clearly intended to do so, staff did not contact Alex’s parents. They were therefore left unaware of the concerns. The school lacked systems for recording and monitoring important actions such as this. This was a missed opportunity to alert Alex’s family to herself harm and direct them to appropriate support. A member of staff has said that he spoke to Alex and offered her access to support in school. When Alex reportedly declined this support staff should have seen this as something that potentially increased her level of risk. School systems at the time did not provide staff with guidance on managing self-harm or assessing risk. Staff did not keep any records of information and actions as was required by the school safeguarding policy. This hampered the effectiveness of their response. Since Alex’s death School 1 have developed and implemented excellent materials to help staff respond to self-harm by pupils. These materials, together with other material in development locally and material published nationally should be used by Nottinghamshire County Council to develop model guidance on self-harm for all Nottinghamshire schools [Recommendation 1.] Alongside this, Nottinghamshire Safeguarding Children Board should update their guidance on self-harm to reflect the organisational and procedural changes that have taken place since it was last revised. They should amalgamate the two slightly different sets of guidance on self-harm they currently make available. [Recommendation 2.] School 1 should audit the implementation and effectiveness of their new arrangements for responding to self-harm. [Recommendation 3.] Evidence from Alex’s computer suggests that by early 2014 she was seeking out web sites on depression. Step Grand Uncle seems to have been in continuous contact with Alex with messages that have a sinister implication when we know of Step Grand Uncle’s history - ‘Just being pleasant and talking to me could get you so much.’ 45 Step Grand Uncle had access to Alex from around 2002. He was a convicted child sex offender who was jailed after he abused and threatened a teenage girl in 2003. Step Grand Uncle visited Alex’s family and went on holiday with them. They knew something of his conviction for sexual offending but did not believe he was a risk. From 2003 until 2009 Step Grand Uncle was managed by Kent Police as a registered sex offender. They visited him annually, as required by MAPPA guidance but do not appear to have re-visited and updated their risk assessment of him between 2003 and 2009. They kept track of his welfare and his feelings but should have been more intrusive - particularly questioning his access to children. In 2008 Kent Police became aware that Step Grand Uncle had access to the internet, contrary to what he had told them. They also learned that he had taken intimate images of a married woman with whom he had a relationship and then shared them when the relationship came to an end. This was reminiscent of the how he had tried to control his previous child victim when he abused her – taking indecent images of her, threatening to share them as a means of control and then sharing them when she resisted him. This should have led to a re-assessment of the level of risk Step Grand Uncle posed. Kent Police knew that the woman with whom Step Grand Uncle had a relationship had children but did not investigate further what contact he had with them or what risk he might pose. In 2008 Step Grand Uncle declared that he made extended visits to Nottinghamshire to visit Step Great Grandmother. Kent Police did not inform Nottinghamshire Police of this. Had they done so Nottinghamshire Police could have made enquiries to establish what opportunities Step Grand Uncle had for contact with children in Nottinghamshire. Mother told Police that they saw Step Grand Uncle about three times a year when he visited his mother. It appears that it was during his visits to Nottinghamshire that Step Grand Uncle took indecent images of Alex in her bedroom. Kent Police believe the photographs were taken in 2007 or 2008, so these offences took place at a time when Step Grand Uncle was being managed as a 46 registered sex offender. Kent Police’s management of Step Grand Uncle as a registered sex offender had some shortcomings. Kent Police IMR reports that working practices have improved and that current training covers the inadequacies identified in this case. However, it would be appropriate to review the effectiveness of current practices in the light of learning from this case. [Recommendation 4.] It is unclear what information Alex’s parents had about Step Grand Uncle. Nottinghamshire Police implement the Child Sex Offender Disclosure Scheme, (Sarah's Law.) This provides a mechanism for parents and carers to request information about the criminal record of offenders who may have contact with their children. It is five years since this law came in to force and it would be appropriate for Nottinghamshire Safeguarding Children Board to refresh the public’s knowledge of the law and how it can be used to protect children and young people. [Recommendation 5.] This report discussed earlier the factors known to be associated with young suicide. We now know that Alex was probably exposed to three of these risk factors: • previous self-harm • abuse • depression Prior to her death however, only one of these risk factors was known – her self-harm. Her abuse was not known, other than to Alex and her abuser, prior to her death. The possibility that she was experiencing depression is only inferred from the later analysis of her internet history. It does not appear to have been apparent to those who knew her. Risk factors in suicide are not simple indications of an impending suicide. If we take self-harm as a ‘risk factor,’ we know from research discussed earlier that self-harm is a high frequency event among young women at school. By comparison, suicide by 47 young women is statistically quite uncommon. The overwhelming majority of those young people who self-harm at school do not go on to commit suicide. As such, Alex’s self-harm did not predict that she would go on to kill herself. What it did do, however, was to suggest that she had a higher level of risk and that appropriate protective action should be taken: • Informing her parents so that they could play a part in keeping her safe • encouraging them to seek medical advice • when Alex declined support, seeing that as a matter to raise concern levels. When School 1 did not take these actions effectively an opportunity was missed to reduce Alex’s risk of suicide. The other risk factor that was potentially under the control of agencies was Step Grand Uncle’s abuse of Alex. When he declared to Kent Police that he was making extended visits to Nottinghamshire, Kent Police should have informed Nottinghamshire Police. This would have triggered child protection procedures in Nottinghamshire to establish what opportunity for contact he had with children and what risk he posed. Evidence from Kent Police suggests that Step Grand Uncle took indecent photographs of Alex, in her Nottinghamshire home, at a time when he was a registered sex offender, supervised by Kent Police. We know from his previous behaviour that Step Grand Uncle had used indecent images to put pressure on women. If he was doing that with Alex it may have been a contributing factor to her depression and death. When Kent Police failed to inform Nottinghamshire Police of Step Grand Uncle’s visits an opportunity was missed to protect Alex from abuse and so reduce her risk of self-harm and death. Alex’s mother and step-father do not appear to have been aware of the seriousness of Step Grand Uncle’s previous conviction when they allowed him access to their family. The provisions of ‘Sarah’s Law’ could have given them a way to find out more about the risk Step Grand Uncle posed to their family. If they had that information they might have reached a different judgement about allowing him contact with their family. 48 In judging whether Alex’s death could have been predicted or prevented the author is mindful of the conclusion of Marion Brandon29 at the Centre for Research on the Child and Family, who has examined the evidence from serious case reviews. She concludes that ‘Not all young suicide can be predicted or prevented.’ We should also remind ourselves that even with the benefit of hindsight and a police investigation, we may not be aware of all the factors that led to Alex taking her own life. In the light of what we now know it would be reasonable to conclude that opportunities were missed to identify that Alex was being sexually abused and thereby to reduce the risk that Alex would take her own life. 10.1 The delay in instigating a serious case review Nottinghamshire Police had suspicions in May 2014 that Step Grand Uncle was a factor in Alex’s death. They liaised with Kent Police and a search warrant was executed at his home address on the same day. Step Grand Uncle was questioned further on 2nd October 14 and was due to answer bail on 13th November 2014 (presumably for charging purposes). Nottinghamshire Children’s Social Care was kept updated by Nottinghamshire Police regarding their concerns in relation to Step Grand Uncle. At some point between May 2014 and November 2014 Nottinghamshire Police had sufficient information to suggest that Step Grand Uncle had abused Alex. At this point Nottinghamshire Police or Nottinghamshire CSC could have made a referral for consideration of a serious case review. The referral eventually came when the case later reached the Nottinghamshire Safeguarding Children Board (NSCB) Child Death Overview Panel (CDOP) for review. This review normally takes place when all investigations into the deaths, including the inquest, have been completed. CDOP reviewed the death at their monthly meeting on 24th April 2015 and the view of the meeting was a referral should be made for SCR 29 Marian Brandon (2012) ‘Young Suicide and Serious Case Reviews’ paper presented at 8th BASPCAN International Congress April 2012, Queen’s University Belfast, accessed from http://www.baspcan.org.uk/files/Brandon%20Marian%20S7.4%20Tues%2010.45.pdf 49 consideration. This referral to the SIR Sub Group was made by the CDOP chair on 11th May 2015. In line with all other NSCB partner agencies, Nottinghamshire Police and Nottinghamshire Children’s Social Care have an obligation to refer cases for consideration of a SCR where they believe the criteria for SCR may have been met. This should be done in a timely manner. Since these events Working Together 2015 included content intended to clarify the Serious Incident Notification process. The guidance requires Local Authorities to notify Ofsted and local safeguarding children boards of any serious incident involving a child within five working days of them becoming aware of it. As a result Nottinghamshire Children’s Social Care has introduced processes for submitting Serious Incident Notifications (SINs) which should lead to both Ofsted and NSCB being notified of serious incidents in a timely manner. It has been reinforced within members of the responsible NSCB sub group that all agencies have a responsibility to identify cases for consideration of reviews at an early stage. 50 11 Recommendations The following recommendations have been discussed and agreed by agencies through the SCR Panel process. Recommendation 1. Nottinghamshire County Council should develop model guidance on self-harm for Nottinghamshire schools. This should draw on: • the learning from this SCR • the school level material developed by School 1 • the material developed by SHARP for Nottingham City secondary schools • the emerging revised EPS guidance • an updating of the safeguarding board guidance • examples of national good practice This work should be developed with representatives of schools, health services, children’s social care and the independent and voluntary sector. The views of young people should also be reflected, either by local consultation or by reference to other recent projects that have given expression to their views. When developed, this material should be disseminated to schools and schools should be advised on how to customise the model policy to reflect their own internal structures and local provision. Action: Nottinghamshire County Council Education. Recommendation 2. Nottinghamshire Safeguarding Children Board should update their guidance on self-harm to reflect the organisational and procedural changes that have taken place since it was issued in 2014. They should amalgamate their two slightly different sets of guidance in to one. Action: Nottinghamshire Safeguarding Children Board. Recommendation 3. School 1 should audit the implementation and effectiveness of their new arrangements for responding to self-harm. They should consider if their new arrangements could be further strengthened by: • providing students as well as staff with training and guidance on recognising and responding to self-harm • undertaking a regular audit of compliance with practice 51 • reviewing their policies on sharing of information about a pupil who is self-harming Action: School 1 Recommendation 4. Kent Police should review the effectiveness of their management of registered sex offenders in the light of learning from this case. This should consider: • do officers always thoroughly investigate the offender’s opportunities for contact with children? • do officers use risk assessment in a dynamic way – regularly updating their assessment and using new information to review their judgements about risk? • do officers routinely inform other forces or agencies when a RSO has contacts outside of Kent? Action: Kent Police Recommendation 5. Nottinghamshire Safeguarding Children Board and its partner agencies should review its communication and engagement with parents and carers. They should ensure that key messages around safeguarding risks are delivered effectively and help equip parents to protect children. This will include reference to the use of Sarah’s Law in Nottinghamshire and how it can be used to protect children and young people. Action: Nottinghamshire Safeguarding Children Board. Dr John Bradley 15.9.2016 |
NC050518 | A 3-week-old baby taken to hospital by ambulance. No health issues were found, raising concerns about fabricated or induced illness (FII). Learning includes: the need to access and consider all available information about parents when making a referral, undertaking a pre-birth assessment or challenging another service in respect of an unborn child; the importance of effective challenge between professionals, including use of escalation policies; the need to recognise the potential risk to a child if a parent has a history of fabricating illness; and ensuring there is information sharing and consideration of the father of an unborn child, even if it seems unlikely they will be involved in the child's care. Recommendations include: partner agencies consider the Child Safeguarding Practice Review Panel's report on male carers ('The myth of invisible men', 2021) to ensure that services are more effective at engaging, assessing and planning for and with men in the protection of children; seek assurance from partner agencies regarding professionals having access to both historic and current information to make decisions in safeguarding work; consideration of the RCPCH guidance on FII ('Perplexing presentations (PP)/fabricated or induced illness (FII) in children', 2021) and a review of the local escalation policy for the resolution of professional disagreement to ensure procedures reflect best practice.
| Title: Child safeguarding practice review (CSPR): Skylar. LSCB: Portsmouth Safeguarding Children Partnership Author: Nicki Pettitt Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Version 8 Final 1 Child Safeguarding Practice Review (CSPR) Skylar1 Contents 1. Introduction page 1 2. Process page 1 3. Learning page 2 4. Recommendations page 11 1 Introduction 1.1 In 2021 the PSCP agreed to undertake a Child Safeguarding Practice Review, as they recognised the potential that lessons could be learned about the way that agencies work together to safeguard children in Portsmouth by the considering a case of a young baby to be referred to as Skylar. 1.2 The professional involvement with the family of Skylar was reviewed in order to identify learning for the wider systems and for practice in cases where there are parental risk factors that may impact on the care and protection of a child. The case raised issues about the identification of risk pre-birth and the response to concerns about the future care of a baby where the parent is vulnerable due to their mental health, learning needs and a history of seeking support with suspected fictitious illnesses. 1.3 Learning was been identified regarding: • The need to access and consider all available information on the parents when making a referral, undertaking an assessment or challenging another service in respect of an unborn baby • Effectively giving and receiving challenge • Recognising the potential risk to a child if a parent has a complex history with mental health issues that include a tendency to fabricate illness • Considering and engaging the father 2 The Process 2.1 An independent lead reviewer was commissioned2 to work alongside local professionals to undertake the review. Individual agency chronologies, including analysis, were provided to the Rapid Review. They identified important single agency learning that the wider review has built on. The agencies involved included those predominantly providing services to adults. 1 This is a non-gender specific name chosen by the child’s Mother 2 Nicki Pettitt is an independent social work manager and safeguarding consultant. She is an experienced lead reviewer of Serious Case Reviews and Child Safeguarding Practice Reviews and is entirely independent of the PSCP Version 8 Final 2 2.2 Professionals who had been involved at the time were included in discussions about the case, along with agency safeguarding professionals. Due to the on-going response to Covid-19, three practitioner participation sessions3 were held in August 2021 using video technology. 2.3 The lead reviewer spoke with Skylar’s mother during the review in order to identify any learning from her perspective. Skylar’s father did not respond to a request to engage with him. 3 The case considered 3.1 Skylar was born in hospital and went home to live with parents shortly afterwards. The baby was putting on weight as expected in the community and was seen regularly by midwives, the health visitor and the perinatal mental health service. When the baby was three weeks old the mother took Skylar to hospital by ambulance reporting a number of health issues. There was no evidence of any concerns following tests and professionals raised concerns about the risk to the child of the mother fabricating illness. 3.2 Skylar’s mother had a very difficult childhood. She was in the care of the local authority until she was 18 where she experienced a number of placement breakdowns, including spending time in residential care where she was known to pose a risk to herself and potentially others. Both adult mental health and the learning disability service knew Skylar’s mother due to her moderate learning disability and mental health issues, although she did not tend to engage with support. Over ten years after she left care she became pregnant with Skylar, her first child. 3.3 Very little was known about the father of the baby beyond his name and date of birth during the pregnancy. It is now known that he was well known to children’s services in another part of the country due to the physical abuse of his older children. 4 The Learning 4.1 At the request of the PSCP this report will focus on what is considered to be the most important learning from the review. The learning points are identified below and are followed by a summary of the analysis enabled by this review of Skylar’s case. Learning point 1: When considering if the threshold for a referral for a social work assessment is met, health professionals should review all of the information available, including the parent’s history. This history and a detailed analysis of why there is a risk of significant harm should be clearly reflected in any referral sent to the MASH and all available health information should be considered in any assessment undertaken. 4.2 Considering the case of Skylar enabled those involved to reflect on the importance of ensuring that any referral, sharing of information or challenge is accompanied by details of all the information known about the family and clear and focused reflection on what risk this may hold for an unborn baby. This is not as straightforward as non-health professionals may assume, as there are numerous health systems that are not accessible to all who work with a patient. Even within one hospital there are 3 The sessions were organised via Teams. The first focused on the early identification of risk by health professionals and the quality of referrals to CSC, the second focused on professional curiosity and the whole family approach, the last considered professional challenge. Other issues were also identified in the sessions and are included in this report Version 8 Final 3 numerous IT systems, and it is difficult to find all of the known information on a patient. Skylar’s mother frequently attended A&E prior to and during her pregnancy, and the maternity assessment unit while pregnant. She told the review that she found the maternity unit very helpful and supportive. The community midwives who saw her regularly and who consulted with other professionals about the case were not aware of these attendances at the time however. They shared during the review that they usually rely on the expectant woman to disclose a hospital attendance, and they will then check the systems to find out more. In this case Skylar’s mother did not share this information and as there was no process in place for this information to be shared routinely with the midwives, they were not aware of this as a potential issue for unborn Skylar. The review was told that a working group is now in place to ensure that this information sharing gap is addressed in future. As the mother in this case often also attended hospitals in neighbouring areas, there needs to be professional curiosity when trying to establish the extent of any issue. 4.3 All referrals about children where professionals have a concern are sent to the MASH email address. In this case there were four referrals by health professionals in the pre-birth period due to concerns about the potential impact on the baby of mother’s issues. The first went to the MASH and the next three were forwarded to the team who undertook the first assessment for management overview, as it was less than three months since the case closed. The first referral was from a midwife and contained information about the mother being care experienced and having mental health issues. As is expected and good practice, the MASH health navigator summarised much of the mother’s extensive history, including stating that there were on-going concerns due to the mother’s learning disability and mental health including recent overdoses, and her numerous concerning attendances for reported but not evidenced health issues. They recommended a pre-birth assessment and a S47 response to consider the extensive and complex history and the potential impact on the baby. The review established that this was a helpful piece of work which went some way to sharing the history. Although it was available on the I.T system, it was not considered by the social work team who undertook a visit to complete the children and family assessment. No checks were then undertaken with any health professionals who knew the mother during the assessment and before a decision was made to take no further action. 4.4 In a neighbouring authority the MASH has a system where the health navigator creates a case note on the social care system, which makes their work more accessible to those undertaking the assessment. The review also asks whether this helpful piece of work should also be available to other professionals working with the family, such as health visitors. The review established that this information is included on SYSTM1 which is available to a number of health agencies. There was no evidence it was accessed in this case by those who were working with Skylar, this appears to be because the case note was placed onto the mother’s record as there was no record at the time for Unborn Skylar. Those making referrals, working with a family or escalating concerns about another agency’s response need to ensure that they know as much as they can about the risks and vulnerabilities within a family, and this includes seeking and accessing available information on the parents. The piece of work undertaken by the health navigator in the MASH following the first referral was available to be used and built on by those assessing, by those making further referrals and those later escalating their concerns about the proposed response and the assessments made, but they were not aware of it. It Version 8 Final 4 was only when this review was undertaken that the majority of those involved with Skylar were aware of it and its contents. 4.5 The MASH manager confirmed to the review that there is an expectation that when a referral is moved from the MASH for a social work assessment, that all of the information that the MASH provides needs to be considered. A lot of work has been undertaken on the quality of information seeking and sharing in the MASH. It is generally thought to be high quality and has received compliments in inspections and audits. It is therefore essential that this work, understanding and analysis are considered by those who are then going to undertake the assessment. There is also an expectation in local procedures that during a child and family assessment parental consent is sought for direct communication with the professionals who know the family, including those working with the adults. The recommendation from the MASH was for a pre-birth assessment and it was clear that there was a belief that there were enough indicators of potential harm to justify a through and robust assessment. 4.6 There is no specific pre-birth assessment tool/model in Portsmouth. The review was told that the children and families social work assessment process would be used but that there should be a focus on preparation for the birth, the potential to care for a baby and what family support was available. While Children and Family Service (CFS) professionals have stated during this review that they undertook thorough assessments, the assessment completed was based on just one-off single agency visits that largely relied on the mother’s self report and did not consider the extensive history before concluding that further social work involvement was not required. The issue of pre-birth assessments was raised by the national Child Safeguarding Practice Review Panel in their September 2021 national CSPR ‘The Myth of Invisible Men’. They found that improvements were required in this area and suggest that partners answer the following questions: ‘Have you audited the quality of pre-birth assessments, are they undertaken as early as needed and are they informed by information and assessments on a multi-agency basis? Are the histories and backgrounds of both parents included in them routinely?’ Feedback received from CFS is that it is the expectation that assessments completed on an unborn baby should include more than a one-off visit, should include historic information on both parents and require checks with those working with the family, such as midwives, adult mental health services, the parents GP, and so on. A recommendation has been made in regard to this. 4.7 The Hampshire, Isle of Wight, Portsmouth and Southampton (HIPS) Unborn/Newborn baby Protocol was updated and published in March 2021. It states clear multi-agency expectations when there are concerns for an unborn baby. It includes clear pathways and templates for pre and post birth plans, and a one-minute guide for health care staff who may identify pregnant women where there are existing risk factors that may impact upon the wellbeing of their unborn/ newborn baby. There was no reference to this policy in this case. Although the updated version would not have been embedded in practice at the time that concerns were emerging about Skylar, the previous protocol was in place and was also not referred to. Learning point 2: As stated in the PSCP Re-Think process, giving and receiving honest challenge is a crucial part of any effective safeguarding system. Version 8 Final 5 4.8 In 2008 Munro et al4 raised the importance of practitioners working in child protection being able to admit they may be wrong and to revise their views following reconsideration and/or challenge5. She wrote that ‘assessments are fallible, and contexts constantly changing. Therefore, professionals need to keep their judgements under constant critical review’. Munro et al noted a tendency to ‘stick to an initial hypothesise’ even in light of challenge from other professionals or more information becoming available. There were a number of occasions during the work with Skylar and their mother where an open-minded review of what was known prior to the birth was required. 4.9 The review has seen evidence of communication by email, telephone and in meetings where requests were made that the case be allocated to a social worker and a plan made for the unborn Skylar.6 The response to this challenge was a request from CFS for more evidence to be provided in order for the threshold to be reached, rather than an understanding that there were other and alternate views about the risks to Skylar from Mother’s issues which needed to be considered more thoroughly. In the words of Munro, ‘the need to constantly revisit – and if necessary revise – initial assumptions in the light of either fresh evidence or a fresh view of that existing evidence is essential if judgements are not to be rendered unsound as the premises and circumstances on which they were based change.’ Although staff expressed that they were worried and voiced their belief that the unborn baby was at risk, there is no evidence of any formal use of the HIPS escalation Policy for the Resolution of Professional Disagreement.7 This appears to be because of either a lack of knowledge of the policy, the time it was felt it would take to undertake such a challenge, and a hope that progress could be made without it. The fact that this was a pre-birth case gave professionals time to try and persuade their colleagues of the risks they felt would be present following the birth of Skylar. However while there were a number of challenges made directly to the social work team by various professionals around the time of Skylar’s birth, they were largely undertaken in isolation and did not include all of the concerns and a joined up analysis of the risks. 4.10 The PSCP have devised their own model to encourage and promote challenge and reflection. ‘Re-think’ was launched early in 2021. Due to feedback from inspections and serious case reviews, it was acknowledged that there was a need to encourage more challenge. It was known that while some cases can get ‘stuck’, there was a reluctance to use the formal partnership escalation protocol. Re-think is a new option to allow professionals to pause and reflect with colleagues in an open and collaborative way. There is a hope that it will be used to discuss disagreements like those evident with Skylar. The PSCP believe it will ensure that professionals are less defensive or frustrated and will enable better safeguarding and support for the children being worked with. The review agrees that it is a positive attempt to resolve a long-term issue. 4.11 In the Re-think model an independent facilitator is used from a small pool of suitably experienced staff to find a way forward alongside the professionals involved. In the case of Skylar, the manager 4 Fish, S., Munro, E. and Bairstow, S. (2008) Learning together to safeguard children: developing a multi-agency systems approach for case reviews. Social Care Institute for Excellence 5 ‘The single most important factor in minimising errors is to admit that you might be wrong.’ Munro et al 2008 6 https://portsmouthchildcare.proceduresonline.com/p_threshold.html# 7 https://hipsprocedures.org.uk/skyyty/safeguarding-partnerships-and-organisational-responsibilities/escalation-policy-for-the-resolution-of-professional-disagreement Version 8 Final 6 who had been involved in the initial decision making was asked to review the conclusion of the assessment. To ask the same professionals who have made decisions to then review them without any further scrutiny from someone who was not involved is unlikely to lead to a change in the plan. Particularly when they may understandably feel resentful about the challenge to their own or their team’s practice, leading to a defensive rather than open minded review of the case. A model where an independent facilitator is used is a good one to avoid this dynamic. 4.12 The Re-think process was launched in February 2021 and was available around the time that concerns about the response to unborn Skylar were being discussed by various professionals. There was no consideration of using the process, probably because it was very new and not yet embedded. At least one of the professionals involved in the case was not aware of the Re-think process at the time of the sessions held for this review (August 2021) so it appears that further work is required to ensure that it becomes as helpful as is hoped. The review was informed that due to the demands on services from COVID-19, the launch was a ‘soft’ one and that further work is to be undertaken during 2021 to promote and embed the process. 4.13 Other options were also available at the time, including involving more senior managers in discussions about this case. While this happened to a certain extent in the health agencies and CFS, it had little impact. The involvement of safeguarding leads within health would have been a helpful response that was not used at the time. There was also the potential in the child protection procedures for any professional to call an Initial Child Protection Conference. This rarely, if ever, happens. A number of the health staff involved in this case were not aware this was possible, so the safeguarding leads across health agencies agreed that they will ensure that they put a process in place for future use should this be required. They will also communicate this option across their agencies when and if the need arises. 4.14 The idea of escalating a disagreement is not one that is well understood in a lot of health settings. The concept of asking for a second opinion is more common and is readily used by doctors in particular. Those involved in the review shared that when promoting the ‘Re-think’ and HIPS escalation policy with health professionals, to compare it to the idea that a second opinion is being sought might be helpful to ensure it is used more readily across health agencies. Learning point 3: All professionals need to be aware of the potential risk to a child of a parent who has a complex history with mental health issues that include a tendency to fabricate illness, and of the need to seek advice in such cases. 4.15 As well as her learning disability and the complex and potentially significant mental health issues that the mother had to manage, the impact of her own experiences as a child and her time in care also required robust consideration by the professionals involved in respect of unborn Skylar. Research into Adverse Childhood Experiences (ACEs) shows that when a person experiences numerous types of abuse or neglect as a child, and the longer they experience them for, the worse their physical, mental and social outcomes are likely to be. This includes the possibility that their children will be known to safeguarding services, and that they will require support in the future with their longer-term mental Version 8 Final 7 health. In Skylar’s mother’s case, she was very well known to partner agencies as a child due to abuse and neglect, and then as a child in care. At one point she was the subject of a child protection plan under three categories at once (neglect, emotional harm and physical abuse.) These experiences were likely to have an impact when she became a parent, particularly as there was little evidence of any services managing to provide the on-going and significant support in her adulthood that she was likely to need in order to recover from her past. 4.16 The 2016 triennial review8 of serious case reviews stated that abuse and neglect experiences in the parents’ own childhood are often found to have posed a risk to their children. Skylar‘s mother’s history made her extremely vulnerable in her own right and means she required support individually and as a parent. Getting her to accept support was likely to require skilled intervention. A survey of over 2000 children in care ‘Our Lives Our Care’ by Coram Voice and the University of Bristol (2018) found a widespread mistrust of professionals amongst those spoken to. Although Skylar’s mother’s experience of care had been some years before, she continued to be wary of professionals and she told the lead reviewer that she was very concerned that her child would be taken away. This was likely to have had an impact on her level of candour with professionals, on whether she would accept her need for support, and on her meaningful engagement with professionals. This complication needed to be considered by those involved, particularly those who were assessing her ability to parent, the level of risk to a baby, and the chance of her agreeing to the long term support she was likely to require. She told the review she has found the support more recently very helpful and would have appreciated more support prior to the bay’s birth. 4.17 Those who met Skylar’s mother stated that she does not admit to having any learning issues other than dyslexia and does not present as having a learning disability. The lead reviewer also noted this when she spoke with her as part of the review. Skylar’s mother appears confident and proficient when speaking to professionals, and they were almost exclusively reassured by her presentation. The police noted that they do not have a flag for a learning disability on their system for the mother, which may also be because of assumptions being made about the way that she presents. This can often be the case with adults who are care experienced. The ability to engage with and reassure professionals can be learned and can provide a false sense of security to professionals who are not alert to this possibility. This appears to have been the case with Skylar’s mother. Professionals need to ensure that they are balanced in their consideration of the history reported by professionals and by parents, to ensure that all views are given appropriate credence. While it is important to consider the views and history provided by the parent, they should not be the sole voice in an assessment. It is important to include any history and information from adult based services when planning for a child, so that parental self-reporting alone is not relied upon. There was a lot of information available about Skylar’s mother that needed to be considered, including reports of her extensive and recent overdoses, her seeking of medication and treatments for conditions including epilepsy, diabetes and a stroke when there is no proof that she had these conditions, and the impact of her low IQ.9 The fact that she was 8 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 (May 2016) Sidebotham et al 9 Said to be around 65, which significantly limits intellectual functioning Version 8 Final 8 open to the hospital high intensity user group as recently as 2020 due to the excessive number of A&E attendances needed to be shared and explored. 4.18 The detail of the mother’s time in the care of the Local Authority was largely unknown to those involved prior to the care proceedings starting on Skylar. This was reportedly due to in depth information not being carried over to the new system when Social Care records were migrated in 2019/20. During the meetings with front line professionals, the review was told that historic records need to be requested and this does not tend to occur pre-birth unless significant concerns are identified. When this was questioned with senior managers, it was confirmed historic records are readily available and it is the expectation is that they are accessed when an assessment is being undertaken. The review was told that there are people working for Portsmouth City Council who remember the mother from her time in care and as a care leaver who could have provided helpful background information had they been asked. Professionals need to remember to consult those who have worked in agencies for a significant amount of time. This might include managers, IROs and conference chairs. 4.19 The mental health of a parent should be considered in the context of the impact on the care provided or likely to be provided to a child. This review found that there was insufficient consideration or overly optimistic consideration of this impact during the social work assessments and when the health visitor agreed that early help support via ECHO10 was likely to be sufficient following the birth of the baby. While ECHO is a positive programme that provides helpful support to those who most require it, there was a concern shared during the review that the limitations of the programme may not be fully understood across agencies. The concerns that were shared by professionals about Skylar’s mother’s needs prior to and following the baby’s birth led to the health visiting service recognising that ECHO alone would not be sufficient to safeguard Skylar and stating this to CFS who had determined this was the most appropriate course of action for Skylar’s mother. 4.20 Those with concerns were not entirely clear about the potential risk to a baby from a mother who has a history of fabricating issues about her own health, until the hospital attendance that led to the referral for this review. There was a clear view that Skylar’s mother sought attention from health professionals and that there was rarely any real substance to what she reported about her own ailments. Until Skylar’s second attendance at A&E when three weeks old, no professional had stated that there was a clear and present risk to the baby of the mother using the child to continue to gain support and attention, and that this could potentially lead to an acceleration of the mother’s behaviour. During this attendance she reported that she had called an ambulance as Skylar had gone floppy and was bringing up green bile at home. There was no evidence of any illness following medical investigations, including some invasive procedures to establish whether Skylar was suffering from a twisted gut. The attendance led to a high level of concern from hospital staff given Mother’s history, some noted evidence of neglect of the baby and her observed care and handling of the baby while in A&E. There was assertive and positive practice from the senior paediatrician who refused to allow the child to be discharged due to concerns about what could happen to the baby in their mother’s care. 10 Enhanced health visiting offer for families who require additional support due to parental risks/ concerns Version 8 Final 9 4.21 The report of Skylar’s condition from the mother in the context of fabricated or induced illness in a young baby is deeply concerning as such episodes can be induced through suffocation or strangulation and parents can escalate behaviours if they don’t receive the response they are looking for. The Royal College of Paediatrics and Child Health (RCPCH) published a report ‘Perplexing Presentations11 (PP) and Fabricated or Induced Illness in Children’ in March 2021, around a month before Skylar’s presentation at hospital. It provides best practice advice for paediatricians in the medical management of PP and FII cases to obtain better outcomes for children, and has led to earlier recognition of possible FII, which may not amount to likely or actual significant harm at the time. The case of Skylar highlights some of the difficulties with this approach as the risk of FII may not meet the threshold for safeguarding procedures prior to a serious incident. The guidance is very helpful however when considering this issue, as it ‘aims to provide a framework for earlier intervention to explore the concerns of children, families and professionals in order to try, if this is possible, to address the issue of a perplexing presentation well before significant harm has come to the child or young person whilst also outlining when immediate action may be required.’ Safeguarding procedures need to be reviewed to ensure that they allow good preventative practice in this area. They already allow for action due to a ‘risk’ of significant harm, and Skylar needed to be considered as at risk of FII prior to their birth. 4.22 While there is a lot of information available about identifying a child where a PP or FII has happened, there is little research available about the future risk to a child expected by an adult who has a personal history of FII. The research available12 states that, as in this case, perpetrators of FII are high users of obstetric services and that they tend to require interventions in the delivery, such as inducement of labour or caesarean sections, and that these women require monitoring during pregnancy due to the risk associated with the condition. A high proportion of mothers involved in FII in respect of their children have been found to have a personality disorder - the diagnosis previously given to Skylar’s mother. The key signs include ‘emotional instability, disturbed thinking, impulsive behaviour, and intense but unstable relationships with others. It is thought that some mothers who carry out FII find the situation of their child being under medical care rewarding.’ 13 When there is any concern that a parent’s mental health condition may pose a serious risk to a child, specialist advice should be sought in order to understand the condition, the risks and what might help. All professionals need to have open discussions with each other that recognise each other’s area of expertise and to ensure that assessments are holistic and based on multi-agency knowledge and experience. 4.23 There was good practice in regard to individual professionals sharing information and their concerns about the mother of Skylar becoming a parent. For example, the GP and the consultant gynaecologist wrote to each other and shared information about the inconsistencies in the medical history that the mother was reporting to professionals. There was evidence of information sharing between adult mental health and the perinatal mental health service and between the midwifery service and the 11 The RCPCH Child Protection Companion 2013 extended the definition of FII in 2013 by introducing the term Perplexing Presentations with new suggestions for management 12 The perpetrators of medical child abuse - A systematic review of 796 cases (2017) Gregory Yatesa and Christopher Bass 13 https://www.nhs.uk/mental-health/conditions/fabricated-or-induced-illness/causes/ Version 8 Final 10 health visitor. What was lacking was all of the information and expert opinions being considered together. 4.24 There was no consideration of whether the mother met the criteria for involving the adult safeguarding team or if a referral should be made to the adult MASH in regard to the mother in her own right as a vulnerable adult, despite how well known she was, particularly in the hospital setting. In Portsmouth, there is a commitment to promoting the 'family safeguarding approach'. This should include raising awareness of the criteria for referring to the Adult MASH or taking advice from the Adult Safeguarding Team among professionals in both adult and children’s services. A recommendation has been made to encourage and support this. Learning point 4: Even where a family report that the unborn baby’s father is not likely to be involved in its care, it is important to ensure there is information sharing and consideration of the father. 4.25 Research14 shows that professionals do not always engage with fathers, that they have limited expectations of them, and that when plans are made to support or protect children it is often assumed by professionals, and the parents themselves, that ‘parent’ really means ‘mother’. When seeking or sharing information and when undertaking any assessment, the father of a child, including of an unborn baby, should not be missed or an after-thought. They should be an integral part of any plan for a child, including considering if they are a risk or a protective factor. When considering what support may be available to a family, paternal families should also be routinely considered. All professionals have a responsibility to engage with fathers and to question any apparent lack of engagement with the father from other agencies. 4.26 When the first referral was made to the MASH early in the pregnancy, checks were undertaken by the police including on the Police National Database (PND) when nothing came up locally. The PND system was down on the day however and checks were not completed later when the glitch was fixed. Further checks were completed following the baby’s second presentation at hospital, and again nothing was identified due to the incorrect spelling of the father’s name. It was during the Rapid Review process that details of Skylar’s father’s concerning history were found. Skylar’s mother told the review that she was honest with staff at the time about his heavy drinking and verbal abuse. If this is the case, it was not reflected in records or assessments. 4.27 For health professionals there are systems issues that can hinder the meaningful engagement with a child’s father. The System 1 templates do not clearly request a father’s information, and consent of the father to include him is not easily sought and gained when they are working or not present during appointments. Before a baby is born the records tend to be the mother’s and it is not thought to be appropriate to include much information pertaining to the father unless a record is opened for him, which is a possibility if consent is gained. Good practice suggests that a child’s Health Visitor should meet with a father or mother’s partner, but this does not happen in every case, due to capacity and pragmatic limitations if a father works out of the home. 14 Family Rights Group, Fatherhood Institute, Daryl Dugdale (Bristol university), Professor Brigid Featherstone (Open University) 2012 Version 8 Final 11 4.28 In the case of Skylar, the mother reported that she was in the process of separating from the baby’s father and that he would soon be leaving the family home. This was accepted and there is little evidence of any meaningful engagement with him by any agency that was considering the support that Skylar’s mother was likely to require when the baby was born. Her word was taken that he would not be involved. This was not checked with him or discussed with them as a couple in order to see if any support could be available in the short to medium term following the baby’s birth, and to seek background information on his experience of parenting. The HIPS unborn/new born baby protocol states that ‘it is important that all agencies involved in pre and post birth assessment and support fully consider the significant role of fathers, partners, wider family members or other significant adults in the care of the baby even if the parents are not living together and where possible involve them in any assessment.’ 4.29 There needs to be a whole system focus on the need to engage with a child’s father (or other secondary carer) whenever services are being provided to a family. In the 2015 NSPCC report, Hidden Men - Learning from Serious Case Reviews15. It is pointed out that men can be ‘ignored by professionals who sometimes focus almost exclusively on the quality-of-care children receive from their mother and/or female carer.’ Individual practitioners should be encouraged to always to ensure that they ‘think father/think man’ when working with families. As this review was drawing to a close, the third national CSPR16 was published. It focuses on the circumstances of babies under one who have been harmed or killed by their father or other males in a caring role. One of the specific questions that the review considers is ‘how can the safeguarding system be more effective at engaging, assessing and planning for and with men in the protection of their children (or those for whom they have parenting responsibility)?’ A recommendation for the PSCP has been made in regard to this issue. 5 Conclusion and recommendations 5.1 Prior to the birth of Skylar, the referrals, assessments and attempts at professional challenge largely lacked the required detail in both content and analysis. Once the baby born and then when it was presented at the hospital for the second time, there was a good response with clear statements of risk and escalation to ensure the baby was protected, despite a number of professional disagreements. It was not until the baby had been presented at hospital and subject to unnecessary procedures that a child protection response was implemented, and it was then that the extent of mother’s own history of fabricating illness was established and the father’s concerning history was identified. There had been indicators of concern about the couple’s relationship, including the large age gap between them and allegations of verbal domestic abuse made then withdrawn by the mother during the pregnancy, but limited professional curiosity about him. 5.2 It is incredibly hard to predict significant harm in the future in the case of a first time parent where their ability to parent a baby has not yet been tested. The GP described their dilemma as ‘my gut feeling was concern, but it was incredibly hard to put the extent of these concerns onto paper, as it was a perceived risk for the future and there was little hard evidence that could be put forward.’ The health 15 https://learning.nspcc.org.uk/media/1341/learning-from-case-reviews_hidden-men.pdf 16 https://www.gov.uk/government/publications/safeguarding-children-under-1-year-old-from-non-accidental-injury Version 8 Final 12 care professionals who knew the mother wanted her to have the chance to prove herself, but felt she needed to do so with safeguards in place for the baby. 5.3 The review has found the need for a number of recommendations in order to ensure that the learning from this review has a positive impact on practice and systems. They were devised in collaboration with the PSCP Learning from Cases Committee who are responsible for the action plan. Recommendation 1: The PSCP to ask all partner agencies to consider the questions included in the National CSPR published in 2021 in order to ensure that services are more effective at engaging, assessing and planning for and with men in the protection of children Recommendation 2: The PSCP executive to request a progress report on the embedding of the Re-think model Recommendation 3: The PSCP to seek assurance from partner agencies regarding professionals having access to both the historic and current information that is required to make decisions in safeguarding work. This should include consideration being given to health professionals working with children having access to information compiled in the MASH regarding the parents Recommendation 4: That the PSCP seeks assurance from Children and Families Service that • All of the information compiled in the MASH and held by other professionals is sought and considered by social workers undertaking assessments • Social work assessments completed on an unborn baby include more than a one-off visit, historic information on both parents and checks with all professionals working with the family • All social work staff are aware of the expectation that historic information (pre-Mosaic) is available and must be accessed when completing assessments Recommendation 5: That the PSCP considers the RCPCH report ‘Perplexing Presentations and Fabricated or Induced Illness in Children’ and requests that the HIPS procedures are reviewed to ensure they reflect best practice in this area of safeguarding Recommendation 6: The PSCP to work with the Portsmouth Safeguarding Adults Board to plan for raising awareness about making adult safeguarding referrals when required |
NC52239 | Death of a 15-year-old boy in September 2019. Child A was fatally stabbed after responding to a message on social media to meet some friends. Child A had an Education Health and Care Plan due to having moderate learning difficulties. Family was known to services from 2005, mainly in relation to issues around housing, Mother's immigration status and Father's mental health. Children's Social Care conducted family assessments in 2012 and 2014. Child A moved schools in 2017 and there were concerns about his affiliations to gangs and being groomed for criminal exploitation. Police investigation resulted in the convictions of two defendants for Child A's death, who were sentenced in July 2020. Ethnicity and nationality not stated. Learning includes: this review mirrors other national and local reviews, studies and case reviews that show the disproportionality of Black boys of African Caribbean heritage who are more likely to be susceptible to risks of criminal exploitation; housing services were not engaged in multi-agency discussions about how agencies were seeking to reduce the risks to Child A; frequent moves between boroughs hampers and delays services to children and their families. Recommendations include: ensure practitioners in Early Help services are equipped to work with children and families affected by criminal exploitation; ensure staff are equipped to identify, assess and make plans for children whose learning disability increases their susceptibility to criminal exploitation, where contextual safeguarding is an issue; ensure that guidance, best practice and training around multi agency safeguarding discussion and meetings involves housing services.
| Title: Child safeguarding practice review: Child A. LSCB: Greenwich Safeguarding Children Partnership Author: Greenwich Safeguarding Children Partnership Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 1 Introduction 1.1 This Child Safeguarding Practice Review (CSPR) is being conducted in response to a 15-year-old boy (referred to in the report as Child A) resident in Greenwich with his mother and siblings. Child A was known to a number of services in Greenwich and neighbouring boroughs. He had an Education Health and Care Plan (EHCP) due to having moderate learning difficulties. At the time of this death he was allocated within Children’s Social Care (CSC) in Greenwich. This was due to concerns about his behaviour and risks associated with being gang affiliated. Child A was fatally stabbed in September 2019 in the London Borough of Newham after responding to a message on social media to meet some friends. 1.2 The case was notified to the Greenwich Safeguarding Children Partnership (GSCP) and a Rapid Review meeting took place a few days after his death. Members recommended a Local Child Safeguarding Practice Review should take place and notified the National Panel who agreed with the recommendation. 1.3 At the time of writing the review a police investigation had been conducted resulting in the conviction of two defendants for Child A’s death. They were sentenced to lengthy prison sentences in July 2020. 2 Key principles underpinning the review 2.1 Child Practice Safeguarding Reviews (CPSR) are an important learning tool for any organisation and the review aims to be as inclusive as possible to ensure that all voices are heard. With that in mind the panel had some key principles in mind. These were: • Recognition that safeguarding children is a complex area of work, particularly in the area of contextual safeguarding • The importance of understanding not only who did what, but why they did what they did, the underlying reasons that led individuals and organisations to act as they did are equally important in obtaining a full understanding of what happened • Understanding practice from the viewpoint of the individuals and organisations is vital to being able to form a view based on what was known and what was knowable at the time rather than using hindsight. • Relevant research and case evidence informed the panel’s thinking about best practice • Practice is critiqued from the child’s perspective • The family should be involved in the review as much as possible 3 Terms of Reference 2 3.1 The Terms of Reference are attached at Appendix 1. Agencies involved with the family were asked to analyse their involvement via a brief written submission. The timeframe for the review is from the start of agencies’ involvement as this gives context to the later events. Agencies first became aware of Child A in 2014 and the panel used this early history to build a picture of him and his family. The summary of professional involvement therefore starts there. 3.2 The Terms of Reference were agreed with the Panel overseeing the review. The broad areas that the Panel agreed were the most important to look at were: • Agencies understanding and response to Child A’s gang association? • The capacity of each agency to respond swiftly and effectively to the increasing risks in safety planning for Child A and his family. • How agencies assessed other aspects of Child A’s lived experience e.g. home life, school, significant relationships, extended family, community etc. • Agencies response to risks of gang involvement when looking at emergency moves for families? • How were Child A’s learning needs and associated vulnerabilities assessed in light of his gang affiliation? • Agencies understanding of the threshold about high risk missing young people and their response? • How the voice of the child was represented by agencies? • The impact of Child A being a victim of modern slavery • What good practice did agencies demonstrate? • How effective was management supervision and oversight in this case? 4 Review Process 4.1 The report is based on the agencies’ submissions (referenced above) and a practitioner event with key staff that had worked with the family and knew them well. The report author had access to other documents relating specifically to the family such as assessments and minutes of relevant meetings held with the family. 4.2 In order to provide context to the working practices at the time of the review, the author also read a number of contemporary policies and procedures. These are referenced in relevant sections. 5 Agencies Involved in the Review • Children’s Social Care, Greenwich • Children’s Social Care, Bromley • Children’s Social Care, Croydon • Youth Offending Service, Greenwich • Metropolitan Police Service (MPS) • Housing Services Bromley 3 • Bromley Children’s Project • St. Giles Trust • Greenwich Community Safety Partnership • Harris Federation (Greenwich Academy) • Lewisham and Greenwich NHS Trust • StreetVibes Academy 6 Summary of professional Contact Family Members Age at the time of the death of Child A Child A 15 years Younger sibling 10 years Older sibling 17 years Mother 41 years Father (not resident in the family home) 37 years 6.1 Agency’s submissions as part of the review process have been co-ordinated into a combined chronology, summarised here. Further factual information is provided in subsequent sections to add context where relevant. 6.2 A specific feature of this family was the number of times they moved which inevitably hampered the timeliness and delivery of services to them. For ease of reference the table below details the family’s moves between 2005 and 2019. Date Details of move 2005 Living in the London Borough Croydon 2014 Evicted from property in Croydon. The family’s whereabouts not clear but believed to be in Bromley. March 2016 Bromley accepted a duty to house the family and they were accommodated immediately in temporary accommodation July 2018 The family moved to different temporary accommodation in Croydon May 2019 The family moved again to temporary accommodation in Greenwich Early background 6.3 Historically the family were known to services in Croydon from as early as 2005, mainly in relation to issues around housing, Mother’s immigration status and Father’s mental health difficulties. 4 6.4 Croydon CSC conducted two assessments – one in 2012 and one in 2014. In 2012, a referral was received from Father’s Mental Health Services about issues of contact between Child A (aged 8 at the time) and his father. There were concerns about his father having a diagnosis of schizophrenia, being violent and having perpetrated domestic abuse against Child A’s mother. In 2014, a further assessment was completed when the children aged 5, 10 and 12 were left ‘home alone’ whilst mother went to work. Both assessments were completed without any further action. 6.5 The family are believed to have moved to Bromley in 2014 and were assisted by Bromley’s No Recourse to Public Funds (NRPF) Team. Between 2015 and 2016 Bromley Multi Agency Safeguarding Hub (MASH) received two referrals. In 2015 a member of the public reported that Child A was alone outside a fast food outlet at midnight. The police gave Mother strong words of advice and Bromley MASH wrote to Mother informing her of the referral but took no action. 6.6 At the end of 2016 a further police notification was received by Bromley MASH reporting that child A had been detained after being found in a flat in with “a small blade about 2-3 cm hidden inside a small plastic coating”. Child A was upset and crying uncontrollably. There were concerns that Child A was being groomed into dealing drugs for older juveniles (two 17 year olds were also at the scene). As well as the blade, Child A was also observed to have condoms and lubricant in his possession. When Mother was contacted, she would not attend the police station to be an appropriate adult for child A and she was unable to collect him, reportedly stating that it “would teach him a lesson”. Bromley CSC conducted an assessment with the outcome of support from Early Help Services that the family received throughout 2017. 6.7 In September 2017, Child A moved schools to be closer to his home and towards the end of that year the Early Help work came to an end. The work undertaken was said to have been successful as Mother seemed more on top of running a busy household, she was moving on from the children’s father and had started to run a successful business. Child A had begun to make better choices about his friendship group and although he had some teething problems in his new school, he was beginning to settle. 6.8 The role of the Lead Professional for the family passed to the younger sibling’s school and the Team around the Child (TAC) meetings continued through to the end of 2018. The younger sibling’s school being the lead for these inevitably meant that they focused more on that child’s needs, rather than those of Child A or his older sibling. 6.9 In the summer of 2018 the school referred Child A to Greenwich Adolescent Risk, Safeguarding and Prevention Panel (GRASP) as they had growing concerns about his affiliations. Child A and his family were not living in Greenwich at this 5 time but the referral was made in relation to issues at Child A’s school that was in Greenwich. The referral mainly targeted other students but Child A was included because of his association with them. The panel gave the school details of organisations who could help by talking to groups of students about the dangers of gangs. Child A was not discussed as an individual at this stage as he was deemed to be low risk. 6.10 At around the same time the family moved to Croydon. This proved to be a strain for Child A in getting to school on time. School accommodated him by allowing a later start, but in the September term of 2018 he was late on several occasions. Mother requested a move back to a Bromley school to ease this. This was delayed but then agreed by the Special Educational Needs service (SEN) in Croydon. The process was initiated but never came into fruition. 6.11 In late 2018 Child A was attacked by a group of boys near to his school. A member of staff from school noted the incident and reported it to the school police officer who went to support. The police officer accompanied Child A by ambulance to hospital and remained there until Mother arrived. At the hospital Child A said 5 young people had assaulted him and that he had been punched in the head. He denied that any weapons were involved. 6.12 Staff in the ED contacted Croydon CSC Emergency Duty Team (EDT) for background checks but Child A left hospital before these came through. The following day the information sharing form (sent by staff in the Emergency Department) was triaged by Croydon CSC but did not result in any assessment or on going work. The police took action by putting in place ‘reassurance patrols’ around the area but neither Child A or his mother responded to their attempts to investigate. No suspects were identified and it resulted in a police outcome of ‘No further action’. 6.13 Mother decided that Child A could not return to that school or any school in the Greenwich area due to her feeling that it was not safe for him. Child A’s behaviour deteriorated following his assault and Mother continued to express her concern to the school. It was discussed that she would look for other schools in Bromley. An alternative on line provision was arranged to support his schooling in the interim. Events in 2019 6.14 At the beginning of 2019, Croydon Gangs Prevention Team attempted to contact the family to discuss working with Child A. The family did not engage and the referral was closed down in March 2019 after three failed attempts. Child A had no school place at this time, despite his school making efforts to secure a place for him. His annual review for his EHCP took place and Mother expressed preferences for three schools closer to their home – all three schools declined to accept him. 6 6.15 The family moved to Greenwich at the beginning of May – this was not Mother’s preference but more due to the state of repair of their current property. Child A’s school facilitated an introduction between Croydon Education and Greenwich Education to try and expedite a school place for him. They gave a detailed overview of Child A’s position with school and stressed the importance of a school place as a matter of urgency. Child A had been out of school for five months at this point. To this end in June he was enrolled in an Alternative Provision (AP) in Greenwich where he remained on role until the end of the summer term in 2019. 6.16 At the beginning of July police officers were called to the family home due to an argument between Child A and Mother, which escalated to ‘pushing and shoving’ between the pair. Child A was described as "rude and disrespectful" and this culminated in the police removing him from the house to calm him down. This incident was reported to Greenwich CSC. Before they could respond to the referral it was superseded by another incident that resulted in the AP making a further referral. Child A disclosed to them that his mother would not let him in the house when he returned in the early hours of the morning. He had therefore spent the night travelling around the local area on buses and walking around. 6.17 Mother had been finding Child A’s behaviour difficult to deal with. He had started to come home late and she had refused to let him in at 1am. Mother had tried a number of strategies - she had replaced his smart phone with an ordinary phone and had tried to keep him at home. She suspected gangs and drugs but had no clear evidence. Mother was also aware of an incident with his ‘friends’ whereby Child A said he went to stay at a house in East London for a week. Some boys had accused him of ‘trying it on’ with one of their sisters and he had been threatened with knives because of it. This had prevented him going out for a while but he had started again. He had also been chased by the same group of boys near his school and had gone into the school building to escape them. Greenwich MASH allocated the family for assessment. NB It was conflict with this group that ultimately led to his stabbing two months later. 6.18 Throughout the assessment period in July and August, concerns for Child A’s welfare escalated. He was frequently missing and increasingly aggressive. At the beginning of July he received a four day fixed exclusion from the AP following a violent incident in which he assaulted his mother and caused damage to property in their reception area. The exclusion took him to the end of his scheduled placement at the AP as it was so close to the end of term. School expressed concerns about his safety in the vicinity of his home. In ‘Return Home Interviews’ (RHI) Child A was unforthcoming with information about where he was when he was missing and was annoyed that his mother reported him to the police. Mother began to notice new clothes and possessions that she had not purchased. 6.19 In line with current practice Child A was presented at GRASP as a vulnerable young person and was discussed there a number of times. He was linked with 7 older associates known to be involved in gangs and criminal activity, notably drugs. Greenwich CSC continued their assessment. St. Giles1 became involved with the family and the two agencies worked together undertaking joint risk and safety planning. Strategy meetings were held to try and make a safety plan for Child A and a referral to the National Referral Mechanism (NRM) was made. 6.20 At the end of July workers from St. Giles made a visit to the family home. Child A was guarded and would not discuss his activities or affiliations. He received a call on a ‘burner’ phone and became increasingly anxious and in a hurry to leave the house. He presented as aggressive, anxious and determined to leave – eventually fleeing via the back wall. The following morning, the worker saw Mother and asked if he returned last night and she said that he had not. She had not yet reported him missing. 6.21 Agencies grew increasingly concerned for his safety – A Child Abduction Warning Notice (CAWN) was being considered in relation to two older associates. The possibility of an urgent housing move was discussed with Bromley Housing and they confirmed that if the family were deemed to be high risk then a move could be facilitated. Visits continued to the family and Child A was at times less guarded, speaking of his knowledge of selling drugs and admitted he had sold cannabis. He spoke of the debt drug dealers may accrue if drugs were seized from them. At the same time he expressed an interest in engaging with services and getting involved in activities, such as Go karting. Due to his learning needs he struggled to gauge the risks associated with his behaviour and presented as naive. 6.22 In mid August police officers saw Child A in the company of a known drug supplier. Police believed he was being forced to hold drugs, and when they reassured him that they were concerned for his welfare, he spat out 6 bags of class A drugs. He was returned to his mother and she was advised he would need to return for a caution+32 interview. In his RHI he stated he might be in debt due to the loss of drugs. 6.23 At the beginning of September 2019, the events that led to this review unfolded and two of his associates murdered Child A in an East London borough. 7 Findings Agencies understanding and response to Child A’s gang association 1 St. Giles is a national organisation whose work involves direct, intensive help for young people and those around them. They work with those at risk, through prevention and awareness raising and offer support to parents and professionals working with young people. 2 Voluntary attendance at a police station with 3 stipulations of; not under arrest, free to leave at any time and entitled to legal advice 8 7.1 There were very early indications that Child A was involved in criminal exploitation as whilst the family were living in Bromley an assessment was completed in relation to Child A being detained by the police after being found in a flat with a blade, condoms and lubricant. Child A was 12 at this time and was said to be crying uncontrollably when the police detained him. He was linked to youths much older than him and there were suspicions that he was being groomed to criminal exploitation by selling drugs. There was a swift response and the correct threshold was applied, with the decision that an assessment needed to be conducted with the family. The assessment appropriately included direct work with Child A and some engagement with the rest of his family. There was little challenge to his mother about her initial response when she would not collect him from the police station. 7.2 Consultations were had with other agencies and a meeting held to try and understand the risks but this did not include any kind of mapping exercise to identify peer relationships for Child A. More importantly, it did not examine the impact of his young age, his learning needs and his increased vulnerability due to these factors. Association with other (often older) young people is believed to be a significant factor that increases the chance of involvement in criminal exploitation. Gangs also exploit specific vulnerabilities such as learning needs and these were not sufficiently taken into account. 7.3 Bromley CSC assessed Mother had engaged positively with the assessment and had shown commitment to ensure child A’s safety in the community. At the conclusion of the assessment the school had agreed to identify a mentor to undertake some ‘Keep Safe’ work with child A and the family were allocated Early Help (EH) services. The family received EH services in Bromley throughout 2017, which continued through to the end of 2018 when the family moved. An EH plan was still in place when Child A was assaulted at the end of that year. 7.4 This early episode in Child A’s life is vital to understanding Child A’s vulnerabilities to exploitation and although work continued with the family, this was not focused on Child A and the risks of exploitation. Having completed the assessment, the worker felt that as she got to know the family this was less of an issue. It appeared that Child A had started to make better choices in his friendship group and his older sibling’s behaviour seemed to become the focus of the worker’s attention. Some individual work was completed with Child A but there was no Team around the Child (TAC) until the work had been in progress for six months. Given that Child A was displaying fear and possibly trauma at this stage, a stronger multi agency approach would have been beneficial. This may have elicited a more targeted response to the risk of exploitation in the plan. 7.5 When Child A was assaulted near to school at the end of 2018, this was not responded to robustly by agencies. The hospital ‘information sharing form’ was not a formal referral and it lacked detail regarding the incident. Croydon CSC did 9 not take any action. The rationale for the decision was not recorded but workers did not show sufficient curiosity regarding the incident or assess risks in relation to his current circumstances. This was a serious attack and as such information gathering and multi agency enquiries should have taken place, especially in view of the fact that the Police were involved. There appeared to be little or no communication between CSC and the police about this incident. It is likely that Croydon CSC did not receive this as a formal referral as the hospital staff had sent it for information sharing purposes rather than flagging the safeguarding issue. 7.6 A formal referral should have been made and multi-agency enquiries, including contact with the family would have clarified the circumstances of the assault. This would have led to more knowledge about the concerns about links to gangs and Child A’s vulnerabilities associated with this. Ultimately it would have allowed them to assess the risk to Child A from others in his vicinity. In effect, there was no multi agency response to this incident. 7.7 Croydon CSC were unaware of previous involvement and the concerns about exploitation from Bromley CSC or about his learning needs. They would also have been unaware that at the time of the incident the family were receiving early intervention services via Bromley. This is likely to have also led to earlier link up with the Gangs Prevention Team. Although the Gangs Prevention Team attempted to make contact with the family, after 3 unsuccessful attempts in early 2019 they closed the case without making contact. There is no evidence that this team liaised with other agencies such as school to try and work with the family in a different way and there was a missed opportunity to tap into the work already taking place with the family. 7.8 In the summer of 2019, more concerns were raised in relation to Child A’s association with gangs and more is said about the pace in which they escalated in the next section. The concerns that built over July and August of 2019 were appropriately referred to CSC and allocated for assessment under s17 of the Children Act 1989. On the information known at the time, this was a good response. The allocated social worker responded to tasks swiftly, liaised with the family and professionals and additional resources such as St. Giles were put in place. There was good joint work and liaison between workers from St. Giles and the social worker and they carried out at least one joint visit. Child A was also referred to GRASP and was discussed there a number of times. Agencies response to the increasing risks and safety planning for Child A and his family 7.9 Professionals became aware of increased and escalating risks in July and August of 2019. As stated in the previous section many actions were put in place to try and address the risks to try and reduce them. Child A was missing on several occasions and for lengthy periods. He was often found in the company of other 10 (older) young people affiliated with gangs and drug dealing. Good practice would dictate that resources should not wait to start until the conclusion of an assessment and in this case practitioners and managers demonstrated that help was available to Child A immediately. It is however necessary to look at, (given Child A’s various needs and vulnerabilities) whether the resources allocated and responses made at that time were sufficient to safeguard him. 7.10 There was good communication between agencies at this time. Practitioners were working towards reducing the risks to him and they had a good sense of the fact that a move out of the area would be beneficial. Child A’s mother was also keen to move out of Greenwich back to Bromley. To that end the SW had some liaison with housing in Bromley to try and facilitate a move. This was not however successful in this timeframe and the family’s housing move was not treated as an emergency. This may have been due to Bromley Housing not attending the multi agency strategy meetings, so the gravity of the situation was not fully evident to them. As part of their written submission for this review, Bromley Housing have recognised that they need to attend meetings to be informed of the situation and advise on the course of action from a housing perspective. Similarly, it may have been prudent for CSC to escalate their lack of effective collaboration in the safeguarding plan. 7.11 Some agencies suggested that Child A should be accommodated by Greenwich and removed from the area. What we know from research however is that despite the benefit of physical separation from a contextual situation, this can also introduce other risk factors by isolating young people from their family, thereby making them more exposed to the influence of others. This would likely have been the case for Child A and given his additional vulnerabilities, this action would have been a last resort. It seems improbable that the family, including Child A, would have agreed to this at the time although Mother shared as part of this review that she regrets not moving out of London. A more likely scenario would have been a move to (or at least some respite with) other family members, especially as risks were escalating in August of 2019. The objectives and the plans coming out of the multi agency meetings was to try to build resilience within his immediate family and support Mother to better manage the situation. It is not clear how other agencies understood this rationale but it was not formally challenged, indicating that it was at least accepted. 7.12 Two strategy meetings were held - CSC, the police, Child A’s school (he was not attending but remained on role) and staff from St Giles attended these. These were not strategy meetings conducted to determine whether s47 enquiries should be conducted. Whilst it was good practice to hold multi agency meetings, there is a question about the increasing risks to Child A in the latter part of July into August and whether these should have led to s47 enquiries. The school expressed a view that an Initial Child Protection Conference (ICPC) should be held. The reason this was not pursued was because Mother was seen to be co-operating and receptive 11 to the help being given. 7.13 In mid August during a home visit, Child A admitted selling cannabis. Two days later he was arrested by the police with class A drugs in his mouth which he was persuaded to spit out. This was the strongest indication that Child A was under obligation to sell drugs. The police officers that found him and returned him to his home were worried that he was being coerced and were concerned for his welfare. He mentioned later that he thought he might now have a ‘lien’ (drug bondage debt), as the drugs were lost to the police. 7.14 There was no multi agency safeguarding response to this incident despite it being very compelling evidence that he was at risk from, and being coerced by, others. A multi agency strategy meeting to consider s47 enquiries would have been one approach in this instance to consider Child A’s immediate safety (especially since a referral the NRM had been made). This would have been an opportunity to escalate the concerns, consider the threat he was under from others (especially now he believed he was in debt) and reflect on the capacity of the community-based (including his family) resources to tackle these. This would have been in line with the expectations laid down in Greenwich Partnership’s Threshold document3. 7.15 In cases relating to contextual risk there is always a debate to be had about whether the more traditional child protection processes are effective for risk outside of the home. The multi agency nature of the intervention is, however key. This work did start to take shape in August 2019. For example Mother provided some details of Child A’s more mature associates who could influence him to return home and the police were considering a CAWN (though these did not come into fruition) in relation to some of the young people Child A had been found with. The social worker had also begun to explore family members who could be protective towards him. Sadly, there was little time for these to be developed. 7.16 The panel noted that with children in these circumstances, there is no ‘one size fits all’ approach and that decisions are made on an individual basis. In keeping with this, the National Child Practice Safeguarding Review Panel4 made a recommendation in 2020 for the response to children at risk of contextual safeguarding (i.e. the merits or demerits of formal child protection responses vs. less formal approaches) in Working Together 2018 to be reviewed. 5 In the same review, the National Panel also refer to ‘critical moments’ in a young person’s life, 3 https://www.greenwichsafeguardingchildren.org.uk/wp-content/uploads/2019/10/GSCP-Thresholds-for-website.pdf 4 The National Child Practice Safeguarding Review Panel is a panel of highly experienced and professional experts who form an independent panel which commission’s reviews of serious child safeguarding cases. 5 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/870035/Safeguarding_children_at_risk_from_criminal_exploitation_review.pdf p36 12 generally thought to include (amongst others) exclusion from school, physical injury and being arrested. All three of these things happened to Child A in the time period covered by this review and it is important that agencies recognise these and respond accordingly. 7.17 The referral to GRASP meant that actions were put in place. For example St Giles were allocated to work alongside the social worker. Although GRASP had good knowledge of the other young people (also of concern) Child A was associating with, there was no official mapping. Disruption techniques were discussed such as issuing CAWNs to older associates but these did not materialise in the timeframe. 7.18 As part of the plan Greenwich CSC made a referral to the National Referral Mechanism (NRM). They received a swift response a few days later confirming that Child A met the criteria for being a victim of modern slavery. This had no impact on the services provided by agencies. The review has underlined agencies’ lack of understanding and knowledge about this process and the limitations in its application to be of benefit when dealing with families in this kind of crisis. A recommendation is made to try and address this gap in knowledge. Agencies understanding of the threshold about high risk missing young people and their response? 7.19 Mother appeared to have some resistance to reporting Child A missing when he failed to return home. On occasions he was missing for several days and when he returned he disputed that he was missing and was not willing to share information about where he had been. On occasions when she did report him missing, she felt that she was not always able to convey the seriousness of the situation to the police and that he was not treated as high risk. 7.20 The review has highlighted that there are some discrepancies in the way that risk is perceived when a young person is missing, particularly when this is a frequent occurrence. The police assess high risk as immediate risk to life whereas other agencies would be concerned at a much lower threshold than this. High risk missing young people for the local authority may depend on a variety of factors as vulnerabilities and risk of harm contribute to why a young person may be considered high risk. 7.21 That said in this case there were close working relationships between agencies including both the local missing Police and Central Missing Co-ordinator. The Central missing co-ordinator attended strategy meetings and there was a partnership approach to the Police trigger plan for Child A. How were Child A’s learning needs and associated vulnerabilities assessed in light of his gang affiliation? 13 7.22 The impact of his learning needs was well documented by agencies. He had an EHCP (finalised in 2018) that detailed both his communication issues and his specific difficulties with reading and writing. Practitioners were also aware of his need to please others, for him to fit in with his peers and belong to a group. This is a familiar scenario experienced by the majority of teenagers as they go through adolescence. For Child A this made him particularly vulnerable and more susceptible to exploitation as he did not recognise risky situations. Early on in the timeline of the review, Bromley CSC acknowledged that ‘There was missed opportunity to consider further how Child’s A learning needs might impact on likelihood of further exploitation’ and this work was not carried out with him in the subsequent Early Help service provided by Bromley through 2017 and 2018. 7.23 Although criminal exploitation was the main reason for the referral to Early Help services in Bromley, the focus of this for Child A slipped off the agenda very soon. At the end of 2018 (when the family had moved to Croydon) there was a lost opportunity to work with Child A and his family in regards to his possible gang affiliation. Coupled with the fact that he was out of school at this time for at least six months, this left him vulnerable in the community and inevitably would have meant that he was even further behind his peers academically. In turn this led to difficulties in him being integrated back into a mainstream setting. Although on line alternatives were suggested and tried, Child A did not engage with them. Given his level of learning need he was unlikely to have had the motivation or capability to access this kind of education. 7.24 The assessment and trigger plans completed by agencies in Greenwich in 2019 contain information about his learning needs and state clearly that this factor increases his vulnerability. This demonstrates good identification of the increased risk but it is difficult to see specific interventions aimed at his needs arising from his learning disability manifest themselves in agency’s plans. There was perhaps a lack of creativity in proposed recommendations to engage Child A, given the limited impact discussions and conversations in terms of direct work had already had. A referral to Charlton Athletic Community Trust (CACT) had been made but had not yet started. 7.25 The assessment also rightly had started to identify family members who could help and act as protective factors for Child A, particularly his paternal aunt with whom he was said to be very close. There may have been an opportunity to instigate a family solution earlier in the piece e.g. there was a suggestion that his aunt could offer some respite and a Family Group Conference (FGC) was a recommendation from the assessment. Sadly these things were not in place at the time of his death as there was too little time. 14 How agencies assessed other aspects of Child A’s lived experience and captured his voice e.g. home life, school, significant relationships, extended family and community 7.26 From information gathered during this process from those who knew and worked with Child A, it is clear that he was an extremely likeable and engaging young person. He was interested in clothes and had aspirations to work in the fashion industry and to have his own label. Although he could be challenging, he was brought up in a loving family and his mother did her utmost to try and address the difficulties he encountered. Child A was however extremely vulnerable and his learning needs made him susceptible to the negative influence of others. The many moves and the stress associated with these undoubtedly took their toll on the family and Child A would have been affected by these. 7.27 Various attempts were made by practitioners to engage Child A in direct work and at times he was happy to be involved in what was being offered. At other times however, he was withdrawn and could be less cordial. The social worker and workers from St. Giles took time to spend with him to try and elicit his wishes and feelings but struggled to engage him fully. He became harder to engage in the summer of 2019, no doubt by this time he was deeply involved in the drug world and the short term rewards in terms of money and possessions were difficult for him to resist. He was guarded about his friends and was reluctant to say where he was when he was missing. As stated, workers were well aware of his learning needs and he was encouraged to be open and honest in an attempt to reduce the risks he faced when he was outside the influence of his family. To this end they did as much as they could to ensure that his voice was heard. 7.28 Much has been covered in other sections but the assessment of him and his family undertaken in Greenwich elicited as much information as possible. It took account of his thoughts, aspirations and struggles and those that he was not able to articulate are included in the assessment by describing his body language to indicate his discomfort at times. It would perhaps have benefited from more analysis about the longevity of this problem, drawing on the previous incidents in 2016 and 2018. This would have demonstrated in the assessment to Mother and Child A how much a way of life this was for him and how entrenched it had become. 7.29 The assessments undertaken do speak about Child A and his family and to a certain extent, his community. They do not however analyse the impact of structural inequality and racism he and his family would have encountered up to this point in their lives. Research tells us that black boys in particular, make up the overwhelming majority of young people who are exploited through being recruited to sell drugs. Two very recent studies confirm this notion the studies linked the fact that black children and their families are far more likely than their white counterparts to be affected by poverty, their young people are more likely to be 15 excluded from school and are more likely to be vulnerable to having a negative view of themselves through the effects of racism6,7. When developing services to help young people affected by criminal exploitation it is important to note that the vast majority of these are boys and young men. The challenge of offering services to this group is one being faced by a number of agencies. 7.30 Work to try and establish a safe network in Child A’s own community was due to take place but unfortunately never materialised due to the short time between the completion of the assessment and his death. Similarly, more work was due to take place about his extended family through a Family Group Conference. The effectiveness of communication between boroughs 7.31 Within the review period there were three boroughs (Bromley, Croydon and Greenwich) involved with the family due to their many moves. There were limited opportunities for cross borough communication as much of the time services that were offered were not in place at the time of the moves. There was good cross borough communication at the time of the Greenwich CSC assessment and practitioners were aware of previous involvements. 7.32 Where communication fell short of expectations was in relation to his schooling in the first half of 2019. After the incident at the end of 2018, Child A did not return to school in Greenwich. As he was living in Croydon, his school liaised extensively with Education Services in Croydon to try and expedite an appropriate school place for him. Although an on line provision was found and tried in the meantime, the liaison between the two boroughs was protracted. From a child centred perspective this effectively meant that Child A was out of school until he was enrolled in an AP in June 2019. Given his vulnerabilities and how he benefitted from school as a protective factor, the delay was unacceptable. The review has not been successful in trying to uncover why the allocation of a school place in Croydon was so delayed. It would appear that records were not sufficiently kept and as a result a recommendation is made for Croydon to review their practice and record keeping in relation to requests for school placements from other boroughs. 7.33 When the family moved again in May 2019 (this time to Greenwich) his school went to great lengths to introduce the two education departments so that the progress that had been made was maintained and the momentum gained was not lost. In this time it was noted that three schools had been approached but declined to accept him. Again the reasons for this are not clear but it is another indication that his needs as a vulnerable child were not prioritised. 6https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/870035/Safeguarding_children_at_risk_from_criminal_exploitation_review.pdf 7https://www.london.gov.uk/sites/default/files/rescue_and_response_county_lines_project_strategic_assessment_2019.pdf 16 7.34 During the course of this review it has become apparent that Bromley Housing were not aware that Child A was no longer attending school in Greenwich. The temporary accommodation that was sought was to enable Child A’s easier access to his school. The school however had concerns about him being in the Greenwich area (either schooling or living) due to the incident where he was attacked in late 2018. School had expressed their concern to SEND services in Greenwich but by this time the move had taken place. This demonstrates the importance of Housing’s communication with agencies, when dealing with vulnerable families. 8 Family Contribution Mother’s views on Child A’s education 8.1 Mother stated that she did not believe Child A’s school understood him and his vulnerabilities. She spoke about his additional needs and how he was a visual learner and not always able to meet his potential. She stated that following his exclusion from school there was no plan of support for him, which led to long periods out of education. Mother did not feel that it was safe for Child A to travel the distance to school after he had been attacked. She had wanted to be able to try and keep him safe by taking him to and from school but this was not possible. It was after this that he stopped attending. 8.2 Although the school directed Child A to some home learning online, he was not confident in learning independently, so she felt this was not suitable for someone with his additional needs. Mother tried to help him with this learning, but she also found it challenging. She would have preferred a more collaborative approach in trying to meet Child A’s individual needs. Child A went from a mainstream school with a high level of support to learning from home independently and this was not suitable. He was not motivated to learn online especially when he struggled to understand the work, and this is why he needed a programme tailored to his individual needs. 8.3 Mother said that Child A was out of school for a long period of time and moving to different boroughs exacerbated this. She stated when Child A resided in Croydon they attended a meeting as he was out of education. Croydon informed them that they would arrange for private tutoring at the home which did not happen. Communication between Education and Housing was not good. 8.4 Mother wanted to inform the review that school did explore other schools with her and Child A. At the time she was interested in him attending other schools especially in the Bromley area, however, they did not feel they could meet his needs. Mother thought Child A felt rejected by this, further impacting upon his confidence and self-worth. Child A’s lack of school place for so long should have been escalated to someone senior in Croydon and this may have moved things 17 along. Mother feels that they were ‘sidelined’, and this was unacceptable as Child A was coming up to his GCSE year and she wanted him to do well. 8.5 Mother contested that the right place for her son was a ‘unit’. She felt Child A was easily swayed and vulnerable and therefore the AP did not meet his needs. Mother would have much preferred that Child A was placed back into a mainstream school as she was not keen on what she saw as negative influences. She believes that Child A met some associates at the AP who were not a good role models and led him into being exploited. For that reason, she would have fought hard for him not to attend a ‘unit’ after the summer holidays. She would have much preferred for him to be placed in a mainstream school and to repeat year 9 if it was felt that was necessary for him academically. 8.6 She did however appreciate that the staff at the AP that Child A attended in the summer of 2019 were kind and tried to do their best for him. She had not wanted him to attend this unit for the reasons already stated but she decided to send him as there was no other option at that point. Being out of school altogether was worse for him. 8.7 Mother questioned what schools do to keep children safe when they leave the school premises and whether more could be done. She is aware of schools that offer interventions such as going to find vulnerable pupils in particular ‘hot spots’ and diverting them back home again. She also noted that fast food outlets were attractive to young people but felt that sometimes these could be risky places for them to congregate all together and there should be a system in place to discourage this. Mother’s views on Housing Services 8.8 Mother discussed the risk to the family and questioned if alternative accommodation could have been found to ensure their safety. She further added she remembered a discussion with the social worker around leaving Greenwich. She said that if she could go back in time, she would have left London and that she regrets that she did not do this. 8.9 Mother further felt that Housing was a major issue for them and they did not listen or take note of their individual needs. She felt as though she was left to deal with her housing issues alone and she was often not able to contact the right people. She found this tiring, difficult and challenging. The lack of coordinated services for the family which included Housing was frustrating for her. Police/Children’s Services 18 8.10 Mother said that at the trial she was informed of the assailants’ previous criminal backgrounds which included other aggressive crimes. One of the boys was on tag at the time and was not allowed into Greenwich. Mother questioned was this enough and did CS do enough for those boys when they were growing up. She questioned if the Police and Youth Offending should have monitored Child A’s attacker more closely given the risks he posed. She felt that he had too much freedom to manipulate the system which ultimately led him to be in a position to commit other crimes. 8.11 Mother spoke positively about the help she had received in Bromley in 2017 and was glad that this work had passed to the younger child’s primary school. She said that the whole family had been helped by this process and this had been a coordinated approach which had benefitted them all. The social worker in Greenwich along with the workers from St Giles were also making good progress in getting services to help them and she appreciated this. 9 Lessons Identified 9.1 The overarching multi agency response to contextual safeguarding in Greenwich is generally well developed as noted in the Joint Targeted Area Inspection (JTAI) in 2018.8 There are a number of services to draw on both at a strategic and local level. The following paragraphs detail the main learning from this case which the panel and practitioners involved also thought applied to other children, young people and their families they worked with. 9.2 This review mirrors many other national and local reviews, studies and SCRs that show the disproportionality of black boys of African Caribbean heritage who are more likely to be susceptible to risks of criminal exploitation. National research data confirms these local findings of over representation, which is also replicated in exclusions from school, increased likelihood of being victims of serious crime and being over represented in the criminal justice system. This structural inequality in terms of gender and ethnicity needs to be addressed. 9.3 Housing services were not engaged in multi agency discussions about how agencies were seeking to reduce the risks to this child. As an agency therefore, they were unable to contribute to the plan. This is in part due to Bromley being responsible for placing a family in another borough (or multiple boroughs) as in this case. Discussions at GRASP did not include the family’s location (which had been raised as problematic) and whether a move could be expedited quickly. Colleagues from Greenwich Housing were not invited to try and explore this and support GRASP in helping to convey the seriousness of the situation to their 8 https://www.justiceinspectorates.gov.uk/hmiprobation/inspections/joint-targeted-area-inspection-of-the-multi-agency-response-to-exploitation-gangs-and-missing-children-in-greenwich/ 19 counterparts in Bromley. It should be acknowledged that although these are considerations for learning and future cases, the actual risk in this case was due to a historical incident that no one could have practically foreseen. 9.4 It is a familiar theme from other reviews involving children and their families that frequent moves between boroughs hampers and delays services to them. The review has also noted difficulties for Child A and his family in the quality of the housing provided, their lack of choice in where they were housed and the disruption caused by frequent moves. Mother was very wary of the locations in which she was housed but ultimately had little control over it. As a parent she could exert little influence over this despite the fact that it increased the risks to her and her family. 9.5 Connected to the above, Child A’s schooling was problematic throughout much of this period some of which was exacerbated by the many house moves the family experienced. Being out of school for any reason is a well rehearsed area of vulnerability for those at risk of criminal exploitation. Education services in Croydon failed to recognise the vulnerable position Child A found himself in and did not deal with the damage the delay was causing. In addition, some of his vulnerabilities were increased by the distance he travelled to school (due to the many moves) as well as the substantial periods of time he spent without a school place. His vulnerabilities to criminal exploitation were not taken into account by Croydon education services and he remained exposed to those who would seek to exploit him. 9.6 Children and young people are much more likely to have a positive outcome if their difficulties are recognised at an early stage and they receive help. The trauma and fear caused by criminal exploitation needs to tackled at the outset of the involvement of agencies. The importance of early interventions that are understood and owned by all agencies are crucial. Early signs of criminal exploitation were not fully explored with Child A in 2018 and the focus of the intervention aimed at addressing this became diluted with other family issues. 9.7 The initial response to the concerns about Child A were responded to swiftly and appropriately by Greenwich CSC and members of the Partnership. What is more challenging is the subsequent escalation of events and how these were responded to from a multi agency perspective. GSCP’s threshold document would suggest that the incident in August 2019 whereby Child A was holding drugs in his mouth was an incident of ‘significant harm’ and therefore should have been responded to by way of a multi agency strategy meeting to consider his immediate safety. The use of the statutory framework in these circumstances needs to be clear for practitioners and managers. 9.8 The review has highlighted a national issue regarding the NRM which although frequently used in Greenwich appeared to have no impact on this case. There 20 was confusion and inconsistency about the purpose of such a referral and the impact of what should then be done in terms of good practice. This is a worrying scenario considering the information that came back from them was that they considered that Child A was a victim of modern day slavery. At the time of the incident, Greenwich had no practice guidance in relation to this. This has now been rectified but it is in its infancy and the impact will need to be measured. 10 Recommendations A note about these recommendations The following recommendations should be read in conjunction with individual agency action plans. Although some of them are specific to certain agencies as learning from this review, it should be noted that the learning (and therefore these recommendations) are relevant across the Partnership. 10.1 Bromley Safeguarding Children Partnership to ensure that practitioners in their Early Help services are knowledgeable and are equipped to work with children and families affected by criminal exploitation. 10.2 London Borough of Croydon SEND to conduct its own review as to why Child A’s school placement was delayed. Croydon Safeguarding Children Partnership to oversee the review and assure itself that proper systems and processes are in place when parents request education of their child in the borough. 10.3 Where issues of contextual safeguarding is an issue Greenwich, Bromley and Croydon Safeguarding Children Partnerships should ensure that their staff are equipped to identify, assess and make robust plans for those children whose learning disability increases their susceptibility to criminal exploitation. 10.4 Greenwich Safeguarding Children Partnership should contribute to the national debate about arrangements for the use of statutory frameworks (i.e. Child Protection Enquiries) in cases where contextual safeguarding is an issue. The result of these discussions should inform the Partnership’s approach to enhance the consistency and quality of practice in this area. 10.5 Greenwich, Bromley and Croydon Safeguarding Children Partnerships should ensure that their guidance, best practice and training around multi agency safeguarding discussion and meetings involves Housing services. 10.6 In line with the above, Housing Services in all three boroughs should ensure that they respond to invitations to multi agency meetings and that their policies and procedures reflect their responsibilities to attend these. 10.7 There is an opportunity for GRASP to enhance their role in looking at the context 21 of a family’s location e.g. GRASP meetings should always consider the location of any family and consider what action to take with Housing colleagues if a move is deemed necessary? . 10.8 As a result of learning from this review and similar multi agency reviews where a family’s housing situation has been noted to be challenging, Greenwich Safeguarding Children Partnership should raise this with the National Panel. This is with particular regard to Housing’s role in statutory child protection processes and the effectiveness of notifications to boroughs when families move. 10.9 Greenwich, Bromley and Croydon Safeguarding Children Partnerships should consider their response to children and young people who are deemed victims of modern slavery via the National Referral Mechanism. They should provide guidance to ensure that all staff are aware of this mechanism and ensure that there is a process to assess risk adequately. 10.10 Greenwich Safeguarding Children Partnership to seek assurance that staff employed in Emergency Departments of Lewisham and Greenwich NHS Trust can identify and are equipped to deal with, issues of contextual safeguarding. 10.11 Greenwich, Bromley and Croydon Children Partnerships design a programme of learning to ensure practitioners are skilled in undertaking assessments and carrying out work with children and families from black and ethnic minority communities. This is specifically in relation to practitioners competently assessing the impact of the additional risks black children (particularly black boys) face in the context of contextual safeguarding. Jane Doherty Independent Social Work Consultant October 2020 |
NC52353 | Assault on a 7-months-old child by their father resulting in life threatening injuries. Learning includes: understand the impact of trauma and become more trauma-informed in practice; understand the way in which different faith communities perceive domestic abuse and the difficulty in speaking openly; the importance of professional curiosity and challenge; the importance of clear and factual record keeping and interagency cooperation; create a safe space for multi-agency reflection and supervision; the importance of cultural awareness and challenging assumptions recognising that different families from the same cultural or religious group may have different views and practices. Recommendations include: ensure effective implementation of information sharing, 'Think family' approach, using evidence-based tools, trauma informed practice, resolution and escalation policy; work with community groups to combat domestic violence; host training on effective safeguarding of Black, Asian and minoritised ethnic, cultural and faith groups.
| Title: Child safeguarding practice review: Chid YS. LSCB: Sandwell Children’s Safeguarding Partnership and Dudley Safeguarding People Partnership Author: Sue Walters Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Child Safeguarding Practice Review Child YS Independent Reviewer: Sue Walters 2 Contents 1 1. Introduction to the review Page 3 2. Process Page 3 3. Brief overview Page 4 4. Analysis and identification of learning Page 5 5. Summary and recommendations Page 18 This report is strictly confidential. It must not be shared without the agreement of Sandwell Children’s Safeguarding Partnership (SCSP) and Dudley Safeguarding People Partnership (DSPP). The disclosure of information (beyond that which is agreed) will be considered as a breach of the confidentiality of the children and agencies involved. 3 Introduction 1. This review considers systems and practice between partner agencies in the Sandwell and Dudley areas. The primary purpose of this review is to learn lessons and to use the learning to improve and sustain change. 2. It is important to note that prior to the incident, this family were not known to Children’s Social Care services in Sandwell. Therefore, references to specific learning for Children’s Services, and additionally schools, are pertinent for services in Dudley as this is where the family resided. However, agencies during this review agreed that some of the learning was applicable for both areas and agreed joint recommendations. 3. The family only became known to Sandwell Children’s Trust following the serious attack on YS and took appropriate actions to assess the situation and safeguard both YS and twin sibling. Sandwell Children’s Trust are the providers of Children’s Social Care services in Sandwell. 4. The learning review takes into account the potential for hindsight bias. Hindsight, as in actions that should have been taken in the time leading up to an incident, can seem obvious because all the facts become clear after the event. This tends towards a focus upon blaming staff and professionals closest in time to the incident. 5. An Appreciative Inquiry model is used in order to understand what has happened, within a framework that is participative, collaborative, embraces professional curiosity and challenge, and focuses on what works well and what is valued. 6. The learning identified is in relation to: • The importance of being trauma aware and trauma informed • Impact of domestic abuse • Professional curiosity • Creating a safe space for multi-agency reflection • Cross-border information sharing processes • Cultural awareness and assumptions Process 7. The Child Safeguarding Practice Review (CSPR) was conducted in accordance with the requirements set out in: 4 • The Children Act 20041 (as amended by the Children and Social Work Act 20172) • Working Together 20183 (amended 2020) • Sandwell Children’s Safeguarding Policy and Procedures • West Midlands Safeguarding Procedures 8. In respect of the information considered, personal family details will only be disclosed where it is essential to the learning established during the review. 9. An independent lead reviewer4 was commissioned, facilitated learning events5 and has spoken with the family and produced this report. 10. This review used a ‘systems approach’ via an appreciative enquiry model. Key themes were identified during the Rapid Review and these were then explored within two learning events. The event focussed upon identifying the emerging learning and translating this into system learning and practice improvement. Brief overview 11. The review will refer to the following persons: - YS is the subject child - Twin sibling of subject child - Mother of the subject child, twin siblings and 3 half siblings - Father of the subject child and twin sibling - 3 half siblings of the subject child born of the same mother - Mother’s ex-partner and father of the 3 half siblings 12. Child YS was seven months old when police were called to the home in Sandwell and witnessed Child YS being assaulted by father. The mother had also suffered serious injuries in the same attack and required hospitalisation. Child YS was in a critical condition with life threatening injuries. 13. Child YS is a twin but the sibling was not in the home at the time of the incident and was in the care of paternal grandparents. Father had obtained the property in Sandwell where the incident took place one month prior to the incident. Agencies in Dudley and Sandwell did not know this until after the serious incident. It is thought that mother and Child YS were dividing their time between maternal grandparents’ house in Dudley and father’s new address in Sandwell. 14. Up until the incident it was assumed that mother, Child YS and twin were living with maternal grandparents, maternal aunts and cousins. There had been no change of 1 http://www.legislation.gov.uk/ukpga/2004/31/contents 2 www.legislation.gov.uk/ukpga/2017/16/contents/enacted 3 https://www.gov.uk/government/publications/working-together-to-safeguard-children--2 5 address provided by the mother or recorded for Child YS and twin. It is thought that the address was registered in the father’s name. 15. Father had a previous episode of mental ill health in 2015 which featured aggression and paranoia towards his mother and siblings. There had been previous cannabis misuse, possession of a knife and multiple arrests. Father had resided in Sandwell throughout his life. 16. Child YS and twin had three older maternal half siblings who lived with maternal relatives. The maternal half-siblings had previously been on a Child Protection Plan due to domestic abuse perpetrated by their father which discontinued when the relationship ended and their father left the area. The marriage was an arranged Islamic marriage in Pakistan – the domestic abuse started immediately and continued when they returned to England. 17. The maternal half siblings of Child YS continue to display emotional and behavioural concerns which have resulted in safeguarding interventions historically in Dudley. Analysis and identification of learning 18. The learning in this review includes the three maternal half siblings as well as Child YS and twin. It became apparent during the learning events that there was concern about the welfare of half siblings and their lived experience. 19. In addition, the importance of adopting a trauma informed approach is key learning for both partnerships, as is understanding the impact and consequences of trauma. 20. The learning is informed by a conversation with mother who disclosed that she had experienced domestic abuse by the father of Child YS – until the assault of both Child YS and mother, no previous domestic abuse incidents between mother and father were known. Impact of domestic abuse 21. The mother experienced domestic abuse in her first marriage which resulted in the three half siblings being made the subjects of Child Protection Plans in Dudley, which terminated in 2011 when the domestic abuse and the relationship ended. Since this time, the three half siblings have displayed various behavioural issues, some of which have led to exclusions from school and referrals to CAMHS. Concerns were last shared with Dudley Children’s Services in 2016 via a referral when one half sibling verbalised concerns and there was a potential lack of emotional support from parents. This was explored via an assessment which led to an offer of support from Early Help. 22. Health services in Dudley, in contact with mother during pregnancy and after the birth of the twins, did not document evidence of domestic abuse in this relationship. Routine 6 inquiry questions for domestic abuse were asked by both the midwives and health visitor and the mother answered negatively. 23. The main details regarding father of Child YS were held by his GP in Sandwell but his details were given as the emergency contact on maternity records in Dudley, and not named as the father. Father attended induction of labour although he was not present at the birth by caesarean section. Mother referred to herself as a single parent at the primary birth visit with the health visitor. 24. There were indicators that there were some difficulties in the relationship between Child YS’ parents as evidenced by the father’s comments in a consultation with his GP. Father requested help for anxiety, stating that he had married, and his wife was three months’ pregnant with twins. He informed his GP that there were relationship problems, and his wife was spending more time at her parents’ home. It appears there was no attempt to gain further information regarding pregnant mother in order to share this with other health services. The GP referred him to the IAPT6 service however father did not attend the offered appointment. 25. In addition, the school had been informed that there was tension with paternal grandparents about the relationship between mother and father. 26. Over several years mother had experienced a number of health issues such as gynaecological/urinary problems and long-standing anxiety and depression. There are long-term detrimental impacts of domestic abuse on health. This can include urinary tract infections, gynaecological problems, headaches, anxiety and depression7. 27. When 10 weeks pregnant with the twins, mother visited her GP in Dudley with chronic anxiety. She informed her GP that she was feeling anxious, and the father was not involved with the pregnancy. This information was not shared with the midwife or health visitor. 28. After the birth of Child YS and twin, the mother reported that she spoke about her loss of appetite, sleeping problems and aches and pains with the health visitor and received advice. 29. In conversations with professionals, the mother described her first husband as ‘not nice to them’ and that there had been social care involvement because of his treatment of the children and domestic abuse. At the practitioner events the responses given by the mother to professionals were described as ‘vague’. The disclosure of 6 IAPT Improving access to psychological therapies 7 Cry For Health 2016 7 previous social care involvement did not result in further probing or exploration with Children’s Services. Midwifery records report mother’s longstanding anxiety and previous prescriptions for antidepressants. On at least two occasions the mother reported feelings of anxiety to midwives and was offered the option of a referral to the Perinatal Mental Health service. This history should have resulted in a referral to the Unborn Baby Network in Dudley. Additionally, mother pointed out in her conversation with the author that although she had three older children, a twin pregnancy was a new experience. 30. Mother of Child YS has spoken with the author about experiencing verbal abuse from the twins’ father during her pregnancy. Following the birth, she alleged he would punch and spit at her and she was not allowed to go to the gym and felt trapped. This was allegedly observed by a neighbour as well as the paternal grandparents of Child YS however no reports of concern were submitted by these parties. 31. When mother of Child YS was 6 or 7 months pregnant it is alleged by her that the father was arrested and was taking cannabis. According to police reports he was arrested and convicted at this time for driving while unfit. There is no indication that he was asked about family details or children which could have led to information being shared with Dudley Children’s Services had the existence of the twins been disclosed. 32. A complex picture emerges in which no one professional was able to piece together information to enable a conversation with the other about domestic abuse. The mother’s potential underlying trauma due to previous domestic abuse and the reasons for ongoing anxiety are missed. She repeatedly replied no to the routine enquiry domestic abuse questions asked by maternity services in Dudley and did not want to talk about the twins’ father, preferring to say that she was a single parent. This was in spite of the fact that he was named as an emergency contact and attended induction of labour. Information was taken at face value without any professional curiosity. 33. The experience of trauma affects how people approach services. In this case, the mother said that she did not tell the midwife, health visitor or GP about what was happening to her because she was afraid that paternal grandparents would find out. We know from the work of Karen Treisman8 that being trauma informed is about relationships and connection. In a busy clinic setting it is not easy to build trusting relationships and yet this is at the heart of the way health professionals work. 8 Karen Treisman 2018 8 34. There was only one appointment when the mother was not alone. Routine enquiry questions were asked at all appointments when she was alone. Even so, she did not feel able to disclose abuse. Learning • The workforce needs to understand the impact of trauma and be equipped with the knowledge, skills, and behaviours specific to their role in relation to becoming more trauma‐informed in practice. • Routine enquiry is about asking direct questions about domestic abuse and yet it is more than a checklist. Questions need to be asked sensitively yet confidently. Maternity and health visiting services in both areas should review and evaluate the use of routine enquiry, seeking advice from the IDVA service. • Understanding that some health conditions may be linked to the long-term impacts of domestic abuse is important to prompt practitioners to probe and provide opportunities for women to safely disclose. • The mother’s GP Practice is now part of the IRIS9 programme with associated training. • Understanding the way in which different faith communities perceive domestic abuse and the difficulty in speaking openly is important. In this instance, the mother did not think that she could trust anyone in her community and was afraid that the paternal grandparents of Child YS would find out if she sought help. She described them as being unhappy that she had been previously married and had ‘baggage’. • If the midwives had reviewed the GP records for mother and maternal half siblings and connected these with mother’s anxiety, this might have led to a referral to the Unborn Baby Network. Professional Curiosity and Reflection 35. This is a complex family situation and separate pieces of the family jigsaw were held by only a few services. The main agencies in contact with mother and father were health services and schools for maternal half siblings. There was no full picture of family circumstances, and limited information about the father of Child YS and twin. 36. Practitioners at the learning events used words such as ‘secretive’ to describe mother and the extended family. There was a sense that the family may have acted to deflect professional involvement. These are powerful assumptions to be explored in a supervision process. 9 IRIS is a specialist domestic violence and abuse (DVA) training, support and referral programme for General Practices that has been positively evaluated in a randomised controlled trial. 9 37. Sidebotham et al10 have highlighted the importance of supervision in challenging the use of terms such as ‘non-engagement,’ 'hard to reach,’ ‘resistant,’ ‘difficult’ and in this case ‘secretive’. This can lead to assumptions and prevent the practitioner from developing a trauma-based, open approach and exercising respectful uncertainty. It needs further exploration in supervision. 38. School had increasing concerns about the maternal half siblings and stated that they were not aware that the mother was pregnant with Child YS and twin. However, the mother has stated that the teachers were aware of her pregnancy. 39. Schools for the maternal half siblings had started to complete a genogram to try to understand family connections. They had a growing sense of unease but this did not result in a multiagency meeting, a referral to social care or a discussion with family members. 40. Genograms are a visual family mapping tool which allows practitioners to map a family history through at least three generations. Genograms at a basic level show family relationships in terms of parentage and birth order across the generations, similar to a family tree. However, they should go beyond this more superficial information to capture what is known about family functioning and processes as a cultural genogram. 41. In this case a genogram was helpful but we do not know if it focussed on the more in-depth approach described above. Involvement of the family as well as other key agencies would have opened up a wider discussion including mother’s pregnancy. 42. Mother had informed her GP that one of her older children lived with a maternal relative – this did not lead to any further enquiries. 43. Father had a known episode of mental ill health including aggression and paranoia and was in possession of a knife which led to a 24 hour voluntary assessment in a mental health facility. There were also concerns about cannabis misuse. This information was contained in the father’s GP records. 44. Midwifery and health visiting thought that mother was a single parent pregnant with twins and was living with her extended family. Mother had reported to both services that there had been previous social care involvement which should have prompted further exploration and at the very least a conversation with Children’s Services, and possibly a referral to the Unborn Baby Network. 10 The fifth consecutive analysis of serious case reviews in England undertaken by the same research team dating back to reviews from 2003-2005. The study considers a total of 293 SCRs relating to incidents which occurred in the period 1 April 2011-31 March 2014. 10 45. The health visiting primary birth review for the twins had taken place at the maternal grandparents’ home. Again, mother reported that she was a single parent and did not want to give the father’s details, but had given his details as next of kin in the maternity records. 46. There was no curiosity about the family dynamics and an assumption that living in a large extended family environment was normal for Asian families who provided family support. No history was taken about the older children or contact made with the school or school nurse. 47. No agency knew that Child YS and mother were living with father in Sandwell until after the incident, with Child YS appearing to move between two addresses. Mother did not change her or the twins’ addresses on GP or maternity records. 48. The primary birth visit and follow up contact was undertaken before the impact of COVID-19 on service delivery. An assessment was undertaken at the beginning of COVID-19 and the family remained on the universal pathway resulting in less face-to-face contact for families and children. 49. ‘Knowing but not knowing’ 11 relates to having a sense that something is not right, such as the unease in this case which was felt by schools in particular. This should have prompted a wider discussion with partners however it led to an insular internally focussed response which perpetuated the sense of frustration and, potentially, lack of progress for the older children. It also meant that a valuable opportunity was lost to understand the wider family. This should be explored in supervision processes and professional multiagency discussions. The older children referred to witchcraft and voodoo practices and had nightmares. This was not explored, and a possible assumption was made again that this was part of religious or cultural practices. Learning • Nurturing professional curiosity and challenge are fundamental aspects of working together to keep children and young people safe. There is a need to always apply professional curiosity and triangulate information from all sources to form a working hypothesis. • Clarifying and verifying information is important. The family situation was complex and it was hard to understand who provided care for the children and who was a relative. It is important for primary care practitioners to be curious and think about how to engage with other professionals involved with the family. 11 https://ueaeprints.uea.ac.uk/id/eprint/72448/1/Accepted_Manuscript.pdf 11 • Practitioners can use supervision and multiagency meetings to think about their own judgements and observations. This could include thinking about what support the family would need rather than viewing the role of the father in isolation. There were indicators that the father was experiencing anxiety about his relationship and becoming a father of twins. • Professionals need to think about how to make active enquiries about a child’s father, the mother’s relationships and any adults in contact with the child. These details need to be recorded. • In some cultures, there might be additional barriers that prevent mothers from opening up and discussing their partners’ involvement in their children’s lives. Practitioners need to build understanding about the way different communities and cultures perceive domestic abuse and how women view the role of health services. Supervisors should support practitioners to find ways to engage with mothers and build trust. Information sharing 50. Information sharing was not helped in this case by a number of factors. Midwives in Dudley do not have access to a system known as Badgernet12 unlike Sandwell which allows access to real time maternity information. There are plans to ensure that health visitors, school nurses and community midwives will all have access to the GP EMIS system shortly. 51. Health visitors did not have access to school health records. School nurses are commissioned by Shropshire Local Authority and this created a potential barrier in communication. 52. The health visitors did not follow up with social care or link with school nurses, even though they knew that Child YS had older siblings who had previous social care input. 53. Clear and factual record keeping is important. Previous history reported by the mother about the half siblings’ contact with social care was not documented fully in maternity records. There was no subsequent follow up with social care to verify information. 54. Accuracy is vital and inaccurate recording of information is detrimental to outcomes for children and families. 12 Patient Data Management Information Provides a complete platform solution for the collection, storage, and reporting of live perinatal patient data 12 55. Importance of information held in parents’ primary care records cannot be overstated. Often it is the GP who may have the most contact with a family. In this case, it was the father’s GP who had vital history and knowledge of his mental health and well-being and had recent information about his relationship with Child YS’s mother. As there is often no system link between GP practices across boundaries, this relies on the practitioner to be curious and to dig deeper. It highlights the need for professional curiosity and improved multi-agency practice. This might have involved seeking consent from the father for the GP to share information with the health visitor or midwife and looking at ways of offering the family support. Further follow-up by the GP or another practitioner to review the father’s mental health and well-being would have been helpful. 56. Short appointment slots and busy schedules in primary care do not always allow for opportunities to probe, highlighting the need for professional curiosity and multi-agency practice. 57. In June 2020 the Child Safeguarding Practice Review National Panel announced a new national thematic review which will look at non-accidental injury in children under one, which will also explore working with fathers. 58. ‘Hidden Fathers’ is now the subject of a number of CSPRs. It has been identified that males involved with children may be able to offer support and be considered to be protective factors but that they may also pose risk to children. This cannot be verified unless practitioners explore the family dynamics. 59. In this case, the father’s presence in the family was not understood and in spite of questions from the health visitor the mother did not wish to disclose the father’s details. However, he was known to primary care services and did attend at least one of the twins’ immunisation appointments at the GP Surgery with mother. He was also known to his GP. 60. The fact that the mother and father had separate GPs added to the difficulties in gathering and sharing information. This is not uncommon and has been the feature of a number of Rapid Reviews. 61. Participants in the learning event suggested that GP receptionists could consider asking about any change of address as part of routine booking in. Most GP Practices use an electronic booking-in system and therefore this will need careful consideration. Learning • As noted earlier, triangulation is necessary to establish the facts, gather evidence and inform decision making. The origins of information, such as self-reporting, should also be recorded and whether it has been possible to check and confirm the accuracy. Practitioners should be alert to whether assumptions are being made about a family. 13 • Working with the multl-disciplinary team is necessary to enable GPs to share information and concerns. Learning from working during the COVID-19 pandemic means that it should now be easier and more accessible for practitioners to meet together virtually. • Badgernet is used by many maternity services and improves access to real time information. It is used in Walsall, Wolverhampton and Sandwell but not Dudley. • Health visitors need access to EMIS to improve communication. • Schools are a safe and stable environment for children. The school had information that no other agency had access to, such as the half sibling’s references to witchcraft and voodoo. This was not explored. They had also been trusted by the mother’s sibling who disclosed intrafamilial domestic abuse and that there was ‘control’ in the family. Creating space for multiagency reflection 62. Creating space for multiagency reflection is about leading a quality culture in safeguarding at a systems level. At the heart of this is the need to build a system that promotes professional judgement. This means that systems will need to be better at monitoring, learning, and adapting their practice. DSPP and SCSP will need to consider a range of methods for assessing quality and showing evidence of impact in practice. 63. The use of effective supervision is a means of improving decision-making and accountability. Group supervision and reflective discussions can be even more effective in promoting curiosity, peer learning and safe uncertainty. 64. New information was given to the schools, for example when a family member expressed concerns that maternal grandmother of Child YS was controlling. This was a trigger for reflection and review and a time to pause and triangulate information. 65. The schools played a pivotal role in the gathering of information and forming hypotheses about the family dynamics and the two schools involved shared information. They state they were not aware that mother had a new partner or about the twins’ birth. However, in her conversation with the author, mother stated that the teachers were aware and that the maternal half siblings were excited about the arrival of twins. 66. The schools had a sense of growing unease and started to put together a genogram. There was no referral to Children’s Services via a multiagency referral form (MARF), or consideration of a professionals’ meeting. The schools need to reflect on how to escalate concerns via a professionals’ multi-agency meeting. 14 67. Agencies need to have an understanding of thresholds and an awareness of different roles and responsibilities across the DSPP and SCSP. 68. Genograms are a useful tool and health visiting services and Sandwell Children’s Trust are now using them – these need to be widely used across partner agencies. The use of genograms is good practice and needs to be part of a triangulation process to support analysis. It is important to use the most appropriate genogram such as the three generational cultural genograms. 69. Supervision in schools is a requirement and all schools have a designated safeguarding lead (DSL). This was a case where the intervention of a DSL would have been helpful as would reflective supervision. 70. School nursing had been involved previously when the maternal half siblings were on a Child Protection Plan. The health visiting service were aware of the older children but did not explore this with the school nursing service. This should have prompted a professionals’ meeting with the school to share information and look at options for further action. 71. There are a range of methodologies for reviewing cases such as the Problem Tree (or situational analysis), Signs of Safety, and Kolb’s reflective learning cycle13. Learning • Quality assurance, oversight and challenge of practice are interlinked. The Quality Assurance Frameworks should clearly outline vision, values and principles that drive learning. This should ensure that safeguarding work responds to current challenges and most importantly the lived experience of children. • Leading a quality culture14 should embrace the following key areas: o Vision, values, commitment to quality o Policies, procedures and processes o Standards o Equipped workforce o Quality assurance, monitoring, review and learning activities o Approaches to quality improvement and learning cultures 13 Kolb: Kolb D (1984) Experiential Learning: Experience as a source of learning and development. New Jersey: Prentice Hall Signs of Safety: https://www.signsofsafety.net/signs-of-safety/ Problem Tree: http://www.mspguide.org/tool/problem-tree 14 Seminar from Research in Practice in the States of Guernsey Jan 2021 15 o A whole systems approach – high challenge/high support • Building a quality culture in safeguarding is imperative and creates an environment in which multi-agency practice will flourish, including greater professional curiosity and working together. • A case discussion tool that uses effective evidence-based methodologies would support actions and learning for the system that are grounded in the lived experience of the child. This would promote understanding and build a strengths-based and outcome-focussed approach. • We know that supervision is a vital tool to support safe and reflective practice, and multiagency supervision is useful to test out hypotheses and assumptions. It is useful to pull a meeting together when there is a sense of confusion and unease. • Keep the children’s lived experience at the centre of all discussions. This should focus entirely on understanding about the child, their characteristics, who their family is and what we understand that life is like for them. • Agencies should understand each other’s roles and thresholds. • Every agency is responsible for identifying and implementing its own learning in addition to multi-agency learning. Cultural awareness and assumptions 72. Many assumptions were made about family traditions and cultural diversity. It was considered a good thing that the mother was living with extended family and that this was a normal part of Asian or Muslim culture. This became a barrier and stifled further questioning about the children living in the household. 73. The maternal half siblings had reportedly spoken about voodoo and witchcraft and had nightmares. This was not explored with the mother or wider family who were known to be caring for the half siblings. 74. Different maternal family members collected the maternal half siblings from school over the years alongside other children in the family. 75. The Child Protection Plan for the maternal half siblings was discontinued once their parents had separated and domestic abuse reportedly ceased. However, their father continued on occasions to have contact via school and requested to give them presents for Eid. 76. In the learning events, comments were made about mother and her sister being ‘Westernised’ and that this caused tension in the family. This was not just an assumption about family traditions and culture, but also stereotypes of Asian women. 16 77. A picture emerges of a complex family dynamic in which the thread of trauma is evident in both the lived experience of the half siblings and mother. In her conversation with the author, mother said that she did not disclose domestic abuse to professionals because of fear that this would not be kept confidential and would somehow get back to the father or the paternal grandparents. She referred to the incident as an attempted ‘honour killing’15 and spoke of how the paternal grandparents of Child YS were ashamed of her as she been married previously. 78. Creating a safe space for women to disclose is vital and in particular in health settings. There will need to be careful consideration to explore ways of ensuring that women from Asian communities trust that information will not be divulged. 79. Black Country Women’s Aid estimate that South Asian women may take an extra 10 years before they seek help and therefore children often remain in unhealthy households for a prolonged period. “In South Asian communities they fear disclosures of domestic violence arising from the notion of shame, honour, racism and lack of awareness16.” 80. There are two family lines of inquiry: the father’s family and the mother’s family. Little information was known about the father and his background but there was information about the mother’s family. 81. Assumptions were made about extended families living together and that this was normal practice in the Asian community. This assumption may have prevented practitioners visiting the home from asking more challenging questions about family and childcare. 82. Professionals need to exercise real professional curiosity and use their own professional initiative – as one practitioner said ‘make it our business’ to understand family traditions and diversity. 83. Professionals should recognise that different families from the same cultural or religious group may have different views and practices. They should recognise the importance of asking individuals and families about what matters to them and challenge assumptions. 15 Honour based violence is a violent crime or incident which may have been committed to protect or defend the perceived honour of the family or community. It is often linked to family members or acquaintances who mistakenly believe someone has brought shame to their family or community by doing something that is not in keeping with the traditional beliefs of their culture. 16 Source NSPCC ‐ Campaign Briefing 5 Children experiencing domestic violence in South Asian Communities 17 Learning • DSPP and SCSP should work with faith communities to raise awareness of the need for neighbours and communities to support women and report domestic abuse. • Both safeguarding partnerships should link with the Black Country Women’s Aid IDVA service and other organisations such as the Muslim Women’s Network to understand the prevalence of domestic abuse in different faith communities and what support is available. Trauma informed and trauma aware 84. Trauma informed systems acknowledge that every interaction is an intervention and relationships are at the core of the work. Trust is at the heart of this approach. Lencioni17 refers to this as vulnerability based trust: that is, the ability to have a relationship with a family, client or colleague based on honesty and the ability to challenge and manage conflict and integrity. 85. This does not preclude the need to provide critical challenge and have honest conversations. Bruce D Perry18 refers to trust as ‘the currency for systemic change’. This requires an equipped workforce with an understanding of trauma informed ways of working. 86. Trauma informed systems prepare people to reflect and not react. The journey to becoming trauma informed begins with being trauma sensitive and aware. 87. All of the children in this family have experienced adverse childhood experiences (ACEs) and will require support. The long-term impact of childhood exposure to domestic violence and abuse has been well-documented. The most significant risk of long-term harm is found in children who are exposed to domestic abuse during infancy. This can harm the development of the brain and impair cognitive and sensory growth. 88. The mother of Child YS has experienced significant trauma as a result of domestic abuse. She is experiencing flashbacks and is struggling to make sense of what happened. From a trauma informed perspective we can potentially see signs of ‘shut down’ with professionals in that she did not feel able to disclose and answer honestly 17 5 behaviours of a cohesive team Patrick Lencioni 18 ― Bruce D. Perry, The Boy Who Was Raised As a Dog: And Other Stories from a Child Psychiatrist's Notebook 18 to the routine enquiry questions. In some ways, this is similar to Judith Herman’s19 description of ‘psychic numbing’ as a disempowerment and disconnection from others through experience of trauma. Learning • There is a large evidence base surrounding the links with ACEs and trauma and their long-term impact on the health and wellbeing of children and families. • It is important to raise awareness of ACEs as a foundation for continuing to develop trauma informed approaches. • Recognising the complexity of this task and moving to a trauma informed approach requires a whole system response. Reflective points for the SCSP and DSPP to consider: • How can the partnerships influence the necessary cultural and systemic changes across all partner agencies in terms of trauma informed approaches? • How will the partnerships be assured that agencies are working together to improve joint reflection on cases? • How will the partnerships embed and monitor understanding of cultural diversity? • How will the SCSP and DSPP be assured that people are doing what they should be doing rather than a focus on operational elements of each agency/partner? Summary 89. The need to build robust quality assurance into safeguarding is essential. There should be a culture of continuous learning and improvement across agencies working together to safeguard and promote the wellbeing of children. 19 Judith Herman (1992) Trauma and Recovery ‘It is well known that the effect of childhood trauma and adversity can be moderated by strong, stable relationships and that poor outcomes following childhood trauma are not inevitable. In order to transform the lives of infants, children, and young people we need to transform the lives of the adults who take care of them. This will involve a whole system approach with action at various levels to both strengthen the case for early intervention and prevention as well as working together to support adults, who may be experiencing adversity to improve outcomes for the whole family.’ – The State of Child Health: Adversity is not Destiny – Developing a Trauma Informed Approach across Ayrshire and Arran, October 2019 19 90. This is a complex family situation and while we can pull out learning across the system it is not possible to conclude that this would have alerted professionals to a potential serious incident. However, had information held by services been shared then there might have been greater curiosity about the father of Child YS. 91. Professionals have good intentions when working with families. Sometimes, cultural practices, systems and processes lead to poor decision-making and information sharing. 92. Underpinning this review is the need for professional curiosity and ‘digging deeper’. It points to the need to seek out multi-agency views when there is ‘unease’ or concern. This should complement supervision processes and is not a replacement. 93. Improvements are planned to improve information sharing in maternity services and enabling EMIS information sharing between midwifery, school nursing, health visiting and GP practices in Dudley. 94. The School Nursing service will transfer to Dudley Council in April 2021 and this is an opportunity to improve pathways and strengthen the safeguarding offer. This should include a spotlight on the transition between health visiting and school nursing. 95. The use of genograms by the schools in Dudley was good practice. However, a standardised approach for culturally competent 3 generational genograms would be beneficial in both Dudley and Sandwell. 96. Health visiting services have now introduced training to ensure that genograms are used effectively and this should include the same 3 generational cultural genogram to be completed with families. 97. Engagement with fathers is highlighted in many reviews. However, this requires information about the father and in this case there was no triangulation between midwifery in Dudley, who had the father’s details as an emergency contact, and health visiting. The father was registered with a GP in Sandwell which made this more challenging. 98. The challenge of cross border working featured in this review. The mother moved between Dudley and Sandwell, but no agency was aware that this was happening as recorded addresses did not change. 99. Hindsight bias is powerful and actions that should have been taken in the time leading up to an incident can seem obvious because all the facts become clear after the event. What hindsight does is it blinds us to the uncertainty with which we live. That is, we always exaggerate how much certainty there is. Because after the fact, everything is explained. 20 Everything is obvious. And the presence of hindsight in a way mitigates against the careful design of decision making under conditions of uncertainty.” — Daniel Kahneman Recommendations Discussion with partners identified common learning themes for both Dudley and Sandwell. 1. The SCSP and DSPP should seek assurance that there is effective information sharing across health services as outlined in the single agency action plan, in particular between Primary Care, Midwifery, Health Visiting and School Nursing. This should include when sharing information across boundaries. 2. The SCSP and DSPP should seek additional evidence that there is a ‘Think Family’ approach in the above named health services and contact with fathers is documented and recorded. 3. The SCSP and DSPP should gain assurance that all agencies are using evidence-based tools, such as those referred to in the report, to inform assessments and analysis. 4. The DSPP and SCSP should have training in place on effective safeguarding of children from Black and Minority Ethnic, Cultural and Faith Communities to include understanding barriers and challenges that may impact on engagement. 5. The SCSP and DSPP should work with the Domestic Abuse Strategic Partnership, Black Country Women’s Aid, and other organisations such as the Muslim Women’s Network and other community groups, to promote awareness of the need for neighbours and families to report domestic abuse and develop community resilience. 6. The DSPP and SCSP should seek to develop a shared understanding of trauma informed practice and ACEs with its partner organisations and explore good practice in other areas, such as NHS Scotland, to develop a training framework. The partnerships should also: a) Consider a leadership statement to show commitment to becoming a trauma informed partnership. b) Create a forum for sharing and developing trauma informed practices including from other areas. c) Develop a set of resources to promote trauma informed practice. This will lead to the development and use of multiagency policies and supervision strategies that are restorative and transformational. 21 7. The DSPP should seek assurance that schools and partner agencies are familiar with and use the Resolution and Escalation policy in cases where they feel ‘stuck’. As a result of the above recommendations an action plan will be developed and the DSPP and SCSP will ensure that learning is widely disseminated, and actions are implemented. |
NC52371 | Thematic review based on rapid reviews for four infants presented with suspected non-accidental injuries. The infants were presented with injuries during the Covid-19 pandemic lockdowns in 2020. Reflections include: how to support universal services in exercising professional curiosity, appropriate information sharing and onward referral; how to ensure that universal services, such as health visiting and midwifery, retain technological advances developed during the pandemic, whilst also ensuring that opportunities for direct contact remain the primary source of insight into a child's daily life; how to address issues around potential diminutions of workplace peer-to-peer support and reflection if remote working is retained for safeguarding professionals; issues of inter- and intra-agency professional communication and data sharing being complex and problematic; if the pandemic impacted on the quality of case management record keeping, and implications this holds for professional reflection, supervision and assessment of risk; how to reassert the unique perspective and value of universal services like health visiting and midwifery. Makes no recommendations, but reflects on three main issues: the adaption and transition of services through the pandemic and lockdowns; mental health issues unique to the circumstances of the pandemic, particularly for expectant and young mothers and families; new arrangements for continuance of services sometimes 'removing' men in families from professional view.
| Title: Injuries to babies during the pandemic lockdown. LSCB: Somerset Safeguarding Children Partnership Author: M.A. Peel Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Introduction - A Thematic Local Safeguarding Practice Review for the Somerset Safeguarding Children Partnership: Injuries to babies during the pandemic lockdown Brief Background to this Thematic Review This thematic review was commissioned by the Somerset Safeguarding Children Partnership (SSCP) where I am Independent Scrutineer. Whilst it is not unprecedented for an Independent Scrutineer with a partnership to take on the role of an independent author, as I do here, some context and explanation is necessary. I have found in several other roles as Independent Chair and latterly Independent Scrutineer, that undertaking a review of this sort as an independent author is the single best way to gain an accurate, up-to-date and unvarnished insight as to how safeguarding partnerships actually function on a day-to-day basis. A view was taken by the Executive of the SSCP, following completion of rapid reviews for four very young infants presenting with suspected non-accidental injuries (NAI) that, whilst unlikely from initial consideration, there might be some connection between these cases, as well as opportunities for reflection and learning, that warranted closer independent consideration. The rapid reviews concluded that a thematic review would be the best way to address these issues, and the response received from the national Child Safeguarding Practice Review Panel supported this view. 2 A fifth rapid review, relating to a further instance of suspected non-accidental injuries for a similarly very young infant, was not added to the baseline of the thematic review on the basis that immediate improvements and recommendations at practice level (across all five cases) might be put into immediate effect without undue delay, such that this thematic review might address any systemic, structural and strategic issues revealed. An Independent author? Other than having been Independent Scrutineer for the SSCP since January 2020, I have no previous professional association or connection with Somerset, or any of the agencies there to the best of my knowledge. My professional background over the past thirty or so years lies wholly in the field of safeguarding and child protection; in practice, as an academic and as an independent researcher and Chair. For example, I am presently Independent Scrutineer for the child safeguarding partnership in Nottinghamshire in addition to Somerset and was previously Independent Chair for Lambeth and Leeds. It is essential for any reader to understand from the outset that the views represented here are my own, working as an independent author, and follow from the evidence I have accessed and reviewed. Similarly, that ‘evidence’ in this instance reflects what I have read from ‘case-recording’ and other written material I have accessed OR was by what I was directly told by professionals and others who participated in the consultation process. This is not a legal or judicial process, and hence the use of the term evidence must not be misconstrued. Finally, it was agreed with the Executive of the SSCP at the outset, that any errors in respect of fact included by mistake in any draft of this review, once spotted, would be corrected, but that any differences of opinion in relation to findings and recommendations would need to be agreed with me before any changes might be made. The Pandemic and the Process of this Review There are two elements to stress in this regard; the first being the implications of conducting this thematic review remotely, via MS Teams, the telephone, email and other written communications and recording, the second being the impact of the pandemic and lockdown on the safeguarding support received by the expectant and new mothers of the babies at the centre of this consideration. 3 In relation to the implications for this review, it is self-evident to say that it is less than ideal to conduct this sort of work remotely. Overall, I have taken the view that I must do the best I can, given present constraints, looking to be creative where possible in terms of strong communication, and going the extra mile in terms of review of paperwork, recording and other documentary source material. I will go on to address the implications of the pandemic and lockdown on the quality and quantity of support and other services that the families received in more detail in later sections of this review. I certainly found evidence of creative attempts to offset the impact of the pandemic from professionals. For example, where expectant mothers were anxious about professionals coming into their homes and potentially bringing the virus with them into a confined space, of these becoming ‘walking’ outdoor meetings, to maintain contact, build relationships and continue to offer oversight, advice and support. Similarly, where GP surgeries were not readily accessible in the usual way through the pandemic for clinic-based visits (weighing etc.) alternative spaces (family hubs) were swiftly put in place so this vital monitoring and contact could continue. Initial Scoping and Review My first step in taking this work forward was to request as much documentary evidence as I could get my hands on from the range of agencies involved and, in all instances these requests were met fully and without undue delay. Completed rapid reviews for these infants were evidently the most important documentary sources consulted, as they enabled me to gain insight into what had happened in each case, some narrative and context in relation to the circumstances, and some overview of how the Partnership had supported and engaged with the families through the process of reflection and reassessment required by rapid review. Quality of Rapid Reviews My finding is that the quality of rapid reviews completed here, whilst relatively brief and somewhat lacking in analysis, were of good standard, to the extent that it is neither appropriate nor necessary for me to simply replicate the descriptive chronologies and other evidence presented in them here along with 4 actions for future learning and improvement included in rapid review. Furthermore, the rapid reviews have already been submitted to the National Panel, and responses received. I choose instead to use the limited time available for this review to go beyond the scope of the completed rapid reviews, and address in particular systemic, structural and strategic issues following the evidence reviewed in a stepwise manner. Contact with Family All efforts were made to contact close family members such that they were aware of the progress of this review, and to invite them to participate if they wished to do so. There has been no response to this invitation to date. 5 What does recent research tell us about NAI and very Young Infants? The following information was sourced from the most up to date evidence-based research I could find published in April 2020 (Baird, E. Non-accidental injury in children in the time of COVID-19 pandemic 2020). It is likely that additional research with respect to the impact of the pandemic on safeguarding generally, and NAI in particular, will take time to reach the point of publication, and it is strongly suggested that an additional data trawl be undertaken by the Executive of the SSCP in this regard around one year subsequent to publication of this review, such that a more informed and potentially accurate understanding can be reached. Baird reviews early evidence of an increase in NAI during the pandemic, and concludes, “Non-accidental injury is the tragic outcome of a complex interplay between the individual, relationship, community and society, and COVID-19 will only compound this. It must be a diagnosis which we seek to actively dismiss, to safeguard the children under our care, as it is the failure to recognise the abuse that often leads to the child’s demise.” And goes on to suggest, “Social isolation is a risk factor intrinsic to the perpetrator of abuse and intrinsic to the family structure. As we have all been asked to limit our social contact in the light of COVID-19, the support that normally comes with socialising with friends and wider relatives is lost. The sudden withdrawal of nurseries, schools, youth programmes and time with other relatives takes away not only the respite of childcare, but also the early warning system that these places would normally provide. Children with developmental delay and additional needs are at particular risk of abuse, and the loss of respite and support networks for these families is a particularly cruel blow. Social isolation to many families means confinement, often with multiple children, in small dwellings with no access to outdoor spaces in which families can relieve the stress of lockdown. These conditions make for a tense and volatile environment. NAI is more prevalent in families with lower incomes, and financial uncertainty has been further associated with increasing this risk. This was seen during the last economic recession, where there was a substantial increase in abuse and mortality from non-accidental head trauma. Through financial uncertainty, COVID-19 further 6 adds an element of stress to a precarious situation for many children, and this effect will be long lasting. Another known risk factor for NAI is the lack of access to healthcare. We are actively encouraging patients to stay away from hospitals to minimise the risk of spreading COVID-19, however we may also be inadvertently heightening the risk of NAI in the process. Child abuse and neglect will continue to happen, but behind closed doors; we just won’t know about it. Mental health services are also particularly fragile at this time. Mothers with postnatal depression and psychosis may have less support, and infants are particularly vulnerable in this setting. Any member of the household may have mental health issues, including substance abuse, which may be less well supported in these challenging times, and this poses a risk to the child living with them.” The following risk factors for NAI were found to be especially important: • Social isolation • Lack of early warning system • Loss of support systems • Low income and financial uncertainty • Lack of access to healthcare • Healthcare systems under stress. Baird concludes, “Not only are many families under (additional) extremely stressful circumstances, (during the pandemic) but healthcare systems are too. The increasing burden of COVID-19 presents a real challenge to maintain the standards that are normally in place. Staff working (outside) their normal roles and may not be as familiar with the presentation of NAI”. Overall Findings at Micro level: a Review of Practice I have not found that the actions or inactions of any professional or agency materially contributed to the harm suffered by the infants considered in this review. Indeed, there is considerable evidence of individuals and agencies doing the absolute best they could, in unprecedented and very challenging circumstances, for which they are to be commended. On consideration of all the written evidence, and as a result of meetings with both practitioners and managers, I have not found any clear link or association between any of the cases reviewed. It would appear therefore that the non-accidental injuries presented reflect similar but unconnected separate episodes. 7 Once non-accidental injury was raised as a possibility, in each instance the evidence verifies that the response across the Somerset Safeguarding Children Partnership was swift and co-ordinated. My overall finding however is that the pandemic and lockdown did affect the quality of universal safeguarding support these families received. Initial advice from professional bodies, in the early stages of the lockdown, to curtail or even stop face-to-face contact altogether, whilst quickly revised (within four to five weeks) to enable safe contact with expectant and new mothers to continue, and encourage professionals to use new technologies creatively to address any additional need and increased level of anxiety brought about by the pandemic, self-evidently changed the way in which universal safeguarding services were offered thereafter. For example, health visitor and midwife contacts that would previously have occurred in family homes, (whilst evidently done well elsewhere or through the use of alternative means such as social media) could not directly ‘pick up’ on the subtle cues and changes within a household that seasoned professionals tend to ‘sense’. Crucially, changes to family composition, deterioration in parental mental health, changes of partner all under the auspice of caring for a newborn infant with the additional stress of lockdown were not as directly evident as they would have been in the normal course of affairs. This was exacerbated through: • Midwives and health visitors working from home, leading to the loss of discussion, reflection and ‘soft supervision’ that normally occurs between professional colleagues working closely together in the workplace, which, in turn, has carry-over implications for formal supervision. • The impact of greater use of social media and emails for communication with expectant and young mothers, at a time of isolation and heightened anxiety around health, resulted in an ‘avalanche’ of emails. Time taken to respond to emails, simply ate into time for recording, reflection and review. So, whilst there have been gains from the adoption of new communications technologies, it is also fair to say there have also been losses. • A contextual lack of professional curiosity, both in general terms, and more specifically in respect of the potential impact of new husbands/ male partners not being ‘seen’ and sufficiently taken into account their physical and mental health, their backgrounds with respect to safeguarding and the impact upon them and the wider family of having 8 a newborn at home, whilst isolated through the pandemic was not considered sufficiently. • An underestimation of the degree to which the normal range of anxieties and concerns around pregnancy and childbirth might be exacerbated by fear of contracting Covid 19, the social isolation brought about by the lockdown and any pre-existing mental health issues. Evidently standard operating procedures could not be followed in such ‘non-standard’ circumstances, which is raised here not as a criticism, but rather a reflection of unprecedented circumstances. Overall Findings at Macro Level: a Review of Systems, Structure and Strategy In commissioning this thematic review, the Somerset Safeguarding Children Partnership was clear that they were positively open to the prospect of using the review to enable wider creative challenge and facilitate learning and improvement of arrangements for safeguarding. Of course, as a review author, one is also always very much aware of a parallel and understandable wish on the part of commissioning Partnerships to come up with an ‘answer’: a magic bullet simple solution which guarantees that tragic and usually unprecedented events ‘cannot happen again’, an understandable wish, but perhaps other than in the simplest of circumstance, usually undeliverable. So, I will take the partnership’s permission to think outside the box seriously and look to challenge at the level of strategy and structure, as a means of assisting you to reflect, reconsider and re-evaluate, even if on balance you conclude that present arrangements remain satisfactory. In their annual report (2020) the Child Safeguarding Practice Review Panel set out a summary of six key practice themes that ‘make a difference’. I would suggest that this thematic approach, derived directly from evidence, is useful not only in terms of conceptually grouping generic results, but also as a more analytic vehicle to think through the wider (macro) issues within a single review, as I will attempt to do here, with a slightly changed ordering. As a result, I will pose a series of questions for the Somerset Safeguarding Children Partnership to address, based on the evidence considered in this review. 9 It is my view that the process of addressing and responding to these questions may serve to clarify and reinforce the Somerset narrative around safeguarding, while also drawing out and consolidating the potentially different perspectives of the statutory partners. It is ESSENTIAL that any reader understands these questions are NOT reflective of problems or deficits I have found, but rather are raised as catalysts for discussion and dialogue for the Partnership. (i) Practice Theme 1 - Sharing information in a timely and appropriate way Baird’s research (cited above) suggests that ‘lack of an early warning system’ is one of a series of risk factors associated with increased incidence of non-accidental injuries during the period of the pandemic. As the cases reviewed here are indicative of just such an increase in non-accidental injuries, it is reasonable to examine the degree to which changes in the delivery of health visiting and midwifery services contributed to any impoverishment of the safeguarding early warning system in Somerset. On balance of evidence, I think it is appropriate to speculate that the issues mentioned above around: time required to respond to much increased email and social media contacts, generally heightened public anxiety and fear during the pandemic, lack of ‘soft supervision’ and peer-to-peer support in the workplace and reduced access and oversight previously facilitated through direct contact and home visitation are at least some of the elements contributing to a reduced early warning system, and contextualising reduced professional curiosity. Given that we are not yet through the pandemic, and that there is considerable uncertainty around how services will adapt and function in the short to medium term, all efforts need to be made to ensure that the early warning system provided by universal services is as effective as possible. All professionals with responsibility for safeguarding, and especially all universal service providers, should be reminded and positively encouraged to refer onward any concerns around possible risk of non-accidental injury they detect. In this sense, our ‘early warning’ system needs to be as sensitive as possible and accurately calibrated to whatever present circumstances prevail, especially where the prevailing circumstance takes us outside of the normal range, as has been the case during the pandemic. Similarly, for example, it is appropriate to ask if arrangements for universal safeguarding, such as Midwifery and Health Visiting for example, are adequate and/or sufficiently flexible to meet demand, even if current increased demand is a temporary facet of the pandemic. 10 Q1 How will the Executive of the SSCP, support universal services with respect to exercising their expert professional curiosity and, where concerns are raised as a result, encourage appropriate information sharing and onward referral? Q2 Does the increased demand for universal services, such as health visiting and midwifery, suggest that, in the light of the issues raised by the cases reviewed here, consideration should be given to reviewing present deployment, caseloads and circumstances in which enhanced support might be offered, and reflecting upon how this correspond to the Ockenden requirements? (ii). Practice Theme 2 - Understanding what the child’s daily life is like. As I have already observed above, it is my view that the pandemic did impact on the degree to which universal services, such as health visiting and midwifery, had the opportunity to pick up on subtle changes within families. The degree, to which any professional can gain an accurate understanding of what a child’s daily life is like, requires access to good direct data, with respect of context, change and development, the ability to ask questions and exercise professional curiosity and, critically, the opportunity to reflect and seek the formal and less formal advice and guidance of others. It is likely that, at the end of the pandemic, safeguarding services will not revert to previous modes of working and a new ‘hybridised’ model, incorporating some of the creative uses of technology for example, will become the new normal. Whilst there are evidently many benefits to extending the range of ways services can communicate with and support children and families, there may also be costs if such new ways of working inadvertently compromise opportunities for universal services to observe and take the whole ambit of a child’s daily life into account. It is my opinion that there is no substitute for home visits, and that whilst technology can supplement them, it cannot and should not replace them. Q3 How will the Executive of the SSCP ensure that as we emerge from the pandemic, universal services such as health visiting and midwifery have the capacity to retain the technological advances developed during the pandemic, whilst also ensuring that home visiting and other opportunities for direct contact remain the primary source of professional insight into what a child’s daily life is like? 11 Additionally How can the Partnership best ensure and evidence that the extended use of new technology around supporting vulnerable expectant and young mothers, is as efficient, effective and ‘joined up’ with existing safeguarding systems as possible, and is sufficiently resourced?’ Q4 If remote and home-based working are (to some extent) retained for safeguarding professionals, how will the Executive of the SSCP address issues around a potential diminution of workplace peer-to-peer support and reflection, and provide regular opportunities for professionals to continue to work together ‘in the same room’ whether directly or through creative use of technology? (iii). Practice Theme 3 - Responding to changing risk and need Q5 What was especially striking in undertaking this independent review was the lack of emergency planning AT NATIONAL LEVEL providing leadership for all constituent elements of safeguarding partnerships across the nation. Such a seeming lack of preparedness, especially in the early stages of the lockdown, directly contributed, in my view, to discrepancies and discontinuities in the safeguarding system as local responses, whilst well-intentioned and creative, were inevitably narrow, variable and piecemeal, as to some extent is evidenced here. The lack of central emergency planning and direction for safeguarding is all the more surprising given the warning of the SARS outbreak in 2003, and is something I feel should now be addressed to the National Child Safeguarding Practice Review Panel by the Executive of the SSCP for their consideration. (iv). Practice Theme 4 - Working with families (and young people) where their engagement is reluctant and sporadic Baird (cited above) describes a risk factor for non-accidental injury during the pandemic around circumstances in which the health system is under stress, which perhaps may seem something of a statement of the obvious in the context of a global pandemic! I would speculate however that here she is making a more generic point with respect to year-on-year funding in a context of increasing demand and competition for resources, and I will make that assumption moving forward. 12 Adding to my earlier comments around the costs as well as benefits of use of new technology in safeguarding, there has clearly been a massive and unprecedented evolution in this regard as a consequence of the pandemic. It would however be fair to say that the professions around safeguarding have historically been at best slow (and some would argue at times resistant) to the use of new technologies and that consequently what has happened recently may be something of an aberration outlier. A common theme in the consultation process for this review and indeed many others was concern and frustration with respect to accessing different IT data systems between and sometimes within agencies. It was evident that this reflected different and sometimes inaccurate understandings of data protection legislation. This is clearly a potential barrier to appropriate intra and inter-agency communications around safeguarding which, given the permissive nature of legislation around safeguarding, is unacceptable in 2021. It seems appropriate therefore to ask a question with respect to how far the adoption of new technologies with regard to risk of non-accidental injury has been reactive OR is indicative of a more ‘joined up’ effective and efficient use of these new opportunities. Whilst this issue has general applicability, such consideration is beyond the remit of this review. One of the following questions (6) whilst largely addressed to Health as a key safeguarding partner, should also be addressed I would suggest as a wider issue, and a consideration for the Partnership as a whole. Q6 Why is easy and appropriate inter- and intra-agency professional communication specific to safeguarding still reported to me by practitioners as complex and problematic in Somerset? This should be considered both in terms of peer-to-peer contact and communication, but also in terms of the degree and ease with which safeguarding professionals from one agency can directly access (appropriate safeguarding) data held by partner agencies. (v). Practice Theme 5 - Critical thinking and challenge One of the consistent comments I heard in my meetings with practitioners especially, but from managers too, relates to decreased time available for record keeping during the pandemic. Practitioners will quite understandably prioritise direct work with public and the creative responses I have noted as a result of the unprecedented circumstances of the pandemic, all eat into the limited time available. Certainly 13 practitioners reported such a ‘squeeze’ on their time during the pandemic (especially during the early stages) and that recording was the area squeezed down as a result. Giving priority to keeping services running and responsive during the pandemic is understandable, but it is worth asking a question here as to the possible ‘impact’ that reduced (and implicitly poorer) recording might hold for management, supervision, planning, reflection and assessment of increased risk. Research in this area has historically found that good quality and timely recording is basic to professional reflection and case management, and in that sense records should be seen to be ‘live’ documents that officers should use regularly and refer to proactively. Clearly it is of concern therefore, if the impact of the pandemic has been to reduce the efficacy of recording, that this will potentially have carry-over detriment for safeguarding more generally, as is possibly so in relation to the cases reviewed here. Q7 What impact has the pandemic had on the quality and currency of recording, and what implication (if any) does this hold for professional reflection, for supervision and assessment of risk? Case recording can and should be more than a simple retrospective ‘listing’ of contact and content. At best recording should be used as a proactive tool to assist professionals with reflection, spotting trends and changes which may impact on safeguarding and planning for the future. The evidence considered here however would suggest that (under the intense pressure of the lockdown and pandemic) recording was seen as a secondary, time consuming and relatively unimportant task. Q8 Would there be value for key safeguarding partners in developing a common safeguarding recording protocol and shared recording system? NB. I note that the continuation of separate inspection regimes for the three statutory safeguarding agencies make this an especially challenging question, and one which should also be considered by the National Child Safeguarding Practice Review Panel. (vi). Practice Theme 6 - Organisational leadership and culture for good outcome The focus of this thematic review has very largely been on the impact of the pandemic on universal services. 14 Elsewhere in this review I have used a term borrowed from Baird to describe these services as an ‘early warning’ system for safeguarding, which is so self-evidently the case that I would be surprised if this provoked any dissent or disagreement. I would suggest however that, despite this being the case, the centrality and expert assessment that providers of universal services, such as health visitors and midwives, bring to the safeguarding conversation is (nationally) still not sufficiently strongly expressed or sufficiently carefully listened to and taken into account. This would certainly seem to have been the case, at least to some extent, in the cases reviewed here. If I am even partially right in this matter, this raises some serious potential questions in terms of the effectiveness of early intervention. Q9 How might the health economy in Somerset, as a statutory safeguarding partner, take the lead across the safeguarding partnership to reassert the unique perspective and value of universal services like health visiting and midwifery in a safeguarding conversation that draws all partners closer together and encourages greater mutual appreciation of ‘different’ safeguarding perspectives? Response from Somerset to this Thematic Review: Measurement of Effectiveness This review contains nine questions that I suggest the Somerset Safeguarding Children Partnership should address and respond to by the end of April 2022 at the latest. Response to the questions should initially be addressed by the Executive of the SSCP, with tasks delegated to subgroups, agencies, the SSCP Business Unit or individuals as felt appropriate. This with the caveat that the response as a whole must reflect the range of the statutory safeguarding partnership, and not be dominated in any way by the views or actions of any single perspective or agency. The questions are posed to provoke reflection and, as such, there are not specific outcome data measures that I wish to append to them, other than my view that it may be of benefit to give serious consideration to the issues raised, whether that results in change or that going through the process simply reinforces your view as a partnership that the ‘right’ responses are already in place for Somerset. I would expect the overall response to this thematic review to be ‘published’ by the end of April via the SSCP website, to thus be open to public scrutiny. I would wish to be sent a copy of the overall response to this thematic review and reserve the right to respond, but would only envisage doing so in extremis. 15 Use and limitation of this review There are three main issues to reflect on here: 1. An issue of ‘timing’ through, the pandemic. In gross terms the safeguarding response to the pandemic can be broken down into two elements. The period of initial response to the first lockdown when face-to-face contact was precluded, and the latter period through the second lockdown, when services had ‘adapted’ to new circumstances, and creative mechanisms to preserve face-to-face contact were in place. The evidence I have considered in this review strongly underscores the exceptional efforts made by universal safeguarding services such as midwifery and health visiting in Somerset to accommodate and adapt to the unprecedented circumstance of the first lockdown, and find new ways of working following the best advice available at the time to maintain an effective service, that kept all involved safe. By the time of the second lockdown, clearly much more was known, both locally and nationally, and a more nuanced and informed response was consequently possible, for example, with a degree of face-to-face visiting becoming feasible again. It is my opinion that the issues for the cases reviewed here outlined in the rapid reviews, greatly reflect this period of adaption and transition through the pandemic and lockdowns, and hence of an issue of timing. 2. Mental health issues unique to circumstances of the pandemic. The degree of anxiety and the effect of the isolation caused by the pandemic and lockdowns is well reported, but as yet insufficiently evaluated to analyse with any degree of authority or accuracy. It is however pertinent to speculate that if this was found to be the case for the population in general, that it is likely to be even more so for expectant and young mothers and families, even where there was no prior suggestion of problems with mental health. It was reported to me, for example, that one reason health visitors moved to offer face-to-face contact outside the home was in response to families not wishing to take the ‘risk’ of allowing professionals into their homes. Whilst certainly not conclusive this is, I would suggest, indicative of a heightened level of anxiety, and the understandable (deeply human) need to keep children safe. 16 It is my opinion that the issues for the cases reviewed here outlined in the rapid reviews, greatly reflect this period of adaption and transition through the pandemic and lockdowns, and hence that the understanding and sensitivity of these circumstances as a catalyst to mental health issues, whilst initially and inevitably less than perfect, has subsequently improved considerably. 3. Invisible men. The combination of issues reflected upon above, unique to the timing of the pandemic and lockdowns, drawing together the consequences of isolation and anxiety and requiring professionals to adapt immediately to hugely different working environment. Especially with regard to the squeeze on face-to-face contact and home visiting that would have happened in the normal course of events, would appear to have had an unanticipated effect of largely ‘removing’ the men involved from professional ‘view’ with regard to assessment of emerging safeguarding concerns. Face-to-face contact with women alone outside the home was a logical and laudable response to a set of unique circumstances. But such arrangements lost the contextual richness of home visits. It was reported to me, for example, that where there had been a change of partner, and a new man was now at home, this was sometimes not known, as would have been more readily apparent had home visits been possible. It is my opinion that the issues for the cases reviewed here outlined in the rapid reviews, greatly reflect this period of adaption and transition through the pandemic and lockdowns, and that new arrangements for continuance of service sometimes had the effect of making the men involved to some extent invisible. Post Script The intellectual property of this review rests with both the author and the commissioning Somerset Safeguarding Children Partnership (SSCP). The conclusions expressed here have been drawn from meetings with practitioners both individually and in groups, meetings with managers both individually and in groups, and from extensive reading of documents kindly made available to me through the Somerset Safeguarding Children Partnership Business Unit, or from professionals directly. I have supplemented the ‘data set’ drawn on here with reference to publications made by the national Child Safeguarding Practice Review Panel and a brief literature review of non-accidental injury during the pandemic. Given the limited time available to complete this work, I would suggest that the data drawn upon offers a reasonable ‘snapshot’ of what transpired, but no more and is not an attempt on my part to definitively ‘tell the story’ of the cases considered, as I set out in the introduction. 17 Dr. M. A. Peel January 2022 |
NC52248 | Death of an 8-month-old girl in 2016. Holly was found unconscious and not breathing in the family home, and was pronounced dead at hospital. Learning includes: professionals should encourage parents to elaborate when conversations reveal stress factors that could affect their capacity to care for their children; family members being registered with different GP surgeries could be a weakness from a safeguarding perspective; pathways for support staff in managing the risk of not being able to see children at home would enable staff to persist in their follow-up with families where increased risk factors are identified; professionals ensure that vulnerabilities identified at an early stage in work with families reduce rather than increase over time; the safeguarding risk factors associated with babies and very young children, particularly that children under 1-years-old are the most likely age group to die through abuse or neglect. Recommends that the safeguarding partnership ask agencies to provide evidence they have completed proposed actions and to summarise their impact.
| Title: Serious case review: overview report: Holly. LSCB: Blackburn with Darwen, Blackpool and Lancashire Children’s Safeguarding Assurance Partnership Author: Isobel Colquhoun Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review Overview Report Holly Author: Isobel Colquhoun Date: 22nd June 2021 Publication Date: 28th July 2021 1 Contents 1. Background to the Review Page 2 2. Key Lines of Enquiry Page 5 3. Analysis Page 17 4. Recommendation Page 18 This report has been written so as to preserve the anonymity of the child. The Children’s Safeguarding Assurance Partnership has: Represented the children by different names and adult family members by role; Not necessarily reflected the children’s true gender; Avoided the use of exact dates where possible; and, Removed details about services which could lead to the recognition of the children and family. 2 1. Background to the review 1.1 When Holly died, aged 8 months, her death was initially unexplained. An ambulance had been called in the early morning to the family home, where Holly lived with her mother, (MH), her father (FH), and her 2-year old sibling, Olivia. Both parents were 19 years old. The family’s ethnicity and language are reflective of the majority local community. 1.2 MH reported having fed Holly in the night and wrapping her in a blanket as she was cold. In the morning, she found Holly, unconscious and not breathing, with the blanket wrapped round her face and neck. Holly was taken to hospital where she was pronounced dead, shortly after arrival. 1.3 The Sudden Unexplained Death in Childhood process was initiated and police attended the family home. Due to circumstances presented to officers, both parents were arrested on suspicion of murder. Olivia was taken into police protection and placed with local authority foster carers. 1.4 Five days after Holly died, a referral was made to the Local Safeguarding Children Board (LSCB). The LSCB undertook a rapid review of information readily available to agencies and organisations. At that point, the initial post-mortem was inconclusive and the results of further tests were awaited. 1.5 Agency chronologies indicated that Holly and family members had open involvements only with universal services. A pattern of inconsistent engagements with health services was found but there was no evidence either of child neglect or that the children had been otherwise at risk of harm in their parents’ care. 1.6 A month later, following communication with the national Child Safeguarding Practice Review Panel, it was agreed that a ‘proportionate and focussed Serious Case Review’ should be undertaken. 1.7 In January 2019, the LSCB commissioned an independent reviewer to facilitate the review. It also appointed a panel of senior representatives of key agencies to contribute to the case analysis and to oversee the conduct of the review. 1.8 At the first SCR Panel meeting in March 2019, the methodology for the review was agreed. It was intended that the review would be conducted using a hybrid systems approach which would include single agency case analyses and a learning event for practitioners and managers from relevant local agencies and organisations. As the police investigation was current at that point, however, it was agreed that the practitioner learning event would be delayed due to the potential for practitioners to be called as witnesses. 1.9 Parents and grandparents would be informed that a serious case review was to take place but the nature of the police involvement precluded family participation at that point. 3 1.10 In the meantime, using a bespoke template, single agency case analyses were completed by the local teaching hospital NHS Foundation Trust; Holly’s GP practice; MH’s GP practice; education services; and, the police. Due to their very limited involvement with MH in the past, children’s social care (CSC) was not asked to provide an agency report. Representatives from CSC, however, provided information to the following SCR Panel meeting which was held in June 2019. 1.11 At that meeting, Panel members considered the single agency analyses of practice. No safeguarding issues were identified and there were no immediately obvious lessons for multi-agency practice. It was reported that the police were preparing to pass the case investigation file to the Crown Prosecution Service (CPS). It was also noted that care proceedings in respect of Olivia were continuing. Appropriate reporting links between care proceedings and the criminal process had been established. 1.12 The Panel proposed that the practitioner learning event take place in September 2019 when, it was anticipated, the criminal investigation would have concluded. Panel members were asked to confirm how agencies would be represented. 1.13 In the event, decision making in respect of the criminal investigation was not completed by that date. Communication between the police and CPS continued throughout 2019 and into the New Year 2020. Concerned about the delay, the Partnership Business Manager and the Independent Reviewer agreed, therefore, that the SCR panel should be re-convened, formally to consider what steps needed to be taken to ensure that the review was completed. A panel meeting was arranged for 20 March 2020. 1.14 On 18 March 2020, however, the local authority and partners were required to prioritise their responses to the COVID-19 outbreak. The upcoming panel meeting was, therefore, cancelled. At that point, it was thought that multi-agency review processes could be resumed by May 2020. This, however, proved not to be the case as the operational impact of COVID-19 continued to be significant. A virtual panel meeting, therefore, took place on in June 2020. 1.15 At that meeting, it was noted that both care proceedings and the criminal process were still active. It was not known whether new information had come to light during either process which could have had an impact on learning for agencies, had it been known before Holly’s death. Concerns were expressed by Panel members about the time that Holly’s sibling had been in foster care, with her permanent living arrangements uncertain. Police and CSC undertook to provide further information to the review. 1.16 Since this review was commissioned, there have been a number of local and national changes to the process of undertaking multi-agency safeguarding reviews. LSCBs in the area have been replaced with a local safeguarding children partnership which includes Blackburn with Darwen, Blackpool and Lancashire. Serious Case Reviews have been 4 replaced by Child Safeguarding Practice Reviews, although this report has been published as an SCR to reflect its designation at the time of commissioning. 1.17 The key lines of enquiry for the SCR are as follows: a) How well did agencies understand family circumstances prior to Olivia’s birth? b) How effective were services to family members following Olivia’s birth and prior to Holly’s birth? c) How effective were services to family members following Holly’s birth? d) How effective were safeguarding measures taken immediately following Holly’s death? e) What work by agencies had a positive impact on family members? f) What steps could have been taken to improve the service provided to family members? g) What actions have agencies taken or do they propose to take as a result of what they have learned from their reviews of practice? h) What impact does information obtained during the course of legal proceedings have on learning? 1.18 In the early autumn of 2020, with the difficulties in meeting with practitioners and managers remaining, an interim report for the partnership was completed based on the information available. 1.19 It was anticipated that the interim report would form the basis of a future practitioners’ event which would explore whether there were particular factors that influenced decision-making and practice in this case which could provide learning for practitioners providing universal services to children. It was also acknowledged that, in the circumstances, participants might benefit from sharing their perspectives, thoughts and feelings with other professionals who were involved with the family. 1.20 When criminal matters in respect of Holly’s death were resolved at the beginning of 2021, arrangements were put in place to hold a virtual learning event with practitioners who had been involved with the family at the time. Unfortunately, for a variety of reasons, only the most recent health visitor and a manager from midwifery services were able to attend. 5 2. Key lines of enquiry 2.1 How well did agencies understand family circumstances prior to Olivia’s birth? 2.2 When Olivia was born, MH and FH were themselves children; aged just 17. Both parents were living in FH’s family home. MH and FH had attended the same high school from Year 8. No significant pastoral concerns were noted by the school in relation to either young person. There was no involvement either with Pupil Welfare Services. 2.3 In 2014, MH was the subject of child protection enquiries. These followed allegations made by another individual against a member of MH’s family. No allegations of abuse had been made by, or in respect of, MH. Enquiries were undertaken by CSC to assess the risk of significant harm to MH. MH, aged 15, was found to be ‘fully aware’ of the allegations and was reported to have no unsupervised contact with the alleged offender. Adults around her were considered to be protective. No adverse childhood experiences were identified during this process. MH was made the subject of a child in need plan for three months. 2.4 On leaving school, FH enrolled twice at college, but did not complete either course. Although outreach was made to FH, his attendance remained poor. FH was still on roll at college when Olivia was born, but the baby’s birth was unknown to the college. The college was not in a position, therefore, to offer FH targeted pastoral support. 2.5 MH is reported to have attended further education for a period, after Olivia was born. She did not, however, complete the course. Olivia attended nursery when MH was at college. 2.6 MH is well known to GP Practice 1 where she has been a patient since she was a baby. She is the only member of the family registered at that surgery. MH has a chronic health condition and has been described by her GP practice as a frequent user of same-day health services, a pattern which is ‘unusual for a young person of her age’. The GP analysis states that this suggests a young person who does not manage her health and well-being well. The GP analysis acknowledges that the reasons underlying her pattern of presentation were not explored with MH. 2.7 When MH was pregnant with Olivia, she was offered support through the Family Nurse Partnership. The Family Nurse Partnership is a specialist service for young first-time mothers, providing personalised support through pregnancy and into a child’s second year. MH, however, declined this offer as she felt that she had sufficient support from FH and from both their families. MH was seen regularly throughout her pregnancy by community and specialist teenage pregnancy midwives. 2.8 While she was pregnant, MH was twice offered appointments with the allocated health visitor. MH, however, did not attend either. This meant that an early opportunity was lost for the health visitor to talk with the young parents about baby development, their preparation for parenting, and to identify any health, social or family issues which might 6 have existed. The health chronology indicates that, given MH’s age, it would have been good practice to continue to pursue contact with her so that a comprehensive understanding could be acquired of parents’ circumstances prior to the baby’s birth. 2.9 MH’s attendance for ante-natal care was found to be good and no concerns were identified. The record does not clearly indicate, however, what midwives understood about MH’s circumstances during her pregnancy. No details have been provided as to who attended ante-natal appointments with her, as this was not recorded routinely at the time. It is not known whether FH was seen or spoken to by any health professional during that time. It is not known to what extent professionals had fully explored MH’s needs, as a child herself. 2.10 The health analysis reports that during MH’s pregnancy with Olivia ‘liaison between midwives and health visitor appeared non-existent and as such is highlighted as an area for great improvement’. The report comments that ‘with enhanced communication, MH’s engagement with the health visitor might have improved, providing an opportunity for the health visitor to gain a deeper insight into parents’ circumstances and the role of wider family members’. 2.11 How effective were services to family members following Olivia’s birth and prior to Holly’s birth? 2.12 MH was unwell during labour with Olivia. Olivia spent a short time in the special care baby unit before being discharged with MH two days later. Olivia’s birth weight was recorded as being on the 91st centile. Four routine community midwife visits took place in the post-natal period. 2.13 Health visitors provided a universal public health service to MH and Olivia. This meant that the health visitor would undertake 5 ‘core visits’ during Olivia’s first 2½ years. 2.14 The health visiting new birth assessment visit took place when Olivia was 9 days old. Both parents and the baby’s paternal grandmother (PGM) were present. The health visitor registered Olivia with the local children’s centre although the service was not accessed by parents. 2.15 Two further appointments were made to see mother and child face-to-face but both were described as being ‘failed’. On each occasion, the health visitor left a note for MH and Olivia to attend clinic. The health single agency analysis notes that there is no evidence in the record of a plan to address what were now four missed visits by the service. 2.16 It appears that Olivia was initially registered with GP Practice 1. When Olivia was 7 weeks old, she was referred by the GP for paediatric assessment with possible viral infection. She was admitted to hospital and remained there for six days. 7 2.17 A week after she came out of hospital, Olivia was taken for baby developmental review and her first immunisations at GP Practice 1. MH also had her post-natal review where ‘nothing of concern’ was noted. On that same day, the health visitor had ‘ad hoc’ contact with MH, who was with PGM, in the GP waiting room. MH told the health visitor that while Olivia had been in hospital, staff had told her that she had been over-feeding the baby. MH was screened for depression; no further inquiry was indicated. 2.18 A month later, Olivia spent another two nights in hospital with a chest infection. Following discharge, however, she was not taken by parents for paediatric review. The hospital telephoned MH who said that Olivia was much better. 2.19 In October 2016, the health visitor made a planned home visit to completed Olivia’s 3-4 month review. At that point, Olivia was attending nursery while her mother was at college. MH was again screened for depression and no concern was identified. 2.20 Then, when Olivia was five months old, her parents registered her with GP Practice 2 where FH, PGM and other family members were already patients. As Olivia had had her first two rounds of vaccination at GP Practice 1, arrangements were made for her to complete her 3rd round of immunisations. This was not easily achieved. 2.21 In the New Year 2017, MH called the out-of-hours GP service at around 4pm as Olivia’s high chair had collapsed. There was no apparent injury but the baby was crying. MH was advised to speak to her GP within an hour, but she did not contact the surgery and did not take Olivia for two follow-up GP appointments. 2.22 The following month, having been taken to the GP about another matter, Olivia was noted to be overweight for her age. Parents were advised to complete a food diary which would be reviewed in 4-6 weeks. There is no evidence, however, that this proposal was followed up. Olivia had not yet been taken for her 3rd vaccinations, despite reminders and offers of appointments. 2.23 At the next planned home visit by health visitor, MH raised concerns about Olivia’s weight as ‘people had made comments’. Over the course of the next four months, the health analysis indicates that the health visitor team supported MH to ‘manage Olivia’s nutritional needs and to establish and maintain a healthy weight’. During this time, the health visiting offer had been increased to Universal Plus to allow the provision of additional support such as listening visits and extra phone calls. This was a time limited intervention. The allocated health visitor changed during these months. 2.24 Just after her first birthday, Olivia was taken for her third set of immunisations1. Unfortunately, not all elements of the immunisations could be administered and obtaining these necessitated further visits to the surgery. Despite efforts by the surgery, however, those final elements were not delivered while Olivia was in her parents’ care. 1 Immunisations are normally completed by the time that a child is sixteen weeks old. 8 2.25 Around this same time, MH attended her own GP as her second pregnancy had been confirmed. As no risks were identified in respect this pregnancy, universal ante-natal care services were offered. MH and FH were invited to attend Baby Steps, a perinatal educational programme for parents-to-be. This 10-session course is delivered by the NSPCC. MH and FH did not take up the offer of a place on the course. Since then, the Baby Steps programme has changed from an ‘opt-in’ to an ‘opt-out’ service. This has the advantage that referring midwives are now informed if parents choose not to attend. 2.26 By the autumn of 2017, parents had moved with Olivia to their own accommodation. A community nursery nurse visited to complete Olivia’s 2-year developmental review. There was no response and a contact card was left. There is no evidence of any further contact from health visiting service at that point, either to undertake Olivia’s developmental review or to assess whether family need had changed. 2.27 In the meantime, MH had suffered acute exacerbation of her health condition associated with poor compliance medication. Despite this occasioning admission to hospital for three days, MH did not attend follow up appointments with the nurse specialist. 2.28 Following these events, GP practice 1 wrote to MH about having had 11 DNA (Did Not Attend) appointments in the previous 5 months. The GP analysis acknowledges this is a high rate of DNA appointments but notes that it is in the context of approximately 400 missed appointments every month at the same surgery. The practice states that it has since enforced a new ‘DNA policy’ which appears to be reducing the rates of missed appointments at the surgery. It is generally the view of the practice, however, that patients with capacity carry the onus of responsibility for their own health once they have been offered appropriate care. 2.29 Around this same time, Olivia was seen twice in the course of a week by out-of-hours GP service. At the first visit, Olivia was given treatment for nappy rash with secondary bacterial infection. MH was advised to take Olivia to her GP if her condition worsened. A week later, however, she was taken back to the out-of-hours service with extensive nappy rash and a rash on her face and neck. There is no evidence that these out of hours appointments were followed up by GP or health visitor. 2.30 In the New Year 2018, the health visitor telephoned MH to arrange an antenatal visit. This was the first contact that the practitioner who contributed to the review had had with MH. MH said that she had some ‘tightenings’ in her abdomen. The health visitor advised MH to make immediate contact with the midwife/ maternity unit. MH was checked by a midwife and medical staff. She was discharged home with advice and given an appointment for a growth scan. 2.31 A week later, the health visitor ante-natal visit was undertaken as planned. MH and Olivia were present. MH impressed as a quiet, somewhat shy person who was polite and friendly. No concerns were identified about domestic abuse, alcohol misuse or MH’s mental health. 9 MH reported that FH worked long hours (more than 12 hours per day) but that, as she was tired, he helped out when he was home. MH said that she had good support from family. The health visitor talked to MH about possible susceptibility to gestational diabetes. 2.32 Although MH was offered growth scans and glucose tests, she did not attend hospital for those appointments. On one occasion, she attended with reduced foetal movements. She declined regular foetal monitoring of baby’s heart, however, saying that she would rather come in to hospital if worried. 2.33 Six weeks after MH’s visit to hospital with ‘tightenings’, Holly was born at 37 weeks gestation. Labour appears to have been straightforward. Holly’s birth weight was on the 50th centile. FH was present during the labour. Holly and MH were discharged the day after Holly was born, following safe sleeping advice. FH and MH were just 19 years old. Olivia was 20 months, still a young toddler. 2.34 In summary, therefore, prior to and following Olivia’s birth, MH was eligible for support through the Family Nurse Partnership programme. Both parents were also able to access perinatal support through Baby Steps as well as family support through the local children’s centre. Parents declined these services, citing a supportive family, although professionals appear not to have explored the nature of that support. There is no reference to parents having a wider network of friends. 2.35 Although MH engaged appropriately with specialist teenage midwifery services throughout her pregnancy, as time went on; parents demonstrated a generally reactive rather than a pro-active approach to health matters. When they had concerns about Olivia’s health, they took her to the GP or to out-of-hours services. When any immediate problems were resolved, however, parents often did not take her for follow-up or review. This was a similar pattern to MH’s engagement with services in respect of her own health needs, including during pregnancy. As mother and child were registered with different practices, however, this would not have been evident to their respective GPs. FH’s approach to managing his health needs is unknown. 2.36 There were no indicators during this time either that Olivia was at risk of significant harm in her parents’ care or that parents would pose a risk of significant harm to their unborn child. 2.37 How effective were services to family members following Holly’s birth? 2.38 Information provided to the review indicates that Holly was seen twice by community midwives on discharge from hospital. One of these visits would have been on the following day. When Holly was three days old, however; MH called 111 to say that Holly had had yellow skin for two days. MH was advised to speak to the out-of-hours GP service, but there is no evidence that this happened. 10 2.39 Two days later, MH made a second call to 111. On assessment, Holly was found not to be very unwell but, given that this was the second call for a young baby in two days, it was thought that ‘the mother may need some support’. Parents were, therefore, advised to take Holly to the hospital ED. There is no record of Holly being taken to the ED on that date. 2.40 The ambulance service has confirmed that it would not routinely contact the ED to provide details of the call or to check whether the baby had been taken. Had there been safeguarding concerns, however, ‘111 staff are trained to discuss with a Clinical Duty Manager, to raise a safeguarding alert, to alert the hospital and to call the hospital at the end of the time frame to check attendance’. 2.41 At that stage, Holly was still under the care of community midwives and should, on this same day, have had her ‘heel prick’ test. There is no cross-reference to this, however, in the reports available to the review. 2.42 Two days later, now a week old, Holly was taken to see the GP with what was described as a ‘worsening condition’. The GP noted that Holly ‘looked quite jaundiced’. She was also reported to have a ‘sticky’ umbilicus. Holly was referred to the children’s assessment unit for same day assessment. The GP was unaware of 111 calls as parents had not yet registered the baby with the practice. The birth information had been sent to GP practice 1 where MH was registered as a patient. Holly was registered with GP Practice 2 on this visit. 2.43 Holly was taken to hospital and treated with antibiotics and phototherapy. On admission, Holly was found to have a fungal infection in the folds of her skin. A ‘wound’ in one of the baby’s armpits was cleaned and dressed. The chronology notes that it is not clear from hospital records whether staff offered support in respect of infant hygiene and bathing. 2.44 Two days after her admission, Holly was discharged home as jaundice was improving. Oral antibiotics were prescribed for the next five days. The GP practice was informed and information was shared with health visitor. 2.45 The health visiting offer to new-born Holly was again ‘universal’. At that time, this meant eight home visits, to include an extra new-birth visit, a 3-4 month review and a school-ready visit. This increase was part of an improved offer to ‘help health visitors to identify concerns at an earlier stage and refer to additional support’. 2.46 After a number of attempts to make an arrangement with MH, the health visitor made her first new-born visit to the family home five days after Holly was discharged from hospital. Both parents and both children were present. The health visitor gained a positive impression of the family. During the visit, the health visitor talked to parents about the safe care of an infant. 11 2.47 Although notification had been sent to the health visitor from the hospital about Holly’s hospital admission, the health visitor did not recall having received it at this point. In her experience, that would not be unusual given how recently the baby had been discharged. The couple, however, did not refer to Holly’s having been in hospital. As a result, the health visitor was not able to explore the impact of recent events on parents’ confidence and levels of anxiety. She also had no knowledge of potential issues relating to hygiene and skin care. The health visitor would have expected parents to have shared such significant information. 2.48 The next two attempts by the health visitor to see the family at home have been described as ‘failed encounters’. On the second occasion, the health visitor was able to make telephone contact with MH who said that she had been out with her mother-in-law. Holly was said to have ‘some vomiting after feeds’. The health visitor gave MH appropriate advice. 2.49 When Holly was around 2 months old; the health visitor made her 6-8 week review visit to family home. Parents and both children were present. On this occasion, the room was very warm and the health visitor was a little concerned about a rash on Holly’s chest. As the room got cooler, however, the rash faded. The health visitor talked to the couple about temperature control and provided a room thermometer. 2.50 All routine aspects of the second new-born visit were completed and no concerns were voiced or observed. Enquiries in respect of MH’s mental health had a ‘positive response’. MH was seen cuddling and talking to Holly. The health visitor recalled that the couple referred to ‘struggling financially’ and that FH was ‘returning to work soon’. It is not known, however, how long the family had been without his wages or what the impact of this had been. Family support was reported to be continuing, but again no detail was noted in the record. 2.51 As before, the health visitor’s impression of family life was positive. Parents were friendly and relationships appeared relaxed. The family home was well furnished and the children had age appropriate toys. Although a number of appointments had been missed or re-arranged, the reasons that MH gave for changing arrangements had been reassuring. 2.52 Around this time, GP Practice 1 began efforts to determine at which, if any, GP practice Holly had been registered, given that she was not registered with them. The details of interagency communications were not recorded, but it is noted that MH was spoken to and she confirmed that Holly was now registered at GP Practice 2. GP Practice 1 analysis reports, however: “It appears that in endeavours to ensure that the baby was registered with a GP, MH slipped through the net for a post-natal appointment”. The practice notes that this is ‘something we will look into’. 2.53 Over the course of the next 2 months, the health visitor made three visits to the family home but was not able to gain access. The health visitor left a calling card on each occasion but she was not alarmed by the lack of response from parents. In the health 12 visitor’s experience, while difficulty in arranging a new-born visit is somewhat unusual; a significant minority of parents begin to disengage from the service as the baby develops. At this point, the health visitor had completed two of the three core visits expected. 2.54 In mid-June 2018, Holly was not brought to GP for her first round of immunisations: the surgery initiated what is described as its ‘DNA’ protocol. The SCR Panel has discussed the use of ‘DNA’ in respect of appointments for children who rely on their parents or carers to bring them. Since 2018, health practitioners have been encouraged to change their recording in medical records from ‘did not attend’ to ‘was not brought’. The purpose of this change was to shift focus from the fact that the appointment has been missed and rather to emphasise the potential impact on children of health appointments which have not taken place as planned. This is a significant element of the local strategy to improve the early identification of potential neglect. 2.55 In August 2018, Holly was taken to the GP with a viral infection. This was ‘an uneventful examination’: Holly appeared ‘well, happy and smiley’. The GP analysis states that this and any previous presentations were ‘not symbolic of a pattern’ and so were ‘not significant’. At this point, however, Holly was around 5 months old and had not yet started infant immunisation programme. Given Holly’s presentation with a virus, this was perhaps a missed opportunity to explore this with parents. 2.56 Two weeks later, MH was advised to attend out of hours GP service following a 111 call in respect of her own health. There is no evidence that she did so. 2.57 When she was almost six months old; Holly had her first childhood immunisations and developmental review by the GP. Although this was significantly delayed, Holly was found to be developing in line with expectations and systemic examination was also normal. By this point, however, Holly had ‘missed the window’ for rotavirus vaccination which is usually given in two oral doses for babies aged 8 and 12 weeks. Rotavirus infections are the leading cause of infections causing vomiting and diarrhoea among young children in the UK. An appointment was made for second immunisations. 2.58 The following day, the health visitor attempted unsuccessfully to undertake Olivia’s 2-year developmental review. Again a contact card was left. At this point, the family had not been seen by health visitor services for 5 months. The health chronology notes that there was no evidence of a plan in the record to pursue contact or of consideration of the appropriateness of the current health visiting tier. 2.59 During the next five weeks, family members missed four further health appointments. MH did not attend two appointments for asthma review; Holly was not brought to appointment for her second immunisations; and, a re-arranged appointment for final immunisations for Olivia was cancelled by a ‘parent’ as Olivia was unwell. This latter appears to have been the last contact between parents and agencies/ organisations before the emergency calls when Holly was found to be unresponsive. 13 2.60 In summary, therefore; from the time that Holly was born, the family’s pattern of accessing health services continued in a similar way. When parents were concerned about Holly’s jaundiced presentation, they contacted out-of-hours services for advice but they did not follow up recommendations for direct examination. When Holly’s condition showed no improvement, however, she was taken to the GP, from where arrangements were made for her to be admitted to hospital. 2.61 Two core visits were completed by the health visiting service. These appear to have met expectations of practice in terms of delivering safety advice through safe sleeping and temperature control. Although discussion identified potential pressures in respect of FH’s working arrangements the implications were not explored. 2.62 It is acknowledged that it is difficult to build trusting working relationships with parents when contact is limited, either by the nature of the offer or when gaps develop when parents are not at home when visits are planned. This much reduces the chances of creating an environment in which sensitive issues can be discussed. This does not, however, reduce the expectation that professionals will encourage parents to elaborate when conversations reveal stress factors that could affect their capacity to care for their children. 2.63 Throughout the period, a number of health appointments did not take place in a timely manner. In particular, the children were not consistently brought for childhood immunisations and, as a consequence some elements of protection were not able to be given. Similarly, parents did not ensure that the children’s development was reviewed at the usual stages, despite professional efforts. While Holly was found to be developing normally when her early stages development review completed; when Olivia was brought into care, her speech and language were found to be delayed. 2.64 Although parents’ pattern of engagement with professionals might have been consistent with underlying concerns about their care of the children; there were no suspicions of additional concerns such parental substance misuse, domestic violence or parental mental ill health. Home conditions were good. No allegations of poor child care had been made by extended family or members of the community. While there was some evidence of poor hygiene practices; on the basis of information known to professionals at that time, there was no evidence that Holly was at risk of significant harm either through abuse or neglect. Holly’s death, now confirmed to be the result of a criminal act, appears, therefore, to have been unpredictable. 2.65 How effective were safeguarding measures immediately following Holly’s death? 2.66 Professional actions following Holly’s death were consistent with expected practice. Olivia was taken into police protection. She was taken for a child protection medical where she was found to have an unexplained bruise on her cheek. Non-accidental injury could not be ruled out but the primary concern for her safety was the risk of harm from parents who were suspected of causing her sister’s death. 14 2.67 A child protection strategy meeting was held and child protection enquiries began. Both parents had obtained independent legal advice and they agreed to Olivia being accommodated by the local authority when police protection expired. As noted earlier, Olivia subsequently became the subject of care proceedings. 2.68 What work by agencies had a positive impact on family members? 2.69 Good midwifery care throughout both pregnancies ensured that the risks to both mother and infant were minimised, resulting in the safe delivery of healthy babies and a well mother. As already indicated, health visitors supported parents to manage Olivia’s nutritional needs when there were concerns about her weight. 2.70 GPs treated the children for minor ailments as they were brought to their attention, initiated immunisation programmes and referred for paediatric assessment when required. MH appears to have had confidence in her GP practice, as she chose to remain there despite the children receiving services elsewhere. As with the children’s GP, GP Practice 1 responded quickly when MH recognised that her own condition was becoming critical. The practice was also active in ensuring that Holly was registered with a GP. 2.71 Olivia was protected when concerns were identified about the circumstances of Holly’s death. 2.72 What steps could have been taken to improve the service provided to family members? 2.73 Professionals recognised that MH and FH were young parents and that this was a vulnerability. As a result, they attempted to engage the couple with the range of resources which are designed to support prospective, new and, in particular, young parents. When offers of services and community support were declined, however; there appears to have little attempt to establish the nature of the support being provided by family or to consider whether there might be outstanding need. 2.74 The midwifery/ health visitor agency analysis acknowledges that midwife records are ‘factual and practical’, reflecting more of a ‘medical’ model than a ‘person –centred’ approach. As a result, the record gives little sense of MH as a young person or of her experience as a young mother living away from home. At the same time, while the health visiting model of care was more ‘holistic’, the records did not provide an understanding of either parent’s background or family members’ lived experiences. The analysis suggests that a more enquiring approach could have built a better understanding of parents’ history and everyday lives. 2.75 The relevant health trust report acknowledges the need to gather clearer information about children’s lived experiences and to record these appropriately. It indicates that this 15 now forms part of mandatory training. It is expected that information on the child’s lived experience will be documented within the electronic universal templates. 2.76 Although inconsistent engagement was a key characteristic of parents’ habitual response to health services; the reasons for this were never explored. Communication between health disciplines was also less than optimal. In particular, the importance of communication between midwifery and health visiting services is highlighted as fundamental to service delivery. The agency analysis recognises that ‘the lack of information sharing in this case, particularly during MH’s first pregnancy…may have impacted on her engagement with the health visiting service’. 2.77 GP Practice 2 has identified that there was no communication between the practice and health visiting services during much of the review period. The GP attributes this to the changes to health visitor provision which meant that weekly visits with a named health visitor no longer took place. In fact, the review has been assured that the practice does have a named health visitor and the Designated Nurse (CCG) has ensured that the practice has been given the details. 2.78 Both GP practices acknowledge that there were some difficulties caused by MH being registered at a different practice from the children and their father. The case review panel commented that this seemed an unusual arrangement although the CCG described it as ‘quite common across (the town)’. The Designated Nurse (CCG) has indicated that this practice could be considered to be a weakness from a safeguarding perspective and that, where possible, families are encouraged to use a single surgery. 2.79 What actions have agencies taken or do they propose to take as a result of what they have learned from their reviews of practice? 2.80 The health agency analysis has identified there was no pathway in place to support staff in managing this risk of not being able to see children at home. It notes that ‘a robust pathway that considers the potential impact of vulnerabilities… would enable staff to persist in their follow-up with families where increased risk factors are identified’. It has been reported to the review that there has been some progress in respect of this issue but conversation with the health visitor identified that details of a new pathway have not yet made their way to local practitioners. 2.81 GP Practice 1 has identified that review processes for patients such as MH could be improved and also intends to ‘look into’ a system to minimise the chance of missing post-natal appointments. 2.82 GP Practice 2 has developed a workflow protocol for new born babies and under -5s to ensure that notifications of new born babies are monitored so that they can be registered with the practice, irrespective of whether the mother is a patient. Systems to improve attendance for immunisations are included in the protocol. 16 2.83 Family members were not known to police other than in the circumstances described within the key lines of enquiry. Practice by officers was consistent with agency expectations and so no additional lessons were learned. 2.84 Education/ the parents’ school have not identified any lessons or suggested any actions for change. 2.85 What is the impact on learning of information about family life obtained since Olivia has been looked after? 2.86 Two court processes were initiated following Holly’s death; the criminal case and public law proceedings in respect of Olivia. The criminal case concluded before trial when MH’s plea was accepted by the CPS. Both legal processes have had access to, and the capacity to interrogate, information and testimony which was not available to this review. The local authority has, however, provided the Partnership with some details of family life obtained through assessments commissioned as part of care proceedings. 2.87 It is reported that MH and FH had been a relationship since they were in school. MH moved to live with FH’s family when she was 16 years old. As noted above, the couple remained in the household until Olivia was almost 18 months old. FH was one of a large number of siblings and step-siblings. His family is described as having provided ‘a stable and supportive family experience with a good network of support’. CSC indicates that FH and MH relied heavily on support for paternal family, particularly PGM, ‘for many aspects of caring for the children’. When the family moved into their own accommodation, PGM and paternal uncle provided child care, financial help, and assistance with domestic chores, such as shopping and cleaning. MH told CSC, however, that she had been unable to leave the house alone with the two children as ‘she did not have a double buggy’. 2.88 As noted earlier, at the point that Olivia became looked after, her speech was delayed. Although she appeared to have a good level of understanding, she had limited production of language. She has since been referred to Speech and Language Therapy and, at the last report, was ‘making good developmental progress with her foster carer’. Olivia is said to present as ‘quite an anxious’ child who took time to settle with her carers and who continued to demonstrate anxiety behaviours when she experienced change. It is not known to what extent this anxiety was an existing condition or was the result of the events which so suddenly changed her everyday life. Information relating to Olivia’s understanding of what happened to her sister has not been given. 2.89 CSC records indicate that parents were ‘not together as a couple’ prior to Holly’s death, but that they continued to live in the same house. This was not known to health professionals. 2.90 In assessments, both parents spoke about ‘arguing over money and blaming each other for not being able to pay the bills’. FH is described as having worked long hours and, as noted above, MH has said that she was unable to leave the house in his absence. It is likely, 17 therefore, that the primary responsibility for everyday child care was MH’s, albeit with support from wider family. 2.91 Establishing a good bedtime routine appears to have been a challenge for parents. MH, in particular, is said to have ‘found some elements of parenting difficult’, including ‘Holly screaming at night’. It is not known to the review to what extent FH or other family members were aware of MH’s struggles. 2.92 Overall, new information from CSC confirms that paternal family provided active support to parents in a variety of ways. It also identifies additional pressures on MH and FH which had not previously been recognised. The reported breakdown in parents’ relationship, financial concerns and the tiredness induced by everyday living are particularly significant. Those pressures are likely to have had an impact on parents’ capacity to provide the children with the care they needed. It is possible that, had a fuller picture of family life emerged, additional community support could have been provided which could have helped alleviate parental stress. The family history suggests, however, that such offers may well have been refused. 3. Analysis 3.1 When multi-agency reviews are undertaken in respect of children who have died as the result of abuse or neglect, it is compelling to believe that there must have been signs, which if responded to differently, could have prevented the loss of that life. As described in the key lines of enquiry, however, there is no such evidence in Holly’s case. Although a number of vulnerabilities have been identified (some with hindsight); Holly was not obviously a child in need or at risk of significant harm. This, therefore, ‘brings into sharp relief the unpredictability of many deaths or serious harm in the context of child abuse2’. 3.2 At the same time, elements of the learning identified by single agency analysis are reflected in a previous local SCR (Child CE) recently published by the Children’s Safeguarding Assurance Partnership. That review emphasised the need for professionals to be ‘actively curious about members of the household, family dynamics and actual, or potential, risks to children’. In addition, as analysis in this case reveals, professionals should particularly ensure that vulnerabilities identified at an earlier stage in work with the family reduce rather than increase over time. The importance of reference to records and communication between disciplines are highlighted as significant in supporting this practice. 3.3 This review makes no recommendations for changes to multi-agency safeguarding practice. The dissemination of the report’s findings will, however, offer an important opportunity to remind professionals of the particular safeguarding risk factors associated with babies and very young children and what those risk factors mean for practice. 2 Child Safeguarding Practice Review Panel Annual Report 2020 18 3.4 Primarily, it should be remembered that children under 1 are the most likely age group to die through abuse or neglect3. Children under 1 have also been consistently a high proportion of subjects of serious incident reports and serious case reviews4. Learning from such reviews has, over the years, informed changes to midwifery ‘screening’ for parental risk factors and to the advice given to all new parents in respect of safe handling of babies and safe sleeping. A summary of risk factors and learning for improved practice with infants was published by NSPCC in 2017 and provides a helpful guide for professionals working with families where there are children under 2. 3.5 It is also notable that, as a consequence both of the incidence of serious incidents involving non-accidental injuries to babies and of the levels of violence involved; the national Child Safeguarding Review Panel intends to make non-accidental injuries to babies the focus of its next thematic national review. It is understood that the Panel has already a commissioned a literature review and undertaken preliminary work. Publication of learning from that review will offer the Partnership another opportunity to reinforce the messages for safeguarding practice with babies and very young children. 4. Recommendation The Safeguarding Partnership should ask agencies which have contributed to the review to provide evidence that they have completed proposed actions and, where possible, to summarise their impact. IC 12/04/21 3 NSPCC Statistics briefing, child deaths by abuse and neglect September 2020 4 Ofsted, Ages of Concern 2011 and Child Safeguarding Practice Review Panel: Annual Report 2018-2019 |
NC52370 | Sexual abuse of several children over a period of time. The perpetrator was found guilty of numerous offences of child sexual abuse against known and unknown children and given a sentence of life imprisonment with a minimum term of 25 years in prison. Learning includes: think the unthinkable and maintain professional curiosity in work with children and families; reflect on cases to fully explore and understand what is happening within a family rather than make assumptions or accept the situation that is being presented. Identifies a number of strengths in multi-agency responses where the children were already known to services, including good record keeping, information sharing and communication; and evidence of children's voices being sought and listened to. Makes no recommendations but the learning has been embedded in the local safeguarding children partnership child sexual abuse strategy.
| Serious Case Review No: 2022/C9337 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. Case H Local Child Safeguarding Practice Review (LCSPR) Page 1 of 2 Case Summary A Local Child Safeguarding Practice Review (LCSPR) was commissioned to consider a case where several children had been sexually abused over a period of time. The Perpetrator was resident in the same area as the children. Following a police investigation and examination of extensive evidence, the perpetrator was found guilty of numerous offences of child sexual abuse against known and unknown children and given a sentence of life imprisonment with a minimum term of 25 years in prison. There were a number of identified strengths in multi-agency responses where the children were already known to services: • Good record keeping and information sharing between agencies was in evidence. • Good general communication between agencies and no identified barriers. • Evidence of children’s voices were in general being sought and listened to. • Evidence of CAMHS, non-statutory counselling services and school raising and reporting safeguarding concerns appropriately. The reviewer found that no agency either separately or together made any judgements or actions in this case that would generate recommendations for action, and the multi-agency panel were unanimous in agreeing with this finding. Individual practice decisions were carefully considered and, in some cases, questioned as part of the review, however there were no indicators of systems failures and there were no deficits in multi-agency working which might otherwise have exposed the abuse. When any sequence of events is forensically examined, areas of deficit in best practice will be found. The agencies where improvements in practice were identified had already recognised and addressed them. The Police recognised a need to review their responses when attending domestic incidents to remain open to possible child safeguarding issues and action has been taken to bring about changes which have been reviewed in subsequent inspections of the service. Social Care recognised that staff must maintain professional curiosity, to contextualise information received with prior knowledge, and be prepared to think the unthinkable. Reflections on cases reviewed across the country as well as the briefing on the theme of Child Sexual Abuse held on the NSPCC website will be incorporated into the existing local safeguarding training offer and reflected in the local SCP Child Sexual Abuse Strategy. Training is already in development to support procedures including reminders for practitioners of the need to think the unthinkable and retain professional curiosity at all times. Agencies may also wish to assure themselves through existing internal audit frameworks, that there are no systemic issues present, that staff are professionally curious, and that management oversight and safeguarding supervision enables reflection on cases and prior case knowledge, encouraging practitioners to ‘think the unthinkable’. Themes in common with other reviews The NSPCC holds a range of case review reports from across the country with the theme of Child Sexual Abuse. In 2020 they considered case reviews published since 2017, where children experienced sexual abuse and they produced a briefing paper. Case H does have an area in common with the other reviews around the need to maintain a respectful uncertainty and professional curiosity at all times to guard against accepting alternative explanations for sexual abuse. This is particularly applicable to more vulnerable children. Professionals should challenge one another through positive, robust questioning of child protection decisions, practices, and actions. Case H Local Child Safeguarding Practice Review (LCSPR) Page 2 of 2 “The learning from these case reviews highlights that professionals must be able to recognise and respond to sexual abuse. Professionals need to be able to work effectively within multi-agency frameworks to ensure all information is shared and acted upon via suitable processes and in a timely manner. Professional curiosity should be displayed in interactions with families, carers and other practitioners to ensure that the child’s safety remain the focus and are appropriately addressed.” (NSPCC 2020) If you do one thing take the time to….. Think the unthinkable and maintain professional curiosity in your work with children and families, reflect on cases to fully explore and understand what is happening within a family rather than make assumptions, or accept the situation you are being presented with. How this learning was achieved The review was commissioned by the SCP and an external reviewer was appointed. The terms of references for the review included the following lines of enquiry: • Were the decisions and actions taken by agencies reasonable and proportionate in the circumstances? • Were there any other actions that should have been taken? • Were there any gaps in information sharing within and between agencies that could have informed ongoing work and assessment? • Are there lessons to be learnt that would inhibit such offences being committed in the future? • Was the voice of the child sought, and acted upon appropriately? • Was there sufficient professional curiosity and / or professional challenge in this case? • Were there any missed opportunities for single or multi-agency working in this case? The reviewer was given access to scoping information and a combined chronology. The reviewer met with practitioners and managers via Microsoft Teams (due to pandemic restrictions) from across a range of agencies. The reviewer wrote to the families involved to explain the purpose and scope of the review and to offer an opportunity if they wished to contribute to the review, or had anything they wished to say, but they all declined the offer. The reviewer wrote to the perpetrator to offer an opportunity for them to contribute to the review which they accepted and subsequently the reviewer met with them in prison. This meeting did not add anything new to the review since the perpetrator was either unwilling or unable to assist, minimising and now partly denying their offending, though they did acknowledge harming the children emotionally. Training and resources The SCP already offers a variety of face to face and online training courses for the children’s workforce including elements of child sexual abuse. The SCP will shortly publish a Child Sexual Abuse Strategy, toolkit, and training to support existing procedures and resources. The SCP maintains a policies and procedures website which includes information on child sexual abuse published reports on the theme of child sexual abuse can be found on the NSPCC website. |
NC047223 | Death of a 12-week-old baby boy whilst co-sleeping with his mother. Police arrested the parents, following anonymous allegations of heavy drinking and drug taking in the family home, but there was insufficient evidence and no further action was taken. No concerns were identified about the care of Baby D before or after his death. A range of agencies had been working with the family due to the increasingly challenging behaviour of Baby Ds half-sibling Child P. Mother had reported feeling overwhelmed by Child Ps behaviour, and a social work assessment had taken place the day before Baby Ds death. Issues identified include: need for some improvement in agencies delivery, recording and coordination of advice about safe sleeping and need for improved public and professional awareness of the issue of safe sleep. Recommendations for the local safeguarding children board (LSCB) include: consider introducing consistent safe sleep assessment and recording arrangements for health professionals and carry out regular audits to evaluate the delivery and recording of safe sleeping advice.
| Title: Baby D: a serious case review. LSCB: Suffolk Safeguarding Children Board Author: Kevin Harrington Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Kevin Harrington Associates Limited BABY D A SERIOUS CASE REVIEW Kevin Harrington JP, BA, MSc, CQSW Page 2 of 18 CONTENTS CONTENTS .................................................................................................. 2 1. INTRODUCTION ...................................................................................... 3 2. ARRANGEMENTS FOR THE SERIOUS CASE REVIEW ....................... 3 3. METHODOLOGY USED TO DRAW UP THIS REPORT ......................... 4 4. FAMILY BACKGROUND ......................................................................... 5 5. THE INVOLVEMENT OF THE AGENCIES CONTRIBUTING TO THIS REVIEW ................................................................................................... 5 6. THE FAMILY ............................................................................................ 8 7. THE AGENCIES ...................................................................................... 8 7.1 Introduction ...................................................................................... 8 7.2 The General Practitioner ................................................................. 9 7.3 West Suffolk Hospital NHS Foundation Trust. .............................. 9 7.4 Suffolk County Council: Health Visiting and School Nursing Services ............................................................................................ 9 7.5 East of England Ambulance Service NHS Trust ......................... 10 7.6 Suffolk Constabulary .................................................................... 10 7.7 Suffolk County Council, Children’s Social Care Services ......... 11 7.8 Ipswich and East Suffolk CCG and West Suffolk CCG: Health Overview Report ............................................................................ 11 8. KEY THEMES ........................................................................................ 11 8.1 Safe Sleeping for Babies .............................................................. 11 9. RECOMMENDATIONS .......................................................................... 14 APPENDIX A: THE LEAD REVIEWER ..................................................... 15 APPENDIX B: TERMS OF REFERENCE .................................................. 16 Page 3 of 18 1. INTRODUCTION 1.1 This report concerns a baby, referred to in the report as Baby D, who died at the age of 12 weeks. He had slept in the same bed as his mother who awoke to find that he had died during the night. 1.2 These matters were brought to the attention of the Suffolk Local Safeguarding Children Board (SLSCB). The Chair of that Board, Ms Sue Hadley, decided that the circumstances of the child’s death required that a Serious Case Review (SCR) should be conducted, in line with the government’s guidance1. This is the Overview Report from that SCR. 1.3 An SCR must be carried out when a child dies and there are concerns that the child may have been abused or neglected. In this case those concerns related only to the issue of whether the sleeping arrangements for the child had been safe and satisfactory on the night of his death. There had been no previous concerns about the care of Baby D, and none emerge from this review. 2. ARRANGEMENTS FOR THE SERIOUS CASE REVIEW 2.1 This SCR was formally initiated by Ms Hadley on 24th August 2015. The SLSCB appointed an experienced independent person – Mr Kevin Harrington2 - to act as Lead Reviewer and to write this report. Mr Harrington has been assisted by the officers of the SLSCB and a reference group of senior representatives from the agencies which had been involved with the family of Baby D. 2.2 All those agencies were required to submit a chronology and a report containing an analysis of their involvement. Those agencies are detailed in the table below, and are subsequently referred to by the acronyms / abbreviated forms provided. AGENCY NATURE OF INVOLVEMENT Suffolk Constabulary Investigated the circumstances of the death to determine whether any crime had been committed Suffolk County Council, Children and Young People’s Services (CYPS) No significant involvement in respect of Baby D Suffolk County Council Health Visiting services Provided a full health visiting service following the birth of Baby D Suffolk County Council School Nursing service No involvement in respect of Baby D The General Practitioner Provided GP services to the family throughout the period under review 1 “Working Together to Safeguard Children” (2015), referred to in this report as Working Together 2 Appendix A of this report contains brief autobiographical details, Page 4 of 18 Health overview report – Ipswich and East Suffolk Clinical Commissioning Group (CCG) and West Suffolk CCG This agency has provided an overview of all NHS services provided to the family East of England Ambulance Services Involved only in conveying Baby D to hospital following his death West Suffolk Hospital NHS Trust Maternity services 2.3 The Terms of Reference for the review, adapted so as to be suitable for publication, are at Appendix B. They are drawn from Working Together 2015, amended to reflect issues specific to the circumstances of this case. 2.4 The agencies were asked to review their involvement with the family during the two years before the death of Baby D. This was because some agencies had been significantly involved during that time with an older half-sibling, a child of the mother, Ms M, from a previous relationship. This child is referred to in this report as Child P. 2.5 The Terms of Reference for the review state that “The timeline of involvement with the sibling, pre-dating the birth of the subject, will be an important reference for the review.” It is important when conducting reviews such as this that the events leading to the review are seen in the context of the contributing agencies’ overall involvement with the family. However, it is also right to emphasise that this is not a review of the agencies’ involvement with Child P. That involvement did not arise from safeguarding concerns. There is nothing in the agencies’ contact with the family in respect of Child P which would lead to a Serious Case Review being carried out. On the conclusion of this review the content of this report which does refer to Child P was shared with his father. 3. METHODOLOGY USED TO DRAW UP THIS REPORT 3.1 This report is based principally on the Management Reviews and background information submitted by the agencies, subsequent Panel discussions and dialogue with the agencies and the family. 3.2 This report consists of A factual context and brief narrative chronology. Commentary on the family situation and their input to the SCR. Analysis of the part played by each agency, and of their submissions to the review. Identification and analysis of key issues arising from the review. Conclusions and recommendations. Page 5 of 18 3.3 The conduct of the review has not been determined by any particular theoretical model but it has been carried out in accordance with the underlying principles of the statutory guidance, set out in Working Together. The review “recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight3; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings”. 3.4 The government has introduced arrangements for the publication of Overview Reports from Serious Case Reviews, unless there are particular reasons why this would not be appropriate. This report has been written in the anticipation that it will be published, and it is suitable for publication. 4. FAMILY BACKGROUND 4.1 Baby D’s family are white British and have lived in Suffolk for many years. Baby D lived with his mother, his father Mr F, and his half-brother. Previously Ms M had been married to Mr G, the father of Child P. 5. THE INVOLVEMENT OF THE AGENCIES CONTRIBUTING TO THIS REVIEW 5.1 Child P started school in 2013, by which time the parental relationship was in difficulties: Ms M and Mr G were to divorce later that year and there is evidence that their separation was acrimonious. 5.2 Child P’s behaviour at school gave cause for concern from an early stage, although the head teacher has reported that there was no history of this at pre-school. Ms M consulted the family GP about this, reporting a range of behavioural difficulties. From then on, throughout the period under review, there was mounting evidence of cause for concern about the behaviour of Child P, which became extremely challenging, and his family’s ability to manage this. 5.3 A range of agencies worked intensively with the family to try to tackle this. The relationship between the birth parents remained strained but both of them, and other family members, tried to co-operate and work with the agencies. However there is little evidence of any enduring improvement in the situation, which will have been very stressful for the family. Those pressures will have been compounded at times by housing problems – they moved house not long before Baby D was born - and some financial difficulties. 3 This review does not rely on hindsight, and tries not to use hindsight in a way that is unfair. It does use hindsight where that promotes a fuller understanding of the events and their causation. Page 6 of 18 5.4 In July 2014 Ms M’s pregnancy with Baby D was confirmed. At her first contact with ante-natal services it was recorded that Ms M said that she had previously used cannabis and alcohol. (When interviewed for this review she said that she had never used cannabis and made no such comment). She went on to make full and appropriate use of maternity services throughout the pregnancy. She proactively contacted midwives to talk about the stress she was experiencing as a result of the difficulties with Child P, and was also assisted with this during the pregnancy by her GPs. 5.5 Ms M had some ill health during the pregnancy and spent some days in hospital on two occasions. Baby D was then born prematurely, at nearly 36 weeks’ gestation, following a difficult labour. There were some post-natal complications requiring treatment on a neonatal ward but in due course Baby D was routinely discharged from midwifery care. 5.6 The Health Visitor’s New Birth Visit was carried out when Baby D was two weeks old. The Health Visitor recorded that there was good attachment between baby and mother and that the home conditions were good. At a follow up visit a week later the Health Visitor again noted good attachment and that the baby was content and feeding well. 5.7 During these weeks after the birth of Baby D agencies noted some improvement in Child P’s behaviour and decided to decrease some of their intensive interventions with the family, although investigations to explore the underlying causes for Child P’s problems continued. There is evidence of liaison between school nursing staff, dealing with Child P, and the Health Visitor about this. However the improvements noted were very short-lived and, after a week, agencies decided that the previous level and nature of their input should be restored. 5.8 Around this time the Health Visitor saw the family at home for the third time, when Baby D was about six weeks old. The Health Visitor again noted good attachment between baby and mother and good home conditions. The baby had gained weight, although parents reported some feeding difficulties and the Health Visitor gave advice appropriately, planning to review the situation in two weeks’ time. 5.9 The family took Baby D to the GP for the routine 4-8 week post-natal check, and the GP described him as alert, attentive and gaining weight appropriately. His mother spoke again about feeding problems and the GP agreed that this would be monitored. 5.10 The agencies working with the family in respect of Child P were concerned about the stress Ms M was experiencing and her low mood, and shared information about this. The Health Visitor again visited the family and spoke with Ms M about her worries, all of which related to Child P rather than the baby. The Health Visitor made an appointment for Ms M to see her GP although she did not in fact see the GP on this occasion, because of a misunderstanding as to which GP she was registered with. Page 7 of 18 5.11 The Health Visitor called to the home again the following day, on this occasion to carry out their routine “six week visit”. The situation with Baby D remained the same, with age appropriate development observed, good attachment from both parents who were seen to handle the baby confidently and gently, while the home remained clean and tidy. 5.12 However the agencies dealing with the family in respect of Child P were becoming increasingly concerned about that situation. Despite intensive, co-ordinated input Child P’s behaviour was causing mounting concern, as was Ms M’s ability to cope with this. There was an additional concern in that Mr F was now working away from home during the week, so that the pressures on Ms M became greater. One of the lead professionals working with the family discussed the situation with the Health Visitor and they agreed to visit together. 5.13 Before they were able to do so agencies were alerted to a situation in which Ms M’s whereabouts could not be traced for several hours. Family members cared for the children until Ms M made contact, reporting that she had become overwhelmed by the situation and needed time alone. Ms M spoke to various professionals and agreed that a referral should now be made to the local authority’s Children and Young People’s Services (CYPS). 5.14 The referral was made by the school which Child P attended and arrangements were made for a social work assessment. That assessment was arranged jointly with the lead professional who was already involved with the family and went ahead without delay. Ms M told these professionals that she did not think she could continue to care for Child P. This led to discussions with Child P’s father and an agreement that with immediate effect Child P would move to live with him. 5.15 Sadly, Baby D died the following day. Ms M had brought the baby to sleep with her and woke to find that he had died during the night. Emergency services were called and he was taken to hospital but it was confirmed that he had been dead for some time. A police investigation was commenced in line with standard arrangements in such circumstances. 5.16 It emerged that Baby D’s parents and some friends had been drinking at a local public house the evening before the death. It was later said that they and friends then returned to the family home where more alcohol was consumed, and it was alleged that some of those present were using illegal drugs. In that context, although there was no suggestion that there was any maltreatment of Baby D, the decision was taken that this SCR be carried out. Page 8 of 18 6. THE FAMILY 6.1 Baby D’s mother and father were visited twice by the Safeguarding Board Manager in connection with this review. At the first visit, in October 2015, they were formally advised that this SCR was being carried out and why that was necessary. The purpose of the second visit in February 2016 (when the Lead Reviewer was unable to attend) was to explain the outcomes of the review and to go through this report with them. On both occasions their distress, and particularly that of Ms M, was very evident. 6.2 They told the Board Manager that overall they felt this report appropriately reflected the events leading up to the death of Baby D. However Ms M expressed her concerns regarding the recording made by the midwife at the early stage of her pregnancy, that she had previously used alcohol and cannabis. Ms M wishes it to be known that she had never used cannabis and stated that toxicology tests following her child’s death showed no evidence of the drug. 6.3 The parents said that they had not received any information about safe sleep or co-sleeping from any of the health professionals with whom they had contact. Ms M also said that while in hospital following the birth of Baby D she had the baby in bed with her, day and night. She reported that, although she was warned that the baby might fall out of bed, nothing was said about the dangers of co-sleeping. 6.4 This is not consistent with the reports to this review from the hospital and other agencies. It is not the policy of West Suffolk NHS Foundation Trust to advocate or facilitate co-sleeping. The agencies’ accounts, including the extent to which contemporaneous records were made, are described elsewhere in this report. The conflicts between these accounts will not now be resolved but, in any event, it is clear that the key lessons to be learned from this review do relate to safe sleeping. 6.5 The parents also reported some dissatisfaction with the nature and quality of their contact with some of the maternity services provided. The detail of those comments, which do not relate to safeguarding, has been fed back to the relevant agencies. 7. THE AGENCIES 7.1 Introduction 7.1.1 This section of this report considers the involvement of each of the agencies contributing to this review, in the order that they appear in the chronology, highlighting any key lessons learned. 7.1.2 “Safe sleeping”, the only significant cross-cutting issue to arise from this review, is considered separately below. Page 9 of 18 7.2 The General Practitioner 7.2.1 The GP was appropriately and fully involved with the family throughout the period under review. Ms M chose to stay with this GP even after moving some distance away because she valued the quality of care provided. The Management Review summarises this: “The primary care offered to both children and Ms M in her care for them was of an excellent standard and does not give rise to any “lessons learned”. 7.3 West Suffolk Hospital NHS Foundation Trust. 7.3.1 This hospital provided maternity care for Ms M and her baby. Ms M was entirely co-operative with maternity services and there are no issues arising, relevant to this review, in respect of the clinical care provided during the pregnancy and thereafter, although, as described above, the family have now expressed some dissatisfaction with aspects of the service provided. 7.3.2 The hospital has identified some weaknesses in record keeping. Staff had not fully complied with requirements accurately to document routine enquiries about domestic abuse and misuse of alcohol. Staff will be reminded of these requirements although there is no indication of any domestic abuse during the review period, and no firm evidence that misuse of alcohol affected the care of Baby D. 7.4 Suffolk County Council: Health Visiting and School Nursing Services 7.4.1 The report from this agency is particularly significant in the sense that the Health Visitor was the professional who had most contact with the family directly in respect of Baby D. 7.4.2 The report notes some issues relating to record-keeping but otherwise there is clear evidence that the Health Visitor‘s input was timely, proactive and in line with good professional practice standards. The Health Visitor was also alert to the issues relating to the older child, liaised appropriately with the relevant services and recognised the potential implications for Baby D. The Management Review reflects that “Baby D’s health records indicate no concern for his health, development, care and attachment with his parents…Attachment had been considered at all contacts between him and his parents, and lots of positive interaction recorded including confident and gentle handling. He lived in a clean tidy home with loving parents and the health visitor had never seen any evidence of substance use (alcohol or drugs)”. 7.4.3 School nursing services were involved only in respect of Child P. Page 10 of 18 7.5 East of England Ambulance Service NHS Trust 7.5.1 This service was involved only in attending the home and conveying Baby D to hospital where his death was confirmed. The report from this service notes that the call they received was allocated the highest priority, but that they were unable to attend within the target time of 8 minutes. Instead it took 11 minutes for the ambulance to arrive. This is attributed to the remote location and the distance the ambulance had to travel. On arrival the crew immediately identified that Baby D had already died and it was futile to attempt resuscitation. No learning points arise for the service from their limited involvement in this case. 7.6 Suffolk Constabulary 7.6.1 Police had no significant involvement with any family member prior to the death of Baby D. 7.6.2 Police and ambulance services were called to the family home by Mr F following the discovery that Baby D had died. A police investigation commenced. The parents gave an account of going to a local public house and returning in the early evening before settling down for the night. Ms M fell asleep with Baby D in her arms and awoke to find that he had died. There was no indication of any injury to the child. Police inspected the home and found it clean and tidy. Nothing about the parents’ presentation or demeanour gave any cause for concern. 7.6.3 Police concluded that the death was unexplained; that there were no suspicious circumstances and it was a tragic accident. The matter was to be referred to HM Coroner and a subsequent post mortem gave the cause of death as Sudden Unexplained Death in Infancy or Childhood (SUDIC). 7.6.4 Some days later police received anonymous information to the effect that they had been given an inaccurate/incomplete account of the events prior to the death. It was alleged that a number of people had been involved in the events at the public house and the family home on the evening before the death, and that illegal drugs had been taken. It was further said that, when the body was found, attempts had been made to conceal the events of the previous evening and to tidy up the home before emergency services were called. 7.6.5 This raised the possibility that an offence may have been committed. Police carried out new investigations which to a limited extent confirmed the anonymous report received. A number of people had been at the home, there was some noise nuisance and some of those present were drinking heavily. Both parents were arrested in the course of these enquiries. However police concluded that there was insufficient evidence to meet the “Full Code Test4” and no further action was taken in relation to any prosecution. 7.6.6 Police have identified key issues which they took into account. The parents’ evidence had not been entirely consistent and there were allegations that Ms M 4 The “Full Code Test” sets out the principles to be followed by police and prosecutors in making decisions on whether or not to charge a suspect. Page 11 of 18 was drunk, although equally there was evidence that she consumed little or no alcohol. She has been absolutely clear that she was not drunk, and in fact did not drink at all as she was driving. 7.6.7 There was no independent or toxicology evidence to support the allegations made, while ambulance and hospital staff did not have any concerns about the parents’ presentation. Most importantly, the pathologists’ findings were inconclusive and there was evidence that, prior to these events, the care of Baby D had been of a high quality. 7.6.8 In their report to this SCR police confirm that their management of this situation was necessary and appropriate. The situation was dealt with in line with the Constabulary’s policy and procedures and no new learning points arise from this review of their involvement. 7.7 Suffolk County Council, Children’s Social Care Services 7.7.1 The local authority’s CSC service has provided a full review of their work but this relates almost entirely to the “Early Help” services provided in respect of Child P. There are no matters arising from the brief involvement of social workers just before the death of Baby D. 7.8 Ipswich and East Suffolk CCG and West Suffolk CCG: Health Overview Report 7.8.1 The Designated Nurse for Child Protection from the Ipswich and East Suffolk CCG and West Suffolk CCG has submitted a report which takes an overview of the work of the NHS agencies involved. The key issues from that report are reflected above in respect of each agency. 8. KEY THEMES 8.1 Safe Sleeping for Babies 8.1.1 This SCR is unusual in that in almost every respect the care of Baby D was exemplary and he was a much loved, healthy child. The issue which has led to this SCR is the sleeping arrangements on the night that he died. 8.1.2 On that night Baby D and his mother slept together in the same bed – often referred to as “co-sleeping”. This is not an unusual practice. The National Childbirth Trust (NCT) has suggested that perhaps half of the mothers in the UK co-sleep with their baby at some time. 8.1.3 However it is clearly evidenced5 that there is an association between co-sleeping and Sudden Infant Death Syndrome (SIDS). Consequently the 5 See, for example, Mitchell, E., 2010. Bed sharing and the risk of sudden infant death: parents need clear information. Current Paediatric Reviews, 6(1), pp.63-66. Page 12 of 18 Department of Health has advised that co-sleeping is inadvisable when one or both parents: Is a smoker. Has consumed alcohol. Has taken any drugs, prescription or otherwise, that might cause drowsiness or affect how deeply you sleep. May be extremely tired. 8.1.4 The risks of co-sleeping are also increased where a baby: was born prematurely (37 weeks or less). had a low birth weight (less than 2.5kg or 5.5lb). has a fever or any signs of illness. 8.1.5 It can be seen that there are some correspondences between these risk factors and the circumstances in which Baby D died. This is not to say that the death was a consequence of one or more of the associated issues, but the association should be recognised, and forms the basis for the decision to conduct this SCR. 8.1.6 As a result of the growing recognition of the risk factors associated with SIDS, all relevant agencies have increased the extent to which they require staff to talk to families about safe sleeping. Each of the NHS agencies involved in this SCR has considered this and reported back as follows: Neither the GP nor the midwife gave any safe sleeping advice to the family, assuming that the Health Visitor would do so. The Health Visitor did not give safe sleeping advice ante-natally – there was no ante-natal contact with the Health Visitor because of confusion about the family’s address. The Neonatal Unit gave detailed advice about safe sleeping, including co-sleeping, both verbally and in writing, and this is documented. It is not the policy of West Suffolk NHS Foundation Trust to advocate or facilitate co-sleeping. The Health Visitor gave detailed advice about safe sleeping on two post-natal visits, but did not make a note of having done so on the child’s records. So, some advice was given appropriately but there is room for improvement for the agencies to meet the standards they set themselves, and in the overall co-ordination of how advice is given. 8.1.7 The SLSCB has also provided the following account of the work carried out to improve public awareness and staff awareness, of the issue of “safe sleep”. “The SLSCB held a Safe Sleep Launch in 2014 in partnership with the Lullaby Trust. 65 delegates attended. Safe Sleep guidelines were produced. The guidelines’ purpose is to support practitioners to give appropriate information In December 2014, The National Institute of Health & Care Excellence (NICE) recommended all healthcare professionals and families be fully informed of the association between co-sleeping and SIDS. Page 13 of 18 and advice to parents/carers to enable them to make an informed choice about safer sleeping arrangements for their babies. Leaflets, posters and links to Safe Sleep Advice are on the SLSCB website. Safe sleep leaflets were promoted with midwives and health visitors in particular and information packs sent out to children’s centres. http://suffolkscb.org.uk/information-and-links/safer-sleep/ A professional’s newsletter went out from the LSCB in December 2014 giving safe sleep information to professionals. Information for teachers was included as part of the PSHE framework for parenting sessions. A further initiative was run by Public Health6 in 2015. The Health and Wellbeing Board website ‘Health and Wellbeing Suffolk’ have a Safer Sleeping Suffolk web page with a range of videos, leaflets posters etc. A printable safer sleeping guide was produced and there is a short video that includes key information regarding drinking, smoking, co-sleeping etc. There was media coverage at the time and circulation to professionals to ensure that safe sleep messages were delivered to all new parents. Midwives and health visitors both ask about safe sleeping arrangements and give out leaflets. http://www.healthysuffolk.org.uk/projects/safer-sleeping/ Further Safe Sleep events will be run in Spring 2016”. 6 The Public Health service, managed within the local authority, is the lead agency for promoting safe sleeping in Suffolk Page 14 of 18 9. RECOMMENDATIONS 9.1 In the unusual circumstances of this SCR, the principal recommendations relate to the role of the SLSCB in a) improving professional practice in relation to safe sleeping and b) contributing to arrangements which promote public awareness of the importance of safe sleeping. Recommendation 1 The SLSCB should explore, in consultation with the Child Death Overview Panel (CDOP)7, the Clinical Commissioning Groups and Public Health services, the introduction of consistent safe sleep assessment and recording arrangements, to be undertaken by health professionals for all new babies in Suffolk. Recommendation 2 The SLSCB should continue to work with Public Health services and other partner bodies to promote public alertness to the importance of safe sleeping for infants. Recommendation 3 The SLSCB should carry out regular audits to evaluate the extent to which a) safe sleeping advice is being given to families by professionals and b) professionals are keeping full records of having done this. Recommendation 4 Any incidental learning identified as part of the analysis and chronology will be captured in a single agency action plan which will be monitored by the SLSCB. 7 CDOPs are responsible for drawing together and considering all child deaths in a locality, including deaths which may raise safeguarding concerns. This is in line with Chapter 5, Working Together 2015. Page 15 of 18 APPENDIX A: THE LEAD REVIEWER Kevin Harrington trained in social work and social administration at the London School of Economics. He worked in local government for 25 years in a range of social care and general management positions. Since 2003 he has worked as an independent consultant to health and social care agencies in the public, private and voluntary sectors. He has worked on some 50 Serious Case Reviews in respect of children and vulnerable adults. He has a particular interest in the requirement to write SCRs for publication and has been engaged by the Department for Education to re-draft high profile Serious Case Review reports so that they can be more effectively published. Mr Harrington has been involved in professional regulatory work for the General Medical Council and for the Nursing and Midwifery Council, and has undertaken investigations commissioned by the Local Government Ombudsman. He has served as a magistrate in the criminal courts in East London for 15 years. Page 16 of 18 APPENDIX B: TERMS OF REFERENCE These are the Terms of Reference for this SCR, modified so that they are suitable for publication. 1. Introduction A decision was made by SLSCB’s Independent Chair to undertake a Serious Case Review in respect of Baby D, who tragically died in sudden and unexpected circumstances. It was decided, on the basis of the consultation and discussion with the relevant parties, that this case met the criteria for a Serious Case Review (SCR) as laid out in statutory guidance issued by HM Government in Working Together to Safeguard Children 20158. 2. Aims of the Review To review the circumstances leading to Baby D’s death in order to establish what lessons, if any, are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children. To identify clearly what those lessons are, both within and between agencies; how and within what timescales they must be acted on and what is expected to change. To involve the family of Baby D as considered appropriate and in accordance with their wishes and feelings. To complete an independent SCR Report for presentation to the SLSCB within 6 months of commencing the review and assist in the preparation of the report for publication. The final SCR Report will: Provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence; Be written in plain English and in a way that can be easily understood by professionals and the public alike; and Be suitable for publication without needing to be amended or redacted. 3. Scoping Period for the Review The review will consider agency involvement with family members in the two years before the death of Baby D. The timeline of agency involvement with a half-sibling, pre-dating the birth of the subject, will provide an important context for the review. Agencies will be requested to review records held in relation to the family and provide additional details of any significant information or involvement with the family outside of the prescribed timescale at their discretion. 8 Working Together 2015, HM Government Page 17 of 18 4. Governance Arrangements The SLSCB Case Review Panel will be responsible for all commissioning arrangements and will monitor progress of the review to ensure it meets the requirements of Working Together 2015. The independent Overview Report Writer will be entirely independent of SLSCB. They will develop the learning recommendations and write the SCR Overview Report. An officer from each agency involved with the case will be tasked with the completion of a chronology detailing the involvement of their service, along with a thorough analysis of the quality of the service offered. The chronology and analysis will follow a prescribed format agreed by the Overview Report Writer. A Reference Group of senior managers will be responsible for assisting the Independent Overview Report Writer in providing a local strategic overview, organisational context and challenge as the analysis of professional practice and learning develops. Members of the Reference Group will provide support to the analysis and chronology writers throughout the review process and will ensure that reports and any subsequent requests for information from the Overview Report Writer are provided within the agreed timescales of the review. 5. Methodology The emphasis of this review will be on the involvement of ‘primary’ level services i.e. universal health services and early intervention/non-statutory children’s services. All agencies should produce a robust, comprehensive and accurate chronology of their engagement with the child and family. The chronology should also detail contacts with other key agencies working with the family, demonstrating the effectiveness of joint working and information sharing between services and each chronology should be accompanied by an open, thorough and critical detailed analysis of the information gathered. The analysis should consider whether there were any areas of culture, language or disadvantage and/or social exclusion for the family and its potential impact on the outcome for the child, any relevant statutory requirements and/or procedures and any learning already identified. In the event that there is a parallel continuing criminal investigation, the police representative member of the SCR Reference Group will work closely with the SLSCB and Senior Investigating Officer to ensure that any interviews and/or information sharing takes place appropriately so as to minimise the opportunity for conflict between the SCR process and criminal investigations/CPS activity. This would be informed by current ACPO/CPS Guidance9 around such parallel processes. 9 Liaison and information exchange when criminal proceedings coincide with Chapter Four Serious Case Reviews or Welsh Child Practice Reviews 2014, ACPO & CPS Page 18 of 18 6. Involvement of Family Members SLSCB recognises the value that the involvement of family members can have in the SCR process and will ensure their expectations are managed appropriately and sensitively. As part of this review process the Overview Report Writer or a person nominated by the Overview Report Writer will seek to engage with family members so that their views can be taken into account within the discussions and analysis of professional practice. 7. Reflection and Review of the Multi Agency Sudden Unexplained Death in Childhood (SUDIC) Investigation Process SLSCB is carrying out a parallel piece of work, undertaken outside the scope of this SCR, which considers how agencies work together after the sudden unexplained death of a young child. The learning from that exercise will be drawn together with the SLSCB response to this SCR report. 8. Liaison with outside bodies, including the Department for Education and National Panel of SCR Independent Experts Until completion of the SCR Independent Report and consideration of its content by the SLSCB, no information arising from it or in connection with it should be shared with any organisation outside of the review process without the express authority of the SLSCB Independent Chair or in their absence the Vice Chair. LSCB SCR Response – Baby ‘D’ Introduction This report concerns a baby, referred to in the report as Baby D, who died at the age of 12 weeks. He had slept in the same bed as his mother who awoke to find that he had died during the night. These matters were brought to the attention of the Suffolk Local Safeguarding Children Board (SLSCB). The Chair of that Board, Ms Sue Hadley, decided that the circumstances of the child’s death required that a Serious Case Review (SCR) should be conducted, in line with the government’s guidance as laid out in HM Government Working Together to Safeguard Children 2015. A SCR must be carried out when a child dies and there are concerns that the child may have been abused or neglected. In this case those concerns related only to the issue of whether the sleeping arrangements for the child had been safe and satisfactory on the night of his death. There had been no previous concerns about the care of Baby D, and none emerge from this review. This SCR was formally initiated by Ms Hadley on 24th August 2015. Suffolk LSCB appointed an experienced independent person, Mr Kevin Harrington, to act as Lead Reviewer and to write this report. Kevin Harrington trained in social work and social administration at the London School of Economics. He worked in local government for 25 years in a range of social care and general management positions. Since 2003 he has worked as an independent consultant to health and social care agencies in the public, private and voluntary sectors. He has worked on some 50 Serious Case Reviews in respect of children and vulnerable adults. In writing the report Kevin Harrington was assisted by the officers of Suffolk LSCB and a reference group of senior representatives from the agencies which had been involved with the family of Baby D. The report consists of A factual context and brief narrative chronology. Commentary on the family situation and their input to the SCR. Analysis of the part played by each agency, and of their submissions to the review. Identification and analysis of key issues arising from the review. Conclusions and recommendations The conduct of the review has not been determined by any particular theoretical model but it has been carried out in accordance with the underlying principles of the statutory guidance, set out in Working Together 2015. The review: “recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight1; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings”. The agencies were asked to review their involvement with the family during the two years before the death of Baby D. This was due to some agencies having had significant involvement during that time with an older half-sibling, a child of the mother, Ms M, from a previous relationship. This child is referred to in this report as Child P. However it is also right to emphasise that this is not a review of the agencies’ involvement with Child P and there is nothing in the agencies’ contact with the family in respect of Child P which would lead to a Serious Case Review being carried out. Apart from the circumstances leading to his death, the agencies found no cause for concern. Baby D was healthy and was well loved and well cared for throughout his life. However he died after sleeping in the same bed as his mother – co-sleeping. This practice is known to be associated with Sudden Infant Death Syndrome (SIDS). Issues related to SIDS lead to the principal recommendations from the review, set out below. The LSCB held an extraordinary Board meeting on the 7th March 2016 to consider the Serious Case Review report. It fully accepted the lessons learned and recommendations outlined in paragraph 9 of the report. It then went on to consider the actions already taken to date as a result of the learning, their impact, and any further actions required to address the learning. 1This review does not rely on hindsight, and tries not to use hindsight in a way that is unfair. It does use hindsight where that promotes a fuller understanding of the events and their causation. Recommendations In the unusual circumstances of this SCR, the principal recommendations relate to the role of the LSCB in: a) improving professional practice in relation to safe sleeping; and b) contributing to arrangements which promote public awareness of the importance of safe sleeping. Recommendation One: Suffolk LSCB should explore, in consultation with the Child Death Overview Panel (CDOP), the Clinical Commissioning Groups and Public Health services, the introduction of consistent safe sleep assessment and recording arrangements, to be undertaken by health professionals for all new babies in Suffolk. Public Health is in discussion with CCGs to agree specific KPIs to maximise and monitor implementation of Safer Sleeping Suffolk Strategy and its 6 messages and provision of a thermometer for all mothers and their new babies. The LSCB Health sub-group, in conjunction with the Chair of the CDOP, will lead on the consultation and exploration of consistent assessment and recording arrangements and report back on the progress made to the LSCB via sub-group reporting at regular intervals. Recommendation Two: The SLSCB should work with partner bodies to promote public alertness to the importance of safe sleeping for infants. Suffolk LSCB first launched a campaign to promote public awareness to the importance of Safe Sleep in 2014 in partnership with the Lullaby Trust. As part of that campaign, guidelines were developed and information shared with all partner agencies, including information for Teachers to support PSHE framework for parenting sessions. Safe sleep leaflets were promoted with midwives and health visitors in particular and information packs sent out to children’s centres. A further initiative was run by Public Health, in conjunction with the LSCB, in 2015. The Health and Wellbeing Board website ‘Health and Wellbeing Suffolk’ have a Safer Sleeping Suffolk web page with a range of videos, leaflets posters etc. A printable safer sleeping guide was produced and there is a short video that includes key information regarding drinking, smoking, co-sleeping etc. There was media coverage at the time and circulation to professionals to ensure that safe sleep messages were delivered to all new parents and to encourage midwives and health visitors to both ask about safe sleeping arrangements and give out leaflets. http://www.healthysuffolk.org.uk/projects/safer-sleeping/ In response to this Review, and as part of an ongoing awareness raising campaign by the LSCB and Public Health, two safe sleeping events are taking place in March and April 2016. They are free and open to anyone working with children and their families. The first event attracted in excess of 50 professionals from across the LSCB partnership. The programme includes: Suffolk Safer Sleeping Strategy – Implementation update Evidence update/Data/Risk Factors SUDIC process – A police perspective Lullaby Trust presentation Safer Sleeping Suffolk Evaluation – survey results Table Top Discussions as to how to spread the Safe Sleep message. A Safe Sleep newsletter and information for schools will be sent to all LSCB partners, including Children’s Centres and Schools. Recommendation Three: The LSCB should carry out regular audits to evaluate the extent to which: a) Safe sleeping advice is being given to families by professionals; and b) Professionals are keeping full records of having done this. The LSCB Learning and Improvement Group will ensure that all agencies who have a responsibility to give Safe Sleep advice as part of ante-natal and post-natal care undertake regular auditing and report to the L&I Group. Implementation of a consistent message as outlined in Recommendation One will lead to the potential for an over-arching audit to assess the effectiveness of safe sleep messages across the Health partnerships. Recommendation Four: Any Incidental learning identified as part of the analysis and chronology will be captured in a single agency action plan which will be monitored by the LSCB. Action plans and first progress reports to come to the Local Safeguarding Board meeting on 26th April 2016 for approval. The action plan will be monitored by the LSCB Learning and Improvement Group with exception report to each Board meeting. |
NC52282 | Unexplained death of a 2-year-7-month-old girl in December 2018. Child V experienced neglect and delayed development. Learning includes: when the siblings of an unborn baby are subject to a child in need plan (CiN) the multi-agency CiN meetings should discuss the likely effects and ensure there is multi-agency agreement prior to closure of the plan; conduct a parenting assessment so that practitioners have realistic expectations of parents and to minimise the vulnerability of children; need to use processes and tools to identify, assess and respond to neglect; the voices and lived experiences of children should inform all assessments and interventions; there needs to be a multi-agency assessment if there is a disclosure of sexually harmful behaviour; strained professional relationships can impact on multi-agency cooperation and safeguarding practice. Recommendations include: improve the early identification of and response to neglect; remind partner agencies about the decision making process prior to closure of a CiN or child protection plan; consider the development of pathways with adult services to assist with the assessment of parents and carers when there are concerns about their cognitive ability; identify the barriers to the effective use of tools to support the early identification, assessment and analysis of neglect, specifically, Graded Care Profile 2; robustly monitor and evidence the impact of the voice of the child in practice; identify and address barriers to the effective use of the escalation policy.
| Title: Independent overview report of the serious case review concerning Child V. LSCB: Buckinghamshire Safeguarding Children Partnership Author: C. Connor Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Buckinghamshire Safeguarding Children Partnership Independent Overview Report of the Serious Case Review Concerning Child V January 2020 Author: Dr. C Connor 2 Contents Page Introduction 3 Methodology 3 The Family 4 Background Information 4 Agency Involvement 4 Analysis 9 Good Practice 26 Context 27 Conclusion 27 Learning and Recommendations 28 3 1 Introduction 1.1 In January 2019 Buckinghamshire Safeguarding Children Board decided to undertake a Serious Case Review in respect of a child aged 2 years 7 months who will be known as Child V. It was agreed that the criteria for carrying out a Serious Case Review had been met1. 1.2 Child V was found unresponsive during a visit to see her Mother, half siblings and maternal grandparents. Child V died the following day due to a cardiac arrest likely to be caused by a natural but undetermined cause2. Child V and her older sibling were subject to Child Protection Plans at the time. 2 Methodology 2.1 The purpose of this review was to identify whether improvements were needed in the way that agencies work together for the prevention of death, serious injury or harm to children and to identify good practice. Lessons learned have been clearly identified and contributed to an existing improvement plan which is sustainable and explicit about what is expected to change and within what timescale. Progress against the improvement plan is reported to each Improvement Board meeting, which is chaired by the Commissioner, and is reviewed at each of the monitoring visits that Ofsted undertake. 2.2 It was agreed that the review would consider the professional involvement with the family from November 2015 when Mother booked for antenatal care for Child V until the death of Child V in December 2018. Relevant information prior to these dates was also considered and included agency involvement due to concerns about the neglect of Sibling 1 and Sibling 2 between 2012 and 2014. 2.3 Information provided to the review included a multi-agency chronology, and other relevant documents 3. Professionals met to explore issues relating to multi-agency practice and opportunities for learning. The SCR Steering Group 4 contributed to the learning and recommendations to ensure that actions resulting from this review complement the improvement activities of the Buckinghamshire Safeguarding Partnership and avoid duplication. The contribution of all those involved enabled a greater understanding of the context in which practitioners and managers worked at the time and maximized opportunities for systemic learning. 2.4 The detailed Terms of Reference considered throughout this Review are included at Appendix ii. In summary, the review focussed on two overarching questions which broadened the opportunity for learning whilst retaining focus on the presenting issues: 1SCR’s have been replaced by child safeguarding practice reviews which should be considered for serious child safeguarding cases where: abuse or neglect of a child is known or suspected and a child has died or been seriously harmed. https://www.gov.uk/government/publications/working-together-to-safeguard-children--2 2 Ruling by the Coroner, December 19 3 Minutes of meetings, reports, policies and procedures in place at the time etc. 4 Managers and safeguarding leads 4 What can we learn from this case about the effectiveness of practice in Buckinghamshire to identify the neglect and abuse of children? What can we learn about the assessment of risks and vulnerabilities (known at the time) and how these influenced decision making and intervention? 2.5 Children’s Services remain involved with the family and it was decided not to involve the children directly in the review process. On balance, it was thought that participating in the review would risk further trauma at what was known to be a difficult time. Mother, Father and maternal grandmother were informed by letter that the review was taking place5. The independent author met with maternal grandmother, Father and paternal grandmother6 and their views are reflected in this report which will be shared with the family prior to publication. 3 The Family 3.1 Mother had four children, Child V was the youngest. A was the father of Sibling 1 and Sibling 2 and S was the Father of Child V and Sibling 3 and will be referred to as Father in this review. At the start of this Review Child V was unborn and Sibling 1 was 10 years old. 3.2 Other family members mentioned in this review are the maternal and paternal grandmother of Child V who will be referred to as MGM and PGM respectively. 4 Background Information 4.1 In 2010 Sibling 1 and Sibling 2 (aged 2 and 4 years at the time) were found wandering in the park by police officers who returned them home. No referral was made to Children’s Social Care. In 2012 Sibling 1 and Sibling 2 were subject to a Child Protection Plan (CPP) under the category of Neglect and this was stepped down to a Child in Need (CiN) Plan in 2013. Mother was pregnant with Sibling 3 at this time. It was recorded that Schools did not agree with the decision to end the CPP. 4.2 In 2014 the Police received a complaint from a neighbour who stated that Sibling 1 and Sibling 2 were playing with knives in the road7 and this information was shared with Children’s Social Care. 5 Agency involvement between November 2015 and December 2018 5.1 The agencies involved with the family during this time period included; Buckinghamshire Children’s Social Care (CSC) Buckinghamshire Healthcare Trust (BHT) CCG/GP 5 The letter was shared with parents by a relevant professional who was able to support them to understand the contents 6 The views of Father and paternal grandmother were obtained during a virtual meeting with the independent author and a representative from the safeguarding partnership 7 Said to have been taken from the kitchen without parents knowing, Father informed the review that he was in work at the time 5 Children’s Centre Thames Valley Police (TVP) One Recovery Bucks (ORB) Primary School 1 Nursery School 1 A summary of agency involvement of direct relevance to this review is included in the table below and reflects information within agency records. DATE ACTIVITY AGENCY November 2015 Antenatal booking, Referral to consultant due to Mother’s mental health history and safeguarding midwife as Mother informed the older children had been subject to CP Plans. BHT maternity December 2015 Child and family (C&F) assessment requested by practice improvement manager8. CSC February 2016 C&F assessment completed. Child in Need Plan recommended. CSC May 2016 Growth scans due to static foetal growth (under 5th centile). Child in Need Review meeting Professionals expressed concern that risks may change following the birth of unborn baby and discussed whether the Child in Need plan could remain in place. CSC Management decision to close the case and a referral was made to the Family Resilience Service (FRS). Child V born BHT maternity CSC BHT maternity December 2016 Disclosure at school by a third child of alleged sexual behaviour by Sibling 1 towards her and Sibling 2. Information shared with CSC. Strategy meeting and single agency Section 47 inquiry. The S47 inquiry concluded that there was no evidence of sexually harmful behaviour and highlighted concerns regarding neglect and poor home conditions, ICPC recommended. School CSC January 2017 It was decided at the ICPC that the threshold for child protection was not met and the children to be supported by a Child in Need Plan. CSC February 2017 Vulnerable Families Meeting - Health Visitor (HV) concerned that Child V may be showing some signs of developmental delay. GP March 2017 Child in Need review meeting Family Assessment team to support with parenting work Family Support Worker to focus on boundary setting and praising the children – 6 sessions CSC April 2017 Referral made by a member of the public. Sibling 3 was seen running into the road wearing only a nappy, this was alleged to have happened on two previous occasions. Additional concerns Anonymous referral to police 8 To clarify if there was ongoing neglect 6 were about the care of Child V, older children receiving little attention from parents, out late at night in bedclothes and no shoes and domestic abuse. Strategy meeting and Section 47 inquiry. May 2017 S 47 outcome - Managers decision, CiN to continue. CSC June 2017 Vulnerable Families Meeting. Child in Need Review: HV concerned that with so much for the family to do they are not able to prioritise the developmental needs of Child V. GP July 2017 Child in Need Review: Mother acknowledged little progress with the CIN plan due to family illness. CSC August 2017 HV development review found Child V’s development was delayed and noted there was lack of stimulation to support normal development. Level of support increased to Partnership Plus. Children’s Centre September 2017 Child in Need Review Child V needs to develop: problem solving, fine motor skills, communication and speech FAST team have closed their involvement with the family because the family did not engage. Bailiffs attended the family home due to historical debts, repayment plan agreed. CSC October 2017 Anonymous referral: Sibling 3 found wandering in the park and taken home, Child V reported to be covered in faeces and house smelt of cannabis. Strategy meeting, S 47 inquiry – ICPC to be requested FSW home visit – Mother confirmed separation from Father. Mother disclosed domestic abuse and was advised to contact Women’s Aid. ICPC – children made subject to a Child Protection plan under the category of neglect. CSC Police CSC December 2017 Sibling 1 told teachers that he had not eaten dinner, breakfast or lunch. SW informed and safeguarding concern form submitted by school. School January 2018 Core group. Parental issues dominated discussion. Sibling 1 and Sibling 2 often unkempt and dirty Sibling 2 has persistent head lice First Child Protection Review; SW not available and a representative attended who did not know the case and had not read the social work report. No significant change and there remain areas where the CSC CSC 7 children are at risk of harm if parents continue to not to make the changes needed. Child V needs more encouragement to have opportunities to develop. February 2018 Core group no record on CSC case notes. Parents to undergo parenting assessments CSC March 2018 Mother became unable to cope with the care of the children. Sibling 1 and Sibling 2 become looked after and were placed with Maternal grandparents. Sibling 3 and Child V placed with Father and PGM Core group Arguments between mother and Father due to Father telling other parents that the children have been removed. School safeguarding concern – Sibling 1 used inappropriate sexualised language in school. Strategy Discussion. Police record; Sibling 3 disclosed to Father sibling 2 had engaged in a sexual act with him. CSC looking to delay return of children to Mother due to negative parenting assessment. Father still awaiting his assessment. Core Group Mother has supervised contact with the children each Saturday. Parenting assessment of Mother was negative. New SW allocated. CSC School Police CSC April 2018 Health Visitor report following home visit to Father and PGM: Child V continues to appear delayed with her development and this may be due to the neglectful parenting she has had with lack of opportunities. Father has requested information and advice, due to his own needs he will require a lot of practical support with parenting Child V to ensure that her physical and emotional needs are met. HV is unsure how this will be achieved. Child V observed to be very miserable and clingy, this is likely to be caused by being more unsettled since she has not had contact with her mother. BHT Health Visitor May 2018 Core group Child V observed to be clingy and grizzly and will continue to live under a voluntary arrangement with her Father and PGM in LA2. CSC 8 June 2018 GP liaison meeting – Child V discussed Core group, no record on CSC case notes. HV record; Child V continues to live with Father and PGM however both have negative parenting assessments. Local authority is seeking care orders for Sibling 3 and Child V. MGM passed viability assessment and Sibling 1 and Sibling 2 are to remain in her care. GP Children’s Centre /CSC July 2018 Second CP Review CSC August 2018 Unannounced home visit by HV to Father and PGM PGM wishes to change health visitors, social worker and GP PGM reported that the contacts with Mother upset Child V. BHT Health Visitor September 2018 Core Group meeting: Sibling 3 is now attending Primary School in LA 2. SW and head teacher very concerned that this is not in the best interests of Sibling 3. LA application for Interim Care Orders for Child V and Sibling 3 was not granted due to insufficient evidence to support removal of the children. Court directed that: Both parents are to have a psychological assessment. Father is to have a cognitive assessment of his learning needs. School to organise full cognitive assessment for Sibling 1 to identify specific learning difficulties. Child V and Sibling 3 to remain living with father in LA 2 until the completion of court proceedings. CSC October 2018 Core group; Ongoing issues between the children’s parents. Concerns about the sexualised behaviour of Sibling 3. CSC November 2018 Sibling 1 cognitive assessment completed and concluded very low cognitive ability. School December 2018 Father contacted GP concerned that Child V had been coughing for a few days. Unable to bring her to the surgery that day, no concerning features, to see the following morning. GP appointment regarding cough advice given TRIGGER INCIDENT Report of 2 year old in cardiac arrest at house of MGM whilst visiting half siblings and Mother. Taken to hospital by ambulance and Child V died the following day. GP 9 6 Analysis 6.1 Guided by the Terms of Reference for this Review specific themes emerged following analysis of all the available information and discussion with practitioners at the learning and recall events and the SCR Panel. Exploration of each theme enabled rigorous examination of practice and identification of opportunities to improve the systems to safeguard children in Buckinghamshire. 6.2 The themes identified were; Quality and effectiveness of assessments and decision making Professional understanding of parental mental health, domestic abuse and substance misuse and the potential impact of these factors on Child V and siblings Parenting Capacity Recognition of and response to neglect Professional understanding of the lived experience of the children Multi-agency cooperation and information sharing and escalation 6.3 It is important to note that each theme impacted on the others in a systematic and dynamic way. The effectiveness of assessment and decision making influenced the ability of professionals to recognise and address long term neglect. In addition the voice of the child was not prioritised and this impacted on professional understanding about the lived experience of the children. Each theme will be discussed separately within the analysis. Quality and effectiveness of assessments and decision making 6.4 During the period considered by this review one Child and Family Assessment and three Section 47 inquiry reports were completed before Child V and siblings were made subject to a child protection plan. It was noted within the multi-agency chronology that the assessments were incomplete and had significant limitations. Professionals at the learning event and the SCR review panel acknowledged that the assessments did not contain sufficient information to adequately inform decision making regarding the support and intervention required to effectively safeguard Child V and siblings. A combination of factors contributed to the poor quality of assessments which included: high turnover of social workers, poor record keeping, lack of information about historical events and inconsistent multi-agency cooperation. 6.5 It was known that Mother had mental health difficulties and agency records contained frequent references to parental substance misuse. In addition, professionals involved with the family expressed concerns about the ability of Mother and Father to meet the needs of Child V. The potential impact of parental mental health and substance misuse on children is well recognised and the provision of support to parents when there are concerns about parental capacity is expected practice. It was a significant omission that these factors were not explored within the assessments and this will be addressed as a specific theme within the analysis. 10 6.6 The initial Child and Family assessment recommended that a Child in Need (CiN) Plan would provide an appropriate level of support to the family, however information contained within the assessment was limited. Father of unborn Child V and Sibling 3 was not consulted and the level of support that he could offer to Mother was unknown. Father of Child V and Sibling 3 informed the independent reviewer that he could not recall having an input to any assessment and stated that he received little support from any professional during the period considered by this review. The birth father of Sibling 1 and Sibling 2 was not considered as part of the assessment and the relationship between the children and their Father was not known. 6.7 Omission to assess the contribution that Fathers can make to safeguard children has been a consistent finding within Serious Case Reviews nationally9. Lack of information about Fathers within assessments has been a recurrent theme in serious case reviews within Buckinghamshire. A Thematic Review of serious case review reports published by BSCB between 2009 and 2019 found lack of information about Fathers to be a factor in half of the reviews. It is important that consideration is given to why this continues to be a practice issue and why previous actions to improve the involvement of fathers in assessments have had limited impact. 6.8 The assessment also contained information which appeared to be inaccurate and inconsistent. It was recorded that Mother had reported feeling lonely and isolated as she had moved away from her family10. The assessment concluded however that Mother had settled into the local area, had some supportive friends and was engaging with the Local Authority. There was no evidence that Mother had any supportive friends and whilst she had agreed to the Child and Family assessment, engagement with the Local Authority had been inconsistent. Previous engagement was not considered when making referrals to services which required parental commitment. 6.9 The Child and Family Assessment noted that concerns of neglect were ongoing. It was acknowledged that Mother was 20 weeks pregnant and predominantly a single parent to three children, one of whom had significant additional learning needs (Sibling 1). The CiN Plan focussed on support for Mother to manage the behaviour of Sibling 1, Sibling 2 was referred to young carers. Professionals were not aware if Father was involved in the parenting of Sibling 3. Father informed the review that at this time he was living with Mother and the children and worked long hours. Father said that the relationship with Mother was abusive and he was unable to tell anyone. 6.10 At the second CiN Review meeting the SW informed colleagues that they were leaving the authority and it was appropriate for the CiN plan to close and a referral made to the Family Resilience Service (FRS)11. It was recorded that professionals from health and education expressed concerns that the risks may change after the birth of Unborn Child V and that Mother may feel overwhelmed which could impact on her mental health and ability to care for the children. Professionals asked if CSC would consider keeping the case open until after the 9 Hidden Men: Learning from Serious Case reviews. NSPCC, 2015 10 whilst pregnant with Child V 11 Following reorganisation and service development the FRS is now known as the Family Support Service https://www.bucksfamilyinfo.org/kb5/buckinghamshire/fsd/advice.page?id=GmFSf5vKl3s&= 11 birth of Child V. There was no exploration of the different views between professionals. It was decided12 to close the case and the multi-agency chronology noted that the rationale for this decision was unclear. This practice did not follow local guidance about the contribution of all professionals when making a decision to close a CiN plan13. 6.11 There was a lack of understanding amongst professionals regarding the decision making process to close a CiN plan which should be a multi-agency decision. At the learning event it was noted that a TAC meeting should take place when stepping down from CiN. There was a view that no agency or practitioner takes responsibility for these meetings and they are not coordinated. Whilst a TAC meeting did take place it was ineffective and not sustained. 6.12 There was no evidence that the vulnerability of Unborn Child V was considered in the decision to close the case to CSC. The impact of a new born on Mother who was already struggling to meet the needs of her children does not appear to have been recognised or addressed. The FRS was a consent based service and Mother’s previous lack of engagement with services was not considered. It was not known whether Mother would be willing or able to engage with the service. 6.13 Practitioners at the Learning Event stated that the case should have stayed open as there had been limited change following a previous CiN plan for neglect. It was evident from records that Mother was struggling to care for three children one of whom had additional needs and there were concerns at the time about Mother’s ability to cope with a fourth child. 6.14 The SCR Steering Group noted that there was no requirement at the time for practitioners to undertake a specific Unborn Baby Assessment and it would have been expected that the needs of an unborn baby would be included within an updated C&F assessment. Practice has since changed and an UBB assessment would now be completed if a Mother caring for children with known vulnerabilities and involved with CSC becomes pregnant. 6.15 During the timeline for this review there were three strategy meetings within ten months in response to referrals about the welfare of the children14. A decision to undertake a Section 47 inquiry was made following each strategy discussion. Poor assessment, flawed decision making and ineffective practice to safeguard Child V and siblings contributed to the escalation of concerns as discussed below. 6.16 The first referral was made by school six months after closure of the CiN Plan. The referral detailed a disclosure from another child about the sexualised behaviour of Sibling 1 towards herself and Sibling 2. In the absence of disclosures from Sibling 1 and Sibling 2 and denial by Mother and MGM that the alleged incident could have taken place, the possibility of Sibling 1 presenting with sexually harmful behaviour was not explored further. The Section 47 inquiry 12 By a manager at CSC 13https://www.proceduresonline.com/buckinghamshire/chservices/p_cin_plans_rev.html?zoom_highlight=child+in+need#3.-reviews-of-child-in-need-plans 14 Two anonymous referrals from the public and a further referral from school following a disclosure by a third party child regarding sexually harmful behaviour of Sibling 1 12 found ongoing evidence that Mother was struggling to meet the needs of the children15 and concerns were expressed by school regarding the presentation of the children who were reported to smell and have dirty uniforms. An Initial Child Protection Conference (ICPC) was recommended. At the ICPC it was decided that the threshold for Child Protection had not been met and that the family would be supported under a Child in Need Plan. 6.17 It was agreed by the steering group for this review that the assessment, decisions made and intervention agreed were not adequate to address the level of historical and persistent concerns including the emergence of sexually harmful behaviour. There was no evidence that previous history of social care intervention, lack of engagement by Mother and ongoing exposure of the children to long term neglect was considered. Child V was new born at this time and there was no effective consideration by professionals of the risk and impact of neglect on a vulnerable baby. Professionals involved with the review stated that there was an over optimistic view of parental ability to change and no evidence of parental motivation to change or understanding of whether Mother and Father had the capacity to adequately safeguard the children. MGM stated that SW’s were constantly changing and only visited for five minutes to check there was food in the cupboards and then left. Mother usually knew when the visits were taking place and tidied the house in advance. 6.18 A second Section 47 inquiry took place four months later following two further referrals from the public one of which was made via the NSPCC. The referrals included concerns about lack of supervision, domestic violence and cleanliness of Child V. It was decided by a CSC manager that the children should remain supported by a CiN plan. The rationale for this decision was that the Family Action Support Team had only recently become involved with the family and a period of time was required to understand the effectiveness of this intervention. 6.19 This decision was not adequate to protect and safeguard the children. The Health Visitor had noted concerns at this time about the delayed development of Child V and more urgent and proportionate action was required. Each event appears to have been viewed in isolation and there was no evidence that consideration was given to previous history and the limited impact of previous intervention was not reviewed. Following an anonymous referral five months later the children were made subject to a Child Protection (CP) Plan under the category of neglect. Sibling 3 had been found in the park alone and taken home, Child V was reported to be covered in faeces and there was a smell of cannabis in the house. 6.20 It was acknowledged at the practitioner’s event that the family were in crisis and safeguarding concerns had escalated. Whilst there were strategy meetings and assessment in response to separate incidents, there was a missed opportunity to complete a holistic assessment to clarify the risks and vulnerabilities that Child V and siblings experienced. The children were exposed to long term neglect and there was evidence that this had impacted on the development of Child V and the wellbeing of Siblings 1, 2 and 3. The pace of change was insufficient to safeguard the children. 15 During a home visit by the SW there was no bedding on the beds, the children had nits and the presentation of sibling 1 and 2 at school and Sibling 3 at nursery was a concern (said to be dirty with a bad odour and frequently hungry) 13 6.21 Research has shown that taking a systematic approach to enquiries using a conceptual model is the best way to deliver a comprehensive assessment for all children. Buckinghamshire County Council Local Assessment Protocol (2017)16 noted that: all assessments in Buckinghamshire should be undertaken using the framework for assessment within national guidance17. The assessment framework contains three domains: The child’s developmental needs, including whether they are suffering or likely to suffer significant harm The capacity of parents or carers (resident and non-resident) and any other adults living in the household to respond to those needs The impact and influence of wider family and any other adults living in the household as well as community and environmental circumstances The domains were not fully understood and information was presented as descriptive within assessments with little analysis. 6.22 Lack of a thorough Child and Family Assessment had a significant impact on decisions made to safeguard Child V and siblings. Whilst the records of practitioners (specifically health and education) contained detailed information about concerns and risks these were not included within a wider assessment. There was a lack of understanding about the impact of risk factors and vulnerabilities and no effective plan to manage these. 6.23 When Mother was unable to care for the children Child V and Sibling 3 were placed with Father and PGM in LA 2. There were significant concerns at this time about the ability of Father to keep the children safe and provide adequate care. Father had parental responsibility and PGM was considered to be a protective factor however during court proceedings the assessments of Father and PGM as potential future carers of Child V and Sibling 3 were negative. Had assessments been more thorough with meaningful involvement of multi-agency partners it is possible that Sibling 3 and Child V would not have been placed with Father without a robust support plan to ensure that the needs of the children would be met. Father and PGM stated that they were involved with professionals (school, GP and Health Visitor) in LA2 and the wellbeing of Child V and Sibling 3 improved whilst in their care. Communication between professionals in LA1 and LA2 was limited and this had an impact on the support provided which lacked coordination and focus. 6.24 This discussion has demonstrated that without a holistic and thorough assessment, decisions to safeguard children and young people may be limited and inadequate. Shortcomings within the assessment process impacted on other themes within this review, specifically the identification of and response to neglect as discussed below. 16https://bscb.procedures.org.uk/assets/clients/5/6b_BCC%20Local%20Assessment%20Protocol%20FINAL.pdf 17 Working Together 2015 14 Learning Point 1 When the siblings of an unborn baby (UBB) are subject to a Child in Need Plan it is important that there is an opportunity within the multi-agency CiN meetings to: Discuss the impact of a new baby on the family circumstances Include the UBB on the Plan with specific reference to risks and vulnerabilities Ensure there is multi-agency agreement prior to closure of the Plan. Learning Point 2 It is important that Child and Family Assessments include relevant historical information and contributions from partner agencies, children, parents and carers to inform understanding of and response to safeguarding concerns. In the absence of a comprehensive assessment decision making may be flawed and children exposed to unnecessary risks. Professional understanding of parental mental health, domestic abuse, substance misuse and the potential impact of these factors on Child V and siblings 6.25 Concerns about parental mental health, domestic abuse and substance misuse were recorded by practitioners, however there was no effective analysis of these issues within assessments and there was little consideration given to the impact on Child V and siblings. Parental mental health 6.26 Information about Mother’s mental health was known to agencies and recorded by practitioners. Maternity notes from the antenatal booking for Child V stated that Mother was to be referred to a consultant due to her mental health history. The author of the CSC chronology noted that adult mental health services had not been contacted during the Child and Family Assessment despite mother’s significant history of mental health issues. 6.27 It was acknowledged within agency records and by practitioners at the learning event that excessive demands were placed on Mother within the CiN and CP processes. It was known that Mother was involved with multiple professionals and there was a sense that Mother was unable to address all the required actions. Limitation in assessments and poor decision making contributed to the lack of a coherent multiagency plan to support Mother and Father to meet the needs of the children. It is of significance that six months into the CP Plan Mother became overwhelmed, unable to meet the demands of the plan and said that she was unable to care for the children 6.28 There is extensive research evidence that demonstrates the impact of parental mental health problems on children. Advice provided by the NSPCC states that parental mental health problems can affect a parent’s ability to provide the care that children need. Parents or carers may: Have mood swings Find it difficult to recognise their children’s needs 15 Or struggle with keeping to routines such as mealtimes, bedtimes and taking their children to school18. There was evidence of all these issues within the multi-agency chronology. Record of a Health Visitor at the time Mother said that she was unable to cope with the children stated: Mother presented as tearful and lacking in energy and interest. She is reported to have been very low and unwell and for the past few weeks this has been reflected in the children appearing neglected and unkempt when arriving at school. 6.29 There were regular references within the multi-agency chronology to Mother struggling to meet the needs of the children and specifically the developmental needs of Child V. Whilst parental support was provided via the Family Resilience Service and Family Support Services Mother did not engage consistently and frequently cancelled or was not at home for pre-arranged visits. It was unclear whether support, specifically the Family Resilience Service was experienced by Mother as an additional pressure. It is possible that Mother cancelled visits due to stress and anxiety however there was no evidence that this was explored with her. 6.30 Parental mental health problems were identified as a factor in over half of a sample of 33 serious case reviews in England from 2009-2010 (Brandon, 2011)19. Learning from published case reviews has shown that professionals sometimes lack awareness of the extent that a mental health problem may impact on parenting capacity. This may result in a failure to identify potential safeguarding issues. 6.31 A guide to parental mental health and child welfare (SCIE, 2011)20 highlights key recommendations for practice which include: effective screening tools to identify adults with mental health problems who are parents, assessment of the whole family and effective planning to meet the individual needs of each family member. There was evidence that Mother’s mental health had deteriorated however it was not until the children were no longer living with her that Mother was advised to return to the GP and it was agreed that a referral to the adult mental health team should be made21. Parental substance misuse and domestic abuse 6.32 During the child protection process additional concerns emerged regarding the substance misuse of Mother and Father and allegations of domestic abuse by each parent against the other. The relationship between the parents became increasingly acrimonious. It was necessary to have separate core groups as it was not possible for parents to prioritise the needs of the children over their own disagreements. 18 https://www.nspcc.org.uk/keeping-children-safe/support-for-parents/mental-health-parenting/ 19 Brandon, M. et al. (2011) A study of recommendations arising from serious case reviews 2009-2010 (PDF). [London]: Department for Education 20 Think child, think parent, think family: a guide to parental mental health and child welfare (SCIE 2011p6) 21 Health Visitor records of core group 16 6.33 It was acknowledged at the practitioner’s event that the needs of Child V and siblings were not always prioritised due to conflict between the adults. At times professionals focussed on supporting the adults with their issues rather than the needs of the children. MGM said that she told Mother and Father that their constant arguing would have a negative impact on the children. 6.34 Concerns about domestic abuse and substance misuse were known at the time of the S47 inquiry which resulted in the children remaining subject to a CiN plan. The decision to give a longer period of time for family support services to have an impact was not sufficient to safeguard Child V and siblings, given the information that was available to agencies at the time. It was acknowledged by the author of the CSC chronology that there had been an over optimistic view of the parents ability to change. Had there been a thorough exploration of domestic abuse allegations and substance misuse concerns, it is likely that a more proportionate decision to safeguard Child V and siblings would have been made. 6.35 Father said that he had been unable to tell anyone about the abuse he was experiencing and when he tried to leave the relationship Mother told the children that he didn’t love them. Father acknowledged that both he and Mother had misused substances and said that he accessed support to address substance misuse when he left the family home. Whilst it is unclear if Father would have spoken to professionals about his experience of substance misuse and domestic abuse at this time, he did not have the opportunity due to lack of involvement in assessments and limited engagement with practitioners. 6.36 A comprehensive assessment and in depth professional understanding about how risk factors (mental health, substance misuse and domestic abuse) interact, is essential to ensure that interventions are effective and to promote the safety and wellbeing of all members of a household. At the learning event practitioners expressed the view that whilst concerns were recorded there was a lack of multi-agency coordination to address issues as they emerged. There was also little consideration given to the support required to reduce the impact of parental substance misuse and domestic abuse on Child V and siblings. Learning Point 3 When there are concerns about parental mental health, substance misuse and/or domestic abuse it is important that practitioners understand how these difficulties interact within the family and this information informs assessments and decisions to safeguard and reduce the impact on the children. Parenting Capacity 6.37 Assessment of parental capacity is a significant domain within the assessment framework and includes: basic care, ensuring safety, emotional warmth, stimulation, guidance and boundaries and stability. Agency records during the timeline for this review include frequent reference to the concerns of practitioners that parents were unable to meet the needs of Child V and siblings in any of these areas. There was limited consideration given to whether Mother and Father required additional support to enable them to parent effectively and this was a significant omission. It was the view of the SCR steering group that a cognitive assessment should have been completed for Mother and Father. 17 6.38 Practitioners stated that Mother had a poor ability to retain information, and although she could appear to want support she actively avoided some situations. It was not possible to be confident whether this was deliberate avoidance or a processing or memory problem. It was known that Mother had attended a special school however there were no discussions with her about what would help her to work effectively with professionals to meet the needs of Child V and siblings. Plans to safeguard the children (CiN and CP) placed considerable demands on Mother and there was little consideration given to whether she needed support to make the required changes. 6.39 MGM said if someone had explained to Mother what may happen if things didn’t improve she may have understood why it was important to change. MGM said that Mother never thought that she would lose the children. It is likely that Mother was advised at various times by different practitioners about the possible consequences should the care of Child V and siblings not improve. It is not possible however, to have confidence that Mother fully understood what she was told or that she was able to retain the information provided by professionals. 6.40 It was known that Father could not read or write and school provided some support to develop these skills. Father told the Health Visitor that due to his own learning difficulties he sometimes found it hard to follow what was being said, or understand the language/jargon often used in meetings. The Child and Family Assessment made reference to Father having learning difficulties and queried how much support he was able to provide Mother. Other than observe and record there was no understanding of how the additional needs of Father impacted on his capacity to parent Child V and Sibling 3. At the learning event practitioners said that Father often repeated what had been said to him and it was possible that some practitioners mistakenly accepted this as Father understanding what had been said. 6.41 Father said that he had asked professionals to write things down for him and recalled the actions of one social worker who had been particularly supportive in doing this. Father said that not all professionals were as supportive and stated that: ‘I was not listened to, judged and bullied by some’. Father said that he was unable to get his voice heard in meetings even when he had an advocate and that he was unable to challenge minutes which were often inaccurate. 6.42 Practitioners spoke about the challenge to support Mother and Father to improve their care of the children. Intervention and support was provided without a clear understanding of parenting capacity and had limited impact, lacked focus and did not improve the outcomes for Child V and Siblings. It is important to note that Practitioners from different agencies, specifically health and school worked hard to provide support and improve outcomes for the children and there was some good practice. However, as noted throughout this review, intervention provided without a thorough assessment and coordinated multi-agency plan may not be adequate or appropriate to effectively safeguard vulnerable babies and children. MGM said that nothing was done to help Mother and Father become better parents and she was unsure who to speak to about her concerns. PGM said that from her experience the paternal family was not given sufficient support by CSC. 18 6.43 Mother and Father had cognitive assessments during court proceedings, which were outside the timescale considered for this review. Father subsequently received a diagnosis of learning disability which provided clarification about the support required to assist him to parent effectively and placed a duty on the local authority to ensure that Father’s needs were met in this regard. Parents with learning disabilities must be given every opportunity to show that they can parent safely and be good enough parents, with appropriate support22. Working with parental learning difficulties has emerged as a theme in previous Buckinghamshire SCR’s23. It is important that lessons are learned to reduce the risk of further repetition and that there are robust systems and processes to facilitate the assessment of parents when there are concerns about their capacity and ability to meet the social, emotional and developmental needs of children. Members of the SCR steering group were clear that the learning from this review provides an opportunity to clarify and strengthen cooperation and pathways between adult and children’s services to support the provision of appropriate and proportionate assessments of parental capacity when there are safeguarding concerns regarding children. 6.44 At the practitioners event it was noted that it was a challenge for safeguarding professionals from Schools to question parents or to freely express their views in CP meetings due to concerns about damaging the relationship with the family. Practitioners stressed the importance of maintaining a positive relationship with parents to be able to work with them. This approach is problematic and it is important that practitioners across agencies are consistent in their communication with parents and work collectively to put the needs of the children at the centre of all work. Practitioners highlighted the need for training for professionals 24 to become more confident in having challenging conversations with parents and carers about safeguarding concerns for babies and children. Practitioners at the learning event said that confident and experienced practitioners may be able to actively challenge parents and carers, however, practice was described as inconsistent. 6.45 Disguised compliance was reflected in some agency records to describe the presentation of Mother and Father. Disguised compliance involves parents and carers appearing to co-operate with professionals in order to allay concerns and stop professional engagement25. Given the lack of understanding about parental capacity it is not possible to have confidence that the presentation of Mother and Father was one of disguised compliance. Both parents experienced significant challenges which impacted on their ability to parent. When parental engagement is framed as disguised compliance without a comprehensive assessment with clear evidence and analysis, there is a risk that the underlying support needs of parents may be overlooked. 22 Good practice guidance on working with parents with a learning disability (2007). University of Bristol , Esmee Fairboune Foundation 23 Baby/Child E, M and Q 24 Specifically designated safeguarding leads in schools 25 Reder, P.Duncan, S. and Gray, M. (1993) Beyond Blame: child abuse tragedies revisited. London: Routledge 19 Learning Point 4 In the absence of a parenting assessment it is a challenge for Practitioners to have clarity about the capacity of parents to understand safeguarding concerns and confidence in the ability of parents to protect children. This may result in practitioners having unrealistic expectations of parents and the vulnerability of children could increase. Recognition of and response to neglect 6.46 There is significant evidence to demonstrate that neglect has the potential to compromise progress across the seven dimensions of development identified in the Assessment Framework: health, education, identity, emotional and behavioural development, family and social relationships, social presentation and self-care skills 26 . Brandon et al 27 acknowledged that health and education professionals and social workers often find it difficult to identify indicators of neglect or recognise their severity. Unlike physical abuse the experience of neglect rarely produces a crisis that demands immediate attention. 6.47 Neglect has serious consequences for children and young people of all ages however there is evidence to suggest that it has a particularly adverse impact on the development of very young children 28 . Babies and young children are inherently vulnerable and low birth weight babies are especially fragile and at higher risk of abuse and neglect29. Child V weighed 1.98kg at birth which was induced at 36 weeks gestation due to foetal growth restriction. Siblings 1, 2 and 3 were under 10 years of age during the period considered by this review. 6.48 Whilst there were strategy meetings in response to individual incidents, historical information was not considered and the cumulative impact and risk of long-term neglect was not recognised. The author of the CSC chronology prepared for this review noted that the social work assessments did not reflect the impact on the children of ongoing neglect. 6.49 Child V was 18 months old when the ICPC took place and it was recorded that the children had been subject to long term chronic neglect. It was evident from the multi-agency chronology that the HV, FSW, school and nursery provided substantial support to the family however the impact of this was limited due to many missed appointments, failed home visits and inconsistent engagement by both Mother and Father. 6.50 Sibling 3 was accepted into the Nursery full time without payment as professionals recognised that Mother was not coping with the children and Practitioners thought that Sibling 3 would be safer at the nursery than at home. It 26 Pathways to harm, pathways to protection: A triennial analysis of serious case reviews, 2011 -2014. Sidebotham P et al. DH 2016 p8 27 Brandon M, Ward H et al., DH Nov 2014Missed opportunities: indicators of neglect – what is ignored, why and what can be done? P7 28 Missed opportunities: indicators of neglect – what is ignored, why and what can be done? Brandon M, Ward H et.al. Research Report DH Nov 2014 29 Sidebotham P et al. DH 2016 p13 20 was reported that the behaviour of Sibling 3 had regressed30. School and Nursery supported Mother to provide uniforms, shoes, and at times, food for the children. MGM said that she always checked each day to make sure that the children had sufficient food. It is possible that this additional support masked the reality that Mother and Father were unable to provide for the children’s basic needs and unable to cope with the behaviour of the children. Whilst the assistance provide by School and Nursery was necessary to meet the basic needs of the children this was insufficient to reduce the impact of long-term neglect which they experienced. 6.51 Decisive action to safeguard the children from further neglect was only taken when the concerns were undeniably serious, difficult to dispute and highlighted by a member of the public. Sibling 3 had been taken home by a member of the public when wandering in the park unsupervised. An anonymous referral was made to CSC and reported that the children were very dirty and hungry, Child V was covered in faeces and the flat was described as dirty and smelling strongly of cannabis. 6.52 Even when subject to a CP plan the pace of change for the children was very slow and there was persistent evidence of neglect. School recorded that Sibling 1 and 2 were often unkempt and dirty. Sibling 1 told teachers that he sleeps in his clothes and Sibling 2 regularly had head lice. The HV recorded that Child V continues to appear delayed with her development and this may be due to the neglectful parenting she has had with lack of opportunities. The serious impact of neglect on the growth and development of the children was recorded, however, a multi-agency response with a coordinated plan to address presenting concerns was lacking. It was noted at the learning event and within discussions of the SCR Panel that practice could be described as ‘watch and wait’ and action to address neglect during the course of this review ‘inadequate’. It would have been appropriate to refer Child V for a paediatric assessment to clarify if there were medical reasons underpinning the delayed development and this has been addressed as single agency action. 6.53 Practitioners at the learning event spoke about the immediate transformation when Sibling 1 and Sibling 2 moved to live with MGM. The following day Sibling 1 and Sibling 2 attended school in a clean uniform and their physical hygiene had improved. There were ongoing concerns when Child V and Sibling 3 went to live with Father and PGM and additional risks emerged as noted within the HV records: soiling issue for Sibling 3 may take a long time to address and I continue to be worried about the child being caught in the middle of adult difficulties. 6.54 The HV completed the year 2 developmental check for Child V during a home visit whilst living with Father and PGM. It was recorded that: Father will continue to need a lot of input, support and reinforcement of parenting techniques in order to continue to keep her safe and meet her needs. There is a challenge around this due to his illiteracy and possible cognitive difficulties. 6.55 Father and PGM said that they worked hard to establish a routine and it was very difficult as they lived in a different area and they did not receive enough support. 30 Sibling 3 had been observed breaking toys, kicking, pushing and putting hands around the necks of other children 21 It was known that Father would require additional support to parent Child V and Sibling 3, however, there was lack of consideration given to his needs and limited support was provided. PGM was perceived by professionals to be a significant protective factor. Father stated: ‘I asked for help and was told I couldn’t do it. I felt that I was never going to keep the children as CSC did not want that’. Child V and Sibling 3 had unmet needs due to persistent neglect and there was lack of coordinated multi-agency support to address these. 6.56 During the timeline of this review neglect was one of the priorities for the Buckinghamshire Children’s Safeguarding Board. Buckinghamshire multi-agency neglect strategy was revised in September 2017 and noted: Neglect represents a key issue for the BSCB and now fits within the Early Help, Thresholds and Neglect priority. This reflects the fact that we recognise all our partners play a key role in picking up the signs of neglect, particularly the early signs (p4). Key aims of the neglect strategy are: To improve the identification and assessment of children and young people, including unborn children, living in neglectful situations before statutory intervention is required, including the use of appropriate assessment tools. To developing and sustain a clear Multi-Agency response to neglect 6.57 The Graded Care Profile is an evidence based assessment tool endorsed by safeguarding partners in Buckinghamshire for use when working with families where neglect is a concern. The tool helps identify support needs, build relationships and improve the identification and recording of neglect Extensive training on the implementation of the GCP has been delivered to practitioners and guidance about when to complete the GCP is contained in policy and procedures. 6.58 The steering group for this review noted that a GCP should have been completed for Child V and siblings at the time Child V was born if not earlier. Limited use of the GCP within Buckinghamshire has been known for some time and was highlighted during this review, to be an ongoing and significant issue of concern, particularly when there are long term concerns regarding neglect. 6.59 At the learning event practitioners expressed mixed views about the usefulness of the GCP and stated that: ‘it takes too long to complete’, ‘it is only offered when families are at child protection level’ and ‘it should be completed much earlier’. Without a tool to measure neglect concerns may be viewed in isolation, the long term cumulative impact on children may not be recognised or monitored, and children will remain subject to neglect without appropriate support and intervention as experienced by Child V and siblings. 6.60 Given the concerns and information known at the time about the neglect of Child V and siblings it should have been standard practice to complete a GCP when the family were in receipt of early help support and intervention. This would have enabled professionals working with the family to be explicit about concerns, agree the change required with Mother and Father and evidence the capacity of 22 the parents to implement change. Omission to use the required tool to identify neglect contributed to Child V and siblings experiencing long term neglect for a considerable period. 6.61 There was consistent reference to the delayed development of Child V during this review. Whilst it was not possible to totally discount a medical cause, agency records indicated that practitioners believed neglectful parenting and lack of stimulation to be significant contributory factor for the developmental delay experienced by Child V. It was clear that Child V was not provided with opportunities to thrive and develop. Child V did not experience good enough care and support during her life and this will have had a significant and negative impact on her lived experience. Provision of a limited response to concerns regarding neglect emerged within this review as a systemic issue, of relevance to all agencies. Learning Point 5 When processes and tools to identify, assess and respond to neglect are not used, children may be exposed to long term risk and harm without adequate support or intervention. Professional understanding of the lived experience of the children 6.62 Whilst professionals had significant contact with Child V and siblings, work was not conducted in a way that was consistently child focussed. Understanding the lived experience of the child is a complex process and the importance of professionals having a child centred approach is well recognised. Listening to the voice of the child has emerged as key learning in SCR’s31. 6.63 There was little evidence that practitioners had considered the lived experience of the children in a way that influenced change and improved their wellbeing. Within this review much emphasis was placed on providing opportunities for the children to talk32 and less time considering what they may have said about their home situation if they had spoken. It was acknowledged by practitioners that there was too much reliance on the child speaking. There was limited evidence that consideration had been given to using age appropriate approaches to understand the lived experience of Child V. 6.64 Agency reports reflected some observations of Child V and siblings and recorded some comments that Sibling 1, 2 and 3 made to professionals. These will be discussed under the headings, behaviour and voice of the child. Behaviour 6.65 The behaviour of children can be a clear indicator of their emotional state and on occasions Sibling 1 presented as very needy at School however the behaviour was labelled challenging. Learning points from previous SCRs have highlighted the importance of recognising behaviour as a means of communication and the 31 The voice of the child: learning lessons from serious case reviews. Ofsted 2010 32 School nurses saw Sibling 2 for 8 weeks however she didn’t want to speak 23 implications of doing so for practice (Ofsted 2011 p 1833, Sidebotham P. Brandon M. 2016 p118)34. 6.66 There was little consideration given to understanding what the children may have been attempting to communicate by their behaviour or the potential cause of their behaviour. Agency records contain examples of behaviour which could have been an attempt by Child V or a sibling to communicate their distress which included: Child V was observed by the HV during a home visit to bite Mothers arm and head-but her as she sat on her knee. Child V ignored Mother when she said no and Mother asked the HV how to manage this behaviour. School informed the SW about concerns regarding what were described as aggressive outbursts by Sibling 1. Child V was seen pressing herself against the glass door with her back turned to adults during a core group35. Sibling 3’s behaviour has regressed recently, he has become destructive, breaks and throws toys. There is no discipline and parents are unable to cope with his behaviours. 6.67 There were some examples of reflection by the HV within agency records which included; Child V was observed to be very miserable and clingy; this is likely to be caused by being more unsettled since she has not had contact with her mother. Due to many distractions and difficult relationships between adults, Child V’s developmental and emotional needs may not be met. At each HV contact she appears to be left to her own devices with no adult being proactive in finding her something to do. It has become apparent over the last two (core group) meetings that Child V will have been exposed to drug abuse and domestic violence. The parents will not have been able to put her needs first while in these situations. This will have been impacting on Child V’s feeling of security and parental responsiveness to her physical and emotional needs is in question. 6.68 There was an allegation of sexually harmful behaviour involving Sibling 1 during the timeline for this review. A third party child disclosed sexual activity towards herself and Sibling 2. The initial disclosures were investigated by the police and there was no further action following denials by parents that the behaviour could have taken place and no further disclosures from the children involved. It was recorded by CSC that there was no evidence to substantiate the concerns. 6.69 There was no evidence from agency records that the BSCB Harmful Sexual Behaviour: Procedure and Guidance was followed36. The S47 inquiry noted that: Sibling 1 does not present with sexualised behaviour and there was no evidence to substantiate the concerns raised. Information from children and adults appears to have been accepted without further assessment. Inappropriate sexualised 33 The voice of the child: learning lessons from serious case reviews Ofsted 2011 34 Sidebotham P. Brandon M. et al Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011- 2014 DfE 2016 35 When a disagreement between parents quickly escalated into a loud argument 36 http://bscb.procedures.org.uk/qkqsp/children-in-specific-circumstances/harmful-sexual-behaviour-procedure-and-guidance 24 behaviour is often an expression of a range of problems or underlying vulnerabilities and it was a missed opportunity to explore the disclosure further within a multi-agency assessment. A safeguarding concern regarding Sibling 1 using inappropriate sexualised language at school was recorded some months later and there was no further assessment or exploration of possible causes, this was a significant omission and ongoing issues relating to sexually harmful behaviour were overlooked. Voice of the child 6.70 Examples of what the children said were recorded by different agencies. Whilst the information did provide some insight into the well-being of the children and details were shared with the social worker this had limited impact on the support provided. Examples included; Sibling 1 told staff at school that I am rubbish I am going to fail. School offered support with self esteem Sibling 1 said that he had not eaten dinner, breakfast or lunch. The SW was informed. Whilst at school doling an activity to learn about weight, sugar was placed in to small bags to demonstrate to the children. Sibling 3 stated we have white bags at home of stuff like that. The school reported to Social Care and the local TVP contact. Sibling 3 said daddy hurt me when explaining a scratch to his face, and mummy smacked me when explaining light bruising. Sibling 1 told school that Sibling 3 dropped Child V and he was scared. Sibling 3 disclosed to Father that a paternal half sibling had engaged in a sexual act with him. 6.71 There was little evidence that the children’s voice was responded to in a meaningful way during the timeline for this review. Practitioners reported that the children will have been impacted by their experience of neglect, domestic abuse and the substance misuse of parents. However, the support and intervention provided did not lead to a significant change in their lived experience. 6.72 At the practitioners event it was stated that practice has changed with the Strengthening Families approach and the child’s voice is increasingly being heard. The challenge will be to move beyond listening and recording, to reflect on the child’s experience in a way that has a positive influence on the support provided. Buckingham Safeguarding partnership recently hosted a ‘Voice of the Child’ partnership event and there is a strategic drive to develop practice in a way that is clearly child focussed. Learning point 6 It is not sufficient to record observations of children and/or what children say. If the voices and lived experiences of children do not inform assessments and interventions, it is likely that they will not feel listened to, intervention may not be appropriate and concerns could escalate. 25 Learning point 7 In the absence of a multi-agency assessment following a disclosure of sexually harmful behaviour, underlying problems and difficulties may be overlooked. Multi-agency cooperation and escalation 6.73 Practitioners involved in the review described practice as reactive rather than pro-active. Agencies worked individually to monitor progress rather than responding with partners to emerging concerns and engaging with the family in a meaningful way that had a positive impact on the children. 6.74 Partner agencies were aware that CSC was acutely understaffed during the time considered by this review and some practitioners went beyond their role to support the family. For example, the HV made additional visits due to concerns about the family and knowledge that there was at times no allocated social worker. In addition, health and education records of core groups and CiN meetings were very detailed, in contrast to those of CSC. At this time it was decided by senior CSC managers that minutes of core groups did not need to be recorded to alleviate some pressure on the service. However, this decision caused additional challenges as there was limited information on the system to assist new social workers to understand the issues of concern. 6.75 At the learning event practitioners spoke about significant inconsistencies in child protection practice and said that much was dependant on the skills and experience of the social worker. Core groups were described by Practitioners as listening events rather than meetings to actively review the progression of a plan. Practitioners spoke about pushing for action at the core groups and not always feeling respected or listened to. 6.76 Strategy meetings were of variable quality and the correct practitioners did not always attend. Contributions from professionals in health and education was often missing and resulted in limited information sharing which impacted on subsequent decisions and actions. There was a view at the learning event that strategy meetings are now more effective and the quality of discussions is monitored by strategic safeguarding leads. 6.77 There were challenges with information sharing throughout the timeline for this review. Practitioners described difficulties in contacting social workers and spoke about frustrations when some workers left at short notice without a replacement being allocated. Each new SW effectively had to start again, information on the ICS system was out of date and it was problematic for new SW’s to understand the issues facing children and families. Due to high caseloads there was no time to read large files before meeting with the family and starting work. High turnover of social workers and limitations in staffing had a significant impact on this case. 6.78 There was a significant disconnect in this review between CSC and education. Designated Safeguarding Leads (DSL) from school described raising safeguarding alerts on many occasions and there were clear records of the concerns raised by school with CSC. There was a high level of frustration about the number of times school had been advised to address issues directly with 26 parents. It was evident that school and nursery knew the children and family well and offered a significant amount of help and support. School provided food and clothing at times and cleaned the children when they arrived at school dirty. This was not enough however to safeguard the children and the family should have been open to CSC much earlier supported by a multi-agency plan with clear manageable targets and tangible outcomes. 6.79 There were many occasions during the period considered by this review that professionals could and should have used the escalation policy. The escalation process was not used effectively by any agency although all had serious and significant concerns about the wellbeing of the children. There appears to have been an acceptance amongst partners that escalation would not make any difference to the children. BSCB have delivered extensive training on the escalation policy however, it is unclear how this training has impacted on practice. It was acknowledged by the steering group that some escalation is currently taking place however the procedure is not routinely followed and concerns are raised directly with strategic safeguarding leads. It is important that partner agencies are able to challenge each other when there are concerns that practice is not in the best interests of babies and young people. 6.80 There was very little multi-agency cooperation evident during the timeline considered by this review. Practitioners agreed that improving multi-agency cooperation and practice is the responsibility of all partners. Positive professional relationships based on trust and mutual respect should have an impact on the outcomes for babies and children. Practitioners spoke about the importance of having opportunities to develop and nurture multi-agency co-operation. Learning Point 8 When practitioners have concerns about practice to safeguard children it is important that these are escalated using the correct procedure. Omission to do so may result in drift and delay in the provision of appropriate support and intervention to safeguard children. Learning Point 9 When professional relationships between partner agencies become strained and challenged this can impact on the effectiveness of multi-agency cooperation and the quality of practice to safeguard children and young people. 7 Good Practice 7.1 Partner agencies were aware of the challenges experienced by CSC at the time considered by the review. There were some examples of professionals undertaking work that was over and above their responsibility in response to the needs of the Child V and family. Good practice included: School provided support to Father with reading and writing Health Visitor made additional visits to support the family School supported Mother to provide clothing and shoes Nursery offered a place to Sibling 3 at no charge 27 8 Context 8.1 During the period considered by this review Children’s Social Care in Buckinghamshire County Council experienced a period of turmoil. Two consecutive Ofsted inspections (2014 and 2018) concluded that children’s services were inadequate and there was a change in leadership at a strategic and practice level. In addition, many social workers left and whilst there have been significant efforts to recruit, social worker vacancies remain. 8.2 Findings of a recent monitoring visit which focussed on services for children in care noted that there have been limited improvements 37. Ongoing concerns mirror the findings of this review; children continue to experience a frequent change in social worker, quality of practice is variable and assessments not regularly updated which makes it difficult to understand children’s lived experience and current needs. 8.3 At the learning event practitioners said that practice at the time was process driven, non-compliance by SW’s was an issue and practice standards were not always met. A comprehensive improvement plan is currently being implemented by CSC, the learning and recommendations from this review aim to strengthen and complement the improvement journey. 9 Conclusion 9.1 This review was triggered by the death of Child V from cardiac arrest determined by the Coroner as likely to be caused by a natural but undetermined cause. During the 18 months of her life Child V experienced neglect and delayed development. Information provided to the review evidence that the social, emotional and developmental needs of Child V and Siblings 1, 2, and 3 were not met. 9.2 It is important that consideration is given to how the learning and recommendations identified in this review will be shared with all partners working together to safeguard children in Buckinghamshire County Council. The main purpose of a review is to prevent similar practice shortcomings affecting the lives of vulnerable babies and children who are powerless to care for themselves. 9.3 It is a concern that practice issues identified in earlier BSCB reviews have been repeated within this review for Child V. It is important that partners understand why previous actions to improve practice have had limited impact and this understanding informs the implementation of recommendations from this review. 9.4 The review was guided by two overarching questions; What can we learn from this case about the effectiveness of practice in Buckinghamshire to identify the neglect and abuse of children? What can we learn about the assessment of risks and vulnerabilities (known at the time) and how these influenced decision making and intervention? 37 https://files.ofsted.gov.uk/v1/file/50134640 28 9.5 Child V and siblings 1, 2, and 3 were known to be experiencing long term neglect however, the response of agencies was fragmented and there was a lack of effective multi-agency assessment. Plans were overwhelming for parents, lacked child focus and did not have clear outcomes. The capacity of parents to effectively safeguard Child V and siblings were not understood or assessed. The impact of long term neglect on Child V and siblings was not adequately recognised and intervention to improve their life experience had limited impact. 9.6 The influence of poor assessment on practice was evident throughout this review. Decisions about intervention and the provision of support were not proportionate or robust as the available evidence about the lived experience of Child V and Siblings 1, 2 and 3 was not assessed systematically. It was evident that practitioners cared about Child V and Siblings and wanted their lives to improve. School and health worked particularly hard to ensure that records were kept and the children seen as often as possible. Without a clear multi-agency plan to respond to emerging concerns any change was not sustained. 9.7 The views of Father and PGM have been reflected throughout this review and informed the learning and recommendations. Father and PGM provided robust feedback to this review, particularly with regard to their experience of not being listened to by professionals. It is not possible to change the events detailed in this review, or remove the distress experienced by Father and PGM. However, it is important to note that implementation of the recommendations from this review should have an immediate impact on the ongoing work to support Father. 9.8 It was evident from this review that multi-agency relationships have been significantly tested, due in part to the period of turmoil experienced by CSC. Agencies were working in isolation and there was limited evidence of a coordinated multi-agency approach to address the needs of Child V and family. It is important that opportunities are provided to develop and sustain constructive relationships between practitioners in partner agencies. Improved professional relationships will contribute to practice improvement and better outcomes for children and families. Learning and Recommendations Learning Point 1 When the siblings of an unborn baby (UBB) are subject to a Child in Need Plan it is important that there is an opportunity within the multi-agency CiN meetings to; discuss the impact of a new baby on the family circumstances include the UBB on the Plan with specific reference to risks and vulnerabilities ensure there is multi-agency agreement prior to closure of the Plan. Recommendation 1 The Safeguarding Partnership to seek assurance that learning from this review is addressed in the new practice standards regarding unborn babies 29 Recommendation 2 All partner agencies are reminded about the decision making process prior to closure of a CiN or CP plan. Learning Point 2 It is important that Child and Family Assessments include relevant historical information and contributions from partner agencies, children, parents and carers to inform understanding of and response to safeguarding concerns. In the absence of a comprehensive assessment decision making may be flawed and children exposed to unnecessary risk. Recommendation 3 The Safeguarding Partnership to seek assurance that: learning from this review is addressed in the new practice standards and procedures regarding assessment multi-agency contribution to assessment at all levels is facilitated and supported by effective processes Learning Point 3 When there are concerns about parental mental health, substance misuse and /or domestic abuse it is important that practitioners understand how these difficulties interact within the family and this information informs assessments and decisions to safeguard and reduce the negative impact on the children. See Recommendation 3 Learning Point 4 In the absence of a parenting assessment it is a challenge for Practitioners to have clarity about the capacity of parents to understand safeguarding concerns and confidence in the ability of parents to protect children. This may result in practitioners having unrealistic expectations of parents and the vulnerability of children could increase. Recommendation 4 The Safeguarding Partnership considers the development of pathways with adult services to assist with the assessment of parents and carers when there are concerns about their cognitive ability. 30 Learning Point 5 When processes and tools to identify, assess and respond to neglect are not used, children may be exposed to long term risk and harm without adequate support or intervention. Recommendation 5 Buckinghamshire Safeguarding Partnership with partner agencies identifies the barriers to the effective use of tools to support the early identification, assessment and analysis of neglect, specifically, Graded Care Profile 2. Recommendation 6 Buckingham Safeguarding Partnership to seek assurance that arrangements to improve the early identification of and response to neglect are included and monitored within the current improvement plan. Learning point 6 It is not sufficient to record observations of children and/or what children say. If the voices and lived experiences of children do not inform assessments and interventions, it is likely that they will not feel listened to, intervention may not be appropriate and concerns could escalate. Recommendation 7 The Safeguarding Partnership to seek assurance that learning from this review is addressed within process and procedures regarding voice of the child and there is robust monitoring to evidence the impact of the voice of the child in practice. Learning point 7 In the absence of a multi-agency assessment following a disclosure of sexually harmful behaviour, underlying problems and difficulties may be overlooked See Recommendation 3 31 Learning Point 8 When practitioners have concerns that the risks children are exposed to and the vulnerabilities experienced are not effectively addressed it is important to escalate concerns using the correct procedure. Omission to do so may result in drift and delay in the provision of intervention and support to safeguard children. Recommendation 8 Buckinghamshire Safeguarding Partnership with partner agencies to identify and address the barriers to the effective use of the escalation policy. Learning Point 9 When professional relationships between partner agencies become strained and challenged this can impact on the effectiveness of multi-agency cooperation and the quality of practice to safeguard children and young people. Recommendation 9 Buckinghamshire Safeguarding Partnership together with partner agencies, identify and develop opportunities to improve multi-agency cooperation and professional relationships. This should include the development of effective professional relationships when children live in another Local Authority. Recommendation 10 Buckinghamshire Safeguarding Partnership shares the learning from this review with partner agencies and practitioners. |
NC042946 | Serious injury of 6 1/2-week-old twin babies, who were admitted to Somerset hospital and found to have serious head injuries and body bruising. Father was convicted of unlawfully and maliciously inflicting grievous bodily harm and received a sentence of 45 months' imprisonment, Mother was found not guilty of any offence. Mother and Father known to have had troubled childhoods and history of paternal mental ill health and conviction for violent offences. Family had contact with a number of services, including 7 local authority areas, 29 health agencies, 3 police forces and 7 housing authorities/agencies. A strategy discussion had been held by Somerset children's services and plans were in motion for a child protection conference at the time of the incident. Considers issues of: pre-birth assessments and rights of the unborn child; the role of police welfare checks; the need for professionals to challenge each other appropriately; working with mobile families who regularly cross organisational boundaries; and the use of research to inform practice. Makes interagency and various single agency recommendations covering children's social care, housing services, legal services, GPs and NHS Trusts and the police.
| Title: Serious case review: overview report: in respect of Baby A and Baby B LSCB: Somerset Local Safeguarding Children Board Author: Jane Wonnacott and Gillian Earl Date of publication: 2013 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Overview Report 19.03.13 Page 1 of 100 Somerset LSCB Serious Case Review Overview Report In respect of Baby A and Baby B Report Authors Jane Wonnacott BA MSc MPhil CQSW AASW Director In-Trac Training and Consultancy Ltd Gillian Earl RGN RHV MA Associate In-Trac Training and Consultancy Ltd Overview Report 19.03.13 Page 2 of 100 CONTENTS Page 1 Introduction 3 2 The Serious Case Review Process 4 3 Family Context 8 4 Summary of Professional Involvement With The Family 9 5 Professional Involvement: North Somerset and Oxfordshire (0-19 Weeks’ Gestation) 14 6 Professional Involvement: Nottingham Pre Birth 16 7 Professional Involvement: Delivery and Hospital Post Natal Period 22 8 Professional Involvement: From Hospital Discharge to Serious Injuries 34 9 Thematic Analysis of Issues in this Case 47 10 Lessons Learnt 74 11 Conclusion 78 12 Overview Report Recommendations 80 13 Health Overview Recommendations 82 14 Individual Management Review Recommendations 86 Appendix 1: Terms and Reference and Scope of the Review 97 Overview Report 19.03.13 Page 3 of 100 1. INTRODUCTION Circumstances leading to this serious case review 1.1 Baby A and Baby B (twins) were admitted by ambulance to a Somerset Hospital at the age of six and half weeks and found to have serious head injuries and body bruising. Mother, Father and the twins had recently moved to Somerset from Nottingham and were living with family in the area. Both parents were arrested and charged with Grievous Bodily Harm. The result of the criminal trial was that Father was convicted of unlawfully and maliciously inflicting grievous bodily harm, and received a forty five month prison sentence. Mother was found not guilty of any offence. 1.2 Mother and Father had received services in seven different local authority areas and had been in contact with a significant number of health providers, both during pregnancy and following the birth of the twins. 1.3 In view of these circumstances, the chair of Somerset Safeguarding Children Board decided that the case met the criteria for a serious case review under statutory guidance1, which requires that a review should be considered where a child sustains a potentially life threatening injury and the case gives rise to concerns about the way in which local professionals and services worked together to safeguard and promote the welfare of children. 1.4 As identified in Working Together to Safeguard Children (2010), where partner agencies of more than one LSCB have known about or have had contact with the child, the LSCB for the area in which the child is, or was ordinarily, resident should take lead responsibility for conducting the serious case review. Any other LSCBs that have an interest or involvement in the case should co-operate as partners in jointly planning and undertaking the serious case review. In this case at the time that the decision was made to undertake the serious case review the children were living in Somerset and the degree and extent of involvement by other local authorities had yet to be determined. 1 HM Government (2010) Working Together to Safeguard Children London: DCSF. Chapter 8 paragraph 8.11. Overview Report 19.03.13 Page 4 of 100 1.5 Somerset Safeguarding Children’s Board, holding lead responsibility for conducting the review, made every effort to ensure that Nottingham LSCB were included appropriately in the review process. The steps that were taken to ensure this were: • An invitation to the individual management review authors to meet the serious case review panel (the Nottingham Children’s Social Care and Health authors attended). • An invitation to members of the Nottingham City Safeguarding Children’s Board to attend a Somerset serious case review panel (this was achieved via teleconference). • Two members of Somerset serious case review panel travelled to Nottingham to meet serious case review panel members. • The sharing of draft Overview Reports in advance for comment and feedback. 1.6 In addition all organisations submitting reports to the Somerset serious case review panel were offered an opportunity to review and offer feedback on the draft overview reports. 2. THE SERIOUS CASE REVIEW PROCESS 2.1 John Snell, Somerset Safeguarding Children Board Independent Chair, was appointed to chair the serious case review panel and oversee the process. 2.2 Members of the serious case review panel were: Somerset LSCB Co-ordinator Somerset LSCB Deputy Chair Service Director, Safeguarding & Care Designated Doctor Somerset and North Somerset Local Safeguarding Children Boards Designated Nurse Somerset Local Safeguarding Children Board Detective Inspector Avon and Somerset Police Overview Report 19.03.13 Page 5 of 100 Principal Educational Psychologist Somerset County Council LSCB Audit Officer 2.3 Two experienced independent overview authors were appointed to prepare the overview report: 1. Jane Wonnacott, Director, In-Trac Training & Consultancy Ltd, a qualified and experienced social worker. 2. Gillian Earl, Independent Consultant and In-Trac Associate, an experienced safeguarding nurse consultant. The authors attended panel meetings in order to ensure that the views of the panel were taken into consideration in the preparation of the final report. 2.4 The terms of reference and scope of the review were agreed and are appended to this report (Appendix 1). 2.5 Following a preliminary review of agency records it was agreed that individual management reviews would be required from: • Oxfordshire County Council. • Oxfordshire General Practitioner Services. • Avon and Somerset Police. • Nottingham CityCare Partnership (Health). • Nottingham City Children’s Social Care. • Northern Lincolnshire and Goole Hospitals NHS Foundation Trust. • Derby Hospitals NHS. • Nottingham University Hospitals. • Somerset Social Care. • Somerset GPs. • Somerset Partnership NHS Foundation Trust (formerly Somerset Community Health). Overview Report 19.03.13 Page 6 of 100 • Derbyshire Social Care. • Somerset Health Overview Report. 2.6 The following additional information was requested and received : • Addendum Report Nottingham CityCare Partnership. • Addendum Report Nottingham City Children’s Social Care. • Telephone Strategy discussion minutes [Somerset Social Care & Avon and Somerset Police]. • Additional information from Avon and Somerset Police. • Typed transcript of telephone calls between the Nottingham social worker and Somerset Direct. • Recordings of telephone calls between Nottingham social worker and Somerset Direct. 2.7 The individual management reviews were scrutinised by the panel in order to ensure that they focused appropriately on the information and learning relevant to their organisation. A summary evaluation of the individual management reviews was completed for Somerset Safeguarding Children Board. Information from the reviews has been assimilated into this overview report. 2.8 Following further consideration it was agreed that an individual management review was not required from the following organisations, due to their limited contact with the parents during the review period or the historical nature of their involvement. Instead, reports and / or chronologies of prior involvement were requested from: • North East Lincolnshire Children and Family Service. • Somerset County Council Special Educational Needs Service. • Taunton and Somerset NHS. • NEMS Benefits Service. • Nottinghamshire Healthcare NHS Trust (Mental Health Services). • Derbyshire Police. • Nottinghamshire Police. • Thames Valley Police. • Cherwell District Council – Housing. Overview Report 19.03.13 Page 7 of 100 • Nottingham Support Service 1. • Nottingham Support Service 2 (Floating Support Services and Central Access Point). • Hostels Liaison Group (HLG) Nottingham. • Charitable Hostel – Derbyshire. • North Somerset Housing. • NHS Direct. • South Western Ambulance Service. • East Midlands Ambulance. • Weston Area Health Trust. • GP practices North Somerset NHS. 2.9 Additional papers considered by the panel to assist their understanding were: • Ofsted (2011) Inspection of Safeguarding and Looked After Children’s Services, Nottingham City. • Ofsted (2011) Annual unannounced inspection of contact, referral and assessment arrangements within Nottingham City Council Children’s Services. • Nottingham Family Support Strategy February 2011. • A Guide for the Police, CPS and LSCB to assist with the liaison and the exchange of information when there are simultaneous Chapter 8 SCRs and Criminal Proceedings (April 2011). • Inspection report Somerset County Council Children’s Services (Ofsted 2011). 2.10 During the latter stages of the review process information was received from Somerset County Council Legal Department regarding the estimated timings and nature of the injuries to Baby A and Baby B. The information noted metaphyseal fractures present in both babies that were likely to have occurred sometime prior to the final serious injury. Family Involvement 2.11 The Serious Case Review Panel was advised by Somerset Police that family members should not be contacted until after criminal proceedings had been Overview Report 19.03.13 Page 8 of 100 completed. Letters were sent to both parents and paternal grandmother outlining the serious case review process, explaining that they could immediately submit any comment in writing to the serious case review panel. Following conclusion of the trial Mother, grandmother and Father were again contacted and asked whether they wished to contribute to the review. Father did wish to see the overview author and he was therefore visited in prison and his views sought about the services provided to the family. Putting learning into practice 2.12 As the review was not finalised until after the trial it was important that immediate action was taken by agencies to make any relevant practice improvements identified without waiting for the final overview report. The action plans that accompany this review do demonstrate that in most cases this happened. However, there were challenges in monitoring this process when the review was being led by one Local Safeguarding Children Board and many of the recommendations related to six other areas some distance away. 2.13 Somerset Local Safeguarding Children Board has made every effort to ensure that all relevant Boards are aware of the process of this review but each individual Board will need to take responsibility for monitoring progress of their own action plans. 3. FAMILY CONTEXT 3.1 Both parents of Baby A and B are described as White British and both can be described as having troubled childhoods. They were subject of child protection plans. 3.2 Father has lived in the south west region for most of his life, only moving to Oxfordshire and Nottingham following his relationship with Mother. He had spent time in the care of Somerset County Council as a young person and there is some evidence of mental health problems. He was also known to the police following violent incidents resulting in a number of criminal convictions. Overview Report 19.03.13 Page 9 of 100 3.3 Mother grew up in Derbyshire, where she was one of several siblings. There have been frequent suggestions that the Mother may have a learning disability but there is no evidence of any formal testing to confirm this. Just prior to meeting Father she was living in a hostel in for vulnerable young women in Derbyshire and, following her relationship with Father moved to North Somerset where her pregnancy with the twins was confirmed shortly afterwards. 4. SUMMARY OF PROFESSIONAL INVOLVEMENT WITH THE FAMILY 4.1 Following confirmation of Mother’s pregnancy in North Somerset: • Mother moved to Oxfordshire to stay with her brother, citing domestic violence from her partner. Mother reconciled with Father, was evicted from her brother’s home and moved with Father into a tent in Oxfordshire. Health, Children’s Social Care, Police and housing agencies had contact with the family at this point. • Mother and Father moved to Nottingham, moving in with a friend until they obtained their own accommodation. Nottingham Children’s Social Care, housing organisations and health agencies were all involved with the family during this pre-birth phase. • Mother went into premature labour ten weeks before her estimated date of delivery and was admitted to hospital in Nottingham before being transferred to hospital in Grimsby (where the twins were born), due to the lack of Neonatal Intensive Care cots in Nottingham. • The twins (together with both parents) were transferred to Derby hospital’s Neonatal Intensive Care Unit, then back to Nottingham where they were discharged into the community. • Within forty eight hours Baby A was re-admitted to hospital in Nottingham and discharged the following day. Nottingham Children’s Social Care continued to be involved. • A few days later without telling professionals that they were leaving Nottingham, the family moved to Somerset to stay with paternal grandmother. According to Father, their intention at this point was to find Overview Report 19.03.13 Page 10 of 100 somewhere to live where they felt safer than they did in Nottingham. • During the eleven days the family spent in Somerset they were visited by professionals from three services (Police, Health and Social Care) on seven occasions. A number of planned visits to the family were unsuccessful. The babies were also seen by the GP and in Accident and Emergency on one occasion prior to their final admission with unexplained injuries. 4.2 As demonstrated by the above history, Mother and Father have had contact with a number of services beyond universal provision, both prior to and during the period covered by this review. This has therefore been an extremely complex review involving seven local authority areas, twenty-nine individual health agencies, three police forces and seven housing authorities / agencies. 4.3 The picture is further complicated by Local Government reorganisations which have resulted in Father’s early records moving between North Somerset, the (then) Avon County Council and Somerset County Council. Father was born in the administrative region of Avon County Council, an authority which had been created in 1974 and took over the government of the northern region of historic Somerset. In 1996 Avon ceased to exist and two new unitary authorities took over the government of the northern part of Somerset, North Somerset District Council and Bath and NE Somerset District Council. 4.4 Organisations that had contact with the family during the review timeframe: Area Organisation Length of time involved. (From first to last contact) North Somerset GP services Two different practices involved at same time for Father: 3 months NHS North Somerset Mother: 2 months 26 days Father: 3 months Weston Area Health Trust, including one visit to UBHT 2 weeks North Somerset Housing 1 day NADA 1 contact Oxfordshire Cherwell District Council Housing 2 months 19 days Thames Valley Police 4 days Child, Education & Families Directorate 1 month 6 days Overview Report 19.03.13 Page 11 of 100 Oxford Health NHS Foundation Trust General Practitioner Midwifery & Health visiting service 19 days between 1st and last contact Primary Care records cover 2 months 3 days Nottinghamshire Nottinghamshire Healthcare NHS Trust 3 months 5 days (no physical contact) Nottingham CityCare Partnership (Health) 3 months 12 days Nottingham University Hospital NHS Trust 4 months 2 days Hostels Liaison Group 2 weeks Nottingham Housing Support Service 1 4 months 9 days Nottingham Housing Support Service 2 24 days East Midlands Ambulance Service NHS Trust 4 months Nottinghamshire Police 14 days (no physical contact) re PMG 8.2.11 Children’s Social Care 4 months + 11 days NE Lincolnshire Grimsby Hospital 9 days Children’s Social Care 1 day (no physical contact) Derbyshire Derby Hospitals NHS Foundation Trust 9 days Derbyshire Social Care 5 months 3 weeks Derbyshire Constabulary Historical contact only Charitable Hostel 4 months Somerset South Western Ambulance Service 9 days Somerset Community Health (now Somerset Partnership Foundation Trust) 14 days NHS Direct 5 months 3 weeks (three contacts) Children’s Social Care 13 days Taunton and Somerset NHS Trust Incident hospital 1 day Avon & Somerset Police 9 months 4 days 4.5 The organisations which had the most extensive contact with the family during the timeframe for this review were those in the Nottingham City area. Within Children’s Social Care the family were first the responsibility of the screening and duty team, passing to the long term community team following the completion of the initial assessment. A children’s centre was also involved, with a level 3 worker from the centre carrying out a parenting assessment. Level 3 workers within the centre carry a case load of Child in Need (CIN) cases and targeted pieces of work to be completed on cases that are open to Social Care. Overview Report 19.03.13 Page 12 of 100 4.6 The context for the delivery of services was identified by the Nottingham City Children’s Social Care individual management review author as a situation where the organisation ‘has experienced difficulties with recruitment and retention of staff within their screening and duty team which has meant that there have been a number of agency social workers and agency team managers, although it now has three permanent team managers in post. From August to December 2010, the teams were extremely busy, with a significant number of referrals.’ (para 1.5) 4.7 The Ofsted inspection of referral and assessment arrangements which took place whilst the family were in Nottingham (August 2011) noted improvements in the service and that social work vacancy rates were minimal as a result of senior managers ensuring the recruitment of suitably qualified workers to permanent positions. The most recent Ofsted inspection of Safeguarding and Looked After Children’s Services (November – December 2010)2, also noted that workloads were manageable and that decisive action had been taken to identify and respond to increased referral rates in all key agencies. 4.8 Despite identified workload pressures in 2010, the Nottingham Children’s Services individual management review author also commented that: • The service is well resourced and well funded. • There are no cost issues in relation to the provision of parenting placements. • There is no hesitation in instigating either S47 enquiries or court applications and there are high numbers of children in care. 4.9 The individual management review author also identified current practice improvements relevant to this review: • Re-organisation of the work. • Co-location of the safeguarding team (health and social care). • Named nurse now attending the management meetings. • Robust escalation policy (reviewed 2010). • Working together to integrate services. 2 Ofsted (September 2011) Annual unannounced inspection of contact, referral and assessment arrangements within Nottingham City Council children’s services http://www.ofsted.gov.uk/local-authorities/nottingham Overview Report 19.03.13 Page 13 of 100 • Proposed implementation of a joint supervision policy (health and social care). 4.10 The organisational context for Somerset Children and Young People’s Directorate during the time period covered by this review was that all child protection enquires would be filtered through ‘Somerset Direct’. Somerset Direct is a triage service and handles contacts from the public and professionals. There is a direct link for callers who consider their call has a child protection element. This service has been identified by a recent Ofsted inspection as: ... an outstanding model. Managers are knowledgeable and supportive and set high work standards. The presence of qualified social workers and managers within this service is appropriate in determining appropriate thresholds for intervention3 4.11 The process within Somerset Direct is that when the telephone is answered, callers are directed to choose a direct link if their call has a child protection element. Calls are taken by advisors working closely with the social work team to identify if the contact has a child protection element or meets the Children’s Social Care threshold. The initial contact may result in a number of actions, including a referral, and is passed to the team leader of a local ‘pod’. 4.12 Teams in the Somerset Area Office are divided into four ‘pods’ composed of four to five social workers, senior social work assistants and support workers. Cases are allocated in turn to each pod. The pod meets every morning to discuss and manage their work. A new area manager came into post four days after the family arrived in Somerset. 5. PROFESSIONAL INVOLVEMENT: NORTH SOMERSET AND OXFORDSHIRE 3 Ofsted (June 2011) Annual unannounced inspection of contact, referral and assessment arrangements within Somerset County Council children’s services http://www.ofsted.gov.uk/local-authorities/somerset Overview Report 19.03.13 Page 14 of 100 (0-19 weeks gestation) 5.1 Following confirmation of her pregnancy by a North Somerset GP practice, Mother was offered good medical care, but no social history was obtained by either the GP or the midwife although routine questions were asked about domestic violence. On each occasion she gave a negative response or indicated exposure to violence from her wider family. 5.2 Meanwhile Father was being treated by his GP for symptoms relating to his mental ill-health and he also informed the GP that his partner was pregnant. 5.3 Mother’s brother (Maternal Uncle) who lived in Oxfordshire called his own social worker concerned that Mother’s partner (Father) was very controlling and that Mother was very unhappy and isolated. Following ‘an alleged domestic abuse incident by Father’ and this call, Mother moved to stay with Maternal Uncle, a move facilitated by a voluntary domestic violence organisation in North Somerset. 5.4 On arrival in Oxfordshire Mother (now thirteen weeks pregnant) registered with a GP who recorded she had left her partner with the support of a Domestic Violence Unit. Mother was booked with the midwife, referred to a consultant obstetrician and Mother’s brother’s family health visitor was alerted. 5.5 Mother asked Father to join her in Oxfordshire, prompting her brother to follow the advice of his own social worker. The social work advice was that he should ask Mother to move out of his home. Despite Mother’s vulnerability there was no immediate assessment at this point by Children’s Social Care, seemingly due to the possibility that Mother would not be permanently resident in the area. 5.6 The local housing department in Oxfordshire decided that Mother was intentionally homeless and should return to the hostel in Derbyshire. Mother refused, moving with Father into a tent in the Oxfordshire area. Once the housing office became aware of this, bed and breakfast accommodation was arranged that night, and the couple advised to make a homeless application. This they did but, but due to still having a tenancy in North Somerset, they could not be offered Overview Report 19.03.13 Page 15 of 100 housing in Oxfordshire. 5.7 During the time Mother and Father lived in the tent they were seen twice by Thames Valley Police. Firstly, an anonymous member of the public spoke with a police community support officer on patrol and told them that Mother was pregnant with twins, had previous mental health problems, and was homeless and living in a tent with Father who had been violent to her previously. The police community support officer submitted an internal intelligence report which, due to its internal nature, did not trigger any multi-agency discussions. 5.8 On the second occasion they were alerted to the couple’s situation via an anonymous phone call to the police station, as well as from a member of the public to an officer on patrol. A Thames Valley police sergeant visited the campsite and spoke with the couple. He also spoke with Mother alone about domestic violence and asked her if she was okay and happy to remain with Father. She confirmed she was. 5.9 Communication between Health and Social Care in Oxfordshire appears confused by the fact that Mother was initially living with her brother who already had a social worker. The GP contacted social care and at this point appears to have assumed the same social worker was also working with Mother. No formal referral to Children’s Social Care was made by the GP due to Mother refusing her consent, although a letter of support to housing was offered. No contact was made with the practice child protection lead, or a member of the safeguarding team, regarding the GP’s concerns. Should Children’s Social Care have received a referral from the GP, this is likely to have prompted an initial assessment as it is clear that at this point Oxfordshire Children’s Social Care had begun to explore the potential vulnerability of Mother. Evaluation of Practice North Somerset and Oxfordshire (0-19 weeks gestation) Practice issues were: � A focus by Health professionals on medical needs rather than a holistic assessment Overview Report 19.03.13 Page 16 of 100 of both medical needs and social circumstances. The need to do this was particularly acute once it was confirmed that Mother was expecting twins, with additional stresses likely to result from a multiple birth. � A failure to make connections between Mother and Father although Father was registered at the same GP practice in North Somerset. � Although the GP in Oxfordshire liaised well with a number of different professionals, there was no co-ordinated plan in place. 6. PROFESSIONAL INVOLVEMENT: NOTTINGHAM PRE-BIRTH 6.1 At approximately nineteen weeks pregnant Mother moved to Nottingham, presenting at Out Of Hours medical services with pregnancy related symptoms, and was referred to other health care professionals. Children’s Social Care teams in Oxfordshire and Nottingham received notification of Mother’s attendance at hospital. She again presented at hospital in Nottingham three weeks later, and a referral outlining a number of risk factors was made by the Nottingham midwife to Nottingham Children’s Social Care requesting a pre-birth risk assessment. Nottingham confirmed to Oxfordshire Social Care that since Mother was remaining in Nottingham they accepted case responsibility. Oxfordshire Children’s Social Care therefore closed their case file. 6.2 Once it was recognised by the Oxfordshire health visitor that Mother had left the area but had not yet registered at a Nottingham GP surgery, she contacted her Trust’s named nurse who then appropriately contacted her safeguarding colleague in Nottingham to flag Mother’s name as a vulnerable pregnant adult. 6.3 On arrival in Nottingham there were challenges in pulling together a full picture of the family’s current situation, partly influenced by uncertainty as to where Mother and Father would be living and exacerbated by the fact that Mother appeared to be selective in the information she shared with each professional. The couple had contact with a number of housing services who demonstrated good practice by proactively working with the couple, for example, making appropriate and comprehensive referrals to Children’s Social Care outlining several risk factors, Overview Report 19.03.13 Page 17 of 100 including the likelihood that the babies would arrive early. There is also evidence of continued liaison with Children’s Social Care, including joint visits. 6.4 Mother informed the Nottingham social worker in the screening team that she had been on the ‘at risk register’ as a child and gave them the contact details of her social worker in Derbyshire. Derbyshire Social Care confirmed that Mother’s case was open to the learning disability team and that there had been limited recent involvement with her due to lack of engagement. No psychological assessment had been undertaken. Following completion of an initial assessment, the case subsequently transferred to the long term team within Nottingham Children’s Social Care and was allocated to a social worker whose role was to complete a core assessment. 6.5 Alongside the core assessment a PAM (Parenting Assessment Manual) assessment4 was commenced by the family centre in conjunction with the allocated social worker. Interviews carried out for this review have revealed that that during this process there was a degree of conflict between the two professionals involved. 6.6 At various times the social worker commented to other professionals that she thought the case might reach the threshold for child protection. For example, Derbyshire Children’s Social Care records note a request for information from the social worker saying Nottingham were initiating child protection procedures and considering care proceedings. Housing records also note that the social worker informed them that the case was ‘borderline child protection’. However, supervision notes continue to document that the case was to be managed as ‘children in need’. 6.7 Meanwhile routine ante natal care was being provided by health. When Mother was seen by the Obstetric Specialist Registrar he referred Mother to the perinatal mental health team because he identified Mother as being ‘at extremely high risk of post natal depression’. Details of her current mental health status were not documented. Mother was not seen by this service, as she went into labour on the 4 A PAM assessment is a structured research based parenting assessment designed to be carried out by those who have been trained in its use. Overview Report 19.03.13 Page 18 of 100 day of her appointment and, following later contact, failed to make any further contact or appointment. 6.8 Questions were appropriately asked of Mother during ante natal appointments about the possibility of domestic violence, to which she replied, ‘No, never’. However, it was not always possible to follow this up during subsequent appointments, due to Father’s presence. 6.9 During this period Mother and Father frequently reported problems with the downstairs neighbours. Father confirmed to this review that housing was a major source of stress. He has told this review that he did not feel safe in the flat as he believed there were gangs and prostitutes living on the floor below. Housing issues appear to have dominated much of the communication between the parents and the social worker, with Father sending numerous texts, often at night, complaining about their situation. The content of these text messages was not recorded within the social work file, highlighting the need to keep pace with new forms of technology and their relationship to traditional recording methods. 6.10 The Nottingham social worker did request information from Somerset Children’s Social Care regarding Father’s family background as it was known he had been in the care of Somerset as a young person. The files were recalled from Somerset’s archives and extracts sent to Nottingham from his family files, but there was no information about Father’s progress whilst in care, or relevant information such as his conviction for arson and referral for anger management sessions. 6.11 A core assessment record was completed within the time frame agreed with the Nottingham social worker’s manager. However, it repeated the details from the initial assessment and left most of the domains blank. It stated that the issues would be addressed in the ‘full core assessment’ and that a PAM assessment would be completed. This does not appear to have been challenged by the Nottingham team manager and is a significant issue since later on Somerset Children’s Social Care assumed that a full core assessment had been completed, indicating the children were ‘in need’ rather than ‘in need of protection’. Overview Report 19.03.13 Page 19 of 100 6.12 The same day that the core assessment record was completed, the health visitor initiated a safeguarding supervision file in respect of the family. The request contained relevant details of the family history, the fact a PAM assessment was ongoing and noted that there was a plan for a joint visit with a social worker. At this point, apparent discrepancies between the views of Health and Children’s Social Care start to emerge which were not explored by either party. 6.13 It was good practice that during this period the midwife referred and liaised with the allocated health visitor, giving information about the family history. The health visitor contacted the social worker who advised of the history, the PAM assessment and the fact that the parents had a tenancy support worker who was helping to furnish the flat. A joint visit was agreed between the social worker and health visitor, as well as an arrangement for a meeting to take place once the twins were born. In the event the joint visit did not take place as the social worker was unable to be there, but the family were visited by the health visitor and midwife. 6.14 During this period (which included Christmas) the parenting assessment continued, with Mother revealing more of her history and commenting that meeting Father was the best thing that happened to her, as he supported her after her Mother’s death. 6.15 At thirty one weeks of pregnancy, Mother was admitted to the labour ward via ambulance, accompanied by Father. On the same day the Nottingham social worker and the children’s centre worker continued with the PAM assessment whilst Mother and Father were on the labour ward. Mother at this point was on a drip and the inappropriateness of this action does not seem to have been recognised by the workers nor challenged by staff on the ward. 6.16 Afterwards the children’s centre worker discussed the case with her team manager and concluded that it seemed the parents would be able to support each other but would need support from the children’s centre with their parenting. As housing was noted to be an issue, the children’s centre worker subsequently wrote to the housing organisation to point out the unsuitability of the current Overview Report 19.03.13 Page 20 of 100 accommodation. 6.17 During Mother’s labour, there was communication between the hospital midwife, health visitor and perinatal mental health team. All were clear that Mother would still require assessment from the perinatal mental health team following the birth. The named midwife for safeguarding was also contacted by the ward and further information was obtained from Children’s Social Care noting that there was an ongoing assessment, that the category was Children in Need and there would need to be a discharge planning meeting. 6.18 Whilst in labour, Mother was transferred to Northern Lincolnshire and Goole Hospital (Grimsby) in accordance with the Trust’s in-utero transfer policy, due to no neonatal cots being available locally. A medical transfer letter to the Grimsby obstetrician stated ‘lots of social issues which have been explained to your midwifery staff’. The social worker was also informed. 6.19 On admission, a full history was taken from Mother and they were noted to have a social worker. Both parents were noted to be anxious and displaying slightly hostile attitudes towards care given so far. 6.20 Baby A and Baby B were subsequently born prematurely at thirty one weeks’ gestation, by emergency caesarean section. Both babies were small for gestational age and were transferred to the neonatal unit. Evaluation of practice Nottingham Pre-birth (Nineteen weeks gestation – birth at thirty weeks) Practice Issues were: � Proactive work by Housing organisations who made appropriate and comprehensive referrals to Children’s Social Care. � An acceptable initial assessment by Children's Social Care, however, once the case passed to the long term team in Children's Social Care for a core assessment, there was a delay in allocation and an apparent lack of attention paid to the fact that the Overview Report 19.03.13 Page 21 of 100 babies were likely to be born prematurely. � Confusion within Children's Social Care long term team as to the type and level of risk. The social worker referred to child protection procedures when talking to other agencies; however, supervision notes record that the case was Child In Need. It is possible that although the social worker expressed her own views to others, these views were modified during supervision with her manager. � It was unacceptable that the core assessment consisted of the initial assessment, cut and pasted onto core assessment documentation. A serious omission was the lack of any systematic gathering of information about family history and an over reliance on self reporting by Mother and Father. � No assessment of the degree and extent of possible parental learning disability. � A lack understanding of the role of the parenting assessment (PAM) in relation to the core assessment. The PAM is designed to complement (not replace) the core assessment but in this case there is no evidence of any assessment work at all apart from that related to PAM. This should have been picked up by the team manager in their supervision of the social worker, as should the implications of a degree of conflict between the children’s centre worker and social worker. � Inappropriate behaviour in continuing the assessment process whilst Mother was in labour, and no challenge to this by hospital staff. � Mother’s various presentations at emergency medical services was not identified as a pattern of help seeking which may have been a warning sign including anxieties about becoming a parent (Brandon, 2008)5. � Health professionals recognised vulnerabilities but at times appeared to be dealing with immediate health issues whilst passing over to Children’s Social Care the responsibility for managing safeguarding concerns. � Good practice by midwives who created an opportunity to ask about domestic violence when Father was not present. � An appropriate referral to the perinatal mental health team was made in respect of Mother although she went into labour on the day she was due to be seen and, following later contact, she failed to make a further appointment. � No discussion or referral by professionals to the community learning disability team, adult mental health services or substance misuse team to assess, assist and guide 5 Brandon, M., Belderson, P., Warren, C., Howe, D., Gardner,. R. Dodsworth, J. Black, J., (2008) Analysing Child Deaths and Serious Injury Through Abuse and Neglect: What Can We Learn. London DCSF Research report DCSF-RR023 Overview Report 19.03.13 Page 22 of 100 interventions for promoting parenting capacity. � The tendency for both Mother and Father to respond affirmatively to any requests to attend appointments or fill in forms from professionals, may have encouraged over-optimistic assumptions about the extent of the parents’ understanding, level of engagement with professionals and capacity to put into practice any plans agreed (Cleaver and Nicholson 2008)6. � Little consideration by any agency of the stress being placed on the couple by the number of appointments they were expected to keep, often in one day. A more co-ordinated approach may have reduced the negative impact of these demands and allowed a clearer assessment of the couple’s capacity to engage appropriately with professionals. � When the twins were transferred in-utero to Grimsby, it was not good practice for medical staff to state in the transfer notes, ‘lots of social issues which have been explained to you by midwifery staff’. The duty obstetrician responsible for Mother’s antenatal care at this time did not take full responsibility for ensuring that the safeguarding concerns, identified whilst at Nottingham, were appropriately documented and passed onto Grimsby, relying instead on midwifery staff to provide relevant information verbally. 7. PROFESSIONAL INVOLVEMENT: DELIVERY AND HOSPITAL POST NATAL PERIOD 7.1 Whilst in Grimsby, hospital records indicate that the twins made progress and the parents were ‘attending to feeds and cares’. Father has spoken very positively to this review about the help and support that the family received from hospital staff during this time. 7.2 However, there were a number of significant concerns about the behaviour of the parents which were identified, not fully assessed, nor shared with the Nottingham social worker in writing. These concerns included hostility of Father towards staff, Mother missing feeds and parents having little insight into the responsibilities involved in caring for twins. These issues prompted a discussion with the hospital 6 Cleaver H, Nicholson D (2008) Parental Learning Disability and Children’s Needs: Family Experience’s and Effective Practice. Executive Summary DCSF Overview Report 19.03.13 Page 23 of 100 safeguarding team who contacted the local social work office (North East Lincolnshire Children’s Social Care) but only regarding ‘money’, and a one-off hardship loan was made. The Nottingham social worker also asked the hospital to continue to supply food to Father, funded by Nottingham Children’s Social Care. 7.3 Liaison between the hospital and the Nottingham social worker was via telephone. The message conveyed to the hospital by the social worker was that there were ‘no child protection concerns’ and the twins were safe at the present time. 7.4 At nine days old Baby A and Baby B were transferred to Derby Hospital for continuing care nearer home. The transfer documentation from Grimsby did set out issues relating to the social history and parental care of the twins in hospital, but this was not in a clear format and was only identifiable from disparate parts of the records. Verbal communication from Grimsby Hospital and the Nottingham social worker to Derby Hospital reinforced the view that this was a case of ‘Children in Need’. 7.5 On admission to the Derby Neonatal Intensive Care Unit the parents were accommodated at the Children’s Hospital. Staff on the Unit received a telephone call from the Nottingham social worker asking for items usually provided by parents to be given, along with meals for Father, due to benefit problems. When advised that meals were not provided to fathers, the social worker’s response to the hospital staff was that Social Care could not offer any funding for meals and asked for compassion to be shown. Health managers then agreed food would be provided. 7.6 The named midwife from Nottingham appropriately contacted Derby hospital advising the ward of the vulnerabilities of the parents, details of their social worker and that the babies should not be discharged without a discharge planning meeting. 7.7 The Nottingham social worker visited the parents in Derby hospital and spoke to ward staff who had increasing concerns about the ability of the parents to meet the needs of the twins. Following the social worker’s visit, Derby Hospital staff Overview Report 19.03.13 Page 24 of 100 appropriately initiated Safeguarding Children & Young People – Risk communication and action planning paperwork, including the fact that the family social worker had told Grimsby hospital that the twins were ‘not a child protection issue’ and that both parents required a high level of support to meet both babies’ needs. The named midwife contacted the social worker to request a multi-agency meeting. 7.8 The family care sister informed the named midwife that a child in need status did not reflect the level of risk that the babies faced; they should be transferred into child protection and a strategy meeting held. The named midwife contacted the Nottingham social worker and contemporaneous records document that the social worker was noted to appear ‘aggressive’ in her manner. There is no indication that at this point the social worker was willing or able to assimilate the information from the hospital and consider whether this indicated a need to move from her view that the babies were not at risk and threshold for child protection enquiries had not been reached. 7.9 The Nottingham health visitor wrote a letter to housing supporting a request by Mother and Father to be re-housed. 7.10 Derby Hospitals Safeguarding paperwork was completed with a copy for Nottingham University Hospital. Adult risk factors were identified and also those for the babies (prematurity and low birth weight) with the section on risk being ticked under Neglect. Two days later the unit was contacted by Nottingham University Hospitals to say two beds on transitional care were available. Following discussion with the Nottingham social worker, the babies were transferred back to Nottingham. Derby Hospital faxed to Nottingham University Hospitals a copy of their safeguarding paperwork. On their return to Nottingham, the Nottingham social worker requested that the midwives noted information about parenting capacity, competence and any concerns to assist with a Child In Need assessment. 7.11 On the day the twins moved back to Nottingham at eighteen days of age, Nottingham University Hospitals Trust medical records record that a support Overview Report 19.03.13 Page 25 of 100 worker within the hospital noted Mother and Father intermittently needed help with feeding and changing the babies. A number of concerns, new and old, were identified, including a report that Father had been rude to another patient in the ward by shouting and swearing about her, and was wandering the wards at night refusing to go home. Mother was noted to have left the babies in wet clothes and failed to feed them when they were hungry. 7.12 At this point, challenges to Mother and Father regarding their parenting appear to have triggered a number of complaints or threats of complaints against hospital staff. 7.13 The Nottingham social worker supported the parents in a complaint against the housing support service. This was despite the high level of support that the housing organisation had offered over and above that which might have been expected, given that the parents had no ties within the Nottingham area. 7.14 The babies were deemed by the hospital to be fit for discharge once a ‘social plan’ was in place. Meanwhile the social work intervention focused on housing issues, including a discussion between the social worker and their team manager about the possibility of s20 accommodation, as the social worker felt that the current accommodation was unsuitable and the babies would be at risk of significant harm. Social Care records show that the parents agreed the property was not suitable and were prepared to have the babies accommodated on a temporary basis and Father confirmed to this review that he would have agreed to the babies living with foster carers at this point. There appears to have been no discussion of the possibility of a parent and baby placement, but Father told this review that he would have welcomed such an opportunity to learn how to be a parent. 7.15 The parents were advised to make a homeless application, and the social worker and team manager decided to await the outcome of that application before deciding whether to accommodate the twins. The hospital waited for Children’s Social Care to resolve the couple’s housing issues and a decision was made by midwifery management that Father could stay overnight with Mother and babies in Overview Report 19.03.13 Page 26 of 100 a side room. The decision of the housing department was that they were not able to re-house the couple, resulting in increasingly anxious texts sent from Father to the social worker about the housing situation. He also complained that the social worker wasn’t helping them and they now wanted to return to Derbyshire. 7.16 The Nottingham social worker and a colleague from the team visited the parents in hospital and discussed their housing situation and advised them to make a housing application to Derbyshire. The senior midwife was given the team manager’s number to discuss with him the decision by housing not to re-house the parents. It was recorded in the social care file that the team manager discussed the situation with the service manager and s20 accommodation was thought to be inappropriate as the main issue was considered to be housing. The service manager asked for a home assessment and a discharge planning meeting was arranged for three days later. 7.17 The Safeguarding Children Service supervision file noted telephone contact between the named midwife (NUH) with the safeguarding children nurse specialist to discuss the management of the case and concerns that the main focus was on the housing issues. No focused risk assessment, review of the case records, or contact with previous units or an agreed joint action plan for attendance at the discharge planning meeting appears to have been undertaken in the light of their concerns. 7.18 The social worker was advised by Derbyshire Housing Department that Mother would be able to bid on properties in Derbyshire, but would not be accepted as homeless due to the Nottingham property. As a result the parents went to Derbyshire the same day, being away all day and not responding to attempts by the ward to contact them. The ward contacted the social worker who contacted the parents and advised the ward they would be back after 19:00 hours. They returned at 22:00 hours and made a formal complaint about the care the babies had received whilst they were away. 7.19 The social worker also received three texts from Father, the first complaining about the midwife, the second about revisiting housing and the third asking for Overview Report 19.03.13 Page 27 of 100 bed and breakfast accommodation. The following day, further texts were received from Father regarding the housing issue. 7.20 The next day, the parents were still asleep at 09:15 hours and the babies not fed. Mother, when asked, said that she had fed them at 09:00 hours but no milk had been collected. At 13:30 hours, the parents were again found to be asleep in their room and needed prompting to feed and look after the babies. 7.21 The midwife discussed with the deputy ward sister and safeguarding midwife’s concerns regarding parenting skills, lack of concern re feeding times and general care for their babies. She was advised if there were concerns to raise them with the social worker. Her concerns were not shared at the discharge planning meeting. 7.22 The parents expressed concern that Baby B had a red mark noted on side of face and he was reported to be arching his back, following review by the neonatal doctor. No marks were seen and no medical problems identified. It is possible that the red mark may have been attributable to contact from the cot side and may have been an attempt to stop the twins’ discharge from hospital planned for the next day. 7.23 The discharge planning meeting, chaired by the team manager from Children’s Social Care, was a pivotal point in this case when there was an opportunity to assess the accumulating risks and develop a plan to keep the babies safe from harm. However, not all professionals invited to the discharge planning meeting had an in-depth knowledge of the family and two key practitioners (children’s centre worker, and midwife who had expressed concerns) were unable to attend. As a result relevant concerns were not shared during the meeting, with the main focus being housing issues, and the needs of the parents overshadowed those of the babies. The health visitor recorded the meeting as a ‘strategy meeting’, indicating differing views between professionals regarding the status of the meeting. A plan of action noted in Children’s Social Care records agreed: • Discharge the following day (Saturday). • Social worker to go with parents and obtain equipment for the babies before discharge (£250 Grant). Overview Report 19.03.13 Page 28 of 100 • PAM Assessment to be completed. • No midwife available to visit over the weekend. • Daily visiting from Monday shared between professionals. • Parents to be shown how to bathe and make up feeds prior to discharge. • Environmental health to visit flat next week to assess. • The case to be reviewed in one month. 7.24 Health staff attending later identified that there was a difference in opinion about the purpose of the meeting, risks identified, a difference in perception and they felt not listened to. 7.25 The social worker received a number of texts from Father that evening complaining about the heating, wanting to leave the flat and move into bed and breakfast, also enquiring about a promised pushchair. Evaluation of Practice Delivery and hospital post natal period (Birth - 4 weeks) Identification of risk post birth: communication across Health and Social Care Following delivery at Grimsby Hospital, and then at Derby Hospital, a number of social and safeguarding concerns were identified by hospital staff. Some of these were passed onto the Nottingham social worker while others were not, the level of communication possibly being influenced by the clear message from the social worker that there were ‘no child protection concerns’. At times there appeared to be a lack of robust record keeping by health professionals in respect of concerns raised, which may have been influenced by the view expressed by the social worker that this was a Child In Need case. Alternatively, professionals may have been influenced by the threat of complaints made by the parents and social worker. The social worker did request that hospitals noted the interaction between parents and babies, but contact by the social worker was via the telephone, apart from one visit to Derby. A visit to the hospital in Grimsby and a meeting with staff at an early stage would possibly have facilitated a fuller sharing of information, as would a more formal approach to planning with all three hospitals. Whilst distance was most likely a factor that made visiting Overview Report 19.03.13 Page 29 of 100 difficult, this was a missed opportunity for some focused assessment and planning at a point where the babies were safe. There seems to have been little consideration by the social worker of the significant concerns expressed by the hospitals, particularly in relation to parental failure to understand and respond to the babies’ needs for consistent basic care such as feeding and changing. There are clear indications of the ‘care conflicts’ described by Reder et al (1993)7, where parents’ own needs are such that they are unable to tolerate the needs of the dependent child. Parental behaviours and inconsistent care of the babies in hospital would have suggested that care would be problematic in a home environment. There is no evidence of any assessment which included a focus on bonding within hospital, the parents developing relationship with the babies and its impact on attachment and risk once they were home. Role confusion Because observations were being requested within a medical / nursing setting rather than one specialising in child protection, it was important to have specified the criteria by which concerns should be judged, including whether they indicated risk of significant harm. In addition there may have been the potential for role confusion in which tasks appropriate to one profession (social worker) were assigned to others (nursing staff) who had neither the skills nor responsibilities or time to carry them out8. Documentation within hospital Although there is documentation about whether the physical needs of the babies were met there is no documentation about the couple relationship, the parental attitude to the pregnancy or the birth or their ability to provide warmth, stimulation and consistency. The midwives and nurses involved with the family during their extended stay in three hospitals would have observed valuable information about the parents’ attitude to their babies, their ability to provide a range of care, and the developing attachment relationship. In this case, such information was not fully documented, collated and shared with the social worker appropriately. This lack of robust documentation may have been influenced by the minimising of concerns by the social worker, poor communication and / or a lack of 7 Reder, P. Duncan, S., and Gray, M. (1993) Beyond Blame: Child Abuse Tragedies Revisited. London: Routledge. 8 Reder, P. Duncan, S., and Gray, M. (2003) Lost Innocents: A Follow-up study of fatal child abuse. Sussex: Brunner-Routledge page 84. Overview Report 19.03.13 Page 30 of 100 understanding of professional roles, expectations and clarity of task. Collaborative working Multi-agency working within this period was lacking structure and was insufficiently robust. There was, for example, lack of clarity regarding roles and responsibilities when practical issues such as finance, food and accommodation for Father and clothes for Mother were concerned, causing some tensions between hospital staff and the Nottingham social worker. The use of emotive language by the social worker was unhelpful (e.g. that parents should be ‘shown compassion and not left to starve’) and did not promote effective multi-agency working. Despite significant concerns at Grimsby / Derby hospitals, the request for a strategy meeting was not responded to appropriately by the social worker and there is no evidence that she discussed this request with her manager. The perception of one hospital individual management review is that hospital staff lacked confidence in challenging the social worker and refrained ‘from voicing concerns when these had been ‘dismissed’ by others considered to be better qualified or to have more authority’ (Brandon et al 2008)9. Working with hostile parents Although it was the view of health staff at Grimsby and Derby hospitals that the case should be managed as child protection rather than Children In Need, once the babies transferred to Nottingham the approach within Children’s Social Care was case management under s17. There was a continued focus on housing issues, and potential risk was not assessed on the basis of a full knowledge of family history or the current response to the babies which was causing concern within the hospital. These concerns included parents being angry and aggressive as well as failing to attend consistently to the care of the babies, and the threat of complaints. Brandon et al (1998) identified situations where parental hostility resulted in workers becoming frozen which hampered their ability to reflect, make judgements and act clearly10. The social worker does not appear to have 9 Brandon, M., Belderson, P., Warren, C., Howe, D., Gardner,. R. Dodsworth, J. Black, J., (2008) Analysing Child Deaths and Serious Injury Through Abuse and Neglect: What Can We Learn. London DCSF Research report DCSF-RR023 Page 94 10 Brandon, M., Belderson, P., Warren, C., Howe, D., Gardener, R., Dodsworth, J., Black, J. (1998) Analysing Child Deaths and Serious Injury Through Abuse And Neglect: What Can We Learn. London: DCSF page 90 11 Munro, E . (2008) Effective Child Protection 2nd Edition London: Sage 12 Morrison, T. (1990) ‘The emotional effects of child protection work on the worker’ Practice 4 253-271 13 Brandon, M., Belderson, P., Warren, C., Howe, D., Gardner,. R. Dodsworth, J. Black, J., (2008) Analysing Child Deaths and Serious Injury Through Abuse and Neglect: What Can We Learn. London DCSF Research report DCSF-RR023 Page 93- 94 14 Brandon, M., Belderson, P., Warren, C., Howe, D., Gardner,. R. Dodsworth, J. Black, J., (2008) Analysing Child Deaths and Serious Injury Through Abuse and Neglect: What Can We learn. London DCSF Research report DCSF-RR023 Page 94 15 Sidebotham, P., & Weeks, M. (2010) ‘Multidisciplinary Contributions to Assessment of Children in Need’ in Horwath (ed) The Child’s World London: JKP Overview Report 19.03.13 Page 31 of 100 discussed these concerns with her manager; neither was there an analysis of the response of the parents who, when challenged about the hospital’s concerns, deflected the social worker by making complaints about health and housing professionals. During this period, complaints by parents were not collated and assessed as indicative of raising stresses and anxieties that may have impacted on capacity to parent. It is surprising that the social worker made a complaint to Nottingham Housing Support Service 1 on behalf of the parents, given the high level of support that Nottingham Housing Support Service 1 offered outside their remit. It is possible that this was indicative of a worker who was not receiving effective supervision designed to promote critical reflection, objectivity and consideration of the biases that may have been influencing practice (Munro 2008)11, (Morrison 1990)12. The emotional impact on health staff of the complaints made against them (especially when the complaints appeared to be supported by the parents’ social worker), together with dealing with the challenging behaviours of both parents, especially Father, appears unrecognised and unacknowledged. Supervision with a safeguarding focus provided by someone with expertise in this area (in addition to midwifery supervision which has a different focus) may have identified an action plan to support and assist staff in managing the behaviours presented by the parents and kept the focus on the safeguarding, including appropriate documentation. Instead there appeared to be minimal contact with the family awaiting their transfer to another hospital. The Nottingham University Hospital individual management review recommends that the ward manager (sister) should oversee complex safeguarding cases and it will be important that this overview includes an opportunity for reflection and management of emotional impact and the complex dynamics involved in child protection work. Father confirmed to this review that housing was a major source of stress. He has told this review that he did not feel safe in the flat as he believed there were gangs and prostitutes living on the floor below. Housing issues were important as additional stressor but they were only part of the overall picture. In the days prior to the babies’ discharge from hospital in Nottingham; Children’s Social Care focused mainly on housing issues rather than pulling together an assessment which analysed the behaviour of the parents within the context of Overview Report 19.03.13 Page 32 of 100 risk to the babies. There were indications that the parents were extremely stressed and Father confirmed to this review that he would have agreed to the babies living with foster carers. However, because s20 was discussed with the team manager as a possible response to housing concerns, this was deemed an inappropriate course of action. It is unfortunate that the manager was not more probing at this point, prompting the social worker to reflect critically on the current information, particularly the response of the parents post birth. There appears to have been no discussion of the possibility of a parent and baby placement but Father told this review that he would have welcomed such an opportunity to learn how to be a parent. The discharge planning meeting The discharge planning meeting held at Nottingham Hospital was a pivotal point in this case. It continued the social work focus on practicalities rather than a comprehensive assessment of need and risk, although the health individual management reviews have identified that during the meeting, a number of differences were identified between professionals. There was evidence that: • Historical and current concerns were not shared and discussed openly. • The format of the meeting was unstructured. • There were difficulties in keeping the focus on the babies’ needs, rather than housing and other practical issues. • The chairing did not allow health staff views to be valued and listened to. • The majority of professionals present were not in agreement with the outcomes of the meeting. • The CityCare Partnership safeguarding nurse tried hard to raise relevant concerns but felt ‘defeated’ and only slightly reassured that a daily visiting plan was in place and a review planned for one month rather than three months as proposed by Children’s Social Care. • The impact on staff present of having both parents and babies at the meeting. The view of the social care staff at the meeting appeared to be that the parents were vulnerable and needed support, whilst health staff were concerned about their ability to Overview Report 19.03.13 Page 33 of 100 parent and the potential for neglect the babies. This may not have been helped by the presence of both parents and the babies at the meeting, which could have stifled debate about current concerns by health staff. As identified by Brandon et al (2008)13, ‘sustained professional challenge was often found difficult in such cases with a difference of opinion or judgement rarely pursued to a satisfactory conclusion’ often due to lack of confidence, knowledge or experience. There is a need for ‘the importance of sustained and dogged professional challenge’ in such cases. As the staff attending were reported to be experienced and knowledgeable professionals, their behaviour during and after the meeting appears influenced by a lack of confidence in the process of escalating concerns, thus reducing the effectiveness of multi-agency working. Research has identified that it is not enough for agencies to attend meetings in order to share information; they also may need to be proactive. It is for each agency to challenge other agencies where there is disagreement, and to bring to the attention of their own line management, and ultimately the line management within the other agency, any feelings that inadequate account has been taken of their view.14 This did not happen in this case. Not all professionals invited to the discharge planning meeting had an in-depth knowledge of the family: two key practitioners (children’s centre worker and midwife expressing concerns) were unable to attend. As a result relevant concerns were not shared during the meeting, with the focus of the needs of the parents overshadowing those of the babies, whose needs appeared minimised. There was a fixed view that this was a Child In Need case and there was a lack of collation and evaluation of readily available information to identify and act on known risks to the babies (Sidebottom & Weeks 2010)15. The safeguarding health staff present expressed concern as to the outcome of the meeting, but did not escalate these concerns or seek the advice and support of a more experienced colleague, such as the designated nurse or senior manager. In addition, the consultant neonatologist in charge of the twins’ care should have been involved in ensuring that any remaining concerns were resolved prior to the babies’ discharge (Laming Recommendation 70). The decision to discharge the babies on a Saturday is very questionable given that these were vulnerable infants with identified social problems. Although acute health services offer Overview Report 19.03.13 Page 34 of 100 a twenty four hour, seven day a week service, the full range of statutory services are not available and it has been documented that weekends can be a time of heightened risk for vulnerable children. 8. PROFESSIONAL INVOLVEMENT: FROM HOSPITAL DISCHARGE TO SERIOUS INJURIES 8.1 On the Sunday morning after discharge the community midwife visited the family home and saw both babies. They were described as clean and well cared for with appropriate clothing and bedding. That evening Father sent a text to the social worker complaining of noise from the neighbours and asking whether the social worker had found them a pushchair. A few hours later in the early hours on Monday morning, the Ambulance Service received a 999 call from the flat reporting that Baby A had breathing difficulties. Examination did not reveal any breathing problems but both babies were taken to Nottingham University Hospitals Accident and Emergency Department. This was the first of two occasions where ambulance staff acted in a highly professional manner by taking both babies to hospital for examination. 8.2 Although no medical concerns could be identified, it was decided to admit both babies. Baby A was admitted to an Oncology Ward (due to pressure on beds) with Mother, whilst Baby B was with his Father in a parent’s flat within the hospital. Admission to the oncology ward was by no means ideal since staff there would not be used to assessing the implications of a sudden re-admission in circumstances such as these. The agreed plan was to contact the hospital safeguarding team the following morning. 8.3 Records at the point that Baby A and Baby B were re-admitted to hospital in Nottingham suggest that nursing staff were worried about the capacity of the parents to meet the babies’ needs. Father informed the social worker by text of Baby A’s admission. She contacted the ward at 07:45 hours the morning after admission and asked staff there not to let the parents leave the ward. This was an unusual request, which they did not feel able to comply with, as no legal orders Overview Report 19.03.13 Page 35 of 100 were in place. As a result the ward staff discussed their concerns about this request with the hospital safeguarding team. 8.4 Nursing concerns were appropriately raised with the social worker and the team manager. The team manager’s response was that nothing had changed since discharge and concerns had not been raised at the discharge meeting. 8.5 The named nurse appropriately relayed background information on the twins to the paediatrician with the result that the babies remained in hospital longer than would usually be the case. However, she did not escalate concerns to senior managers and/or call a professionals’ meeting, and appeared reassured by the social worker’s comments. Baby A’s consultant paediatrician was therefore subsequently reassured that a child in need plan was in place, resulting in Baby A’s discharge. 8.6 The continuing care sister was contacted with regard to Baby A’s admission as she had intended to visit the family home. It is noted in the health records that the social worker had expressed concerns to the continuing care sister that the house was cluttered, she had spent time cleaning up and that she had concerns regarding their discharge, despite the babies being at home less than twenty four hours prior to readmission. The social worker reported that the service manager had felt that discharge home, and not into foster placement, was appropriate. It was agreed that no home visit would take place whilst babies were in-patients. 8.7 Father sent a text to the social worker identifying that the paternal grandmother (in Somerset) had said the family could go and stay with her. He also sent a further text with paternal grandmother’s contact details and address. The social worker sent an alert to the emergency duty team, as the twins were to be discharged and their return to the home address planned. The social worker advised on the notification form that if the emergency duty team became involved and there were ‘concerns about parenting, to place twins in a place of safety’. 8.8 The Nottingham social worker contacted Somerset Children’s Social Care requesting a home visit to paternal grandmother’s to see her living conditions, due Overview Report 19.03.13 Page 36 of 100 to concerns about Father’s upbringing. At this point there was some confusion between the Nottingham worker and Somerset Direct as to the best means for sending information. This was because the Somerset Direct worker had failed to explain that a secure e-mail facility was available. The Nottingham social worker therefore faxed to Somerset the initial assessment. 8.9 The information faxed to Somerset by the social worker only consisted of the initial assessment completed three months previously, and did not include sufficiently detailed information about past history or more recent observations regarding parental behaviour, or referrals made by other agencies. The lack of timely sharing of the core assessment meant that Somerset Children’s Social Care assumed that a core assessment had taken place and the twins had remained Children in Need rather than subject of section 47 enquiries. Had Somerset seen the core assessment they would have been aware of its limitations. 8.10 At the same time the Nottingham social worker completed a CRIMMs form (request for police information) on paternal grandmother, authorised by another team manager and faxed to the Nottinghamshire Police Child Abuse Investigation Unit. There was delay of fourteen days in Nottingham Children’s Social Care ascertaining information from the Nottinghamshire Police regarding paternal grandmother, with the delay apparently caused by the fact that Mother and Father were moving out of the Nottinghamshire force area. The fact that the case had not been assessed as reaching the section 47 threshold meant that at no time had there been a request by the Nottingham social worker for a police check regarding the parents. A check would have revealed a number of violent incidents involving Father which could have informed the assessment process. 8.11 The twins were discharged from hospital that day, aged four weeks and four days. The paediatric consultant was advised by the safeguarding nurse that a ‘tight package of care’ was in place with no need for a further discharge meeting. The social worker was informed of the discharge and the hospital records note that home visits were planned for Thursday and Friday. No discharge summary was completed and no conclusion of a written safeguarding plan in the notes. Overview Report 19.03.13 Page 37 of 100 8.12 On the same day, three texts from Father and one from paternal grandmother were sent to the Nottingham social worker, complaining about the neighbour. In one, Father said he was scared to go back to the flat and reiterated a request for bed and breakfast accommodation. 8.13 The following day, another Nottingham social worker spoke with Father about his concerns regarding his neighbour. Father stated that his social worker was with him and assisting him with these issues. This social worker also recorded that the twins had not been linked on Care First (the IT system) to their parents, and were recorded as having Mother’s surname. 8.14 That day another text was sent by Father to the social worker, wanting to know what time she was visiting and reminding her to bring the pushchair with her. Father also apologised for being upset with her. The social worker visited the same day and saw both twins asleep in their cot. The flat was described as untidy with a smell of dirty washing (no washing machine) and parents stated they did their washing at their friend’s house. Mother and Father had not yet provided the social worker with their friend’s details, although asked. The following issues were noted: • Kitchen clean. • Tins of food in bedroom. • Bags of rubbish in front-room. • Mother and Father still talking of visiting paternal grandmother; asked to wait for agreement to go following CRIMMs check and welfare check on her. 8.15 Later that day the family visited the Children’s Social Care office to see the social worker and collect a pushchair. The twins were wrapped in a cotton blanket and their parents were advised by the social worker that the babies needed a whole blanket on top as quite cold outside. 8.16 The same day, the Somerset Direct social worker telephoned the Nottingham social worker to clarify what she wanted Somerset to do. The following was discussed: Overview Report 19.03.13 Page 38 of 100 • No evidence for s47. • Discharge planning meeting held on discharge from hospital (date given). • Request for Somerset to visit daily and contact health visitor. • Police check on paternal grandmother and home visit. 8.17 Following discussion with the Somerset team leader it was agreed with the Somerset Direct social worker that it was not appropriate for twins to travel pre assessment, and that information shared by Nottingham indicated a high level of concern. The Nottingham social worker, when advised of this view, said that it would be difficult to stop the family visiting, and following a home visit the family had confirmed that they were adamant they wanted to move to Somerset the following week. The Somerset Direct social worker recorded that the Nottingham social worker seemed agitated and annoyed when advised that a manager would need to authorise a ‘welfare check’. 8.18 The same day, following discussion between the Somerset Direct social worker and team manager, the social worker contacted Nottingham Social Care to speak with a manager to advise that the four week old babies should remain in Nottingham pending assessment. The Nottingham duty manager was not available and it was agreed that the duty senior would ring back (it is not documented that this happened). 8.19 At 11:00 the following morning (Thursday), the Nottingham Hospital continuing care sister visited the family flat with a student nurse. A musty smell was noted (a mixture smoke, possible damp and lack of cleanliness) with the kitchen door closed, and described by Father as ‘a mess’. Both babies were in a cot covered by a loose blanket and Mother was in bed. Several large vomit stains were noted on the sheet and both babygrows. The continuing care sister was advised that the sheets and clothes were in the wash and babies waking hourly for feeds. Four empty bottles were noted on the mantelpiece and she was told that bottles were being made up fresh for each feed. The continuing care sister discussed her observations and concerns with both parents and arranged a return visit to provide resuscitation training. Overview Report 19.03.13 Page 39 of 100 8.20 Following the visit the continuing care sister attempted to speak with the social worker but was unable to make immediate contact. It then seems that the family must have travelled to Somerset (the immediate move possibly triggered by awareness of the concerns of the continuing care sister), as when the health visitor called later that day there was no reply. The paternal grandmother later confirmed with the social worker that the family were on their way. Following this no access visit, they contacted the Nottingham social worker and, once advised that the family had moved to the paternal grandmother’s, immediately liaised with health professionals in Somerset. This swift sharing of information ensured that the babies and parents were registered with a GP practice and were seen by the Somerset health visitor. However, the verbal information given by the Nottingham health visitor to her counterpart on Somerset did not include all the risk factors that were in the file and the file information did not arrive until after the serious injuries had occurred. 8.21 Somerset Children’s Social Care acted promptly in escalating the case to s47 and initiating a strategy discussion. However, the telephone strategy discussion did not include health colleagues which should have happened given the circumstances of two premature babies who had not yet reached their expected delivery date, with possibly complex medical needs. The decision at this point was to convene an initial child protection conference in fifteen working days, the delay designed to ensure all relevant information was gathered and analysed in order to inform decision making at that point. 8.22 A plan was put in place for daily visiting to the family and information was shared between the health visitor in Somerset and Children’s Social Care. The health visitor, for example, advised the Children’s Social Care team leader when they could not gain entry to the home for a planned contact following considerable attempts to gain entry. GP records were minimal with regard to the babies and when they were seen, no history was taken or enquiry made as to how the parents were managing following their move. 8.23 Two police ‘welfare visits’ were undertaken in the short time the babies were in Somerset and the babies were also taken to the emergency department at the Overview Report 19.03.13 Page 40 of 100 hospital and seen by an on call GP. Mother described a history of the twins’ dark stools/pain and the GP discussed the babies with the paediatric senior house officer, who had no concerns. The paediatric senior house officer spoke to Mother, offered reassurance and arranged to ring her the next day. Information about this visit was faxed to the GP but not the health visitor, causing some confusion when the health visitor next saw the family and thought they were describing a hospital admission in Nottingham. Had the health visitor had the information about the history of dark stools she may have assessed the current symptoms that were being described to her (green stools) as underfeeding, and taken more urgent action. 8.24 Children’s Social Care sought legal advice on one occasion but the advice given was that the threshold for legal intervention had not been reached. 8.25 The Children’s Social Care team leader did discuss the case with the area manager and it was agreed that the arrangement for daily visits was sufficient. The team leader also advised during interview for this review that his ‘gut feeling was not great as there was no concrete evidence of what the needs were’. Within Children’s Social Care there was a delay in accessing historical information about Father since his files were located at another office. Once the files were retrieved seven days prior to the babies’ injuries, and information was given by the police regarding previous convictions, there is little evidence that this was analysed and consideration given as to whether the type and level of risk had changed. 8.26 Four days before the serious injuries, the health visitor contacted Somerset Children’s Social Care and advised that no one was at home for her planned visit. She had returned a short while later, again finding there was no one in and then had tried to contact their mobiles, which were switched off. She had then put a note through the flat door advising the family she would try again later. 8.27 The visit to the family the next day (Saturday) was by an experienced senior social work assistant who noted that one of the babies was ‘agitated’. 8.28 No contact was arranged for the next day (Sunday) and on Monday (13:30) the Overview Report 19.03.13 Page 41 of 100 social worker made a planned home visit, finding there was no answer and no response to a telephone call. The situation was discussed with the team leader and following numerous attempted telephone calls, contact was made with the parents at 16:05 hours. As the social worker had had to respond to a placement breakdown and could not visit later that day, a visit was rearranged for 16:30 hours the following day. 8.29 At 07:09 hours on Tuesday morning ambulance control received a 999 call from Mother concerned that Baby A was not breathing. It is commendable that the ambulance crew took both babies to hospital since Mother disclosed that she planned to take baby B to see the GP as he had a bump on his head. 8.30 At 08:00 hours a referral was made to the Children’s Social Care emergency duty team by staff nurse from Somerset hospital. They advised that neither child should leave hospital and to call the police if parents tried to take them. Evaluation of practice From hospital discharge to serious injuries Records at the point that Baby A and Baby B were re-admitted to hospital in Nottingham suggest that nursing staff were worried about the capacity of the parents to meet the babies’ needs. These concerns were appropriately raised with the social worker and the team manager. The team manager’s response that nothing had changed since discharge and that concerns had not been raised at the discharge meeting, was inappropriate and maintained the ‘fixed view’ that this was a case of Children In Need. Records indicate that the manager failed to investigate in more detail why there might have been such a quick readmission, to really listen to the concerns of health staff or reflect on whether the discharge planning meeting had adequately addressed parental capacity to care for the babies. Further discussion with the social worker and a thorough analysis at that point would have included consideration of: • Increasing parental stress evidenced by the number of text messages to the social worker and Father’s attitude within hospital, including swearing at Baby B when feeding. • The lack of medical evidence for breathing difficulties and the possibility this was a Overview Report 19.03.13 Page 42 of 100 cry for help from the parents. The named nurse appropriately relayed background information on the twins to the paediatrician, with the result that they remained in hospital longer than would usually be the case. However, she did not escalate concerns to senior managers and/or call a professionals meeting, but appeared too easily reassured by the social worker’s comments. Baby A’s consultant paediatrician was therefore subsequently reassured that a Child In Need plan was in place, resulting in Baby A’s discharge. Communications between nursing and medical staff in order to ensure plans were in place for discharge demonstrated good practice (Laming 2003), but in this case there had been insufficient challenge of the practice within Children’s Social Care. The impression is that ‘exaggeration of hierarchy’ (Reder et al 1993)16 was operating, with the social worker perceived as being better qualified or having more authority. There is evidence of lack of clarity by the Nottingham social worker regarding discussions concerning the possibility of s20 accommodation. The social worker’s comment to the continuing care sister that the service manager had not agreed that this was appropriate in a situation where the main issue was housing, does not fit with other Social Care records. These do not indicate that there was any formal discussion with the service manager to explore this option. It was good practice that the continuing care sister attempted to contact the social worker following the concerns that she noted about the care of the babies two days after discharge. However, telephone contact was not made until the next day and an e-mail sent two days later, by which time the family had moved to Somerset. The health overview report comments that the continuing care sister could have been more proactive and tried emergency numbers that could have alerted agencies that the family appeared to have fled (para 10.5). It is possible that the concerns of the continuing care sister had been picked up by the family and had triggered the sudden move to Somerset, and an understanding of the content of this visit would therefore be important in any analysis of risk. The concerns were eventually passed to Somerset by the Nottingham social worker and at this point did inform Somerset’s analysis and contributed towards the decision to commence section 47 enquiries. 16 Reder, P., Duncan, S., and Gray, M. (1993) Beyond Blame: Child Abuse Tragedies Revisited London: Routledge. Overview Report 19.03.13 Page 43 of 100 Following the continuing care sister speaking with the social worker, records note that an s47 would have been raised if the family had still been in Nottingham. This was followed by the Nottingham team manager having a discussion with the independent reviewing officer where it was agreed that if the family moved back to Nottingham, an urgent, initial child protection conference would be called. This suggests that the fixed view previously held, that this was a ‘Child in Need’ case, had shifted into child protection, influenced by the contact from the continuing care sister following her visit to the family, offering the social worker detailed information about her concerns. At the point that the family moved there was delay of fourteen days in Nottingham Children’s Social Care obtaining information from the Nottingham Police regarding paternal grandmother, with the delay apparently caused by the fact that Mother and Father were moving out of the Nottingham force area. The fact that the case had not been assessed as reaching the section 47 threshold meant that at no time had there been a request by the Nottingham social worker for a police check regarding the parents. A check would have revealed a number of violent incidents involving Father which could have informed the assessment process. It was appropriate for the Nottingham social worker to make contact with Somerset as soon as she became aware that the family were considering staying with paternal grandmother. However, the request for information centred on the capacity of the grandmother to provide an appropriate environment and did not clearly identify any concerns about parental capacity to meet the babies’ needs. Analysis of the conversation between the Nottingham social worker and Somerset Direct indicates that there was some confusion regarding appropriate methods for communication exchange. The Nottingham social worker did not fully understand the centralised contact system in Somerset and a Somerset Direct worker did not inform the Nottingham social worker that there was a secure e-mail system. This resulted in information being faxed through. When information was faxed to Somerset by the social worker, this only consisted of the initial assessment completed three months previously and did not include sufficiently detailed information about past history or more recent observations regarding parental behaviour or referrals made by other agencies. The 17 Munro. E (2008) Effective Child Protection 2nd edition. London: Sage page 145 18 HM Government. (2010) Working Together to Safeguard Children Para 5.83 19 Written feedback from Police SCR panel member and IMR author dated 9.11.11 Overview Report 19.03.13 Page 44 of 100 lack of timely sharing of the core assessment meant that Somerset Children’s Social Care assumed that a core assessment had taken place and the twins had remained Children in Need rather than subject of section 47 enquiries. Had Somerset seen the core assessment they would have been aware of its limitations. It was good practice that following a no access visit by the Nottingham health visitor and midwife, they contacted the social worker and, once advised that the family had moved to Somerset, immediately liaised with health professionals in Somerset. This swift sharing of information ensured that the babies and parents were registered with a GP practice and were seen by the Somerset health visitor. However, the information given verbally was only partial and did not contain all the information within the health visitor records recording possible risk factors. This would have influenced the Somerset health visitor’s assessment. Liaison was also undertaken with the Somerset social worker and GP. Records were minimal with regard to the babies when reviewed by the GP, without a social history being undertaken or enquiry as to how the parents were managing following their move. As previously identified, professionals ‘need to make a clear, detailed record of events so that past history is available to be scrutinised’17 and for on-going risk assessment, including whether the babies or Mother are seen by another member of the practice. Somerset Children’s Social Care acted promptly in escalating the case to s47 and this decision was confirmed as appropriate when information was received from the Nottingham social worker about the concerns of the continuing care sister. However, there was a delay in accessing historical information about Father since his files were located at another office. Once the files were retrieved seven days prior to the babies’ injuries, and information was given by the police regarding previous convictions, there is little evidence that this was analysed and consideration given as to whether the type and level of risk had changed. The telephone strategy discussion did not include health colleagues, which was unfortunate, given the circumstances of two premature babies who had not yet reached their expected delivery date, with possibly complex medical needs. It would have helped the planning process if this telephone meeting had been followed up within forty eight hours with a second face-to-face meeting to review the action plan agreed. This second Overview Report 19.03.13 Page 45 of 100 meeting would have included all relevant professionals, information about Father’s previous convictions and ensured that the action plan remained appropriate, whilst further information was gathered, collated and analysed for the forthcoming conference. It was reasonable for there to be a delay of fifteen working days in convening the initial child protection conference to ensure all relevant information was gathered and analysed in order to inform decision making at that point. This is in line with government guidance.18 The Children’s Social Care individual management review records that legal advice was sought on one occasion but the advice given was that the threshold for legal intervention had not been reached. This advice was given as part of an informal discussion when the lawyer was in the building for another purpose. At that point little was known about the background and there is no reason to argue the advice was not sound, based on the information given to the lawyer. However, the informal nature of the interaction meant that full consideration was not given as to the potential significance of missing information and whether an urgent, more formal review was needed when this was obtained. There was evidence of good information sharing between the health visitor in Somerset and Children’s Social Care, for example, advising the Children’s Social Care team leader when they could not gain entry to the home for a planned contact on Friday, following considerable attempts to gain entry. There is no documented evidence of robust joined up working within primary health. For example, there is no record that when the babies and Mother were seen by the GP there was any consideration that the concerns about the social circumstances were known, further explored or discussed with the health visitor although an ‘alert flag’ (non-specific) had been added to their notes . The fact that the emergency visit to the out of hours GP at the hospital was not known to the heath visitor is significant, since it clearly led to some degree of confusion in the health visitor’s communication with the family. The health overview report also notes that had the health visitor had the information, she may have assessed the symptoms being described as underfeeding and taken more urgent action. Two police ‘welfare visits’ were undertaken in the short time the babies were in Somerset. Whilst this demonstrates good multi-agency cooperation, the role, responsibility, purpose or focus of the police undertaking ‘welfare visits’ in these circumstances is unclear, since Overview Report 19.03.13 Page 46 of 100 the case involved premature babies who had not yet reached their expected date of delivery. It would be a challenge for a non-medical professional to assess their health and wellbeing adequately, which also appears a relevant concern with regard to the visits undertaken by the student social workers over two Saturdays. The police representative in the serious case review panel has advised there will invariably be occasions where the police may be required to assist in such cases by responding to concerns about the welfare of children expressed by another agency. This case has, however, exposed how little information the police staff had been provided with as part of the request to attend. The police role outside of normal office hours should only arise in three instances, firstly to execute police emergency child protection police powers, secondly to assist Children’s Social Care in executing an order of the court such as an Emergency Protection Order, or thirdly to support the Local Authority in their enquiries where a breach of the peace may occur. This is not force policy but a reflection of best practice as regards professional responsibilities and experience and, of course, a ‘golden thread’ of child protection awareness must run through everything police staff do.19 In this case none of those three criteria was met. The visit to the family the next day (Saturday) was by an experienced senior social work assistant. Arranging a social work visit on a Saturday is commendable, and appropriate feedback to a manager was arranged. The possible explanation for the apparent ‘agitation’ of one of the babies was not explored and with the benefit of hindsight it is possible that the baby may have been in some discomfort from a fracture to his femur. Similarly it is possible that the ‘pain’ described by parents at the emergency hospital visit was due to more than bowel problems. This is not to criticise individual actions, as medical advice to the panel is that such fractures would be hard to detect, but it does reveal the limitations of daily visiting in protecting babies from harm. No contact was arranged for the next day (Sunday) and due to work pressures and problems contacting the family, no further visits were completed prior to the serious injuries on Tuesday. It is unclear what the contingency plan was for such circumstances, where the agreed daily visits had not been achieved. It was known that the family at times were hard to reach (turning off telephones, not at home for planned appointments, and difficulty gaining access when the bell wasn’t working, dependant on other residents opening the Overview Report 19.03.13 Page 47 of 100 communal entry door) which may have suggested the family’s disengagement with professionals. In these circumstances, it may have been appropriate to contact the area manager, although discussion did take place between the team leader and social worker. 9. THEMATIC ANALYSIS OF ISSUES IN THIS CASE What was life like for the babies? 9.1 Although these were young, non-verbal infants, it is important that professionals were able to consider their experience of the world and the impact that this was likely to have on their growth and development. The evidence within this review would suggest that for Baby A and Baby B, the world would have been an uncertain place with a lack of consistency in the care they were receiving, especially following their discharge from hospital. At times, they would have felt warm, dry and comfortable and at others hungry and lacking physical and emotional warmth, with parents anxious and at times distracted from being able to meet their basic needs. 9.2 The babies were cared for in three different hospitals by their parents, with a number of concerning incidents noted which should have been referred more robustly to Children’s Social Care. The evidence suggests that their basic care needs were not consistently met by either parent and a variety of hospital staff had to step in to ensure their needs were attended to. Following discharge, they spent three days in the sole care of their mother and father and a further twelve days supported by paternal grandmother. Whilst in-patients, or in the care of their parents and later at paternal grandmother’s, there is no documentation of any assessment of the impact of these arrangements on the emotional development of either baby, although physical conditions are recorded. A mother’s (or father’s) sensitive perception and acknowledgement of her (or his) infant’s emotional state, enables her (or him) to make sense of her (his) baby’s inner feelings and offer comfort appropriately; it appears unlikely that this happened and should have been noted as an important indicator for the future ability to care and emotional development of the babies. Overview Report 19.03.13 Page 48 of 100 9.3 As identified by Hart (2010)20 researchers have found that as early as two months, infants and mothers, while they were looking at and listening to each other, were mutually regulating one another’s interests and feelings. This provides the foundation for positive emotional and behavioural development and depends upon a close consistent relationship with a caregiver. In this case consistency would have been hampered by both the nature of the parental care they were receiving as well as the babies’ frequent hospital moves. 9.4 Following their discharge and whilst in the sole care of their parents, their standard of care quickly deteriorated and would have increased their level of discomfort as evidenced by: • Dirty bottles lying around. • Both babies found in soiled clothes and bedding. • Complaints by their parents about ‘excessive’ crying. • Further attendance at hospital. • Health professionals who identified that Baby A was being underfed – green stools, crying. 9.5 The culmination of these concerns appears to indicate increasing distress in Baby A, which may be factor contributing to re-admission to hospital with breathing difficulties. 9.6 Baby B did gain weight following discharge, whilst Baby A, just before and following the move to Somerset, was noted to have lost weight, presenting with green stools (which is likely to have been a sign of underfeeding) and was noted to cry a lot, causing concern and anxiety to his parents. Both babies may have already been suffering pain from an abusive incident. The assessment process The Significance of History 9.7 Both Mother and Father had significant involvement with statutory agencies as children and young adults. This was not systematically considered in relation to its potential impact on parenting capacity, from the time Mother was pregnant though 20 Hart D. (2010) ‘Assessment before Birth’ in Horwath, J The Child’s World London: JKP. Page 187 Overview Report 19.03.13 Page 49 of 100 to the serious injuries to Baby A and Baby B. There are differing reasons for this at various points in the case: • A focus on the medical aspects of pregnancy, resulting in social history not being explored either verbally or through scrutiny of medical records, for example, at the point the pregnancy was confirmed by the GP. • Poor record keeping resulting in significant information being either unavailable or partially known. For example, Father’s psychiatric history in Scotland which was partially recorded within the GP records and not shared with any other professionals. • Lack of a thorough core assessment in Nottingham which asked the right questions regarding family history, pulled together all known information and systematically analysed its meaning and impact. • Mobility of Mother and Father, resulting in information not always being available at the point of transfer. For example, the family history as known in Nottingham was not shared by the Nottingham social worker at the point Mother and Father moved to Somerset. • Information about Father’s history as a young person in Somerset being located in files in a different part of the County, which were not scrutinised to inform decision making immediately the family moved into the area. Even when Somerset Children’s Social Care received the files and information from the police regarding past convictions, there is no indication that the significance of this information was integrated immediately into the assessment of risk. 9.8 There is the impression that within Children’s Social Care in Nottingham there was a genuine desire to give the couple a chance to succeed. This was understandable, but it led to a situation where insufficient attention was paid to historical information which would have assisted an assessment of potential parenting capacity. Despite the social worker and the team manager being in receipt of this knowledge, it was not deemed significant enough to explore in detail and used to inform an assessment of parenting capacity. The focus instead was on practical issues, such as housing rather than the psychological capacity of the parents to parent the babies. An understanding of care and control conflicts Overview Report 19.03.13 Page 50 of 100 (Reder et al 1993)21 would have helped to identify that both parents’ past experiences were likely to impact on their capacity to respond to the needs of two demanding infants, without considerable support. Calder (2008)22 notes that care and control conflicts arise when: ‘Parents’ own childhood experiences of adverse parenting leaves them with unresolved tensions which spill over into their adult relationships ...Their children are most at risk during the early months/years when they are most dependent and when they carry meanings for their parents associated with unresolved parental conflicts. This is compounded for parents living in stressful circumstances. Thus, an escalating scenario can develop in which stresses to the parental care-control conflicts come together over days and weeks and can lead to one precipitating and serious/fatal incident’ (p210) 9.9 The assessment may have shifted focus had s47 enquires been instigated and police checks (CRIMMS) been carried out. A check on Father would have revealed his violent background and, with the combination of already known factors relating to his childhood, would have alerted practitioners to potential risks once he became a father. Quality of pre-birth assessments 9.10 A significant factor in this case was the lack of effective, pre-birth assessment, with a key factor being an apparent lack of understanding that the twins were likely to arrive early and therefore the usual timescales needed to be adjusted to take account of this. It is notable that one of the few references to this ‘potential early delivery’ in the records is by the housing worker, rather than professionals within health and social care. 9.11 The lack of effective pre-birth assessment was evident from the point that Mother presented as pregnant. There was a lack of curiosity, by health professionals, regarding her social circumstances in the early stages of pregnancy and a lost opportunity to bring together significant information, in such a way that risks could 21 Reder, P., Duncan, S and Gray, M., (1993) Beyond Blame: Child Abuse Tragedies Revisited. London: Routledge 22 Calder, M. (2008) ‘Risk and Child Protection’ in Calder, M. (ed) Contemporary Risk Assessment in Safeguarding Children. Lyme Regis Russell House. Overview Report 19.03.13 Page 51 of 100 be clearly identified. 9.12 If a screening risk assessment tool had been used by health professionals such as Greenland, C. (1987)23, Browne, K. & Saqi, S. (1988) or Whipple, E. And Webster-Stratton, C. (1991), the couple would have been quickly identified as likely to struggle with parenting, requiring an urgent and early referral to Children’s Social Care. Reder and Duncan’s (1999)24 examples of child abuse risk factors developed from these research studies provides a clear indication of the potential risks in this case. From the overall list several significant factors are present, namely: • Parental history of abuse or neglect. • Learning difficulties or inadequate education. • Fractured family including marital disharmony or violence. • Financial difficulties or poverty. • History of violence or criminality. • Drug misuse. • History of suicide attempts / mental illness. • Poor use of medical care. 9.13 There is evidence at an early stage in this case of ‘interacting risk factors’, Brandon et al (2008)25, that should have worried professionals and it is therefore of concern that health practitioners did not seek the advice of more experienced colleagues, such as the named or designated professionals. 9.14 According to the integrated chronology, the first health safeguarding referral was made by an Oxfordshire midwife, when Mother and Father were living in a tent when Mother was sixteen weeks pregnant. This was entirely appropriate since the midwife carried out a health and social care assessment in which Mother scored four, indicating a high risk. However, there is no record of this referral having been received and acted upon and no further follow up by the midwife to ensure her 23 Greenland, C. (1987) Preventing CAN Deaths: An International Study of Deaths Due to Child Abuse and Neglect. London: Tavistock Browne, K. & Saqi, S. (1988) ‘Approaches to screening for child abuse and neglect’ in Browne, K., Davies, C., Stratton, P., (eds) Early Prediction and prevention of Child Abuse, Chichester: Wiley Whipple, E., and Webster-Stratton, C. ‘The role of parental stress in physically abusive families’ in Child Abuse and Neglect 15: 279 - 91(1991) 24Reder, P., and Duncan, S. (1999) Lost Innocents: A Follow Up Study of Fatal Child Abuse. London: Routledge 25 Brandon, M., Belderson, P., Warren, C., Howe, D., Gardner, R., Dodsworth, J., & Black, J. (2008) Analysing Child Deaths and Serious Injury Through Abuse and Neglect: What Can We Learn. London DCSF Research report DCSF-RR023 Overview Report 19.03.13 Page 52 of 100 concerns were dealt with. This was another lost opportunity to ensure that a comprehensive assessment took place pre-birth. It is significant that at this point it was alleged that Mother was addicted to codeine, yet no one explored this further and recognised the possible implications of this for both Mother and the unborn babies. 9.15 The Thames Valley Police individual management review highlights the fact that the general definition of a child within legislation (Children Act 1989 and 2004) is that of a young person under the age of eighteen, and does not include unborn children. The report indicates that this may have been a factor in a police officer failing to report concerns, as it was felt child protection concerns were only relevant once a child was born. 9.16 It was whilst the parents were living in Nottingham that there was the best opportunity for a thorough pre-birth assessment. The parenting assessment tool used within Nottingham is the Parenting Assessment Manual (PAM) which is particularly useful for work with parents with learning disabilities, although it does have a wider application.26 Whilst the PAM assessment is not pre-birth specific, it can be used in such circumstances, with domains 11-31 of the assessment being particularly relevant and domains 1-10 being completed post-birth (Dr Sue McGaw, PAMS Training Ltd, personal communication September 2011). Whilst it is understandable that PAM would have been seen as appropriate in this case, the pre-birth aspects of this assessment should have been completed alongside a thorough core assessment, which gathered and analysed information from the family and the whole network that had been involved with them over time. 9.17 Government guidance regarding specific issues to be addressed in relation to pre-birth assessments simply states that the same procedures and time scales should be followed when there are concerns about the welfare of an unborn child27. In this case, guidance was followed, in as much as a core assessment had been signed off as completed, however, the quality of this assessment was inadequate and it did not address any of the pertinent issues that should have been explored 26 Parent Assessment Manual developed by Sue McGaw, Special Parenting Service, Cornwall Partnership NHS Trust. 27 HM Government (2010) Working Together to Safeguard Children London: The Stationery Office Overview Report 19.03.13 Page 53 of 100 in a timely manner pre-birth. The inappropriate sign off by the manager at this point has been commented upon within the Nottingham social care individual management review. 9.18 The Nottinghamshire individual management review has clearly highlighted the lack of pre-birth risk assessment. The numerous interacting risk factors in this case, alongside few protective factors, should have alerted professionals well before the birth that risks were significant and resulted in a pre-birth child protection conference. This should have prompted a fuller assessment utilising all known information, a baseline from which to measure future change and structured planning, focusing on the protection of the babies from harm. 9.19 The paucity of useful guidance (national or local), effective supervision or local training within Nottinghamshire regarding factors to consider in relation to pre-birth assessments, was likely to have contributed to a situation where good practice was not well embedded within the team. There is a comment in the Nottingham Children’s Social Care individual management review that one of the reasons the case was allocated to that particular social worker was because of her experience in this area of work. This appears to have led to a situation where her practice was insufficiently scrutinised by the team manager, particularly in relation to the implications of pre-birth assessments and multiple births. 9.20 It was wholly inappropriate to attempt to continue the PAM assessment whilst Mother was in labour, a situation which should not have arisen had there been a more thoughtful approach to the likely timescales within which a pre-birth assessment involving multiple birth needed to be completed. Assumptions and learning disability 9.21 A major assumption that appears to have been made throughout work with this family was that both parents had a learning disability; there was a lack of precision in the terminology used, with a failure to distinguish between learning difficulties and learning disability. Both parents frequently informed professionals that they had a ‘learning disability’, which professionals appeared to accept at face value, without questioning this statement or looking for collaborating Overview Report 19.03.13 Page 54 of 100 evidence. 9.22 In relation to Mother, this assumption seems to have started when she was a young person in Derbyshire and was referred to the learning disability team for assessment. Referral for an assessment was good practice if there was any doubt about her functioning; however, since she did not attend the appointment the exact nature of any learning disability was never determined. 9.23 The situation with Father is less clear, with him being represented by the official solicitor within current care proceedings. Terminology within the records is confusing regarding his intellectual ability. He did attend special school, but it is likely that it was the combination of a below average IQ and emotional vulnerabilities stemming from his background that led to the need for special education, rather than a learning disability alone. 9.24 In any event, lack of clarity in relation to both Mother’s and Father’s psychological functioning and imprecise reference within the records to ‘parental learning disability or difficulties’ may have diverted professionals from a focus on the potential risks to the babies. The use of the PAM assessment alone, without a concurrent core assessment with a focus on both risk and need, indicates an assumption that the main issue was parental learning disability, rather than a multiplicity of risk factors which were likely to impact on the parents’ capacity to provide safe care. It is far more likely that mental health issues and vulnerabilities as a result of past experience would affect parenting capacity, yet these issues were not the focus of the assessment process. 9.25 In this case, assumptions and lack of clarity led to the worst of both worlds, with neither the potential learning disability being assessed properly and appropriate supports put in place, nor a proper focus on assessment of risk. Overview Report 19.03.13 Page 55 of 100 9.26 Babies harmed Parental support needs not identified No psychological assessment Assumptions both parents were learning disabled Lack of focus on risk Protection for babies not in place Babies harmed Assessing the need for accommodation under s20 9.27 As identified earlier in this report there was a level of confusion within Nottinghamshire Children’s Social Care about the possibility of accommodating the babies under s20. The individual management review rightly comments that it was inappropriate to consider section 20, when the main issue identified was housing and that ‘there appears from the record to have been no discussion regarding any concerns about the parents’ ability to care for the babies and that this factor was not part of any rationale for considering s20 accommodation.’28 9.28 At this point, it would have been appropriate to stop and consider whether the fact that the parents were apparently so willing to agree to accommodation was an indication of capacity to care safely for the babies. Reder and Duncan noted that having an awareness that families may give overt warnings of child abuse means that practitioners must be prepared to take seriously statements about not being able to cope or requests for the babies to live elsewhere. Such admissions need to be seen as an indication of the need for further assessment, which did not happen in this case (2003)29. 28Nottinghamshire Children’s Services individual management review para. 2.46 29 Reder, P Duncan, S (1999) Lost Innocents A Follow -Up Study of Fatal Child Abuse. London: Routledge. Overview Report 19.03.13 Page 56 of 100 9.29 By the time the parents had moved to Somerset, they gave the impression to professionals that they could manage the twins without support. It was recognised that this was a risky situation that needed further assessment, but the level of risk was not seen to be significant enough to prompt discussions with the parents regarding this assessment being within a residential setting. The moment to identify this as a possibility had been lost prior to the move and did not form part of the information excange between Nottingham and Somerset. Assessing the significance of allegations of domestic violence 9.30 Domestic violence can be expressed in a number of ways. It is very common for there to be more than one form of abuse occuring and it may have been going on for a period of time. 9.31 It is worrying that none of the agencies involved with Mother and Father undertook any assessment that included consideration of domestic violence and especially its potential impact on parenting. Consequences (2005)30 which may apply to either or both parents can include: • Loss of self confidence as a individual and as a parent. • Inability to bond and form a relationship with their child. • Feeling undermined as a parent and individual. • Feeling emotionally and physically drained with little to offer the babies. • Emotional distance between parent and child. • The potential to take out their frustrations on their babies. • Inability to deal with their babies’ behaviours. The same guidance also identified that it was important not to solely focus on the mother as the only parent of the child and that the role of the father needs to be clarified and understood. It is also important to understand the dynamics of the perpetrator’s relationship to other members of the family and to consider any services required to meet the need for his behaviour to change and to support for Mother. In addition the utilisation of a Multi-Agency Domestic Violence Risk Identification threshold scale (2007), such as that developed by Barnardo’s, may have made this task easier for all the staff involved ensuring that the risk to 30 Lincolnshire ACPC (2004) Children who experience Domestic Violence Guidance: Lincolnshire Overview Report 19.03.13 Page 57 of 100 Mother from the Father was appropriately assessed around domestic violence.31 9.32 All professionals working with families, where there is actual or potential domestic violence, must consider issues around confidentiality and safety. Professionals also need to be aware of each agency’s boundaries of confidentiality and be clear about roles and responsibilities. In addition, women must be given the opportunity to talk to professionals on their own, separate from the ‘perpetrator’, which did not always happen in this case. If this is not done, women may deny the violence because of the fear of the consequences (2004)32. The midwifery service did document when Mother was asked routinely about domestic violence, or when she was not asked due to the presence of Father, but other services and agencies did not. 9.33 When there is domestic violence in the home, small children and babies may not understand what is going on, but they often display signs that they are unhappy and feeling insecure. They may be more demanding and cry more, needing more attention and cuddles (2004)33. Following their discharge home, both twins appeared to be unsettled, resulting in Baby A’s re-admission to hospital shortly after discharge. On arrival in Somerset, excessive crying may have been influenced by underlying tensions or violence between the parents. Given previous allegations around domestic violence and the known impact on young children and babies, this area did not appear to have been considered within any assessment in either Nottingham or Somerset. 9.34 The National Health Service has introduced specific training and guidance (2005)34 for health professionals, to assist them to take a more pro-active approach to the problem. Starting with midwives (following prima facie evidence that pregnant women and their unborn child are at increased risk)35, the aim was to raise awareness throughout primary and secondary care about the true extent and cost of domestic violence, including asking routine questions regardless of whether or not there are signs of abuse, or whether domestic violence is 31 Barnardo’s (2007) Multi-agency Domestic Violence Risk Identification threshold scale. Can be found at http://www.londoncp.co.uk/pdfs/supp_sg_dv_app1_riskmat.pdf 32 Lincolnshire ACPC (2004) Children who experience Domestic Violence Guidance: Lincolnshire 33 Childline (2004) Domestic violence information sheet. Childline: London 34 Department of Health (2005) Responding to domestic violence: A handbook for health professionals 35 Department of Health (1998) Health Services Circular HSC 1998 / 211 Section 1 Overview Report 19.03.13 Page 58 of 100 suspected. There is evidence and guidance that repeated enquiry at various intervals increases the ‘likelihood of disclosure’.This did not happen in this case and there was a lost oppprtunity to ask questions and document responses in order to inform all future assessment and plans. Understanding the meaning of behaviour 9.35 Assessments in this case generally failed to move beyond immediate practical considerations to a more in-depth understanding of the psychology of the family and the meaning of parental behaviour. This was particularly the case in the immediate pre-birth and post-birth period in Nottingham. 9.36 For example, Reder et al (2003)36 identified that some parents made disguised admissions or ‘covert warnings’ of abuse of the child, which professionals needed to be able to translate and assess. These included expressed concerns for the child’s health, which was displaced to an innocuous problem often a few days before an assault. In this case a number of possible covert warnings were: • Two days prior to the twins’ first discharge, the parents expressed concern about a mark on the side of Baby A’s face, together with him arching his back (found to be well on examination). • Following the discharge planning meeting, both parents were noted to be angry and aggressive towards staff and Father expressed anger at the poor care received on the ward. • Baby A was re-admitted to hospital less than 48 hours after his discharge, with difficulty breathing, and was found to be well on examination (it should be noted that it is possible that the breathing difficulties could have been caused by the action of the parents, such as shaking). The potential significance of these incidents was not recognised by either health professionals or the Nottingham social worker. 9.37 In addition, the increasing anxiety of the parents, particularly Father, evident in the 36 Reder, P., Duncan, S and Gray, M., (1993) Beyond Blame: Child Abuse Tragedies Revisited. London: Routledge Overview Report 19.03.13 Page 59 of 100 texts to the Nottingham social worker, was not understood as a potential indicator of abuse. The fact that the parents were willing to agree to section 20 accommodation was not assessed as a potential plea for help and acknowledgement of their own fear that they could not care for the babies. The interview with Father during this review process has confirmed the initial view of the serious case review panel that he would have welcomed residential care at this time, particularly if this was a parent and child placement. 9.38 Another aspect of behaviour that needed further consideration as part of the overall assessment is the use of complaints by the family. Consideration could have been given as to whether these were used to regain a sense of control, or divert practitioners’ attention away from criticism of the parents’ capacity to parent. The failure to address the significance of complaints extended to consideration as to their impact on practitioners, and whether fear of being complained about could have influenced the likelihood that adverse aspects of parental behaviour would be highlighted. Whether or not this was the case is purely speculative, but there is no evidence that it was considered. The most appropriate place for consideration would have been within supervision (see paragraphs 11.56 - 57). 9.39 The issue of ‘disguised compliance’ has come to the fore, particularly following the serious case review into the death of Peter Connelly in Haringey.37 The second serious case review noted that: ‘The un-cooperative, anti-social and even dangerous parent / carer is the most difficult remaining challenge for safeguarding and child protection services. The parents / carers may not immediately present as such, and may be superficially compliant, evasive, deceitful, manipulative and untruthful. Practitioners had the difficult job of identifying them among the majority of parents who are merely dysfunctional, anxious and ambivalent’. (para 4.2) In this case, there is evidence that the parents superficially engaged with the Nottingham social worker and were at times positive in their texts to her about the 37 Haringey LSCB (March 2009) Serious Case Review Child ‘A’. Published by the Department for Education on 26th October 2010. Overview Report 19.03.13 Page 60 of 100 support she was providing. What is less clear is whether they deliberately manipulated professionals, or were so anxious and frightened about their circumstances that when the help they were receiving did not address their immediate needs, they simply attempted to regain control by making their own decisions without consulting with professionals. The interview with Father would appear to confirm that the latter is the most likely explanation. Recognising and responding to the vulnerability of young babies 9.40 The recent thematic report by Ofsted38 identifies the particular vulnerabilities of young babies and is clearly of relevance in exploring practice issues in this case. Findings from the Ofsted evaluation in relation to timeliness and quality of pre- birth assessments are in accord with the issues explored above. Other issues relating to an underestimation of the risks resulting from parents’ own needs and the need for improved assessment of and support for parenting capacity, are also relevant here. 9.41 Prior to the move to Somerset, there appears to have been little consideration of the fragility of the babies, combined with the parental stressors that were known to be present. It is hard to understand why, within Nottingham, the case was not considered to have reached the threshold for section 47 intervention either before, or immediately after, the birth of the twins. There was overwhelming evidence of factors that were likely to affect parenting capacity, combined with structural factors such as housing, and clear evidence that both parents were unable to consistently provide for the physical and emotional needs of two fragile premature babies. 9.42 Once the family moved to Somerset risks were recognised, but the task was how best to respond whilst gathering and analysing all the relevant information. This is of particular relevance, given the current medical view that the babies are likely to have received the injury to their femurs either before or during the time they were in Somerset. Protecting the babies at this point was a particular challenge in the light of legal advice that the threshold for court action had not been met. 38 Ofsted (October 2011) Ages of concern: learning lessons from serious case reviews Reference. 110080 Overview Report 19.03.13 Page 61 of 100 9.43 The response to instigate daily visiting appears reasonable. However, in this case the exact purpose of the visits was not sufficiently clear and they did not achieve the desired result in identifying any cause for concern or preventing the final injuries. It is possible that the visits, in fact, increased the parent’s anxiety at this point. 9.44 Whether or not any professional should have identified that the babies were injured is debatable. Dale et al (200539) note that the degree to which infants experience pain is a contentious issue and quote David (2004)40: Fractures cause two kinds of pain. One is acute pain resulting from the forces applied to the bone and the pain resulting from the bone breaking. The other is ongoing pain in the days and weeks after a fracture has occurred. The immense variability means that over-confident assertions are worth avoiding … in infancy, rib fractures and metaphyseal limb fractures often produce no detectable ongoing pain at all ... the point is that caution is required before concluding that a reasonable carer should have known that something was seriously amiss in a child with rib or metaphyseal fractures. It therefore seems likely, that in this case, professionals would not have been able to identify definitively the fact that the babies were being harmed, and the health visitor would not have picked up the injuries on examination. However, as identified elsewhere in this report, there were a number of interacting factors which were indicative of heightened risk to the twins. 9.45 The ambulance service in Somerset did immediately recognise the vulnerability and potential injury to both twins despite only having been called out in respect of Baby A. This, followed by the exemplary work of the emergency medical team in Somerset (health overview report para 10.16), will have prevented further harm. Communication within and across organisational boundaries 9.46 Communication across boundaries was particularly important to consider in this 39Dale, P., Green, R., and Fellows, R., (2005) Child Protection Assessment Following Serious Injuries to Infants. Chichester: Wiley. 40 David, T. J. (2004a) ‘Avoidable pitfalls when writing medical reports for court proceedings in cases of suspected child abuse’ Archives of Disease in Childhood 89. 799-804 page 802 Overview Report 19.03.13 Page 62 of 100 review, due to the highly mobile nature of the family. The panel were struck by the capacity of the family to move swiftly, often long distances, without the knowledge of practitioners working with them. This clearly provided many challenges in the sharing of information. 9.47 It was apparent that a factor affecting the efficient transfer of information was a lack of understanding between practitioners of the different systems in places in different parts of the country, and the need to clarify what these are when attempting to transfer information. The conversation between the Nottingham social worker and Somerset Direct clearly demonstrates that the Nottingham social worker was unfamiliar with the system in operation in Somerset, and that the Somerset Direct worker was not sufficiently aware that this might be the case. The resulting irritation on both sides is evident from the transcript of the conversation and did not facilitate the smooth flow of information. Quality of information 9.48 Assessments will only be as good as the information on which they are based. In this case, throughout the period covered by this review, all known information failed to be gathered, collated and analysed in such a way that risks could be identified. There are a number of factors that appear to have inhibited this process that relate to communication between professionals. 9.49 The mobility of the family was undoubtedly a factor affecting the quality of information used to inform assessments and decisions. Within Oxfordshire, and in the very early stages of work in Nottingham, the impression from the records is that since this was likely to be a transient family there was little to be gained by beginning a concerted attempt to gather and evaluate all known information. Similarly, although social workers in Somerset requested information from Nottingham, there was no speedy follow up in order to ensure this was received quickly and, likewise, Nottingham did not ensure that all relevant history was passed on in a timely way. Workers in all organisations were likely to have been influenced by the fact that this family tended to move from one place to another rapidly and without warning. Overview Report 19.03.13 Page 63 of 100 9.50 Communication depends upon one party recognising the importance of the information they hold and the other party asking the right questions. The child protection literature has consistently identified the tendency of professionals to ‘hold on to their beliefs about a family, despite new evidence that challenges them’ (Munro 2008)41. In this case, the definition of the family as one where parents were vulnerable, having possible learning difficulties and needing support, pervaded work throughout the pre-birth and immediate post-birth phase and was most noticeable in the lack of good quality information and analysis informing the core assessment and discharge planning within Nottingham. This, combined with treating information received discreetly and failing to consider any fresh developments in the context of what was already known about the family (Reder el at (1993)42, meant that any new alerting information about the babies’ safety was dealt with in isolation and, as a result, thresholds of concern were not reached. 9.51 A different picture may have emerged if the most recent events had been collated and integrated with the previous concerns already identified. This accumulated knowledge would have raised an awareness of the increasing risk, so that these concerns reached a critical threshold which would have determined a different response in Nottingham, such as section 47 enquiries, prior to the family’s move to Somerset. With the benefit of hindsight, this appears to have happened once the family had already left, influenced by the quality of the safeguarding information shared by the continuing care sister with the social worker. 9.52 The lack of section 47 enquiries within Nottingham, combined with the knowledge that a core assessment had taken place, meant that even though Somerset had not seen the core assessment it was possible to make the assumption that the family’s circumstances had been fully explored and there had been no need within Nottingham to escalate the case to section 47. Sight of the core assessment would have revealed its limitations and may have prompted a speedier gathering and analysis of information by Somerset Children’s Social Care. 9.53 The quality of information received will also be influenced by the clarity of 41 Munro, E. (2008) Effective Child Protection London: Sage page 137 42 Reder, P Duncan, S. And Gray, M (1993) Beyond Blame: Child Abuse Tragedies Revisited. London: Routledge Page 87 Overview Report 19.03.13 Page 64 of 100 communication from one professional to another, regarding what is required. The failure to check that each party is attributing the same meaning to the information being conveyed has been identified as a feature in other reviews.43 In this case, it is not clear that requests for information or tasks to be carried out by others were always understood in the same way by all involved. On a number of occasions, professionals were given the task of monitoring the parents; for example, the midwives on neonatal units and the daily visiting plan agreed in Nottingham and Somerset following discharge from hospital. In the first instance, health staff were left to monitor the parents’ early parenting skills by ‘reporting any concerns’, however, they were not made fully aware of the nature of the concerns or the factors to be observed, resulting in little ‘quality information’ being offered to the social worker. In the second instance, the plan identified ‘daily visiting,’ but no criteria were identified for what would constitute success or failure of the plan. Sharing information across Health Trusts 9.54 A common thread which affected the ability to understand fully the significance of previous history, was that of professional records which were either not completed well enough or available at relevant and appropriate times. Professionals ‘need to make a clear, detailed record of events so that past history is available to be scrutinised’ to inform any future interventions. Patterns can be detected only if practitioners have written down a precise account of what happened’ (Munro 2000 quoted Horwath 2010)44. The Health overview report identifies (para 10.15) that insufficient information was made available to each new set of health professionals involved, leading to evidence of the ‘start again syndrome’. For example, following the babies’ discharge from hospital and the family’s move to Somerset the late transfer of the health visiting records inhibited previous concerns about the parents’ ability to care for their babies from being used to inform assessments. 9.55 In this case, practitioners were often making decisions on complex matters without the benefit of previous records influenced by the number of times the family moved and the significant number of different professionals seen. At times, practitioners were wholly dependent on verbal information offered by the parents 43 Reder, P. and Duncan, S. (2003) ‘Understanding Communication in Child Protection Networks’ Child Abuse Review 12 82-100 44Horwath, J. The Child’s World London: Jessica Kingsley Publishers. Page 81 Overview Report 19.03.13 Page 65 of 100 without the benefit of collaborative evidence from health records. The transfer of medical records across boundaries is dependent on patients registering with a new GP when they move to a new location. The GP then has to request their previous records, a process which may take a number of weeks to complete which, in cases such as this, was not helpful. However, if the professionals involved had discussed their concerns with a named or designated professional, the exchange of information across health boundaries could have been more speedily and effectively managed. 9.56 In this case, information sharing across Health Trusts was complicated by the number of times the babies moved from hospital to hospital. The evidence points to a lack of consistency in the way that information was transferred, plus the time taken to assimilate this information and use it to understand the particular circumstances of the babies. 9.57 Adult Health services, such as Community Learning Disability, Substance Misuse or Mental Health services could have brought specialist knowledge concerning the nature and extent of any ‘alleged’ learning disability, substance misuse or mental health problems. However, although there was an attempt in Nottingham to involve the perinatal mental health team because of concerns that Mother was at risk of post natal depression, there was no overall assessment of her mental health needs. In relation to Father, the information known to the GP in North Somerset that he had received mental health services in Scotland, and comments relating to post traumatic stress, were not highlighted in communications with others when the family moved. An early referral to adult health services may have been able to offer particular interventions or provide access to relevant services, including focused assessment; thus there was a missed opportunity in this case (Horwath 2010)45. The role of meetings in the communication process 9.58 The discharge planning meeting has been identified as a pivotal moment in this case. It was an opportunity for practitioners to bring together all known information and use this to inform a plan, aimed at promoting development and keeping the 45 Horwath, J. The Child’s World London: Jessica Kingsley Publishers. Page 345 Overview Report 19.03.13 Page 66 of 100 babies safe. However, this meeting was not attended by all the key people who had worked with the parents (i.e. children’s centre worker and midwife) and the process of the meeting was such that health practitioners did not feel their concerns were heard. The fact that a meeting has taken place might reassure professionals, evidenced by the social work team manager dismissing subsequent concerns when the babies were readmitted, because they had not been raised at the meeting. However, attention needs to be paid to the quality of the meeting process and in this case it seems that ‘groupthink’46 was evident, with a pressure on those with a divergent opinion to conform to the dominant view. At the time, these concerns were not appropriately escalated to the designated nurse or senior manager. Making sure that not only the right people attend such meetings, but also that all opinions are sought and heard and that there is reflection after the meeting as to whether any further action is needed, is crucial to the effective use of such meetings in safeguarding children. 9.59 The review also raises issues about the need to ensure that all relevant information is used to inform strategy discussions. In Somerset there was no health presence at the initial strategy discussion, which meant that vital health information regarding two premature babies with considerable health needs was lost. The Somerset Children’s Social Care individual management review highlights the need to ensure that there is clarity needed, as to when such a discussion needs to be face to face, rather than via the telephone. Consideration also needs to be given to ensuring the right people attend such discussions / meetings in line with government guidance and that such discussions should include ‘children’s social care, the police, health and other bodies as appropriate’47. Partnership working Professional challenge – relationships across the network 9.60 Approximately half of all serious case reviews are in relation to babies under one year of age, underlining the importance of effective universal services provision for young children, for example, health visitors and Early Years services such as 46Janis (1982) quoted in Munro (2008) Effective Child Protection London: Sage. Page 148 47 HM Government (2010) Working Together to Safeguard Children. DCSF-00305-2010. Para 5.56 Overview Report 19.03.13 Page 67 of 100 children’s centres (2010)48. In this case, a high number of health professionals was involved with the family from different health organisations, across a number of counties, with key professionals expressing concerns about the parents (antenatally and postnatally). Their voices and opinions were not heard by the Nottingham social worker and team leader, who appeared not to value alternative views, or treat them with respect and therefore utilise the expertise of the whole network effectively. This is demonstrated by: • Minimising of concerns raised by ward staff at Grimsby during the discharge planning meeting. • The safeguarding nurse feeling ‘defeated’ during the discharge planning meeting (IMR Addendum Report page 7). • Minimising concerns when Father was reported to have sworn at Baby B, whilst staying in hospital accommodation. • The social worker in making and supporting complaints from the family against professionals. 9.61 Polarisation between agencies can have a negative impact on working together and result in the potential for staff to withdraw from their safeguarding role to the detriment of the child and family. It is relevant to highlight that three different hospitals were asked by the Nottingham social worker to document concerns and pass them to her. None did this effectively and this may have been influenced by culture and the personalities involved. This may have also impacted on the health professionals involved, who did not discuss or escalate their concerns with managers. Using expertise 9.62 Research undertaken by Ward et al (2010)49 identified that many parents reviewed, who had harmed their children, were ‘struggling with mental health problems, drug and alcohol abuse and domestic violence. Several birth fathers had criminal convictions for violence. Few had supportive partners, friends or family members who could help with neighbourhood factors and housing problems, compounding parental problems - all factors present in this case. The 48 Brandon, M., Bailey, S., and Belderson, P. (2010) Building on the learning from serious case reviews: a two year analysis of child protection database notifications 2007 – 2009. Research brief DFE-RB040 49 Ward, H., Brown, R., Westlake, D., and Munro, E. (2010) ‘Infants suffering or likely to suffer, significant harm: A prospective longitudinal study. Research Brief DFE-RB053 page 3 Overview Report 19.03.13 Page 68 of 100 research also identified that assessments demonstrated an unfocused multi-agency approach, often influenced by a lack of clarity around roles, responsibilities and expectations. 9.63 In this case, there were several instances where it was unclear what was being expected, for example, in the case of ‘monitoring’ within hospital and daily visiting when the babies were discharged. The role of welfare checks was raised within the Avon and Somerset Police individual management review and is an example of the need for greater clarity regarding roles and expectations. Police would not have the expertise to assess the wellbeing of premature babies with substantial health needs, yet the term ‘welfare check’ implies this is the case. It is also unclear whether the student social worker, conducting one of the daily visits, would know what to look for in relation to health and development of the twins. The plan developed at the strategy meeting for daily visiting appears without clarity of purpose, or agreed criteria for judging the safety and wellbeing of the twins or consideration as to who was the right person to be undertaking the task. 9.64 The need to recognise and use expertise effectively has been recognised in other reviews. Brandon et al’s study (2005)50 of serious case reviews in Wales noted that: ‘The barrier to the collation and analysis of relevant information often appeared to be a failure to recognise and understand expertise rather than a lack of communication … skilled use of expertise and consultation in a coordinated manner could result in more rigorous assessments and promote greater professional trust, confidence and challenge.’ Using expertise requires receptivity and respect for what others can bring to the discussion, as well as robust relationships across the professional network. Both were compromised in this case. The expertise within the health community was not fully utilised. The observation by the Nottingham Housing Support Service 1 worker that the babies were likely to be born prematurely seems to have been forgotten, and there is evidence of a difficult relationship between the Nottingham 50 Brandon, M., Dodsworth, J., and Rumball, D. (2005) ‘ Serious Case reviews: Learning to Use Expertise Child Abuse Review 14 160-176 (2005) Overview Report 19.03.13 Page 69 of 100 social worker and the children’s centre worker, which may have affected the quality of analysis. 9.65 Recent research has raised questions concerning the acceptable threshold for significant harm, particularly where neglect and/or emotional abuse are key issues. It notes ‘If the welfare of the child is indeed the paramount consideration, then both practitioners and policy makers need to ask far more stringent questions, concerning what constitutes acceptable and unacceptable levels of parenting in a civilised society.’51 In this case, there appeared to be a difference in professional / agency opinion about whether the babies were in need, or in need of protection. This was especially evident when housing and health professionals expressed child protection concerns and made appropriate referrals, whilst the Nottingham social worker and team leader held the fixed view that they were children in need. Whilst Children’s Social Care does have lead responsibility for child protection, there is a need to use escalation/dispute resolution processes effectively, in order to ensure that there is a proper debate concerning thresholds where opinions differ. The Nottingham Children’s Social Care individual management review author informed the serious case review panel that considerable attention has been paid to the use of escalation processes and the Ofsted inspection of safeguarding (January 2011) noted good partnership working and that a dispute resolution policy is in place. The individual circumstances of this review indicate that the Local Safeguarding Children Board will need to ensure that the scrutiny processes focus on consistency and effectiveness of the application of dispute resolution procedures. Working with mobile parents 9.66 As identified above, these were highly mobile parents with the capacity to move long distances at short notice. This demanded organisational skills, as to travel with such young babies on public transport would not have been straightforward. However, mobility affected the quality of information sharing and potentially the commitment of professionals to comprehensive information gathering and analysis of this information, when it seemed likely that the family would move. 51 Ward, H., Brown, R., Westlake, D., and Munro, E. (2010) ‘Infants suffering or likely to suffer, significant harm: A prospective longitudinal study. Research Brief DFE-RB053 page 7 Overview Report 19.03.13 Page 70 of 100 There is little evidence that the underlying reason behind their mobility was adequately explored or incorporated into an assessment of risk. The focus continued to be on practical matters, such as housing (which was of course important), rather than also considering the psychological perspective; i.e. what was the meaning of their behaviour? 9.67 Closure was identified by Reder et al (1993)52 in approximately 50% of the child deaths they studied. This involved such behaviour as parents at times shutting themselves away from professionals by refusing to open the door, or failing to keep appointments, as in this case. Another way in which families ‘closed off’ was through ‘flight’, in which parents moved home repeatedly, often at short notice and without telling the professionals involved. This behaviour was identified to be primarily an issue of control, with parents feeling that they had so little influence about what was happening in their lives they could gain control by attempting to shut professionals out. Consideration of how far this dynamic was present in this case would have enhanced an understanding of parenting capacity. 9.68 At times, there is evidence that practitioners unwittingly exacerbated the problem by encouraging movement to another area, believing this was in the best interest of this family or others in their network. The NADA worker, for example, supported Mother in obtaining train tickets to go and stay with maternal uncle 1 and the conflicting needs of maternal uncle 1’s family and Mother in Oxfordshire, resulted in the Oxfordshire social worker advising maternal uncle 1 to evict her. 9.69 Systems and resources also contributed to mobility, with Mother being transferred to Grimsby hospital because of the lack of specialist cots in Nottingham. Whilst well meaning, the transfer of Mother and the twins again, from Grimsby to Derby then back to Nottingham, increased the likelihood of lost information and consistency in the care and assessment of the twins and the parents. As identified in the Health overview report (para 9.19), unborn babies / children should not be transferred to other hospitals without proper documentation and transfer of full social information and direct telephone communication made to the receiving on-call community paediatrician / paediatric consultant. If such documentation is not 52 Reder, P., Duncan, S., and Gray, M. (1993) Beyond Blame: Child Abuse Tragedies Revisited. London: Routledge Page 99 Overview Report 19.03.13 Page 71 of 100 received, the consultant in charge (or nominated deputy) of the case, should contact the referring hospital to request such documentation is forwarded. The use of Named or Designated health professionals should also be considered as a resource for effective information sharing between different organisations, regarding any safeguarding concerns. Following full consideration of this issue, the health overview report recommends that when infants are transferred out of area to access specialist medical care, further transfers should be limited to transfer back to the local area. The role of supervision 9.70 The importance of effective supervision in child protection work is well documented in government guidance and reviews53 54. In this case, there is little evidence that supervision enabled the reflection and critical thinking required, or encouraged the appropriate use of professional challenge where appropriate. 9.71 Within Oxfordshire, there is no evidence that supervisors encouraged the social worker for maternal uncle 1’s family to think more broadly about the potential risks to Mother’s unborn child. This, combined with the GP’s lack of consultation with named professionals, meant that all known and relevant information was not brought together by Children’s Social Care and passed to Nottingham. 9.72 Of particular concern was the quality of supervision provided to the Nottingham social worker who had the most contact with the family. The lack of focus on an assessment of risk within supervision has been appropriately highlighted by the Nottingham individual management review, which recommends that supervision case discussion records be amended to include a section on ‘current assessment of risk, if any’. This does not, however, address an issue which emerges from the integrated chronology, which is the way in which the social worker was interacting with others and her apparent anxieties about the case. It is noticeable from the chronology that she was informing others that the case was likely to be child protection, or even moving towards care proceedings, yet the supervision records almost immediately following these conversations do not include any discussion about these views and simply refer to this being designated Child In Need. It is 53 HM Government (2010) Working Together to Safeguard Children. DCSF -00305-2010. Paragraphs 4.50 and 4.51 54 Munro, E. (2011) The Munro Review of Child Protection Interim Report: The Child’s Journey. Page 53 Overview Report 19.03.13 Page 72 of 100 possible to speculate that the social worker projected her anxieties outwards, rather than being encouraged to name and explore these within supervision. The impact of anxiety on child protection practice has been well documented over many years,55 with Munro (2011)56 noting that, ‘The emotional dimension of working with children and families plays an important part in how social workers reason and act’. The social worker concerned had only recently returned to work after a two year absence, and there is little evidence that consideration was given as to the personal impact of this case on her, particularly since she was receiving a number of texts form the family outside usual working hours. The dynamics of the relationship between the worker and the family and the information this could contribute to an overall understanding of the case, do not seem to have been explored. 9.73 Supervision did not adequately address the impact of professional relationships. There is evidence from the chronology that the social worker came across at times to others as aggressive, highlighting the challenge for supervisors in really knowing the level of interpersonal skills being employed by their supervisees. This is particularly the case in social work, where so much work takes place out of sight of the supervisor. Within health, although there is now evidence that hospital staff did not feel that they had a good working relationship with the social worker, supervision was not used to explore how to manage this appropriately and ensure that it was not having a detrimental effect on practice. 9.74 The Nottingham Social Care individual management review identifies that social work practice in this case was below the standard that would have been expected and immediate management action was taken to ensure that operational issues identified in the practice of the social worker and the team manager were immediately addressed. It is also important to acknowledge that all agencies have a responsibility to challenge practice when they have continuing concerns about case management, including the option to escalate their concerns to senior managers within their agency. 9.75 Although in midwifery ‘supervision’ is not typically the mechanism used to manage 55 For example: Morrison, T.(1990) ‘The emotional effects of child protection work on the worker’ Practice 4 (4) 253-271 56 Munro, E. (2011) The Munro Review of Child Protection Interim Report: The Child’s Journey. Para 3.17 Overview Report 19.03.13 Page 73 of 100 conflicts between a midwife and other professionals (a midwife would generally initially discuss such conflicts with their line manager, the ward sister), they could thereafter seek support and advice from a safeguarding nurse. This appears not to have happened in this case. 9.76 The role of ‘informal supervision’ between health professionals who do not access supervision on a regular and formal basis, poses a particular challenge for child protection supervisors. Staff contributing to multi-agency assessments, such as the midwives and neonatal staff, requires support and regular supervision to ensure that any anxieties they may hold about either the task or process are identified and supported. To enhance any such multi-agency work, staff involved need to have a clear structure, to fully understand each other’s roles and responsibilities and to feel confident to challenge any decisions made they do not agree with. In such cases, supervision may need to be directive as well as reflective, to ensure that the responsibility for the family is shared by all the professionals involved. Appropriate supervision should have monitored and challenged any concerns identified about professional and family collusion, with appropriate intervention as necessary (Horwath 2010)57. 9.77 All professionals delivering universal services have key roles to play, in the identification of children who may have been abused or neglected and those who are likely to be, thus helping to build up a picture of the child’s situation and alert the appropriate professional if there is a concern. When health professionals are unsure of what action to take or options available to them, they should seek the support of either the named or designated professionals, which did not appear to happen in this case. 9.78 Named professionals have a key role in promoting good professional practice within their organisation and providing advice and expertise for fellow professionals. They usually have specific expertise in children’s health and development, child maltreatment and local arrangements for safeguarding and promoting the welfare of children and would have been a valuable source of advice and support. Whilst designated professionals are a vital source of 57 Horwath, J. (2010) The Child’s World London: Jessica Kingsley Publishers. Page 107 Overview Report 19.03.13 Page 74 of 100 professional advice on safeguarding children, their services were not fully accessed in this case. This was a missed opportunity by the named professionals, especially following the discharge planning meeting and Baby A’s admission to hospital shortly after his first discharge. 10. LESSONS LEARNT 10.1 Many of the lessons from other reviews, in relation to babies under one year, apply in this case. In particular there is evidence that assessments failed to identify the interaction of a number of risk factors that should have concerned professionals. The presence of mental health problems (Father and Mother), history of violence (Father), substance misuse (Mother’s codeine use – Father’s previous amphetamine use), possible domestic violence and parents who had received compromised parenting themselves, was not properly assessed and did not result in a coherent plan to protect the babies. The issue for this review is why did this occur, what lessons can be learnt and what can be done to improve practice in the future. 10.2 Important factors appear to have been a lack of understanding of the implications of a multiple birth, the likelihood that the babies would be premature and the possibility of medical complications making the babies more vulnerable. The delay in completing a robust pre-birth assessment was therefore particularly significant and resulted in over-optimism that the parents would be able to provide safe appropriate care. Caring for twins provides a number of challenges and for these parents, with their own vulnerabilities and needs, a comprehensive pre-birth assessment should have highlighted the risks and resulted in a coherent multi-agency plan before they were born. There are indications that the parents themselves were aware of their own limitations and immediately after the birth would very likely have agreed to section 20 residential assessment. This option was not considered as the focus was on the inappropriateness of using section 20 for what was perceived to be housing rather than a child protection issue. This option was again not considered in Somerset, this time because the parents were not requesting it and appeared to be coping with support. The importance of listening to parents who are giving clear warnings through their behaviour that Overview Report 19.03.13 Page 75 of 100 they are not coping needs to be recognised, as a failure to respond at that point may mean the opportunity for intervention is lost. 10.3 The issue of the right of unborn babies to protection is fundamental here. Government guidance in Working Together to Safeguard Children 2010 does note that the same procedures should be followed when there are concerns about the unborn child. However, there is nothing in the guidance to support good practice in relation to pre-birth child protection processes, nor to highlight any issues that should be considered in relation to multiple births. The Thames Valley Police individual management review helpfully highlights the fact that child protection legislation only applies to children once they are born and suggests that this should be amended to protect the rights of the unborn child. 10.4 At no time, particularly pre-birth, were professionals explicitly utilising any frameworks to assist them in identifying risk. The PAM assessment’s primary focus was on parental functioning and in conjunction with a good core assessment may well have contributed to an understanding of risk. However, there was no core assessment, the PAM assessment was not finished and in fact, some key modules can only be completed after birth, when parenting can be observed. Ward et al (2010)58 suggests that utilising a simple methodology developed by Jones et al (2006)59 and underpinned by research evidence has proved a useful means of identifying which children are at greatest risk of suffering significant harm in the future. Another useful framework both pre and post birth may have been the signs of safety approach60, which understands safety as ‘strengths demonstrated as protection (in relation to the danger) over time61. The explicit use of such frameworks may have assisted in the consideration within Nottingham and Somerset as to whether the threshold for legal intervention had been met. 10.5 One response to the concerns in the case was to set up a daily visiting schedule both in Nottingham and Somerset. The plan for daily visits needs careful 58 Ward, H., Brown, R., Westlake, D., and Munro, E. (2010) Infants Suffering, or Likely to Suffer, Significant Harm: A prospective longitudinal study. DfE Research Brief DFE-RB053. 59 Jones, D., Hindley, N., and Ramchandani, P. (2006) ‘Making Plans: Assessment, Intervention and Evaluating Outcomes’, in Aldgate, J., Jones, D., and Jeffery, C. (eds) The Developing World of the Child. London: Jessica Kingsley Publishers 60Buffa, J., and Podesta, H. (2004) ‘Partnership and Risk Assessment in Child Protection Practice Protecting Children 19 (2) 36-48 61 This is fundamental to the signs of safety approach developed by Andrew Turnell and Steve Edwards. See: www.signsofsafety.net. Overview Report 19.03.13 Page 76 of 100 consideration as, unless the purpose and limitations of the visits is clear, it may result in a false sense of security across the professional network. As this case demonstrates, it is likely that the babies had already suffered fractures to their femurs during the period that visits had occurred and the schedule did not prevent the final severe head injuries. In fact it is possible that the visits themselves raised the parents’ anxieties. Where daily visiting is taking place it is important that the purpose is made explicit to families and the professionals who are carrying them out and there are clear contingencies in place if visits are not achieved. 10.6 Linked to the issue of the visits are a cluster of issues relating to ensuring the right people with the right qualifications and experience are carrying out tasks. The police officer asked to carry out a welfare check had eight months operational service and was asked to undertake a potentially complex task and their opinion as to the welfare of the babies is likely to have been given considerable weight by others. As a result of this case and others, Avon and Somerset Police are working on a protocol which will clarify the role of welfare checks and who should be charged with carrying them out. 10.7 Other issues have emerged concerning roles within the system, including ensuring that the right people (i.e. those with direct knowledge of the parent’s capabilities) attend discharge planning meetings and the need for strategy discussions to include health personnel, particularly where there are young babies with medical issues. 10.8 The need for professionals to challenge each other appropriately has been a feature of many serious case reviews. In this case there appear to have been a number of factors that prevented constructive challenge at various points, most notably during the time the twins were in hospital post birth. The prevailing social work view that this was a situation of ‘Children in Need’ was not adequately challenged by nursing staff who, having seen the parents’ daily interaction with the babies, had serious concerns about their capacity to parent. The overriding impression was that there was a reluctance to challenge social workers who were perceived to have more expertise in child protection matters and the perceived Overview Report 19.03.13 Page 77 of 100 ‘aggressive’ communication style of one social worker compounded this view. This was particularly crucial at the point of the discharge planning meeting when, despite escalation polices within the LSCB, the disquiet of nursing staff only emerged as a result of information gathering for this review. LSCBs, therefore, need to take steps to move beyond policies and procedures in this area and take steps to examine the health of interagency relationships on a regular basis. 10.9 This case has clearly highlighted the challenges associated with working with mobile families who regularly cross organisational boundaries. As well as the practical issues relating to information transfer, as evidenced by problems in the transfer of information between Nottingham and Somerset Children’s Social Care, the review has also identified that mobility needs to be treated as information in its own right. In this case, for example, it is possible that the sudden move to Somerset was because the continuing care sister in Nottingham was unhappy about the standard of parenting. The reason for mobility therefore needs to be questioned and understood within the context of an assessment of risk. Professionals also need to be careful not to increase mobility inappropriately, such as when Mother was encouraged to move from North Somerset to her brother’s home in Oxfordshire. Additionally, in this case, the lack of suitable cots resulted in vulnerable babies moving through three hospitals in the first few weeks of their life. 10.10 The importance of reflecting, throughout any assessment on the dynamics of family/professional interaction, is evidenced throughout this review. At times, the parents appeared to be engaged with professionals, drawing them in as a source of support, mainly with practical matters. On other occasions, they were openly hostile, using the complaints system apparently to deflect professionals from questioning too deeply in areas they did not wish to explore. In addition, there is evidence that they also gave clear warnings to professionals that they did not feel able to cope with the babies; warnings that were not apparently heard. There are also indicators that the phenomenon of ‘closure,’ identified by Reder et al (1993),62 may have been apparent with professionals finding it hard to access the family towards the end of the time frame for this review. Relationships with the 62 Reder, P., Duncan, S., and Gray, M. (1993) Beyond Blame: Child Abuse Tragedies Revisited. London: Routledge Overview Report 19.03.13 Page 78 of 100 family were therefore complex. There is little evidence that supervision in any agency enabled professionals to reflect on the dynamics of the relationship they had with the family and the meaning of their behaviour. 10.11 The need for effective supervision is therefore a key lesson from this review. Effective supervision would have enabled professionals to stand back from the day to day case management, focus on the risk factors present in this case and consider their likely impact on outcomes for the babies. Effective supervision would also have focussed, whilst the babies were in Nottingham, on the dynamics of family/professional relationships as well as relationships between professionals and the impact these may be having on outcomes. It is possible that the perceived style of communication of the Nottingham social worker hid an underlying anxiety about this case and there is no evidence that this was explored properly in supervision with her manager. 10.12 One important lesson particularly relevant within health agencies is the need to use consultation with named and designated professionals, combined with escalation processes if necessary, when there is concern regarding the actions of others within the professional network and constructive challenge has not resulted in the desired outcome. 10.13 One final lesson is the need to ensure that all professionals are aware of relevant research and use this in their work. In this case, knowledge of well documented risk factors in relation to the vulnerability of infants, parents’ history and current behaviour would have assisted decision making. 11. CONCLUSION 11.1 In this case, Baby A and Baby B were injured whilst living in a family situation which, when all the facts are taken into account, could have predictably led to a less than optimal outcome. Whilst the severity of the injuries could not have been predicted, there were clear signs that Mother and Father were struggling to provide the care needed by two vulnerable, premature babies. An important issue Overview Report 19.03.13 Page 79 of 100 is therefore whether there were opportunities to prevent the injuries? 11.2 The most obvious opportunity was during pregnancy In Nottingham when a comprehensive pre-birth assessment would have revealed family histories indicative of parents who, at best, would need a great deal of support to care for twins. The combination of a twin pregnancy, two vulnerable parents, Father’s history of violence and few support structures should have led to a structured assessment of risk prior to the birth. 11.3 The second opportunity to prevent the injuries was during the immediate post birth period when the parents were giving clear signals that they were finding it difficult to cope. A combination of a discharge planning meeting that did not include information from concerned health professionals, and a failure to really listen to what the parents were saying, both verbally and through their actions, meant that there was a focus on practical issues such as housing, rather than potential risk. Health staff remained concerned, but failed for whatever reason to escalate their concerns to senior management. 11.4 The final opportunity was following the parent’s sudden move to Somerset, when the earlier failure to conduct a full assessment resulted in a paucity of relevant information being passed to Somerset. Although the case at this point was immediately identified as high risk, again historical information that should have been available about Father was not integrated into the ongoing assessment, nor did it inform a discussion with the legal team regarding whether the threshold for legal intervention had been met. Although there was well co-ordinated professional activity providing intensive visiting to the family at this point, it is likely that both babies had already received some injuries. It is possible that the final serious injuries could have been prevented by greater clarity regarding the purpose of the welfare visits and a more intrusive approach by professionals. However, it cannot be assumed that this is the case. 11.5 The main conclusion must be that the failure to prevent the injuries stemmed from the cumulative effect of a number of organisations over time failing to integrate all known information about the family, recognise risk including the particular issues Overview Report 19.03.13 Page 80 of 100 relating to a multiple birth and work together effectively across professional and area boundaries. That said, it should be noted that this was a particularly challenging situation due to the number of moves, some of which were precipitated by organisations themselves. Managing such cases requires strong effective management, supervision and support for professionals to enable them to stand back, reflect and identify risk whilst working with constantly evolving complex situations on a day to day basis. 11.6 The most important element of any review must be whether it has a positive impact on future practice. Individual management review authors have considered their involvement in this case and made many recommendations for practice improvement which have been accepted by senior managers and are in the process of being addressed. A number of additional recommendations are made by this overview report which require either a multi-agency approach to service improvement or a shared vision of good practice across LSCB member agencies. These relate to pre-birth assessment practice, staff supervision, inter-professional relationships and use of research to inform practice. It is the view of the serious case review panel that these recommendations address key issues which are at the heart of practice issues in this case. 12. OVERVIEW REPORT RECOMMENDATIONS All LSCBs involved with this review are asked to consider the recommendations from the overview report, health overview report and individual management reviews relevant to their area. The chair of Somerset Safeguarding Children Board will write to the chairs of Nottingham, Derbyshire, North East Lincolnshire, Oxfordshire and South Somerset and North Somerset, in order to bring to their attention the findings of this review and invite them to develop and monitor action plans which will address the lessons learnt. 12.1 LSCBs should review their pre-birth assessment guidance to ensure that it highlights the particular risks that need to be considered in the case of multiple births and the need to gather and analyse all relevant historical information. Overview Report 19.03.13 Page 81 of 100 12.2 LSCBs should ensure that an audit of pre-birth assessments takes place, in order to ascertain whether they are fit for purpose, in line with the guidance and adequately analyse the potential risk to the unborn child. 12.3 LSCBs should review supervision arrangements across the partnership and establish, implement and audit a core standard for safeguarding supervision. The standard should: • Focus on the quality of supervision delivery. • Take account of differing governance arrangements, supervision cultures and organisational structures for the delivery of supervision. • Take account of Working Together to Safeguard Children (2010 para 4.51) and promote a style of supervision which: � Keeps a focus on the child � Avoids drift � Maintains a degree of objectivity and challenges fixed views � Tests and assesses the evidence, based on assessments and decisions � Addresses the emotional impact of work. 12.4 LSCBs should ask agencies to review their internal escalation and resolution processes and ensure that policies are combined with regular activity to evaluate and review the health of relationships at the front line and first line manager level. 12.5 LSCBs should review and monitor single agency or multi-agency safeguarding training strategies to ensure the promotion and embedding of relevant research, in relation to the assessment of risk and young babies, the importance of cumulative histories in analysing risk and working with resistant and/or mobile families. 12.6 Somerset LSCB should raise with the appropriate Government department, the issue that unborn children currently do not have the same right to protection in law as children post-birth, and ask that Government child protection guidance should adequately address the rights of the unborn child. Overview Report 19.03.13 Page 82 of 100 13 HEALTH OVERVIEW RECOMMENDATIONS It is recognised that only the Somerset Local Safeguarding Children Board and partners can implement an action plan; however, it is highly recommended that these recommendations are disseminated to all NHS Clusters and Local Safeguarding Children Boards for both their consideration and implementation as standards of good practice. 13.1 NHS Somerset Director of Nursing will write to the Strategic Health Authorities Directors of Nursing to request them to recommend that NHS Trusts have in place, a policy for multi-agency pre-birth planning between 18-20 weeks gestation, where there is recognition of parental risk factors and/or safeguarding concerns to the unborn/newborn child • Early identification of high-risk families must include a holistic evaluation of any risk factors to unborn children, particularly where there is known domestic violence and parental mobility. • There should be recognition of the likelihood of early delivery for all pregnancies but particularly when the mother is expecting twins. • Safeguarding concerns to the new born child should be identified through holistic assessment by 18-20 weeks gestation and a multi-agency pre-birth planning meeting held to develop a pre-birth plan with additional measures in place in the event of premature birth. • GP record keeping policies should require all vulnerable families’ records to be ‘flagged’ with born/unborn children. Record keeping policies should be amended to include unborn child in line with the Children Act 1989 despite foetuses having no legal status. 13.2 NHS Somerset Director of Nursing will write to the Strategic Health Authorities Directors of Nursing to request them to ensure that all health provider services have a Did Not Attend/Missed Appointment policy with reference to children where there are safeguarding concerns across all Overview Report 19.03.13 Page 83 of 100 health specialities, including where children and pregnant mothers may attend. • All NHS Providers to have in place a Did Not Attend/Missed appointment policy for all health services accessed by antenatal mothers and children 13.3 NHS Somerset Director of Nursing will write to the Strategic Health Authorities Directors of Nursing to request them to recommend that all Obstetric/Neonatal health services should review policies to ensure clinical need, vulnerability and safeguarding concerns are included in the decision making for hospital transfer and discharge, ensuring both family history and documentation are provided in a timely manner, and there is clarity of purpose for discharge planning and strategy meetings. • When unborn infants are transferred out of area in order to access specialist neonatal care, further transfers must be limited to transfer back to the local area to promote continuity of care, information sharing and child protection planning. All transfers should be made on the basis of clinical need only. • Unborn babies/children should not be transferred to other hospitals out of area when there is no identified clinical need for this transfer. Where transfers are required for a clinical need proper documentation and transfer of full ‘social information should be made by direct telephone communication to the receiving on-call Community Paediatrician/Paediatric Consultant. If this is not received, it should be ‘chased up’. • Where there are safeguarding concerns, weekend/bank holiday discharges should be avoided if possible to minimise the involvement of staff that are unfamiliar with highly complex families, avoiding ‘start again’ assessments. There must be clarity of the status of all professional and discharge meetings with appropriate attendance from all agencies. Professionals with key information who consider they should attend should request an invitation. The meeting should incorporate: • good preparation Overview Report 19.03.13 Page 84 of 100 • practitioners prepared and empowered to challenge decision making • good minutes including appropriate and timely distribution 13.4 NHS Somerset Director of Nursing will write to the Strategic Health Authorities Directors of Nursing to ask them to recommend that NHS Trusts review information sharing pathways and escalation policies to ensure health professionals are clear about their duty to share information when there are child protection concerns, and the process to escalate these concerns, to include the secure and prompt transfer of information when families move out of area. • Health professionals must be clear about their duty to share information, escalate cases and refer to Children’s Social Care, if necessary, without the consent of parents where the welfare of children or UNBORN children is likely to be compromised. Designated and Named professionals should facilitate this if necessary. • There must be careful and concise sharing of concerns about parenting ability and risks to the unborn child between agencies and health services when families move areas. • All practitioners are accountable for their practice and must challenge other agencies’ decisions when required. Designated Professionals must be accessible for advice and support to assist staff to use the escalation process where there are appropriate concerns. • There must be consideration of a clear policy for prompt and secure transfer of children’s health records to the receiving authority for both children in need or subject to a child protection plan. Transfer of information through Named Nurses should also be used. • When new services are set up to provide urgent care services such as the acute care GP, there must be consideration of the pathways for information sharing to health visitors on attendances by children. Overview Report 19.03.13 Page 85 of 100 13.5 NHS Somerset Director of Nursing will write to the Strategic Health Authorities Directors of Nursing to ask them to recommend that early identification of high-risk families must include a holistic assessment, targeted history taking and the evaluation of the risks and protective factors to the unborn children. • Sufficient consultation time for all health professionals should be allowed for holistic and complete history taking especially at first contact, and ‘patterns’ of behaviour and risk factors noted where there are concerns. Every effort should be made to confirm information given in a history independently and to contact/receive information from previous health workers responsible for parents, unborn babies and children, where they may be parenting concerns. • Nursing observations as to parental management skills and their behaviour is an important CONTRIBUTION to a ‘Parenting Assessment’ but because of the artificial environment of a hospital setting cannot replace it. There needs to be clarity that such information does not form a complete formal parenting assessment as understood by other agencies. • There should be consideration of the appropriate policy for admission of children with faltering growth/neglect in specialist children hospitals to an appropriate ward with due regard to safeguarding concerns • Where parents are recorded as having ‘learning difficulties’ early ‘baby handling’ teaching skills should be instigated with sufficient time for reinforcement of lessons. • Professionals should expect to see and check vulnerable children and not be inhibited by parental excuses to not disturb, particularly when ‘serious neglect’ issues are identified. 13.6 NHS Somerset Director of Nursing will write to the Strategic Health Authorities Directors of Nursing to ask them to recommend that all NHS Overview Report 19.03.13 Page 86 of 100 Trusts review their training materials and give consideration to the need to be amended such that the learning points which have emerged are clearly embedded in professional training. 14. INDIVIDUAL MANAGEMENT REVIEW RECOMMENDATIONS Derby Hospitals 14.1 That medical and nursing staff are supported and developed by a programme of further specific training in identification of attachment issues in the NICU environment, adult risk issues, parenting assessment, recording and communication of concerns. 14.2 Safeguarding team to facilitate involvement of learning disability liaison nurse or safeguarding adult officer with LD background in cases of concern where parents have a learning disability 14.3 That Derbyshire County Council Children and Younger Adults Department review the protocol for sharing information with other Local Authorities to ensure a timely response North Lincs and Goole Hospital 14.4 To review the protocol and name of the child protection care pathway 14.5 To review the current level 3 safeguarding training to increase course content in relation to recognition and impact of parental learning disability 14.6 Develop specific child development training for staff groups working on neonatal units across the hospital sites 14.7 Develop a formal communication process for transfer / handover of care from midwifery to neonatal units ensuring the inclusion of all family / social history 14.8 Develop a timely records transfer process between midwifery and neonatal unit to ensure no loss of information Overview Report 19.03.13 Page 87 of 100 14.9 Develop a process of parental assessment for parents of children on neonatal units NHS North Somerset 14.10 Safeguarding Training for all GPs to encompass their role as gatekeepers of information, and that they need to take a more holistic view of patients as parents. 14.11 GP training is audited on an annual basis 14.12 Pre-birth planning arrangements are audited Nottingham Support Service 2 14.13 All Access Point staff undertake in house safeguarding training Nottingham Support Service 14.14 Work between agencies to be further examined internally and areas for improvement identified 14.15 Handling of complaint: there is evidence to indicate that communication between the Social Worker and Manager was good through the investigation and the complaint was resolved to everyone's satisfaction. However, records of the contact could be better, which needs to be addressed with Manager of Nottingham Support Service 1. 14.16 Contact following on from the complaint was with the Manager but records are not clear. This will be addressed with Manager Nottingham University Hospitals NHS Trust 14.17 Complete the planned update of the existing Trust policies (Safeguarding Vulnerable Adults; Mental Capacity Act) 14.18 Update the In-utero Transfer Guideline to include safeguarding Overview Report 19.03.13 Page 88 of 100 14.19 Update the Trusts Transfer & Discharge policy to include safeguarding 14.20 Have a debriefing meeting between NUH and Social Care once the SCR is completed to identify lessons learned regarding the interagency relationship 14.21 At that meeting it should seek solutions to the need for formal communication regarding risk issues, particularly category and severity, between Social Care and NUH 14.22 Produce guidance clarifying roles and responsibilities for ward staff regarding parenting observation and assessment 14.23 Ensure that all staff attend safeguarding training according to Trust Policy 14.24 Ensure that the nature of the individual’s safeguarding responsibility is reviewed at annual appraisal (appraisers therefore need to be trained accordingly) 14.25 Re-emphasise the need of internal escalation to the responsible consultant when there are safeguarding difficulties 14.26 Ensure that the staff who attend Discharge planning meetings are the appropriate staff and that they understand their role and understand that the organisation should support discharge only when it is satisfied that a satisfactory plan is in place 14.27 Ensure that where care is provided at home by NUH staff that there are clear roles and responsibilities in place for escalating safeguarding concerns 14.28 Ensure that the staff of the Family Health Directorate, have Learning Disabilities training 14.29 Continue its current work on Information Governance and address this issue particularly with the family health team Overview Report 19.03.13 Page 89 of 100 14.30 The Family Health Directorate should work with their neonatal consultant team to review how they discharge their responsibility on the postnatal wards for babies with social concerns which are often outside the overview abilities of medical registrars 14.31 The Family Health Directorate should ensure that the feeding charts identify who has fed and provided care to babies on our wards 14.32 The Family Health Directorate should emphasise to its ward managers their oversight role in cases of complex social issues, in particular where non-registered staff have been involved 14.33 The Family Directorate should re-emphasise the importance of adhering to policy for parents being resident of the wards 14.34 The Family Health Directorate should work with the Obstetric team to review how the outcome of referrals to the perinatal mental health team is communicated to the mother’s NUH record 14.35 The Family Health Directorate should re-emphasise to its staff the importance of adhering to its In-utero transfer policy with respect to completing incident forms 14.36 The Safeguarding team should address training issues in those areas where communication with them was not timely 14.37 The Safeguarding documentation should be reviewed to ensure that the paperwork supports ready access to the correct ‘Risk’ Information 14.38 ED should explore what processes they have in place to deal with patients who present with complex social issues and are not already known to Social Care locally 14.39 The Family Health Directorate should ensure that there is appropriate advise/support given to the safeguarding team should issues arise that they Overview Report 19.03.13 Page 90 of 100 cannot manage. Nottingham CityCare Partnership 14.40 Nottingham CityCare Partnership will arrange training for frontline staff in relation to Parents with Learning Disabilities and the impact upon children. 14.41 The Nottingham CityCare Partnership Named Nurse for Safeguarding Children will ensure that all the Safeguarding Children Nurse Specialists and the Domestic Abuse Nurse Specialist in the Safeguarding Children Service are fully aware of the Escalation Process where there may be immediate concerns for the safety and well being of a baby, child or children and know what immediate action to take 14.42 A review of the Escalation Process by Nottingham City Safeguarding Children Board Nottinghamshire Healthcare NHS Trust 14.43 That the ‘trilogy of risks’ are added to the screening tool for post natal depression 14.44 That the Trust’s DNA policy is used in all directorates 14.45 All Perinatal Mental Health Practitioners have a knowledge of the usage of the CAFs Nottingham City C&F 14.46 Where families have been known to previous local authorities, Social Care team managers will ensure that background information is sought from those authorities prior to authorising a Core Assessment 14.47 In the case of pre-birth assessments where there are identified safeguarding risks / indicators, an initial planning meeting to commission the assessment must be chaired by a CTM or a CSCTM. This meeting should allocate key tasks, record risks and identify the timescale and review process. Overview Report 19.03.13 Page 91 of 100 14.48 All contact with a Service User, even via text message, will be recorded and form part of the child’s case file 14.49 An electronic recording system is developed for the family community teams which complements and has a clear interface with the social Care Carefirst and Castle systems. 14.50 Supervision case discussion records will be amended to include a section on ‘current assessment of risk, if any’ 14.51 All discharge planning meetings will consider a current assessment of risk 14.52 Social Care will develop a policy regarding highly mobile families 14.53 The outcome of a CRIMMs check will be copied directly to the team manager who must make a written acknowledgment on the file that he/she has read the contents and a managerial view of risk. 14.54 Training is developed in respect of pre-birth planning and rolled out across social care and family community teams. 14.55 Concerns about individual issues of competence should be addressed within the appropriate line management arrangements. Oxfordshire Health NHS Foundation Trust 14.56 To improve the level of knowledge regarding Child Protection processes for General Practitioners 14.57 To improve communication between Midwifes, General Practitioners & Health Visitors 14.58 To formalise the process to follow up complex / high risk pregnant women who do not attend appointments / move out of area 14.59 Social Services telephone calls to be managed by the respective Named General Overview Report 19.03.13 Page 92 of 100 Practitioner 14.60 Improved use of General Practitioner codes and flagging system 14.61 To ensure that all staff working in a PHCT have received a commensurate level of Safeguarding training 14.62 To ensure that the correct advice is given to patients who present as ‘homeless’ Oxfordshire County Council: Children, Education & Families Directorate 14.63 Domestic Abuse training and guidance is reviewed to ensure that the cycle of abuse and reconciliation is adequately reflected and that an understanding of reactions to abuse are included. 14.64 The ‘pre-birth referrals’ procedures and protocol for children moving across boundaries are reviewed and updated to ensure that pre- birth cases are referred quickly and not held open without active assessment or support being provided . 14.65 Where a third party moves in to a household where there is active CEF involvement guidance is developed to assist practitioners in knowing when to refer to the assessment team. 14.66 An audit and dip sample of referral recording and address checks is undertaken . 14.67 CEF to explore how the relevant aspects of the course ‘Principles of learning disability support’ can be delivered to CEF staff. Thames Valley Police 14.68 Thames Valley Police to review the initial training of PCSOs to ensure the inclusion of guidance on how to correctly record and refer (internally) safeguarding concerns. 14.69 Thames Valley Police to circulate a bulletin to PCSOs containing guidance on how to correctly record and refer (internally) safeguarding concerns. Overview Report 19.03.13 Page 93 of 100 14.70 Thames Valley Police to review their Domestic Abuse Policy and Operational Guidance to ensure sufficient guidance is provided in relation to what may constitute an ‘incident’. (Any changes to be published) 14.71 Thames Valley Police to issue a bulletin to the Domestic Abuse and Child Abuse Units reminding them to create a CEDAR record whenever an intelligence report results in further Police action and in particular a referral to another agency. 14.72 Thames Valley Police to review the management of intelligence reports once received within the Child Abuse Investigation Units, Domestic Abuse Units and by the Vulnerable Adult Co-coordinators to ensure compliance with the ‘Management of Police Information’ guidance in terms of creating an audit trail. 14.73 Thames Valley Police to review their Child Abuse Investigation Policy to ensure it contains reference to the importance of considering the welfare of unborn children. (Any changes to be published) Somerset County Council Children and Young People’s Directorate 14.74 If another local authority or agency requests a welfare visit or other task, expectations for this visit or task should be agreed and sent out in writing. 14.75 Somerset Direct (SD) should always advise the caller of the secure email facility. 14.76 Somerset Direct should always clearly identify advisors by their full name, whilst ensuring personal security. 14.77 Somerset Children's Social Care should have clear guidance relating to failed home visits including contingency and reporting arrangements. 14.78 Somerset Children's Social Care, in conjunction with LSCB partners, should set out clear criteria relating to welfare visits specifying roles and responsibilities. 14.79 Somerset Children's Social Care should in consultation with partners clarify: ●When a strategy meeting must be face to face Overview Report 19.03.13 Page 94 of 100 ●When it is appropriate to have a telephone conference ●When a respective specified agency (e.g. health) must be included in the strategy. 14.80 Somerset Children’s Social Care, through the Somerset LSCB, to share the above with the South West procedures group as examples of good practice. Avon and Somerset Constabulary 14.81 All ‘Welfare checks’ should be carried out be qualified Child Protection professionals with police attendance reserved for occasions only where police powers are required. 14.82 Where 5.1 is not possible, by virtue of the fact an emergency check is required, a strategy discussion should take place between a CAIT supervisor and the agency before the checks are carried out. The risks can then be analysed and a considered plan agreed prior to the visit taking place. The officer attending should ideally be a CAIT officer; if another member of staff attends they should receive a briefing direct from the CAIT supervisor. The results of the visit should then be subject of a further strategy discussion. 14.83 Protocol agreed between Social Services and police to reflect procedures to follow in the event of emergency checks being required by police. 14.84 ISO procedure to be introduced into Force Communications to reflect an appropriate response to such requests in the future. 14.85 All Avon and Somerset Constabulary staff likely to come into contact with the public to receive appropriate child protection training, including risk indicators of abuse. This should be by delivery of the existing NCALT training module in the first instance. 14.86 Where a need for an Initial Child Protection Conference is highlighted there should be ability to fast track those where children are at most risk. 14.87 All police contact with children about whom there are concerns should be Overview Report 19.03.13 Page 95 of 100 reflected in a comprehensive intelligence report that should be submitted in a timely manner and shared with CAIT staff for analysis. Taunton & Somerset NHS Foundation Trust 14.88 Clinical case to be used in the Trust ongoing Safeguarding training programme. 14.89 Recommendations from this SCR to be incorporated into Trust Safeguarding procedures and audit programme as appropriate. 14.90 Learning from this SCR to be used Trust ongoing Safeguarding training programme. Somerset County Council Legal Services 14.91 Submit e-mail to every lawyer within the Social Care team, strongly urging them to maintain a record of any conversation with client(s) where it could be construed that legal advice has been given (even if no matter subsequently arises as a result of that advice). 14.92 Message to instruct that where such records are created, they should be added to the Norwel case management system on every occasion in the event that a legal matter does arise (i.e. the Service is formally instructed to take further action). 14.93 The format of any such record is to be at the discretion of the lawyer providing the advice, provided that it clearly details any recommendations provided, even if that recommendation is to take no further action at the time. The recommended (but not mandated) format is an e-mail to the recipient of the advice as soon as is practicable after the event. Somerset Partnership NHS Foundation Trust 14.94 A review of the processes currently in place to ensure professional records of high risk cases are transferred swiftly between organisations must take place. Consideration must be given to how information from outside Somerset is obtained in order to guarantee the seamless provision of key services to families; consistently delivered, ensuring children remain safeguarded. Overview Report 19.03.13 Page 96 of 100 14.95 A Significant Event Audit meeting should take place with the health visitor team involved in this case. The Area Manager, Locality Safeguarding Children Nurse and Named Nurse should attend to discuss all the issues in this case and to identify any individual learning required from the individuals involved. 14.96 The lessons learnt from this review must be disseminated to the individuals concerned, the health visiting team and the wider organisation, illustrating the concerns identified and reiterating best practice processes. The relevant local and national policies and guidelines should be referenced and their usage reiterated to all staff. Overview Report 19.03.13 Page 97 of 100 APPENDIX 1: TERMS OF REFERENCE AND SCOPE OF THE REVIEW The terms of reference for the review were agreed by the panel chair. The timescale for the review was established as being from the time Mother moved to North Somerset, met Father, became pregnant and up to the point that the twins were admitted to hospital with serious injuries, and non accidental injury was established to be the most likely cause. It was agreed that the overall aim of the serious case review process would be as described in Working Together to Safeguard Children 2010, i.e. to • Establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children. • Identify clearly what those lessons are, both within and between agencies, how and within what timescales they will be acted on and what is expected to change as a result. • Improve intra-agency and inter-agency working and better safeguard and promote the welfare of children. Authors were also asked to consider the earlier childhood history of the parents in order to understand the attributes they brought to parenting. Each author was also asked to assess whether any information their organisation held about either parent, which lies outside the prescribed timescale set out above, was relevant to the issues raised and lessons learnt. Authors were asked to construct a comprehensive chronology of involvement by the organisation and/or professional(s) in contact with the child and family over the period of time set out in the review’s terms of reference. Where an agency had relevant contact with the alleged perpetrator, it was specified that the chronology should also cover these actions and should ask whether everything was done which might reasonably have been expected to manage effectively the risk of harm posed by the alleged perpetrator[s] to the child. Overview Report 19.03.13 Page 98 of 100 Report authors were asked to consider the following key questions: • Were practitioners aware of, and sensitive to, the needs of the children in their work and knowledgeable both about potential indicators of abuse or neglect and about what to do if they had concerns about a child’s welfare? • When, and in what way, were the child(ren)’s wishes and feelings ascertained and taken account of when making decisions about the provision of children’s services? Was this information recorded? • Did the organisation have in place policies and procedures for safeguarding and promoting the welfare of children and acting on concerns about their welfare? • Where appropriate, what are your agency’s thresholds for instigating Initial Assessments, Core Assessments, multi-agency strategy discussions and Section 47 investigations? What guidance do staff have in completing these assessments? • What guidance and protocols does the agency have in respect of families with accommodation difficulties, where there are child protection concerns? • What guidance and protocols does the agency have in respect of families who are highly mobile and move across agency geographical boundaries and where there are child protection concerns? • What guidance and protocols does the agency have for working with non-compliant families and the issue of ‘missed’ visits and appointments and where there are child protection concerns? • What arrangements are in place for hospital discharge meetings for families where there are child protection concerns? • What expectations regarding visiting does your agency have for children (including seeing the child awake) and families where there are child protection concerns? What visits were defined in plans for this case and was the visiting pattern adhered to? • What were the key relevant points/opportunities for assessment and decision making in this case in relation to the child and family? Do assessments and decisions appear to have been reached in an informed Overview Report 19.03.13 Page 99 of 100 and professional way? • When did your agency learn of the pregnancy of Mother? • Was risk identified and responded to appropriately in your organisation’s planning and intervention? • How has the organisation made decisions regarding pre-birth planning? What training, advice and guidance is available to staff and what protocols and procedures informed the judgements made? • What are the agency’s protocols and criteria regarding parenting assessments? How are parenting issues identified and required outcomes agreed, implemented and monitored? • Did actions accord with assessments and decisions made? Were appropriate services offered /provided, or relevant enquiries made, in the light of assessments? • Was communication within your organisation, and between your organisation and others, timely and effective in this case? • Were there any issues in communication, information sharing or service delivery between those with responsibilities for work during normal office hours and others providing out of hours services? • Where relevant, were appropriate child protection or care plans in place and child protection and/or looked after reviewing processes complied with? • What training and guidance is available to staff working with parents who have, or may have, a learning disability? What evidence is there of guidance and protocol being followed in this case? • What training is provided for staff in your organisation regarding child development, especially regarding new born infants? • Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability of the child and family and were they explored and recorded? • Were senior managers or other organisations and professionals involved at points in the case where they should have been? • Was the work in this case consistent with each organisation’s and the LSCB’s policy and procedures for safeguarding and promoting the welfare of children and with wider professional standards? Overview Report 19.03.13 Page 100 of 100 • Were there organisational difficulties being experienced within or between agencies? Were these due to a lack of capacity in one or more organisations? Was there an adequate number of staff in post? Did any resourcing issues such as vacant posts or staff on sick leave have an impact on the case? • Was there sufficient management accountability for decision making? |
NC52194 | Death of a 13-month-old child in February 2019. Child CD was found head down in a fabric toy box at the bottom of the bed, cold to the touch. Ambulance services were called but Child CD did not show signs of life and resuscitation was not attempted. Ambulance crew expressed concerns regarding the home environment and circumstances in which Child CD was found. Parents were arrested on suspicion of murder/neglect but no charges were levied against them. Family had re-located three times during the review's timeframe. Mother had experienced adverse childhood trauma at home and in school. Both parents had a history of alcohol and drug misuse, depression, and could be non-compliant with their medication regimes. Father had a history of homelessness and Mother did not always engage with services. Ethnicity and nationality not stated. Learning includes: maternity services should provide assurance that routine domestic abuse enquiry is effective, and not a widespread issue; Early Help may be indicated when families move frequently; there should be a robust assessment of family needs when women with a significant history of mental/emotional instability are pregnant and in the post-natal period to support them in caring for infant and their other children. Recommendations include: safer sleep and the risks to mobile infants/toddlers should remain a focus of local multiagency activity; a focussed response and co-ordinated multiagency working with adolescents with complex health and social needs on the edge of statutory intervention; assessing and working with young fathers (the hidden male) who have or assume childcare responsibilities is crucial.
| Title: Serious case review Child CD: executive summary. LSCB: Blackburn with Darwen, Blackpool and Lancashire Children’s Safeguarding Assurance Partnership Author: Jane Carwardine Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Blackburn with Darwen, Blackpool and Lancashire Children's Safeguarding Assurance Partnership Serious Case Review Child CD Executive Summary Author: Jane Carwardine Date: January 2021 Page 1 of 13 Table of Contents SECTION SUB SECTION PAGE CONTENT Section 1 2 Background to the Serious Case Review (SCR) Section 2 4 A Summary 2.1 4 A Portrait of Child CD 2.2 4 The Family & Social Network. 2.3 6 Historical Information up to 1st April 2017. 2.4 7 An Analysis of the Period May 2017 to January 2018: Child CD’s Antenatal Period. 2.5 8 An Analysis of the Period January to April 2018: Child CD birth - 3 months. 2.6 8 An Analysis of the period April to July 2018: Child CD 3 - 6 Months 2.7 10 Relevant Events and Episodes of Care: Child CD 6 Months to the Final Incident. Section 3 11 Overarching Conclusion. Section 4 13 Recommendations Page 2 of 13 SECTION 1: BACKGROUND TO THE SERIOUS CASE REVIEW (SCR) 1. The Incident: On the day prior to Child CD’s death (early February 2019), the family attended the children’s centre communication group, went shopping, celebrated mother’s birthday and mother built a wardrobe in Child CD’s bedroom. Father was at the family home during the evening and night. Mother described the day as horrendous as Child CD (aged 13 months) was unwell. Mother thought this was due to teething. Child CD was crying excessively, extremely clingy, reluctant to eat or have routine daytime sleeps. She put Child CD down to sleep earlier than usual (1630hrs) and followed medical advice previously given in respect to the management of febrile illness and upper respiratory tract infection. She left Child CD undressed, in a nappy only and medicated her infant with paracetamol at bedtime. Child CD was placed in the usual sleep environment, which was an adapted cot-bed that allowed the infant to get out of bed to play. Child CD was not checked during the evening/overnight as mother did not want to disturb her infant. She felt she would hear her infant shout if support were needed. 2. The following morning (0730hrs) Child CD was found by mother, head down in a fabric toy box. The fabric toy box was next to the wall, at the bottom of the bed and used to store swimwear. Child CD was cold to touch and was moved onto the bed. Mother made a 999 call to the police who contacted the paramedic emergency service. The service immediately dispatched an ambulance and an advanced paramedic. Both parents and a pre-school sibling were present at the scene. 3. On arrival the paramedic crew assessed Child CD did not show signs of life and resuscitation was not attempted. Their assessment was that due to the post-mortem changes observed on the body Child CD had likely died a few hours previously. In line with local policy Child CD was transferred to the nearest hospital’s accident and emergency department for assessment by a paediatric consultant. The sudden unexpected death in childhood protocol pathway was initiated. Child CD’s parents declined to accompany their infant to hospital, understandably exhibited extreme distress but also displayed aggressive/accusatory behaviours. The ambulance crew expressed concerns regarding the home environment and in the circumstances Child CD was found. It was documented “Child CD was alone on the bed, wearing a nappy, there was no cot in the room, the room was cold and there appeared to be various bruises to the infant’s face and body”. The bruising noted by the ambulance crew was later advised to be as a result of Child CD’s death. It was related to the position the infant at the time of death and pooling of blood. The crew submitted a safeguarding alert to the local authority children’s services department, due to the circumstances of the infant’s death and concerns for the sibling’s welfare. 4. The provisional post-mortem findings undertaken by a pathologist concluded: positional asphyxia as the cause of death (pending the outcome of toxicology tests). the presence of a group A streptococcal infection - this was required to be notified to Public Health England, although was not identified as a cause of death. 5. A criminal investigation was initiated and both parents were arrested on suspicion of murder/neglect. They were interviewed and released with no further action planned in respect to the suspicion of murder. Toxicology samples were taken around the time of the police interviews. The review has been informed there was nothing relevant identified in the samples that could have assisted the police investigation. Parents were to remain on police bail until March 2019 in relation to the offence of neglect. In May 2020, the case review panel was informed that there would be no charge levied against either parent. Page 3 of 13 6. According to national protocol children’s services submitted a serious incident notification to the local safeguarding children board (LSCB), which has since been replaced by the children’s safeguarding assurance partnership (CSAP). The unexpected death of Child CD was notified to relevant statutory bodies according to national guidance. In late February 2019, the LSCB’s case consideration panel completed a rapid review. The recommendation was the criteria for a SCR was met and the decision was ratified by the LSCB chair. In early March 2019, a notification of the decision was made to Ofsted, DfE and the Child Safeguarding Practice Review Panel. The national panel ratified the LSCB decision. A multiagency case review panel was established to work alongside an independent reviewer to support the reviews completion planned for September 2019. The completion of the review was delayed pending the outcome of the criminal investigation and work recommenced in May 2020. The final review was completed for submission to the CSAP in December 2020. The safeguarding partners agreed the report in January 2021 and to its publication as a Serious Case Review, notwithstanding subsequent changes to statutory guidance for reviews. Practitioner participation was secured. It was not possible to secure parental and family participation during the review process, however just prior to publication the review was shared with mother. 7. The case review panel established the following terms of reference. 1) Was relevant historic information about child and family functioning known and considered in the multiagency risk assessment, planning and decision-making in the period leading up to Child CD’s death? 2) Was the multiagency planning robust, appropriate, effectively implemented, monitored, and adequately reviewed in the period up to Child CD’s death to reduce the risk of harm? 3) To what degree did agencies challenge each other regarding the effectiveness of the risk management, planning and decision making? 4) Were the respective statutory duties of agencies working with the child, parents and family fulfilled? 5) Were there organisational, contextual obstacles or difficulties in this case that prevented agencies from fulfilling their duties? 6) Were the vulnerabilities for the child adequately assessed/managed in the context of planning and intervention to manage the risk for Child CD? 8. Following the collation of a multiagency chronology the following key lines of enquiry were highlighted as the focus for the review. 1) Information sharing and how did this impact on intervention and outcomes for the child/ren? 2) Did professionals understand the whole picture of family functioning and safeguarding concerns? 3) Was there evidence of a longitudinal assessment of this family’s safeguarding concerns and recognition of the cumulative risk of harm? 4) Was there evidence of multiagency working or did agencies revert to silo working? 5) Was the child’s voice heard and their lived experience understood in practice? 6) Understanding the effectiveness of cross boundary service provision. 7) Supporting the domestic abuse agenda. 8) Coordination of care and frequent changes of professionals allocated to the case. 9) Early Help including step up and step down. 10) Mother’s vulnerabilities to include her, age when homeless, depression and anxiety issues, obsessive compulsive disorder, attachment issues and lack of psychological availability to her children. 11) The message of ‘Walking Alongside’ families rather than leaving vulnerable parents and children to find their own support. Page 4 of 13 12) Further consideration of the males in mother’s life and their impact on the family, including the level of contact that father had with mother and her children. 9. The process has considered parallel enquiries/investigations to avoid any conflicts of interest. 1) All agencies were asked to disclose investigations or staff interviews undertaken. None were identified. 2) The coronial inquest had not concluded on completion of the review. 3) The constabulary commenced a criminal investigation following the death of Child CD. In May 2020, the investigation was concluded and no charges were levied against either parent. 4) A case review will be undertaken by the child death overview panel (CDOP) according to national and local guidance1 on completion of this review. The child death review meeting has been completed. 5) Family Court proceedings have been completed in respect of the older sibling, who has now been placed for adoption. Section 2: A Summary . This section provides a brief summary of the main body of the overview report and contains brief detail with some analysis of the key issues raised. 2.1 A Portrait of Child CD. 10. Practitioner conversations and parental police statements helped to build a pen-portrait of Child CD. The agency records did not secure a robust perspective of Child CD’s presentation or experience of everyday life. Mother described Child CD as a very agile, vocal, mobile baby who liked to play independently and alongside the sibling. The infant was cruising, not walking independently and would sometimes play with toys without parental supervision. Mother advised Child CD would ask to play with the sibling or might say “mummy just left me”. Mother attended the children’s centre parenting groups regularly to support her children’s development. 11. Practitioners observed Child CD to play, socialise normally and was always well presented during contacts. Mother/child interactions were noted to be mostly to be appropriate and positive. The incidents of concern will be highlighted later in this review. Following Child CD’s birth, the health visiting service regularly monitored the infant’s growth, which was maintained around the 75th centile2. Developmental assessments were completed in accordance with expected practice. There were no concerns highlighted until the 12 month health visitor assessment when Child CD’s personal and social skills were lower than the expectations. Mother was advised regarding age appropriate play, the use of books and encouraged to attend the children’s centre’s groups to support the infants development. 2.2 The Family & Social Network. 12. Mother was the children’s main parent/caregiver and had lived locally all her life. They lived in private housing and re-located on three occasions during the review’s timeframe, the last re-location was prior to Child CD’s birth. The reasons for the family moving were unknown but this pattern of re-location is not unusual in the local population. Her contact with local authority housing services was 1 See Chapter 5, Child Death Reviews, Working Together to Safeguard Children- a guide to interagency working to safeguard and promote the welfare of children. July 2018. HM Government. 2 Centiles show the expected growth pattern for infants and children on a growth chart. An infant following the 75th centile means the infant is bigger than 75 out of 100 children of the same age. Page 5 of 13 minimal. Agency records and practitioner conversations identified the home environment, was consistently good, exceptionally clean, tidy, and ordered. Mother would seek support from a range of practitioners but at times could be challenging, volatile and difficult to engage dependant on her emotional/mental state. It was challenging for her to accept professional advice or support. 13. She struggled historically to maintain her mental and emotional wellbeing and this was well documented. As early as 2013 (aged in her early 20s), mother presented to a variety of NHS services with distressing symptoms related to fluctuating mental ill health (anxiety, depression, intrusive thoughts of self-harm, paranoid thoughts) and disclosed using alcohol and cannabis. There was no further evidence in respect to understanding her substance misuse behaviours. 14. There is evidence she experienced significant adverse childhood trauma both at home and in school. She did not engage with specialist mental health services, was reluctant to talk about her experiences or attend specialist services for therapy. GP services predominately managed her care through medication due to her reluctance to engage in other types of therapy. In 2015/16, during her first pregnancy her struggles with her mental health were again highlighted. She was supported by the GP, the crisis mental health team and perinatal mental health service but again could be non-compliant in respect of medication. In 2018, following the birth of Child CD she discussed with the health visiting service the long term challenges in managing anxiety but was again reluctant to consent to a referral to mental health services, preferring to be supported by the GP through medication. GP services advised they were managing her care in respect of anxiety/depression along with an obsessive compulsive disorder. Her compliance with antidepressant medication was variable and the service had regular contact to encourage her compliance with treatment. The general practitioner triggered numerous telephone contacts with mother to monitor her wellbeing following the birth of Child CD’s sibling. (Good Practice) 15. Child CD’s father did not cohabit with the family, originating from an area in the United Kingdom (over 300 miles away). During Child CD’s life father was nomadic, moving back to his home area and returning locally to enable contact with his infant. He was registered as homeless and actively supported by local housing and third sector homeless services on three occasions during the review’s timeline. (Good Practice) The review has identified he was in contact with and assumed childcare responsibilities for the children and supported mother following the birth of Child CD. The consistency or frequency of this contact was unclear to agencies involved. The parental relationship was unstable, sometimes appearing supportive yet other times volatile. There were frequent incidents of concern documented. Mother made a series of complaints in the antenatal period regarding harassment, and then again during Child CD’s life. These incidents are discussed in the comprehensive overview report. Locally, father had no known support networks, his sister lived in his originating area. He described mother as a friend to housing professionals. Professionals in contact with father advised he was easy to work with and complied to their requests for action. 16. There has been limited information provided to gain a longitudinal perspective of father’s health. In the months following Child CD’s birth he smashed up allocated accommodation on two occasions, whilst expressing suicidal ideation on one of these occasions. He registered with a local GP practice (September 2018) whilst supported by a homeless service worker. Father had a diagnosis of anxiety and depression. Following communication with a previous GP in a cross boundary area, the local GP practice prescribed antidepressant therapy. Father disclosed his compliance with antidepressant medication was not always consistent. He requested sleeping tablets which were not prescribed, with the GP offering alternative options e.g., not drinking energy drinks and creating independent sleep patterns. On an occasion father disclosed to his homeless worker challenges with alcohol misuse. Mother stated during the police interview he had previously smoked cannabis and used cocaine. He had no arrests or convictions for drugs/alcohol related offences. The information provided does not confirm he had significant challenges with substances. Page 6 of 13 17. Child CD’s pre-school sibling regularly attended a local children’s centre. Whilst in nursery, the child was noted to be friendly and exhibited age appropriate interactions with peers and other adults. There were no concerns about the child’s developmental progress. The child was noted to be clean, dressed appropriately, with adequate spare clothing and was equally happy to be dropped off and picked up from nursery by mother. The child’s relationship with the nursey worker was described as positive. When attending the centre’s messy play group following the birth of Child CD there were occasional concerns with regards to mother’s interactions resulting in the child being extremely upset. These incidents are described in the comprehensive overview report. Positive interactions were also observed and mother sought appropriate advice from health services for a range of minor ailments and issues. 18. Child CD’s maternal grandparents lived nearby. Grandma was documented to be in regular contact and often present when mother had health appointments for herself and her children. A number of practitioners identified mother’s relationship with her own mother could be fragile, volatile, and unstable. Their relationship had broken down nine days prior to Child CD’s death and the children’s centre was advised by mother that maternal grandma should not be allowed to pick up her elder child. Mother was supported by an auntie and three close friends. The review identified these relationships appeared to be constructive and offered positive support to the family. 2.3 An Analysis of the Historical Information up to 1st April 2017. 19. Mother’s adolescence was a challenging time experiencing significant adverse childhood experiences. She had multiple vulnerabilities including substance misuse, emotional/mental health instability, family stress/ violence/ breakdown, was disengaged from education, homelessness, behavioural challenges and social isolation. It is unclear whether there was a comprehensive multiagency early help response to assessment, planning and intervention to support a whole-person approach in the management of her complex and interlinked vulnerabilities. Education were not always aware of her vulnerabilities. There was evidence the GP practice and social worker worked together under a child in need plan, were successful in securing her trust and made significant attempts to link her into the support services to help her manage her challenges ( emotional, mental distress, homelessness). Unfortunately, mother would not engage in talking therapy and treatment which may have helped to address the root cause of her challenges. 20. A key question the review was asked to consider is how adolescents with such complex and interlinked vulnerabilities would be currently supported in practice. Practitioner conversations identified demographically there remains large numbers of adolescents locally with the same challenges as Child CD’s mother. The numbers were likened to those of an inner city area. Additionally, the area attracts many transient adolescents from cross boundary local authority areas. These adolescents often remain difficult to reach out to, with agencies facing significant challenges in effectively engaging them in interventions to support their development into adulthood. Whilst some may meet the threshold for statutory intervention and will be well supported through multiagency assessment, planning and intervention others remain partially or fully hidden. They may dip in and out of services with no comprehensive, whole person approach to assessment, planning, intervention, and risk management. Practitioner conversations have highlighted more recently the local area has developed a range of multiagency and coordinated services to work with this group of young people. The focus being the young person remains at the centre of the assessment, planning and intervention. This is a positive development and the issue should remain a focus of commissioning and provider activity to monitor continued improvement. 21. The review has not been asked to look in depth at this period however the chronology provides evidence of coordinated interagency working (GP, midwife, perinatal mental health team, health Page 7 of 13 visitor, the children centre) to support mother’s mental and emotional wellbeing during the pregnancy and following the birth of her first child. There appeared to be an accurate assessment of her family needs with appropriate levels of intervention based on the health visiting offer of universal plus. It is notable that during this period mother appeared to develop positive relationship with key professionals offering support and this also coincided with a short period of stability in her mental/emotional wellbeing. (Good Practice) 22. Learning Points suggested during this period. LP 1: Is the safeguarding partnership assured multiagency arrangements effectively support all adolescents with complex and diverse needs through a single pathway and team around the child that remains focussed on the needs of the child as opposed to the needs of the system? 2.4 An Analysis of the Period May 2017 to January 2018: Child CD’s Antenatal Period. 23. During this period, the parental relationship developed from a friendship into a relationship during which time Child CD was conceived. There is evidence father spent time and lived in the family home but was also in contact with homeless/housing services. Their relationship was unstable at times and parents separated prior to the birth of Child CD. There were a number of incidents highlighted, linked to domestic abuse due to perceived harassment by father through text messages. Additionally, father expressed concerns through an alert in respect of mother’s emotional wellbeing. There was some evidence of positive information sharing between multiagency partners, however the information gathered did not trigger professional inquisitiveness or additional support for the family. The assessment of family needs was often made without access to the full range of multiagency information available. It was based on a single incident rather than a holistic picture. At that time, the step down processes to support families through early help was emerging as an adhoc system. Recent conversations have highlighted the system has been strengthened however there remains significant challenges embedding early help processes into multiagency practice consistently. This needs ongoing multiagency agency commitment from both a provision and commissioning perspective to ensure the system becomes embedded into frontline multiagency practice. Mother was compliant with her antenatal care and responsive to service requests. 24. Learning Points suggested during this period. LP 2: Maternity Services had robust systems in place to support domestic abuse enquiry however an omission still occurred. Therefore, maternity services should provide assurance to the safeguarding partnership that routine domestic abuse enquiry is effective, and this is not a widespread issue. LP 3: The safeguarding partnership should be assured that the process to assess alerts that are considered to be malicious is sufficiently robust and is always inclusive of multiagency information. LP 4: PVPs in respect of adults are now recorded on both the adult and child health visiting records. The safeguarding partnership should be assured of the effectiveness of the system. LP 5: The safeguarding partnership should through quality effectiveness processes receive assurance that the step up and down processes are effectively supporting families. LP 6: The adherence to the expectations of multiagency early help guidance is inconsistent in practice and the pace of change is sluggish with practitioners who work with families making decisions whether to opt in or out of the process. All relevant agencies should ensure their workforce engages with the expectations of the multiagency early help guidance and provide assurance of effectiveness to the safeguarding partnership and commissioners of the services. Page 8 of 13 LP 7: Early Help may be indicated when families move frequently. Multiagency practitioners should investigate and ascertain whether the family has challenges i.e., victims of antisocial behaviour, debt etc. LP 8: There should be a robust assessment of family needs when women with a significant history of mental/emotional instability are pregnant and in the post-natal period to support them in caring for infant and their other children. The universal plus health visiting offer should always be a consideration to enable this support. 2.5 An Analysis of the Period January to April 2018: Child CD birth - 3 months. 25. During the first 3 months of Child CD’s life there were a number of incidents indicative this could be a family under stress. In isolation each of the incidents would not have met the threshold for statutory safeguarding intervention however had the potential to impact negatively on the everyday life of the children. There was some evidence of positive information sharing between the health visiting and general practitioner services. However, the support offered to support mother in the management of infant feeding challenges was not robustly coordinated between universal services. An anonymous referral to children’s social care was closed down without the children being seen and not all the universal services were contacted for information. Communications were not sufficiently robust with email used to ascertain key information regarding the risk to the children and universal services did not always share relevant information. There was no evidence of a longitudinal assessment of the family needs and parenting capacity. Information sharing was not as effective as it should have been with key services in contact with the family not always being aware of each incident. There was missed opportunities for services to work together to assess and support this family. Mother began to demonstrate a reluctance to consent to information sharing or accept support as her mental health challenges escalated. 26. Learning Points suggested during this period. LP 9: Infant feeding support should be effectively coordinated between all services to ensure families receive timely and consistent feeding advice for their infants. LP 10: The safeguarding partnership should be assured through commissioning and quality effectiveness processes that mothers with a history of are exhibiting unstable emotional and mental well-being will be assessed accurately and prioritised for an enhanced health visiting service. LP 11: Children’s Centres have internal systems to log safeguarding concerns, these concerns do not always meet the threshold for a multiagency safeguarding referral to assess the need for statutory intervention. It is crucial the centres are inquisitive and with parental consent, share relevant information with partner agencies to ensure the opportunity to provide a structured early help approach. LP 12: All anonymous contacts that raise significant concerns for the welfare of babies and young children should be robustly assessed. This can be achieved through communication with all agencies involved with the family. A current picture of their presentation, the risks they face and everyday experience of life should always be established and the children should be seen. 2.6 An Analysis of the period April to July 2018: Child CD 3 - 6 Months. 27. In this period the homeless and housing services worked effectively with Child CD’s father to support his re-location. The information highlights father had significant contact with the family Page 9 of 13 during this period, sometimes taking a sole caring responsibility. However, there was no focus on developing father’s role as a caregiver or assessing his role and presence in family life. The homeless service provides emergency accommodation, drop in sessions and food. It also works intensively with homeless young adults during life skills sessions. These sessions do not currently include developing childcare or caregiving skills which could be an opportunity for these young adults who become parents or assume childcare responsibilities. The services that respond to the needs of vulnerable adults should remain alert to the safeguarding children issues when it is known the young person is in contact with children. 28. The focus of intervention remained on mother who was understood to be the children’s sole carer. During practitioner conversations it was highlighted key services (midwifery, health visiting, children’s centre, general practitioner) in regular contact with the family, would not have re-visited their understanding of father’s involvement in family life or his role in childcare provision unless there had been an indication to do so. Practitioners should always remain inquisitive in relation to adults providing childcare and this should remain a line of questioning during contacts with families. It is positive that currently engaging fathers is a current focus through the Better Start offer through the health visiting service. However, at the time there was limited focus on father who was in effect a hidden male. 29. There were continued incidents. Mother made a number of police reports due to feeling harassed by text messages and a perceived burglary. She thought these were linked to father’s actions. Information sharing systems were more robust resulting in children social care stepping her case down to the early help hub as the threshold for statutory intervention was not assessed to be met. At this point there had been a number of recorded incidents so it could be argued that the threshold was met for a child and family assessment. The early help hub stepped the case down to the health visiting and children’s centre services, however there is no evidence of further activity. 30. Mother’s expressed concerns regarding a change of health visitor. The system encourages health visitors to formally handover cases when a family moves home or changes GP and is assessed to have additional needs. Building and maintaining trusting partnerships with families when the main carer has unstable emotional health is crucial, therefore frequent changes in key workers should be minimised and the views of parents should be considered to support ongoing work with families. The service increased their offer to universal plus. 31. Learning Points suggested during this period. LP 13: Building and maintaining trusting partnerships with families when the main carer has unstable emotional health is crucial, therefore frequent worker changes should be minimised, the views of the family taken into consideration and a transition handover period considered. The system should be adaptable to be able to accommodate, the family taken into consideration and a transition handover period considered. LP 14: All services engaging in intervention with young adults, (who have or assume childcare responsibilities as parents or through their contact with children) should ensure their intervention includes the development of childcare responsibilities, be alert to potential child safeguarding issues, along with other strands of intervention supporting development of their life skills. LP 15: All practitioners should remain inquisitive and alert to adults involved in providing care to children. This should always remain a line of enquiry and not a one off enquiry. Page 10 of 13 2.7 Relevant Events and Episodes of Care: Child CD 6 Months to the Final Incident. 32. During this period mother consulted her general practitioner. Her mental/emotional wellbeing fluctuated. She declined the support of the health visiting service, even though they remained in contact with mother. The general practitioner actively followed mother’s care through telephone contacts when she did not attend for planned consultations. (Good Practice) Mother’s adherence to her medication regime could be chaotic. For reasons unknown she changed her general practitioner practice and the system changed her allocated health visitor. The final health visitor being the fourth change since Child CD’s birth. 33. Father re-engaged with homeless services having returned from his originating area where he had been evicted from homeless property after smashing up his room. He remained keen to remain near Child CD. The information reviewed does not provide clarity of his contact with Child CD during this time, although the police statements identify mother would contact father if she needed support. 34. There was no direct communication between the health visiting service or the general practitioner. Mother sought support from the health visitor at the general practitioners request, which generated a contact and development assessment for Child CD. Safer sleep advice was provided; it is not known whether the health visitor was aware Child CD was sleeping in an adapted cot bed meaning the infant was not being placed in a safe sleeping environment. The service reduced the health visiting offer to universal provision. The SUDC Prevention Group has recently reviewed the strategies and initiatives around safer sleeping advice, support, and promotional materials. Changes to promote knowledge and understanding were launched in July 2020. This is positive intervention and should become embedded into practice. The health visiting service was not fully aware of the incidents in the children’s centre or contained within the police reports. This information may have strengthened the service’s assessment of family needs. Given mother’s continued unstable emotional/mental health, the previous known concerns, and Child CD’s low level development it may have benefitted the family to remain on the universal plus offer of health visiting intervention. 35. There continued to be incidents logged by the children centre, the general practitioner and incident reports to the police. The children centre logged five incidents during this period. These issues/events were not shared with other services in contact with the family, nor was the centre aware of other agency information relating to the issues of harassment or maternal mental health. It has not been established why information was not shared but the centre advised that whilst these incidents were of concern the children were frequent attenders and were generally happy, well presented children who related positively towards their mother and vice-versa. 36. There were two further police reports made by members of the public. The first being Child CD left in a car unsupervised and the second a child being seen being dragged down the street by mother. The police responded to both these incidents, saw the children, and had no concerns for their welfare. PVP’s were not generated which was a missed opportunity to share information with multiagency partners and to generate a child protection alert especially in respect of the second incident. The agency review of this incident is the behaviour of mother was clearly aggressive and concerning enough to warrant a member of the public to contact police. It suggests a vulnerable child PVP should have been submitted to share these concerns. This would have ensured all agencies were aware of mother’s aggressive behaviour towards her children. Mother’s explanations were accepted without further investigation and information was not shared with multi-agency partners, meaning that there was no opportunity to review the bigger picture. These events occurred in the weeks prior to Child CD’s death. 37. Early February 2019: The Final Event. During the day prior to Child CD’s death, the family attended a children’s centre communication group, went shopping, celebrated mother’s birthday and mother Page 11 of 13 built a wardrobe in Child CD’s bedroom. Father was at the home during the evening and night. Mother described the day as horrendous. Child CD was unwell which was thought to be due to teething, was crying excessively, extremely clingy, reluctant to eat or have the routine day time sleeps. Mother decided to put Child CD down to sleep a couple of hours earlier than usual (16 30hrs). Mother followed medical advice given 10 days related to the management of febrile illness and upper respiratory tract infection, through temperature control and additional fluids. She left Child CD undressed, in a nappy and medicated her infant with paracetamol at bedtime. Child CD was placed in the usual sleep environment, which was a cot-bed bed adapted to allow Child CD to get out of bed to play. Child CD was not checked during the evening or night as mother did not want to disturb her infant and would normally hear if her infant needed support. The following morning (0730hrs) Child CD was found by mother, head down in a fabric toy box at the bottom of the bed which was next to the wall. The box was normally used to store swimwear. Child CD was cold to touch and was moved onto the bed. Mother made a 999 call to the police. The police contacted the paramedic emergency service who immediately dispatched an emergency ambulance and an advanced paramedic. Both parents and an older pre-school sibling were present at the scene. 31. Learning Points suggested during this period. LP 16: A lack of consent should not deter a professional from sharing information if it is assessed this is justified and necessary to safeguard the vulnerable child/adult. This is a development issue for the multiagency workforce. LP 17: The Safer Sleeping Guidance for Children now includes a sleep assessment tool for professionals to complete with parents and also a parental awareness review tool. Both the booklet and the guidance includes sleep advice for toddlers. This was launched in July 2020. This is positive intervention and should become embedded into practice for all agencies. Its implementation should be subject to scrutiny. SECTION 3: OVERARCHING CONCLUSION. 38. The review has identified areas of good practice and learning where multiagency partnership working could be strengthened. During the period following Child CD’s birth key services were experiencing significant transition and there were capacity issues in the workforce, this has since improved. The review acknowledges that multiagency safeguarding practice has been strengthened in the period since Child CD’s death through improvements made by multiagency partnerships. Examples of the improvements include the development of new multiagency guidance and policies to improve multiagency responses to cases at the differing thresholds of concern. Improvements have been made in the MASH to ensure information is collated and assessed by a multiagency team. An early help hub has been established by children’s services to provide leadership and support to multiagency professionals when working with families requiring support through early help. 39. Ultimately, Child CD was placed in an unsafe sleeping environment, enabling the infant to move into an unsafe position thereby causing positional asphyxia. Locally the issue of inappropriate sleeping positions has been considered by the CDOP, following the sudden and unexpected deaths of a number of children under the age of 2 years who were placed in inappropriate sleeping environments. Improvements have been planned and the project launched (July 2020). However, it is important this becomes embedded into frontline practice for all multiagency partners in the way safer sleep messages for infants has been implemented. The effectiveness of the campaign should be monitored and remain a focus of health promotion for all multiagency services. The review process has identified safer sleep advice nationally is focused on babies and does not address Page 12 of 13 adequately unsafe sleep environments when mobility increases in infants. The learning from this review should be shared nationally. 40. Information sharing was most effective between closely aligned services but not all services held the total information about the fourteen documented significant incidents and the range of other issues that have been raised within the review. Information about key incidents was not always alerted to relevant multiagency professionals having regular contact with the family. Each agency held some information but there was no evidence that professionals were inquisitive or searched for missing information. This meant there was a less than robust assessment of the cumulative risks for these children living in an environment where the main caregiver had fluctuating mental/emotional health and unstable support relationships. 41. The review has considered how the principles of early help were applied at the time. Maternal refusal to consent was a significant feature. However, the principles of early help were seldom considered in practice and the system not well understood. In addition, the step down process to early help when the threshold for statutory intervention was not met was unclear. It is positive the review has identified the system has been strengthened with the development of early help hub however there remains challenges in the system when securing practitioner and agency involvement in early help cases. Some practitioners advised they were not involved in the early help process. All agencies need to understand their role in respect to facilitating multiagency early help. There is no multiagency data available to monitor the current effectiveness of this system and the review has been informed that no performance monitoring occurs within agencies excepting children’s services. It is a contractual expectation for some agencies to monitor early help provision but no evidence was provided to assure this occurs in practice. 42. Mother’s history highlights the need for agencies to work effectively with adolescents who are on the edge of statutory intervention. Mother’s case is not isolated case as the review was informed her presentation as an adolescent remains a significant problem for many adolescents locally who have complex health and social needs. It is recognised that there are now in place many services/systems locally that offer support and work together in planning support for adolescents. This is a significant improvement. 43. Father was involved intermittently in family life and at times provided sole care to the children. His involvement was hidden to many services who were unaware of his function within family life. Professionals acknowledged the challenges in working with absent fathers. Working with non-cohabiting fathers/partners to assess and build their parenting capacity is essential and there is evidence that this is considered more often in practice now. The homeless services undertook significant interventions with father which were supportive. However, this intervention does not consider their role in childcare which is a potential opportunity for improvement. 44. There were challenges in partnership working with mother. Mother actively sought the support of universal services (health visiting, general practitioner, and children’s centre) and there was evidence she had previously sustained positive professional relationships. However, a deterioration in her mental/emotional wellbeing often coincided with a change in key professionals during child CD’s life. The allocation systems (health visiting) are complex and struggle to consider the individual’s needs so was not able to respond to mother’s concern about another change of health visitor during Child CD’s life. When working with families and building trust time is needed to build relationships and if possible frequent changes of professionals should be minimised. 45. The motivation of front line practitioners to support this family was evident and the review has not identified any omissions in practice that directly contributed to Child CD’s death. Page 13 of 13 SECTION 6: OVERARCHING RECOMMENDATIONS 1. Agencies should assure the safeguarding partnership in respect of the learning points. 2. Safer sleep and the risks to mobile infants/toddlers should remain a focus of local multiagency activity with consideration of highlighting the potential of this issue nationally. 3. The quality effectiveness of early help as a multiagency response should to subject to performance monitoring. 4. There should be a focussed response and co-ordinated multiagency working with adolescents with complex health and social needs on the edge of statutory intervention. 5. Assessing and working with young fathers (the hidden male) who have or assume childcare responsibilities is crucial. This should be a focus of multiagency partnership working. |
NC043724 | Death of a 23-month-old boy in May 2012, as a result of ingesting heroin. Post mortem revealed evidence of regular exposure to heroin and occasional exposure to cocaine and amphetamines. Father was convicted of manslaughter and mother was convicted of causing or allowing the death of a child. Mother had suffered a major accident several years prior to Daniel's birth which left her with significant physical difficulties and pain. Maternal history of drug and alcohol misuse and offending; she had one older child who did not live with the family. Paternal history of prolific offending and drug misuse. Both parents were known to addiction services, had separate key workers, were involved in a methadone programme and were known to have used heroin during Daniel's life. Family was well known to children's services. Issues identified include: lack of focus on the child; professional optimism; insufficient management and supervision; consideration of family history; insufficient information sharing; and working with resistance and avoidance. Makes various inter-agency and single agency recommendations, covering: Wolverhampton Safeguarding Children Board, health services, children's centres, GPs, police and drug and alcohol services.
| Title: Serious case review relating to Daniel who died aged 23 months: ethnic origin: white British: overview report. LSCB: Wolverhampton Safeguarding Children Board Author: Wolverhampton Safeguarding Children Board Date of publication: [2013] This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Restricted No information in this report may be used, copied or distributed without prior permission of WSCB Final WOLVERHAMPTON SAFEGUARDING CHILDREN BOARD Serious Case Review relating to Daniel. who died aged 23 months Ethnic Origin: White British Overview Report Restricted No information in this report may be used, copied or distributed without prior permission of WSCB Final i Summary Daniel died in May 2012 when almost 2 years old, the death was as a result of ingestion of heroin. Post mortem hair sampling indicated that Daniel had been regularly exposed to heroin and occasionally to cocaine and amphetamines. Both parents were prosecuted in relation to the death and are currently serving prison sentences. Wolverhampton Safeguarding Children Board completed a Serious Case review as required by Regulation 5 (1) (e) of the Local Safeguarding Children Board Regulations 2006. The review was undertaken as described in the statutory guidance Working Together 2010 having been commenced prior to the publication of the 2013 version of the guidance. As described in Working Together to Safeguard Children 2010 (8.5), the overall purpose of a Serious Case Review is to: establish what lessons are to be learnt from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and improve intra- and inter-agency working and better safeguard and promote the welfare of children. A panel comprising senior agency representatives from Wolverhampton Safeguarding Children Board, Wolverhampton City Council, Wolverhampton City Clinical Commissioning Group and West Midlands Police, chaired by an independent consultant, was established to oversee the process of the review. None of the panel members had any direct involvement with the family or line management responsibility for practitioners who worked with the family. An independent consultant was commissioned to bring together the overview report. Both consultants were independent of all organisations involved in the review and had considerable experience of Serious Case Reviews. Each organisation that offered services to Daniel‟s family produced a detailed chronology of their involvement and an Individual Management Review (IMR). IMRs were provided by: Wolverhampton City Council Children and Young People's Social Care Early Intervention and Children‟s Centres Wolverhampton City Clinical Commissioning Group General Medical Practice Royal Wolverhampton NHS Trust Acute and Emergency Services Maternity and Health Visiting Black Country Partnership Foundation Trusti Addiction Services West Midlands Ambulance Service West Midlands Police i Providers of addiction services in Wolverhampton at the time of the review. These services have been re-commissioned and are now provided by a consortium of NACRO, Aquarius and Birmingham and Solihull Mental Health NHS Foundation Trust. Restricted No information in this report may be used, copied or distributed without prior permission of WSCB Final ii Reports were also received from West Midlands Probation Service and Occupational Therapy Services who had contact with the father and mother respectively before the timeframe of the review. A Health Overview report that brought together an overview of health service involvement and was the IMR for the health commissioners was provided by the Designated Professionals for safeguarding children for Wolverhampton City Clinical Commissioning Group. The IMRs looked openly and critically at individual and organisational practice, to establish whether the case indicated that changes could and should be made and, if so, to identify how those changes will be brought about. The IMR authors, identified by organisations, were senior officers who had no direct involvement with provision of services to the family. Significant Events Daniel‟s parents had been known to Addiction Services for some time before the timeframe of this review. Both were known to have used heroin and during the timeframe both were on a methadone programme prescribed by the Addiction Service. Their involvement with the service continued throughout Daniel‟s life. The parents had separate keyworkers to manage their care. The mother had disabilities, including mobility difficulties, as a consequence of a major accident several years prior to Daniel‟s birth. When the mother became pregnant she was referred to a Specialist Midwife for substance using mothers and a Consultant Obstetrician managed her obstetric care. In view of the known potential impact on parenting capacity of substance use and mother‟s impaired mobility the addiction workers made a referral to Children‟s Social Care when the mother was 22 weeks pregnant. A Social Care Worker undertook an Initial Assessment, and a parenting assessment was completed over an eight-week period starting during the 29th week of the pregnancy. Daniel‟s delivery was well planned to take full account of the mother‟s health issues. Daniel‟s health and development was monitored by health visitors through some home visits and clinic attendance. Daniel received immunisations at the appropriate times and no concerns about health or development were identified. During Daniel‟s life there were eleven multiagency Child in Need meetings, convened by Children‟s Social Care and attended by practitioners involved in the care of the family. Unfortunately there was lack of consistency in attendance at the meetings and on occasion relevant information, especially about the parents‟ substance use and engagement with other services was not available. The meetings recognised the potential negative impact of the parents‟ drug use on Daniel and focussed on supporting them in addressing this. There were indications that the parents did not always fully engage in services offered to them. The Child in Need plans developed at these meetings were not robust and did not sufficiently address the risks to Daniel of his parents‟ substance use. There was insufficient enquiry by the practitioners about the specifics of the parents‟ drug use and their consideration of Daniel‟s safety. The mother, as a result of her accident, had significant physical difficulties and pain. She was prescribed medication for pain by the GP. Pain was her cited reason for use of heroin in addition to her prescribed methadone. Unfortunately there was no collaborative working between the GP practice and the Addiction Service, which may have better addressed her pain and reduced her need for illicit drugs. Restricted No information in this report may be used, copied or distributed without prior permission of WSCB Final iii During Daniel‟s life there were a number of domestic incidents in which the police were involved and for the six months before the death the father was not fully resident in the family home. There was appropriate information sharing by the police about the domestic incidents although they had no on-going involvement and were not part of any interagency intervention with the family. Analysis Daniel died as a result of an event that had not been foreseen by any of the professionals involved with the family. However the full extent of the potential risks were not acknowledged by any of the practitioners and, had they been more professionally curious, had more „respectful uncertainty‟ and been more assertive in their approach to the family, Daniel‟s death may have been avoidable. It is well recognised that parents who use drugs can and do parent their children well but substance use can sometimes negatively affect parents‟ capacity adequately to meet their children‟s needs. The assessment of this is dependent upon parents‟ cooperation and candour, which were not always evident in this case. The analysis of the information available from the chronology and IMRs focussed on a number of emergent themes and identifies a number of missed opportunities for practitioners to understand fully Daniel‟s circumstances. Child focus – practitioners did not fully understand, or seek to understand the day-to-day experience of the child. Working with substance using parents – including missed opportunities to better manage the mother‟s substance use as pain control and to address safety issues around safe storage and use of substances. Assessment – missed opportunities for in depth, rigorous, family centred assessments of the parenting, the impact of substance use and the mother‟s disability. Working with resistance and avoidance – missed opportunities to recognise and address lack of compliance and engagement with services. Interagency working – there were examples of good interagency working but also some missed opportunities for information sharing and collaboration between professionals. Management oversight and supervision – recognition of importance of supportive yet challenging supervision of practitioners to guard against „over optimism‟ and „fixed thinking‟ and to maintain a child focus. Lessons to be Learned Assessments must be based not only on how children are presenting at the time of contact but also on what is known about the impact of parental behaviour on the long term outcomes for children. When working with complex and challenging families, especially when resources are limited and professionals feel pressured, it is essential that practitioners have access to skilled supervision to support challenge, reflection and professional development, but also to provide emotional support and opportunities for personal development. Practitioners in all agencies need to be reminded of the importance of comprehensive record keeping that maintains a focus on children and their welfare. Working with substance using parents and families where there is resistance and avoidance is challenging. It is recognised that the best way to address these issues Restricted No information in this report may be used, copied or distributed without prior permission of WSCB Final iv is through good interagency working. The systems need to be in place to support this collaboration with a clear understanding of the different roles, responsibilities and perspectives of the different agencies. Complexity is often also a feature of the lives of such families, making assessment even more challenging. In order to make these assessments and to offer effective interventions, practitioners require the skills to develop relationships and to maintain those relationships in circumstances when challenge is necessary. The same skills are also needed to maintain a collaborative working relationship with colleagues from other agencies when perspectives and priorities differ and challenge of the professional perspective or activity is required. Professional, interagency challenge must be underpinned by clear procedures. Successful interagency collaborative working is underpinned by structures such as Child Protection Conferences and Child in Need meetings. It is essential that practitioners have the opportunities and tools necessary to contribute effectively to these meetings. Recommendations The way that Daniel died may not have been predictable but may have been avoidable. Indicators identified by practitioners suggested that, although there were potential concerns for the long term well being of Daniel, these did not amount to serious and immediate risk to Daniel. From the information gathered in the Serious Case Review process there were lessons to be learned about the interventions with Daniel‟s family and a number of recommendations have been made as a result. 1. To ensure improved outcomes for children Wolverhampton Safeguarding Children Board (WSCB) should endorse the recommendations and action plans of the individual agency IMRs and ensure that there is a robust mechanism for monitoring their implementation and evaluating their effectiveness. 2. To ensure the quality and effectiveness of Serious Case Reviews, no matter what methodology is used in the future, WSCB must seek to ensure that partner agencies recognise the importance of SCRs and allow authors and other contributors sufficient time and resource to complete IMRs or other reviews that are timely, of appropriate quality and are signed off by an officer/manager of sufficient seniority to ensure ownership of recommendations and to drive through implementation within the organisation. 3. WSCB should assure itself that all assessments that relate to safeguarding children are undertaken by appropriately qualified and experienced practitioners who are supported by appropriate levels of supervision. 4. WSCB should develop an interagency pathway and protocol for assessing the needs of unborn babies in all circumstances where there is the likelihood of compromised parenting. 5. To ensure interagency collaboration and provision of effective interventions WSCB in conjunction with the Adult Safeguarding Board should review and if necessary update the recently produced interagency guidance „Hidden Harm - parental substance misuse and the effects on children‟ and any guidance with respect to the „Think Family‟ agenda and ensure that there are mechanisms in place to assure themselves of their implementation and effectiveness. Restricted No information in this report may be used, copied or distributed without prior permission of WSCB Final v 6. WSCB should be assured by service commissioners that providers of drug and alcohol services to substance using parents have a safeguarding and a family focus as well as providing appropriate person-centred care. 7. WSCB should seek assurance from partner agencies that practitioners and managers are fully cognisant of procedures, guidance and best practice with respect to: a. thresholds for intervention at different levels b. assessment c. interagency communication d. record keeping including use of chronologies e. contribution, through attendance and provision of reports of appropriate quality, to interagency safeguarding meetings including Children in Need meetings as well as Child Protection conferences and that there is management oversight of their operation. 8. To improve outcomes for children and to ensure practitioners are appropriately skilled, WSCB should assure itself that training and other professional development opportunities are available to practitioners and managers/supervisors in partner agencies about how best to work with avoidant and resistant families and which provides an understanding of barriers to parental engagement and strategies to overcome these barriers. The impact of this should be evaluated by multiagency audit. 9. To ensure effectiveness of interagency working with children and families, WSCB should develop, disseminate and implement policies, procedures and guidance for practitioners and front line managers in partner agencies in respect to management of professional disagreements, professional challenge and appropriate escalation. Once implemented the effectiveness should be evaluated by audit. 10. To ensure effectiveness of interagency working with children and families WSCB should develop and disseminate practice guidance about the operation and multiagency contribution to Child in Need and other interagency meetings which includes standards for invitations, attendance, provision of reports, meeting notes, action plans and monitoring of progress towards clear, agreed outcomes for children. Single agency recommendations were made in each of the IMRs and endorsed by the panel. Action plans have been drawn up by each of the organisations and the progress will be monitored by WSCB. Restricted No information in this report may be used, copied or distributed without prior permission of WSCB Final Contents Page Summary i - v 1. Introduction 1 2. Serious Case Review Process 5 3. Family Involvement 6 4. The Facts Family Background Summary of Significant Facts 7 8 5. Analysis 29 6. Lessons to be Learned 39 7. Inter-agency Recommendations 41 8. IMR Recommendations 43 Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 1 About the Author A qualified nurse and health visitor since 1976 the author had been, until November 2008, Consultant Nurse, Safeguarding Children and Designated Nurse for Child Protection and Looked After Children in Somerset for 8 years; prior to that she was Named and Designated Nurse for Child Protection in Cambridgeshire. She now works as an Independent Consultant. She has experience as a member of a number of Serious Case Review Panels and has written Overview Reports, for a number of LSCBs in England and Wales, and Individual Management Reviews. 1. Introduction 1.1. Regulation 5 (1) (e) of the Local Safeguarding Children Board Regulations 2006 requires Local Safeguarding Children Boards (LSCBs) to undertake reviews of serious cases and advise authorities and their Board partners on lessons to be learned. A serious case is defined as one where: “(a) abuse or neglect of a child is known or suspected; and (b) either - (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.” 1.2. In May 2012 Daniel, aged 23 months, was found unresponsive and not breathing at home by the mother in the early morning. An ambulance attended the scene where Daniel was found to be pulseless and not breathing. Basic life support was performed by ambulance personnel and Daniel was transferred to the nearest hospital but was pronounced dead. Post mortem toxicity investigations were reported several months after Daniel‟s death and showed heroin toxicity as a cause of death. 1.3. An extraordinary meeting of the Serious Case review Sub-group of Wolverhampton Safeguarding Children Board (WSCB) held on 13th December 2012 agreed that the criteria for undertaking a Serious Case Review were met and recommended that a Serious Case Review (SCR) should be carried out. 1.4. The review having been commenced prior to the publication of the 2013 of Working Together in March the SCR was carried out under the guidance from Working Together to Safeguard Children, 2010, Chapter 8, however principles of the new guidance were taken into account. 1.5. As described in Working Together to Safeguard Children 2010 (8.5), the overall purpose of a Serious Case Review is to: establish what lessons are to be learnt from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and improve intra- and inter-agency working and better safeguard and promote the welfare of children. Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 2 1.6. A Serious Case Review Panel (the panel) was established to oversee the process of the review. The panel comprised senior representatives of agencies represented on WSCB. It was chaired by Fergus Smith, an independent Social Care consultant and an experienced chair of Serious Case Review Panels. He was appointed by WSCB as someone of experience and authority and independent of each of the reporting agencies. 1.7. The role of the independent chair is to ensure that the SCR process is completed in as timely way as possible so as to provide a full set of reports for the Safeguarding Children Board. He is responsible for quality assuring the process and reports and requiring changes and further work where necessary, including challenging where there appears to be insufficient or missing information. The independent chair is responsible for ensuring that there is sufficient independence in the process. 1.8. Panel Members represented the following services: 1.9. All panel members had knowledge of, and expertise in, the services provided to the family, but were independent of operational management of the services under review. 1.10. WSCB commissioned a consultant with appropriate expertise and experience who is independent of all of the agencies involved in the SCR process to prepare the overview report. 1.11. The Panel determined the key learning objectives for this SCR as: o To look openly and critically at individual and organisational practice and to establish whether there are lessons to be learned about the way local professionals and agencies work together to safeguard children both in this specific case and more widely in other work. Wolverhampton City PCT/CCG Designated Doctor for Safeguarding Children Designated Senior Nurse for Safeguarding Children West Midlands Police, Detective Chief Inspector, Public Protection Unit Wolverhampton City Council Head of Service, YOT Lead Manager for Children‟s Centres Wolverhampton SCB Head of Service, Safeguarding Children Coordinator CDOP/SCR (Admin Support) Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 3 o To identify clearly what those lessons are, how they will be acted upon and what is expected to change as a result and to consider how learning will be disseminated to practitioners and across agencies. o To determine whether the circumstances of the case indicate a need to revise and update existing procedures, policies, practice or protocols. o To lead to improvements in inter-agency working to better safeguard and promote the welfare of children. o To determine whether any other remedial actions are necessary. 1.12. Individual Management Reviews (IMRs) were requested of all agencies involved with the family in accordance with Working Together guidance. Reviews were requested from the following agencies: Wolverhampton City Council Children and Young People's Social Care Early Intervention and Children‟s Centres Wolverhampton City Clinical Commissioning Group General Medical Practice Royal Wolverhampton NHS Trust Acute and Emergency Services Maternity and Health Visiting Black Country Partnership Foundation Trust1 Addiction Services West Midlands Ambulance Service West Midlands Police Reports were also received from West Midlands Probation Service and Occupational Therapy Services 1.13. A health overview report was also provided by the Designated Professionals. This constituted the IMR for the Clinical Commissioning Group (previously the Primary Care Trust) and considered the way that the health organisations interacted together. 1.14. Organisations were asked to identify appropriately experienced IMR authors who were independent of any line management responsibility for services provided to the family members and asked to certify this in the IMR. 1.15. The purpose of an IMR is to look openly and critically at individual and organisational practice, to establish whether the case indicates that changes could and should be made and, if so, to identify how those changes will be brought about. Any significant concerns identified relating to practice should be responded to as soon as possible to ensure that all children receiving a service are safeguarded. 1.16. IMR authors were provided with a standard template used by WSCB; this helped to ensure consistency and completeness of the reports. 1.17. IMR authors attended a training session that addressed the purpose and process of SCRs and IMRs and were offered support from experienced IMR authors. 1 Providers of addiction services in Wolverhampton at the time of the review. These services have been re-commissioned and are now provided by a consortium of NACRO, Aquarius and Birmingham and Solihull Mental Health NHS Foundation Trust. Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 4 1.18. The time under scrutiny within the review was the period of Daniel‟s life and antenatal period. 1.19. In line with the Working Together guidance the areas of consideration required of IMR authors were: o Were practitioners aware of and sensitive to the needs of the child in their work, and knowledgeable both about potential indicators of abuse or neglect, and about what to do if they had any concerns about a child‟s welfare? o When, and in what way, were the child(ren)‟s wishes and feelings ascertained and taken account of when making decisions about the provision of children‟s services? Was this information recorded? o Did the organisation have in place policies and procedures for safeguarding and promoting the welfare of children and acting on concerns about their welfare? o What were the key relevant points/opportunities for assessment and decision making in this case in relation to Daniel and the family? Do assessments and decisions appear to have been reached in an informed and professional way? o Did actions accord with assessments and decisions made? Were appropriate services offered/provided, or relevant enquiries made, in the light of assessments? o Were there any issues, in communication, information sharing or service delivery, between those with responsibilities for work during normal office hours and others providing out of hours services? o Where relevant, were appropriate child protection or care plans in place, and child protection and/or looked after reviewing processes complied with? o Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability of the Daniel and his family, and were they explored and recorded? o Were senior managers or other organisations and professionals involved at points in the case where they should have been? o Was the work in this case consistent with each organisation‟s and the WSCB‟s policy and procedures for safeguarding and promoting the welfare of children, and with wider professional standards? o Were there organisational difficulties being experienced within or between agencies? Were these due to a lack of capacity in one or more organisations? Was there an adequate number of staff in post? Did any resourcing issues such as vacant posts or staff on sick leave have an impact on the case? o Was there sufficient management accountability for decision making? What do we learn from this case? o Are there lessons from this case for the way in which this organisation works to safeguard and promote the welfare of children? Is there good practice to highlight, as well as ways in which practice can be improved? o Are there implications for ways of working; training (single and inter-agency); management and supervision; working in partnership with other organisations; resources? o Are there implications for current policy and practice. Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 5 In addition to the above generic terms of reference, the Serious Case Review Panel agreed that agencies should address the following issues, which are specific to this case: o were threshold decisions clearly outlined, if so how? o what was the quality of the Child in Need Plan, its implementation and the planning and review process? o what consideration was given to the impact of historical parenting experience in the assessment process? o what was the impact of parent substance misuse and domestic abuse on the care provided to the children? o what was the analysis and rationale for closure of the case and the understanding of the on-going care provision; o where there are multiple staff involved within an agency, was there continuity of care planning. 1.20. In order to ensure that the IMRs were of a sufficient standard and that they addressed all aspects of the terms of reference the SCR panel requested that the completed IMR be agreed and signed off by the Senior Officer in the organisation who had commissioned the report, was responsible for the quality and timeliness of the report and who will be accountable for ensuring that the recommendations are acted upon in a timely manner within their organisation. 2 Serious Case Review Process 2.1. As described above a Serious Case Review Panel (the panel) was convened and chaired by an independent consultant. The role of the panel was to oversee the process of the SCR on behalf of the Wolverhampton Safeguarding Children Board, to ensure close contact with IMR authors and to ensure robust, independent scrutiny and critique. 2.2. The panel endorsed the Terms of Reference for the Review and met at strategic points during the process. 2.3. IMRs and detailed chronologies were submitted to the panel and an Integrated Chronology was constructed. This formed the basis for the examination of significant events contained within the overview report. 2.4. The Panel met on seven occasions to oversee the SCR process. The overview author was in attendance at panel meetings. Draft IMRs were scrutinised by the panel and authors were invited to a meeting at which the panel were able to clarify issues arising from their IMRs. The meeting also provided an opportunity for authors to receive feedback about the quality and content of the IMRs before submitting a final version. Final versions were submitted to the panel after final „sign off‟ by senior managers/officers in the organisations who were expected to provide additional quality assurance. 2.5. The finalised IMRs were scrutinised by the panel and overview author. It was confirmed that all had been signed off by a senior officer/manager in the organisation to ensure appropriate ownership within the organisation for implementation of recommendations and action plans. Each organisation developed an action plan to ensure implementation of the recommendations. Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 6 2.6. The IMRs were generally of at least adequate quality, although the panel required significant redrafting of one in particular. There was a significant delay in receipt of the final draft of one IMR. The panel expressed concern that some organisations did not adequately recognise the work involved in producing a good IMR and did not afford authors sufficient protected time to complete the task. This has led to a recommendation to the Wolverhampton Safeguarding Children Board and its partner agencies. All IMRs were presented in standard format ensuring that all elements of the requirements of the Terms of Reference were addressed. The methodology used to complete the IMR was clear in all cases however the interviewing of personnel by the IMR authors was restricted due to the ongoing criminal investigation; this was a limitation of the review. 2.7. The independence of the IMR authors was clear for all of the reviews. 2.8. Most of the IMRs provided an appropriate level of analysis of agency involvement highlighting both deficits in practice and examples of good practice. Some, but not all, of the IMRs demonstrated the use of research evidence to underpin the analysis. There was an obvious attention to the needs of the child and the recommendations mostly focused on improving outcomes for children although this was not always made explicit. The IMR recommendations, in most part, flowed appropriately from the lessons learned and were Specific, Measurable, Achievable, Realistic and Time bound. 2.9. The panel scrutinised the overview report and agreed recommendations and the integrated action plan prior to submission to the Wolverhampton Safeguarding Children Board. 2.10. As indicated above the on-going police investigation and criminal process impeded the full involvement of practitioners in the review process because of their possible involvement as witnesses. IMR authors were therefore generally restricted to examination of professional records and other documentation in their preparation of reports. It can be argued that good documentation should provide sufficient data to examine the professional intervention and decision making processes. However more involvement of practitioners in the process of serious case reviews increases opportunities to understand practice from the viewpoint of the individuals involved and reduces the impact of hindsight bias. The panel considered this dilemma but agreed that it was preferable to go ahead with the review, taking account of these restrictions, rather than delay the process thereby delaying the learning from the review. 3 Family Involvement 3.1. Family members were informed of the review and the parents‟ consent for access to their medical records obtained. Legal reasons meant that it was not possible to gather the views of the parents or involve them in the review due to the on-going criminal process 3.2. Following the completion of the criminal procedures both parents were convicted in relation to Daniel‟s death. Both parents pleaded guilty, father to manslaughter and the mother to causing or allowing the death, and were given prison sentences. 3.3. Following the completion of the review the parents were given the opportunity to discuss the findings of the review. The overview author and one of the panel Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 7 members saw the mother in prison. She was accepting of the findings of the review and the recommendations. 3.4. Following this contact with the mother a member of her extended family wrote to the Chair of the LSCB to offer reflections on agency involvement with the family. Consequently they, and thereafter several other members of both sides the extended family, were seen by an SCR panel member, their comments and observations have been incorporated into a revised overview report. 3.5. All family members who contributed information indicated that Daniel was a delightful child, who appeared happy and healthy although grubby at times. They were reassured that services were involved with the family but members of the mother‟s family considered that they should have been contacted for information about their involvement and support that they were offering. 4 The Facts Family Background 4.1. The mother 4.1.1. Daniel was the mother‟s second child; she was aged 32 years when Daniel died. The mother‟s first chid did not live with the family and had no connections with the case. 4.1.2. The mother was involved in a serious accident seven years before Daniel‟s birth. This resulted in her receiving significant financial compensation, which allowed her to buy a house, when Daniel was six months old, for the family to live in. Initially the accident resulted in the mother being a wheelchair user with other health problems, although her mobility improved during the timescale of the review. Unfortunately the mother‟s primary medical records for a five-year period, which included the time of the accident, could not be located within the timescale of the review; therefore relevant details of her disability are limited. 4.1.3. The mother was known to use a variety of substances both prescribed and illicit. She was first assessed by the Addiction Service when she was 22 years old when she disclosed daily use of heroin. A substitution prescription (methadone) programme was started but not sustained and she was discharged from the service two months later. She recommenced a methadone programme two years later. It was noted that she had injected heroin in the past but during the course of the review she disclosed only use by smoking. She also took prescribed opiates as a means of pain control. Family members indicated that she also regularly consumed significant amounts of alcohol. The mother was involved with the Addiction Service before and throughout the period of the review; a keyworker was allocated to work with her. 4.1.4. The mother had an offending history from the age of twenty until the time of the accident, having been arrested on a number of occasions and ten crimes reported. The offences were theft and loitering. There was no formal police involvement from the time of the accident until her arrest in relation to the death of Daniel. 4.2. The father 4.2.1. The father had a significant offending history that began when he was sixteen and mostly relates to offences of theft of and from vehicles. His criminal behaviour was linked to his heroin dependency. He reported to the probation service that he had Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 8 started using illicit drugs aged 12 years and heroin when 16 years. He served a fourteen-month prison sentence for robbery when he was 26 years. Due to his offending behaviour the father was classed as a prolific offender until the age of 26 and was managed by the police Offender Management Team. The last involvement with this team was a year before the birth of Daniel and his offending history declined thereafter. 4.2.2. The Probation service were involved with the father between the ages of 19 and 22 years when he was involved in persistent criminality and again when he was 26 years in relation to the robbery offence. 4.2.3. The father was known to be a drug user although had minimal criminal history for drug related offences. 4.2.4. The father was known to the Addiction Service since he was aged 24 years and was in and out of treatment thereafter. He was re-referred to the service on his release from prison several months before Daniel‟s conception. He attended an initial appointment but disengaged. A practitioner from the Addiction Service was allocated as a keyworker for the father throughout most of the period of the review. 4.2.5. None of the IMRs indicated how long the parents had been in a relationship. 4.3. Summary of Significant Facts from the Integrated Chronology of Agency Involvement (Comments and author‟s analysis are included in shaded boxes throughout the narrative chronology) The antenatal period 1st Trimester 4.3.1. The first practitioner to be made aware of the pregnancy was the mother‟s key addiction worker who appropriately referred to the specialist midwife who was, at the time, part of the Addiction service. The parents then saw the GP to discuss the pregnancy. It is noted by the GP that the mother was taking a number of medications and was smoking and taking alcohol, that she was involved with the Addiction Service and was on a methadone programme. The GP referred to the midwife attached to the practice who appropriately confirmed that the specialist midwife in the Addiction Service would be the responsible midwife. The mother‟s alcohol use was not specifically identified as an issue in any of the agency chronologies but was raised as a significant issue by all extended family members who offered information to the review. Family members suggested that she regularly drank heavily throughout Daniel‟s life. Excessive alcohol consumption and related problems are common among clients in methadone maintenance treatment2. It would appear that practitioners did not perceive alcohol intake as a significant issue either because it was not disclosed, the mother was not questioned about it or it was normalised by practitioners. The risk of heroin related overdose is significantly increased by alcohol use. The risks to children of the impact of alcohol are as 2 Hillebrand J, Marsden J, Finch E, Strang J.(2001) Excessive alcohol consumption and drinking expectations among clients in methadone maintenance. J Subst Abuse Treat. 2001 Oct;21(3):155-60 Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 9 significant as those of other substances both in relation to the short term intoxicant effects and the longer term health effects. Use of alcohol should always be continually considered as a part of any assessment of substance using parents. 4.3.2. The specialist midwife first saw the mother during the ninth week of pregnancy and completed a comprehensive assessment of her health, social circumstances and obstetric needs. In view of the mother‟s physical disability, as a result of the accident, and her substance use she was referred for consultant obstetric care. She was seen the following week in the hospital antenatal clinic by a midwife specialising in work with vulnerable women. 4.3.3. The father was seen for an initial assessment by an outreach addiction worker during the early weeks of Daniel‟s gestation. This was a further attempt to engage him in service provision after his failure to engage in the previous months. This was a wide-ranging assessment during which the father disclosed having been abused as a child, there were no other references to this in any IMRs or any indication that it was pursued further with him. An appointment was made for him to be medically assessed within the service. He attended this appointment and it was noted that the father was injecting heroin into his groin. He was started on buprenorphine - an opioid used as a heroin substitute. It is noted in the Addiction Service IMR that the doctor does not appear to have referred to the previous assessment completed by the outreach worker two weeks previously and there is no indication of consideration of the father‟s disclosure of child abuse. 4.3.4. During the same week there is a police intelligence system entry in respect of the father that mentions the pregnancy and indicates concerns about a third party living at the family address and the possibility of drugs being sold from the premises. This information was not shared with other agencies. 4.3.5. A consultant obstetrician saw the mother during the eleventh week of pregnancy, she had an ultrasound scan and in view of the problems that were a result of her previous accident an elective Caesarean section at 39 weeks was planned. It was noted that she was taking MST (slow release morphine) and methadone; it was also noted that she had a history of taking amitriptyline (an antidepressant) although no details of this are included in the chronology. She was also seen at this time by an addiction practitioner and requested an increase in her methadone prescription; she was offered an appointment with a doctor in the Addiction Service two days later but declined, a further appointment was arranged in two weeks time. The mother‟s substance use is not clearly detailed in the chronology; it would appear that there was little coordination between services with respect to prescribing. The heroin substitution with methadone was managed by the Addiction Service and the morphine (MST or Zomorph) was prescribed by the GP. 3Methadone substitution during pregnancy is encouraged as it carries lower risk than continued illicit use of 3 Department of Health (England) and the devolved administrations (2007). Drug Misuse and Dependence: UK Guidelines on Clinical Management. London: and Black Country Partnership NHS Foundation Trust, Addiction Services, Service Procedures Handbook (undated) Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 10 heroin. The aims of the maintenance approach, also known as 'substitution' or 'harm-reduction', are to provide stability by reducing craving and preventing withdrawal, eliminating the hazards of injecting and freeing the person from preoccupation with obtaining illicit opioids, and to enhance overall function. To achieve this, a substitution opioid regimen (a fixed or flexible dose of methadone or buprenorphine to reduce and stop illicit use) is prescribed at a dose higher than that required merely to prevent withdrawal symptoms. The aim is generally to prescribe a maintenance dose that stops or minimises illicit use. If illicit opiate use continues, increasing the dose of the prescribed opiate may be necessary. There is often a need to increase methadone prescription during pregnancy, in order to minimize „on-top‟ use of heroin due to increasing blood volumes. Detoxification can be attempted during the second trimester but is not recommended in early or late pregnancy; it should not generally be undertaken in the third trimester because there is evidence that maternal withdrawal, even if mild, is associated with foetal stress, foetal distress, and even stillbirth. It is not clear if the mother‟s methadone prescription took full account of the morphine being prescribed by the GP. It would appear that the mother had been prescribed methadone over a long period and as such prescriptions were regular and issued for longer periods than would be expected for users newly engaged in a maintenance or substitution programme. There is indication throughout the chronology that the mother was not fully compliant with the requirements of the Addiction Service for regular contact and review. It would appear that practitioners were tolerant of this, possibly because she had been involved with the service over a long period or it may have been influenced by her disability. This resulted in prescriptions continuing to be issued even when she did not attend for expected medical review in the Addiction Service. As already indicated there did not appear to be a coordinated approach to the medicines management and limited medical oversight of the prescribing. 2nd Trimester 4.3.6. The mother did not attend the medical appointment or one arranged for the following week. A methadone prescription was made available at a pharmacy; it is unclear what dosage had been prescribed. 4.3.7. During the week in which the mother had failed to attend the second medical appointment the father‟s keyworker referred him to an outreach worker to follow up his failure to collect his methadone for three days; he was on daily, supervised consumption at a pharmacy. Normally failure to attend the pharmacy would result in the withdrawal of a prescription. This resulted in a home visit two days after the referral. A further keyworker appointment was made and kept for the following day. The father disclosed continued use of heroin, cocaine, cannabis and alcohol. A further medical appointment was made for the following week at which a further methadone prescription was issued. He attended review appointments for next two consecutive weeks and two further appointments at two weekly intervals. His disclosed use of heroin was reducing and the methadone increased as part of the substitution programme. At the last of these appointments he said that he had not Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 11 used heroin for three days and expressed a desire to be drug free in time for the baby‟s birth. There is some confusion in the chronology about the opioid substitution that is being prescribed for the father (methadone or buprenorphine). Clinical guidelines2 suggest that people in receipt of opiate substitution should be required to take their daily doses under the direct supervision of a professional (often a pharmacist) for a period of time contingent upon compliance; this is often three months. After this time methadone is prescribed for unsupervised consumption, sometimes restricted to daily pick up by the individual, otherwise weekly prescriptions are issued. Prescriptions would normally be issued during contact between the individual and a keyworker. It would appear, although it is not entirely clear from the IMR that the mother‟s prescriptions were for a longer period than a week. The Addiction Service has a procedure for follow up of missed appointments but there are indications that these were not fully adhered to, although the procedure offers limited direction about timescales for follow up. 4.3.8. During the 20th week of the pregnancy the mother attended an Addiction Service medical appointment with the father. She admitted „dabbling with heroin‟ and a urine test was positive for it. She attended an antenatal appointment and a routine anomaly scan was done; this was normal. The mother attended antenatal appointments at 28 weeks, 30 weeks (at home), 32 weeks, 33 weeks (obstetrician), 35 weeks and 37 weeks. These contacts were in line with NICE guidance4. 4.3.9. The following week the father‟s addiction worker and the team leader in the Women‟s Team, who was also a specialist midwife, discussed the case and it was agreed that a referral should be made to Children‟s Social Care to safeguard the welfare of the unborn baby. The referral was discussed with the parents, by the mother‟s keyworker at a home visit and by the father‟s keyworker at a clinic appointment. It was noted that the father had made progress in his drug reduction and that he would be the main carer for the baby due to the mother‟s disability, therefore framing the Social Care referral in the context of the provision of support rather than focussing on the impact of the parents‟ drug use on the unborn baby. This is the first indication of any communication or collaborative working between the addiction practitioners involved in the care of the two parents that focussed on the unborn baby. The Black Country Partnership NHS Foundation Trust, Addiction Services undated documents “Services for Women and their Children” and “Maternity Pathway” indicate the requirement for earlier referral and in view of the lack of full engagement of both parents with the service this may have been appropriate. If the practitioners had low level concerns about the welfare of the unborn baby it may have been appropriate for a CAF (Common Assessment Framework) to have been initiated very early in the pregnancy; this could have facilitated a more wide-ranging, interagency approach to assessment of the needs and welfare of the unborn baby. 4 National Institute for Health and Care Excellence, Clinical Guideline CG62 Antenatal Care Issued 2008. Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 12 The CAF process could have resulted in interagency intervention as a Team Around the Child involving a wider range of practitioners. A clear interagency LSCB process or protocol for managing the care of unborn babies for whom there are safety and welfare concerns would have provided a framework for more robust interagency collaboration and clearer decision making about the level of response that is needed in individual cases (CAF (early help), Child in Need (Section 17) or Child Protection (Section 47). 4.3.10. The referral to Children‟s Social Care, made in the 22nd week of the pregnancy, provided details of the parents‟ drug use and their engagement with the Addiction Service including involvement of the specialist midwifery service; there was also referral to mother‟s disability. The Social Care IMR indicates that the focus of the referral was more on the mother‟s disability than the impact of the parents‟ drug use. The case was allocated to an unqualified Social Care Worker in the Duty and Assessment Team who completed an Initial Assessment over the next week. There is no indication in the chronology of direct contact between the Social Care Worker and the parents as part of this assessment, although this is presumed to have occurred, as there is reference to information about their drug use and access to family support. Nor is there indication of contact with other practitioners for contribution to the assessment other than the specialist midwife. It is of concern that an assessment of a potential child protection concern was undertaken by an unqualified worker, albeit one with experience. The details of the contact made with the family – number of contacts, with whom, where they took place etc. are not included in the chronology. The outcome of the assessment however was that further assessment was required, via a core assessment which appears to have been appropriate. Initial Assessments undertaken, at the time, under The Framework of Assessment of Children in Need and their Families (HM Govt. 2000) 5 are time limited assessments undertaken to determine whether the child is in need, the nature of any services required, from where and within what timescales, and whether a further, more detailed core assessment should be undertaken, it is expected that any professionals involved with the family would contribute to the assessment. 4.3.11. The initial assessment was authorised by a Team Manager and it was recommended that the case should transfer to a locality team within Children‟s Social Care for a pre-birth Core Assessment and a Child in Need Plan. A referral was made for a pre-birth parenting assessment, this was assigned to a Family Centre to complete. These on-going referrals were completed within two days, however the case was not allocated within the locality team for a further three months. The delay in allocation to complete a core assessment meant that any interagency planning to address the safety and welfare of the unborn baby was delayed until after the baby‟s birth. 5 This guidance has been superseded by the new version of Working Together to Safeguard Children (HM Govt. 2013). Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 13 4.3.12. During the 27th week of the pregnancy a Duty Social Worker from the locality team attended a joint home visit with the Family Centre Family Worker, at the request of the Family Centre worker to plan the parenting assessment. After the home visit the Family Centre worker was sufficiently concerned for their manager to contact a manager in the Children‟s Social Care Locality Team to expedite allocation as they considered that a Child Protection Conference would be appropriate. 4.3.13. Three days after this visit the father attended a police station requesting help with completion of a DVLA application. The officer completed a standard information sharing log (WC392) to share information with Children‟s Social Care about the father‟s past history of drug use and abuse when a child, which may impact on his parenting capacity. Two weeks later there was a conversation between a social worker and a police officer recorded in the Social Care chronology but not in the police chronology. The police officer reconfirmed the concerns about the parents‟ drug use documented in the proforma. There is no indication that this information sharing led to any action or that the police were involved in any of the future planning. This was a missed opportunity for on-going interagency working. 3rd Trimester 4.3.14. A Family Worker from the Family Centre started a parenting assessment during the 29th week of the pregnancy; it comprised six contacts over an eight week period. On the first and subsequent visits the mother was complaining of morning sickness and unable to tolerate her methadone and had consequently been using heroin. There is no indication that the worker discussed this with other practitioners working with the family; it would have been appropriate for consultation with the Addiction Service who were prescribing the methadone and the GP who may have been able to offer advice about management of the vomiting. Issues addressed in the parenting assessment included feeding, play and stimulation, home safety, childhood and drug use, impact of drugs on parenting capacity, emotional warmth, guidance and boundaries and stability. At the end of the assessment a referral was made to a Children‟s Centre for outreach support, it was received on the day of Daniel‟s birth. At the time of Daniel‟s birth the worker who completed the parenting assessment reported to the, by then, allocated social worker recommending that the baby should be cared for by the parents at home. As identified by the Social Care IMR author this was a decision that should have been part of a core assessment undertaken by a qualified social worker in collaboration with other professionals. The delay in allocation to a social worker precluded this. 4.3.15. Between the referral to Children‟s Social Care and Daniel‟s the father attended appointments with the Addiction Service nine times and did not attend on a further three occasions. Prescriptions for methadone were provided but he continued to disclose use of heroin, both injected and smoked. He claimed to only use heroin Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 14 when unable to collect the methadone, however all drug tests were positive for heroin. A month before Daniel‟s birth a doctor in the Addiction Service agreed to the father stopping supervised consumption of methadone, it is not clear if he continued on daily pickup or longer term prescriptions were provided. The doctor was apparently aware of the pregnancy and the involvement of Children‟s Social Care but there is no indication of any interagency communication. 4.3.16. The father failed to attend the next medical review citing his partner‟s illness as the reason. The specialist midwife had made a home visit on the same day, documented that the father was present but there was no indication that the mother was unwell. There was no communication between the two workers to gain an understanding of this discrepancy and a possible indication of the parents‟ lack of candour. The decision making around the father‟s change from supervised consumption to take home is unclear. The NICE guidance6 and Department of Health Guidance recommend supervised consumption for a minimum of three months until compliance is assured. The father requested several times to stop supervised consumption however his attendance was unreliable and his compliance inconsistent. The IMR indicates that the relevant risk assessment was not undertaken. The presence of a child in the home should have added another dimension to the risk assessment; there is no indication that this was considered. There is no indication in any of the IMRs that the issue of safe storage of both prescribed and non-prescribed drugs was raised with the parents. Once methadone is prescribed for unsupervised consumption, or even supervised when pharmacies are not open on a Sunday and at least one dose is given to take away, it is essential that advice is given about safe storage to prevent accidental overdose, especially if there are children in the household. This should be the responsibility of all professionals involved including prescribers and dispensers (pharmacists). The advice needs to be reiterated frequently and by all involved professionals as there is some evidence that it is not always remembered or acted upon by users.7 Some Addiction Services provide lockable boxes to individuals to ensure safe storage of methadone etc. 4.3.17. During the same period the specialist midwife visited the mother, at home, six times, during which the mother disclosed continued use of heroin. Only one drug test is documented which was positive for heroin. It is assumed that the mother continued to be prescribed methadone although it is not clear how much was prescribed or for what period. She was seen once for a medical review in the Addiction Service a month before Daniel‟s birth, by the same doctor who had seen the father the previous 6 National Institute for Health and Care Excellence Drug misuse: psychosocial interventions‟ (NICE clinical guideline 51) and „Drug misuse: opioid detoxification‟ (NICE clinical guideline 52) Issued July 2007: National Institute for Health and Care Excellence, Clinical Guideline CG62 Antenatal Care Issued 2008 7 Mullin, A, McAuley, RJ, Watts,DJ, Crome,IB and Bloor, RN (2008) Awareness of the need for safe storage of Methadone at home is not improved by the use of protocols on recording information giving Harm Reduct J. 5: 15. Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 15 month. Her relationship with the father was noted and there is evidence that the doctor appropriately discussed the impact of drug use on the unborn baby. She disclosed continuing use of heroin. It is unclear if the mother was also taking prescribed morphine at this time. 4.3.18. Two weeks before Daniel‟s birth the case was allocated to an agency social worker, this was three months after the completion of the initial assessment. Daniel’s life Birth - 6 months 4.3.19. The mother was admitted to hospital the day before a planned Caesarean section. This planned admission allowed for assessment of her disability etc. and was an example of good practice. Daniel was born in good condition and showed minimal withdrawal symptoms. The mother requested discharge from hospital on the day after delivery but was encouraged to stay and care for Daniel. The specialist midwife who cared for the mother during her pregnancy also led her care in hospital; this was another example of good practice in providing continuity of care. Daniel and the mother were discharged home from hospital on Day 3. Children‟s Social Care was informed of the birth and discharge from hospital and a discharge notification was sent to the GP and health visitor. There was no formal interagency planning around Daniel‟s discharge from hospital. A discharge planning meeting would have offered an opportunity for all professionals involved with Daniel‟s care to be clear about their roles and responsibilities and the potential risks to Daniel. It is probable that the risks to Daniel were not considered sufficiently high for it to be considered necessary to hold such a meeting. 4.3.20. A community midwife visited the home on the next two days; no concerns were identified and it was noted that the father was sharing the care of Daniel. 1st Child in Need Meeting – Daniel 1 week old 4.3.21. A Child in Need meeting was held when Daniel was one week old. It was attended by the parents, the allocated social worker and the Family Support Worker from the Family Centre; none of the other involved practitioners were present. It is not clear who had been invited to the meeting or when it had been arranged. All professionals involved in the care of the family should have been invited to the meeting and given sufficient notice of the meeting to enable them to attend, to send deputies or at very least to have provided written information about their involvement. The effectiveness of interagency meetings is dependent on the availability of all of the relevant information and preferably the attendance of all relevant professionals. It is important that records are kept of invitations to and attendance at interagency meetings to allow monitoring of appropriate interagency engagement. There were no health professionals present at the meeting and there is no evidence that the Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 16 resultant Child in Need plan was distributed to practitioners who should have been present, had an on-going role to play with the family and were indeed assigned responsibilities in the plan. 4.3.22. There were midwifery visits on days 8, 10, 14 and 21; no concerns about mother or baby were identified. The records contained no reference to on-going social care involvement and there was no formal handover to the health visitor. 4.3.23. A home visit was made to the mother by a new addiction worker on Daniel‟s 8th day. The mother stated that she had not used any illicit substance and was continuing with her methadone programme. The worker noted that the baby appeared well although there is no indication of discussion of the impact of drug use. 4.3.24. The following day the father attended an appointment with his keyworker; the mother and baby accompanied him. He denied any use of heroin or crack since Daniel‟s birth, this was confirmed by drug testing. He disclosed use of cannabis and alcohol; the worker discussed the potential impact of these on parenting. There was a change of father‟s addiction keyworker and appointments were arranged at a different venue. 4.3.25. The social worker referred both parents for counselling to Adult Mental Health Services, possibly in relation to their disclosures of abuse in their childhoods, although this is not clear. There is no indication of how this referral had been negotiated with the parents or whether the worker had discussed the referral with other practitioners. The parents did not engage with the service and a letter was sent four months later closing the case without any intervention. This appears to be the only action taken by this agency social worker, who left the service two weeks later. The case remained unallocated again for another two months. 4.3.26. On Daniel‟s 14th day the specialist midwife who was also the mother‟s addiction worker, visited the family and gave the mother a methadone prescription. No drug testing was done which may have confirmed the mother‟s claim that she had not used any illicit substances since Daniel‟s birth. Daniel was noted to be well and to have gained weight. 4.3.27. On the same day the health visitor made a primary visit as part of the normal health visitor programme. It is unclear how much the health visitor was aware of the parents‟ drug use or whether it was addressed during the contact. The mother informed the health visitor that she would be changing GP practices; this would result in a change of health visitors. The health visitor transferred Daniel‟s records to another health visitor when the new GP practice was confirmed. There does not appear to have been any formal handover between the midwifery service and the health visitor. This would have been good practice for all families but especially important where there are potential concerns about the welfare of the Danielnd the parenting capacity. It is not obvious that the health visitor was aware of involvement of Children‟s Social Care or the previous parenting assessment that had been undertaken through the Family Centre. Had the health visitor and the addiction workers attended the Child in Need meeting held the previous week a coordinated approach to working with the family may have been possible; this would have been advantageous. There is no indication that a detailed Family Health Needs Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 17 Assessment was undertaken by the health visitor, this would have been good practice to provide a baseline for planning of ongoing care for Daniel and other family members.8 4.3.28. When Daniel was 23 days old the mother‟s addiction worker visited, both parents were present, a drug screen was negative. On the same day the father cancelled an appointment with his addiction worker ostensibly due to his illness that had not been noted by the mother‟s worker. There was no communication between the two workers. On the same day a worker from the Children‟s Centre made a prearranged visit to assess the family‟s needs for Children‟s Centre involvement. It does not appear that the worker was aware of the involvement of other services. The appointment was rearranged for the following week, as the parents were about to go out. The Children‟s Centre worker consulted with other agencies and the next visit was carried out jointly with the Family Centre worker who had undertaken the parenting assessment. This allowed for handover between the two workers and is good practice. The Children‟s Centre worker completed an assessment; although the CAF format was used it was not formally registered as a CAF and was not made available to other practitioners. The Children‟s Centre worker discussed the family with a Duty Social Worker and with the Family Centre worker who had completed the parenting assessment. 4.3.29. For the next five months the Children‟s Centre worker had contact with the family almost every week, either by telephone or home visits. 4.3.30. Daniel was taken to the child health clinic when one month old, nutritional advice was offered. Daniel was noted to be feeding well and settled. When six weeks old Daniel was seen by the GP for a routine medical examination, no concerns were identified. The mother also had a postnatal check, this was the first time that she had been seen at the new GP practice and, at the time, the GP did not have access to her medical records. There was discussion about her medication, the mother was requesting further prescription of morphine and the GP arranged to see her again in two days to discuss this in more detail. The mother did not attend that appointment but did attend three days later and saw a different GP. The GP contacted the keyworker in the Addiction Service to discuss the drug programme and the parallel prescription of morphine and it was agreed that the worker would discuss the issue with the medical team in the Addiction Service. The GP requested the medical records and the week after the appointment and, on receipt of the records, wrote to the Addiction Service. The following week the GP decided to prescribe the morphine as requested by the mother and issued a prescription for one month. The Children‟s Centre worker became involved in negotiations between the two GP‟s surgeries and the Pharmacy to access the correct prescription. 4.3.31. Daniel was taken to the clinic at 9 weeks for weighing. There was also attendance at 12, 16 and 22 weeks for immunisations. 4.3.32. Over the same two week period the Children‟s Centre worker also mediated with the Housing provider over repairs of a broken window, which had not been done as quickly as the mother wished. There is indication that the Children‟s Centre worker 8 Shribman, S and Billingham, K (2009) Healthy Child Programme – Pregnancy and the first five years, London Department of Health Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 18 was aware of relationship difficulties and arguments between the parents. There is no record of the Children‟s Centre worker communicating with other practitioners, which would have been appropriate. 4.3.33. The following week the mother‟s addiction worker visited the home, this was the first time she had been seen by the service for a month, the mother having cancelled an appointment due to unspecified „personal problems‟ although the nature of these were not pursued. The mother disclosed use of heroin the previous night, confirmed with a drug screen. This home visit was a missed opportunity for the worker to assess the safety and welfare of Daniel with respect to the parents‟ substance use. 4.3.34. Since Daniel‟s birth the father had seen his addiction worker five times having failed three appointments. He disclosed having continued using heroin regularly, although he claimed a four week period of abstinence. He also disclosed continuing use of cannabis at night. He had been on a programme of gradual reduction in methadone at his own request. He also disclosed that the mother was using both heroin and cannabis, especially at night as a means of pain relief. 4.3.35. There is no indication that the worker ascertained where and when the parents were using the heroin or cannabis, where Daniel was at the time and their ability to care for the baby when under the influence. There is some evidence to suggest that the parents were both using heroin at the same time; if this had not been the case it may have lessened concerns, as there may have been a better chance of one being more able to meet the needs of the very young baby. There is no indication that any of the workers asked about or saw Daniel‟s sleeping arrangements. 4.3.36. When Daniel was 10 weeks old an unqualified worker from Children‟s Social Care was allocated the case and undertook a home visit two weeks later. There is little detail about the purpose, content or outcome of this visit; the main focus was the family‟s potential house move. This was the first contact with a worker from Children‟s Social Care for three months. 4.3.37. When Daniel was fourteen weeks old the police attended the family home. The mother had called an ambulance because she had apparently been pushed to the ground by the father in an argument; she cancelled the ambulance before it arrived. The police, being aware of the call, attended to carry out a „safe and well check‟, they entered the property, only the mother was present and there were no signs of disturbance. The mother had no visible injuries and declined to make a complaint. It appears that the father and Daniel were not at the home and it is not known where they were. Although this was a minor incident and officers did not consider it necessary at the time to share information about the incident with Children‟s Social Care, this was a missed opportunity. Albeit this was a fairly minor domestic incident it is well recognised that the domestic abuse has a detrimental effect on the welfare of children and is a frequent feature of serious case reviews and when combined with parental substance misuse can have a significant negative effect on the welfare of children9,10 and therefore information should have been shared with Children‟s Social Care about the incident. 9 Cleaver, H., Nicholson, D., Tarr, S. and Cleaver, D. (2007) Child Protection, Domestic Violence and Parental Substance Misuse: Family Experiences and Effective Practice. London: Jessica Kingsley Publishers Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 19 4.3.38. The mother was seen on the same day by the GP with a viral infection. This prompted the GP to follow up the request for information from the Addiction Service, it was ascertained that the mother had an appointment for a medical review the following month. The GP did not pursue this any further at the time. The prescriptions for morphine continued to be issued monthly for the next six months. It was noted that the mother had failed to keep a number of orthopaedic appointments that were aimed at addressing her hip pain. This could have been seen as an indicator of the mother‟s lack of compliance with services. 4.3.39. The following day the mother‟s addiction worker visited the home. The mother was upset by the domestic incident, she admitted using some heroin due to the stress of being on her own with full care of Daniel. There is no indication of challenge of the heroin use, especially having sole care of the child, although the worker recognised that the mother‟s physical disability may impact on her parenting capacity and therefore contacted Children‟s Social Care the following day. It was mooted that the mother may need support from Adult Services but there is no indication that this was pursued. The Children‟s Centre worker also saw the mother at home that day and appropriately discussed the impact of the relationship difficulties on Daniel. The Social Care Worker next visited the family three weeks later. 4.3.40. The following week the father saw his drugs worker, he discussed the domestic incident, and he said that he had been stressed due to cramped living conditions in the family home, lack of sleep and childcare responsibilities. The worker explored ways of managing stress. There is no indication that this information was discussed with the mother‟s keyworker or other agencies; this was a missed opportunity for a more collaborative approach to considering the needs of the couple. 4.3.41. The next day the Children‟s Centre worker made a home visit. Both parents were present having reconciled. It is noted that the family would be moving house in six weeks time. Daniel was reported as well other than having a cold. The Children‟s Social Care worker visited on the same day, also noted that Daniel had a cold and that the family were moving home. It was agreed that the core assessment would be delayed until the family had moved home, the rationale for this delay is not clear. 4.3.42. Over the next two months the Children‟s Centre worker made weekly contact either by telephone or home visits. The father saw his drugs worker two weekly. The mother was seen by her drugs worker once. Both parents continued to use heroin „on top‟ of their prescribed methadone and, in the case of the mother, prescribed morphine. 2nd Child in Need Meeting - Daniel 5 months old 4.3.43. When Daniel was 22 weeks old a Child in Need meeting was held at the family home. The Children‟s Centre worker, the Social Care worker, the father‟s drugs worker and both parents attended. It does not appear that the health visitor or GP were invited to the meeting. There are no minutes taken of the meeting and professionals did not provide any written reports of their involvement. The process and outcome of the meeting are not documented in the chronology, although the father‟s addiction worker recorded that the plan was for the father to engage with the service to address his 10 Brandon, M et al. (2008) Analysing child deaths and serious injury through abuse: What can we learn? A biennial analysis of serious case reviews 2003-2005 . Research. Department for Children, Schools and Families. Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 20 use of illicit drugs and provide consistent negative tests. Any interventions by any of the practitioners to safeguard Daniel are not apparent, therefore the effectiveness of the Child in Need plan must be questioned. As highlighted by the Children‟s Social Care IMR the lack of management oversight and support is of concern. The case had been allocated to an unqualified worker, a core assessment had not been completed and the plan to safeguard Daniel appears to have entirely focused on the father‟s drug use. There is little apparent focus on the child‟s experience of day-to-day life or the way that the needs are being met. Daniel was a very young, vulnerable baby, entirely dependent upon the parents to provide for his needs. There is no apparent assessment of the parents‟ attitudes to or interactions with Daniel, nor any assessment of his attachment behaviours. 6 months – 1 year 4.3.44. By the time that Daniel was six months old his parents had moved into a new home. The mother‟s engagement with the Addiction Service was inconsistent although her methadone prescriptions continued. The father‟s engagement was better although his lack of candour about his heroin use was illustrated by positive drug tests when he had denied „on top‟ use of heroin. The Children‟s Centre worker continued weekly contact with the family until transfer to another Children‟s Centre had taken place. 4.3.45. Two weeks after the house move the mother called the police asking for the father to be removed from the house, however she then cancelled the call as he was leaving. The police attended the house the following day to conduct a „safe and well‟ check. The mother was present she indicated that she had asked the father to leave as he was not „pulling his weight around the house‟. Officers described the house as „immaculate and well maintained‟ and saw no evidence of drug abuse. It is unclear whether or not they saw Daniel or how much of the house they saw. The incident was assessed by the police safeguarding team and deemed low risk. Information was shared with Children‟s Social Care and the GP using a standard reporting method. 3rd Child in Need Meeting – Daniel 7 months old 4.3.46. A Child in Need meeting was held in the family home a month after the house move. It was attended by the Children‟s Social Care allocated worker, supported by a social worker, father‟s addiction worker, the Children‟s Centre worker, the health visitor and both parents. The focus of the meeting again appeared to be the parents‟ drug use. Accurate, detailed information about their attendance at Addiction Service appointments, drug screens, prescribing levels etc. was not provided. The parents claimed clear drug screens for six weeks but this was not confirmed and was in fact inaccurate. There was discussion about the incident to which the police had been called two weeks previously, but it is not clear whether the father was resident again or not. Daniel had been seen by the health visitor in clinic in the week prior to the meeting his growth and development were documented as satisfactory, and he was noted to be bright, alert and sociable. There is no apparent discussion of the domestic incident by the health visitor with the mother. Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 21 4.3.47. Two weeks after the Child in Need meeting the Children‟s Centre responsibility was transferred to another Children‟s Centre following a joint visit by workers from both. This provided a good opportunity for handover and continuity and was good practice. A care plan for engagement with the new Children‟s Centre was drawn up to cover the next nine months. At the visit the parents expressed keenness to attend groups and activities at the Children‟s Centre with Daniel. The health visitor and Children‟s Social Care worker were informed of the transfer, again this was good practice. 4th Child in Need Meeting – Daniel 8 months old 4.3.48. At the beginning of the next month, when Daniel was 8 months old another Child in Need meeting was held, attended by the Social Care worker, with the support of a social worker, the health visitor, father‟s addiction worker and the parents. There was no representation from either Children‟s Centre. The health visitor completed a developmental assessment on the same day and Daniel was noted to be meeting all developmental milestones. There was no evidence of significant progress of the Child in Need plan. The parents continued to deny illicit drug use to some practitioners in spite of positive drug screens. The impact on Daniel of his parents‟ lifestyle does not appear to have been robustly assessed by any of the workers. 4.3.49. Two weeks after this meeting the father was arrested in Scotland and charged with a drug offence, he was initially remanded in custody and the mother became the main carer for Daniel. There was good information sharing between the Addiction Service and Social Care. The allocated Social Care worker offered support to the mother which she declined saying that she had family support; the details of which were not pursued. There is no indication that other practitioners were informed, it would have been appropriate for the Children‟s Centre worker to have been told as they were in regular contact with the family and may have been able to offer more accessible support. 5th Child in Need Meeting – Daniel 10 months old 4.3.50. Another Child in Need meeting was held two months after the previous one; Daniel was ten months old. In the intervening period father had regular contact with the Addiction Service, the mother had only one brief contact at home when it had been inconvenient for her for a keyworking session and she had failed to attend a medical review; her methadone prescriptions were, however, maintained. The Children‟s Centre worker had repeatedly attempted to engage the family in a variety of activities but the family had not attended. The Social Care worker made one unannounced home visit although this appears to have been somewhat superficial. Daniel was seen at a child health clinic on the day before the meeting and was noted to be growing well. The meeting was attended by the Children‟s Centre worker, father‟s addiction worker, the health visitor and the parents. It was chaired by the Social Care worker. Although the parents‟ non-engagement in groups was noted by the Children‟s Centre worker details of invitations, attendance and non-attendance was not made available. It was noted that the parents continued to use illicit substances in addition to prescribed methadone, although details of frequency etc. was not provided. The aim of the plan continued to be „to ensure Daniel is cared for in a safe and secure environment and that the parents cease to use illegal substances‟, there appears to Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 22 be little detail that suggests that the plan was specific or measurable, other than the provision of safety equipment by the Children‟s Centre worker. A further meeting was planned for the next month. 4.3.51. Two weeks after the meeting the mother saw the GP to request an increase in her morphine prescription to manage her pain. It was noted that she had missed a specialist hospital appointment and was asked to follow this up. The GP IMR author suggests that in view of the pattern of missed appointments it would have been appropriate for the GP to have liaised directly with the hospital. On the same day the mother also attended an appointment with the drugs worker also complaining of pain she disclosed use of heroin to manage the pain. The father cited the mother‟s pain as a reason for them both using heroin. There is no indication of any communication between the parents‟ addiction workers or with the GP, all of which would have been appropriate. There was a failure of the practitioners to give full and appropriate consideration of Daniel‟s needs and welfare given that the mother was complaining of severe pain and both parents were using heroin possibly at the same time. It is possible that the pain level, as well as impacting on her drug use may have had an impact on her parenting capacity. 4.3.52. Prior to the next Child in Need meeting the Social Care worker discussed with the Children‟s Centre worker a plan to step down the case to a CAF level, rather than a Child in Need, therefore closing the case to Social Care, the suggestion was that the Children‟s Centre worker should be the Lead Professional. This plan had been agreed between the Social Care worker and the manager. The Social Care worker visited the family at home. The mother discussed her pain and the resultant need to take heroin as pain relief, she told the Social Care worker that the GP had prescribed paracetamol and ibuprofen which was insufficient pain control, she also complained that the GP was treating her differently because of her addiction. There is no indication that the Social Care worker was made aware that the mother was also being prescribed morphine by the GP. It would appear that the mother was not being entirely candid with the children‟s workers and it would have been appropriate for the Social Care worker to have liaised with both the mother‟s addiction worker and the GP or in view of the imminent Child in Need meeting invited the GP to the meeting or at least have sought information from them. 6th Child in Need Meeting – Daniel 11 months old 4.3.53. At the meeting, attended by both parents‟ addiction workers, the health visitor and Social Care worker, the Social Care worker proposed the downgrading of the case this suggestion was challenged by the mother‟s addiction worker. In view of the continued heroin use by both parents, the mother‟s poor pain control and the failure to attend any activities in the Children‟s Centre as previously agreed it was Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 23 considered that the parents were prioritising their own needs over Daniel‟s and therefore the Child in Need plan should be maintained. 4.3.54. The Social Care worker went on planned, extended leave soon after the meeting and the case was not reallocated and there was no Social Care intervention for the next five months. 4.3.55. The week after the meeting the mother saw her GP to discuss her pain relief, although information is gathered about the social situation there does not appear to have been detailed consideration of the impact of the mother‟s disability and drug use on her parenting capacity. The morphine prescription was issued monthly up to and beyond the scope of this review without any further medication review. There is no evidence of liaison with other involved practitioners. At the very least it would have been expected that the GP discuss the situation with the health visitor as part of the primary health care team. It would also have been appropriate for there to have been liaison with the Addiction Service to coordinate the opiate prescriptions and to consider alternative strategies for pain management. It was noted that the mother had a specialist hospital appointment in two months time; although it was known that she had previously failed to attend appointments there is no indication that this was addressed directly with her. This was a significant missed opportunity for a multiagency response to managing the mother‟s drug use, both prescribed and illicit. The GP had previously attempted to establish dialogue with the Addiction Service but with little success. A letter was received by the GP with respect to a medical review in the Addiction Service but not until four months after the consultation. The mother‟s addiction worker was also aware that the mother misused morphine by saving tablets on days that she took heroin, then taking double doses. Although it is documented that this is discussed with the mother there is no indication that there was any proactive response or consideration of liaison with the GP. On one occasion the mother informed the addiction worker that she was seeing the GP to further discuss the morphine prescription, there was no indication that this occurred. 1 - 1½ years 4.3.56. When thirteen months old Daniel was seen in the hospital Accident and Emergency Department with a bleeding lesion on the cheek. A referral was subsequently made by the GP for specialist treatment and after a single specialist consultation Daniel had day surgery to remove the lesion when 20 months old. 4.3.57. Over the next three months there was limited intervention with the family. The father continued to have mostly fortnightly contact with the addiction worker. The mother attended three Addiction Service appointments. Daniel was seen once in the clinic for an immunisation and observed to be growing and developing well. The Children‟s Centre continued encouraging attendance at groups and activities with limited success. Concerns about an uncovered pond in the garden were raised regularly by the Children‟s Centre worker but not addressed by the parents. Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 24 7th Child in Need Meeting – Daniel 15 months old 4.3.58. When Daniel was fifteen months old a Child in Need meeting was held. It was attended by the father‟s addiction worker and the Children‟s Centre worker, the Social Care worker was reported as arriving late for the meeting and there is no record of the meeting in the Social Care chronology and it does not appear that the meeting was documented in any way other than by the practitioners who attended. The mother claimed to be heroin free, no drug test had been documented for six months. The father was seen by his addiction worker on the same day, he tested positive for heroin. 4.3.59. Three weeks after this meeting both of the parents were seen by their respective addiction workers. They both disclosed heroin use again citing the mother‟s pain as the reason. 4.3.60. The following month the case was allocated to a new Social Care worker. A new health visitor saw the family at home and undertook a family assessment; the parents discussed their previous history and their drug use. The health visitor noted that the home was clean and tidy and that there were age appropriate toys for Daniel who was noted to be well apart from a cold. The health visitor was told that Daniel was to see the GP about this, although there is no record of this contact. The health visitor documented that she had detected a „stale smell of drugs in the home‟ there is no indication that she shared this observation with other practitioners or discussed it with the parents; it should have raised concern that Daniel had been exposed to substances in the home. Having been told by the mother that a Child in Need meeting was planned for the following day, although unable to attend the meeting the health visitor very appropriately contacted Social Care to ensure an awareness of the change of responsibility. 8th Child in Need Meeting – Daniel 16 months old 4.3.61. The Children‟s Centre worker and both of the parents‟ addiction workers attended the family home for a Child in Need meeting however it would appear that the Social Care worker failed to attend. The mother indicated that there were relationship problems, she denied any „on top‟ use of heroin, no drug test was done. The father disclosed continuing heroin use two or three times a week, a drug screen was positive for heroin. There is no record in the Social Care chronology of the meeting. 4.3.62. Three days later the police were called by the father after the parents had argued and the father had removed Daniel from the family home. Officers attended the address where Daniel and the father were and confirmed that Daniel was „safe and well‟. Officers visited the family home and saw the mother; they detected a strong smell of cannabis. The mother denied any use of Class A drugs but said that the father continued to use heroin. The incident was reported to Social Care using both the normal reporting mechanism and directly by telephone with the allocated Social Care worker. Both parents also independently contacted the Social Care worker about the domestic incident. The father indicated that the mother had accidentally struck Daniel. The following day the Social Care worker spoke to the father on the telephone; the father claimed to be drug free and that he and the mother had agreed that they would live apart and share the care of Daniel. There is no indication that the Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 25 Social Care worker made any attempt to see and assess the health and safety of Daniel in situ with either of the parents. 4.3.63. Two weeks after the domestic incident the father, accompanied by Daniel, was seen by his addiction worker, a drug screen had been positive to opiates, morphine, cannabis and methadone. There is no recorded comment about Daniel‟s welfare or presentation. On the same day the Children‟s Centre worker telephoned the mother, she complained that she had no pain relief but was not using heroin. The worker encouraged the mother to contact PALS11 presumably to seek advice about or possibly complain about the pain management by the GP. The mother agreed to attend „Play and Stay‟ at the Children‟s Centre. It is unclear whether the worker was aware of the extent of prescription of morphine as pain relief by the GP or the failure of the mother to attend specialist hospital appointments the purpose of which were to address the seat of the pain. There is no indication that the worker sought advice about this from any of the other professionals but responded to the mother‟s version of events. 4.3.64. Two weeks later the health visitor attended the family home for a prearranged visit, the father answered the door but had forgotten the appointment and access was denied; a follow up at the clinic was arranged for one week, they did not attend. It is not clear if the father was resident in the family home or visiting. 4.3.65. Two days later the mother contacted the police wanting assistance to remove the father from the premises, no offences were disclosed and no „domestic incident‟ referral was made. On the same day the mother requested a home visit by a GP who attended and prescribed antibiotics for her for a chest infection. It does not appear that there was any discussion about the „domestic incident‟ that day or the previous one of which the GP had been notified. It does not appear that issues of pain relief or the mother‟s failure to have a surgical procedure, because she had not wanted to stay in hospital, were addressed. 4.3.66. Two days later the mother‟s addiction worker visited the home. The mother was complaining of a chest infection and said that she was expecting a GP visit – none is documented. She denied any illicit drug use and requested a drug screen, no result is recorded. On the same day the Social Care worker visited the home, both parents were present, although there are no details in the chronology of the content of the visit it is recorded that the worker planned to hold a Child in Need meeting the following month with a view to closing the case. 4.3.67. The next day the Children‟s Centre worker visited the home both parents were present. Daniel‟s general development was reported as good. The mother said that she still had no pain relief but appeared to be coping well, it is ascertained that she had not contacted PALS. The father was claiming to have been heroin free. It is unclear whether the parents had reconciled or not. 11 Patient Advice and Liaison Service and NHS service that offers confidential advice, support and information on health-related matters Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 26 18 months until death 4.3.68. Three weeks later the mother was arrested for shoplifting, she was arrested and admitted the offence. She was subject of community resolution and paid for the goods therefore there was no further action. 4.3.69. Over the next three weeks Daniel, now eighteen months old, was taken by the mother to a „Stay and Play‟ group. Daniel had little interaction with other children but was said to have enjoyed the session, this was appropriate behaviour for a child of this age. The father attended an appointment with his addiction worker, he tested positive for heroin; he also disclosed regular cannabis use, including immediately before the appointment. Daniel was with him; it does not appear that the risks to Daniel were addressed. The worker discussed the possibility of detoxification and rehabilitation over the next year. On the same day the health visitor made a home visit and saw the mother and Daniel. Daniel was said to be well although had seen a GP the previous week – there is no record of this in the chronology. The health visitor was told by the mother of the planned Child in Need meeting the next week. The health visitor informed the Social Care worker that she would be unable to attend the meeting. 9th Child in Need Meeting – Daniel 19 months old 4.3.70. The father‟s addiction worker, the Children‟s Centre worker, the allocated Social Care worker, a student social worker and the parents attended a Child in Need meeting in the family home. It was noted that the parents‟ relationship had broken down and that the father was to stand trial in Scotland in relation to the drug offence the previous year. The detail of arrangements for the care of Daniel in light of the relationship split does not appear to have been addressed. The addiction worker had discussed an occasion when they had noted a strong smell of cannabis coming from the family home, the worker had not gained access to the home at the time and it is not clear of Daniel was present but it certainly raised the likelihood that Daniel would have been inhaling cannabis. This was the ninth Child in Need meeting and there was no indication that there had been any sustained change in the parents‟ behaviour or in their engagement with activities that would benefit Daniel. There was indication that Children‟s Social Care had wanted to move towards closing the case but this had not been supported by other practitioners and therefore remained open. The lack of clarity about the expectations of a Child in Need plan and the informality of the process resulted in difficulty in measuring change, progress or the reverse. The failure of practitioners to provide details of parents‟ attendance at appointments and groups, drug screens etc. also limited the opportunities to get a clear picture of their engagement. 4.3.71. The day after the meeting the mother attended a medical review at the Addiction Service, she claimed to have been drug free for two months but had used heroin two days previously, however it is recorded that she had tested positive in both of the two Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 27 previous months. A letter containing details of the contact was sent to the GP but not received until two months after the appointment. 4.3.72. The next day the father reported to the Social Care worker that there had been another domestic incident, the police were not involved, there was no follow up and it is not recorded whether Daniel was present. 4.3.73. The following week the father failed to attend an appointment with his addiction worker because he had been attacked. He was seen the next day by mother‟s addiction worker during a home visit to the mother. The father had injuries and appeared unsteady on his feet but did not want to report the incident to the police. The worker was unsure if the unsteadiness was due to the influence of drugs or the assault. The Social Care worker was informed and followed up with a home visit the following week. 4.3.74. Two weeks later the father failed to attend an appointment with his addiction worker, the reason given was that the mother had had surgery, this had also resulted in his prescription running out leading to several days of heroin use. He was due to appear in court in Scotland the following week. The Social Care worker spoke to the mother on the telephone and ascertained that she was recovering well from her operation and would be going to Scotland with the father; a family member would be caring for Daniel. There was no check made on the suitability of these arrangements. Details of the surgery were not recorded in either the GP or the hospital IMRs therefore the accuracy of the information cannot be confirmed. The lack of information may reflect on the completeness and quality of the IMRs. 4.3.75. A week later the Social Care worker telephoned the mother and was told that the father had been acquitted in Scotland. A home visit was made the following week when the worker observed the parents arguing in front of Daniel apparently because the father had stolen money from the mother, it would appear that they were living apart at this time. 10th Child in Need Meeting – Daniel 21 months old 4.3.76. Two weeks later, Daniel was 21 months old, a Child in Need meeting was held, it was attended by the Social Care worker, the Children‟s Centre worker, both of the parents‟ addiction workers, a manager from the Addiction Services and both parents. The mother‟s addiction worker provided details of negative drug screens over the previous three months, it does not appear that there was mention that there had also been positive tests or that the mother had disclosed heroin use on the previous day. The father also disclosed on-going heroin use. It was noted that the parents were living apart, Daniel was living with the mother and the father was having regular contact. It was noted that a core assessment had not been completed; there was further discussion of downgrading the case in spite of concerns about both parents‟ continued failure to remain abstinent, there were also concerns expressed about the mother‟s anger issues. It was noted that Daniel had benefitted from attendance at „Play and Stay‟, however attendance had been erratic, details of numbers of sessions Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 28 attended or missed were not made available. Details of the mother‟s ability to be the main carer for Daniel was not explored. 11th Child in Need Meeting – Daniel 22 months old 4.3.77. A further Child in Need meeting was held after six weeks, the parent‟s were still living apart and the mother was said to be coping well with Daniel‟s care. Both parents continued to use heroin, although the mother‟s use was said to be less than it had previously been, however she had recently disclosed some use of cocaine, there had been discussion of the mother engaging in a methadone reduction programme. It is noted in the meeting that the father‟s living accommodation was unsuitable for Daniel although there is indication that Daniel had already spent time there. The plan remained largely unchanged although the Social Care worker restated the plan to close the case to Social Care. It does not appear that the decision to downgrade the case from Child in Need was challenged by the practitioners present at the meeting. As identified earlier the health visitor was not formally invited to a number of the Child in Need meetings and therefore was not always present. In view of health visitors‟ responsibilities for the health and welfare of pre-school children it is essential that they are fully engaged in any interagency meetings relating to such children and should be standard invitees. It is well recognised that attendance by GPs at such interagency meetings is limited and health visitors can often helpfully act as a conduit between GPs and other agencies. 4.3.78. The Social Care worker visited the father in his home the following week and ascertained that it was unsuitable for Daniel to be there, although it is not clear whether or not the father acted on this. The father had started a driving job; this was seen as a positive development. The following week a Social Care Team Manager a completed a case closure summary. It was noted that a core assessment had not been completed and that there were continued concerns about the parents continued use of illegal drugs. There is no evidence of consultation with other professionals about the closure and it is unclear if they were informed of the closure. There do not appear to have been any significant changes effected by the Child in Need plan over the almost two years that it had been in place. 4.3.79. When seen the next day by his addiction worker the father confirmed that he was still in employment - this had prevented him attending an appointment and collecting his methadone prescription. He had moved back in with the mother and Daniel. There does not appear to have been any challenge of the father about him being employed as a driver, it must be questioned whether this was a safe occupation for him in view of his known use of illicit opiates, over and above his opiate substitution Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 29 programme, which would be likely to negatively impact on his driving ability and he would have been at risk of committing an offence. 4.3.80. A week later an ambulance was called to the family home where Daniel was found to be not breathing, transferred to hospital and declared dead on arrival. Daniel had been sleeping in the parents‟ bed. A large quantity of dried and drying cannabis was found in the house and a number of cannabis plants were found growing in the roof space. Both parents were questioned by the police and bailed pending post mortem examination. Post mortem toxicology seven months after the death indicated that Daniel had died as a result of heroin poisoning and both parents were arrested and charged in relation to Daniel‟s death. Hair samples indicated that Daniel had been exposed to cannabis, opiates, cocaine and amphetamines. In court hearings the father admitted manslaughter and the mother admitted „causing or allowing the death of a child‟ and a charge of manslaughter was not pursued. Both parents have been sentenced to custody. 5 Analysis 5.1. Serious Case Reviews provide the opportunity to consider complex cases with the benefit of hindsight and to have an overview of the involvement of a range of practitioners in the knowledge of the tragic outcome for the child. Neither of these is available to the practitioners engaged in providing the services for the family. Practitioners may be less able to see emergent patterns especially when they are engaged in the complex tasks of developing and maintaining relationships with parents and other professionals whilst ensuring that there is a clear focus on the safety and welfare of vulnerable children. Although the IMRs gave some consideration to some of the contextual issues facing practitioners involved with Daniel‟s family the individual context could not be explored because of the restrictions in interviewing staff. The Children‟s Social Care, Health Visiting and the Addiction Service IMRs identify high volumes of work and/or staff turnover and sickness as contextual issues that impacted on the case. In addition the addiction service was subject to restructuring and management changes, which can provide challenges for practitioners affected by transitions. 5.2. Daniel‟s death was the result of ingestion of a large quantity of heroin; no information was available to the review of the mechanism whereby Daniel accessed the drug. It also became evident through post-mortem hair strand analysis that Daniel had been regularly exposed to heroin and cannabis and occasionally to cocaine and amphetamine. None of the professionals involved with the family had foreseen the possibility of the child being given heroin by one or other of the parents or having access to it accidentally. However all professionals involved with this family were aware that both parents used illicit substances and both regularly admitted smoking both heroin and cannabis. There appears to have been insufficient consideration given, by all of the practitioners, to finding out about and challenging the parents‟ use of drugs in the presence of Daniel and therefore his exposure to secondary inhalation. Family members who visited the house were aware of a strong smell of cannabis, which must also have been apparent to professionals but was only documented by the health visitor. Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 30 5.3. Smoking of heroin is considered less harmful to the user than injection; it reduces the chances of contracting blood borne infections and drug overdoses and is therefore encouraged as part of harm reduction. This does not give any consideration to the potential impact on others of smoke inhalation. 5.4. Although the death of Daniel, in the way that it occurred, may not have been foreseeable the full extent of the potential risks were not acknowledged by all of the practitioners involved with the family. Daniel‟s death may have been avoidable had practitioners been more professionally curious, had more „respectful uncertainty‟12 and been more assertive in their approach to the family. This may have led them to look beyond the presentation of the parts of the home that they saw and see the other areas, notably where Daniel slept. They may have looked beyond Daniel‟s apparent well-being and given more thought to what life was like from Daniel‟s perspective. Although Daniel was developing normally and appeared happy and well loved there were sufficient indicators that the parents were unable or unwilling to change their lifestyle. Had Daniel survived, the parents‟ lifestyle would almost certainly have negatively impacted on the child‟s outcomes. In view of Daniel‟s age the risks of access to noxious substances should have been fully addressed. It was noted that the home was well presented and there was evidence of the availability of age appropriate toys, however it would appear that practitioners were insufficiently curious to inquire into Daniel‟s sleeping arrangements. Had they done so the immediate risks to Daniel may have been identified and his death prevented. There appears to have been insufficient authoritative enquiry about when, where and how the parents used their drugs and insufficient emphasis given to Daniel‟s safety. 5.5. It is recognised that parents who use drugs can and do parent their children well but substance use can negatively affect parents‟ capacity adequately to meet their children‟s needs13,14,15 and Brandon et al (2009) found that in a third of the Serious Case Reviews there was a current or past history of parental drug use16. As identified in Cleaver et al (2011) p43 “Research which explores the association between parental problem drug misuse and abuse suggests parental drug use is generally associated with neglect and emotional abuse (Velleman 2001). Parents who experience difficulty in organising their own and their children‟s lives are unable to meet children‟s needs for safety and basic care, are emotionally unavailable to them and have difficulties in controlling and disciplining their children (Hogan and Higgins 2001; Cleaver et al. 2007)”. A number of the known risk factors were in evidence in this family, probably the most concerning of which was the parents‟ apparent lack of will to work in an entirely open and honest way with practitioners from all agencies. The mother‟s lack of engagement was worse than the father‟s exemplified by her repeated failure to attend appointments with the Addiction Service and to engage 12 Laming, Lord, (2003) The Victoria Climbié inquiry: report of an inquiry by Lord Laming (PDF). Norwich: TSO p205. 13 Cleaver, H, Unell, I and Aldgate, J (2011) Children‟s Needs – Parenting Capacity (2nd Edition), London, TSO 14 Working Together to Safeguard Children A guide to inter-agency working to safeguard and promote the welfare of children (2010) HM Government, London 15 Velleman, T and Templeton, L (2007) Understanding and modifying the impact of parents‟ substance misuse on children, Advances in Psychiatric Treatment 13:79-89 16 Brandon, M., Bailey, S., Belderson, P., Warren, C., Gardner, R. and Dodsworth, J. (2009), Understanding Serious Case Reviews and their Impact: A biennial analysis of serious case reviews 2005 – 2007 London: Department for Children, Schools and Families Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 31 with activities in the Children‟s Centre with Daniel. However most health appointments for Daniel were maintained suggesting some prioritisation of his needs. Although the lack of engagement was recognised by practitioners it was often blamed on the mother‟s disability and level of pain and there was insufficient challenge by practitioners. Where expectations of actions, such as attendance at appointments and provision of urine specimens, were specified by practitioners there was no evidence of the consequences of non-compliance being clearly set out for the parents or followed through; there was a lack of authoritative response or escalation. The case was maintained throughout as a Child in Need, there were some indicators that suggested that Daniel was at risk of suffering significant harm but these were not extreme and Daniel was seen to be a child who appeared well and happy, who was developing well and for whom there were no glaring concerns, these concerns may have become manifest had Daniel survived. 5.6. The analysis of the circumstances of this case is considered in relation to a number of emergent themes. As Lord Laming said in his report in 2009 “ultimately, the safety of a child depends on staff having the time, knowledge and skill to understand the child or young person, and their family circumstances.”17. In this case there were a number of missed opportunities for practitioners fully to understand the Daniel‟s circumstances. Barlow and Scott report that: “a recent overview of the evidence about effective interventions for complex families where there were concerns about (or evidence of) a child suffering significant harm, showed the importance of providing „a dependable professional relationship‟ for parents and children, in particular with those families who conceal or minimise their difficulties”18. 5.7. Focus on the child 5.7.1. There is little information in any of the IMRs that provides a picture of what life was like on a day to day basis for Daniel. Descriptions, including those from family members, generally suggested that he was a well loved, happy and contented child who was growing and developing within normal limits. Many of the practitioners had access to the family home on a number of occasions. The standard of the home environment, especially once the family had moved, appeared good. This was commented on in the Police IMR “The home occupied by (the mother) was described by officers as well presented indeed „immaculate‟. Nothing seen in the home apparently indicated a chaotic or risky lifestyle”. It has been a feature of other Serious Case Reviews that home conditions have, on the surface, been acceptable but areas of the home not generally seen by visitors are not of the same standard. At the time of death Daniel was found in the parents‟ bedroom in which there was quantities of dried and drying cannabis and a variety of drug paraphernalia. It does not appear that the sleeping arrangements for Daniel were ever questioned or seen; because of the size of the house it was assumed that Daniel had a separate bedroom and that the upstairs would have been the same as the visible parts of the house. The Children‟s Centre worker provided the family with safety equipment and was persistent in repeatedly raising safety concerns about a garden pond; the parents‟ failure to address this should have been considered as a proxy indicator of their lack of cooperation. 17 Lord Laming (2009) The Protection of Children in England: A Progress Report, TSO Norwich p10 18 Barlow, J. with Scott, J. (2010), Safeguarding in the 21st century: Where to Now?, Dartington, Research in Practice. P24 Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 32 5.7.2. Daniel was seen a number of times by Addiction Service practitioners both in clinic and home settings but as identified in the IMR there is little focus on the needs of the child, there is no documentary evidence that indicates that practitioners were aware of his presentation or interactions between the child and his parents. Adult focussed practitioners cannot be expected to be able to assess fully parenting capacity but should be able to provide insight into the impact of the individual‟s substance use on their ability to meet the day to day needs of a child at different ages and stages of development. It is recognised that the focus of the Child in Need plans was to help the parents control their substance misuse so that they could focus on the welfare of Daniel but there are indications that this was not robustly managed. There was a lack of clarity about the need for regular drug testing, interpretation of the findings and monitoring of the engagement with the service. In the context of interagency working, engagement with an adult service can act as a proxy measure for the importance that the parents put on the need to modify their behaviour to meet the needs of their child. 5.7.3. The health visiting service contact was minimal, based upon universal service only, the mother‟s disability and substance use should have been sufficient to indicate that the family should receive targeted support19. The Children‟s Centre workers did focus on the needs of the child but there is indication that they were also sidetracked by the needs of the mother for example by intervening in accessing her morphine. 5.8. Working with Substance using Parents 5.8.1. It is well recognised that substance and alcohol misuse can have an adverse impact on parenting capacity, often because parents find it difficult to maintain a consistent focus on the needs of their children. The links between substance misuse and neglect are strong and substance misuse is often associated with other problems, especially adverse socio-economic circumstances. In this case the socio-economic circumstances were less of an issue than is often the case due to the mother‟s accident compensation, which allowed her to buy a house. It is also known that substance misuse can have a negative impact on parent-child attachment. Parents who use narcotics are often less emotionally available to their children. Substance misuse is also frequently associated with secrecy, denial, chaotic lifestyle and with criminal activity. It is also acknowledged that substance misuse services and child welfare services have different „professional missions‟ and inter-professional tensions are almost inevitable. Therefore close attention to the need for collaboration or, at a minimum, good communication between the services is vital. 5.8.2. Difficulties in maintaining engagement of adults who misuse substances with services are also well documented and to some extent evident in this case. Services seeking to help parents in meeting their parental responsibilities need proper engagement by the adults, however they may be viewed by the parents as intrusive and potentially threatening and their fears get in the way of full engagement. It is a difficult balancing act for practitioners from all services to develop and maintain a helpful alliance with the parent whilst retaining a child-centred focus. There is also a difference between the goals and timescales for the two services. Adult focussed substance misuse services work in the context of a chronic and long term problem where relapse may be considered as a stage in recovery whereas child welfare services need to respond 19 Department of Health (2009) The Healthy Child Programme – Pregnancy and the first five years of life https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/167998/Health_Child_Programme.pdf Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 33 to the acute safety needs of children and must consider the negative impact on their health and development whilst the adults address their own problems; the two timeframes may be at odds with one another. 5.8.3. In spite of the potential for difficulties there is evidence in this case that the different professional constructs of the adult focussed services and the child focussed services were not a major obstacle and there is evidence of instances of good information sharing between agencies and engagement in interagency working. This is exemplified in the consistent attendance by addiction workers at Child in Need meetings However there remains a need to ensure that the services work in a collaborative way and that practitioners have training, protocols, guidance and support to help them work in the „crossover‟ to provide services that are parent friendly, child centred and family sensitive. 5.8.4. It is possible that practitioners viewed the family in a different light to other parents who misuse substance because of their relative affluence. Many substance users come to the notice of statutory agencies because of criminal activity to finance their addiction and it is often these circumstances that contribute to the negative impact on children. These parents were able to access drugs without recourse to regular criminal activity. 5.8.5. Practitioners in all services accepted the mother‟s disability and consequential pain as motive for her on-going substance use. She often cited her pain as a reason for using heroin in addition to prescribed methadone and morphine. She also disclosed continued use of heroin during the pregnancy because she was unable to tolerate methadone due to sickness. The parallel prescription of two opiates was not managed in a coordinated way. Methadone is prescribed by Addiction Services as a means of risk reduction in use of illicit substances. As identified above (4.4.5/6) in a maintenance or substitution programme methadone is prescribed at a level high enough to prevent withdrawal symptoms from the illegal opiate heroin. In many circumstances heroin addiction develops through an individual‟s need to dull pain, often this is emotional pain. It is also recognised that people who are on methadone maintenance programmes do not gain pain relief from the opioid in the same way as those who are not opiate dependent20. The fact that the mother was „legitimately‟ suffering physical pain due to her injuries should have led to a more robust, specialist medical approach to pain management in collaboration between the Addiction Service the GP and a specialist pain management service. This may have improved the likelihood of her pain being managed in such a way that she would not have needed to misuse both prescribed and illicit drugs and have enabled her to focus on Daniel‟s needs. 5.8.6. The use of cannabis by both parents was known to all practitioners, a health visitor documented a smell of cannabis in the house, family members who visited the house indicated that it was ever-present but it appears to have been normalised by practitioners and not identified as a significant risk to the child. 5.8.7. One of the most obvious and immediate risks to the safety of young children when parents use substances is the potential of accidental ingestion. Home safety advice for all parents includes the need to keep all potentially dangerous substances away 20 Alford, D.P, Compton, P. and Samet, JH (2006) Acute Pain Management for Patients Receiving Maintenance Methadone or Buprenorphine Therapy. Ann Intern Med. 2006 January 17; 144(2): 127–134. Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 34 from children and in childproof containers. It should be the responsibility of all professionals involved with families to consider home safety issues and to raise these with parents at every opportunity. This is of particular importance for substance using parents who should be regularly reminded of the danger to children of the substances that they use. Prescribers and dispensers have particular responsibilities and part of the role of keyworkers in Addiction Services should be to offer advice about safe storage of medications and to regularly check that this advice is understood and acted upon. 5.9. Assessment 5.9.1. “The effectiveness with which a child‟s needs are assessed will be key to the effectiveness of subsequent actions and services and, ultimately, to the outcomes for the child. p viii”21; “Fundamental to establishing the extent of a child‟s need is a child-centred, sensitive and comprehensive assessment. p28”22 As suggested by these quotations good assessments are fundamental to identifying and addressing the needs of children. However assessment is a complex activity and the quality of assessment is key to the significant decisions that affect outcomes for children in both the short and long term. 5.9.2. Good assessment of the needs of children requires practitioners to take full account of all of the relevant information including the history of the parents. Information needs to be gathered but in order to understand how that information will impact on the health and welfare of children it needs to be analysed. In order to understand the impact that using substances will have on parenting capacity it is necessary to understand the pattern of use, the physical and emotional effects on the adults and to gain an understanding of the priority that the adult gives to their relationship with the substance in relation to other priorities. There is some evidence that parents whose „principal attachment is to a substance‟ may have difficulty in forming attachments with their children.23 In order to assess the parenting capacity practitioners have the challenge of overcoming the secrecy and denial that characterises much substance abuse. Parents who misuse substances perhaps have more reasons than most for being guarded in their sharing of information with professionals. Practitioners need to be able to develop sufficiently trusting relationships to be able to overcome the resistance and fully to understand the motivation and capacity of the parents to adjust their lifestyle to meet the needs and demands of a young child. 5.9.3. The need for support for this family was identified early on in the pregnancy by the Addiction Service and by the Police. It may have been appropriate for an early assessment to have been started using the Common Assessment Framework (CAF) but the addiction workers decided that a referral to Children‟s Social Care for a higher level assessment was required however this was delayed until after the twentieth week of pregnancy. A defined protocol for interagency involvement in the care of unborn babies where there are concerns about compromised parenting would provide a clear structure and process for pre-birth assessment. 21 Department of Health (2000) The Framework for the Assessment of Children in Need and their Families 22 Lord Laming (2009) The Protection of Children in England: A Progress Report , Norwich, TSO 23 Kroll, B and Taylor A (2003) Parental Substance Abuse and Child Welfare, London, Jessica Kingsley Publishers Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 35 5.9.4. The Initial Assessment completed by an unqualified worker in Children‟s Social Care was superficial and did not get a multiagency perspective of the family and, in spite of a number of workers being allocated to the case over a period of almost two years, a Core Assessment was not completed. Only one of the workers allocated to this family was a qualified, but locum, social worker and their contact was very short term. An assessment undertaken by a worker with the skills and knowledge of a qualified social worker, with the benefit of contribution from other professionals, may have taken more cognisance of the parent‟s own histories, included a better understanding of their substance use and its potential impact on the well-being of the baby and their capacity for change. The assessment may then have resulted in a more robust plan that recognised the potential risks to Daniel. Indeed the Children‟s Social Care IMR indicates that had the assessment been more comprehensive child protection procedures would have been initiated. This indicates a lack of appropriate management oversight at the time. 5.9.5. The significance of history of both of the parents does not appear to have been fully addressed. The father was known to have been abused as a child and there is indication that the mother had also. The social worker who was allocated the case for a month around the time of Daniel‟s birth made a referral to adult mental health services for counselling for both parents but this was done without consultation with other involved professionals and was not taken up by the parents. No other exploration or intervention was offered. Calder (2008) notes that care and control conflicts arise when: „Parents‟ own childhood experiences of adverse parenting leaves them with unresolved tensions which spill over into their adult relationships ...Their children are most at risk during the early months/years when they are most dependent and when they carry meanings for their parents associated with unresolved parental conflicts.”24 5.9.6. The pre-birth parenting assessment undertaken by the Family Centre worker focussed on the provision of basic care and followed a format. The outcome of this parenting assessment was the basis for a decision within Children‟s Social Care that it was safe for Daniel to be discharged home with the parents. This decision should have been based upon a multiagency assessment of the parents‟ history and current drug use and their ability to meet Daniel‟s needs. It would have been more appropriate for this decision to have been made at a pre-discharge planning meeting, probably instigated by the maternity service and attended by representatives of all of the agencies involved. 5.9.7. The assessment undertaken by the Children‟s Centre worker at the beginning of their involvement when Daniel was a month old was an example of good practice. The relevant factors that may have impacted on the parenting of Daniel were identified and it was noted that the parents were able to meet Daniel‟s basic needs and to provide sufficient positive interactions, love and emotional warmth. The assessment led to a clear support plan involving regular visits by the worker and engagement in activities by the family and the Children‟s Centre. The former outcome was met but the family did not engage in any activities and the requirement was dropped from the plan. The Children‟s Centre worker made numerous attempts to secure interagency collaboration with little success. When the Children‟s Centre allocation transferred 24 Calder, M. (2008) „Risk and Child Protection‟ in Calder, M. (ed) Contemporary Risk Assessment in Safeguarding Children. Lyme Regis Russell House. Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 36 due to the family move there was some handover but it appears that the new worker did not have access to all of the previously gathered information. 5.9.8. It would appear that the health visitor undertook limited assessment of the parents‟ parenting capacity, in light of the mother‟s reduced mobility it was identified that the father would be offering most of the care. It is not apparent that a family health needs assessment was undertaken by a health visitor until there was a change in allocation when Daniel was 17 months old. 5.9.9. The assessment, planning and intervention offered by the Addiction Service was based on a person-centred approach, each parent was considered separately and therefore there was no co-ordinated approach to assessment of risk and provision of services taking account of the two adults as part of a family. 5.9.10. The Child in Need meetings were the main vehicle for assessing the progress of the plan, however the plans were not well formulated, they lacked clear measurable targets or outcomes and when reviewed at subsequent meetings the information provided was not precise enough to assess progress or otherwise. Had the Addiction Workers provided clear details of treatment plans for the parents supported by data about drug testing and had the Children‟s Centre workers provided details of numbers of sessions attended or not, decisions about the effectiveness of the plan would have been more grounded. 5.9.11. Although practitioners were aware that Daniel had a sibling it does not appear that any consideration by any of the practitioners of their needs, safety and welfare whilst in the family home or of their impact on Daniel. Although the mother indicated that she was in receipt of support from her extended family the extent or suitability of this was not part of any assessment and was a missed opportunity. 5.10. Working with resistance and avoidance 5.10.1. Barlow (2010)25 states “Lack of cooperation on the part of families is a key factor preventing effective assessment and needs to be included as a key indication of risk in the assessment process. Lack of cooperation should be used to justify compulsory interventions" p57. 5.10.2. Daniel‟s parents were not overtly resistant to working with professionals, they allowed Child in Need meetings to be held in their home, attended most of Daniel‟s health appointments and responded to his health needs, although they were not always compliant with plans to meet their own needs. There was however evidence that they were not as compliant as practitioners thought they were. 5.10.3. There is little evidence that the parents had a full understanding or acceptance that there were specific requirements for them to significantly change their behaviour or their parenting styles. As identified by Horwath and Morrison (2001)26 using an adapted version of Prochaska and DiClemente‟s model of change there are a number of sequential elements of motivation necessary for genuine and lasting change, there is also the need for parents to have the capacity as well as the motivation to change. As identified above the lack of comprehensive assessment of 25 Barlow, J. with Scott, J. (2010), Safeguarding in the 21st century: Where to Now?, Dartington, Research in Practice. 26 Horwath, J and Morrison, T. (2001) Assessment of Parental Motivation to Change in The Child‟s World: Assessing Children in Need (ed Horwath, J) London, Jessica Kingsley Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 37 the parenting capacity meant that there was never a clear understanding whether motivation or capacity were present, nor was there real clarity about what changes were required. 5.10.4. One of the identified risks in working with resistant families is the tendency towards over optimism, small positive changes or lack of obvious negative impact on children are imbued with more significance than is justified. In this case the apparent close relationship between Daniel and his parents and the lack of obvious concerns about Daniel‟s health and development in particular distracted practitioners from the risks to the child‟s health and welfare in the longer term. The Child in Need plan throughout was focussed on the parents addressing their substance use. Later there was also a focus on home safety and providing opportunities for Daniel to attend activities, as identified above the plans were insufficiently robust to challenge the parents about their non-compliance with both of these issues. 5.10.5. The mother was probably more resistant than the father. She persistently failed to attend appointments with the Addiction Service, particularly medical reviews. Drug tests appear to have only been done when she wanted them. She resisted intervention by the Children‟s Centre worker to facilitate communication between the GP and the Addiction Service to regulate her medication in order to control her pain. In spite of pain control being the mother‟s stated reason for „on top‟ heroin use as well as prescribed morphine she failed a number of medical appointments with a specialist to address the underlying physical cause of the pain. The father often cited the mother‟s use of heroin as the reason for his continued use. 5.10.6. In order to overcome the resistance and lack of candour, practitioners need to have the skills to develop and maintain relationships and have a well developed capacity for empathy with adults whilst retaining a focus on risks to children. It is also well recognised that in order for practitioners to work in this way they need highly skilled supervision to provide additional insights on the family, space and opportunity for reflection in and on practice and emotional support to workers who are intervening with emotionally demanding families. 5.11. Interagency working 5.11.1. When interagency work in child welfare is successful it is likely to best meet the needs of children, families and indeed practitioners. It allows for the different areas of practitioners‟ expertise to complement each other, leading to an understanding of individual families‟ problems from a comprehensive perspective and to form the basis of effective cooperative action. The basis of good interagency work is knowledge and acknowledgement of roles and responsibilities based within a shared understanding of the needs of children and a clear agreement about what works to meet these needs. This is a constant challenge to practitioners who have competing demands and limited resources. When interagency working is a challenge practitioners need opportunities to explore the situation and their feelings within safe and skilled supervision. 5.11.2. There is evidence throughout the chronology of some good interagency working although some gaps are evident. The initial referral to Children‟s Social Care resulted in a fairly prompt result leading to an Initial Assessment. The failure to allocate the case for a Core Assessment led to significant drift and practitioners such as the Family Centre and Children‟s Centre workers were left unsure with whom they should Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 38 communicate about their concerns. A more assertive approach and the use of escalation procedures by the Family Centre and other practitioners could have resulted in a more timely allocation of the case. 5.11.3. Child in Need meetings were held throughout Daniel‟s life, albeit with significant gaps at times. Attendance at these meetings was variable and health professionals were often absent, sometimes due to failure to invite them. The value of these meetings was questionable. The plans that were drawn up were insufficiently detailed and outcome focussed to allow for measurement or evaluation of their effectiveness, or to provide sufficient challenge to parents. 5.11.4. There is evidence of some good communication between practitioners but there are a number of instances that can be characterised as „silo working‟. This was particularly evident between the Addiction Service and the GP. When the mother registered with the second practice, some efforts were made by the practice to establish communication with the Addiction Service and to address the concerns about parallel prescribing of opiates. However when this collaboration was not forthcoming it was not pursued and although information about medical consultations in the Addiction Service was passed to the GPs it was not received until many weeks after the review and was thus of limited use to the GP. There was also little evidence of collaborative working between the GPs and the health visitors. This is a working relationship that is often viewed by other agencies as a close one and there is an expectation of a regular flow of information and teamwork. The lack of an allocated social worker for much of the period meant that there was no one practitioner with a coordinating responsibility making silo working even more likely. 5.12. Management oversight and supervision 5.12.1. It is well recognised that in order for professionals to work successfully with families, but especially those who are challenging, resistant, avoidant and complex they need access to skilled, professional management and supervision. This is especially important where resources are stretched, caseloads are high and practitioners and managers are under pressure. The IMRs of each of the frontline services in this case give indications that this was the context in which they were working. 5.12.2. Supervision is defined by Morrison (2005)27 as “A process by which one worker is given responsibility by the organisation to work with another/other workers in order to meet certain organisational professional and personal objectives which together promote the best outcomes for service users and stakeholders”. It is recognised as having a number of functions including management oversight to ensure maintenance of standards, professional development and support; defined in Proctor‟s model as normative, formative and restorative with focus on meeting organisational, professional and personal objectives. In exemplary supervision the three elements are maintained in overall balance, although one may have to take precedence over the others in response to different circumstances. 5.12.3. There were a number of indicators that levels of management oversight and supervision were insufficient across agencies. Within Children‟s Social Care, the case was almost entirely allocated to unqualified workers and high levels of management oversight, support and guidance should have been expected but were 27 Morrison, T. (2005) Staff supervision in social care: making a real difference for staff and service users, 3rd ed. Pavilion, Brighton Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 39 not evident. Had there been more management oversight and challenge of the Child in Need plan the lack of progress may have been identified and a more robust plan implemented. The failure to complete a core assessment was not addressed and a manager considered it appropriate to close the case after two years of service involvement without the completion of a core assessment, without consultation with other professionals working with the family and without any real evidence that change had been effected by the parents sufficient to ensure Daniel‟s safety and welfare. 5.12.4. Different models of supervision are available for different practitioners and for some there is a differentiation between caseload management and professional (clinical) supervision. Children‟s Centre workers and Health Visitors for example bring selected cases for discussion with a supervisor. The choice of cases, albeit within an agreed framework, is determined by the practitioners. Where there has been normalisation thresholds for concern may be raised and risks may not be identified, practitioners may fail to recognise this and not bring such cases for consideration; supervisors must therefore be alert to this and employ strategies to overcome it. 5.12.5. A different aspect of management oversight highlighted is the need within Addiction Services for robust medicines management systems. 6 Lessons to be Learned 6.1. Assessment of parenting capacity is a complex task and made especially challenging when parents are not open and honest. It must take account of the perspectives of all practitioners involved with the family especially those who are in most direct and regular contact with the family. Assessments must be dynamic, not based on fixed views that may be over optimistic. “One of the most common, problematic tendencies in human cognition … is our failure to review judgements and plans – once we have formed a view on what is going on, we often fail to notice or to dismiss evidence that challenges that picture.” (p9).28 Assessments must be based not only on how children are presenting at the time of contact but also on what is known about the impact of parental behaviour on the long term outcomes for children. 6.2. It is essential that practitioners are supported by skilled supervision that supports them in the challenging tasks of working with families. When working with complex and challenging families especially when resources are limited and professionals feel pressured, it is essential that practitioners have access to skilled supervision to support challenge, reflection and professional development, but also to provide emotional support and opportunities for personal development. It is particularly important when practitioners feel overwhelmed and lack confidence, especially if this leads to a failure to take key decisions. Supervisors need to help practitioners to have a sense of direction, to keep them on track, especially giving thought to whether the current approach is working and to maintain a clear record of decision-making. Supervisors need to be able to stand back and have oversight of a case and have clear processes for regular review and follow-up. The management function of supervision must also be acknowledged and managers must exercise their responsibilities for monitoring standards of professional practice and addressing 28 Fish, S., Munro, E. and Bairstow, S. (2008) Learning together to safeguard children: developing a multi-agency systems approach for case reviews, London: Social Care Institute for Excellence. Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 40 deficits. Agencies need clear lines of management accountability for decision making and all managers and practitioners must be aware of them. 6.3. Practitioners in all agencies need to be reminded of the importance of comprehensive record keeping that maintains a focus on children and their welfare. Observations of children and their interactions with parents and other adults are essential for assessing attachment behaviours that are central to a clear understanding of the welfare of children. Detailed chronologies and analysis of the family and social history of adults who are parents are also an essential component of good safeguarding practice. Managers and supervisors in all services have a responsibility for ensuring that records are appropriately maintained and include analysis, in respect of the impact on the safety and welfare of children, of information that is gathered or received. 6.4. The dilemmas that different agencies face when working with parents who misuse substances cannot be underestimated. It is recognised that the best way to address these is through good interagency working. The systems need to be in place to support this collaboration with a clear understanding of the different roles, responsibilities and perspectives of the different agencies. Practitioners need to have the opportunities to understand one another‟s different responsibilities and to reflect on their own within a safe environment. This is supported by interagency training and other professional development activities. When parents are engaged with a service it is essential that in addition to person centred care there is a recognition of their role as a parent and if more than one family member is engaged there should be information sharing, cooperation and collaboration between practitioners – a “Think Family” approach 29; this should extend to the wider family. 6.5. The challenges of working with families who are resistant and avoidant also should not be underestimated. Practitioners need the skills and tools to assess parenting capacity and their willingness and capacity for change. Complexity is often also a feature of the lives of such families, making assessment even more challenging. In order to make these assessments and to offer effective interventions, practitioners require the skills to develop relationships and to maintain those relationships in circumstances when challenge is necessary. The same skills are also needed to maintain a collaborative working relationship with colleagues from other agencies when perspectives and priorities differ and challenge of the professional perspective or activity is required. There are times when this professional, interagency challenge needs to be supported by clear procedures to address them. Practitioners must be aware of and feel empowered to use such protocols as the Escalation Procedures. 6.6. Successful interagency collaborative working is underpinned by structures such as Child Protection Conferences and Child in Need meetings. It is essential that practitioners are given the opportunities and tools necessary to contribute effectively to these meetings. Procedures and guidance with respect to arrangements, including timescales, for convening of Child Protection conferences and other interagency meetings must be followed if they are to be effective in safeguarding children. Child in Need meetings should be given the same importance by professionals as Child Protection conferences and although it is appropriate for there to be less formality in 29 DCSF (2009) Think Family: Improving Support for Families at Risk Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 41 the process of the meetings it is essential that the relevant information is available to ensure robust planning to maintain the safety and well being of children. Recommendations The way that Daniel died may not have been predictable but may have been avoidable. Indicators identified by practitioners suggested that, although there were potential concerns for Daniel‟s long term well being, these did not amount to serious and immediate risk to him. From the information gathered in the Serious Case Review process there were lessons to be learned about the interventions with Daniel‟s family and a number of recommendations have been made as a result. The single agency recommendations, set out below, are those made by IMR authors and are subject to action plans to address them within the agencies. A multiagency action plan will be drawn up by Wolverhampton LSCB to address the multi-agency recommendations. 7 Interagency recommendations 1. To ensure improved outcomes for children Wolverhampton Safeguarding Children Board (WSCB) should endorse the recommendations and action plans of the individual agency IMRs and ensure that there is a robust mechanism for monitoring their implementation and evaluating their effectiveness. 2. To ensure the quality and effectiveness of Serious Case Reviews, no matter what methodology is used in the future, WSCB must ensure that partner agencies recognition of the importance of SCRs and allow authors and other contributors sufficient time and resource to complete IMRs or other reviews that are timely, of appropriate quality and are signed off by an officer/manager of sufficient seniority to ensure ownership of recommendations and to drive through implementation within the organisation. 3. WSCB should assure itself that all assessments that relate to safeguarding children are undertaken by appropriately qualified and experienced practitioners who are supported by appropriate levels of supervision. 4. WSCB should develop an interagency pathway and protocol for assessing the needs of unborn babies in all circumstances where there is the likelihood of compromised parenting. 5. To ensure interagency collaboration and provision of effective interventions WSCB in conjunction with the Adult Safeguarding Board should review and if necessary update the recently produced interagency guidance „Hidden Harm - parental substance misuse and the effects on children‟ and any guidance with respect to the „Think Family‟ agenda and ensure that there are mechanisms in place to assure themselves of their implementation and effectiveness. Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 42 6. WSCB should be assured by service commissioners that providers of drug and alcohol services to substance using parents have a safeguarding and a family focus as well as providing appropriate person-centred care. 7. WSCB should seek assurance from partner agencies that practitioners and managers are fully cognisant of procedures, guidance and best practice with respect to: a. thresholds for intervention at different levels b. assessment c. interagency communication d. record keeping including use of chronologies e. contribution, through attendance and provision of reports of appropriate quality, to interagency safeguarding meetings including Children in Need meetings as well as Child Protection conferences and that there is management oversight of their operation. 8. To improve outcomes for children and to ensure practitioners are appropriately skilled, WSCB should assure itself that training and other professional development opportunities are available to practitioners and managers/supervisors in partner agencies about how best to work with avoidant and resistant families and which provides an understanding of barriers to parental engagement and strategies to overcome these barriers. The impact of this should be evaluated by multiagency audit. 9. To ensure effectiveness of interagency working with children and families, WSCB should develop, disseminate and implement policies, procedures and guidance for practitioners and front line managers in partner agencies in respect to management of professional disagreements, professional challenge and appropriate escalation. Once implemented the effectiveness should be evaluated by audit. 10. To ensure effectiveness of interagency working with children and families WSCB should develop and disseminate practice guidance about the operation and multiagency contribution to Child in Need and other interagency meetings which includes standards for invitations, attendance, provision of reports, meeting notes, action plans and monitoring of progress towards clear, agreed outcomes for children. Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 43 8 Individual Management Review Recommendations 8.1. Wolverhampton City Council Children‟s Social Care 1. Specialist pre- birth Core Assessment which provides a balanced view of the history and functioning of the family together with ongoing specialist Core Assessments which provide analysis of the child‟s journey. 2. All children referred to Social Care, regardless of status to have a Core assessment together with genogram, eco-map30 and on-going chronology 3. Clear direction and task assistance to be provided by Managers to the allocated worker at the point of allocation. Evidencing good management oversight and agreeing timescales for review of service and actions throughout the involvement of Social Care with the family. 4. Chronological information to be formatted from the onset of intervention and continually updated and attached to Case File. 5. Workers to develop strategies that support them in planning and organising workload and completing timely assessments and plans. 6. Good communication between Key partner agency Managers and Social Care Managers. 7. Refocus Family Support to offer early intervention whilst also providing families known to Social Care the opportunity of accessing ongoing services without the need for Social Care as a part of a new multi-agency Family Support. 8. All cases referred to Social Care and held within the service to be assigned a worker who is qualified and skilled in the process of assessment and planning. 8.2. Wolverhampton City Council – Children‟s Centre 1. A complete record of case history to held electronically for all families 2. Family assessments are carried out on an ongoing basis and make use of information from other agencies 3. A consistent approach to case management is implemented across Children‟s Centres 4. Ensure a robust process is in place for the transfer of cases from one Centre to another to ensure continuity of provision and understanding of case history 5. Establish a protocol for the escalation of issues through management routes across Children, Young People and Family Support. 30 An Eco-map is a graphical representation that shows ecological systems in an individual's life Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 44 Health Services 8.3. Health Overview 1. Each health provider in the future submit one IMR of the services provided. This should include contributions from the different specialist departments e.g. Health Visiting, Paediatrics, Emergency Department and Maternity Services with authorship from the respective clinical specialities as appropriate and amalgamated into a single agency IMR for submission to avoid repetition and variance of recommendations. 2. All providers on receipt of a request for an IMR should nominate a senior officer on behalf of the chief executive to sign off and regulate quality and adherence to submission dates. Those tasked with authorship of an IMR or part of the IMR should be provided with dedicated, protected time to write their contribution and this should be monitored by the above senior officer 3. Once methadone is prescribed for unsupervised consumption, or even supervised when pharmacies are not open on a Sunday and at least one dose is given to take away, it is essential that advice is given and documented about safe storage to prevent accidental overdose, especially if there are children in the household. This should be the responsibility of all professionals involved including prescribers and dispensers (pharmacists). Health Visitors should include home visits as part of their planned intervention to families with under 5s where one or both parents is a substance user, a component of such intervention being to assess home safety arrangements. 4. All health practitioners working with families who are subject to interagency meetings (Team around the Child, Child in Need or Child Protection Conferences) should be fully involved in the care planning, provide reports of their involvement and ensure that details of meetings (minutes where available) are included in records. 8.4. Black Country Partnership Trust 1. All Addiction Service staff (including managers and medical staff) to attend Record Keeping Training to ensure clear and accurate recording, and filing of multi-agency minutes and care plans. 2. All Addiction Service staff (including managers and medical staff) to book on required safeguarding children‟s training 3. Review service policies and procedures to ensure child protection is incorporated appropriately, in particular the DNA, supervision, and „use on top‟ policies. Review basic documentation to ensure child protection is incorporated i.e. risk assessments and care plans. 4. More robust working arrangements between staff who are „key working‟ members of the same family. Restricted No information from this report may be used, copied or distributed without prior permission of WSCB Final 45 5. All staff (including managers and medical staff) to access clinical / safeguarding supervision in line with local and national policy. 6. Increase in family interventions 8.5. General Practice 1. Neonatal discharge summaries are scanned onto both maternal and new neonatal records 2. GP practices on receiving medical records of new patients, to ensure that records are complete, and to track and trace appropriately 3. Consideration is given to increasing collaborative working between Addiction Services and primary care, in patients with complicated needs 4. On ascertaining pertinent medical knowledge regarding parents, the GP ensures that the health visitor is engaged with the family 5. If a child is being looked after outside the nuclear family, there should be evidence in the records as to who has legal parental responsibility. 8.6. Royal Wolverhampton NHS Trust 1. Develop robust hand-over mechanism from maternity to health visiting service for vulnerable women 2. Increase staffing levels of Health Visitors in line with the national Health Visitor Implementation Plan and local action plan agreed by HEE West Midlands & Department of Health 3. Identified staff to undertake agreed level of safeguarding children training 4. Training Needs analysis to be conducted to assess need for additional training to practitioners involved in child in need plans in terms of responsibilities and expectations 5. Child in need minutes and recommendations to be included in the medical record/accessible via portal for access by other professionals. 8.7. West Midlands Police 1. To improve the identification, recording, evaluation and sharing of relevant safeguarding intelligence with partner agencies SERIOUS CASE REVIEW – CHILD A WSCB ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 1 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence 1a To ensure improved outcomes for children Wolverhampton Safeguarding Children Board (WSCB) should endorse the recommendations and action plans of the individual agency IMRs and ensure that there is a robust mechanism for monitoring their implementation and evaluating their effectiveness. WSCB Wolverhampton safeguarding Children Board (WSCB) SCR Committee to receive reports from each organisation on progress of IMR Action plans after 1, 3 and 6 months. Chair SCRC WSCB Board Manager March 2014 On Track First updated action plan reports received from agencies. Further updates to be requested within the agreed timescales. Continually updated action plan 1b All action plans to be signed off within 12 months Chair SCRC WSCB Board Manager September 2014 On Track Updates requested within agreed timescales. SCR Committee minutes reflect challenge and consideration of action plan. 2 To ensure the quality and effectiveness of Serious Case Reviews, no matter what methodology is used in the future, WSCB must ensure that partner agencies recognition of the importance of SCRs and allow authors and other contributors sufficient time and resource to complete IMRs or other reviews that are timely, of appropriate quality and are signed off by an officer/manager of sufficient seniority to ensure ownership of recommendations and to drive through implementation WSCB SCR Sub group to produce detailed specification for IMR authors Specification to be ratified by WSCB and by Chief Officers in all WSCB partner organisations with sign off to WSCB. At the inception of an SCR agreed revised specification to be sent out to Chief Officers of all Chair SCRC WSCB Board Manager January 2014 February 2014 February 2014 onwards On Track WSCB SCR Toolkit under development (currently in draft form). Anticipated sign off by SCRC in January 2014. To be presented to WSCB for ratification. WSCB SCR Toolkit is disseminated to all agencies following approval of the WSCB. SERIOUS CASE REVIEW – CHILD A WSCB ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 2 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence within the organisation. involved organisations 3 WSCB should assure itself that all assessments that relate to safeguarding children are undertaken by appropriately qualified and experienced practitioners who are supported by appropriate levels of supervision. WSCB Report to be received by WSCB at its next meeting, collating information from all partner agencies, confirming compliance with this recommendation and an action plan for addressing any deficits. WSCB to develop minimum standards for CP supervision (CP practice reflection) for use in partner agencies. Report to be received by WSCB at its next meeting from partner agencies confirming arrangements for supervision of staff undertaking CP assessments LPP Committee WSCB Board Manager End January 2014 January 2014 April 2014 On Track Update reports from all agencies requested in readiness for submission to the WSCB meeting to be held in February 2014. A set of standards is currently being devised by the LPP Committee. Multi-agency Minimum standards in place for CP supervision Report from the LPP Committee is submitted to the WSCB at its April meeting. 4 a WSCB should develop an interagency pathway and protocol for assessing the needs of unborn babies in all circumstances where there is the likelihood of compromised parenting. WSCB Multiagency task and finish group to be set up to develop protocol Protocol to be agreed by WSCB and incorporated into procedures WSCB Taks & Finish Group End March 2014 On Track LLP chair has drawn together draft protocol. To be disseminated to LLP membership for consultation and wider comment. Protocol in place which reflects expectations of all members of the partnership. SERIOUS CASE REVIEW – CHILD A WSCB ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 3 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence 4b Protocol to be launched with information disseminated to all relevant agencies and incorporated into single and interagency training May 2014 On Track See above. Protocol is embedded in practice and utilised effectively. 5a To ensure interagency collaboration and provision of effective interventions WSCB in conjunction with the Adult Safeguarding Board should review and if necessary update the recently produced interagency guidance ‘Hidden Harm - parental substance misuse and the effects on children’ and any guidance with respect to the ‘Think Family’ agenda and ensure that there are mechanisms in place to assure themselves of its implementation and effectiveness. WSCB Hidden Harm guidance to be reviewed and if necessary amended in light of the findings of this SCR Briefing sessions about the guidance to be provided for staff involved in providing services for families where substance use is an issue Develop specific interagency training for professionals working with families where substance use is an issue. Include lessons from this and other SCRs about the impact of substance use on parenting in all levels of interagency CP training Learning Development Committee July 2013 March 2014 March 2014 Completed Guidance reviewed, in response to the outcomes from the SCR. Practitioners guidance launched and briefing sessions commenced in July 2013. Bespoke multi-agency training devised by partner agencies which incorporate the findings from the SCR. Hidden Harm training materials incorporate lessons and findings from SCRs where children have suffered as a result of substance misuse. SERIOUS CASE REVIEW – CHILD A WSCB ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 4 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence 5b Regular Multi-agency case audits (MACA) to be undertaken with reports of outcomes and actions to WSCB and Wolverhampton Safeguarding Adults Board (WSAB) to evaluate the effectiveness of the guidance Board Managers – WSCB and WASB June 14 On Track A joint Children/adults process\model for undertaking MACAs to be developed and agreed. Ass the adults and children’s safeguarding boards are now under one head of service this work has started. Robust multi-agency audit process with a focus on the family/household. 6 WSCB should be assured by service commissioners that providers of drug and alcohol services to substance using parents have a safeguarding and a family focus as well as providing appropriate person-centred care. WSCB Wolverhampton Drug and Alcohol Team to report to WSCB at its next meeting to confirm (or report progress) that commissioned substance misuse services consider the needs of all family members who are service users and coordinate services for them Head of Service W-ton Drug and Alcohol Team March 14 Completed A new Integrated Safeguarding Framework has been developed and implemented by WSMS, in consultation with the commissioners, which provides all staff with a framework in which to understand, respond and along with partner agencies help meet the needs of vulnerable children and families. (See Integrated SERIOUS CASE REVIEW – CHILD A WSCB ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 5 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence Single Agency Action Plan for further details). Progress report to be submitted at the next meeting of the WSCB for consideration. . 7 WSCB should seek assurance from partner agencies that practitioners and managers are fully cognisant of procedures, guidance and best practice with respect to: a) Thresholds for intervention at different levels b) assessment c) interagency communication d) record keeping including use of WSCB WSCB to seek reports from partner agencies about their compliance or progress towards compliance WSCB to establish a rolling programme of deep dive multiagency case audits to evaluate compliance with guidance and best practice for each of the identified issues. QP Committee WSCB Business Manager June 2014 September 2014 On Track A mechanism to commence this process is currently being devised. Review processes via Section 11 audit scheduled to take place in April 2014. Outcomes from the Section 11 audit to be monitored via the QP Committee via the forward work plan for 2014. Robust QA committee work plan is in place that reflects effective oversight of partnership activity. Embedded QA indicators which are reflective of the partnership Learning Lessons Briefings are shared with the partnership as a result case audit activity SERIOUS CASE REVIEW – CHILD A WSCB ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 6 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence chronologies e) contribution, through attendance and provision of reports of appropriate quality, to interagency safeguarding meetings including Children in Need meetings as well as Child Protection conferences and that there is management oversight of their operation. 8 To improve outcomes for children and to ensure practitioners are appropriately skilled, WSCB should assure itself that training and other professional development opportunities are available to practitioners and managers/supervisors in partner agencies about how best to work with avoidant and resistant families and which provides an WSCB WSCB to commission a task and finish group to develop and disseminate procedures and guidance incorporating research evidence and good practice examples from other LSCBs WSCB Training subgroup to consider ways to incorporate issues of resistance and avoidance in all interagency CP Chairs of LPP and LDC WSCB Board Manager June 2014 June 2014 On Track LPP committee has devised process wherein other committees can identify key policies and procedures required for creation or review. Working with Resistant and avoidant families is scheduled for discussion at the January meeting of the LDC. Training programme is reflective of current good practice and meets the needs of practitioners and service delivery. Policies and procedures are reflective of legislation, guidance and protocols (national, regional, SERIOUS CASE REVIEW – CHILD A WSCB ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 7 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence understanding of barriers to parental engagement and strategies to overcome these barriers. The impact of this should be evaluated by multiagency audit. training. WSCB Training subgroup to develop and deliver training and other professional development opportunities, for example multiagency action learning sets in relation to working with resistant and avoidant families and to incorporate learning and examples of good practice into wider multi-agency training June 2014 local) 9 To ensure effectiveness of interagency working with children and families, WSCB should develop, disseminate and implement policies, procedures and guidance for practitioners and front line managers in partner agencies in respect to management of professional disagreements, professional challenge and appropriate escalation. Once implemented the effectiveness should be evaluated by audit. WSCB WSCB to commission a task and finish group to develop and disseminate procedures and guidance and to provide briefing sessions for professionals WSCB Training subgroup to ensure that management of professional disagreements and use of escalation procedures is included in multi-agency training at all levels. Use of procedures and guidance to be included in the rolling programme of LPP Committee QP Committee WSCB Board Manager June 2014 On track LLP are considering good practice examples of Escalation policies and a small T&F group is devising a draft to share for consultation. WSCB have overarching Escalation Policy SERIOUS CASE REVIEW – CHILD A WSCB ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 8 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence deep dive multiagency case audits identified in Recommendation 7 10 To ensure effectiveness of interagency working with children and families WSCB should develop and disseminate practice guidance about the operation and multiagency contribution to Child in Need and other interagency meetings which includes standards for invitations, attendance, provision of reports, meeting notes, action plans and monitoring of progress towards clear, agreed outcomes for children. WSCB Templates for invitations etc to be developed and implemented WSCB to commission an audit of attendance at and contributions to Child in need meeting LPP Committee QP Committee WSCB Board Manager July 2014 June 2014 On Track Practice guidance regarding CIN is being devised taking into consideration the new operating model which is being introduced by CSC in April 2014. The guidance will be in place by this time and ensure clarity for professionals CIN toolkit in place for all practitioners. SERIOUS CASE REVIEW – CHILD A SINGLE AGENCY ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 1 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence 1 Specialist pre- birth Core Assessment which provides a balanced view of the history and functioning of the family together with on-going specialist Core Assessments which provide analysis of the child’s journey. Children’s Social Care Assessing Families Training was commissioned and two Consultant workers trained to deliver training on a rolling basis to promote evidenced based practice. Minimum Standards policy for social workers and Managers regarding completion of assessment. Head of Children in Need and Child Protection. Training was commissioned in November 2011 Managers have received training in order to enable them to be champions. Two consultant Social Workers have been appointed and trained in delivering on-going Family Assessment Training to all qualified Social Work staff and to assist in the process of qualitative assessment completion. Completed This process is now embedded within the locality teams and training takes place throughout the year. A systematic and evidence based approach to assessments. This will improve the decision making and planning process for children prior to birth and enable quality plans to be constructed with parents. 2 All children referred to Social Care, regardless of status to have a Core assessment together with genogram, eco-map and on-going chronology Children’s Social Care Individual Action plan for each working highlighting core values and expectations. Managers to complete an Audit of one case per supervisee each week and when authorising Core Assessments. Head of Children in Need and Child Protection. November 2013 Completed Process started in March 2013 and is being reviewed on a monthly basis by Head of CIN & CP and Team Managers. In November all new CIN cases recive an assessment. All CIN cases have an assessment underway or completed. All CIN cases have a genogram/Ecomap 3 Clear direction and task assistance to be provided by Managers to the allocated worker at the point of allocation. Evidencing good management oversight and agreeing timescales for review of service and actions throughout the involvement of Social Care with the family. Children’s Social Care Internal Allocation Policy to be completed outlining accountability and expectations of both worker and Manager at the point of a case being assigned and thereafter. Head of Children in Need and Child Protection. July 2013 Completed ‘Steps of support’ approach has been incorporated into the CSC assessment policy and is being implemented by Social work staff and their supervisors. Confident Workers who with direction have a clear understanding of the presenting risks and are supported by the process of reflection in timely assessment completion and identifying action required. SERIOUS CASE REVIEW – CHILD A SINGLE AGENCY ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 2 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence 4 Chronological information to be formatted from the onset of intervention and continually updated and attached to Case File. Children’s Social Care Policy update outlining expectations of workers and Managers at the start of the child and family journey and thereafter. Head of Children in Need and Child Protection. July 2013 Completed Staff received briefing regarding undertaking chronologies. Chronologies are integral to each assessment for CIN Chronologies are available on each child’s case record. 5 Workers to develop strategies that support them in planning and organising workload and completing timely assessments and plans. Children’s Social Care Managers to task assist workers in completing assessments and plans. Managing diary commitments by smarter and more creative use of time management. Head of Children in Need and Child Protection. July 2013 Completed A training programme has been delivered across the CSC workforce with particular emphasis on organisational skills and prioritisation. This was linked to the inception of the ‘steps to support’ approach. Evidence via supervision and continuous professional development that staff have accessed the briefings and implemented the learning into their practice. 6 Good communication between Key partner agency Managers and Social Care Managers. Children’s Social Care Departmental policy will require updating and require agreement between partner agencies and Social Care in promoting effective communication particularly from manager to manager. Head of Children in Need and Child Protection/ Assistant Director CSC April 2014 On Track Implementation of the New Operating Model will impact on the current information sharing agreements and policies and procedures are in the process of being updated. Increased information sharing and confident challenge across the partnership and evidenced with supervision and multi-agency meetings. 7 Refocus Family Support to offer early intervention whilst also providing families known to Social Care the opportunity of accessing ongoing services without the need for Social Care as a part of a new multi-agency Family Support. Children’s Social Care The restructuring of Child and Family Support will need to offer a multi-agency approach focusing on early intervention together with access to specialist services when needed. Head of Children in Need and Child Protection. Head of Social Inclusion April 2014 On Track The New Operating Model will enhance the delivery of Family Support across the city . There will be enhanced working across the partnership with a specific family focus. To improve the process of supporting child in need, making the need to step up cases less likely whilst also improving the services offered when cases step down. SERIOUS CASE REVIEW – CHILD A SINGLE AGENCY ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 3 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence 8 All cases referred to Social Care and held within the service to be assigned a worker who is qualified and skilled in the process of assessment and planning. Children’s Social Care Allocation of all CIN cases Head of Children in Need and Child Protection. August 2012 Completed Despite a significant number of Child in Need cases being assigned to unqualified staff the process of reallocation to a qualified Social Worker was achieved in July 2012. All Child in Need cases were assigned to a qualified Social Worker 9 A complete record of case history to held electronically for all families within Children’s Centres Children’s Centres Guidance to be re-issued on the completion of electronic recording to ensure a complete case history. Where required re-training of practitioners to take place. CC Sustainability Manager Jan 2014 On Track Database systems have now been set up to enable appropriate recording. User training will be completed in January 2014 Database records have improved accuracy to be monitored through case file audits 10 Family assessments to be carried out on an ongoing basis, making use of information from other agencies. There should be clear links between the assessment and work undertaken with the family Children’s Centres CAF paperwork to be utilised as a basis for all assessments undertaken within the Children’s Centre Assessment training to be devised and rolled out to all practitioners working with families within Children’s Centres CC Sustainability Manager\Childcare Workforce & Equality November 2013 Completed CAF paperwork has been introduced as the basis for all assessments Training on Family Assessment has been organised through Safeguarding for 20 Number of practitioners trained Quality of assessment improves, monitored through case file audits and supervision records SERIOUS CASE REVIEW – CHILD A SINGLE AGENCY ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 4 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence practitioners within Children’s Centres Practitioners are now routinely updating assessments to ensure they reflect the latest work with families 11 A consistent approach to case management is implemented across Children’s Centres Children’s Centres Develop central policies and processes for the management of cases including supervision and case discussion CC Protocol Group January 2014 Completed Policy on supervision already devised and in place A separate policy on reflective practice and case management is in place Evidence through supervision records of in-depth case discussion Number of cases discussed over a 12 month period 12 Implement a robust process for the transfer of cases from one Centre to another to ensure continuity of provision and understanding of case history Children’s Centres Develop a central policy for the transfer of cases setting out the minimum expectations including a face to face discussion and transfer of the full file from one Centre to another CC Protocol Group December 2013 Completed Policy in place and implemented Random checks of files that have transferred from one Centre to another 13 Establish a protocol for the escalation of issues through management routes across Children, Young People and Children, Young People and Family Support Develop a protocol for the escalation of cases where barriers exist between teams through appropriate CC Protocol Group January 2014 Completed The policy is written and will be reviewed in April in line with Evidence in case notes of escalation protocol being SERIOUS CASE REVIEW – CHILD A SINGLE AGENCY ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 5 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence Family Support management channels the implementation of the new operating model principles enacted where appropriate 14 Written, factual, evidence based reports to be submitted by Children’s Centres to all CIN & CP meetings Children’s Centres Develop a protocol for the production and submission of reports to CIN & CP Meetings CC Protocol Group January 2014 Completed Protocol in place and being monitored through supervision Reports available in family file Evidence of reports checked as part of case file audits 15 To improve the identification, recording ,evaluation and sharing of relevant safeguarding intelligence with partner agencies West Midlands Police 1/Identify and form a task and finish group made up of PPHQ , PPU Intelligence, Safeguarding investigators, and other relevant staff to review the use of intelligence in PPU and on LPU. Findings to be presented to the Detective Supt Public Protection and the DHR/SCR Learning Group Detective Superintendent (CHILD) Public Protection Unit May 2013 Completed West Midlands Police have created the Central Referral Unit which receive all reports regarding the safeguarding of children whether generated by partner agencies or internally by front-line officers. The primary function of the CRU is to research any intelligence or information known regarding the relevant nominals and ensure that this information is shared with partner agencies in order to safeguarding children. Officers from the Public Protection Unit attend the Daily Effective information sharing across the PPU and partner agencies SERIOUS CASE REVIEW – CHILD A SINGLE AGENCY ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 6 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence Management Meeting of the Local Policing Unit (which operates 7 days a week) where all crime and incidents of note are reviewed; the role of the PPU officer to to highlight or recognise any safeguarding concerns. The Public Protection Unit (PPU) hold their own Daily Management Meeting (which operates 7 days a week) where intelligence is shared and allocated to the appropriate department to deal with a 24 hour feedback loop. The CORVUS computer system is now used across the force area to hold information on both victims and offenders in a 'one-stop' place called SEV (Single Enterprise View) which is a living document that is continually updated and available to all SERIOUS CASE REVIEW – CHILD A SINGLE AGENCY ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 7 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence officers across the WMP force area. 2/Identify strengths and areas to develop in the submission of intelligence to PPU through the current pathways; crime/non crime vulnerability page, IMS. Findings to be presented to the Detective Supt Public Protection and DHR/SCR Learning Group Detective Superintendent (CHILD) Public Protection Unit June 2013 Completed See above Effective PPU which delivers against WMP objectives 16 Neonatal discharge summaries are scanned onto both maternal and new neonatal records. All GP practices city wide CCG to send a letter to all city practices regarding a required activity. Lessons learnt bulletin to be sent to practices, once SCR is completed Team W training event update slot WCCG/NHS England End December 2013 On Track Correspondence has been sent to the CCG to request approval for the letter to be sent out. Initial training dates for GP level 3 safeguarding children have been arranged for 30.1.14 and 19.3.14. A letter , formulated by the Named GP for Safeguarding Children, is sent to all GP practices within Wolverhampton following approval by the CCG, to address the issues raised. Lessons learned bulletin sent to practices when SCR completed and reiterated through GP training. 17 GP practices on receiving medical records of new patents , to ensure that records are complete, and to All GP Practices city wide CCG to send a letter to all practices regarding a required activity Lessons learnt bulletin to WCCG/ NHS England End December 2013 On Track Correspondence has been sent to the CCG to request approval for the A letter ,,formulated by the Named GP for Safeguarding Children, is sent to all GP practices SERIOUS CASE REVIEW – CHILD A SINGLE AGENCY ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 8 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence track and trace appropriately. be sent, after completion of SCR ,to all practices Team W event training slot update letter to be sent out Initial training dates for GP level 3 safeguarding children have been arranged for 30.1.14 and 19.3.14 within Wolverhampton following approval by the CCG, to address the issues raised. Lessons learned bulletin is sent to practices when SCR completed and reiterated through GP training 18 Consideration is given to increasing collaborative working between addiction services and primary care , in patients with complicated needs GP lead for substance misuse and horizon house To develop a joint protocol , to enable collaborative working with complex patients WCCG/ addiction services End December 2013 On Track A meeting is to be arranged between the Named GP for Safeguarding Children and the Interim Safeguarding Manager Wolverhampton Substance Misuse Service (YP Team) to review arrangements for communication between addiction services and GPs. Liaison has taken place, awaiting confirmation of details for initial meeting. Meeting has taken place to establish protocols by which working together is improved. 19 On ascertaining pertinent medical knowledge regarding parents, the GP ensures that the health visitor is engaged All GP practices city wide CCG to send a letter to all practices regarding good practice CCG/ NHS England End December 2013 On Track Correspondence has been sent to the CCG to request approval for the A letter , formulated by the Named GP for Safeguarding Children, is sent to all GP practices SERIOUS CASE REVIEW – CHILD A SINGLE AGENCY ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 9 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence with the family. letter to be sent out within Wolverhampton following approval by the CCG, to address the issues raised. 20 If a child is being looked after outside the nuclear family there should be evidence in the records as to whom has legal parental responsibility. All GP practices city wide CCG to send a letter to all practises regarding good practice Lessons learnt bulletin to be sent after completion of SCR to all practices Team W event training slot update WCCG/NHS England End December 2013 On Track Correspondence has been sent to the CCG to request approval for the letter to be sent out Initial training dates for GP level 3 safeguarding children have been arranged for 30.1.14 and 19.3.14 A letter ,formulated by the Named GP for Safeguarding Children, is sent to all GP practices within Wolverhampton following approval by the CCG, to address the issues raised. Lessons learned bulletin is sent to practices when SCR completed and reiterated through GP training 21 Develop robust hand-over mechanism from maternity to health visiting service for vulnerable women RWT maternity and HV services Auditable tool and documentation to be developed, implemented Matrons for Maternity and Community Children’s Services End January 2014 On Track Audit Tool not yet implemented. Pathway & Policy devised for midwifery\HV handover. Referred to HV when mother 24 weeks pregnant by Policy & pathway for ratification. SERIOUS CASE REVIEW – CHILD A SINGLE AGENCY ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 10 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence the midwifery service. Ante-natal HV visits for vulnerable families. 22 Increase staffing levels of Health Visitors in line with the national Health Visitor Implementation Plan and local action plan agreed by HEE West Midlands & Department of Health RWT HV Service Recruitment and retention of staff to agreed staffing levels Matron for Community Children’s Services Process continues – annual agreed commissions annually agreed commissions On Track Student HV numbers continue to rise. 30 student HVs recruited for 2014. HV implementation plan 2015 completion. Evidence available from RWT HR. 23 Identified staff to undertake agreed level of safeguarding children training RWT Maternity and HV services Annual training needs analysis Training to be undertaken on an annual basis OLM database monthly compliance reports received Matron for Maternity Service Interim Head of Service for HV Service Summative evaluation March 2014 Completed Training database monthly update. All practitioners aware of their required level of training. Information sent to Head of Services. Appraisals with managers – needs identified Safeguarding Training Report produced for Trust JHSCG August 2013. 24 Training Needs analysis to be conducted to assess need for additional training to practitioners involved in child in need plans in terms of responsibilities and expectations RWT Maternity and Children’s’ Service Practitioners Discussions to be undertaken between Commissioners, Safeguarding Children Lead, Head of Nursing and Matrons for key services regarding the need for this action DSNSC, DSDSC, Heads of Nursing – Education and training and Division 2, and Matrons January 2014 On Track The Safeguarding Children training packages are currently under review by the Safeguarding children safeguarding team to ensure they are compliant with A number of discussions have taken place with the DSNSC by individuals resulting in liaison with the senior nurse for safeguarding children and the SERIOUS CASE REVIEW – CHILD A SINGLE AGENCY ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 11 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence Statutory Guidance, include local guidance and provision and meet the needs of health practitioners to enable them to carry out their role and responsibility to safeguard children. Named Nurses. The DSNSC has observed a number of sessions delivered by the Safeguarding children team. 25 Child in need minutes and recommendations to be included in the medical record/accessible via portal for access by other professionals RWT Children’s service Directorate to agree methodology with support from IT Dept.. Ratification by Clinical records Committee Clinical Director Children’s services February 2014 On Track Consultation with IT in the New Year. Medical records contain key documents that impact on delivery of service to children and their families. 26 All Addiction Service staff (including managers and medical staff) to attend Record Keeping Training to ensure clear and accurate recording, and filing of multi-agency minutes and care plans. Addiction Services Learning and Development Review existing training arrangements and adjust according to need. Report submitted to management on numbers of staff attending training Random Case file Audits Discuss and share concerns within team meetings. Service Manager Team managers Learning and Development November 2013 Completed 1. WSMS have completed 3x recording training seminars for all staff during November 2013. 2. WSMS have arranged 3x2 day safeguarding & child protection training courses for all staff, which will contain a session that specifically Records held within the service are accurate, complete and up to date SERIOUS CASE REVIEW – CHILD A SINGLE AGENCY ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 12 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence addresses the importance of clear and accurate record keeping. 3. WSMS have completed and circulated an Integrated Safeguarding Framework which has a section devoted to the importance of keeping clear and accurate records. 4. All WSMS managers are expected to raise on a weekly basis with all staff the importance of keeping clear and accurate case recording. 27 All Addiction Service staff (including managers and medical staff) to book on required safeguarding Addiction Services Learning and Development Review the existing in-service mandatory training and adjust according to need. Accommodate needs, Team Managers L & D NNSC On-going training Completed 1. All WSMS staff have access to a variety of online training from WSCB, NACRO, Training is addressed in supervision and staff are released toattend . SERIOUS CASE REVIEW – CHILD A SINGLE AGENCY ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 13 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence children’s training NNSC ensuring expectations of required levels are clear etc http://booking.wolvesscb.org.uk/online-booking http://www.nacro.skillgate.com/skg/topics/q.cfm?ses=7356&accesstype=eprog&ur=100285 2. Throughout October 2013, WSMS staff (including senior managers), attended a learning seminar on the outcome of the IMR re DJ (2013). Most importantly the seminars highlighted how all WSMS staff need to ensure their daily practice reflects lessons learnt and best practice. 3. All WSMS teams across the partnership are expected to SERIOUS CASE REVIEW – CHILD A SINGLE AGENCY ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 14 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence evidence weekly safeguarding meetings\safeguarding agenda items, where all live cases which have a safeguarding component are considered and risk updates provided. 4. During Jan-Feb 2014 all WSMS staff will be attending a 2 day safeguarding course which is built around W/T 2010 TG2 prescribed safeguarding training learning objectives, the outcomes of the DJ SCR (2013) and this action plan 2014. 28 Review service policies and procedures to ensure child protection is incorporated appropriately, in particular the DNA, supervision, and ‘use on top’ policies. Addiction Services Safeguarding Review and amend policies and documentation as required Liaise with NNSC to support. Service Managers SGC links NNSC October 2013 Completed 1. The new WSMS Integrated Safeguarding Framework developed in Policies reviewed and updated. SERIOUS CASE REVIEW – CHILD A SINGLE AGENCY ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 15 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence Review basic documentation to ensure child protection is incorporated ie risk assessments and care plans. consultation with the commissioners will provide all staff with a framework in which to understand, respond and along with partner agencies help meet the needs of vulnerable children. 2. The new ISF has now been approved by the WSMS partnership Management Board and has been circulated to all WSMS. 3. The new WSMS integrated CP policy highlightsthe importance for all staff to understand and follow the DNA procedure, which makes specific reference to SERIOUS CASE REVIEW – CHILD A SINGLE AGENCY ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 16 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence consideration of children within the family. 4. The issue of ‘Use on Top’ and its implications was a key learning point highlighted in all of the 4 IMR learning seminars carried out during 2013.. 5. The new WSMS safeguarding\child protection course will devote time to considering the implication of ‘use on top’. 6. WSMS is in the process of reviewing all its basic documentation to ensure that child protection is incorporated into both risk assessments and care plans. 7. WSMS now has in operation a 24 SERIOUS CASE REVIEW – CHILD A SINGLE AGENCY ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 17 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence hour management duty rota, which is accessible to all staff seeking support and guidance in all operational issues, not least safeguarding. 29 More robust working arrangements between staff who are ‘key working’ members of the same family. Strategies for the management of joint cases should be recorded where the situation is complex and children are involved. Addiction Services Review the current arrangements. Facilitate joint keyworker sessions, medical reviews and regular meetings to share information. Service Managers Team Leaders Medics October 2013 Completed 1. Throughout October 2013, all RNY staff (including senior managers), attended a learning seminar on the outcome of the IMR re DJ. The IMR seminars highlight how important it is that all WSMS staff need to ensure that their daily practice reflects the lessons learnt in DJ IMR and current best practice. 2. The new WSMS integrated CP policy highlights the importance of A more confident and competent workforce which understands the complexities of working with the whole family and shares information appropriately to improve outcomes. SERIOUS CASE REVIEW – CHILD A SINGLE AGENCY ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 18 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence all staff of evidencing in case recording the existence of close working relationships between keyworkers where both parents\different members of the same family are in treatment. 3. WSMS now has in place a safeguarding system of 4 DSP’s who meet regularly with the SM to monitor children and adults at risk. 4. Arrangements are now in place that on a fortnightly basis Social Care Staff attend a safeguarding meeting with WSMS staff, where a selected number of cases\CP practice issues are SERIOUS CASE REVIEW – CHILD A SINGLE AGENCY ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 19 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence discussed. 30 All staff ( including managers and medical staff) to access clinical / safeguarding supervision in line with local and national policy. Addiction Services Safeguarding Review the existing Clinical Supervision arrangements and guidance for staff Arrangements and expectations of practise to be made explicit Interim Safeguarding Manager NHS Clinical Managers Complete Completed 1. Until the end of 2013 the YP Senior Practitioner receives regular monthly 1:1 supervision from the Interim safeguarding manager. 2. From January 2014 onwards WSMS SM will receive monthly 1:1 clinical supervision from a registered independent safeguarding consultant social worker. 3. Staff in the YP team currently receive monthly safeguarding group supervision from the interim safeguarding manager. 4. Staff at Thornhurst House Supervision is embedded across the service area. SERIOUS CASE REVIEW – CHILD A SINGLE AGENCY ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 20 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence (Enterprise) receive 6 weekly safeguarding group supervision from the interim safeguarding manager. 5. From January 2014, all WSMS staff will receive bi-monthly safeguarding group supervision from a registered independent consultant social worker. 6. All other NHS staff currently receive clinical safeguarding supervision from NHS staff. 31 Increase in family interventions Addiction Service Safeguarding Continue to review and monitor safeguarding arrangements through identified leads and Effective Service meetings SGC leads Service Managers NNSC Ongoing Completed 1. WSMS have recently agreed and put into action a joint working protocol with children centres to actively and jointly The number of active family interventions is reflective ofgthe population served. SERIOUS CASE REVIEW – CHILD A SINGLE AGENCY ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 21 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence assess, identify and respond to identified need where children aged 5 and under live within a family. 2. As part of the general staff complement, WSMS have 2 fully training and 2 nearly training Family in Focus (FIF workers (Troubled Family Agenda). 3. WSMS are in the process of appointing a full time designated FIF worker. 4. WSMS are in the process of arranging a regional substance misuse forum to enable the sharing of best practice/focus of working with SERIOUS CASE REVIEW – CHILD A SINGLE AGENCY ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 22 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence families. 5. By developing an increasingly positive relationship with Social Care (including a multi-agency substance misuse conference of the Molineux 27.11.13 and developing social care involvement in regular partnership safeguarding meetings), and other local agencies, WSMS is actively promoting a ‘Think Family’ service to an increasing number of service users and affected others. Health Overview Report Recommendations 32 Each health provider in the future submit one IMR of the services provided. This should include contributions from the different specialist WCCG RWT BCPFT Single agency IMR to be provided Attendance at IMR training DSNSG DDSC Head of SGC February 2014 On Track Designated Doctor for Safeguarding Children is to inform key personnel within WCCG, RWT, Development of toolkit by SCR committee. SERIOUS CASE REVIEW – CHILD A SINGLE AGENCY ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 23 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence departments e.g Health Visiting, Paediatrics, Emergency Department and Maternity Services with authorship from the respective clinical specialities as appropriate and amalgamated into a single agency IMR for submission to avoid repetition and variance of recommendations RWT Director of SGC BCPFT BCPFT and NACRO regarding the development of the SCR toolkit. The toolkit includes a Quality Assurance checklist for managers. . SERIOUS CASE REVIEW – CHILD A SINGLE AGENCY ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 24 AP No Recommendation Organisation Actions Required Accountable Officer Timeframe for completion Status (RAG rate*) Progress Evidence 33 All providers on receipt of a request for an IMR should nominate a senior officer on behalf of the chief executive to sign off and regulate quality and adherence to submission dates. Those tasked with authorship of an IMR or part of the IMR should be provided with dedicated, protected time to write their contribution and this should be monitored by the above senior officer WCCG RWT BCPFT Senior Officer Nominated by providers Ensure adequate protected plan built into work plan at initial request of IMR Monitor submission dates and quality Executive lead for Safeguarding WCCG BCPFT RWT February 2014 On Track Designated Doctor for Safeguarding Children is to inform key personnel within WCCG, RWT, BCPFT and NACRO regarding the development of the SCR toolkit. The toolkit includes a Quality Assurance checklist for managers. Development of toolkit by SCR committee. 34 Once methadone is prescribed for unsupervised consumption, or even supervised when pharmacies are not open on a Sunday and at least one dose is given to take away, it is essential that advice is given about safe storage to prevent accidental overdose, especially if there are children in the household. This should be the responsibility of all professionals involved including prescribers and dispensers (pharmacists). WCCG RWT BCPFT Education for all prescribers and pharmacists Leaflet to be prepared for distribution to methadone consumers Exec lead nurse WCCG Des Dr WCCG Named Gp SC WCCG Exec Dir SC RWT, BCPFT End December 2013 On Track The Named GP for Safeguarding Children is formulating a leaflet in conjunction with the Interim Safeguarding Manager Wolverhampton Substance Misuse Service (YP Team). This will be shared with the GPs in the Shared Care Team, Pharmacists and Substance misuse team once the content format has been agreed Draft leaflet SERIOUS CASE REVIEW – CHILD A SINGLE AGENCY ACTION PLAN *RAG Rating: Red = Not commenced Amber = On Track with one month’s drift Green = Completed 25 |
NC046589 | Death of an 11-week-old girl in January 2013, as the result of serious injuries consistent with violent shaking. Post mortem found subdural and retinal haemorrhages and signs of damage to the brain and spinal cord. Skeletal survey revealed an old fracture to the left radius bone and another possible healed fracture in the same bone, believed to have occurred 6-8-weeks prior to the injuries leading to Child D's death. Father was found guilty of Child D's manslaughter. Mother experienced abuse in the family as a child and, as a result, was made the subject of a child protection plan in 2006. During the review process a number of professionals expressed concerns that mother might have a learning difficulty; none of the professionals who had been in contact with mother in the 5-years previously felt she had a learning difficulty. Findings from a detailed assessment following Child D's death identified mother as having an IQ score which placed her in the lowest 3 per cent of the population and identified significant difficulties with memory recall. Father was seen by GP as a young adolescent, in relation to problems with his temper, depressed mood and verbal aggression. Following the incident father admitted assaulting mother on two occasions, neither of which was reported to professionals prior to Child D's death. Following Child D's death, mother reported that Child D had been bruised on three occasions when in the care of father. One of these bruises was seen by four health professionals prior to Child D's death. Identifies themes including: how vulnerable young people who might need additional support when they become parents are identified and helped; the value of information, including social information, being held in GP records; engagement of the father and assessment of his role; professional responses to bruises in small babies; working arrangements between health visitors and GPs; and assessment of parental learning difficulties and their impact on parenting. Makes various recommendations.
| Title: Overview report: services provided for Child D and her family. LSCB: Luton Safeguarding Children Board Author: Keith Ibbetson Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Serious Case Review Overview Report Services provided for Child D and her family Luton LSCB Independent Chair Professor Michael Preston-Shoot Lead Reviewer Keith Ibbetson October 2015 2 Preface by the Chair of Luton Safeguarding Children Board Between March 2013 and June 2014 Luton Safeguarding Children Board conducted a Serious Case Review triggered by the death of an 11 week old baby who died as a result of injuries caused by shaking. The infant is referred to in this document as Child D. This report presents the full findings of the review of provision made by agencies in Luton and at Great Ormond Street Hospital in London. The publication of this report was delayed in order to ensure that it did not prejudice the criminal investigation into her death. Child D’s father was convicted of her manslaughter in July 2015. The functions of the Serious Case Review are to provide a rigorous analysis of the actions and decisions of professionals and to identify ways in which services for other children and young people can be improved. I am grateful for the cooperation of everyone who has supported the work of this review. It is a matter of regret that members of Child D’s family have not responded to offers to participate in the review. The findings of the overview report are presented in the following way: Part 5 of the report is an Executive Summary which provides an overview of the key events, findings and recommendations Parts 1 and 2 explain why and how the review was conducted Part 3 gives a detailed narrative which will enable readers to understand the key events, decisions and actions taken. It also contains a critical appraisal of the services provided highlighting both strengths and shortcomings. This will be of particular interest to those who work within or manage similar services. Part 4 provides a full explanation of the most important findings of the review. Some are findings directly relevant to the death of Child D. Others refer to wider learning for services to safeguard children. I hope that by setting out the report in this way it will be possible for readers with different objectives to find the information that they need. Alongside this report the LSCB has published a formal response to the findings of the Serious Case Review and a plan setting out in detail the actions that agencies and the board have taken since 2013 to improve services. Professor Michael Preston-Shoot Independent Chair Luton Safeguarding Children Board October 2015 Services provided for Child D Serious Case Review Findings 1. Arrangements for the Serious Case Review 1 2. Method used to undertake the Serious Case Review 6 3. Narrative of events 9 4. Evaluation of the services provided and the wider implication for professional practice and service provision 26 4.1 Introduction 4.2 How vulnerable young people who might need additional support when they become parents are identified and helped 26 4.3 The identification of risk or vulnerability in relation to Child Y (Child D’s older half-sibling) 30 4.4 Support and help provided in relation to Child D’s medical condition 32 4.5 Engagement with the father and assessment of his role 33 4.6 Professional responses to bruising in small babies - the recognition of possible signs of abuse of Child D and the action taken by professionals 35 4.7 Working arrangements between GPs and health visitors in relation to the 6-8 week health review and other aspects of the Healthy Child Programme 43 4.8 Access to urgent and emergency health care in Luton for babies and small children 47 4.9 Assessment of parental learning difficulties and their impact on parenting 49 5. Summary of findings and recommendations 52 Appendices I Membership of the SCR review team 55 II List of documents and material considered by the SCR review team and roles of professionals who have contributed 56 III Principles from statutory guidance informing the SCR methodology 57 IV References 58 1 1 ARRANGEMENTS FOR THE SERIOUS CASE REVIEW Introduction 1.1 This report was prepared for Luton Safeguarding Children Board (the LSCB) in order to fulfil the requirements of the statutory guidance Working Together to Safeguard Children 2013.1 The guidance sets out the arrangements for the local interagency review of serious child protection cases. The LSCB is required to identify opportunities to improve the provision that is made for vulnerable children. This overview report provides a public statement of the findings of the Serious Case Review (SCR). In keeping with statutory requirements the LSCB has published the SCR overview report in full. Reasons for conducting the SCR 1.2 The SCR primarily concerns the provision made by health agencies to an infant (referred to as Child D) who died in January 2013 at the age of 11 weeks. 10 days before her death Child D had been admitted to the local general hospital with injuries which gave rise to strong suspicion of serious physical abuse. She was then transferred to Great Ormond Street Hospital (GOSH). The infant was already known there because immediately after her birth Child D had received surgical treatment for a medical condition that had been identified during pregnancy. 1.3 Post mortem examination of Child D confirmed three findings that are strongly associated with injury caused by violent shaking: subdural haemorrhages; retinal haemorrhages and signs of damage to the brain and spinal cord.2 1.4 A skeletal survey undertaken shortly after the serious injuries were identified revealed an old fracture at the lower end of the left radius bone (the forearm near the wrist) and another possible healed fracture in the same bone. In children such injuries are often found to have been caused by abrupt pulling, twisting or swinging, though in Child D’s case the family court has ruled that their cause could not be determined. 1.5 These injuries are believed to have occurred 6 – 8 weeks before the serious injuries that caused Child D’s death. They would not have contributed to the child’s serious illness or death. They would also not have been noticeable in the course of day to day contact with the baby or during the routine medical examinations that Child D underwent during this period. The existence of these injuries is however central to the findings of the SCR because if other signs of possible abuse had been 1 HM Government, Working Together to Safeguard Children – 2013. Chapter 4. This guidance has been superseded, but this has no significant implications for the review 2 That is 1) bleeding into the space between the brain and the skull; 2) bleeding in the back wall of the eye and 3) damage to the brain. Among clinicians and in the courts there continue to be differences of opinion as to whether this ‘triad’ of symptoms can be viewed as diagnostic of such injuries. However in this case there was a consensus among the expert medical witnesses who provided evidence for the care proceedings that injuries caused by shaking had caused the death. 2 reported and investigated these injuries are likely to have been identified. The reasons for this are set out in full in Section 4.6 of this report and in its conclusions in Section 5. 1.6 Child D had an older half sibling (subsequently referred to as Child Y). After the death of Child D the local authority made a successful application for a Care Order in relation to this child. In these proceedings the court found that the injuries that caused Child D’s death were inflicted by her father, but that he did not injure her intentionally. This finding and others made during the course of these proceedings have informed the SCR. 1.7 The SCR has reviewed the provision that was made for Child Y who had for a number of years received services because of concerns about her behaviour and development. There had been no identified safeguarding concerns in relation to her, she had not been the subject of a child protection plan and she had never been in care. 1.8 Working Together 2013 states that the LSCB in the area where the child lived should conduct a SCR when a child has died and ‘abuse or neglect is known or suspected’.3 The circumstances described fit this criterion and the LSCB decided to conduct a SCR. The recommendation to hold the SCR was made by the LSCB SCR group meeting on 11 March 2013. The independent chair of the LSCB Professor Michael Preston-Shoot immediately made the decision to undertake the SCR. Work began at that point to agree the scope and focus of the review. The scope and focus of the Serious Case Review bearing in mind the circumstances of the death and the involvement of agencies with other family members 1.9 The purpose of the SCR is to provide a ‘rigorous, objective analysis’ of the services that were provided to the child and family ‘in order to improve services and reduce the risk of future harm to children’. The LSCB is required to ‘translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children. 4 1.10 It is for the LSCB to determine the scope and focus of the SCR. In its initial discussions the team conducting the review agreed that the SCR would focus on the following areas: The steps taken to identify and assess the mother's vulnerability and parenting capacity (including the impact of possible learning difficulties) The extent to which the father engaged with services The provision made in response to the identified emotional and behavioural difficulties of the older half-sibling (Child Y) 3 LSCB Regulations 2006 (Regulation 5) 4 Working Together 2013 4.1 and 4.6 3 The provision made for Child D and other family members up to the point when the serious injuries were identified Any vulnerability arising from Child D’s pre-existing medical condition and the care provided in relation to this The response of professionals to any indicators of risk identified in relation to Child D. These were not fixed terms of reference. During the course of the SCR it became clear that the following aspects of provision should also be addressed: The arrangements in Luton for the 6-8 week child health assessment The arrangements for access to emergency and urgent health care in Luton for babies and small children 1.11 These matters are considered either because they were found to be significant in relation to the outcome for Child D or because evaluation of them helped understand services for children more widely. In each part of the evaluation (Section 4 of the report) the focus of the finding is made clear. 1.12 The review has considered both the work of individual agencies and multi-agency working and it has sought to understand the role that individual, professional and organisational factors played in shaping the actions taken and decisions made. The task of the SCR is to understand the reasons for any strengths or shortcomings in services. Findings and recommendations 1.13 The SCR has made recommendations to individual agencies or to the LSCB on areas where services can be improved. Some are simple practical steps. In some instances the SCR has produced findings which require further work by the LSCB and member agencies before deciding what action to take. Alongside the publication of the SCR report the LSCB has published a statement setting out the action that the LSCB, member agencies in Luton and Great Ormond Street Hospital have taken in response to the review and how the steps taken will impact positively on services for children. Key periods of agency involvement covered by the SCR 1.14 The SCR has taken account of events during the period between 2007 (the mother’s pregnancy with Child Y – the half sibling) and January 2013 (the admission of Child D to hospital with serious injuries). The review has concentrated most attention on the period between April 2012 and January 2013. It does not consider events that occurred after it had been identified that Child D had been seriously injured. 4 Agencies involved 1.15 The SCR considered the work of the following agencies and contracted professionals. Those with the most significant involvement with the family actively participated in the review: Luton Clinical Commissioning Group (formerly Luton PCT and NHS Luton) – which commissions health services in Luton Cambridge Community Services NHS Trust – which provides community health care for children in Luton, including health visiting services A playgroup; a nursery and a school (all in Luton) attended by Child Y Luton and Dunstable University Hospital NHS Trust – which provided midwifery, child health and emergency department services GP surgeries, the GP Urgent Care Clinic (located at the general hospital) Great Ormond Street Hospital NHS Foundation Trust – which provided surgical services Bedfordshire Police (background information) East of England Ambulance Trust Cambridge University Hospitals NHS Foundation Trust – which provided a specialist ambulance service. The SCR review team 1.16 A full list of the roles and job titles of SCR review team members is set out in Appendix 1. Review team members are experienced clinicians or managers in member agencies or designated health professionals with substantial experience of safeguarding children. Keith Ibbetson acted as lead reviewer and prepared this report on behalf of the review team. He does not work for any of the agencies involved in the review or have any relationship with those involved in the case. He is an experienced SCR author and chair. 1.17 The review team met on six occasions to conduct the review. Review team members were involved in carrying out interviews with professionals who had been involved with the family. Section 2 of this report contains details of the steps taken to conduct the review. Parallel processes that have impacted on the conduct of the SCR 1.18 Bedfordshire Police conducted a criminal investigation into Child D’s death. The review team has been kept informed of relevant information gathered during the course of the investigation. The local authority obtained a Care Order in order to safeguard Child Y (the surviving half-sibling). 1.19 The SCR review team has sought advice from the police and the local authority legal department in order to ensure that the review does not prejudice the legal or civil proceedings. Information from the fact finding 5 civil hearing has informed the SCR findings. The way in which this has been done is described in Section 2 of the report. Agreed extensions to the normal timescale for completion of the SCR 1.20 The SCR has taken longer to complete than the six months set as a guide in Working Together 2013. This was due to a number of factors including the time taken to receive the full post mortem examination findings (which is normal in such cases) and the need to involve a professional who was critical to the review findings who now works overseas. 1.21 The LSCB agreed to delay completion of the report in order that it could consider the findings of the care proceedings. This has enabled it to take account of evidence provided by the parents about events and the full range of expert opinion, both of which have been tested in detail by the court. 1.22 The Independent Chair of Luton LSCB and central government have been briefed about the progress of the review. The LSCB Executive and participating agencies have taken action on areas where immediate concerns about practice were identified during the review process. Involvement of family members 1.23 The mother and father of Child D were informed about the decision to undertake the SCR via their solicitors and invited to contribute. Neither solicitor responded to or acknowledged the correspondence. It was recognised that it was always unlikely that the parents would wish to contribute at a time when to do so might prejudice their position in relation to the care proceedings and to the criminal investigation. Neither wished to contribute after the trial. This has meant that the SCR has been unable to learn from their experience of involvement with services or test their accounts of events. Agreement of the SCR findings and arrangements for publication 1.24 A draft SCR overview report was discussed by the SCR review team and agreed after amendments. The findings of the review have been discussed with staff who were directly involved. The report has been agreed by participating agencies. It was presented to Luton LSCB on 18 June 2014 and accepted by the Board. 6 2 METHOD FOR UNDERTAKING THE SERIOUS CASE REVIEW 2.1 Working Together 2013 sets out principles that should inform the methodology for SCRs. These are reproduced in Appendix 3 and the review has sought to adhere to them. The review process and methodology 2.2 The review was conducted by a team consisting of the independent reviewer, designated health professionals employed by Luton Clinical Commissioning Group, senior staff (Named Nurses, the Named GP and Named Professionals) employed by the main health bodies that had worked with Child D and her family and members of the Luton LSCB Business Unit. Full details of the roles of review team members are set out in Appendix 1. None of the members of the review team had had any previous contact with Child D or other family members. Initially meetings of the review team were led by the lead reviewer. Later meetings were chaired by a senior representative member of a local agency which had had no involvement with Child D in order to provide additional scrutiny of and challenge to the findings. 2.3 The review team compiled a chronology of key events based on the written and electronic agency records. 2.4 Members of the review team conducted interviews with key staff who had been involved with the family and with senior representatives of the agencies who could advise on agency policy and organisational matters. The roles of those interviewed are listed in Appendix 2. The intention was to understand as fully as possible the actions that had been taken and the reasons for them. The review sought to understand events as they had been perceived and experienced by the professionals involved at the time. 2.5 Transcripts and detailed notes of the interviews were discussed at meetings of the review team. The team also reviewed copies of some individual case records and background documents. A meeting between two review team members and key early years and school staff was digitally recorded. The record of this meeting (which related to Child Y) and local authority notes relating to behaviour support and education services were additionally reviewed by Luton Borough Council’s Principal Educational Psychologist in order to provide further expert scrutiny and challenge. 2.6 A decision was made to delay the completion of the review in order to enable it to take account of the findings made by the judge in the care proceedings. This was done so as to ensure that 7 the review was able to take account of all of the information that had become available and of the findings of fact made by the judge. The SCR has not had the opportunity to make any independent assessment of the evidence presented in the court. 2.7 The lead reviewer prepared a draft copy of this report which was discussed at a review team meeting. The findings of the review were then discussed at meetings with staff and managers who had been directly involved. 2.8 The revised overview report was circulated to participating agencies for formal comment and agreement before being submitted to Luton LSCB for discussion and agreement. Camden LSCB has also considered the findings. The framework for making judgements about the actions and decisions of professionals 2.9 Self-evidently there is value in reviewing the history of a case, knowing the outcome and with a fuller knowledge of events. However along with the clarity that hindsight brings the review has been aware of the danger of what is termed ‘hindsight bias’. This arises when the evaluation is unduly influenced by knowledge of the outcome because ‘looking back the situation faced by the clinician is inevitably grossly simplified’.5 2.10 It is easy to criticise the decisions and actions of professionals because they can now be seen to be part of a chain of events that had a tragic outcome. If decisions and actions are judged out of the context in which they occurred it is likely to reduce the value of the investigation. More valuable learning can be obtained by seeking to understand and explain why decisions were made and actions taken taking full account of the influences over professionals arising from the context within which they were working. The SCR has therefore sought avoid hindsight bias. 2.11 In keeping with this approach judgements about actions and decisions take into account the information that was available to the professionals who took them. At certain points it is necessary to evaluate the overall service provision in relation to information that was known to the network of professionals as a whole or ought to have been available if relevant information had been shared. 2.12 The review has been particularly mindful of the danger of hindsight bias in making use of information from the care proceedings, since the court has had the advantage of material 5 Charles Vincent (2010) Patient Safety (second edition ) Wiley-Blackwell BMJ Books, pages 50-52 8 (including admissions made in evidence to the court) that was not previously known to professionals. The report therefore distinguishes clearly lessons based on professional knowledge at the time and information that is now known. 2.13 The review has sought to judge the actions of professionals and agencies against established standards of good practice as they applied at the time when the events in question took place. Nevertheless where the actions of individuals, groups of professionals or agencies as a whole are found to fall short of established professional standards this will be stated, together (where it can be established) with an explanation of why that happened. An organisational or systems approach 2.14 As well as focusing on the actions of the individuals who were directly involved with the family, the SCR has tried to understand and distinguish the influence of a range of organisational factors in the decisions and actions taken. The additional focus on the team, the service, the agency as a whole and the collective actions of agencies together does not diminish the responsibility of individuals to act professionally and to work effectively. It explains the factors that sometimes make it harder for them to do so. Recognition of strengths in professional practice 2.15 Research points to the value of identifying strengths in practice, ordinary things that were done well and the steps that professionals took to provide a good service when faced with difficulties.6 Agencies need to learn from these and promote them as well as learning from shortcomings. When these are judged to be significant, they have been highlighted. 6 See for example Vincent, Patient Safety (op cit); E Hollhangel et al, Resilient Health Care; E Rowley and J Waring (eds) (2011) , A Socio-cultural Perspective on Patient Safety, Ashgate 9 3 NARRATIVE 3.1 This section contains a narrative of events. In Section 4 key episodes are evaluated in more detail where this assists in identifying measures that will improve safeguarding. In relation to Child D this is a full narrative of a short period of agency involvement. This is because the most important learning from the review has arisen from a very detailed evaluation of the interactions between professionals and the family and between professionals working in different agencies at a number of critical points in the case history. The mother’s personal background and family history 3.2 Child D’s mother experienced abuse in the family in which she grew up. As a result she was made the subject of a child protection plan in 2006. Her first child (Child Y) was born in late 2007. In late 2012, during the latter stages of her pregnancy with Child D, the mother gave evidence in civil court proceedings about this abuse. This assisted in protecting younger members of her family. This is referred to further in Sections 3.25 – 3.28 below. The extent of professional knowledge about the mother’s history of childhood adversity and the extent to which this was taken into account in the work that professionals undertook with her when she became a parent is highlighted at a number of points through this narrative and is evaluated in Section 4.2. The father’s personal background and family history 3.3 The GP records of Child D’s father show that in 2004 when he was a young adolescent he was seen by his GP because of problems with his temper, depressed mood and verbal aggression. He was referred for counselling but there is no information to indicate whether he attended. 3.4 None of the professionals who worked with Child D knew about this history or asked the father anything about his background. The father had a different family GP to other family members. 3.5 No other adverse information has been identified about the father’s history. During the care proceedings that followed the death of Child D he admitted assaulting Child D’s mother on two occasions but neither incident had been reported to professionals before Child D was seriously injured. 10 The contact that professionals had with Child D’s father and the limited amount of information that was obtained about him are discussed further in Section 4.5. Professional involvement with the mother during her first pregnancy 3.6 In May 2007 Child D’s mother was referred to the Luton and Dunstable University Hospital (LDUH) for ante-natal care. The mother saw the specialist Teenage Caseload Midwife (TCM) who provided additional support for very young mothers. The TCM gained a good understanding of the mother’s background and family history, including the fact that she had been the subject of a child protection plan and the reasons for this. She understood that the mother had left school early without obtaining any qualifications. The mother was referred to a number of support services and remained in touch with the specialist midwife throughout her pregnancy. 3.7 There was no major medical concern during the pregnancy but the mother was very anxious and arranged to be admitted to the ante-natal ward on several occasions because of back pain and other difficulties. The SCR judged the involvement of the Teenage Caseload Midwife (TCM) to be a strength in service provision which should continue to be promoted and supported by commissioners of health services and the LSCB. Information about the extensive support which the specialist midwife gave the mother and the information she obtained might not have been available to the midwives that cared for the mother during her pregnancy with Child D because at that time (2007-2008) the specialist midwives kept separate paper records of their involvement which were not merged with the hospital’s main medical records. This system has now been changed so that women’s medical records would include information about previous pregnancies. In this case the midwives who dealt with the mother’s pregnancy in 2012 referred to previous medical records and spoke to the TCM to make themselves aware of the mother’s childhood difficulties. This should also be recognised as a strength in their practice. 11 Provision made for Child Y 3.8 Shortly after the birth of Child Y (the older half-sibling) the mother moved approximately 25 miles to the town in which that baby’s father and his family lived. The father had been identified during the pregnancy but had had little contact with services. He was ten years older than the mother. During this time the mother gave her health visitor accounts of conflicts involving the father’s family, which she perceived to be controlling and interfering. There were suspicions of domestic violence which were only confirmed after the couple separated. 3.9 The mother and baby lived close to the father’s family until 2010 and kept a high level of contact with the local health visitor. They moved between the two towns before the relationship ended and in 2010 the mother returned to Luton with Child Y (the half sibling), where they were given temporary housing. 7 3.10 Full written health visiting records were transferred to Luton. The information received by the health visiting service in Luton was that there were ‘no safeguarding concerns’ but that the health visitor had had regular contact with the family because of concerns about ‘temper tantrums, poor feeding and parenting skills’. 3.11 During late 2010 – mid 2011 the mother saw her first Luton health visitor on several occasions. She recognised that there had been domestic violence in her previous relationship and that this could have had a negative effect on Child Y. At one point the health visitor recorded suspicions that the mother might be a victim of abuse from a new boyfriend because she saw her with bruises on her arm. This was explored and the mother denied that there was any problem. 3.12 In January 2011 Child Y started to attend a nursery located near the family’s temporary accommodation. She attended regularly for almost a month until moving to another nursery because the family moved to more permanent accommodation. 3.13 In mid-2011 the mother told her health visitor that she was going through a ‘difficult patch’ because there were going to be court proceedings about the abuse in her family of origin. She was offered support and advice about counselling but refused the offer, saying that at the time she felt well supported by her new partner (the father of Child D) who she had been with for about three 7 The father of Child Y had no further major role in the life of the family during the period under review and he played no role at all in relation to Child D. 12 months. It has been confirmed that this was not the man referred to in paragraph 3.11 above. 3.14 For one term between March and July 2011 Child Y attended a second nursery, located near to the new family home. Her attendance at this was just under 70% though this was not viewed as unusual or concerning because she was not of compulsory school age. 3.15 In September 2011 Child Y moved to another nursery, linked to a church school. Given the family’s religious background this pattern of school and nursery moves was quite normal. The child attended this school for the remainder of the period under review. The mother was entirely open with the nurseries and the school about the moves and the reasons for them and gave contact details of the schools to her health visitor. There is no evidence in this case for believing that the school changes should have been viewed as a potential cause for concern. The LSCB has conducted reviews on a number of children in Luton where the pattern of frequent school moves has been identified as a concern, particularly when a move takes place after concerns about children’s welfare have been raised. This was one of the concerns which led to the development of the LSCB’s safeguarding in schools strategy. 3.16 Between January 2011 and January 2013 the three nurseries and schools identified concerns about Child Y’s behaviour. Symptoms included her difficulty in following instructions, interfering with the play and activities of other children and an inability to sit still and concentrate on activities. At times Child Y was aggressive to adults and other children. 3.17 Staff in the nurseries and schools tried a variety of approaches to assist with these difficulties including: Portage – in which a worker made visits to the family at home to encourage the mother to adopt strategies to manage behaviour which were consistent with the approach being taken at school Discussion at the school liaison meeting which led to a referral for assessment to the Integrated Services for Children with Additional Needs One to one teaching assistant support was provided first for the morning sessions and then for the whole day. 13 3.18 In addition the health visiting service made provision for the family through additional visits by nursery nurses and health visitors in order to support the mother at home. 3.19 In late 2012 the school referred Child Y to the Child Development Centre (CDC). The child was on the waiting list at the time of Child D’s death. It is now understood that in addition to her attachment and parenting difficulties, an underlying medical problem is likely to have accounted for some aspects of Child Y’s behaviour. 3.20 The response of agencies to these problems is evaluated in Section 4.3. There are no concerns about the provision that was made and there is no evidence that any signs or symptoms of abuse were missed. Professional contact with the mother during her pregnancy with Child D 3.21 The mother contacted her GP in March 2012, early in her pregnancy with Child D. Her first foetal scan identified a potentially serious abnormality that would require close monitoring during the pregnancy and surgery immediately after the child’s birth. At her ante-natal booking at the LDUH the mother disclosed a history of depression, which she said had not been treated, three years previously. She identified her current partner as the father of Child D. 3.22 Subsequently the mother regularly attended her planned ante-natal appointments and an outpatient appointment at Great Ormond Street Hospital (GOSH) to discuss the planned surgical procedure. 3.23 The midwives at LDUH obtained previous medical notes and discussed the mother with the specialist TCM midwife to establish if there was any relevant history. The mother was perceived as being young and vulnerable with little support from her own family. However she engaged very well with the ante-natal service, was concerned about the baby’s wellbeing, keen to understand as much as possible about the surgical procedures that would be required and worried about the possible outcomes for the baby. The mother was found to understand instructions and advice if things were put simply and she was diligent in following them. The father was noted to be older than the mother. He attended some of the appointments and was present during the ante-natal home visit. Midwives had no concerns about his presentation or behaviour. 3.24 Conditions observed during the home visit were satisfactory and there were no concerns about Child Y. 14 3.25 Late in the pregnancy the mother was required to give evidence in the family court about the abuse that she had suffered as a child. This successfully helped to protect younger family members. At this time Child D’s mother had contact with the Luton Borough Council social worker who was responsible for the younger children. The social worker visited Child D’s mother at home before the hearing in order to establish how it was affecting her and whether she wanted any additional support or counselling over what had happened. Information and leaflets were provided about possible services. 3.26 The mother said that she did not want to access this straight away because she was focused on her pregnancy and birth and that she was getting good support from her mother and the father of Child D (who were both there). She knew and understood about the medical needs of the baby and the surgery that would be required. She could talk to her boyfriend about what had happened in the past and he was supportive. There was discussion about whether at this point Child D’s mother wanted to make a formal complaint to the police and trigger a criminal investigation about the historic abuse. The social worker explored this with the police, though subsequently the mother did not do so. 3.27 The social worker did not feel that there was any need to discuss what the mother had said with the midwife as it was clear that Child D’s mother had good arrangements in place. The social worker was in fact much more concerned about another family member who was going to give evidence who seemed to be having considerably more difficulties. 3.28 Midwives who were in contact with the mother at this stage knew about the mother’s childhood problems but did not know that the mother was giving evidence in these court proceedings, because she did not mention it. Midwives had to rely on the mother disclosing information about the court case. The circumstances were unusual and so likely to have eluded any normal line of enquiry about her health or welfare. The social worker who was dealing with the rest of the family considered informing other professionals who were working with the mother about her involvement in the court case, but decided that on balance it was not necessary. She discussed this with the mother who told her about the contact that she was having with the hospital and gave her the impression that she was receiving all the support she needed. It is also important to note that the social 15 worker’s main concern at that point was the complex court case because 1) the current protection of a number of other children in the mother’s family of origin was at stake and 2) she was particularly concerned about the welfare of one of the other witnesses. The review has identified that the mother’s midwife did not complete a safeguarding or information sharing alert in relation to the pregnancy. Within LDUH safeguarding alerts are the main mechanism for flagging potential risks to patients and unborn babies. This was because she did not view the mother’s pregnancy as concerning from a social point of view. This decision was understandable, given the mother’s full engagement in the antenatal service and the absence of any specific concern. Because of her medical condition Child D followed an unusual care path after her birth. Taken together these two factors meant that less information was subsequently shared with the health visiting service than the circumstances merited. Even though using the safeguarding alert system in this case might have meant that more information have been subsequently passed to the health visitor the SCR decided that this case did not point to any need to change the current arrangements. There has to be a proper threshold for creating an alert, otherwise the entire system becomes devalued. That threshold must rely on professional judgement. The operation of the system is regularly reviewed and monitored, both within the hospital and through reports to the LSCB. The hospital safeguarding team learns from errors and omissions in its use. This will continue. Provision made in relation to Child D’s medical condition 3.29 Child D’s birth was routine and after being stabilised in the Neo-natal Intensive Care Unit at the LDUH she was transferred to GOSH for surgery. The ambulance crew’s notes indicate that shortly before the transfer the father became very angry. This was because of a reported need to change the hospital that would carry out the operation and incorrect information being inadvertently given over transport arrangements. The ambulance staff involved had no additional specific recollection of events. It is likely that this was viewed as the understandable anxiety of a father with a very ill, vulnerable new-born baby. These notes were passed to GOSH (and became part of the hospital record) but there was no evidence that the father was still angry by the time the family reached the hospital. 16 3.30 Based on the referral information from the LDUH, GOSH noted that there were ‘no social concerns’, because from the LDUH perspective nothing had happened to indicate risk to Child D. 3.31 The planned surgery was carried out successfully and Child D and her mother stayed at GOSH for 3 weeks. During the stay the mother asked to see a hospital family support worker, who in turn referred her to a social worker. The mother was seeking financial support while staying at the hospital – which was provided – but she was also very open about her family background and gave details of her family history of abuse. She identified family members who she did not want to visit. She also indicated that Child Y was staying with the maternal grandmother with the agreement of the local authority. The hospital social worker made contact with a Luton social worker who confirmed that there were family members who might pose a risk to children and should not be allowed to visit Child D in hospital. 3.32 Shortly before discharge the hospital arranged for a play therapist to see the mother to provide advice about how Child Y might react to the appearance of the baby in hospital and the arrival of the baby at home and how the mother might handle this. The parents responded positively to this advice. 3.33 Throughout this admission the mother was regularly observed in her interaction with Child D by nursing staff, medical staff and members of the GOSH social work department. She was perceived as being caring and focused on Child D’s needs. No concerns were raised about her care of Child D and indeed it was noted that she carried out some delicate practical tasks linked to the infant’s medical treatment with skill and confidence. In discussing her childhood problems the mother was viewed as being someone who wanted to take control of her life and prevent any abuse of her own children. 3.34 The father attended one meeting with the GOSH social worker. He was perceived as being concerned and affectionate towards Child D and there were no concerns identified. 3.35 On 7 November 2012 LDUH sent the mother’s GP notice of the transfer of Child D from LDUH to GOSH and confirmation of the child’s medical diagnosis. A copy was sent to the health visiting service and noted on the child’s record. Shortly after, the health visitor made contact with family members to confirm what was happening. On 27 November the allocated health visitor sought an update from the family and was told that Child D remained at GOSH. This was a different health visitor to the one who had dealt 17 with Child Y in 2010 – 2011, but she remained the allocated worker for Child D. 3.36 On 28 November 2012 Child D was transferred back to the LDUH. This was normal practice after treatment of an infant at a tertiary centre and allowed the local hospital to establish the child’s feeding, to monitor the care of the child and to plan a coordinated discharge. This worked effectively and no concerns were noted about the care provided to Child D by the mother. The LDUH sent a discharge letter to the family GP and health visitor who arranged to make her home visit on 3 December 2012. The discharge letter focused on current medical matters and did not contain information about the mother’s social background. An appointment was also made for Child D to be brought to the paediatric ward on the same day. Details of the first GOSH outpatient follow up appointments were confirmed along with a further LDUH paediatric department appointment. The health visiting records confirm these details. From the paediatric ward perspective Child D was treated as a child being discharged from surgery in a tertiary centre, not a baby being taken home for the first time. This did not adversely affect Child D’s health care but it meant that there was no direct contact between the midwives and health visitor and so no information sharing between them. This meant the health visitor was not informed about the mother’s childhood difficulties, which would normally have happened in similar circumstances. Child D’s need for tertiary care at GOSH appears to have caused this disruption in information sharing. In all other respects this was a well-planned and coordinated discharge which optimised the support to Child D and her parents. 3.37 On 3 December 2012 Child D was brought to the paediatric assessment ward at LDUH, weighed and examined. Observations were recorded in the hospital records. 3.38 The health visitor attempted to phone and then to visit the mother and Child D on 4 and 5 December 2012. The health visitor – who had not yet met Child D - was concerned that it was proving difficult to make contact and established that the baby had attended at the paediatric clinic as planned. No further attempted visits were made before 12 December 2012 when the health visitor made a successful unannounced visit to carry out the new birth health assessment. 18 3.39 The health visitor established the medical history from the mother and weighed and examined Child D. The records set out the information obtained. By this time Child D had been home for a week and was feeding well and regularly. There were no concerns about the surgery and the arrangements for medical follow up were clear. Child D had been sick on one occasion after feeding, but this was not considered to be anything abnormal and the parents were advised to take Child D to the GP if she appeared to be ill again. 3.40 The health visitor’s view (provided to the SCR in interview to supplement her records) was that the mother ‘seemed on top of things and there had been no concern from either hospital in respect of her parenting skills’. There was discussion during the visit about the mother’s level of literacy and she said that she had ‘not gone to secondary school just primary school’. She was given information about adult literacy classes at the nearby Children’s Centre. 3.41 As both parents were fit and well and the baby clinic was located very close to their home, they were advised to attend there weekly for Child D to be seen and weighed. The health visitor believed that there was no reason to involve a nursery nurse to provide additional home visits. Attendance at clinic and universal provision under the Healthy Child Programme (HCP) was to be monitored by the Heath Visitor from the electronic records (which would show up any missed clinic appointments). 3.42 The health visitor established that the man present at the new birth visit was the baby’s father. His details were entered into the child health records and linked to Child D’s. This did not give the health visitor access to his health records and there was no reason for the health visitor to think that this was necessary. The health visitor was not aware of the nature and extent of the mother’s childhood difficulties. The reasons for this are described above and considered further in Section 4.2. Given her knowledge of the family and her assessment at the new birth visit the judgement about the level of care required made by the health visitor is viewed by the review team as being justified. 3.43 On 14 December 2012 Child D was taken to a hearing screening, which proved to be ‘normal’. 3.44 On 16 December 2012 Child D was not taken to the Child Health Clinic. The health visitor spotted this and as required by the trust’s procedures undertook a vulnerability assessment. This noted a 19 number of potential risk factors (‘new baby, surgical condition, mother can’t read, financial problems, new relationship, did not attend clinic, phone contact difficult as mum seldom has credit’ and as a result it was agreed to schedule health visitor home visits once a month, rather than rely solely on clinic contact. However there was no urgent need to make a visit because nothing had occurred which had changed the fundamentals of the previous assessment. As a result a home visit and review date was scheduled for 15 February 2013. This took account of the normal scheduled GP 6-8 week check, weekly health clinic appointments and the outpatient paediatric appointment which would have happened in the meanwhile. 3.45 According to the mother’s evidence to the care proceedings at some point over the following two weeks Child D received the first of three bruises which she noticed after the father had been caring for her. She did not bring these to the attention of any professional at the time. 3.46 Child D was taken to the child health clinic on 2 January 2013 which – because of the holidays – was the next available date. Everything was judged to be well and the mother was advised to continue attending weekly. No bruises were observed. 3.47 The following day (3 January 2013) the mother took Child D to her GP for the scheduled 6-8 week check. This check was taking place just after the end of the 6-8 week window because of the inpatient hospital admission and the holidays. 3.48 This check was satisfactory and Child D was noted to be thriving. During the check the GP noticed and recorded a small bruise on Child D’s forehead. The mother explained that this had been caused by the infant’s head resting on a plastic toy in a Moses basket. The mother had brought the toy with her so the GP could see it and the GP noted that it had a hard protruding centre. He noted his intention to liaise with the health visitor, but he did not do so. The record of the care proceedings notes a comment from the GP indicating that the explanation ‘would fit’ the injury; however this comment was not found in the medical records or given to the SCR by the doctor concerned. 3.49 The GP made the record of the 6-8 week check on the surgery’s electronic patient record. The surgery uses a system called EMIS. As part of the normal information sharing arrangement a copy of the record of the 6-8 week check – which included a reference to the bruise - was passed to the community health trust’s child health department. This happens routinely and was not the result of the GP’s desire to communicate with the health visitor. The 20 reference to the check – including the reference to the bruise - was manually copied by an administrator into the Health Visiting records on SYSTMONE (system one) which is the electronic patient record system used by the health visiting service (and a number of Luton GP practices, though not the one attended by the family). 3.50 The health visitor had access to SYSTMONE but there was no reason for her or anyone else in the community health service to refer to the records until the next planned contact or the next scheduled clinic attendance. 3.51 On 9 January 2013 the mother phoned the GP surgery in relation to a minor medical problem linked to Child D’s recent surgery. She attended the surgery and Child D was seen by a different GP. The same bruise was noted, without further action being considered. It is now known that the mother was sufficiently concerned about the bruise herself to take a photograph of it on her mobile phone between the two GP appointments, though no professional knew this at the time. Some months after Child D’s death she reported that this was the third bruise that Child D had suffered, and that one of the previous bruises had been more serious. These episodes are evaluated in detail in Section 4.6 which considers in detail the response of professionals to the bruise on Child D’s head. Section 4.7 evaluates the current arrangements for the 6-8 week check and considers whether there are grounds for involving health visitors in these checks to a greater degree. 3.52 Early on the morning of 10 January 2013 the mother phoned 999 reporting that Child D had stomach pain. She was triaged over the phone by the ambulance service control and advised to contact her own GP. She did not do so, possibly because Child D had an outpatient appointment at GOSH later the same day. The ambulance service has reviewed this contact and believes that on the basis of the information provided, the correct advice was given. 3.53 At the GOSH outpatient department Child D was weighed by a clinic assistant prior to seeing a surgeon for scheduled outpatient follow up of the surgical procedure. The assistant noticed a small bruise on the child’s forehead and asked how it had happened. The mother gave the same explanation as before (which was documented in the paper outpatient record and passed to the 21 surgeon). The clinic assistant also told the review team that the mother had said that the bruise had already been seen by the GP or health visitor (she was not sure which). This remark was not recorded. 3.54 The clinic assistant felt concerned by the bruise but was not entirely sure that a small bruise was necessarily an indication of abuse. She wanted the surgeon to look at the bruise and seek a more detailed account from the parents before referring Child D to the hospital social work department. Before Child D was seen the clinic assistant tried to speak to the surgeon to share her concerns but she did not because when she went into the consulting room he was examining another patient behind a screen. She therefore made an entry on the outpatient assessment form ‘baby has a bruise on her forehead. Mum says a toy on the Moses basket caused the injury’. This was written at the top of the section where the surgeon would write the notes of his examination and marked with a prominent ‘star’ in the margin. 3.55 Between booking other patients the clinic assistant made further attempts to discuss this with the surgeon but each time he was occupied with patients. Before the end of the clinic (when she felt that she would have had an opportunity to discuss the bruise either with the surgeon or with the staff nurse in the clinic) she was called to cover a clinic in another part of the hospital. 3.56 The surgeon examined Child D and made notes relating to the recovery from surgery. There were no concerning complications of the surgery and he asked for Child D to be seen again in four months. These notes were directly below the clinic assistant’s written entry about the bruise. Child D left the hospital without any action being taken over the bruise. The surgeon told the review team that he had no specific recollection at all of seeing this patient. These contacts are evaluated in detail in Section 4.6. Attendance at LDUH emergency Department / Out of Hours GP 3.57 In the evening of 13 January 2013 Child D’s mother called the ambulance service indicating that the baby was ‘struggling to breath’. An ambulance attended the family home. The ambulance service contact is very thoroughly documented. On arrival the crew found Child D sleeping in the mother’s arms. The infant was carefully examined and a detailed history taken, including details of existing medical conditions. The paramedics saw no bruising. The account given by the mother was different from the account 22 given over the phone; this time she indicated that Child D had taken food, vomited, screamed, gone blue and then gone limp but only briefly. 3.58 They did not believe that Child D needed hospital admission, however the paramedics agreed to take Child D and her mother to the LDUH Emergency Department (ED) where she could be seen by a doctor. In effect they were providing reassurance and transport. On arrival at LDUH the mother joined the normal system for patients waiting to be advised whether to attend the ED or to attend the GP Urgent Care Clinic which is based at the LDUH. The ambulance crew gave a copy of their notes to an unidentified member of LDUH staff and left. The notes were subsequently processed and became part of GP and other health records, though they were not seen by the out of hours GP who saw Child D in the GP Urgent Care Clinic that evening. 3.59 Child D was seen by a nurse who carried out the functions of the ‘streaming nurse’ (who signposts patients attending the LDUH as to whether they should attend the LDUH Emergency Department or the GP Urgent Care Clinic). The mother provided an account of Child D’s history and she was advised to take him to the GP Urgent Care Clinic. The nurse (who is a very experienced and highly qualified practitioner) recalls seeing a baby in her mother’s arms and being given an account of ‘vomiting after feeds’. The mother did not mention the history of surgery and made no statement to suggest collapse or ‘not breathing’. It was not the nurse’s role to physically examine or formally triage patients. He felt that the presentation gave no cause for alarm and that Child D should be seen by the GP at the Urgent Care Clinic, rather than referred to the Emergency Department. 3.60 In keeping with the LDUH’s agreed arrangements, the streaming nurse kept no record of his contact, as he was in effect simply pointing patients to the apparently most appropriate service. 3.61 The GP Urgent Care Clinic GP took a history from the mother and examined Child D undressed and on an examination couch. The mother’s version of the history was close to that which she had given the ambulance crew i.e. that Child D had developed a cough and runny nose for past few days and although feeding well had been vomiting after some feeds. On that day Child D had stopped breathing after vomiting following feeding and then went blue for three minutes. On examination Child D was alert and well, had no fever or respiratory distress, was well hydrated and showed no signs of neurological impairment. The GP saw no bruising and felt 23 that the mother appeared to be genuinely caring and appropriately worried. 3.62 Judging by the current clinical picture, the GP felt that the episode would have appeared to a caring parent to have been more grave than it actually was. He did not believe that Child D had stopped breathing for three minutes (because a child who had done so would have been seriously ill) but he understood why in panic an anxious parent might believe that. He saw no reason to admit Child D to hospital and discharged her home with a note to be given to the registered GP stating that the baby had presented with vomiting. Details were provided of the blood sugar levels taken by the ambulance crew and the Urgent Care GP.8 These were within the higher normal range and it was noted that investigation for possible diabetes might be warranted. Further advice might also be needed over the vomiting if it persisted. This hospital attendance has been scrutinised in great detail – both by the SCR and in the care proceedings - because it occurred some 12 hours before Child D was seriously injured. The SCR found no grounds for criticism of the ambulance crew, the streaming nurse or the GP Urgent Care Clinic GP, all of whom are judged to have acted appropriately given the clinical presentation, the circumstances and their roles. It is not clear who the ambulance crew gave their notes to and why they did not find their way to the GP Urgent Care Clinic immediately. It appears that the records were temporarily misplaced, probably because Child D was transported to the hospital by ambulance but then joined the normal public queue. There is no reason to believe that the fact that these notes were not transferred with the patient to the GP Urgent Care Clinic GP had any adverse effect on Child D’s care. The East of England Ambulance Service told the SCR that it had no other evidence of handover arrangements not working smoothly at LDUH. The view of the SCR about the examination undertaken by the GP Urgent Care Clinic GP has been endorsed by the findings of the judge in the care proceedings who found it to be ‘comprehensive and thorough’, ‘careful and professional’. It was agreed by all the expert witnesses that Child D could not have received the injuries that caused her death before this examination because these injuries would have caused an immediate collapse which would have been readily identified by any of the professionals who were 8 Blood sugar was elevated at 12.6 mmol/L when tested by the ambulance crew but it had come down to 8 mmol/L when seen at the Urgent Care Centre which was reassuring. 24 involved. Section 4.8 comments in detail on the factors that have led to the development of the streaming nurse role at LDUH and the wider implications for services. Serious injury to Child D, admission to Luton and Dunstable Hospital and transfer to Great Ormond Street Hospital 3.63 The following morning (14 January 2013) the ambulance service attended the family home as Child D was reported to have gone ‘lifeless’. The baby was clearly gravely ill and was transported to LDUH, before being transferred to GOSH. 3.64 The finding of fact in the care proceedings was that Child D’s father caused the injuries that led to her death on the morning of 14 January 2013 while her mother was in a different part of the home. He is judged not to have done so deliberately.9 3.65 The paramedic records made during this incident note an ‘old bruise’ on Child D. The mother gave doctors at both hospitals an account of Child D having a bruise on her forehead and the same account of its cause. The consultant paediatrician who examined and treated Child D at LDUH that morning is clear that there was no noticeable bruising (other than marks resulting from current and previous medical treatment). 3.66 Child D died some days later. There are no concerns about the care and treatment provided to Child D on the morning of the serious injury. It has not been possible to clarify – because they have no more detailed recollection - what exactly the paramedics meant when they noted an ‘old bruise’ on Child D that morning, or why it was described as being ‘old’. It is noted that it is impossible to age bruises with certainty. If there was an old and noticeable bruise on Child D’s head that morning it is extremely surprising that it had not been recognised by the paramedics, the streaming nurse and the GP Urgent Care Clinic GP who had dealt with Child D the previous evening, two of whom had made detailed examinations. Nor was it seen by the consultant paediatrician on Child D’s admission to LDUH on 14 January 2013. On admission to GOSH later that day Child D was noted to have 9 As the parents did not contribute to the SCR there has been no opportunity to consider this beyond the finding of the court. 25 what was noted in the records as being a ‘resolving bruise’ in a slightly different position on her head to the previously recorded bruise. The age and cause of this injury are impossible to ascertain. 26 4 EVALUATION OF THE SERVICES PROVIDED FOR THE CHILDREN 4.1 Introduction 4.1.1 This section addresses all of the topics set out in Section 1.11 above, as well as additional matters identified in the course of the review: 4.2 How vulnerable young people who might need additional support when they become parents are identified and helped 4.3 The identification of risk and vulnerability in relation to Child Y (Child D’s older half sibling) and the provision made as a result 4.4 Support and advice given in relation to Child D’s medical condition 4.5 Engagement of the father and assessment of his role 4.6 Professional responses to bruising in small babies - the recognition of possible signs of abuse of Child D and the action taken by professionals 4.7 The 6-8 week health review, the Healthy Child Programme and working arrangements between GPs and health visitors 4.8 Access to urgent and emergency health care in Luton for babies and small children 4.9 Professional understanding and assessment of the impact of parental learning disability on parenting capacity 4.1.2 In relation to each theme the report evaluates whether this was significant in relation to the outcome for Child D and in wider service provision for vulnerable children. 4.2 How vulnerable young people who might need additional support when they become parents are identified and helped 4.2.1 Child D’s mother came from a family with severe social difficulties, in which she had suffered abuse. There is no evidence that the Child D’s mother harmed either of her children; however her vulnerability led her to live in relationships in which she and her children were victimised. The family court proceedings judged that her childhood experience had made her less able to protect her children because she did not have the trust and confidence to speak openly to professionals when she instinctively recognised that she and her children were not being treated properly. 4.2.2 The review has considered how information about the mother’s background was transmitted between professionals who knew her in adolescence and those who later worked with her as a young mother, 27 and whether more support could have been offered to her. This seeks to identify whether there are wider lessons for services in Luton. 4.2.3 Section 4.9 deals separately with the question of whether the mother had learning difficulties and how this was assessed and understood by professionals. These two matters are linked. 4.2.4 The preservation and sharing of information about vulnerable adolescents who have become parents has important implications for the identification of risk to children, particularly in the first year of life. In its summary of findings of SCRs dealing with the deaths of infants under one year old OFSTED identify a number of common shortcomings, including the lack of pre-birth assessment; underestimation of the needs of young parents and insufficient support being provided, bearing in mind the vulnerability of babies.10 4.2.5 These are all more likely if the decisions that inform them are based on incomplete information. For example lack of information about a young person’s experience and behaviour as an adolescent may adversely influence a decision about whether or not to undertake a pre-birth risk assessment. This makes it important to understand why information about childhood difficulties may or may not be shared between agencies that worked with a parent when they were a child or adolescent and the agencies later providing antenatal and post-natal care. 4.2.6 The review has tried to understand how this might occur - not in general but in the working arrangements of specific local services. When serious concerns have been identified the responsibility to gather information is likely to fall to local authority social workers. When the local authority is not involved – as in Child D’s case - reliance is placed on information sharing between health professionals. The value of information held in GP records 4.2.7 When the mother became pregnant with Child D, the local authority social care service was involved with younger members of the mother’s family but it had only very limited direct contact with her. She had been removed from a child protection plan five years previously. This is not an unusual set of circumstances. There may be a gap of several years between the involvement of the local authority with a young person and that young person becoming a parent. In the meanwhile the young person may have moved far from where he or she grew up; or there may be no reason for the agencies to be in touch. It can never be guaranteed that information held historically by agencies such as a Youth Offending Team, children’s social care or 10 OFSTED, (2011) Ages of Concern: Learning Lessons from Serious Case Reviews a thematic report. 28 school will be shared with health professionals who are dealing with a young mother or father, unless the agency concerned is asked for it. 4.2.8 The most reliable route to preserve information about the young person so that it is available when he or she becomes a parent is via the GP records which should provide a continuous record of the young person’s contact with health agencies. This places considerable reliance on the GP obtaining, collating and being able to recognise the significance of information about a child or young person that may be relevant to their capacity as a parent and then make the right use of it. 4.2.9 In relation to Child D’s mother her GP practice had information to indicate that she had been subject to a child protection plan, but that information was not summarised or highlighted and no one in the practice was actively ‘mindful’ of it. Understandably the mother’s removal from the child protection plan in 2006 had been viewed as a positive event. However information about her childhood difficulties should have informed everyone’s future work with her. 4.2.10 The safety of small children can be improved by increasing the quality of information that is held about their parents and by making GPs more mindful of its potential significance. Inclusion of social information in GP antenatal referrals 4.2.11 The best opportunity for information about the parent’s history to inform future care is the GP referral for ante-natal care. Currently in Luton there is no consistency about whether GPs include significant background social information in referrals for antenatal care, even when it is held in their records. There are numerous reasons for this. Records may not contain information about important events. The GP records of many troubled young people may not be complete, especially if they have moved home a lot. GPs may not appreciate the potential significance of the social information that they hold in their records. They are not always prompted to provide information by the referral system. 4.2.12 The LDUH has described how this combination of factors leads to huge variation in the information provided by GPs to the antenatal service in Luton: With regards to the referral letters received by GPs for pregnant women there is no standard template / proforma which is used between the GPs and the hospital. This is very much done on an individual basis and varies greatly between GPs. Some are very good and will include relevant medical and social information, some only medical information, whilst others will literally inform us of a woman's pregnancy and could she be seen for care, some are typed and some 29 … is hand written. There is no standardisation of the information received.11 4.2.13 Further variation is added because women may also self-refer to the hospital for maternity services. When this happens ‘they phone in and speak to an admin person who fills in a proforma…this doesn’t take into consideration medical / social information as it is the midwife's responsibility to collect this information by reviewing previous hospital notes and GP records and on seeing the woman at the booking appointment’. Midwives then obtain information directly from GP records although ‘the level of access to records is dependent on the (information sharing) “rights” that the surgery gives the midwife’. 4.2.14 Some women have no GP, in which case relevant social information may be archived or at another GP surgery and very difficult to obtain. 4.2.15 Discussions with health professionals outside Luton indicate that other areas have a more structured approach and have developed template referral letters which prompt GPs to provide a range of relevant background social information. Without wider research it is not possible to know whether there is wide compliance with such approaches and whether different protocols produce better outcomes. The SCR has made a recommendation in relation to this. Significance in relation to wider service provision for vulnerable children 4.2.16 The OFSTED evaluation of SCR findings in relation to children under the age of 12 months stresses the importance of an accurate assessment of the factors that may affect a young parent’s care of his or her child. This relies on collaborative working between antenatal services, health visitors and GPs during pregnancy and throughout the first year of life and on relevant historical information being made available. The evaluation in this case history highlights the factors that can make it more difficult to do that successfully. 4.2.17 In any complex case, health professionals need to be conscious of the need to retrieve as much information as they can from other agencies. They also need to recognise that there may be useful background information held by agencies that knew the mother or father as a child. 4.2.18 The quality of antenatal care could be improved and the support for vulnerable young parents could be targeted more effectively if GPs were more aware of the significance of historical information that they may hold and they were more aware of the value of sharing it with antenatal services and health visitors. 11 Information from the Named Safeguarding Midwife 30 4.2.19 There is no single procedural solution that will ensure that this happens, but GPs, NHS England (which commissions GP services), the Clinical Commissioning Group in Luton and providers of maternity care should research this further and develop a strategy to promote better information sharing at this critical point in care. Although this is not a factor that impacted directly on the outcome for Child D, it is important in relation to the wider vulnerability of children. The SCR has made a recommendation in relation to this. 4.3 The identification of risk and vulnerability in relation to Child Y (Child D’s older half-sibling) and the provision made Significance in relation to the outcome for Child D 4.3.1 The review team has considered whether there were indications of risk or vulnerability in relation to Child D’s older half-sibling and if so how professionals responded. 4.3.2 The causes of Child Y’s behavioural problems were unclear to professionals working with her. The care proceedings have now clarified that there are likely to have been a number of contributory factors, including an organic cause, exposure to family conflict and a small number of episodes of domestic abuse and inconsistent parenting. Child Y’s father (who was in contact with her between her birth and the age of three) and her stepfather (who came into contact with the family when she was five) admitted handling Child Y roughly or threatening her. These admissions were made in the court proceedings after the death of Child D. 4.3.3 Given the pattern of Child Y’s behaviour (described in Section 3 of this report) none of these factors comes as a surprise (especially taking account of the mother’s vulnerability). The difficulty is that without specific evidence of the causes – which would always be likely to come from disclosure by a family member – only the symptoms shown by the child can be addressed. 4.3.4 The SCR team carefully reviewed the interventions that were made with Child Y, based on the information that was available at the time. This was done through review of records and detailed discussion with the teachers, nursery nurses and other professionals that had worked with the child in the three pre-school and school settings. This was also discussed in interviews with the health visitor who had had contact with her during 2010 – 2011. Luton Borough Council’s Principal Educational Psychologist offered additional expert scrutiny and comment. 4.3.5 It was apparent that all of the staff who had contact with Child Y had a very clear memory of her as an individual and had been very aware of her needs and difficulties. In all three education settings records of 31 concerns and interventions were thorough and detailed. It was clear that the nurseries and schools had considered carefully how to respond to the child’s difficulties and used a range of interventions that both at the time and with hindsight were appropriate to the problems that she presented. Shortly before the death of Child D the school referred Child Y to the local Child Development Centre, leading to the identification of her organic disorder. 4.3.6 Throughout there was close liaison between nursery and school staff, health colleagues and educational support and advisory services. The child’s mother was attentive and concerned, kept appointments and made considerable efforts to implement the advice given on emotional support and behaviour management. When it became known that the mother was pregnant and then when Child D required surgery immediately after the birth Child Y’s school was responsive to the change in family circumstances, offered additional support and had contact with members of the extended family who were caring for her. 4.3.7 There is no indication that there were grounds for a referral to social care to have been made at any stage. 4.3.8 Even though it could not identify all of the causes of Child Y’s difficulties the support that the older child and her mother received in playgroup, nursery and school should be considered to be a strength in services. Significance in relation to children in Luton more widely 4.3.9 Over the last two years the LSCB has carried out reviews of a number of children’s cases which have touched on the safeguarding arrangements made for other children in other Luton schools and nurseries. Provision in relation to safeguarding has not always been satisfactory and as a result in 2013 the LSCB launched a strategy for safeguarding in schools in order to address this. 4.3.10 The review has noted that in relation to Child Y there was no handover from the health visiting service to the school nursing service, even though the health visitor had remained actively involved with Child Y until shortly before the child started to attend school. Although the service specification for the health visiting service takes account of the need to identify and transfer vulnerable children this is recognised as being a persistent problem in Luton. That is because over a number of years there has been insufficient capacity in the school nursing service. There is no indication that this lack of handover had any negative impact on the provision made to Child Y as she received a range of supports and was referred directly to the Child Development Centre by the school. 32 4.3.11 This difficulty has been brought to the attention of the Director of Public Health, who on behalf of the local authority currently commissions the school nursing service. The local authority and the NHS trust that provides the school nursing service are already undertaking a review of the provision in Luton which will take account of the need to improve transfer of cases from health visitors. The findings of this review will be reported to the LSCB under its normal working arrangements. 4.4 Support and help provided to the parents in relation to Child D’s medical condition Significance in relation to the outcome for Child D 4.4.1 The SCR has examined the provision made in relation to Child D’s complex medical condition. 4.4.2 The provision made by GOSH to Child D in this regard met her medical needs and was of a high quality. The hospital social work and family support service responded positively to the difficulties associated with a long inpatient stay some distance from the family home. 4.4.3 Between Child D’s discharge from LDUH on 29 November 2012 and 14 January 2013 when serious injuries were identified, Child D’s health care was the responsibility of the GP practice and the health visitor. 4.4.4 The GP offered appropriate advice and undertook the 6-8 week check. This is considered further in Section 4.7. 4.4.5 The health visitor undertook the new birth health assessment approximately a week after Child D was discharged from the LDUH. She persisted after missed appointments because she was aware of Child D’s medical condition and wished to undertake the assessment promptly. 4.4.6 She did not know the details of Child D’s mother’s childhood difficulties and so could not explore them further with her or evaluate how they might impact on her parenting. The main reason for this was that the normal handover arrangements between ante-natal and health visiting services had been bypassed because Child D had been admitted to GOSH for surgery immediately after her birth. 4.4.7 The health visitor’s judgement was that Child D’s health needs would be met if she were taken to weekly clinic as well as planned GP and hospital outpatient appointments. As the parents showed every indication of understanding what needed to happen and of coping well, the health visitor judged that more regular home visits by a nursery nurse (whose role would have been to advise on parenting skills) were not needed. 33 4.4.8 Later when a clinic appointment was missed the health visitor arranged additional contacts. This was an appropriate response to changed circumstances. 4.4.9 At no point did the health visitor notice any concerning aspect to the care that Child D was receiving. 4.4.10 The review has considered whether the judgements of the health visitor about the care provided to Child D might have been different if she had been informed about the extent of the mother’s childhood difficulties. There is no reason to believe that this would have been the case as the very positive picture of care currently being provided to Child D would not have been altered. 4.4.11 Working arrangements between the health visitor and the GP are considered further in Section 4.7. 4.5 Engagement of the father and assessment of his role 4.5.1 The SCR has examined the role of Child D’s father because the involvement of fathers in relation to services for safeguarding children is a matter of public policy interest and is stressed throughout government guidance on the Healthy Child Programme. The absence of information about men who subsequently proved to be a risk to children has been widely examined in the research on safeguarding children.12 4.5.2 The family court has determined that it was the father who caused the fatal injuries to Child D, though that could not have been apparent to any professional at the time. Significance in relation to the outcome for Child D 4.5.3 Compared to the mother, Child D’s father had little contact with professionals. In comparison to some fathers he was quite involved, attending some ante-natal appointments at LDUH and the antenatal appointment at GOSH. He was present at the new birth health assessment. His details were obtained by midwives and the health visitor but nothing significant was noted. 4.5.4 The father had no criminal record of significance in relation to safeguarding and there was nothing that happened in the case history that would have prompted anyone to check for evidence that he had posed a risk to children in the past. There was no such evidence. 12 S Shribman and K Billingham / Department of Health (October 2009) Healthy Child Programme – Pregnancy and the First Five Years of Life See for example HM Government, Brandon et al (2008) Analysing Child Deaths and serious injury through abuse and neglect: what can we learn? (England, 2003-2005) 34 4.5.5 The only incident of note occurred immediately after the birth of Child D when he lost his temper during a mix up over the transport arrangements to GOSH. This was properly detailed in the notes of the transfer made by the ambulance crew and copied as part of the package of material handed over to GOSH. The fact that the notes were handed over without comment suggests that the incident was not viewed as being significant. The staff involved have no further specific recollection. 4.5.6 On admission GOSH were focused on the surgery needed to rectify Child D’s medical difficulties and did not pay further attention to the entries in the notes about the father. In their subsequent dealings with him they had no concerns about his conduct. 4.5.7 Overall professionals sought to involve the father and achieved a good degree of success. Generally procedures and training in Luton reinforce the need to involve fathers in assessment of parenting and discussions about safeguarding. 4.5.8 There is nothing arising from this review to add to what is already known on this issue or to prompt different action. This is an area that the LSCB and its member agencies should continue to keep under regular review as it is a long established area of vulnerability in safeguarding services. However there is no new learning arising from this SCR which points to the need to a specific recommendation to be made in this regard. 4.6 Professional responses to bruising in small babies - the recognition of possible signs of abuse of Child D and the action taken by professionals Professional views of the overall standard of care provided for Child D by her parents 4.6.1 There were no general concerns about the care provided to Child D. All of the professionals who had contact with Child D and the family formed the view that the mother provided care of a good standard. 4.6.2 The SCR has seen and heard considerable evidence which would have supported this, including the following: Evidence of the mother’s concern for the wellbeing of the unborn child, advice followed and appointments kept both at the local hospital and at GOSH during the antenatal period Her detailed interest in the baby’s medical condition and compliance with all advice given Observation of the mother’s attention to Child D’s health needs, and skill in carrying out tasks required of her to care for the baby during the inpatient hospital admission 35 Warm, interested and engaged care observed by all professionals – including in hospital ward settings where staff are experienced in picking up parenting difficulties. 4.6.3 As the mother was the main carer and took Child D to most of her appointments there is less positive evidence of the quality of the father’s care for Child D. However he was noted to be concerned and affectionate, he visited Child D in hospital on several occasions and also attended a number of appointments. 4.6.4 Professional contacts with and views about the father have been described and evaluated in Section 4.5. 4.6.5 The couple were seen interacting with the baby by several professionals and were noted to be responding to the baby and to each other like any ‘normal family’. 4.6.6 The only clear indicator of possible child abuse was the bruise on Child D’s forehead which was observed by professionals on three occasions between 3 and 10 January 2013 as follows: By the child’s GP at the 6-8 week check 6 days later by a second GP at the same surgery At GOSH the following day. Some months after the death of Child D the mother indicated that she saw at least two other bruises on the baby’s face which occurred while she was in the care of her father and indeed that she took photographs of them. No information about these other bruises was ever provided to professionals. Significance in relation to the outcome for Child D 4.6.7 Clinical experience and research on the significance of bruising in an immobile baby as a symptom of possible physical abuse is clear. A recent research review summarises the position as follows: The Welsh systematic review group 13 provide a clear research evidence base for having child protection concerns when there is any bruising on any pre‐mobile baby….Because physical self-control and independent movement is very limited in young babies, it is extremely difficult for them to bruise themselves. Any bruising is likely to come from external sources. The younger the baby the more serious should be the concerns about how and why even very tiny bruises on any part of the child are caused. The explanation …that a pre‐mobile baby hurt 13 This is an established and highly regarded group based in Cardiff that has undertaken systematic reviews on medical aspects of child abuse. Its work has influenced the current NICE guidance on child abuse and wider paediatric practice. 36 herself while in her cot needs to be scrutinised very carefully and treated with suspicion.14 4.6.8 This research has in turn informed NICE guidance to health professionals which states that health professionals should ‘suspect maltreatment if there is bruising in a child who is not independently mobile’.15 4.6.9 As a result – and because of the great vulnerability of small infants – such presentations are treated in child protection training (including on foundation courses) as a significant indicator of potential risk. Universally child protection procedures and guidance indicate that an immobile infant with a bruise should be referred to social care for investigation or to an experienced paediatrician for advice and consultation. Both the Luton LSCB safeguarding procedures and the GOSH procedures are clear on this.16 Luton’s procedures apply to GPs and GOSH procedures cover the roles of all hospital staff. 4.6.10 It has now been confirmed that Child D’s bruise (and possibly some other bruises not seen by professionals) were caused by the baby being roughly handled by the father and that this was a potential warning sign for more serious injuries. It is very likely that if the bruise had been investigated thoroughly other injuries – including her fractured wrist – would have come to light. That being the case action could have been taken to protect Child D before the serious injuries that caused her death. 4.6.11 The SCR has examined these episodes in detail. For the different professionals involved the reasons that they did not report the bruise for further investigation were different, influenced by a range of factors that shaped their judgement and the circumstances in which they saw Child D. Contacts at the GP surgery in Luton 4.6.12 GP1 noticed and recorded the bruise at the 6-8 week check. He asked the mother what had caused it and the mother showed him a plastic toy explaining how the baby might have rolled onto it in a Moses basket. This appeared to the GP to be a plausible account because the toy had a hard centre, because the mother was otherwise considered to be caring and because he had no other concerns about the child. He 14 Marian Brandon et al (2011) Child and family practitioners’ understanding of child development: Lessons learnt from a small sample of serious case reviews University of East Anglia (page 5) 15 National Collaborating Centre for Women’s and Children’s Health - Commissioned by the National Institute for Health and Clinical Excellence (July 2009) When to suspect child maltreatment 16 Luton and Bedfordshire Multi-Agency Child Protection Procedures, http://bedfordscb.proceduresonline.com/index.htm and Great Ormond Street Hospital Child Protection Procedures 37 told the SCR review team that ‘had he any additional concerns at the time he would have referred this to a paediatrician to examine but in the absence of any such concerns he did not’. 4.6.13 He was sufficiently uneasy to have noted that this should be discussed with the child’s health visitor, though he made no attempt to contact her. There is no evidence that it is hard to contact the health visitor, at the least to leave a message. It is more significant that the GP was ambivalent about whether the presentation was concerning or not. 4.6.14 The GP told the SCR that he regretted the absence of the health visitor at the 6-8 week check. This is a practice that ended a number of years ago in Luton and it is not considered by the review team to have been a critical factor in his decision making. However the SCR has considered the involvement of GPs and health visitors in tasks within early years health provision as a wider issue of potential learning and service improvement. This is discussed further in Section 4.7. 4.6.15 Six days later Child D was brought to the surgery again over minor medical concerns. This time the baby was seen by a different GP who also noted the bruise. The SCR knows less about this incident because the GP had no specific recollection of the event. However this was potentially the more significant interaction. At that point there were two options open to the GP. The first was to treat the issues as one which had been resolved by the earlier contact. Psychologically and practically this was the easier option, especially as the first GP was the surgery safeguarding lead and knew the mother. The second was to re-evaluate the significance of the bruise because by that point it would have been less likely that the bruise – if it had been caused by a small baby leaning briefly on a plastic toy – would still be so obviously visible. The doctor chose the former course. Given the clinical consensus about the significance of bruising described above, this was disappointing but it is easy to see why it might have happened. Contacts at Great Ormond Street Hospital 4.6.16 The following day Child D was taken to a surgical outpatient appointment at GOSH. The clinic assistant has given the SCR a very detailed account of her observation of Child D and her interaction with the family. She noticed the bruise while taking routine measurements prior to the child seeing a surgeon. She was concerned about it, but decided that she wanted to seek the surgeon’s opinion and to give him an opportunity to ask the family how it had been caused. In this she was influenced by three factors. First, the bruise was very small and she did not feel that it was necessarily indicative of abuse. Second the parents said that they had already discussed it with another health professional. This was true though the clinic assistant did not know 38 that. Third, she wanted to consult the medically qualified, more experienced and more senior member of staff present before acting. 4.6.17 A strict interpretation of the hospital’s procedures indicates that as well as telling the surgeon it was her responsibility to refer the child to the social work service. However in the circumstances it would not have made sense to do this without first speaking to the surgeon. Her decisions and reasoning were considered and responsible. Her action in highlighting the existence of the bruise in a prominent position in the medical record where in common sense terms the consultant ‘could not miss it’ was sensible. It was reasonable of her to conclude that he would see it and evaluate it further. 4.6.18 She planned (and tried) to talk to the surgeon directly to highlight her concerns but she chose not to interrupt consultations with other patients. Before the end of this clinic she was redeployed to cover another clinic. She has given much thought to the alternative ways she could have used to flag her concerns, including finding a staff nurse. Hospital records show that the clinic assistant had previously made referrals to the social work service over child protection concerns and undertaken quite challenging tasks in cases where there had been suspicions of abuse. She had attended safeguarding training at the level expected by the hospital and a number of more recent less formal updates from the hospital safeguarding team. 4.6.19 The surgeon has no detailed recollection of seeing Child D. Unlike the clinic assistant for whom this was a very unusual event which she had been trained to consider, the evidence is that the surgeon viewed this as a routine outpatient surgical appointment and he noticed nothing unusual. He told the review that ‘my role on the day of the clinic was as the consultant from the paediatric surgical team reviewing a post-operative infant. I was looking for any complications of her previous … surgery and making a plan for … ongoing follow-up’. It is not clear whether the surgeon noticed the bruise or the prominent entry that the clinic assistant had made in the medical record drawing it to his attention. 4.6.20 As he does not remember seeing the clinic assistant’s entry in the medical notes, he cannot explain why he did not act on it. Given the lack of recall the SCR can only highlight factors that it believes may have been significant. The surgeon appears to have understood that his task was to focus on Chid D’s existing medical condition, rather than her overall health and welfare. The lack of a holistic approach to the patient is a recognised deficiency in the ‘medical model’. There is a risk that it may be exaggerated among surgeons, who rely on a highly specialised division of labour in order to accomplish tightly defined and often very challenging tasks. 39 4.6.21 The outpatient clinic is a busy one, however there is no indication that this was a factor reducing the likelihood of the bruise being identified and referred to the social work department in the proper way. 4.6.22 The surgeon’s lack of focus on ‘the whole child’ and on safeguarding responsibilities is likely to have been reinforced by lack of training. Despite a lengthy association with the hospital the surgeon had received only very limited safeguarding training. His last training session was an update session for consultants in 2004 which ceased to be ‘current’ in 2007. Not surprisingly his knowledge of the hospital’s actual child protection arrangements was very general, though he told the SCR that he had been involved in one complex safeguarding case. 4.6.23 The surgeon displayed a worrying attitude to his lack of training when communicating with the SCR, noting that ‘I have received child protection training, but I cannot remember when this occurred’. 4.6.24 The hospital is clearly at fault for not ensuring that annual appraisals addressed the lack of training required by professional guidance and hospital policy. The hospital’s training records show that at the time of Child D’s death its compliance with some aspects of national professional training requirements was poor.17 4.6.25 The GOSH system for regularly monitoring compliance had only been set in place in late 2012. In February 2013, 59% of junior doctors (at grades up to and including senior and specialist registrars) had up to date safeguarding training at level 3. At November 2013 this stood at 69% and in June 2014 it stood at 65%. In February 2013 37.9% of consultant physicians and 31% of consultant surgeons had been trained to level 3. By November 2013 this had risen to 97% and 84%. The level expected during regulatory inspections of hospitals is 80%. 4.6.26 These figures include only staff who have been in post for over 12 months. This is in keeping with the wording of the intercollegiate guidance document. However as training levels are likely to be lower among staff in post for shorter periods the figures given above may overestimate the overall level of staff who have been trained. It would be useful for the hospital to know what the position is in relation to newer members of staff, not least as this would enable it to plan and target training more effectively.18 4.6.27 An additional vulnerability may have arisen from the fact that the surgeon had an honorary role at GOSH. Figures for visiting honorary staff were below 10% in both February and November 2013, although more had completed some online programmes and partly complied 17 Royal Colleges of Paediatrics and Child Health, (September 2010) Safeguarding Children and Young people: roles and competences for health care staff, Intercollegiate Document 18 The hospital has separately provided a description of its arrangements for staff induction under the inter-collegiate guidance document 40 with national requirements. In June 2014, 58% of honorary medical staff had completed level 3 safeguarding training. 4.6.28 GOSH has a very large number of honorary staff who fulfil a wide range of roles, some purely observational. This complicates the monitoring of compliance with training. Some staff have received training in the health trusts and institutions in which they are normally based. The hospital recognises that it needs to continue to monitor the position of honorary and visiting staff so as to ensure that safeguarding training is made available when that is required. 4.6.29 The hospital needs to work to continue to improve its performance in relation to child protection training, ensure that gaps in safeguarding training are identified in staff at all levels through the appraisal process and then that action is taken. Those who have this responsibility need in future to have the full support of trust’s board members in ensuring that this task is prioritised. GOSH needs to ensure that all consultant staff have up to date safeguarding training and that they are in a position to lead their teams on this issue, rather than rely on more junior members of staff to take responsibility for safeguarding. 4.6.30 Attendance at training sessions or involvement in online training will not provide a complete answer. The hospital needs to ensure that all staff are able to reflect on the particular difficulties that may inhibit the implementation of their safeguarding knowledge in the circumstances in which it needs to be applied, such as a busy outpatients clinic in which there is a constant flow of medically challenging cases. This is a more complex task than achieving compliance with numerical training level targets. 4.6.31 The SCR has considered whether the professional hierarchy had a negative impact on the ability of the clinic assistant to assert her concerns in the face of the consultant surgeon’s ‘busyness’. She says that it did not and all the indications are that she is a confident member of staff. However this can be an important factor in inter-professional discussions which the hospital should also address as part of its safeguarding strategy and training programme. Staff at all levels need to be assisted to develop the sort of ‘soft skills’ that are needed to challenge more senior staff when they feel that to be necessary. Significance in relation to wider service provision for vulnerable children 4.6.32 Bruising in an immobile baby is one of the most commonly cited ‘strong’ indicators of physical child abuse. Inexperienced professionals attending foundation training programmes will often correctly identify 41 it as a very concerning presentation. The difficulty is in the transfer of learning from the classroom to the real world. 4.6.33 A recent review of SCRs which studied the importance of professional knowledge of child development identified a number of cases in which professionals had failed to respond to bruising of immobile babies in keeping with the potential level of risk. These all point to other factors in the assessment which served to distract attention from the significance of the bruising. 19 4.6.34 In relation to Child D the main contributory factors in relation to the failure to refer the bruise for further investigation were uncertainty about its seriousness due to its small size (first GP and clinic assistant); factors associated with the task being undertaken (surgeon) and the context in which staff were working (clinic assistant); lack of training and mindfulness of safeguarding as a potential concern (surgeon); failure to question a previous assessment in the light of new circumstances (second GP). This indicates that as well as providing more training the different factors that inhibited action over a strong indicator of potential abuse need to be addressed in the context in which they occur. 4.6.35 This case history should also serve to dispel the belief that a bruise on an immobile baby is less significant because it is small. 4.6.36 One of the factors not cited in the research but cited in some SCRs and anecdotally of importance is that professionals fear 1) damaging relationships with parents and 2) making an allegation that proves to be unfounded. The evidence given by the mother of Child D to the care proceedings is instructive in this regard. At the time it appeared that she was presenting professionals with a definite account of the circumstances in which the bruising was caused. She later admitted that she had no idea how it had happened and that when she described the cause of the injuries (with apparent certainty) she had in fact ‘gone to the doctors with guesses’. A more challenging and sceptical approach might have helped her face up to the fact that the bruise had been caused by her partner’s mishandling of the baby. 4.6.37 Luton LSCB should consider whether there is at present sufficient guidance for professionals on the pathway for discussing and referring 19 The reasons given by professionals were that 1. children had complex health needs or disabilities and the bruising was somehow (but implausibly) connected with this; or 2. the child’s development was otherwise good; or 3. the person who posed a perceived risk of harm to the child (e.g. a dangerous male figure) was believed to be out of the picture; or 4. the parents were hostile or difficult and somehow stopped the practitioner from seeing clearly. Brandon et al Child and Family Practitioners’ Understanding of Child Development: Lessons Learnt from a Small Sample Of Serious Case Reviews (2011) DFE RR100 42 concerns about bruising and the threshold for doing so. A number of LSCBs have developed specific bruising ‘protocols’ and the board should consider whether this should be done.20 If this work is commissioned it should involve consultation with relevant professionals (including GPs) to make it as relevant as possible to their needs. The LSCB should consult with and seek to learn from the experience of other LSCB areas where revised arrangements for responding to bruising have been implemented. 4.6.38 GOSH should satisfy itself that the take up of safeguarding training is rapidly brought into line with the expectations of professional bodies, commissioners and regulators and that training impacts positively on the performance of its staff at all levels. 4.6.39 Reviews commonly refer to the need for professional curiosity.21 This case highlights that as well as understanding the need for this quality ‘in theory’ agencies need to address the difficulties that arise in exercising professional curiosity in the everyday work context. Curiosity should not be viewed solely as a personality trait. Organisations must encourage and enable their staff to be curious. 4.7 Working arrangements between health visitors and GPs in relation to the 6-8 week child health review and other elements of the Healthy Child Programme 4.7.1 This section of the report looks in depth at the approach taken to the 6-8 week check and to working arrangements between GPs and health visitors. This is of wider significance to services for infants and small children in Luton. It stands in addition to the more specific findings on bruising in section 4.6. Working arrangements between health visitors and GP practices 4.7.2 GP1 told the SCR that he ‘regretted the absence of the health visitor at the 6-8 week check which was a practice in the past which was very useful in complimenting medical checks with wellbeing checks and also facilitated person to person discussion and hand over of any concerns’. 4.7.3 The system described by the GP (whereby health visitor allocation was determined by the child’s GP practice and each practice had its own health visitor) ended in Luton some years ago. Health visitors’ perceptions of such arrangements – in Luton and elsewhere – were frequently negative as they often felt themselves to be the junior 20 For example http://www.4lscb.org.uk/documents/Hampshire%20Docs/BruisingProtocolflowchart.pdf ; http://berks.proceduresonline.com/chapters/p_recog_resp.html#phys_abuse 21 See for example K Broadhurst et al (2010), Ten pitfalls and how to avoid them - What research tells us www.nspcc.org.uk/inform 43 partner in the relationship, left by some GPs to sort out the ‘social problems’ with difficult families. 4.7.4 Luton’s health visitors now have caseloads drawn from a number of GP practices. They lead small teams of health care professionals. This is an established national way of organising services which is not going to change in the foreseeable future. Of course no system is without disadvantages. 4.7.5 In Luton there are arrangements which should allow each GP practice to identify the health visitor who is responsible for each child so that GPs can communicate any concerns. Each practice has a ‘link’ health visitor who will identify the child’s allocated health visitor and liaise if there are problems. 4.7.6 The health visitors involved with this family were asked by the SCR to comment on the current approach. They felt that it worked in a satisfactory way, though (inevitably) GP practices related in different ways to the health visiting service. Some link health visitors regularly attended meetings at their GP practice, while others were not invited. Relationships between the health visitors and the GP practice where the mother and Child D were registered were described by health visitors as being ‘good’. 4.7.7 GP practices that use the same electronic recording system as the community health service can agree to ‘share’ information automatically and send one another tasks and updates. Used properly this allows professionals to alert one another to significant developments. Child D’s GP practice used another widely known electronic system which cannot communicate directly with SYSTMONE. Communication between the GP and the health visiting service 4.7.8 Section 3 of this report has noted a range of factors that complicated the provision of health care in this case: the mother had a troubled and abusive family background; Child D had an acute medical condition which resulted in a long hospital admission and disrupted the normal course of post natal discharge; Child Y (the older half sibling) had behavioural problems that had led to a referral to the Child Development Centre. 4.7.9 Despite this degree of complexity at no point during Child D’s life did the health visitor and the GP communicate directly (i.e. by phone, email or face to face) about their contacts with the family. Information about the outcome of the 6–8 week check was added to the community child health record, which the health visitor could access, as part of the routine sharing of information. The GP thought about talking to the health visitor about the bruise seen at that check but did not do so. Tasks and responsibilities were undertaken separately. 44 4.7.10 Recognising this does not imply individual criticism of either party because this approach would be considered normal by most GPs and health visitors. The Department of Health ‘Healthy Child Programme’ envisages a series of contacts with health professionals in the first 3 years of a child’s life. These are ‘opportunities for screening tests and developmental surveillance, for assessing growth, for discussing social and emotional development with parents and children, and for linking children to early years services’.22 Government guidance sets expectations about the quality of each element, while paying little attention to the way in which the different professionals involved might work together more effectively. That is left to local working practice. 4.7.11 In Luton – as in most areas - these checks and assessments are commissioned to be conducted by different health professionals. The service specification of the health visiting service in Luton is to conduct the new birth visit and to ‘promote attendance at all health surveillance checks including the 6-8 week review by the GP and developmental reviews at 12 months and at 24 months’ (emphasis added). It permits greater collaboration and this may happen in some cases. 4.7.12 The SCR review team has considered whether there are ways in which GPs and health visitors could work in a more collaborative fashion in relation to the key tasks in the Healthy Child Programme. This case shows how undertaking more tasks collaboratively, in cases that meet certain agreed criteria, might be beneficial. The health visitor undertook the new birth visit to Child D with no knowledge of the family background – which was readily available from the GP records. The details of the new birth visit – which included details of the plan made by the health visitor to meet Child D’s additional health needs -were never known to the GP. The findings and outcome of Child D’s new birth assessment would have been of potential interest to the GP and given him a much fuller picture of the child’s context before undertaking the 6-8 week health check. 4.7.13 There is a strong case that when an infant has been assessed as having needs beyond those that can be provided by the universal child health programme, developmental assessments and checks that are currently carried out as a single agency or professional responsibility should be undertaken more collaboratively. This would strengthen safeguards for more vulnerable children. 22 Department of Health, (2009) Healthy Child Programme Pregnancy and the first five years of life (page 37). ‘Scan at the 12th week of pregnancy; the neonatal examination; the new baby review (around 14 days old); the baby’s six to eight-week examination; by the time the child is one year old; and between two and two-and-a-half years old.’ 45 4.7.14 Information about the outcome of the 6-8 week check on Child D had been copied onto the electronic record system of the health visitor (SYSTMONE) but under current arrangements she had no reason to seek it out. If she had had this responsibility because Child D had been identified as being vulnerable or had the GP actively identified the existence of the bruise as being something for her attention it would have offered an opportunity for a professional with a fresh pair of eyes to spot a potentially significant sign of abuse. 4.7.15 It is easy to imagine the advantages of GPs and health visitors collaborating more than they currently do, but much more difficult to work out how to make it happen without disadvantaging other important tasks and relationships. For the reasons described in paragraphs 4.7.2-4.7.4 above this is very unlikely to happen through the regular direct involvement of health visitors in examinations at GP practices. However it should be possible through increasingly available means of communicating electronically and sharing records. 4.7.16 At present many discussions about this focus on the difficulties of achieving greater integration, such as the fact that different providers are free to purchase different systems which sometimes do not ‘talk’ to one another. From the LSCB perspective the emphasis needs to be placed on solving the problems by commissioners of health services making clear the basic requirement that every electronic patient record system is able to share information with linked services used by the same vulnerable patients. 4.7.17 Increased use of electronic information sharing of information may open up possibilities but it is not always without disadvantages. It may make professionals less likely to communicate by talking to one another or having meetings (though in this case the GP and health visitor did not talk to one another about Child D). 4.7.18 While there may be no obvious solution which does not have potential disadvantages, there is clearly value in health visitors and GPs in Luton (and those who commission their services) using the published findings of this SCR as a starting point for discussions about how they could implement the Healthy Child Programme differently in relation to particular groups of vulnerable children. The SCR has made a recommendation in relation to this. 4.8 Access to urgent and emergency health care in Luton for babies and small children Significance in relation to the outcome for Child D 4.8.1 Child D was taken by the ambulance service to the LDUH the evening before she was admitted to hospital with serious injuries. Child D was 46 ‘streamed’ by a nurse and seen by a GP working at the GP Urgent Care GP clinic at the hospital. (The term ‘streamed’ is explained below). The GP Urgent Care GP clinic is provided by a private healthcare company. 4.8.2 There is unanimity among medical experts that the injuries that caused Child D’s death were inflicted after that visit. The practice of the professionals did not impact on the outcome for Child D. However Child D’s attendance at LDUH highlights features of the normal way in which children and babies access services at LDUH which merit further consideration. The patient pathway at Luton and Dunstable University Hospital Emergency Department 4.8.3 Members of the public arriving at the Emergency Department (ED) at LDUH are met by a qualified nurse whose role is to ‘stream’ patients (including young children) signposting them to attend either the LD or the GP Urgent Care Clinic which is located at the hospital. 4.8.4 The purpose of this arrangement is to enable members of the public to obtain the right service quickly and to avoid the unnecessary use of ED, when this will bring no added benefit.23 Efforts to reduce inappropriate use of ED also reflect a concern to reduce waiting times and costs (because the hospital makes substantial charges for each patient seen at ED). These are national concerns but they are particularly pertinent in Luton which has a lower than average rate of permanent GP registration, which in turn encourages ED attendance. 4.8.5 Patients who are not obviously gravely ill or injured arriving at LDUH (or in the case of children their carers) are interviewed and visually assessed by a screening nurse. This is a senior and experienced member of staff. The streaming arrangement avoids the need for duplicate payment to be made to LDUH and the GP Urgent Care Centre and locates accountability for the treatment provided with the service that receives the patient after the streaming process. 4.8.6 LDUH does not expect the nurse to make a record of the contact, the advice given or the reasons for it. The term ‘stream’ is used in contrast to the usual ‘triage’ which suggests a clinical input. 23 According to the Luton CCG specification for this service national evidence suggests that approximately 30% of self-attendees at ED have problems that can be managed effectively by a GP or another primary care professional and at least a further 20% have conditions that are amenable to being seen in a primary care setting. National estimates of the proportion of patients who could be treated outside of ED vary between 10% and 40%. Figures quoted on this topic are potentially confusing because they are used to illustrate different perspectives on the problem. Higher figures identify the proportion of patients who might in theory be treated away from ED. Lower figures identify the much smaller number who can in reality be treated away from ED taking into account the actual availability of alternative provision in the local health economy. (Today, Radio 4, 21 May 2014). 47 4.8.7 Whilst this system may seem unnecessarily complex to the ordinary person, it is common for EDs to develop arrangements such as this to manage the relationship between ED and GP Urgent Care. Some hospitals have developed systems which default to the assessment of small children at ED. At LDUH the current arrangement is viewed as being an improvement on the previous system which was to employ trained hospital receptionists to undertake the task with support from a doctor or a nurse if required. Significance in relation to wider service provision for vulnerable children 4.8.8 Prior to the implementation of the streaming arrangement all children under the age of 6 months who presented at LDUH ED were referred to a paediatrician in the ED. The SCR was informed that some professionals at the LDUH had reservations about the introduction of the current system because it meant that fewer children would be seen in ED and because there would be no record of the advice given to the patient being streamed. 4.8.9 When Child D attended the LDUH all infants presenting at the hospital were streamed. When the SCR report was finalised (June 2014) the arrangements had been modified so that the following groups of children were referred directly to ED: any infant under six months any child with an apparent head injury any child arriving at LDUH by ambulance. 4.8.10 Whilst the SCR is clear that Child D’s contact with the GP Urgent Care GP was of a high clinical standard and had no bearing on her death, the fact that this matter has been highlighted offers an opportunity for the health commissioner, the LDUH and the provider of the GP Urgent Care Clinic service to review how the streaming arrangement is working specifically in relation to small children. 4.9 Assessment of parental learning difficulties and their impact on parenting 4.9.1 During the planning phase of the SCR it was noted that a number of professionals dealing with Child D’s mother had expressed concerns that she might have a learning difficulty. This was explored through the review of records and interviews with staff. In order to provide a longer term perspective the review obtained information from social care and education records from the mother’s adolescence. 4.9.2 The SCR was also able to review information from the fact finding in the care proceedings. Prior to this there had been no formal assessment of the mother’s intellectual and cognitive ability. This 48 material showed marked contrasts between the perceptions of professionals who were involved at different points. 4.9.3 The mother’s learning difficulties have no direct bearing on the death of Child D; however it is likely that if their impact on her capacity as a parent had been better understood more or different help might have been offered. 4.9.4 None of the professionals who had been in contact with the mother during the five years prior to the death of Child D felt that she had a learning difficulty. Midwives noted that she had what she described as dyslexia (this was in response to a question asked to all parents in antenatal clinic). However she was in practice able to complete a detailed, written birth plan for Child D’s delivery and showed a very good understanding of her pregnancy and labour and the medical procedures that would be necessary after the baby’s birth. 4.9.5 Very similar comments were made by the nurseries and schools that had contact with the mother over Child Y. They found her able to discuss and understand their concerns about Child Y’s emotional and behavioural development and to implement and review the strategies and suggestions that they made. The social worker at GOSH was impressed with the understanding that the mother had of her past abuse and her determination not to allow anything similar to happen to her own child. 4.9.6 None of the professionals who saw Child D’s mother believed that she had obvious learning difficulties or that this was a factor that might adversely affect her care of Child D. None felt that there was the need to carry out a formal assessment or diagnosis to confirm this and none had the means to do so. Given the material that the SCR has seen relating to the period before the death of Child D there was no apparent need for this to happen. 4.9.7 The mother’s school records present a mixed picture. The mother completed secondary school but did not achieve any qualifications. One secondary school record notes that she had ‘moderate learning difficulties’ and needed additional help. Most records attribute her difficulties in school to low self-esteem and family problems which severely demotivated her. 4.9.8 After Child D’s death the mother underwent a very detailed assessment by a forensic clinical psychologist. The findings contrast markedly with the recent professional views. This assessment identified the mother as having an IQ score which placed her in the lowest 3% of the population and identified significant difficulties with memory recall. The conclusion of the court was that the mother ‘would find independent living quite difficult and would be dependent on other 49 people for more complex daily problem-solving skills’. This in turn would mean that she ‘would find the more complex aspects of parenting difficult, such as those which required quick decision making and prioritising of information’. 4.9.9 The court treated this as an important aspect of the mother’s vulnerability. However the impact of the assessment was a complex matter for the court because after careful consideration it also decided that it was right to place considerable weight on her recollection of events and her credibility as a witness. The court concluded that the mother herself ‘underestimates her abilities’. 4.9.10 An assessment based on only short term contact with a parent who was at the time under a great deal of stress may have limitations. However there is no reason to doubt the psychologist’s overall finding and to recognise that if a more detailed assessment had been triggered sooner it might have offered professionals very useful additional information. This might in turn have influenced the interventions that were made. 4.9.11 This serves to highlight the importance and complexity of assessing whether a person has learning difficulties and the extent to which they may impact on the care of vulnerable children. Child D’s mother had no difficulty in providing practical care for children, either in a general sense or when asked to carry out complex tasks to meet Child D’s health needs. She had no difficulty understanding and implementing plans to help her daughter’s behavioural problems. However the combination of a degree of learning disability and her generally low self-esteem made it difficult for her to manage independently, to judge the actions and intentions of others and to take the actions necessary to protect her children. 4.9.12 So the assessment of learning difficulty has to be related to the person’s social context. For Child D’s mother these aspects of parenting were made even more challenging by the fact that her only other likely source of support – her own extended family – included a number of abusive individuals. She knew that she could not rely on her family to help care for her children safely. Both aspects echo the circumstances of a very vulnerable parent whose child was injured and about whom Luton LSCB conducted a SCR in 2011.24 4.9.13 It is a common experience that full assessments of the impact of learning difficulties on a person’s parenting capacity are usually only available in two circumstances: either when a case has reached care proceedings (as specialist resources are available to support cases in care proceedings) or when the learning difficulties are very marked 24 Child B SCR Executive Summary http://lutonlscb.org.uk/learning.html 50 (and the parent independently meets the criteria for learning disability services). 4.9.14 It is much more difficult for professionals working in circumstances where there are lower levels of identified need (either adult needs or needs of the child) to access assessment and advice on this topic. However it is clear that assessments of parents’ intellectual level and cognitive ability need to be more widely available – and at an earlier point - because they can add to the understanding that professionals such as midwives, health visitors, GPs and social workers have of the factors that are likely to impact on parenting. 4.9.15 This is not a simple matter. Steps to improve services may include commissioning of different services, raising awareness, improved training and making available advice and consultation to staff working with potentially vulnerable parents. Luton LSCB should consider how it can make the most useful contribution to improvements in this provision. The SCR has made a recommendation in relation to this. 51 5 Summary of findings and recommendations The provision made for Child D and other family members 5.1 The SCR was conducted because the post mortem examination of an 11 week old infant, Child D revealed three findings which are strongly associated with injury caused by shaking. In care proceedings it was subsequently determined that the injuries that caused Child D’s death were inflicted by her father and that she had also been roughly handled on one or more occasions by him. The family court determined that the child’s mother did not at the time know how the injuries had been caused. The father was found guilty of Child D’s manslaughter. 5.2 Child D’s mother has also admitted that she shook Child D ‘gently’ when she seemed to have stopped breathing. It is apparent from evidence given in care proceedings and in the criminal investigation and trial that neither parent was sufficiently aware that shaking an infant could cause very serious harm. 5.3 After the death Child D’s mother stated that the baby had been bruised on three occasions when in the care of her father. One of these bruises (possibly not the most serious) was seen by four health professionals on three occasions in the two week period prior to the time when serious injuries were inflicted on Child D. 5.4 After she had been seriously injured it was found that Child D had two fractures, believed to have been 6-8 weeks old. The cause of these has not been determined, though they are of a type and in locations that are consistent with a clinical picture of physical abuse. There are however other possible explanations. Whatever their cause the fractures would not have contributed to the child’s serious illness or death and would not have been noticeable in the course of day to day contact with the baby nor when Child D underwent routine medical examinations. However if they had been identified it is very likely that they would have been treated as indicators of possible abuse and investigated thoroughly. 5.5 Child D had a medical condition identified during pregnancy. Surgical treatment for this potentially serious condition was carried out immediately after her birth. It went well and there are no concerns about the health service support that the child received in relation to this, either at Great Ormond Street Hospital (GOSH) or after her discharge. 5.6 The mother of Child D came from a family in which there was abuse and other social problems and at different times she received a good level of support from professionals over this. Local authority social care services had been involved with the mother in 2006 over this, but 52 had had no substantial recent involvement. The health visitor who provided care to Child D and her mother was not aware of this significant background. 5.7 The antenatal service knew about this but the information was not shared with the child’s health visitor for three reasons 1) during the pregnancy there had been no concerns about the mother and father’s capacity to care for Child D 2) because of her complex medical condition Child D followed an unusual ‘care pathway’ i.e. rather than being discharged straight home after birth the baby was admitted to GOSH for a lengthy inpatient stay, then to a local paediatric ward before going home for the first time and because 3) potentially significant information about the mother’s childhood held in the GP records was not identified and shared with other health professionals. 5.8 Child D’s mother did not harm her but she was less able to protect the baby because of her troubled background and her learning difficulties. The latter had not been apparent to the professionals who had been in contact with her. 5.9 Child D had an older half-sibling who experienced behavioural difficulties from the age of two onwards. A number of factors contributed to these including a medical condition, attachment problems and exposure to incidents of domestic abuse in two of the mother’s relationships. Health and education agencies in Luton responded to the child’s behavioural problems by seeking assessment and involving a range of support services. Their response was entirely appropriate to the needs presented. There were no safeguarding risks identified in relation to Child D’s half-sibling, though there were some shortcomings in the way in which she was cared for. 5.10 The only sign of potential risk to Child D that was observed during the baby’s life was that on three occasions professionals observed a small bruise on the baby’s head. This is a strong indicator of concern in an immobile baby but – for a variety of reasons – the professionals did not refer Child D to the local authority or seek advice from a child protection specialist such as a Named Doctor or Nurse. 5.11 It is not possible to say with certainty what the outcome of such a referral or discussion would have been, but it is very likely that it would have led to further more detailed investigation of the nature of the injury, the plausibility of the explanation given and the context in which the injury had occurred. It is possible that this investigation would have led to the discovery of the fractures that Child D had previously suffered and steps being taken to safeguard Child D before she suffered further injury. 53 5.12 The SCR has examined the specific circumstances in which bruising to Child D was seen but not acted on. It has sought to understand fully the actions and decisions taken and to examine the circumstances in which professionals were operating. It has made recommendations which are designed to reduce the likelihood of similar shortcomings in services occurring again. The wider implications for services to safeguard children 5.13 The review team has used the detailed assessment of the provision made to Child D as a starting point for identifying evidence of wider vulnerabilities in the arrangements to coordinate health services for vulnerable children in Luton and at GOSH. This applies not only to obvious and specific concerns about practice episodes which may have impacted negatively on Child D but also on the way in which health provision is ordinarily made that have been highlighted by the review. Attention has focus on patterns of service provision that occur more commonly and are thus likely to have a wider impact on children. Recommendations and proposals for further work which are linked to the circumstances of Child D’s death 1 The LSCB should share the findings of the SCR with Camden LSCB. Both LSCBs should monitor the action being taken to implement the findings and disseminate the lessons of the review to professionals (while ensuring that discussion of the case does not prejudice the criminal prosecution). 2 Luton LSCB should give detailed consideration to the messages about the vulnerability of babies and the risks associated with even momentary shaking that emerge from the SCR. Member agencies commissioning or providing services to potential parents and parents of small children should take action to improve the safeguarding of children in relation to this. Recent initiatives such as the NSPCC ‘Coping with crying’ and ‘Preventing non-accidental head injury’ programmes should be considered. 3 Luton LSCB should review present guidance for professionals on the pathway for the identification and referral of concerns about bruising. It should consider the value of adding a specific bruising ‘protocol’ to the multi-agency procedures, in consultation with the other LSCBs that share those procedures. 4 Luton LSCB should undertake a review of current approaches to the assessment of learning difficulty as a factor that may influence parenting and consider how best to improve the availability of such assessments at targeted service level and child in need level. 54 5 Great Ormond Street Hospital should ensure that consultants (including honorary members of staff) have up to date safeguarding training and provide leadership to their multi-disciplinary teams on this issue, as they do in other areas of clinical practice. 6 Great Ormond Street Hospital should ensure that gaps in safeguarding training are consistently identified in all staff appraisals, regardless of the seniority or role of the staff member 7 Luton LSCB, commissioners of health services in Luton, Cambridge Community Services NHS Trust, Luton and Dunstable University Hospital NHS Trust and Great Ormond Street Hospital NHS Foundation Trust, should consider further how they can improve the ability of staff to transfer the lessons of training about the recognition of child abuse and neglect into their normal working environment. Recommendations and proposals for further work on wider services for children identified in the course of the SCR 8 Luton GPs, the NHS England Area Team (which commissions their services), the CCG and Luton and Dunstable Hospital should review the current arrangements for information sharing between GPs and LDUH at the point of referral for antenatal booking and during pregnancy. The aim should be to find ways of increasing the identification and sharing of relevant background social information about pregnant women and their partners. 9 As part of the current review of the school nursing service the Director of Public Health for Luton and Cambridge Community Services NHS Trust should consider how to improve transfer of cases from health visitors to school nurses. 10 NHS England, Luton CCG, GPs and Cambridge Community Services NHS Trust should review the current delivery of the Healthy Child Programme in order to explore: 1) whether there are better ways of sharing information between GPs and health visitors (including the use of electronic systems) and 2) whether more tasks in the Healthy Child Programme can be a shared responsibility for health visitors and GPs in cases when the child has been identified as being vulnerable. 11 Luton CCG, the Luton and Dunstable University Hospital (LDUH) and the provider of the GP Urgent Care Clinic should review the safety and the quality of provision made under the current streaming arrangement at LDUH in relation to children under the age of 12 months. 55 Appendix I REVIEW TEAM MEMBERSHIP Agency Designation Luton Clinical Commissioning Group Consultant Paediatrician and Designated Doctor for Safeguarding Children Assistant Director / Designated Nurse Safeguarding Children Named GP for Safeguarding Children and Adults Luton Borough Council Children and Learning Department Head of Specialist Family Support Services Luton and Dunstable University Hospital Lead Nurse for Safeguarding Children Great Ormond Street Hospital and NHS Foundation Trust Head of Safeguarding and Named Nurse Cambridgeshire Community Services NHS Trust Named Nurse Safeguarding Children Luton Safeguarding Children Board Business Manager Administrator Independent Lead Reviewer 56 Appendix II List of documents and material considered by the SCR review team and roles of professionals who have contributed Chronologies of contact with family members from participating agencies Copies of selected original patient records Notes of interviews and discussions conducted with the following professionals: Luton and Dunstable University Hospital NHS Trust Midwives Emergency Department Screening Nurse Paediatrician Safeguarding Midwife Cambridge Community Health Services NHS Trust Health Visitors Luton Borough Council Social Worker Great Ormond Street Hospital NHS Foundation Trust Social Worker Family Support Worker Clinic Assistant Honorary Consultant Surgeon GP Urgent Care Clinic General Practitioner GP practice General Practitioners Schools and nursery schools Teachers, Nursery Worker, Nursery Manager, Teaching Assistant (taped interview) reviewed by the Principal Educational Psychologist Luton Borough Council 57 Appendix III Principles from statutory guidance informing the SCR methodology 1. The approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined. 2. Reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed 3. Professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith. In addition Serious Case Reviews should: Recognise the complex circumstances in which professionals work together to safeguard children. Seek to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did. Seek to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight. Be transparent about the way data is collected and analysed. Make use of relevant research and case evidence to inform the findings. Working Together to Safeguard Children 2013 (Sections 4.9 and 4.10) 58 Appendix IV References HM Government, Working Together to Safeguard Children – 2013 HM Government, LSCB Regulations 2006 M Brandon et al (2008) Analysing Child Deaths and serious injury through abuse and neglect: what can we learn? (England, 2003-2005) M Brandon et al (2011) Child and family practitioners’ understanding of child development: Lessons learnt from a small sample of serious case reviews University of East Anglia K Broadhurst et al (2010), Ten pitfalls and how to avoid them - What research tells us www.nspcc.org.uk/inform E Hollhangel, J Braithwaite and R Wears (2013) Resilient Health Care; Ashgate National Collaborating Centre for Women’s and Children’s Health - Commissioned by the National Institute for Health and Clinical Excellence (July 2009) When to suspect child maltreatment OFSTED, (2011) Ages of Concern: Learning Lessons from Serious Case Reviews a thematic report. E Rowley and J Waring (eds) (2013), A Socio-Cultural Perspective on Patient Safety, Ashgate Royal Colleges of Paediatrics and Child Health, (September 2010) Safeguarding Children and Young people: roles and competences for health care staff, Intercollegiate Document S Shribman and K Billingham / Department of Health (October 2009) Healthy Child Programme – Pregnancy and the First Five Years of Life Charles Vincent (2010) Patient Safety (second edition) Wiley-Blackwell BMJ Books L S C B Serious Case Review in relation to the death in January 2013 of Child D Response from Luton Safeguarding Children Board In March 2013 Luton Safeguarding Children Board began a Serious Case Review (SCR) in relation to the services that were provided to Child D and her family. The review scrutinised the work of the following agencies: • Cambridge Community Services NHS Trust – which provides community health care for children in Luton, including health visiting services • Luton and Dunstable University Hospital NHS Trust (LDUH) – which provided midwifery, child health and emergency department services • GP surgeries and the GP Urgent Care Clinic (located at the LDUH) • Great Ormond Street Hospital NHS Foundation Trust – which undertook surgery on Child D • East of England Ambulance Trust • Cambridge University Hospitals NHS Foundation Trust – which provided a specialist ambulance service. • A playgroup; a nursery and a school (all in Luton) attended by the older half sibling of Child D The full findings of the SCR are set out in the overview report which has been published alongside this response. The publication of this report was delayed in order to ensure that it did not prejudice the criminal investigation into Child D’s death. The table below sets out the main points of learning from the Serious Case Review and the action that has been taken to improve services and make children safer, both in Luton and at Great Ormond Street Hospital. With a small number of exceptions the case review highlighted problems that are not amenable to simple solutions, so that the work to implement the recommendations and to monitor their impact on practice will become part of the long term work of the safeguarding boards and their member agencies. In relation to its previous Serious Case Reviews the safeguarding board has asked member agencies for periodic updates to understand whether the work that has been undertaken have made a positive impact on services and on the lives of children. The board will continue that practice and publish the responses of agencies on its website. Professor Michael Preston-Shoot Independent Chair Luton Safeguarding Children Board October 2015 Luton Safeguarding Children Board Town Hall Extension Gordon Street Town Hall Luton LU1 2BQ Business - 01582 547624 Training - 01582 547555 Learning from the Serious Case Review Action that has been taken since January 2013 and the impact of those measures Continuing work to make children safer and improve the quality of services 1. The case history underlined the high level of vulnerability of small infants and the dangers of shaking them, even momentarily. Luton LSCB decided that agencies that commission or provide services to potential parents and parents of small children should take action to improve parental understanding of this. Luton LSCB and member agencies have implemented this in two ways. Luton LSCB and agencies that work with parents and infants have been working with the NSPCC in an initiative entitled ‘Coping with Crying’. This includes publicity materials, including a DVD, designed to be shown to new parents, and training materials for professionals. The initiative underlines very strongly the dangers of shaking infants and small children. Training materials have been incorporated into the training programmes of Luton LSCB and member agencies. Luton Clinical Commissioning Group (CCG) is also exploring how best to adapt the content of the parent held child health record the ‘Red Book’, to ensure that it provides very clear information on this and that professionals who issue and use the red book draw the attention parents to this information. The first phase of ‘Coping with Crying’ is being evaluated nationally with a view to it being made available in a wider range of hospital and community health settings. Luton agencies will implement the ‘Coping with Crying’ initiative when revised materials become available. Lessons from the current evaluation of the project will be taken into account to improve the dissemination of information to parents. A revised ‘red book’ will be in use in Luton from September 2015. Luton LSCB will continue to challenge member agencies to demonstrate that they are explaining the dangers of shaking a baby to parents, especially those who are vulnerable or under stress. 2. Two health professionals in Luton saw small bruises on an immobile infant, but for different reasons were unable to challenge the accounts given by a parent as to how this had happened. In hindsight it became apparent that the mother herself was looking for answers and would not have been alienated if she had been challenged. Luton LSCB agreed that it would review its guidance for professionals on the pathway for the identification and referral of concerns about bruising and add a specific bruising ‘protocol’ to the multi-agency procedures because that was an Luton LSCB and its member agencies have adopted a specific procedure on bruising (the bruising protocol) which sets out the actions that all professionals are expected to take when they recognise that a child has been bruised. The bruising protocol was adapted from one that had been working successfully in a neighbouring local authority area. It explicitly addresses the action needed in relation to the bruising of a non-mobile baby. This work was completed in 2014. Given the importance of GPs and practice staff in caring for infants particular emphasis has been placed on the protocol in safeguarding training for GPs. A template for The implementation of the bruising protocol will continue to be monitored through audit and reports on local single and multi-agency reviews. Any incident in which bruising in an immobile infant is not dealt with in line with the protocol will be reviewed in detail to understand why that has happened so that there is continual learning on this topic. Learning from the Serious Case Review Action that has been taken since January 2013 and the impact of those measures Continuing work to make children safer and improve the quality of services approach which had been successfully adopted in other areas. recording bruises on children has been added to the version of the SystmOne medical records used by GPs. GPs that do not use this system have received a specific briefing from the named GP. 3. The mother of Child D had a degree of learning disability which was not recognised during the various professional assessments and which is believed to have impaired her ability to protect her child from harm. Luton LSCB agreed to undertake a review of current approaches to the assessment of learning difficulty as a factor that may influence parenting and consider how best to improve the availability of such assessments when parents and children are being assessed and supported A working group drawn from health professionals, social care and early help services has devised a brief assessment format to be used when professional judgement indicates that a parent may need additional support as a result of a learning disability. This will be available to staff in antenatal care, paediatrics, health visiting, social care and early help to assist in identifying the need for additional support and advice. The LDUH antenatal service will seek to identify women who have a degree of learning disability at the antenatal booking appointment. Where specific additional needs are identified a specialist assessment can be commissioned. The LSCB will require agencies to monitor and report back on the effectiveness of this new tool and other changes to improve practice. The Safeguarding Adult Board will also continue to monitor the experience of adults with learning disability who are parents and to challenge agencies where there are gaps in services. Luton’s Adult and Children’s Safeguarding Boards will work towards agreement of a protocol setting out roles and responsibilities in relation to the assessment and support of parents with a learning difficulty 4. Child D attended an outpatient appointment at Great Ormond Street Hospital (GOSH) where a record of a small bruise was made, but the infant was not referred under the hospital’s safeguarding procedures. GOSH agreed that it needed to ensure that consultants (including honorary members of staff) have up to date safeguarding training and provide leadership to their multi-disciplinary teams on this issue, as they do in other areas of clinical practice. The hospital also agreed to ensure that gaps in safeguarding training are consistently identified in all staff appraisals, regardless of the seniority or Level 3 Safeguarding training compliance of medical staff (including Consultants) has substantially improved since the time of this incident. It now stands at 94.2% (an increase from 91.2% in the previous year). The Co-Medical Director circulated an email to consultants confirming with them their responsibilities as the responsible consultant. The leadership responsibilities are clearly defined within individual job descriptions. Level 3 Safeguarding compliance for Honorary Consultants who have a joint GOSH/Institute of Child Health contract and require Level 3 for their role is 90% (an increase from 45% in the previous year). Given its nature as a specialist regional centre the hospital continues to have a large number of honorary members of staff. Arrangements are in place to ensure that the training department can check safeguarding training records of individuals to ascertain compliance rates. Development of key actions for specific situations including bruising are being developed to ensure that best practice is followed at all times. Camden LSCB will continue to monitor and challenge the performance of GOSH in relation to safeguarding. Learning from the Serious Case Review Action that has been taken since January 2013 and the impact of those measures Continuing work to make children safer and improve the quality of services role of the staff member The GOSH Human Resources (HR) Director has contacted all HR Directors from host organisations requesting assurance that staff are compliant at each level and this has increased the trust’s figures by 10%. 5. The SCR identified that as well as receiving relevant training on the identification of symptoms of child abuse, there was a need to improve the ability of staff in all agencies to implement the lessons of training about the recognition of child abuse and neglect in their normal working environment. Luton LSCB and all of the agencies involved in the review agreed to act on this recommendation. Luton LSCB seeks to assure the effectiveness of its training programmes by following up participants by phone and email. It remains the responsibility of professionals, supervisors and managers to test whether staff training is having a positive impact on professional practice. The board’s member agencies are expected to report on this through the periodic assurance reports on safeguarding activity to the LSCB executive and the audits that the board carries out under Section 11 of the Children Act 2004. As part of its training strategy the LSCB is developing a tool to evaluate the impact of training on practice. Section 11 audits and assurance reports will continue to test the impact of training on professional practice At GOSH mandatory training compliance is now assessed at all staff appraisals. In addition managers can access real time reports to check the current compliance status of any member of staff. GOSH safeguarding training now includes specific messages about bruising and specific resources for staff. The Safeguarding Newsletter was sent to all staff, and included in the Trust briefing which was disseminated across the organisation. GOSH has introduced a post training evaluation to identify the impact of training and how staff have incorporated that learning into their practice. The outcomes of these evaluations will inform future training. The Trust continues to work to ensure that best practice is followed by all employees. There is regular engagement with speciality meetings to ensure on-going dissemination of learning to all grades of staff, and random spot check audits will be conducted. The analysis of the impact of training will be reported through the Trust’s internal governance structure. and will inform future training needs. The Trust provided a verbal update to Camden Safeguarding Children Board in June 2015 as part of Learning from the Serious Case Review Action that has been taken since January 2013 and the impact of those measures Continuing work to make children safer and improve the quality of services its Section 11 Audit response. 6. The SCR identified that it is critical that as much information about relevant background factors (such as childhood adversity, domestic abuse and mental health problems) about parents is identified in GP records and shared with antenatal services during the early stages of a woman’s pregnancy. The safeguarding board asked Luton’s GPs and the Luton and Dunstable University Hospital to find ways of increasing the identification and sharing of relevant background social information about pregnant women and their partners when referrals for antenatal care are made. Considerable reliance is placed on the fact that during the antenatal period midwives from the Luton and Dunstable Hospital access mothers’ GP records during the normal course of antenatal care under normal arrangements. This enables a high rate of identification of information about medical and psycho-social concerns contained in medical records The Named GP for Luton has prepared a briefing note for GPs underlining the importance of providing background information to the antenatal service when making referrals A format has been developed for antenatal referrals. The paper system was completed in May 2015. The target date for the completion of the electronic system is December 2015. The board expects the Luton and Dunstable Hospital to continue to monitor any incidents which arise as a result of gaps in background information about parents. Training of GPs will continue to emphasise the importance of providing information about all risk factors in antenatal referrals 7. The review identified the need for more reliable transfer of records to school nurses when a child has received additional support from the health visiting service. The public health service and the provider of the service agreed to include this in the specification for the service The school nursing service is now commissioned by the Public Health section of the local authority. The service specification now makes explicit reference to the need for records of vulnerable children to be identified and brought to the attention of the school nursing service when cases transfer. This will be monitored as part of normal contract compliance 8. Although Child D had complex health needs and her mother had a difficult social background there was very limited sharing of information and no direct contact between the GPs and health visitors involved. It was identified that the electronic patient record database used by most Luton GPs was hindering the sharing of information between GPs and health visitors because its default setting was to not allow health visitors access to information. Luton CCG and NHS England have been working with The LSCB, the CCG and the trust which provides the health visiting service all recognise that closer collaborative working between GPs and health visitors does not rely solely on electronic means of sharing information. Further case reviews conducted in Luton have Learning from the Serious Case Review Action that has been taken since January 2013 and the impact of those measures Continuing work to make children safer and improve the quality of services NHS England, Luton CCG, GPs and Cambridge Community Services NHS Trust agreed to review the current delivery of the Healthy Child Programme in order to explore: 1) whether there are better ways of sharing information between GPs and health visitors (including the use of electronic systems) and 2) whether more tasks in the Healthy Child Programme can be a shared responsibility for health visitors and GPs in cases when the child has been identified as being vulnerable. Luton GPs to enable the default position to be altered allowing health visitors the right to access information in GP records. This has led to a number of developments. Health visitors can now view GP records should they have safeguarding concerns. The named GP introduced a safeguarding template for GP practices which structures the recording of all safeguarding concerns about children in May 2015. A further developed version of this will be available in December 2015 demonstrated the need to promote ways of health visitors and GPs working closely together over the welfare of vulnerable children. The Director of Public Health Luton Borough Council and Luton LSCB will continue to monitor and challenge the effectiveness of health visiting services. NHS England continues to oversee the effectiveness of GP services for children. 9. Luton CCG, the Luton and Dunstable University Hospital (LDUH) and the provider of the GP Urgent Care Clinic agreed to review the streaming arrangement at LDUH Emergency Department in relation to children under the age of 12 months. With effect from September 2014 the arrangements for streaming children at LDUH were changed so that every child under the age of 6 months and every child who is reported or believed to have suffered a head injury is seen at the LDUH Emergency Department, rather than at the Urgent Care Clinic Luton CCG, the Luton and Dunstable University Hospital (LDUH) and the provider of the GP Urgent Care Clinic will continue to monitor the operation of the clinic and the streaming mechanism. Any adverse or concerning incident will be reported and investigated under the normal clinical governance arrangements. |
NC048264 | Death of a 7-year-old girl in July 2014. Her aunt, who she lived with under Special Guardianship Order (SGO), and paternal grandmother were both sentenced to imprisonment for child cruelty. Child J was born with mild learning disabilities and a kidney condition. Her mother was a single parent and had poor mental wellbeing; her father had several other children and spent time in prison. Mother disclosed having thoughts of harming Child J and made allegations of abuse against the paternal grandmother, father and father's new partner. Child J became a Child in Need. She was placed with a foster family at 4-years-old and received support from child and adolescent mental health services (CAMHS) after showing signs of having experienced significant early trauma. She was placed permanently with her aunt (her father's sister) under an SGO, with support under a Family Assistance Order (FAO). During this time the aunt stated Child J was self-harming and deliberately misbehaving. Several concerns were raised about the aunt's punitive parenting style, including a referral to the NSPCC helpline. Uses a hybrid systems methodology to identify findings including: there was a lack of understanding about the impact of early emotional abuse and neglect on young children and the likely manifestation of this in their behaviour; a full assessment which brought together all the available information on Child J in the context of possible physical abuse was needed; the importance placed on engagement with parents/carers can mistakenly leave children at risk. Recommendations include: professionals should not accept the term self-harm in children under 10 without a consideration of potential wellbeing or safeguarding concerns.
| Title: Serious case review: Child J. LSCB: Nottingham City Safeguarding Children Board Author: Jane Wiffin Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Nottingham City Safeguarding Children Board Serious Case Review Child J Report Author Jane Wiffin Serious Case Review Final Report 13.04.2017 Page 2 of 74 Contents 1 INTRODUCTION ................................................................................................................................... 3 2 FAMILY MEMBERS............................................................................................................................... 5 3 NARRATIVE CHRONOLOGY AND APPRAISAL OF THE PROFESSIONAL INVOLVEMENT WITH CHILD J ........................................................................................................................................ 6 4 FINDINGS AND RECOMMENDATIONS ........................................................................................ 37 5 CONCLUSIONS .................................................................................................................................... 65 6 APPENDIX 1 – ..................................................................................................................................... 69 Serious Case Review Final Report 13.04.2017 Page 3 of 74 1 INTRODUCTION The reasons for this Serious Case Review 1.1 This Serious Case Review was initiated because of the sad death of a seven year old girl (known throughout this review as Child J). She was found dead at the home where she lived with her Aunt under a Special Guardianship Order (SGO). Her Aunt was subsequently arrested and stood trial for her murder. Her Paternal Grandmother (PGM) was also arrested. The Aunt was cleared of murder, but found guilty of child cruelty and sentenced to a period of imprisonment. Paternal Grandmother was also found guilty of child cruelty and sentenced to a period of imprisonment. 1.2 Statutory guidancei requires that when a child has died and abuse or neglect is known or suspected, the Local Safeguarding Children Board must carry out a Serious Case Review. Review Methodology 1.3 Careful consideration was given to the best method of conducting the review taking account of the principles set out in statutory guidanceii. The review was undertaken using a hybrid systems methodology. A new chronology document was designed which required all the agencies involved with Child J and her family to outline their involvement, appraise the professional response and to provide information about the context in which that professional response had taken place. Over the period of the review further work was undertaken by some agencies to clarify information and provide more details as necessary. A number of case records were also analysed. Information about the agencies who were asked to submit a chronology and appraisal are outlined in appendix 1. These agencies have subsequently completed action plans to address lessons regarding practice raised by the review. 1.4 A review panel consisting of senior managers from key agencies was convened and chaired by an Independent person, Jane Wonnacott. The panel used the chronology and appraisal documents provided by all agencies as the starting point for their analysis. This report is a product of the work of this panel alongside the practitioner interviews and events. The Panel Designated Nurse Safeguarding NHS Nottingham City CCG Named Nurse Safeguarding Nottingham CityCare Partnership Named Nurse Safeguarding Nottingham University Hospitals NHS Trust Director of Children’s Integrated Services Nottingham City Council Associate Director for Safeguarding Nottinghamshire Healthcare NHS Foundation Trust Serious Case Review Final Report 13.04.2017 Page 4 of 74 Assistant Director and Head of Service Cafcass Service Manager Cafcass Head of Service: Children’s Duty and Targeted Services Nottingham City Council Area Manager DLNR CRC DCI Public Protection Nottinghamshire Police Head of Service Safeguarding and Quality assurance Nottingham City Council Director Education Nottingham City Council Legal Advisor Nottingham City Council Children’s Officer Nottingham City Safeguarding Children Board 1.5 Most of the key professionals involved with Child J and her family were interviewed by the Lead Reviewer and a panel representative; there were only a small number of people it was not possible to interview because they had left the organisation they worked for. This has not affected the final analysis. A number of practitioner events were held to check the developing analysis. 1.6 Jane Wonnacott is qualified as a social worker. She has published two books on supervision and co-wrote with Tony Morrison the national training programme for social work supervisors. Since 1994 she has been the author or chair of many Serious Case Reviews and in 2010 completed the Tavistock Clinic and Government Office London nine-day training programme for panel chairs and authors. She has also attended the 2012 Department for Education Serious Case Review training programme. She is completely independent of services in Nottingham City. 1.7 An experienced Independent Lead Reviewer, Jane Wiffin, was appointed to work with the review panel to carry out the review and produce the final report. Jane Wiffin is a freelance social care consultant and has a professional background as a social worker, with extensive experience of safeguarding practice, developing policy and delivering pre- and post-qualifying education. She is an experienced Serious Case Review author, having completed over 30 reviews. In 2010 she completed the Tavistock Clinic and Government Office London nine-day training programme for panel chairs and authors and she is an accredited SCIE Learning Together Reviewer. She is completely independent of services in Nottingham City. Family Involvement 1.8 Family involvement is very important in any Serious Case Review process. For this review Mother and Father were both asked to contribute. It has not been possible to make contact with Father, despite the Board Staff making a number of attempts to do so. Mother met with the Author and the Chair; she was very open and helpful and her views are incorporated into the report. The Foster carer was also invited to contribute, Serious Case Review Final Report 13.04.2017 Page 5 of 74 and she met with the author on two occasions; she provided useful information, on behalf of her family, and this is incorporated into the body of the report. Aunt and Paternal Grandmother were also asked if they could provide information that would help the review make progress, and both agreed to prison visits. PGM provided some background Family information. 1.9 Aunt was visited in prison, but decided she did not feel able to provide any information to the review. 1.10 This is the full overview report of the Serious Case Review. A decision has been made by the Review Panel and Nottingham City Safeguarding Children Board (NCSCB) that some detailed information about Child J’s siblings and Mother will be removed before publication due to the sensitive nature of the material and to reflect that this adult and children remain living in the same communities. 1.11 The overview report was completed before a full inquest took place. The inquest process provided new evidence and information and this has been incorporated into the body of the report. It became clear during the inquest that Aunt had recorded a number of phone calls and meetings and the information and knowledge that this provided is also incorporated into the body of the report and the analysis that follows. 1.12 The narrative conclusion of the Coroner was that Child J died whilst in the care of her Aunt who had been approved as her Special Guardian. The Coroner found that in the two years prior to death, Child J was the victim of sustained serious physical and emotional abuse. The Coroner also concluded that during the 48 hours before she died, Child J was subjected to horrific violence resulting in multiple internal and external injuries and Child J died as a result of an injury to her brain caused by blunt trauma which, on a balance of probabilities, was an inflicted non-accidental injury. 2 FAMILY MEMBERS 2.1 Name Relationship to Child J Age at time of critical incident Ethnicity Child J Subject of the Review Aged 7 when she died Dual Heritage Mother 25 White Sibling 1 Sister Aged 5 when Child J died Dual Heritage Aunt 23 Ethnic Minority Father of Child J 28 Ethnic Minority PGM of Sibling 1 47 Ethnic Minority PGM of Child J 53 Ethnic Minority Serious Case Review Final Report 13.04.2017 Page 6 of 74 2.2 Child J’s family circumstances were complex. Information about her Mother is contained in the section below. Her Father has a number of different partners by whom he has a number of children. Child J had limited contact with these other family groups and for the purposes of anonymity these children are not included in the family details. 3 NARRATIVE CHRONOLOGY AND APPRAISAL OF THE PROFESSIONAL INVOLVEMENT WITH CHILD J 3.1 This section provides a narrative summary of the professional involvement with Child J focusing on an appraisal of the practice response at different points across the timeframe and comment on why practice was as it was where this is known. It starts with a brief overview of Child J’s family circumstances, which were well known to many, but not all professionals. Information has been anonymised as much as is possible, and dates removed in order to protect the privacy of children and family members. This forms a foundation for the subsequent section which analyses the practice response as a whole. Family Background 3.2 When Child J was born she was diagnosed (antenataly) with a mild brain defect which caused her some developmental delay, mild learning disabilities and delayed motor skills and coordination. At birth she was also found to have damage to one of her kidneys for which she required four hospital admissions and operations in the first two and a half years of her life. The impact of this condition was that she was prone to urinary tract infections and her Mother was advised that she needed to drink large quantities of water. Mother received disability allowance for these health concerns. 3.3 Child J’s Mother experienced a difficult childhood and early adolescence. She met Child J’s Father when she was 16. He was already married, had a child and his wife was pregnant. Mother and Father separated whilst Mother was pregnant with Child J. She met a new partner and they had a child who was born when Child J was 3. Child J’s Father already had two other children by another partner. 3.4 Father has many other children by a number of different partners, some of whom were born at a similar time as Child J. Information was collected for this review about these children and their families and it was clear that there was minimal opportunity for contact between the professional networks. Child J lives with her Mother and Sister: June 2009 – May 2011 3.5 The review period starts when Child J was almost 3 years old. Mother had experienced depression and anxiety from when Child J was born and she was concerned that this had an impact on her parenting and ability to cope with a young child with complex health needs. There were a number of instances where Mother said she had unwanted thoughts of harming Child J, and had described to professional’s harmful behaviours Serious Case Review Final Report 13.04.2017 Page 7 of 74 towards her. As Child J got older Mother said she found her behaviour difficult to manage and that at times Child J had tried to hurt herself. 3.6 Over time there were CAF meetings1, some professionals meetings and the family were provided with some family support services. At this time the health visitor noticed bruises to Child J and a referral was made to Children’s Social Care (CSC). Mother said the injuries were inflicted by Father’s partner whilst Child J was staying with them for a three-week period. Mother said she had concerns that Paternal Grandmother was also harming other children in the family. A child protection inquiry2 was undertaken and it was agreed that family support was to be provided. An initial assessment3 was undertaken which involved Father and his partner which concluded there were no safeguarding concerns. It would have been expected that there would have been enquiries made about the allegations regarding PGM; it remains unclear why these did not happen, but the consequences were that important family information was not available to the subsequent assessment carried out regarding Aunt offering to care for Child J. During this time the school reported concerns about Child J’s poor progress and many absences. 3.7 When Child J was 4 years old, and her sibling 1 year old, there were escalating concerns about Mother’s poor mental wellbeing (she was never formally diagnosed with a mental health disorder). She had minimal support from either of the children’s Fathers. Child J’s Father was involved in criminal activity, for which he would receive a custodial sentence and therefore be unavailable to address the needs of his children (he was also Father to young children in other family units) or support Mother. 3.8 Mother had continuing thoughts of harming Child J and she shared these with a number of professionals and consistently and urgently asked for help. Overall, there appears to have been a muddled approach with the CAF and Child in Need4 processes running alongside each other. There was no clear assessment of the nature of Mother’s difficulties or her lack of any family support, there was never a coordinated single plan and there was no review process to see if the help offered was making a difference to the outcomes and lives of these two young children or helping Mother with her significant difficulties. It is clear, given the level of concern, that Child J and Sibling 1 should have been subject to Child Protection enquiries and plans at this time as a way of addressing the very real concerns regarding Mother’s mental health and assertions 1 The CAF is used when a child and family would benefit from co-ordinated support. An assessment tool often used by agencies such as education, health, or housing is the Common Assessment Framework. This is a standard way of looking at a child's needs and is carried out by a 'lead professional' - someone from the agency working most closely with the child. 2 Children’s Services have a legal duty to look into a child's situation if they have information that a child may be at risk of significant harm. This is called a child protection enquiry or investigation. Sometimes it is called a “Section 47 investigation” after the section of the Children Act 1989 which sets out this duty. 3 The initial assessment is a short assessment of each child referred to Children’s Services focusing on establishing whether the child is in need or whether there is reasonable cause to suspect that the child is suffering, or is likely to suffer significant harm. It may additionally determine the nature of any services required and if a more detailed Core Assessment should be undertaken. 4 Children’s Services decide if a child is in need by assessing their needs. If they decide the child is in need they will normally draw up a plan setting out what extra help they will provide to the child and their family. This is called a child in need plan. The plan should also say when and how the plan will be reviewed. Serious Case Review Final Report 13.04.2017 Page 8 of 74 that she would harm Child J. During the early days of her difficulties Mother was not provided with the necessary level of support which might have enabled her to care for both children and there was a crisis which led to both children coming into care. 3.9 The lack of a clear support plan and the appropriate support services was caused by the arrangements for family support services which existed within the Local Authority at the time. A specialist team of agency staff was formed to provide extra capacity to support existing child in need processes, in recognition that this work often got overtaken by child protection processes when there was low capacity. This decision was taken to enhance the family support process, but had the opposite effect because the team became separate from mainstream work and planning. This approach to the provision of child in need services/family support has since ceased. Placement with Foster Family: May 2011 – July 212 3.10 Sibling 1 went to stay with her Paternal Grandmother (no biological relative of Child J) and Child J initially stayed with a family friend who was assessed as not being able to provide longer term care for Child J. Consequently Child J came to live with her foster family when she was four years old (Sibling 1 moved to live permanently with her own Paternal Grandmother) and Mother agreed for Child J to be accommodated5 (believing this would only be for a short period of time and that both her children would be returned to her care). Whilst in foster care Child J received good quality parenting, contact was facilitated with her Mother and Sibling 1 and Looked after Reviews6 were held regularly. 3.11 Child J came to the placement having experienced both a difficult early childhood and being away from her Mother and Sibling1 unexpectedly at a very young age. This meant she was a traumatised young child and this trauma was manifest in her behaviour; she exhibited anger, aggression, harmed herself and constantly sought the attention of her foster family through means which they found inappropriate and distressing, but for which she had no alternative strategies. 3.12 The foster family were very loving, but inexperienced and were not sufficiently prepared (despite the training they received) for the behavioural manifestation of the significant early trauma to Child J. Consequently, they initially formed a view of Child J as a difficult child and they worried about whether they could be successful in meeting the needs of a child they very much cared about. 3.13 The foster family sought support and advice from CAMHS7 and Child J’s social worker and this helped. The psychological assessment of Mother provided good advice to the 5 Accommodation is when a child or young person is cared for by Children’s Services because the person normally caring for them is unable to provide them with care (whether this is temporary or permanent), for whatever reason. This is also known as section 20 6 When a child is accommodated, their situation is regularly reviewed at a meeting called a Looked After Child review. 7 CAMHS stands for Child and Adolescent Mental Health Services. CAMHS are specialist NHS services. They offer assessment and treatment when children and young people have emotional, behavioural or mental health difficulties. Serious Case Review Final Report 13.04.2017 Page 9 of 74 foster carers about the need to change their style of parenting, with a focus on a lack of control and confrontation, but with love and firm boundaries. This made a difference and Child J became more settled and the foster family more confident. This was a safe and caring time for Child J. 3.14 During the placement a plan was formulated regarding Child J’s health needs. The foster family ensured that all medical appointments were attended and plans to support her health needs carried out. The foster family also facilitated her attendance at school, promoted the development of friendships and after school activities such as dancing which she was said to enjoy. 3.15 Child J was confused about why she had come into care; she appears to have been initially told that it was because her Mother was unwell and she would return home when Mother was better; Mother also believed that the children would return home and told Child J this. Child J missed her Mother and she consistently said that she wanted to return home. These feelings of loss were not always sufficiently addressed; they were discussed in the Looked After Reviews, but no plan formulated to address them. Direct work was undertaken by the social worker and this helped, but the confusion and feelings of loss remained. Making a decision about where Child J and Sibling 1 should live safely for the future 3.16 Mother initially opposed the children being accommodated/in care because she wanted them to return home, but agreed because she wanted to cooperate with professionals whilst further assessments were undertaken and rehabilitation to her care was considered. 3.17 The Local Authority gave serious thought to whether the children could be rehabilitated to their Mother’s care safely. A core assessment8 was completed to consider historical issues and assess Mother’s capacity to parent now and in the future. Father was in prison at this time and he was consulted as part of the assessment. He confirmed he would like to be involved in decision-making regarding Child J. The core assessment raised concerns about Mother’s poor mental health and her previous difficulties in parenting Child J. 3.18 Care proceedings were initiated and an independent psychological assessment was commissioned at the request of the Children’s Guardian9 and facilitated by Children’s Social Care. 8 A core assessment is defined by the Department of Health as an in-depth assessment which addresses the central or most important aspects of the needs of a child and the capacity of his or her parents or care givers to respond appropriately to these needs within the wider family and community context. (DoH 2000, Framework for the Assessment of Children in Need and their Families) 9 A children’s guardian is an independent and experienced social worker who is an officer of the court. Their job is to make enquiries about the child’s circumstances and make a recommendation about what is best for the child in the future. Children's Guardians are organised by a service known as Cafcass. This stands for the Children and Family Court Advisory and Support Service. This is an independent court based agency. Serious Case Review Final Report 13.04.2017 Page 10 of 74 3.19 This assessment was thorough in its execution, but its conclusion did not match the available evidence. Mother was assessed as still finding the thought of parenting Child J very difficult believing that Child J placed significant demands on her. The assessment also suggested that Mother attributed the difficulties she had in parenting Child J to Child J’s personality and behavioural problems, rather than her own depression and anxiety which was of concern. The assessment also highlighted that there was an absence of emotional bonding between Mother and Child J which was reflected in a cold pattern of interactions from Mother. The assessment concluded that “Mother would be able to fulfil her children’s needs on a consistent basis if she receives psychological therapy for her anxiety and depressive symptoms and an intensive parenting course”. 3.20 The Children’s Guardian and the Social Worker both expressed concern about the conclusion of the report and additional work was undertaken by the psychologist. The recommendation of this second report was that Mother needed to undertake weekly Cognitive Behavioural Therapy (CBT)10 with a Clinical Psychologist for at least 6 months and to also attend an intensive parenting course. Mother actively tried to access CBT and found there were lengthy waiting lists. She sought a way to pay for private treatment (taking a loan from a family member) but this was not viable because of the cost and she also looked at parenting courses and sought advice about parenting on the internet. 3.21 Those professionals involved with Mother recognised that she had been open about her early difficulties and had worked to try and address the concerns. Ultimately, the professionals and court had to try and judge whether Mother could safely parent her children in the present and the future. There remained concerns regarding Mother’s difficult relationship with Child J which indicated that the significant changes needed would take too long to achieve and would be outside of the developmental time frame necessary for the wellbeing of both children. The difficult decision was made in November 2011 that it would not be safe to return the children to their Mother’s care and an alternative permanent placement needed to be sought. Assessment of Family Members: 3.22 It was agreed that it was important to try and place both children with family members, which is a clear requirement of current public policy11. This was 10 Cognitive behavioural therapy (CBT) is a talking therapy that can help you manage your problems by changing the way you think and behave. It is most commonly used to treat anxiety and depression, but can be useful for other mental and physical health problems. 11 Where children cannot remain with their parents, the first consideration must be a placement within the extended family. This is consistent with the Children Act 1989 (which requires local authorities to give preference to placing a child within the family network before considering a placement with unrelated carers) and Article 8 of the Human Rights Act 1998 (the right to a private and family life). Serious Case Review Final Report 13.04.2017 Page 11 of 74 straightforward for Sibling 1 who was already living with her PGM (she had a different Father to Child J). Contact was made with Father who was in prison. Child J’s PGM and Father’s wife were approached and both declined to be assessed because of ill health on PGM’s part and overcrowding for Father’s wife. The fact that they both declined to be assessed meant that the historical allegations regarding PGM’s physical abuse of Child J and general concerns regarding Father’s wife care of her own children were not further explored. Assessment of Aunt: January 2012 3.23 Father suggested that there might be members of his family who could care for Child J and he suggested his sister, who agreed to put herself forward to be assessed. Aunt did not know Child J at this point; they had only met once when Child J was much younger. A successful viability assessment was completed by the Social Worker and the court agreed that a Special Guardianship (SG) Assessment12 and parenting assessment would be undertaken. 3.24 The assessment conducted was largely in line with the national guidance regarding Special Guardianship Assessments. These do not require the same depth as fostering or adoption assessments, but do require a lot of work. The assessment did not sufficiently acknowledge that this was a completely new attachment relationship for Child J or explore the implications of this. Information was included in the assessment about Child J’s health and education needs but neither agency was specifically consulted during the Special Guardianship process regarding implications for future planning and services for Child J as outlined in the Special Guardianship regulations13. There is no requirement within the Special Guardianship regulations to seek information from the police, but the social worker believed she had done so and there were no concerns, but there is no record of this request. The police did hold some personal information about Aunt including some details of Aunt’s experiences of being abused by a school teacher, PGM’s abusive treatment of her in her adolescence and some personal information. This information would not have been disclosed unless an “enhanced” disclosure and barring check (DBS) had been sought. This information would not have changed the final decision, but would have indicated that Aunt did not always provide a full account of her recent past and would highlight the need for a well-structured support package. 3.25 Child J’s views about this potential move were not included. The Special Guardianship Guidanceiii makes clear the importance of children being offered the opportunity to express their view, dependant on their age and understanding. Consideration was 12 The local authority must investigate and prepare a report to the court about the suitability of the applicants to be Special Guardians. The information to be included in the report to the court is set out in regulation 21 of the Special Guardianship Regulation 2005, (see Appendix 2: Schedule to the Special Guardianship Regulations 2005). 13 Regulation 12 requires that the local authority consults the relevant PCT (or LHB) or LEA during the course of the assessment, if needs identified relate to services provided by bodies other than social services, and it appears that there may be service implications for health or education services. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/503547/special_guardianship_guidance.pdf Serious Case Review Final Report 13.04.2017 Page 12 of 74 given to this and Child J was felt to be too young to understand the process. Child J had always made clear her desire to go home and had expressed confusion about where she would be living in the future; this indicated that a discussion with her was possible. The inclusion of this information could have led to a recommendation in the subsequent support plan that she might continue to need support regarding this confusion in the future. 3.26 The assessment focused too much on Aunt’s own self reporting of her circumstances and could have reflected more on the potential impact on parenting of Aunt’s experience of being abused as a child/young person; she had reported being beaten by PGM as a child and sexually abused in adolescence by a teacher; researchiv suggests that these early abusive experiences could cause difficulties in parenting, particularly during stressful times. Aunt’s view that she had reflected on those experiences and would never use physical chastisement was untested at this time. The assertion from Aunt that she provided care to her nieces and nephews, which made up for the deficits in their parents’ neglectful care, was discussed with Father’s wife, but not fully explored and it was never observed. This self-report was also accepted by the Children’s Guardian, who had initial reservations about Aunt’s young age, but in the final report for court praised her selflessness in looking after her nieces and nephews. Information was not sought from her employer, a provider of services to elderly people, though three references were sought and received from friends who were members of the church Aunt attended; these people were not interviewed in line with national special guardianship guidance. These references were all positive about Aunt and mentioned her work with children at the church, but more thought should have been given to the fact that these references all came from the same place. 3.27 The national special guardian guidance also makes clear that there should be a full exploration of the prospective special guardian’s family. Information was included, though largely provided from Aunt’s perspective. There was information available about concerns regarding Father’s wife and Mother had made it clear that she had concerns about physical abuse by PGM and some members of the wider family. These were not given sufficient weight and it is of concern that from this point onwards Mothers view about Child J’s circumstances was not valued or acted upon. A genogram was drawn up for the court processes but focused on Mothers family (about whom there were no known concerns), not paternal family. Given the complexity of the paternal family relationships a full picture of the whole family was necessary. It is unlikely that this information would have impacted on the final decision of the court, but could have and should have influenced the final support plan. The Transition process from Foster Care to Permanent Placement with Aunt: April 2012 3.28 The Local Authority began working with Aunt to establish if she could care for Child J. As part of this process the Social Worker took Aunt through Child J’s medical report, her early experiences and her current behavioural difficulties. Aunt said that she Serious Case Review Final Report 13.04.2017 Page 13 of 74 understood these early experiences were difficult and she felt able to meet Child J’s needs. Issues of attachment were discussed. At this point it would have been important to look more closely at the manifestation of Child J’s distress through her behaviour, and note the possibility that parents/carers when under stress can blame the child rather than the trauma. The strategies recommended by the Psychologist, which had been successfully implemented by the foster family should have been discussed at this point. 3.29 The need for careful preparation for Child J’s move to Aunt was discussed in two of the CAMHS consultations, but there were no plans agreed to address the issues raised; this was largely because the purpose of these meetings was to think about what needed to be done, with the expectation that any formal plan would be developed outside of the consultation process as part of normal casework process. The confusion about the decision making capacity of the CAMHS consultation meetings persisted across the whole period under review. 3.30 A brief transition plan was developed and consisted of a timetable of contact sessions over a four-month period; the first was supervised by the foster carer. From this point on the foster carer took on the task of facilitating the contact sessions. The Children’s Guardian expressed concern that there had been no overnight contacts, and these were organised and were successful. There were also no observed difficulties at this time and all the indications were that the relationship between Aunt and Child J was progressing well. The transition planning process for Child J should have been more detailed given that this was a completely new relationship and the needs of Child J were complex. However, there is no expectation of a fuller transition plan in the context of the Special Guardianship process. 3.31 It is unclear how much Child J was aware of the plans for her to live with her Aunt in the early stages of contact. She said she enjoyed the contact sessions but she did not appear to have understood that this was in preparation for moving permanently to her Aunt’s. The Social Worker talked to Child J about this potential transition on two occasions using some specialist books appropriate to her age and stage of development; Child J was said to be relaxed about this, but said she thought she might stay with her foster family and the Social Worker talked about staying with Aunt. A second session was organised, where the issues were once again raised with Child J. The work of social workers in these situations is limited by the nature of the court proceedings, where it is only possible to tell a child they will definitely be moving permanently when agreed by the courts/legal decision making. Care Planning and support for the Special Guardianship Placement 3.32 The Children’s Guardian gave full support to the placement of Child J with her Aunt and recommended that an interim order should be sought in order to test out the success of the placement, that there be at least six months social work support for the placement Serious Case Review Final Report 13.04.2017 Page 14 of 74 and Child J and her Aunt to be offered Theraplay14 by CAMHS when Child J was settled. This endorsement was based on only two visits and it is clear that the Children’s Guardian should have spent more time observing the relationship between Aunt and Child J. The social worker filed the Special Guardianship Support Plan. This proposed six months of social work support with a multi-agency meeting held every three months. The SGS plan outlined the expectations of Aunt which were: Health needs: to ensure that all health needs were met and that Child J attended appointments for urology services and continence services; Education: it was envisioned that Child J would remain at her present school and that the Aunt would support her full attendance and ensure her special educational needs were addressed; Behavioural, social and emotional development: Aunt was to provide Child J with consistent emotional warmth, structure and boundaries, with parenting that was flexible and warm in style. Identity: Aunt to promote direct contact with birth parents and siblings. 3.33 The Special Guardianship Order was granted to Sibling 1’s paternal grandmother. The final decision regarding the permanent carer for Child J was adjourned for three months to see how the placement with Aunt progressed. It was not made clear at this point how any information would be collected regarding this progress and there was no requirement from the court for a further social work or Children’s Guardian statement. Child J moved to live with Aunt: July 2012 3.34 When Child J moved to live with Aunt there were weekly home visits by the Social Worker. Aunt talked about finding Child J difficult to manage, stealing, asking to be physically hit and screaming; Aunt reported that this had led to the neighbours coming to the flat to ask if everything was alright. These were all behaviours reminiscent of the early days of her foster care placement and were assessed as part of the likely difficulties of the transition. Aunt’s view was that these difficulties were caused by Child J’s contact with her mother. The Social Worker was aware from the contact supervisor that contact had been quite emotional and she asked Mother to be more thoughtful about what she said to Child J and to support the placement for her best interests; telephone contact between Mother and Child J was temporarily halted. The Children’s Guardian visited Child J who was seen alone and said she was happy living with Aunt; Aunt reported difficulties managing Child J’s behaviour and that Child J had been verbally abusive to her. Child J permanently placed with Aunt: September 2012 3.35 At the final Court hearing the social worker reported that overall the transition period had gone well. The court did not require further details to be provided, and the early 14 Theraplay is a child and family therapy for building and enhancing attachment, self-esteem, trust, and engagement. It is based on the patterns of playful, healthy interaction between parent and child and is intended to be personal, physical, and fun. Serious Case Review Final Report 13.04.2017 Page 15 of 74 difficulties were seen as part of Child J’s existing complex needs and the transition to a new carer. Child J had expressed a positive view to both the Social Worker and the Children’s Guardian about living with Aunt, and positive interactions between them had been observed. The SGO was granted and the Children’s Guardian recommended on-going support because of Child J’s complex needs; the court agreed that there would be a Family Assistance Order (FAO)15 for one year. This named the family support worker (FSW) as the “appropriate officer”. There is no requirement for there to be a formal plan of how support is provided under a FAO, and it is intended as a “light touch” arrangement with the support being agreed by all parties. At this point the support plan consisted of the Children’s Guardian recommendations and the Special Guardianship Support Plan. The impact of the FAO was that neither of these were implemented and no other plan was formulated. There were no multi-agency meetings held, despite Child J’s complex needs and no planned opportunities for the many professionals involved in her life to come together. Although there was no formal requirement to do this under the FAO, it would have been an important opportunity to think in a multi-agency context about what support was needed, how Child J’s emotional needs, her health needs and educational needs were to be met. The impact of the lack of a plan or meeting made the subsequent professional response to Child J and her Aunt more fragmented and led to a lack of a joined up approach. 3.36 There was a CAMHS consultation meeting a month after the Special Guardianship Order was granted, attended by Aunt, specialist CAMHS professionals and the Social Worker. It was agreed that CAMHS would remain involved and although this service would not usually provide support for children placed with Special Guardians, who would more routinely be seen by CAMHS community services (who would themselves assess what support was required) it was agreed that the continued involvement would provide continuity of support. 3.37 The purpose of the first meeting was an opportunity to review CAMHS involvement with the family and to consider when any therapeutic input (Theraplay) could commence. The meeting was designed to discuss the needs of a child and provide support to the network of carers and professionals; it was not a case work planning or decision making meeting and this was made clear within the minutes of the meeting. The meeting provided Aunt with an opportunity to explore how Child J’s move to live with her was going. Aunt reported difficulties managing Child J’s behaviour and Aunt said this was caused by contact with Mother, particularly walking past her house on the way to school. Actions were agreed to address this and it was also agreed that a change of school would be helpful. 3.38 There was confusion from the start about the CAMHS consultation process, despite the minutes making their status clear. Professionals came to see the meetings as the multi-agency decision making process for Child J. This was not surprising given that they 15 The legal definition of a Family Assistance Order is set out in s16 of the Children Act 1989, which enables a court to make an order requiring a Cafcass officer or an officer from a local authority to advise, assist (and where appropriate) befriend any person named in the order Serious Case Review Final Report 13.04.2017 Page 16 of 74 were the only place (with the exception of two school meetings attended by the family support worker) where professionals came together to discuss Child J. 3.39 At the beginning of the new school term, the school that Child J had attended was informed that Child J was placed with her Aunt as a Special Guardian and that the plan was for Child J to change school. The existing Head Teacher expressed reservations to the Social Worker about the move and the disruption to Child J, but also agreed that walking past Mother’s house might be difficult. The process of the move was started. 3.40 During this time the specialist nurse for continence struggled to make contact with Aunt about an overdue appointment for Child J and telephone contact was attempted, but not achieved until two months later, when Aunt reported her concerns about what she described as Child J’s difficult behaviour and her belief that she wet the bed deliberately. The specialist nurse for continence gave advice and reinforced the need to take a gentle approach, without punishment or blame, in line with existing guidance16; Aunt agreed to this. However, despite Aunt’s concerns she did not bring Child J to the next appointment, but continued to seek support over the telephone. The specialist nurse for continence tried to encourage Aunt to attend appointments. Telephone advice was given once a month for the next three months. During these calls Aunt reported her belief that Child J deliberately wet the bed, had behavioural issues, “self-harmed” and said because of this Child J was being referred to CAMHS for support. The continence service is entirely voluntary and adults’ not bringing children to appointments is not uncommon. The specialist nurse for continence had a plan of action, but the absence of a social, emotional and health care plan for Child J (because it was not required by the FAO) meant that there were no forums at this time to share these issues and therefore the meaning of the contradiction that Aunt was complaining that the continence issues were not improving, but not attending appointments was not known by professionals. It meant that this early evidence that Aunt might not be prioritising Child J’s needs was not known. 3.41 Aunt also cancelled Child J’s appointment at the child development centre. A further appointment was made, there was confusion about addresses and after another failed appointment Child J was discharged from the service. CAMHS contacted the FSW to say that the planned meeting in November had been cancelled by Aunt. These were all important appointments for Child J, but the lack of a mechanism to develop a health plan to coordinate services to address Child J’s health needs meant these separate incidents were seen in isolation from each, and the meaning for Child J not analysed. 3.42 The Social Worker undertook a final home visit with the family support worker two weeks after the FAO was granted, and the FSW took over case management responsibility. The next home visit by the FSW was 8 weeks later and Aunt said she had concerns about Child J’s poor behaviour, reported that she had been swearing, was “self-harming” by scratching, was smearing faeces and she believed that Child J wanted 16 NOCTURNAL ENURESIS: the management of bedwetting in children and young people – FINAL VERSION https://www.nice.org.uk/Guidance/QS70 Serious Case Review Final Report 13.04.2017 Page 17 of 74 to be naughty on purpose. Aunt said she had restricted Child J’s use of the bathroom so she could not drink water, in the hope that this would help with continence issues. It would have been helpful if the FSW had made contact with the specialist nurse for continence at this point to establish an agreed plan of action to address these concerns. If this had been done the FSW would have become aware of the missed appointments and therefore clearer that this was an issue of Aunt not accessing the right support services, rather than Child J having difficulties. This pattern of Aunt being able to deflect concerns from herself, and her lack of accepting the support offered to Child J, was a pattern that firmly established itself and was not noticed. This is addressed in the analysis section. 3.43 A few weeks later Child J’s school noted that she had bruises under her eye and down the left side of her cheek. The school spoke to Aunt about this and she told them that Child J had deliberately harmed herself. School staff were concerned that Child J looked uncomfortable and unhappy whilst this issue was discussed, but this information was not shared with any professional and only became clear during the trial and inquest after Child J died. Over the next two years there were concerns regarding the demeanour of Child J in the presence of her Aunt in a number of different contexts, which were not recorded or shared and this is addressed in the analysis section. 3.44 Aunt told the FSW by phone that Child J had intentionally hit her head on the bed and a visit was organised during the following week. The FSW spoke to the school admin team who confirmed what Aunt had told them. This was not considered to be a safeguarding issue, and information regarding this incident was therefore not passed on to the next school. At the home visit a week later Aunt said the bruises were caused by Child J “self-harming” and that this was caused by contact with Mother; the FSW agreed to address this. Aunt also said that she was concerned about continence issues and was restricting access to the bathroom so Child J did not drink water. The FSW suggested some positive reinforcement strategies including rewards for dry nights. Aunt reported that she had not attended the recent CAMHS appointment. 3.45 The next day the FSW received a letter regarding Aunt’s non-attendance at the continence service for Child J. This was 6 months after the move to live with Aunt, and alongside the non-attendance at the CAMHS appointment these issues should have prompted a review of progress, despite the FAO not requiring this; Aunt had said she was finding Child J difficult to cope with, there were consistent allegations from Aunt that Child J was self-harming and Aunt described Child J’s behaviour as difficult, but Aunt did not attend the services designed to address the needs of Child J and to provide Aunt with advice. This contradiction or discrepancy suggested that review was necessary. There is no evidence that this case was discussed in supervision at this time, and so there was no recorded management oversight of progress; the team manager and FSW reported as part of the Serious Case Review process that they often discussed Child J and her circumstances. The lack of records makes the content of these discussions hard to evaluate. Serious Case Review Final Report 13.04.2017 Page 18 of 74 Child J moves schools – six months after moving to live with Aunt: January 2013 3.46 At this time Child J moved schools. Information was shared by the previous school regarding Child J being placed with Aunt on a Special Guardianship Order and incorrectly that there was a “social worker” when in fact it was a FSW; contact details were provided. However, the transfer of records was delayed and the new school were not aware of Child J’s past history, her health needs or the involvement of CAMHS. 3.47 The terms of the FAO meant that there was no automatic meeting process and the FSW did not organise a meeting with the school. However, this was an important transition in the early days of a new home and relationship for Child J and a meeting would have been an opportunity to consider how this transition would be managed given the discussions between the FSW and Aunt regarding the challenges this new school move might pose for Child J and Aunt’s reported concerns regarding difficult behaviours and “self-harm"; the absence of a meeting meant that there was no working relationship established between the school and Children’s Social Care. There was no handover from the school nurse and it is unclear how much the new school nurse knew about Child J’s past. The school nurse saw Child J eight weeks after she had started at this new school and routine health procedures were undertaken in isolation from other activities to address Child J’s health needs. This was not helpful multi-agency practice. 3.48 At the next home visit by the FSW Aunt reported again that Child J had “harmed herself” and Child J showed her the injuries. The FSW spoke to Child J about this and it was recorded that she said she wanted to be naughty. She also said that she was happy at school and living with Aunt. The contradictions between happiness and self-harm were understood to be caused by Child J’s ongoing difficulties and were reminiscent of the behaviour seen whilst Child J was settling into her foster family. 3.49 The next home visit by the FSW was mid-March 2013 and Aunt reported that she was upset because she felt that school were criticising her and she had been told that Child J was stealing. Aunt told the FSW that there was a meeting planned to discuss these concerns but there is no record of this held by the school or no contact between the FSW and the school. Aunt discussed her continued concerns about continence issues and that she remained concerned about the impact of contact with Mother. The FSW said that contact was important, but agreed to talk to Mother, which she did the next day. The concerns regarding Child J’s behaviour, continence issues and the importance of Mother supporting the placement with Aunt were discussed. Mother was provided with no agreed way to share any thoughts she had about the placement and the emphasis on supporting Aunt, which was absolutely appropriate at this point, did not change despite Mother expressing concerns regarding Child J during contact over time. 3.50 The FSW subsequently discussed Child J in supervision and reported that Aunt was being supported by her family and the Church and she was implementing a strict parenting style to address Child J’s behavioural needs; no further detail is recorded. There was no discussion regarding the current issues at school. Serious Case Review Final Report 13.04.2017 Page 19 of 74 3.51 Four weeks later Aunt took Child J to hospital with a burn to her leg and some bruising to her thigh. On examination the Doctor found further scratches and bruises that Aunt said were due to “deliberate self-harm” for which Child J was going to receive support from CAMHS. Aunt said Child J deliberately stood in front of the heater and this had caused the burn. The hospital reported that Aunt had behaved appropriately and Child J was not observed to be distressed; she was, however, not seen alone or asked what had happened and there was no reflection on the part of the medical team regarding either the likelihood of a child aged 6 engaging in this type of behaviour; if this seemed a likely explanation or the seriousness of such an action by a child of this age. This required further reflection; either to consider a differential diagnosis of safeguarding, in which case advice should have been sought from the safeguarding team or to consider why a child this young was behaving in this way/possibly self-harming and to consider whether appropriate support was in place. The reported involvement of the CAMHS team seemed to have provided reassurance that it was. There was an acceptance of Aunt’s self-report and an uncritical acceptance of self-harm as an explanation for an injury to a young child and this is addressed in the health action plan. 3.52 The attendance at A&E was shared with the emergency duty team at CSC, and a notification passed to the FSW, including that the hospital had no concerns regarding the incident. 3.53 Aunt provided information about the visit to the hospital to school. The Designated Safeguarding Lead (DSL1) reported keeping handwritten notes regarding this incident though it is unclear where these records were kept at this time. DSL1 states that she became aware that she needed to record incidents of concern on a form later that year when she attended safeguarding training and said that she transferred all her handwritten notes onto a concern form she designed in September 2013, and at this time reported that she destroyed all her handwritten notes. This means it is not possible to know what was recorded at the time that each incident took place or what action was taken at the time). It was reported that the FSW was contacted and to have confirmed the detail regarding the burn; there is no corresponding record in CSC files. 3.54 The school nurse was informed of the hospital visit by the liaison health visitor, who asked that the incident was reviewed. The school nurse did contact school, but focused on issues regarding attendance, and the burn was not discussed. It would have been expected that the school nurse would have some oversight of Child J’s circumstances and complex health needs, but although she was never invited to any of the meetings held, the safeguarding concerns were not shared with her by school staff and she never sought to meet with either the DSL or the FSW. This is unusual. The school nurse has a central role to play when there are both safeguarding concerns and complex health needs. Serious Case Review Final Report 13.04.2017 Page 20 of 74 3.55 No one agency explored this incident in sufficient detail and all seemed reassured by what they saw as Aunt’s caring demeanour and confident assertion that this was a deliberate act by Child J and they were reassured by Child J’s lack of distress. 3.56 Follow up appointments were organised with the practice nurse at the GP surgery to change dressings and to check the injury. Aunt took Child J for these appointments and the practice nurse observed what she described as a warm and caring relationship. 3.57 Two days after the visit to the hospital Child J’s Class Teacher noticed bruising to her face and some older bruises. Child J was spoken to and gave different and contradictory versions of the cause, including that she deliberately banged her head against her bed (this is the same explanation provided for concerns of bruising some three months earlier to the previous school). Child J reported that she was punished at home by being made to hold her hands out and facing the wall, being made to strip and go in the bath because of conflicts with Aunt during teeth brushing. 3.58 The Class Teacher recorded this and she passed her notes to DSL1. DSL1 phoned Aunt who reported that Child J self-harmed. This was recorded on a handwritten note and put onto a safeguarding form in September 2013 (the original record was destroyed so it is no known what was recorded at the time or what action was taken). This form, completed some months later, says a message was left for the FSW; there is no corresponding entry in CSC records. If a message was left, it was not appropriate to do so given the seriousness of the incident and without ensuring that the information had been received and next steps agreed. The details of concerns regarding the disclosure made by Child J were subsequently shared verbally (so it is not known how much detail was provided) at a meeting in school attended by the FSW five weeks later. The information about the bruising which led to the original discussion was not. Once again there was no feedback loop. The classroom teacher had shared her concerns, and these had been shared appropriately with DSL1 – but the lack of contemporaneous recording or any action or clarity regarding whether FSW had received the message meant that this concern was not fully addressed. Nine months after moving to live with Aunt 3.59 The next CAMHS meeting took place a week after the burn incident and was attended only by Aunt and CAMHS professionals; the FSW had previously made it clear that she could not attend. Aunt reported her concerns about Child J’s behaviour and continence issues which Aunt believed were deliberate and connected to “self-harming behaviour” (the specialist nurse for continence was not involved in this meeting and so no specialist advice was available). Aunt also reported the incident of the burn was also an incident of “self-harm”. Aunt said she needed to implement punishment such as making Child J stand against the wall with arms outstretched, because Child J was “difficult, defiant and lacked remorse”. The CAMHS professionals were concerned regarding this, and reported expressing these concerns directly to Aunt, but this is not recorded in the minutes. The CAMHS professionals tried to get Aunt to focus on Child J’s difficult early Serious Case Review Final Report 13.04.2017 Page 21 of 74 experiences. Aunt focused this discussion on contact with Mother as an explanatory factor. The issue of Child J’s potential self-harming behaviour was not questioned, and more thought should have been given to either reflecting on the likelihood of this level of self-harm in a six year old and therefore concern about her wellbeing. The professionals at the meeting were persuaded by Aunt’s confident articulation of her concerns regarding these issues. 3.60 After the meeting the CAMHS professionals appropriately agreed that a meeting was needed with the FSW to discuss concerns regarding what they saw as harsh and critical parenting approaches and this was organised for eight weeks’ later. However, the focus at this time was on Aunt’s struggles to manage her own reports of Child J’s difficult behaviour, rather than as a potential safeguarding concern; this was not an appropriate analysis. It would have been the responsibility of the FSW to invite the school to attend the CAMHS consultation sessions, and it is not clear why this did not happen until October 2013. 3.61 In mid-April Aunt told the school that Child J’s burn was infected and that she could not do PE or go swimming. This information was not shared with any agency, and the information not checked or clarified. 3.62 There was a meeting at school at the end of April 2013. This was attended by the FSW, Aunt, DSL1, the school nurse and the Head Teacher. Concerns about “abusive” parenting practices were discussed, which Aunt denied. It is unclear whether Aunt was challenged regarding this disclosure from Child J, Aunt had told the CAMHS professionals a month earlier about adopting this approach, and although the FSW had not been present, minutes had been sent out and a meeting organised to discuss the concerns. There is no action recorded regarding this. The meeting notes also record that the school were made aware of Child J’s continence issues, self-harm and CAMHS involvement. The agreed plan was that the school nurse would liaise with the specialist nurse for continence and the school to inform all professionals, and Aunt, if Child J displayed challenging behaviour. There was no review of this plan and there was no further school meeting with the FSW until 14 months later. 3.63 The CAMHS consultation organised to discuss concerns about Aunt’s punitive parenting practices took place two weeks later in May 2013; it was attended by CAMHS professionals and the FSW, the school were not invited, despite having similar concerns and having spoken directly to Child J about this from her perspective. It is unclear why this was the case, but the meeting lacked a focus on Child J and her experiences. The meeting concluded that Aunt was implementing harsh “discipline” and this was because she was struggling to cope with Child J’s complex behaviours. There was agreement that the observation/attachment session planned for that afternoon would help make sense of Child J’s circumstances, that parenting support would be provided by the CAMHS intensive support team and that Theraplay would be considered to improve the relationship between Aunt and Child J. Although there was recognition that Child J had experienced early trauma, there was insufficient analysis Serious Case Review Final Report 13.04.2017 Page 22 of 74 regarding whether Aunt understood this and was addressing this appropriately, rather than blaming Child J for her difficulties, something which was evident. There was also insufficient attention paid to what impact the current circumstances were having on Child J’s behaviour and what life was like for her given Aunt’s disclosure of harsh and abusive parenting. 3.64 On the same day an observation of Aunt and Child J was undertaken by CAMHS (MIMS assessment17). Aunt provided a lot of background history and outlined her current concerns about Child J’s behaviour. The analysis of the observation itself was that Child J did seek reassurance and comfort from Aunt, but she was not relaxed. The CAMHS professional reflected on this a week later where they noted that there had been positive interactions but that there was also discipline and fear. This information was shared with Aunt, who said the observation had been artificial, but she agreed to accept support from the CAMHS intensive support team which would focus on positive behaviour management. 3.65 In mid-May 2013 the Class Teacher noticed that Child J had a bruised eye. DSL1 was informed of this incident, and she telephoned Aunt who said this was caused by her itching chicken pox scabs, something the school also observed her to do. This was recorded on the DSL1’s handwritten notes and transferred onto a concern form some months later. This form says that Aunt was told that the FSW would need to be informed but there is no corresponding record held by CSC and it appears this incident was not shared at this time. 3.66 The work with the CAMHS intensive intervention service started a month later and a Health Care Assistant (HCA)18, overseen by a manager, was allocated. There were to be six sessions focused on issues of positive disciplinary strategies and addressing Child J’s continence issues. The HCA liaised with the specialist nurse for continence regarding this, but there does not appear to have been discussion about a consistent approach in line with the NICE guidelinesv; for example the HCA implemented a reward programme, something which was considered unhelpful in the Guidance. Aunt told the HCA that she was now more responsive to adopting more positive disciplinary approaches. The HCA saw Child J at school and home and noted a good relationship with Aunt, who joined in games and positive activities. 3.67 The continence nurse met Aunt at this time and they discussed Child J’s behaviour and continence. The school nurse sought advice and supervision from the specialist nurse for safeguarding regarding Child J. Concerns were said to be bruises for which Aunt always had an explanation, Child J’s stealing and self-harm for which CAMHS were involved. It does not appear that there was a discussion about what other agencies 17 The Marschak Interaction Method (MIM) is a structured technique for observing and assessing the overall quality and nature of relationships between caregivers and child. The MIM provides a unique opportunity for observing the strengths of both adult and child and of their relationship. It is, therefore, a valuable tool in planning for treatment and in determining how to help families strengthen their relationships. http://www.theraplay.org/index.php/what-is-theraplay-3/the-mim-assessment 18 Healthcare assistants (HCAs) work in hospital or community settings under the guidance of a qualified healthcare professional. Serious Case Review Final Report 13.04.2017 Page 23 of 74 were doing, whether they shared the concerns and therefore whether a multi-agency discussion was necessary. No action plan was agreed and no contact made with the school nurse or family support worker. 3.68 At the beginning of June 2013 the HCA spoke to DSL1 who reported that she had noticed bruising on Child J’s cheeks, and it was also reported that Child J had reported harsh discipline approaches. The HCA shared these issues with one of the CAMHS professionals who spoke to speak to the FSW. 3.69 At this time the Class Teacher noticed that Child J had bruising to the inner sides of her legs and knees and a mark on the bridge of her nose. When Child J was asked about this, she said she had fallen down the stairs. The Class Teacher shared these concerns with DSL1 who reports she recorded them in her handwritten records. A concern form was written some months later, which said that the bruises were not discussed with Aunt, but shared with the FSW. There is no corresponding entry in CSC records and the contemporaneous notes held by DS1 were reported to having been destroyed by herself. 3.70 The next day the Class Teacher noticed big bruises all down the shin on both legs when Child J got changed for PE. She also noticed a lump on her forehead. This was shared with DSL1 and recorded some months later on the newly designed cause for concern form. It was again recorded that the FSW was informed, but there is no corresponding entry in CSC records and it seems likely this was not shared as it should have been. 3.71 The next day the FSW rang the school and spoke to DSL1 because she had become aware of school concerns regarding bruising. DSL1 shared information regarding bruising on her legs, nose and knees. The FSW was concerned that this had not been discussed with Aunt and it was agreed that a school/home liaison book would be started. 3.72 The FSW shared background information regarding the SGO, bed wetting and self-harming behaviour. These issues were recorded in the DSL1 handwritten records and there is no evidence that the Class Teacher was informed about this conversation or provided with any feedback regarding her concerns. She also did not seek any feedback. 3.73 The FSW asked that all injuries noted by school were shared with her. The DSL1 said that this “would be a daily occurrence”, but the meaning of this was not explored and the FSW did not ask about what records were held. It is clear that the FSW did not have an accurate chronology or any written details of the many concerns held by the teacher and teaching assistants, as one did not exist. It is of concern that both the FSW and DSL1 were happy to discuss the bruises in a general way, rather than discussing the detail. 3.74 This was an opportunity for the school, the FSW and the CAMHS intensive intervention worker to arrange a meeting to discuss concerns about bruising and injuries face to Serious Case Review Final Report 13.04.2017 Page 24 of 74 face. Neither the FSW or DSL1 recognised the critical importance of recording accurately what was said by a child and their parents/caregivers about injuries so the explanations can be explored and concerns about possible non-accidental injuries accurately assessed. This recording is essential and something explored further in Finding 6. 3.75 Aunt spoke to the specialist nurse for continence at this time and reported continued concern; she said she had restricted Child J’s access to the bathroom, but this had led to her drinking urine from the potty. The specialist nurse for continence sought advice regarding this from CAMHS, and was told that this behaviour was likely to be attention seeking and she was encouraged to attend the next CAMHS consultation meeting, which she did. It is unclear why she did not seek contact with the FSW as the case holder, but it seems that she might have been unaware of her role at this point. Again, the lack of either a health plan, or care plan was influential in the lack of an analysis of the available information. The specialist nurse for continence could have sought her own safeguarding supervision, given Aunts punitive and blaming approach. It appears that she was reassured by the involvement of CAMHS. 12 months after moving to live with Aunt: September 2013 3.76 The FAO was granted for one year and when this year was up the FSW appropriately sought advice from her manager about her concerns that Aunt was adopting what she believed to be a harsh and punitive approach to parenting and it was agreed there needed to be social worker input, without the purpose of this being made clear. It also remains unclear why there was not a multi-disciplinary meeting to review the placement at this point. This was not a requirement of the FAO, but was necessary because of the on-going concerns, which were not analysed as being of a safeguarding nature, but were recognised as a need for further support. 3.77 Aunt informed the FSW that she would be away and that Child J was going to stay with a family friend (known as Auntie) who attended the same church as her. The FSW appropriately visited Auntie to ensure that the carer and the accommodation was suitable. This was approved by the team manager. 3.78 The following week the Class Teacher noted bruising to Child J’s cheeks and ears and a cut to her lip. Child J told DSL1 that she had been beaten with a belt and a spoon by the Auntie with whom she had stayed whilst Aunt was away. The Class Teacher wrote a cause for concern form and body map and this was passed to DSL1 who shared it with FSW. The FSW rang Aunt who said that Child J had fallen against a pushchair after she had been sent to her room. There was no feedback to the Class Teacher about action taken, or what the FSW proposed to do to address the concerns. This continued lack of a feedback loop, and the lack of perceived action was not discussed at school, despite the Class Teacher being concerned about it. 3.79 The FSW and the Duty Social Worker visited Child J at home and noted that she had visible bruises, but when asked about them said she had lied about being beaten by Serious Case Review Final Report 13.04.2017 Page 25 of 74 Auntie and had harmed herself by banging against her toys in the bedroom – a slightly different story than that given by Aunt on the phone. The discrepant explanation was not noted, and Child J was not asked about why she might give a different account. Child J said Aunt was still punishing Child J by making her stand in the corner with her arms out, because she was “thieving” water. This does not appear to have been questioned or challenged. There is no evidence that the FSW or the Social Worker provided any feedback regarding the outcome of their visit to DSL1 or that this information was sought. 3.80 The FSW then saw Aunt at home alone where she was described as distressed and she reported finding it difficult to manage Child J’s complex behaviour; evidence of this behaviour was provided by two church members who were with Aunt; one of whom was the family friend about whom Child J had made allegations of physical abuse. This meant that the continued evidence of “harsh parenting” was contextualised again as a response to Child J’s reported difficult behaviour. 3.81 The agreed plan was to speak to CAMHS and discuss what further support could be provided. This was done by telephone contact with a CAMHS professional and it was agreed that there would be further discussion at the next CAMHS consultation, but that the school needed to clearly record bruises and to report them to the FSW. This process highlighted again the confusion about who were the main decision makers in this case. The analysis remained that although there were concerns regarding Aunt, the problem was Child J’s behaviour, rather than Aunt’s response to it, and that CAMHS support was needed. There was no discussion about whether there was a need for a separate multi-agency meeting or a safeguarding response. 3.82 In October 2013 the Class Teacher noticed a small bump and graze on the left of Child J’s forehead. She tried to speak to Child J about this, who seemed upset and nervous. She said she had hit her head at school. It was recorded that this information was shared with the FSW, but there is no corresponding entry in CSC records. It was recorded on an incident form. A week later Child J came to school with bruised finger, which Aunt explained had been caused by jumping on the bed. Child J was also asked about what had happened, and gave the same story. The Class Teacher recorded that she was concerned about Child J’s demeanour, particularly that she made no eye contact. The Class Teacher and the DSL1 were satisfied with the explanation provided by Aunt, and reassured that Child J also provided the same explanation, and so they did not consider that this was a safeguarding issue, but an accident, which did not need to be shared. They were concerned about Child J’s demeanour, but this was not something they usually shared because it was not factual information. This issue is addressed in the analysis section. 3.83 CAMHS and the GP received a letter from a Consultant Clinical geneticist. The letter said that Child J had a disorder associated with renal cysts, risk of maturity onset diabetes, mild learning disabilities and behaviour problems – although it acknowledged that behaviour problems could be caused by a number of issues. The Serious Case Review Final Report 13.04.2017 Page 26 of 74 letter ended with a concern that further kidney problems and diabetes could be a problem in the future. 3.84 There was a CAMHS consultation this same month attended by all the professionals currently in contact with Child J, including for the first time DSL1; Aunt attended with two supporters who she described as spiritual guardians for Child J and who were friends from her church (it is now clear that they were not representing the church in any capacity and their exact status and role was not discussed). One of these adults appears to have been Auntie about whom Child J made allegations of physical abuse but her role was not challenged (it is not clear who was aware of this and the concerns had not been substantiated – this clearly influenced the lack of challenge). There was no discussion about whether it was appropriate or helpful to have these adults present. 3.85 This was the first CAMHS meeting attended by DSL1 from the school and the specialist nurse for continence. Aunt shared a number of concerns about what she described as Child J’s “extreme and shocking and provoking behaviour” connected with continence issues and allegations that she was defecating in the flat and eating faeces. The detail was backed up the spiritual guardians (one of whom was the adult about whom Child J had made previous allegations of abuse). Given the continence nurse was present at this meeting, it is surprising that no plan was formulated to address these issues of continence. The recent allegations regarding bruising were discussed; it was noted that Child J had made some false allegations and that she continued to “harm herself” by biting her lips and scratching. 3.86 Despite all the worrying incidents the meeting concluded that the work of the Intensive Support Health Care Assistant had been positive, but that Child J was “finding it difficult to stick to the agreed plan” and her behaviour remained concerning. Aunt described Child J as “very calculating and manipulative”. The records do not make it clear if this view was challenged or explored in the meeting – or whether she was asked to consider what Child J’s positive qualities were, or what this harsh criticism might mean for a young child. The FSW said she had previously discussed Aunt’s “abusive” parenting approach with her and that Aunt understood this was a safeguarding matter, but there were no actions arising from this. The conclusion was that Child J was a challenging child because of her earlier parenting experiences and the recent geneticists report reinforced professional thinking at this time. These were serious issues regarding a young child, and although professionals were reassured that Theraplay was designed to address these issues it is the view of the Serious Case Review that more thought should have been given to responding to the distress and unsettledness of Child J reported by Aunt. This continued focus on the adults, rather than the child is discussed in Finding 12. This meeting was recorded covertly by Aunt, and this recording was heard as part of the inquest. This record makes clear the way that Aunt dominated the meeting, and was supported in her views regarding Child J as the problem by the two adults who attended with her. The professionals present genuinely believed that they were providing Aunt with a forum to discuss her experiences of parenting Child J, and it was only on reflection when hearing the tape Serious Case Review Final Report 13.04.2017 Page 27 of 74 recording that the dominance and manipulation of the focus of the meeting became clear. This dominance and manipulation meant that Aunt was able to deflect professional attention from the need for a plan of action to address the many concerns, including serious issues regarding continence and self-harm. This is addressed in the analysis section. 3.87 The next month there was an anonymous referral from the NSPCC about two girls being locked in a car at a church car park. It became clear that this related to Aunt, Child J and a niece. The FSW and the Social Worker took this referral seriously and started the process of exploring what had happened. The SW telephoned the safeguarding lead for the church who provided a confused account of what happened. There had been an argument, Aunt had “gone crazy and had hit the woman”. The church safeguarding lead shared concerns about previous incidents where Aunt had put Child J in the corner for misbehaving, but had not considered them serious enough to make a referral; the SW made it clear that the safeguarding lead for the church should have been in contact with Children’s Social Care if she had any concerns19. 3.88 The Social Worker undertook a home visit. It was recorded that Child J looked terrified, and Aunt said this was because she had been caught stealing at school, it is not clear if this version of events was checked with Child J or school. Aunt refuted the allegations. Two witnesses from the church supported Aunt’s version of events. The FSW discussed the NSPCC referral with her manager and because witnesses had supported Aunt’s version of events and Child J had not raised any concerns when seen alone at school, it was agreed there was no need for further action. This incident was seen in isolation from the previous concerns without stopping to think about the cumulative impact on Child J; a chronology of events had never been started and at this point it would have helped with the analysis of recent events. The fixed analysis remained, supported by information from others, but without any professional stepping back and appraising the available cumulative evidence. 3.89 At the end of this month the Class Teacher noted bruising under Child J’s chin, one bruise on top of another, and there was a small bruise on her left ear. She asked Child J about these marks and it was recorded that she said she had caused them by harming herself. This information was recorded on a cause for concern form and a body map of the injuries was completed at the end of the school day. The next day Child J was seen by a Paediatrician for an existing appointment regarding brittle hair and hair loss which was unexplained. This appointment was held after two previous ones had not been attended. The Paediatrician also noted the bruising and was concerned and was to ring CSC the next day. 3.90 DSL1 contacted the FSW to inform her of the concerns and faxed through the written information. The Team Manager and Social Worker discussed the concerns and agreed 19 This incident led to later concerns regarding the safeguarding processes in place within the Church. This was addressed by the Local Authority Designated Officer (LADO) who had several meetings with the church leaders and the church safeguarding team. Work has been undertaken to ensure that the church currently have robust safeguarding processes in place. Serious Case Review Final Report 13.04.2017 Page 28 of 74 to undertake child protection enquiries. The SW rang Aunt who reported that Child J had scratched herself and they had seen a Paediatrician that day who Aunt reported had had not been concerned. 3.91 Appropriately the Social Worker spoke to the Paediatrician, who said that she was concerned about the mark behind the ear and a child protection medical was organised; it was agreed the need for parallel child protection enquiries would be decided once the medical was completed. The rationale for this is not entirely clear. Given the complexity of Child J’s circumstances and recent concerns regarding Aunt’s behaviour at church (which were unsubstantiated) it would have been expected that a full child protection enquiry, in the form of a holistic assessment would have been carried out. The child protection medical assessment was part of this process. 3.92 Child J was brought for the child protection medical by her Aunt and her Father; he reported that Child J had spent the weekend with her half siblings, children from his other families. The Social Worker also attended and gave a history of the most recent concerns about bruising and harsh punishments. The Social Worker reported there were problems with Child J’s behaviour, which was caused either by her past experiences or a mild brain defect; she also reported that Child J self-harmed. This verbal information would have been enhanced by written information or a chronology, something the Paediatricians now routinely seek. A comprehensive child protection medical was undertaken and multiple marks were noted and histories given for all but two of them. The concerns regarding these marks were followed up the next day by a Consultant Paediatrician. He considered that the two marks were unusual, but not bruises and the Consultant Paediatrician agreed to consult a dermatologist about them; this did not happen. Child J was offered an appointment with a dermatologist in February and April of the following year, and she was eventually seen in June 2014 but not in the context of a safeguarding concern and the unusual marks were never evaluated further. 3.93 The Team Manager recorded that she spoke to the Consultant Paediatrician by phone. There is no corresponding entry in the hospital records and the Consultant Paediatrician recorded that he had tried to talk to the Team Manager. A written report was provided three weeks later. 3.94 This reported that Child J had been happy and cooperative. There were two marks that were in areas that did not normally bruise accidentally and were unusual and he had asked for these to be reviewed by a dermatologist. Pictures had been taken. The Consultant Paediatrician reported that Aunt had indicated that there was evidence that Child J bruised easily, and blood tests were organised to rule this out. It is not clear when these tests were undertaken as a confused picture emerged over the following months of Aunt not bringing Child J to agreed health appointments. It was confirmed at some point that Child J did not have a medical condition which caused easy bruising. The actions agreed from the child protection medical did not take place immediately, and were not followed up as would be expected. Serious Case Review Final Report 13.04.2017 Page 29 of 74 3.95 This was another incident which was investigated, but not contextualised alongside the history of incidents, concerns and possible injuries. The child protection medical suggested that no safeguarding action was seen as necessary, but what was needed was a broader and more holistic assessment. 3.96 Aunt had said that a number of the injuries were caused by self-harm and there should have been more concern about this; however, professionals were reassured that these issues were being addressed through contact with CAMHS and did not question exactly what support was being provided. 3.97 There were a large number of marks/bruises and this in itself should have caused all involved more concern; either there was a significant lack of supervision, deteriorating problems with balance (something noted in the past medical history), serious neglect or safeguarding concerns. This required a full assessment. 3.98 In December 2013 there was a CAMHS consultation attended by all currently involved agencies. Aunt reported that Child J was still attempting to “hurt herself” which had led to an examination by a Paediatrician who had concluded that there were no injuries of concern and Aunt reported that Child J “bruises easily”. Aunt reported that she remained concerned about the poor communication from the Class Teacher and it was agreed that it was important that the home-school liaison book was used appropriately. The conclusion was that Child J continued to present with a number of challenges. The recent NSPCC referral and the incident at the Church were not discussed, and it seems clear that CAMHS did not know about these. Aunt covertly recorded this meeting, and again dominated the discussion, supported in this activity by the spiritual guardians. 18 months after moving to live with Aunt 3.99 Over the next six months Child J and Aunt had regular contact with professionals. There was a sense that circumstances had become more settled and the FSW agreed that CSC would cease their involvement when therapeutic support had been started. The need for a multi-agency meeting was acknowledged before this happened but did not take place. 3.100 The specialist nurse for continence sought safeguarding supervision from the specialist nurse for safeguarding where she reflected on the recent non-attendance of Aunt and Child J at planned appointments and Aunt’s critical approach to Child J. The specialist nurse for continence was asked to liaise with the FSW regarding Aunt’s belief that Child J’s continence issues were deliberate and behavioural, when it might be connected to her medical issues. This was an appropriate response, but did not happen. This was the first discussion about whether Child J’s chronic wetting/enuresis was psychological, behavioural, had a medical cause or was a mix of all three. The specialist nurse for continence had telephone contact with Aunt during this time and she reported that Child J had been discharged from paediatric care (she did not say it was Serious Case Review Final Report 13.04.2017 Page 30 of 74 because of non-attendance), that she was due to see the dermatologist and continence had improved. 3.101 There was a CAMHS consultation in February 2014 and all agreed that progress had been made and that Theraplay would commence; given the concerns about self-harm, a dominant theme at this time, it is hard to know why this conclusion was formed. 3.102 In February 2014 safeguarding arrangements changed at the school. The existing DSL1 was joined by a learning mentor – who became DSL2 and the Head Teacher was also part of what was described as the school safeguarding team. It has become clear through the inquest process that DSL2 had little experience of safeguarding and that the Head Teacher did not make clear that he was not just part of the team but had leadership and management responsibility. There were regular meetings to discuss all the children about whom there were concerns, and Child J was regularly discussed. At no point was there any discussion of the concerns held by teaching staff regarding bruising and no chronology was completed for this meeting. There were considerable tensions amongst the school safeguarding team, and from this point onwards school staff reported feeling confused about internal safeguarding arrangements. This is discussed in Finding 8. 3.103 At the beginning of March 2014 school noticed that Child J had bruising on her hands said to have been caused by her brother whilst playing at her PGM house. This was not shared with the FSW because DSL1 believed that the explanation given was consistent with the injury; a safeguarding concern form was completed by the Class Teacher. At the end of March 2014 Child J had further bruises on her hands and two days later she was noted to have a bruise and bump to her head that Aunt said was caused by her banging her head on the car door. There is no evidence that this was shared with FSW or any action taken. It was recorded in the notebook of the Class Teacher. 3.104 The FSW had a case discussion with the Social Worker. She told her that Child J was reported to be stealing food and manipulating her friends at school (unclear where this last issue came from or who reported it). They acknowledged that Child J had had bruises, but these were caused by self-harm and appropriate explanations had been provided by Aunt who had cooperated with all inquiries. 3.105 The FSW saw Child J at school at the beginning of April and she observed her to be happy, but the Class Teacher reported concerns regarding her behaviour. 3.106 A letter was sent to the GP, the social worker and the school nurse by the Community Paediatrician to report that she had seen Child J regarding hair loss and thinning hair. This letter also noted that that Child J had missed two appointments with paediatrics regarding her thinning hair a, giving family emergency as the reason. Child J had also missed two appointments with the dermatologist, and a blood test requested at the Child Protection medical had not taken place. This was evidence of Aunt not addressing Child J’s health needs, that was not responded to or addressed in the professional network Serious Case Review Final Report 13.04.2017 Page 31 of 74 3.107 There was also a visit by the FSW at the end of April where Child J was described as positive and happy, but the Class Teacher said she remained concerned regarding her behaviour and some bruising. The FSW does not appear to have asked for any specific details, and the Class Teacher did not provide any. The Class Teacher was reminded to continue to share any concerns and the FSW gave the Class Teacher her direct number to enable her to do so. 3.108 On the same day as the visit to the school the FSW undertook a home visit where Aunt reported that Child J was still bed wetting, stealing food from school and blaming other children for it. Aunt said they had missed the Theraplay appointment, another example of Aunt raising concerns but not attending appointments intended to provide support to the placement. Aunt continued to say that contact with Mother impacted negatively upon Child J. This was not discussed with Mother or her views sought; Mother was also concerned about how Child J appeared during contact, but was unclear who to share this information with. 3.109 A few days later Aunt told the Teaching Assistant (TA) in Child J’s class of a bruise on Child J which she said had been caused by a child pushing her off a bench. The TA also noted this and a scratch under the eye, which Aunt said Child J had caused herself. This was shared with the Class Teacher, DSL1 and DSL2. It is not clear what the DSL response was, but the Class Teacher was so concerned that she faxed a concern form and body map to the FSW as she had been asked to share any concerns regarding bruising five days earlier. The FSW phoned Aunt who reported that Child J had said that another child had pushed her. Aunt was angry because she believed the school were accusing her of abuse and wanted this addressed with the school. 3.110 The FSW went into school to discuss the safeguarding concern and possible confusion regarding the nature of the injury. She met with the Head Teacher and DSL2. It is unclear why DSL1 was not invited. The Class Teacher and DSL1 were inappropriately not invited so could not explain their overall concerns for Child J or their specific worry about the scratch to the eye which was different to the bruise to the arm. It was agreed that it was of concern that the Class Teacher had faxed a safeguarding form and body map to the FSW, without anyone else in the school being aware of this. It was not acknowledged that this is precisely what she had been asked to do some days earlier. The Safeguarding in Education Guidancevi makes clear that it is best practice to share safeguarding concerns in school with the designated safeguarding lead (DSL) but that there will be times when a member of the school staff will need to share information directly in order to safeguard a child. The Class Teacher in this case had been told by the FSW to contact her directly a few days earlier, but also overall she felt her concerns regarding the safety and wellbeing of Child J were not being listened to and that is why she faxed the form. She was never asked why she had done this. 3.111 DSL2 said she had seen the injury to the eye and had considered that the explanation provided had been consistent with the injury; this did not account for the two different injuries. The issue of Child J being pushed by a child was also acknowledged and it was Serious Case Review Final Report 13.04.2017 Page 32 of 74 agreed this was not a safeguarding issue. The concerns of the Class Teacher and the TA was effectively dismissed. 3.112 During this discussion the FSW shared information about Child J’s complex needs and the importance of taking account of these when considering injuries because Child J bruised easily (self-reported by Aunt and shown not to be true), as well as a history of self-harm, also self-reported by Aunt. DSL2 felt concerned that the school were not fully aware of this background information and had therefore not been able to contextualise their concerns. No actions are recorded as a result of this meeting, but it appears to have cemented the notion that all school staff needed to be sensitive and placatory to Aunt, rather than focusing on the safeguarding of Child J. This position remained and influenced decision making over the last six weeks of the school term. 3.113 The FSW phoned Aunt and shared the content of this meeting with her, Aunt was said to be angry because she felt the Class Teacher was “targeting” her. The FSW sought to reassure Aunt that she was coping well and that the FSW would be ensuring that the school dealt fairly with her and would challenge any actions regarding false allegations. DSL2 also telephoned Aunt; she apologised for the behaviour of school staff and reassured Aunt that she was a good parent, that she was coping in difficult circumstances and the DSL2 would ensure that concerns held by school would be addressed and she would also ensure that the FSW understood the difficulties she was facing. 3.114 Aunt covertly recorded both these conversations, and they were heard during the inquest. They make clear that both professionals sought to placate Aunt, rather than focus on the needs of Child J. It is clear that the telephone calls also undermined a collective view of the needs of Child J, with FSW and DSL2 taking the side of Aunt against other school staff. This was a serious issue and is addressed in the analysis section. 3.115 On the same day as the meeting between the FSW and DSL2/Head Teacher there was a concern logged by playground staff that Child J may have lifted her skirt up in a school queue and she had no underwear on. This was shared with the school safeguarding team, but not passed on to the FSW. 3.116 Aunt asked for there to be a meeting in school because of her concerns about false allegations and the Class Teacher questioning of Child J. This was attended by Aunt and a friend, the Class Teacher, DSL1 and DSL2 and the Head Teacher. Child J’s complex needs were discussed and Aunt drew attention to Child J’s stealing and bed-wetting. The focus was on poor communication by the Class Teacher and TA to Aunt and the conclusion was that there would be efforts made to improve communication through a communications book. The focus on communication, supporting Aunt and being sensitive to Aunt’s needs was inappropriate and led to any concerns about bruising and Aunt’s behaviour to Child J being dismissed. The fixed view held by some professionals Serious Case Review Final Report 13.04.2017 Page 33 of 74 that this was about Child J being a difficult and complex child and Aunt responding to those difficulties became further entrenched. This is discussed in the analysis section. 3.117 The Class Teacher was unable to express her concerns in the meeting; this was influenced by the fixed view held by others that the concerns were false allegations, partly because she was being told off for sending in the concern form to the FSW, and also because Aunt was present and had dominated the meeting. There was clear confusion here regarding the purpose and focus of the meeting. There should have been two meetings. One internal management meeting to discuss the issue of the Class Teacher not informing the school safeguarding team of her actions. This would have been an opportunity to discuss her reasons for doing so- something the Class Teacher could not do with Aunt and a friend present. This could have exposed both the confusion about safeguarding processes in the school and offered a forum for discussing the differences of opinion held across the staff group. The Head Teacher took no leadership role within this. The second meeting should have been a discussion with Aunt where the school robustly supported teachers’ rights to raise concerns about children in the interest in safeguarding. Communication and respect could have been part of this conversation. 3.118 School held two of their now routine school safeguarding meetings in May 2014, but Child J was not discussed at either, despite the concerns shared and many incidents of bruising. This appears to be because there was a view that there were no safeguarding concerns. In May 2014 DSL2 sent an email to all members of staff in the school involved with Child J and asked that any concern forms were either passed to her directly or placed in a box file which was held behind the reception. It is unclear how this was decided upon as there is no record of this decision in the school safeguarding meetings, and leaving concern forms in a public area of the school was not an appropriate decision. 3.119 In mid-May 2014 the FSW carried out a home visit; Child J was reported to be in the car ready to go out. Aunt said Child J was “testing her again” and Child J told the FSW that she was sorry for not telling the truth, there was no further discussion of this as they drove away and this was not followed up. 3.120 In mid-May 2014 there was a meeting with Aunt and CAMHS professionals regarding the start of Theraplay, which had been rescheduled from April. Aunt said that Child J was still self-harming, her continence issues had deteriorated and she described Child J as no longer motivated to make any changes. Issues of stealing were also discussed. Aunt did not bring Child J to the first Theraplay appointment. This was a further example where Aunt complained of struggling, but then did not attend the appointment aimed at supporting her and helping Child J. She was never challenged regarding this. Serious Case Review Final Report 13.04.2017 Page 34 of 74 3.121 At the beginning of May 2014 Child J was discussed at the regular school safeguarding meetings, where no information was recorded beyond DSL2 continuing to provide support. 3.122 The first and second Theraplay sessions took place in June 2014 and were considered to have gone well, with a warm relationship noted and Aunt engaging in play. Child J was said to be controlling at times but Aunt was observed to manage this appropriately. The school contacted the FSW two weeks later to report concerns that Aunt was still using “inappropriate disciplinary approaches”. This was noted, and believed to be being addressed through the Theraplay sessions. 3.123 At the end of June 2014 DSL2 telephoned the FSW to report continued concerns regarding Aunt implementing harsh and critical parenting approaches. DSL2 was informed that CSC would be closing the case because there were no safeguarding concerns after the meeting planned for the following week. 3.124 There was an incident in June (although the date is not clear because no record was produced) that Child J reported that she had been hit by her PGM on the way to school. This was reported to DSL2 who later spoke to Child J in the presence of Aunt and PGM and Child J said that she had hit herself. This was accepted by DSL2 as an explanation, and not reported to CSC. It was completely inappropriate that Child J was asked about this incident in front of the person she had alleged had hit her, and this should have been reported as a safeguarding concern. 3.125 At the beginning of July there was a meeting at school attended by Aunt, the “spiritual guardians” (about who there had been concerns regarding physical abuse), DSL2, the Head Teacher and the FSW. This meeting highlighted that there was feedback from CAMHS that a close relationship was developing between Aunt and Child J; she was described as happier than she had ever been at school and she was helping out at lunchtime supervision. There remained some concerns about Child J’s behaviour which the school were addressing. The FSW said she was closing the case because there was support in place and there were no safeguarding concerns. At this stage there were differences of opinion between school staff. Some felt concerned about Child J and Aunt’s attitude to her, whilst others felt that recent information regarding difficult behaviour and self-harming had helped to make sense of a complex situation, and that Child J’s need would be addressed through continued CAMHS support. There were no concerns expressed by the school that Children’s Social Care were due to cease involvement. 3.126 There was a telephone exchange between the FSW and CAMHS professionals. The FSW informed them of the proposed case closure. The meeting at school was discussed along with the view expressed by Aunt that she remained concerned about Child J’s behaviour and “lack of remorse, being defiant”. The FSW reported that there had been poor communication within school, and that DSL1 had not sufficiently shared Child J’s background and consequently there was a new DSL2 who would be attending the next Serious Case Review Final Report 13.04.2017 Page 35 of 74 meeting. The CAMHS professional thought these were all issues related to Child J’s poor early experiences. The conclusion was that Child J had made progress and a warm and loving relationship had been observed between Aunt and Child J. 3.127 The third Theraplay session took place at the beginning of the next month. Child J was described as subdued and Aunt said something had happened at school. There was no eye contact between Child J and Aunt who “rolled her eyes” when Child J was given a biscuit; this was not explored with her, which is surprising given that the sessions were intended to improve the attachment relationship. Aunt phoned CAMHS after the session to report that Child J had been stealing from school, the church and a shop and she was advised to respond in a non-shaming way. There was a discussion between the CAMHS professionals and it was agreed that peer supervision would be sought to discuss the issues raised. 3.128 During the second week of July there was a CAMHS consultation meeting attended by CAMHS professionals, Aunt, the two spiritual guardians (friends of Aunt’s), and DSL2. Aunt’s concerns about Child J’s behaviour and stealing were discussed alongside ways of managing this sensitively. The relationship with the school was said to be better and DSL2 noted that there had been some incorrect concerns regarding safeguarding which had had an emotional impact on Aunt and these were now resolved by improved communication. DSL2 said Child J was much more settled at school; this was not the conclusion of those who knew her best, the Class Teacher and the TA. Aunt explained that she had a letter from the Paediatrician about Child J’s easy bruising. Child J’s self-harming behaviour was also discussed, that Child J often came up with stories to explain bruising that were inconsistent and also made false allegations against people. 3.129 The CAMHS professionals discussed Child J in Theraplay supervision, and no concerns were raised. 3.130 In July 2014 at the next school safeguarding meeting five days later DSL2 said that she was concerned that DSL1 had not shared with the school safeguarding team Child J’s background; specifically, that Child J had been self-harming since the age of 2, had a medical issue of easy bruising and had made false allegations against adults close to her and other professionals. DSL2 was concerned that these issues had not been taken into account when evaluating whether bruises and injuries to Child J were a safeguarding matter and she reinforced her view that communication needed to be improved and injuries dealt with sensitively with regard to Aunt’s feelings. 3.131 There was an incident in July where the Class Teacher noticed that Child J had bruising to her face, and Child J also drew attention to this. The Class Teacher gave evidence at the inquest that a safeguarding form had been completed and placed in the box in reception, with a copy being kept on the Class Teacher’s own file for Child J. Neither the original nor the copy of this form can be found. It is unclear what action was taken, but DSL2 recorded on a safeguarding form created after Child J’s death that she met with Child J that morning and observed no bruises. DSL2 also recorded on the form Serious Case Review Final Report 13.04.2017 Page 36 of 74 completed post-death that she spoke to Aunt after school who showed her a video on her phone of Child J throwing a doll into the air and Aunt explained this is how the bruises were caused. Also on the form completed retrospectively was mention that Child J also said she had harmed herself and had an ice pack, although no corresponding entry exists on the accident book. This incident was not shared with the FSW; it clearly should have been. It is of concern that this serious incident was recorded after Child J died, and the contents are completely inaccurate, something not known by the Serious Case Review until after the inquest. 3.132 At the next school safeguarding meeting (just before the end of the school term) it was noted that Aunt remained concerned that staff were still judging her and drawing incorrect conclusions given the complexity of Child J’s needs. The conclusion regarding this is unclear, but it appears there was some discussion about ensuring that these issues were addressed effectively through better communication. Once again the needs of Child J were lost through these entrenched, adult focussed views. This is addressed in the analysis section. 3.133 CSC closed the case in July 2014. 3.134 Child J died in July 2014, two years after moving to live with her Aunt. 3.135 When the new term started a meeting was organised for all school staff with an education psychologist to discuss what had happened. Some of the Class Teachers and the TA asked to see her afterwards and they individually shared a number of concerns including: Confusion about safeguarding process within the school Concern that school staff had been told by some members of the school community they should not raise safeguarding concerns directly with Children’s Social Care – and that if you did you would be subject to some criticism Leadership around safeguarding at the school was not robust and was based on personal relationships and disputes Teaching Assistants’ concerns regarding children were not always listened to and they had no opportunity to share their concerns There were concerns regarding the assessment of injuries to Child J. 3.136 There were also concerns expressed about Child J that had not previously been reported or recorded at the school and not shared with other professionals. These included: Child J was terrified of her Aunt and did not want her to know when she was ill Aunt would not allow Child J to go on school trips or join the choir because she said “she did not deserve it” Aunt told Class Teachers and the TA that she should be excluded from school because of what she had done The bruising was of concern because it was so often in unusual places. Serious Case Review Final Report 13.04.2017 Page 37 of 74 3.137 These concerns were addressed in a special circumstances meeting involving the Director of Education and the Local Authority Designated Officer (LADO). An internal investigation was agreed and completed by the Head Teacher. This was found to be inadequate and an external, independent review was commissioned and completed by the LADO. The initial findings of this were that there were concerns about safeguarding activity at the school which had been affected by poor relationships amongst staff and confusion about roles and responsibilities. It was recommended that DSL2 be removed from the school safeguarding team, despite the Head Teacher’s reluctance regarding this. An action plan was agreed and an audit of safeguarding practice undertaken which noted the improvements and changes that have been implemented over the last 14 months. The school have also been inspected by Ofsted who were happy with safeguarding practice at the school and judged safeguarding to be effective. 3.138 The action plan has been revisited in light of concerns highlighted regarding safeguarding processes at the school during the inquest and further work has already been undertaken and more action and support is planned. 4 FINDINGS AND RECOMMENDATIONS 4.1 This section draws together the findings of this Serious Case Review. This was a sad and complex case. The death of Child J was shocking to her Mother, Father, close family members and her foster family who all continue to grieve her loss. It was also a shock to all those professionals who had contact with her, they did not suspect that this would be the outcome and it has impacted deeply on all of them. All those professionals have engaged with this review and have sought to ensure that lessons are learned about practice. There is no evidence that Child J’s death could have been predicted, but the overall purpose of any review is to identify areas of practice that can be improved, to identify systemic factors which need to be addressed and factors identified from which others can learn. This review has highlighted a number of factors that affected the professional response to Child J; although each of these is outlined individually, in this case it was the complex interplay of all that had a profound impact. 4.2 A number of recommendations are made for the Nottingham City Safeguarding Children Board (NCSCB). These have been developed in recognition of the work already undertaken by agencies in response to issues arising from this Serious Case Review and individual agency action plans submitted as part of the review. Information regarding these actions forms part of the response document supplementary to this review report. It is the responsibility of the NCSCB to monitor both the implementation and impact of individual agency action plans and the recommendations set out below. Serious Case Review Final Report 13.04.2017 Page 38 of 74 Finding 1: The importance of recognising the impact of parental mental health on children’s wellbeing and giving parents a clear outline of concerns and actions they need to take as part of any rehabilitation process. 4.3 Child J came into care when she was nearly five years old. The reasons have been outlined in the narrative in section 3, as have the concerns that Mother was not provided with appropriate support for what were very serious concerns and there was a lack of authoritative and purposeful action regarding the impact of maternal mental ill health on children. 4.4 Action was taken to consider whether Child J could be rehabilitated at home, and a full core assessment and a specialist psychological assessment undertaken. This was good practice and provided a firm basis for decision-making. Mother engaged with plans and put the needs of her children first by agreeing with the Local Authority recommendation that the children remained accommodated whilst safe decisions were made for them. At this stage Mother did not always feel clear about what action she needed to take to enable her children to return to her care, despite being briefed by her solicitor and given verbal feedback by the social worker. 4.5 The evidence from the assessments was that there were significant attachment difficulties between Mother and Child J and that Mother continued to attribute responsibility for this to Child J and her personality/behavioural issues. This combination of negative factors has been shown by recent researchvii viiito be a contra-indication for rehabilitation and requires a long period of therapeutic input to address, something that would be outside the developmental timescales for both children. The decision was made to seek to place both children permanently away from their mother’s care. This was a difficult decision, but one that was supported by the evidence. At the same time the psychological assessment proposed Mother undertake therapeutic support which she was unable to access because of long waiting lists and her only other choice was to pay for private therapeutic support – something she could not afford to do. The provision of this support would not have made a difference to the final decision, but Mother’s inability to access those services raises concerns for other rehabilitation cases. This part of the review highlights two key points of learning and necessary improvements to practice: The need for recognition of the seriousness of concerns regarding maternal mental health, particularly when it relates to unwanted thoughts of harming a child and that there is a clear and appropriate response and plan of action. Parents who are required to undertake psychological therapies need to be enabled to access those therapies. Serious Case Review Final Report 13.04.2017 Page 39 of 74 Recommendation 1: The NCSCB should seek assurance that the implications of parental mental ill-health are understood and fully addressed in plans for children and young people. This will include an evaluation of the availability of therapeutic support needs of parents, how this is prioritised and the implications this has for local commissioning arrangements. The need to ensure that parent(s) are provided with a clear written outline about the Local Authority concerns when children are in care on a voluntary basis and rehabilitation is being considered alongside other options. This should make clear actions required of parents in the rehabilitation plan, support to be provided to enable them to achieve these goals and process of review/decision making. No recommendation has been made with regards to this issue in recognition of the work already undertaken by Nottingham City council to address this. This work has been further strengthened by recent case law which makes an explicit requirement with regard to consent. Finding 2: The importance of helping children understand the reasons for being in care and addressing this through appropriate life story/direct work 4.6 Child J was never really clear about why she came into care. This happened in a moment of crisis and it appears that she was told by her first Social Worker that her Mother was unwell and she would return home when she was better, and this was said to her by her Mother who also believed that the plan was for Child J to return home. It appears that Child J experienced profound feelings of loss at this separation which she often articulated. 4.7 Fahlberg (2008ix) has highlighted that it is essential to explore a child’s beliefs about why they think they have come into care. Children in the age range 3 - 5 are at the developmental stage of magical and egocentric thinkingx which can lead them to believe that they were responsible for what happened, either because of what they thought or their behaviour. This belief can impact very negatively and exacerbate the grief response. For Child J she will have been aware that her Mother was finding her behaviour difficult as this was often articulated in her presence. The need for direct work/life story work20 to be undertaken regarding this was discussed in the first Looked After Review and some appropriate direct work undertaken in the transition for the move to Aunt. This lack of clarity about why she had come into care remained and the implications for her that she might have been in some way responsible was never fully addressed and was an outstanding action in the final care plan some 10 20 Life story work is an intervention with children designed to recognise their past, present, and future. It is prominently used with children who will be adopted or placed with other alternative carers. Serious Case Review Final Report 13.04.2017 Page 40 of 74 months later. No recommendation has been made with regards to this issue as it is addressed in the CSC Action Plan. Finding 3: Working effectively with the impact of early trauma on children’s lives 4.8 One of the most influential issues in understanding the professional response to Child J was the lack of a clear understanding of the impact of early emotional abuse and neglect in the past on young children and the likely manifestation of this in their behaviour in the present and the possible response of adults who care for them. Research has highlighted that exposure to long term hostile and neglectful parenting has significant negative consequences for a child’s brain development, and can result in cognitive, behavioural, emotional, social, and physiologically impeded developmentxi. 4.9 The most important part of a child’s development is their attachment relationship with their primary caregiver; if this relationship is damaged the evidence suggests that there is likely to be a profound and significant impact on the child’s emotional wellbeing. If this is unaddressed, children may transfer their negative feelings to their new caregivers. If the response they get (often born out of a lack of understanding) is controlling and punitive, a child’s psychological distress increases, and this becomes further manifest in the child’s behaviour setting up an unhelpful circular patternxii. 4.10 Given her background and the circumstances leading to her coming into care, it is not surprising that Child J was a traumatised child and this trauma was manifest in her behaviour and emotional wellbeing. Child J was placed with a caring foster family who found Child J’s difficult behaviour hard to manage and they attempted to deal with this behaviour through tried and established management techniques. This strategy was not successful or helpful because routine behavioural management techniques do not work for traumatised children and can often exacerbate the problemsxiii. 4.11 There is a clear evidence base regarding the importance of helping foster carers understand behavioural difficulties caused by trauma and to support them to parent therapeuticallyxiv. It is the task of the professionals supporting foster cares/adopters/friends and family carers to provide advice and support about trauma and to notice when it appears that children are being characterised as inherently difficult rather than traumatised. In essence to notice when carers stop understanding that a child is “troubled” and starts to be viewed as “troublesome”. The foster carers for Child J were subsequently provided with help and support and they were able to adapt their parenting style and this led to improvements in how they felt about Child J and how Child J was able to manage her feelings. However, the view persisted that she was a difficult and complex child and this view influenced the subsequent professional response. 4.12 Aunt was made aware of Child J’s early difficult experiences and her poor attachment to her Mother during the Special Guardianship Assessment. The Social Worker said this Serious Case Review Final Report 13.04.2017 Page 41 of 74 meant that Child J was exhibiting challenging behaviour. This was a clear outline of the issues and Aunt expressed appropriate empathy for Child J and agreed that a sensitive and loving response was required. This was emphasised within the SGO where it was said that “Aunt was to provide Child J with consistent emotional warmth, structure and boundaries, with parenting that was flexible and warm in style.” What was not included was the specific advice given to the foster carers from the psychological assessment, with its emphasis on not adopting a controlling approach. The agreed plan was that there would be support from CAMHS for the placement, this had been part of the successful strategy for the foster family. Theraplay was to be provided to build the attachment relationship but this did not happen until 16 months into the placement. 4.13 At this point Aunt had not had full time care of any child and more should have been planned to pre-empt what was likely to be a difficult and on-going transition. Aunt reported difficulties in managing Child J’s behaviour immediately Child J came to live with her. Much of what Aunt reported in these early days was similar to the behaviours reported in the early days of the foster placement, such as screaming, stealing, asking to be hit and issues regarding continence. Aunt’s analysis that Child J’s behavioural difficulties were connected to contact with her Mother was accepted and changes made to these arrangements including a change of school. The fact that this did not alleviate the difficulties as described by Aunt was not noted and there was no consideration that these changes might be exacerbating Child J’s difficulties. 4.14 During the next 18 months Aunt continued to report to all professionals that Child J’s behaviour was unmanageable, that she was self-harming and stealing and increasingly she described Child J as being deliberately naughty, defiant and unremorseful; she moved from describing behaviours to attributing negative personality traits to a very young child. This was not sufficiently challenged directly with Aunt, despite the efforts made to address these behaviours. 4.15 Despite there being much discussion of Child J’s early experiences, the records and discussions suggest that Child J started to be seen as a difficult and complex child by professionals. Aunt, who attended all meetings, fuelled this and self-reported issues regarding Child J; she often enlisted the help of other adults, largely from the church. These behaviours were not actually witnessed by other professionals. At school she was seen as a well-behaved child until towards the end of the review period. Aunt’s negativity (which showed a lack of empathy, and was a long way from the parenting style she agreed to adopt) was not sufficiently challenged. She was difficult to challenge, and there is no doubt that at times she showed “false compliance”xv by agreeing to making changes and understanding professional’s concerns. Early trauma was seen statically as an influence from the past, not something that was operating in the present, seen as justifying Aunt’s punitive approach, but not fully considered in the context of Child J’s emotional wellbeing in the here and now, and that the support mechanisms that were in place were not addressing these issues. Serious Case Review Final Report 13.04.2017 Page 42 of 74 Recommendation 2: The NCSCB should highlight the importance of recognising and understanding early childhood trauma when communicating the learning from this sub-group. It should seek assurance from partner agencies that this issue has been reinforced through internal communication and training routes. Finding 4: The importance of a clear understanding of self-harm 4.16 A central issue across this review was concerns about Child J’s “self –harming” behaviours. This is in inverted commas because it was never established whether Child J was actually self-harming as this was never assessed and the details were never fully documented. None of the adults who reported these behaviours was asked to clearly record what they were witnessing; the records are quite low on detail. Self-harm in children aged 5- 10 years old is uncommon21. There were reports from Mother that Child J engaged in behaviour that was harmful, such as threatening to throw herself out of a window, and there were incidents of hair pulling, pinching, and throwing herself at furniture and threats of throwing herself down the stairs when she was in foster care. It could be argued that these were all behaviours linked to her feelings of loss, a manifestation of her feelings and early trauma. This analysis was not undertaken. 4.17 When Child J moved to Aunt’s she was said to exhibit some of these harming behaviours, and in the first six months Aunt began to refer to them as “deliberate self-harm” something she explained as causative of the burn seen by professionals in the Accident and Emergency Department. There should have been a clearer analysis of what these behaviours were and some professional’s scepticism about whether Aunt’s descriptions and labels were correct or whether there was an alternative explanation/differential diagnosis of safeguarding required. Professionals should have also considered why the “self-harm” as they saw it was getting worse, not better, despite changes made and interventions offered. This should have indicated to all that the analysis regarding the cause of these behaviours might not be correct, and required a re-analysis. 4.18 If what professionals were seeing was self–harm they should have been significantly concerned because of Child J’s young age. The guidancexvi regarding the management of self-harm in children focuses on those over 8 years old in recognition that self-harm in younger children is unusual. The guidance makes clear the importance of an assessment of the self-harming behaviours. There should have been more professional scepticism and curiosity regarding this issue; the professional response at this time was influenced by a combination of confusion about the impact of early trauma and fixed views about the motivations of Aunt in particular who was reporting “self-harm”. 21 A national survey of more than 10,000 children found that the prevalence of self-harm among 5-10 year-olds was 0.8% among children without any mental health issues, but 6.2% among those diagnosed with an anxiety disorder and 7.5% if the child had a conduct, hyperkinetic or less common mental disorder. Nixon (2011) Self-harm in children and young people handbook Serious Case Review Final Report 13.04.2017 Page 43 of 74 Recommendation 3: The NCSCB Practice Guidance regarding self-harm should be updated to address the needs of children aged 5- 10. This update should make clear that professionals should not accept the term self-harm in children under 10 without consideration of potential emotional well-being or safeguarding concerns. Finding 5: Addressing the complex health needs of children including working effectively with continence issues 4.19 Child J had long term complex health needs. These were made clear through her Looked After Children’s medical, and were incorporated into the Special Guardianship Support assessment. When the SGO was granted to Aunt she became responsible for managing Child J’s health needs. She had indicated during the assessment process that she was fully aware of this and committed to ensuring that Child J’s health needs were met; there were no indications that she would not do so and therefore no plan was deemed necessary. Aunt did not always fulfil this responsibility; she failed to attend appointments, and these had to be rescheduled. These did not raise major concerns about Child J’s wellbeing by the school nurse who was satisfied overall with her progress. The concerns raised were all related to issues of continence. 4.20 Child J had long-standing problems with continence, night time bed wetting (known as nocturnal enuresis) and some problems during the day (known as urinary incontinence). These conditions are common in children of Child J’s age and these problems sometimes have an organic cause. Child J was found to have a kidney condition at birth and this required her to drink large quantities of water to avoid infections and this would inevitably have impacted on her ability to stay dry in her early years. 4.21 Her Mother reported this was an issue, as did the foster carer. The specialist nurse for continence provided support when Child J was in foster care and this was largely successful. However, in these early days Child J’s struggles with continence, which were relatively normal, got confused with other concerns about her behaviour and these should have been more clearly separated out. At the first Looked After Review it was agreed that there should be some clarification of whether this was a medical issue, linked to her renal problems, or was part of normal child development; this was never done, and was something the specialist nurse for continence would raise again some 15 months after Child J had been living with Aunt. 4.22 When Child J came to live with Aunt her continence difficulties became a major issue. There are few meetings or home visits with any professional where Aunt did not raise it. Increasingly, Aunt reported to professionals that this was evidence of Child J’s bad behaviour and defiant attitude and her response became increasingly hostile and unnecessarily punitive. This was not challenged by any professional. Serious Case Review Final Report 13.04.2017 Page 44 of 74 4.23 There are clear guidelines about how continence issues with children of this age should be managedxvii. The emphasis is on normalisation, no blame, no shame and strictly no punishments. The guidance makes clear the need to emphasise that children should not be held responsible for being dry as night dryness is a developmental achievement over which the child has no control; very few children wet the bed on purpose. The confusion about personal responsibility is highlighted by the use of star charts that can suggest that this issue is under children’s control. Star charts should be used for cooperation in the treatment programme only. The NICE guidelines make it clear that maltreatment should be considered if a child or young person is consistently reported to be deliberately bedwetting, the parents or carers are seen to repeatedly punish the child and the problem is not addressed by advice. 4.24 This was exactly the situation with Aunt. She consistently blamed and humiliated Child J. She also withheld water, something that had the potential to cause Child J some very serious health problems. The specialist nurse for continence did try to give advice, but she did this in isolation from the other professionals. Aunt asked the FSW for advice, and the intensive CAMHS Health Care Assistant also focussed on continence issues. They all gave different advice. There was no sense that professionals considered what this all meant for Child J or what Aunt’s rhetoric about how “deliberateness” or “lack of remorse” might impact on her both physically and emotionally. Recommendation 4: The NCSCB should ensure that all professionals who are working with children who experience continence issues are aware of the national guidance regarding this. The NCSCB will seek assurance that agencies are clear about what action to take when parents/carers adopt a significantly punitive approach and recognise the need for a coordinated response to these issues. Finding 6: The importance of a good assessment of potential non accidental injuries 4.25 There were long term concerns about possible non accidental injuries to Child J from when she was two years old. These early concerns related to unexplained injuries, potentially caused by her Mother and which were never fully investigated or addressed. In 2010 Child J disclosed that she had been physically abused whilst in the care of her Father, his first wife and PGM. A child protection enquiry and medical was undertaken, but there was no assessment of PGM carried out, despite Child J, who was aged two and a half at this time, making a clear allegation of abuse. This meant that possible early concerns regarding the extended family were not assessed and the possibility of exploring how entrenched the use of physical abuse was within the family was missed. 4.26 There were many concerns regarding bruising and injuries, from six months after Child J moved to live with Aunt. These were noted by school, either by the Class Teachers or the teaching assistants. Up until the summer of 2013 these were held in handwritten Serious Case Review Final Report 13.04.2017 Page 45 of 74 records by the DSL1. The DSL1 was not aware that she needed to record these on a formal safeguarding concern form, and when she completed her safeguarding training she designed a form and in the summer of 2013 she filled these forms in and destroyed her contemporaneous records. This meant it was not clear whether the FSW was informed of five incidents of concern; however, in June 2013 the FSW was made aware that there had been a number of concerns about bruising and neither the DSL1 provided detail and the FSW did not ask for them. 4.27 The Aunt would often pre-empt these concerns about bruising/injuries, either by informing the school what had happened or by ringing the FSW, giving some credence to her subsequent explanations. Information was sought from the school, and Aunt, who alleged that all the injuries were attributed to either Child J’s self-harm or accidents. Aunt often enlisted the help of friends to bear witness to the self-harm and Child J often agreed that she had lied. There were occasions, such as with a bruise to the eye, said to be caused by Child J itching chicken pox, where the professionals witnessed her doing this. 4.28 There were two occasions when Child J was seen in hospital. The first for a burn where all agencies were convinced by Aunt that this was self-harm, and this was agreed by Child J. No further enquiries were undertaken, when they clearly should have been – particularly in the context of self-harm – an issue already explored. On the second occasion a full child protection medical was sought and carried out. This provided a detailed look at Child J’s injuries and was contextualised alongside some of the recent history. The focus here was also self-harm as an explanation for the injuries fitted with the explanation provided; there were two which did not fall into either of these categories, but they were not explored or assessed further. This raises the importance of social workers sharing all available psycho-social information before the child protection medical, so a full holistic picture can be formed. This is addressed in the recommendations that follow. 4.29 Although enquiries were undertaken, there was never a full assessment which brought together all the available information in the context of possible physical abuse. A number of professionals noted that Child J looked uncomfortable in the presence of Aunt when issues regarding bruising were discussed, but this was not routinely shared or recorded. It is essential that professionals are aware of the importance of observing the parent child /relationship and where concerns are held these are noted. 4.30 Although the nationalxviii and local procedures22 make it clear what the definition of physical abuse is, and give a general overview of the process of undertaking child protection enquiries, there is no clear outline regarding what should be covered and what the focus should be. This is in stark contrast to sexual abuse, emotional abuse and neglect all of which have additional guidance locally and nationally. 22 http://nottinghamshirescb.proceduresonline.com/index.htm Serious Case Review Final Report 13.04.2017 Page 46 of 74 4.31 A recent reviewxix makes clear that the first principle of enquiries regarding physical abuse is to be clear about the purpose, which is to establish whether the causes of unexplained injuries in children is accidental, caused by child abuse, is part of a congenital or acquired illness or part of a pattern of poor supervision and neglect. This review could add to this those caused by emotional distress and self-harm. The assessment must also end with a conclusion and professional judgement about the cause, and implications for any services. In this case enquiries stopped where it was found that there was a suitable explanation, and neither the conclusion nor the implication of this was fully recorded. If this was a lack of supervision, and many of the injuries were attributed to accidents, then this should have led to appropriate action. If it was emotional distress and self-harm, an action plan should have been developed. What was of concern here is that the explanations for injuries did not change, and action such as support from CAMHS did not make a difference. This should have indicated that there was not a clear understanding of what was happening. 4.32 The NICE Guidelinesxx which are applicable to all professionals, but not always fully implemented, make it clear that in order to establish whether injuries to children are non-accidental there are a number of issues which must be considered and it is important not to focus on just one area, for example a medical explanation. These are: the nature of the injury; the explanations provided by the child; the explanations provided by the parent and any other person involved; any contradictions or discrepancies in the story; family history and known risk factors; history of other injuries. 4.33 In assessing potential non accidental injury it is important to consider the attitudes and behaviours of the adults caring for the child. Adult behaviour can be attributed either to contextual factors and circumstances, external issues which are outside of an individual’s control or they can be attributed to internal or innate psychological traits or personal characteristics. This is often referred to as understanding behaviour as either situational or dispositional. When trying to understand the cause of behaviour in a safeguarding context it is important to establish whether the influences on adult behaviours are to do with people’s environment and circumstances or some internal characteristics or traits. This will help to establish what would be an appropriate response. Research suggests in a safeguarding context professionals are both reluctant to consider causal factors in this way, and where they do make professional judgements they often get the attribution wrong. 4.34 For Aunt, the cause of her behaviour was seen as contextual or situational; most professionals believed that she was responding to the stresses of caring for a difficult child in difficult circumstances and was not being abusive. There appeared to be little reflection on whether some of her behaviours and responses to the injuries to Child J were dispositional. This is not to use the benefit of hindsight because the outcome is Serious Case Review Final Report 13.04.2017 Page 47 of 74 known, but to suggest that in cases where there is uncertainty about the nature of injuries it is important to consider the causes of adult behaviour and for practitioners to ask themselves if it is dispositional or contextual on a more regular basis. 4.35 This information should then form the basis of an analysis and a clear conclusion drawn from all the available evidence. This did not happen for Child J because there were only limited enquiries. There were discrepant explanations for injuries; the school kept full records of the injuries, but these were not included in the analysis and each incident, of which there were many, was treated in isolation. There were differences of opinion across the professional network about the cause of these injuries, yet there was no professional challenge and no agency invoked the escalation procedure. Ultimately, the assessment of potential physical abuse should be a multi-agency task, differences of professional opinion acknowledged, and this should be reflected in the final conclusion. In this case the dominance of Aunt alongside ineffective multi-agency practices and a lack of a clear framework for assessing potential physical abuse meant that practice in this area was not effective and it remains uncertain what the causes of the many injuries seen were. Recommendation 5: The NCSCB should review the guidance for all professionals regarding the assessment of potential non accidental injury and ensure it is compliant with the existing NICE Guidelines regarding child maltreatment. This revised guidance should also include: Guidance for all professionals about child centred disciplinary approaches A mechanism for ensuring relevant information about a child’s known psycho-social history and history of previous concerns/injuries is completed in preparation for a child protection medical and that this is recorded where it is not possible to do this in advance of the medical this information must be considered alongside the outcome of the examination. Finding 7: Professional approach to child discipline and punishment 4.36 The circumstances in which Child J lived with her Aunt raise important questions about professional beliefs and actions regarding appropriate disciplinary approaches. Aunt was very clear with all professionals that discipline was important and was necessary to address Child J’s behavioural issues. 4.37 The issue of discipline had been discussed during the SGO assessment and Aunt had said that she had been “physically chastised” by her Mother (she underplayed the extent of this actual physical and emotional abuse) and that this had caused conflicts between them into adulthood. Aunt linked this approach to discipline to the family’s cultural heritage, but said that the family recognised that times had changed and that this was now no longer acceptable. Aunt had been clear that she did not see this as part of her cultural heritage and would not engage in such practices and it was agreed that Child J needed sensitive and caring parenting. Serious Case Review Final Report 13.04.2017 Page 48 of 74 4.38 Child J told the school on a number of occasions that she was hit with a brush on her hand, was force-fed and made to face the wall with her hands outstretched. Aunt said this approach was necessary because of Child J’s behavioural difficulties Aunt also described withholding water, locking the bathroom and threatening Child J with punishment. Professionals accepted that Aunt was primarily engaged in disciplinary measures, but that these were overall too harsh and punitive. Work to address this was undertaken with intensive parenting support and more latterly therapeutic training to improve the parent-carer relationship. Aunt reported that this support had changed her approach to parenting, and there was less reporting of concerns. Aunt’s negative attitude regarding Child J’s behaviour remained, but was often counter balanced by warm and caring exchanges witnessed during home visits by the FSW and CAMHS support worker. 4.39 There has been a significant amount of research regarding parenting styles and approaches which contribute to optimal developmental outcomes for childrenxxi xxii. This work consistently identifies that non-punitive disciplinary practices based on reasoning are associated with positive outcomes. Disciplinary approaches which inflict physical or psychological harm are not effective, are harmfulxxiii, and are not consistent with the requirements of either the UNCRCxxiv or the Human Rights Actxxv. A clear distinction is made between discipline which is aimed at meeting the needs of a child and helping them meet adult expectations, as opposed to punishment which is usually initiated to alleviate adult needs and frustrations and is often associated with humiliation of the child. 4.40 There is no evidence that professionals considered that Aunt’s approach to discipline and punishment was in any way a cultural issue, and Aunt never raised this as an issue. Aunt was asked to develop a gentler response and was provided with services by CAMHS to do so. Yet despite a verbal commitment to change, Aunt never stopped her punitive and abusive approach. She should have been more fully challenged regarding this and professionals should have been clearer and more united in their advice about what constitutes effective approaches to discipline as opposed to punishment. 4.41 There are currently no national or local guidelines regarding appropriate disciplinary practices and it is therefore left to professionals to take a view on a case by case basis on what is reasonable. In this case professionals should have had a view that the approach that Aunt took was punitive, not disciplinary, was not focussed on the needs of Child J and amounted to child maltreatment. See recommendation 5 Finding 8: The important role of schools in safeguarding children 4.42 Current Guidancexxvi makes clear the important role that school play in safeguarding children. Schools see children daily and teachers, classroom assistants, dinner staff, playground staff are all in a good position to notice concerns, changes in children’s behaviour and the response and attitude of parents/carers to any concerns raised. All Serious Case Review Final Report 13.04.2017 Page 49 of 74 school staff have a responsibility to identify children who need support, or who are suffering or likely to suffer significant harm. In order for this to happen schools need to have clear and robust systems in place which supports effective safeguarding practice; this would include designated safeguarding professional(s) who bring expertise, guidance and advice, clear recording systems, supervision and policies and procedures. It is also essential that schools are recognised as an integral part of the safeguarding network, are included in meetings, have records, assessments and plans shared with them. 4.43 Child J attended a number of schools. When she lived with her Mother, the school appropriately shared concerns with professionals and provided support to Mother. 4.44 Child J spent most of the time at the school she moved to 6 months after moving to live with her Aunt. This school were aware of brief family details, but the transfer of records to the school was slow, and this meant the school did not have full historical information about Child J’s experience of abuse in the past, her trauma related behavioural difficulties or her health needs. This meant that the school were not aware of the need for a multi-agency meeting. The terms of the FAO were such that under usual circumstances no meeting would have been required, but given the discussion between the FSW and Aunt about how this transition from one school, in the context of other changes, was likely to be difficult, a meeting would have been helpful. The lack of a meeting, coupled with the lack of historic information meant that there was no formal established working arrangement between the school and the wider network, and this was not a helpful start for effective multi agency working. 4.45 It is now clear that the safeguarding arrangements at this school were chaotic and at times unclear. When Child J moved to the school there were unclear processes. There were no established processes regarding recording concerns about children and DSL1 reports she kept a handwritten record of information that was shared with her by teachers and other school staff. DSL1 attended safeguarding training in 2013 and as a result designed a safeguarding form onto which she transferred all these handwritten records ready for the start of term in September 2013. She destroyed her hand written notes. This meant that there were at least five incidents regarding bruising/injuries to Child J which were only communicated verbally and for which there was no written record and there is some dispute regarding the content of the form, completed so long after the actual incident. This was not appropriate safeguarding practice. The FSW became aware of the lack of communication in June 2013 but this did not lead to any reflections regarding what the school did know. 4.46 There were poor working relationships between DSL1 (assistant head) and the Head Teacher which had its roots in both concerns about recruitment practices and personal differences. This led to a new school safeguarding team being developed in February 2014. The Head Teacher saw himself as part of this team, rather than needing to exercise management oversight and to provide an objective supervisory view regarding both the existing personal disputes and the deep differences of professional Serious Case Review Final Report 13.04.2017 Page 50 of 74 opinion. This meant these were never resolved, and ultimately led to several incidents regarding bruising to Child J not being shared with other professionals. 4.47 The school were not initially aware that CAMHS meetings were being held about Child J and issues regarding school, such as stealing, were being discussed; this meant they could not share their perspectives or concerns. Child J had told the school about Aunts’ abusive behaviour to her, and this was recognised by DSL1 as a cause of concern. A school meeting with the family support worker was organised and the issues of “inappropriate parenting” were discussed, Aunt denied the issue and no plan was put in place; these issues were planned to be discussed at a CAMHS meeting in two weeks’ time, but the school were not invited. 4.48 At this next CAMHS meeting issues regarding Child J’s behaviour and stealing at school were discussed, again without school being present and they did not receive the minutes of the meeting or the action plan. The school became aware of CAMHS involvement through the work of the CAMHS Intensive Intervention Service, but were not invited to a meeting until 11 months after Child J had started at the school. It is clear that the school were on the margins of professional thinking regarding Child J for many months, and when they became included Aunt sought to discredit their input by suggesting they were not communicating with her, being critical and did not understand the nature of Child J’s difficulties. This splitting off was largely successful and is addressed below. 4.49 The Class Teacher and TA in both of the school years had many concerns regarding Aunt’s attitude to Child J and noted incidences of bruising. They shared these with DSL1 initially and then DSL2. There was no effective feedback loop and the Class Teacher and TA felt they could not challenge the lack of action. It is important that all professionals working with children are aware of escalation and whistleblowing processes when they have concerns regarding a child which they feel are not being listened to. The circumstances at the school made challenge complex, but it is the professional responsibility of all professionals to ensure that they find a way of alerting others to safeguarding concern and seek feedback to ensure that action is taken. This did not happen for Child J. 4.50 The Class Teacher in the 2013- 2014 year faxed a concern form and body map directly to the FSW as she had been asked to do and was told that this was not a correct course of action in front of Aunt, the DSL and the Head Teacher. This was clearly inappropriate and effectively silenced this teacher. 4.51 The Class Teacher and TA were equally not asked for their views or to consider what information they held, either during the school safeguarding meetings or as part of the work of the FSW. This information was important, and if contextualised alongside the Aunt’s complete negativity about Child J in meetings, was suggestive of emotional abuse. It is striking the extent to which school staff noted that Child J looked downcast when with her Aunt. This was particularly when bruises or concerns were discussed. Serious Case Review Final Report 13.04.2017 Page 51 of 74 These were never recorded or shared with professionals, and only became apparent as a concern at the Trial and Inquest. School staff reported that they were unclear whether they could record or share this information because they believed it to move beyond what was factual. It is critically important that all professionals recognise the need to noticing and respond to how a child appears, and when discussing concerns, they notice the parent/carer – child relationship and record and share concerns regarding this. 4.52 The Class Teacher and TA kept a separate record when they had more general concerns about Child J, for example when she seemed unhappy, but which they considered were not issues of a safeguarding nature, such as Aunt not allowing Child J to go on school outings because she “did not deserve to go” and Aunts request that Child J be excluded or punished because she was naughty. These were worries, but were not issues that would normally be recorded on safeguarding forms, and were also not formally shared across the school network. 4.53 For some of the time the school were on the margins of the professional response to Child J. Aunt was often rude and aggressive to the teachers and TA, and although some boundaries were put around this by the school, there was evidence that Aunt was able to split professional opinion and cause some conflicts between school staff, and other professionals. This was not recognised or addressed, and the lack of any supervisory processes in school regarding the response to safeguarding concerns did not help. 4.54 There were huge tensions within the school safeguarding team which went unaddressed and meant that DSL1 felt unable to challenge the fixed view of DSL2 and the Head Teacher that Aunt was being unnecessarily accused of potential harm. The perspective became about supporting Aunt, and ensuring that communication was improved. This led in the latter stages of Child J’s contact with school with concerns regarding bruising and being abused by adults not being shared with CSC and no action being taken. This was unacceptable. 4.55 Within the review of the circumstances it has been identified that there were strained relationships within the school at times. This was as a result of the school going through a period of change in terms of staff roles and leadership. These concerns led to an internal investigation which was deemed inappropriate and led to an external investigation led by the LADO. This brought about significant changes. Audit has demonstrated that these changes were positive. The full outline of action already taken, and action to be taken is included in the education action plan. 4.56 This action plan has been revisited in light of concerns highlighted regarding safeguarding processes at the school during the inquest and further work has already been undertaken and more action and support is planned. Serious Case Review Final Report 13.04.2017 Page 52 of 74 Recommendation 6: The NCSCB should reinforce the need for all professionals to recognise the important role played by schools in the support and safeguarding of vulnerable children and promote a multi-agency approach to all aspects of assessment and planning for vulnerable children. This action should include ensuring that the Designated Safeguarding Leads Network creates practice standards which reinforces the requirement for schools to routinely follow up referrals to Children's Social Care in writing, including details of all concerns that have been recorded by staff within the school; and establishes consistency in the way that “soft” information that raises concerns about a pupils wellbeing is collected and reviewed both directly during staff supervision sessions and through recording processes Finding 9: The influence of the Special Guardianship Process and Placement with relatives 4.57 Once the decision was made that Child J and her sibling could not be rehabilitated to the care of their Mother, the Local Authority appropriately looked to place them with family members. This is in line with legislation and current national policy. It is also good practice because research suggests that these placements are beneficial to children’s outcomesxxvii. 4.58 Action was taken to seek a possible family placement for Child J. The Courts place a duty on the Local Authority to consider all family members; in this case the adults who were approached were not suitable carers for Child J and the process of them ruling themselves out meant that their unsuitability was not recorded. Mother had always made it clear that she had concerns about these members of the extended family. The pressure to evidence that family members have been consulted influenced practice. They could be considered, but their unsuitability made clear. This acknowledgment would have led to a discussion about the appropriateness of future contact but this never happened. 4.59 Father also suggested one of his sisters and she agreed to be assessed. Mother had no objections to this and the Special Guardianship process was started. 4.60 The Special Guardianship Order (SGO) was introduced in 2005 as an alternative legal pathway to permanent out of home care for children, often within the extended family network.23 It was envisaged that children would be placed with family members or adults with whom they already had a prior and established relationshipxxviii. This meant that within the statutory framework for the SGO there is no requirement for a matching process, introductions, transition planning process or a period of monitoring and the assessment requirements are more limited. These processes are routine for 23 Special Guardianship offers greater security than long-term fostering as it lasts until the child reaches 18, but it does not require the legal severance from the birth family that is the result of an adoption order. A Special Guardianship order gives the Special Guardian parental responsibility for the child. The birth parents remain the child’s legal parents and retain parental responsibility though their ability to exercise this is very limited. Serious Case Review Final Report 13.04.2017 Page 53 of 74 other types of placements. This was profoundly influential for Child J. Child J had only met Aunt once before and did not have an existing relationship with her. This was known and acknowledged and should have been more clearly factored into the transition process. The SGO guidance makes no provision for these circumstances and recent researchxxix has highlighted the need for this to be addressed. 4.61 SGO Assessment: The assessment of Aunt was planned and met most of the requirements of the current SGO Guidance. It was modelled on the national assessment frameworkxxx as would be expected. More could have been done to engage education and health services in the SGO process, although existing information about Child J’s health and education needs were included. Independent references were sought and these were positive, though all from the same organisation, the church, and interviews were not conducted with these individuals. The SGO was granted, and there was no evidence to suggest that it should not have been. In reviewing the assessment and court process there are several points of practice outlined below. 4.62 The need for a psychological assessment of Aunt: Psychological assessments are not routinely undertaken as part of the SGO process, but there will be circumstances where this is necessary. There was a need for a psychological assessment of Aunt because this was a completely new relationship for Child J and Aunt; it was known that Child J had significant emotional, behavioural and health needs and it had been established that she needed a specific style of parenting to overcome her early trauma; Aunt had never parented before and had a complex and traumatised background herself. This indicated the need for a psychological assessment, something that had been undertaken previously to assess whether Mother had the capacity to parent Child J. This psychological assessment made clear that Child J needed sensitive and attuned parenting. At the point of the SGO planning it was not clear whether Aunt could provide this, except for her own assertion about her parenting skills (see the point below). This pointed to the need for a psychological assessment to have a more objective and balanced view. 4.63 Reliance on self-report: The assessment relied almost entirely on Aunt’s self-report. The social worker undertaking the assessment could not know that Aunt was not truthful through the assessment process, but a recent review of child protection processesxxxi has highlighted the importance of the routine triangulation of information and reflection on the extent to which parents/carers views are merely reported rather than analysed. 4.64 Influence of history: Aunt provided information about being physically abused as a child and sexually abused by a teacher and these recent abusive experiences required more analysis. Researchxxxii suggests that abuse in childhood/adolescence can have an impact on future parenting. This is not inevitable, but is dependent on the adult’s awareness of the impact of the abuse on them and the ability to reflect on the influence of these experiences in the present. This should have influenced the support plan more clearly. Serious Case Review Final Report 13.04.2017 Page 54 of 74 4.65 Consultation with Child J: Regulation 21 of the guidance makes it clear that the wishes and feelings of the child for whom a special guardian is being assessed should be consulted about the proposed plan, their thoughts where relevant about their contact with family members and any wishes they have regarding their religious and cultural upbringing. This did not happen for Child J. The issue of consulting children about placements before the final decision is made is a complex one. Those responsible for seeking an SGO can only recommend it; it is the Courts who ultimately make the final decision. Professionals need to weigh up whether to talk to a child about a move that might not take place. In the case of Child J there is no recorded evidence that this debate took place and her views about her future as she had so often shared them were not included in the final assessment or reports to court. 4.66 Police information as part of the SGO: There is no requirement within the SGO Guidance about seeking police information as part of the assessment process. The social worker believed she had sought this information, and it had been returned with no concerns. This information is not available on the CSC files, and the police have no record of the request being made. Personal information was available if an enhanced check had been requested, which related to Aunt’s personal life and would have added to the information provided by Aunt regarding the abuse by PGM and the sexual abuse by the teacher. The information would have made it clear that Aunt had not always been entirely open about her circumstances. It is unlikely that this would have changed the decision to seek the SGO, but would have influenced the subsequent support plan. 4.67 SGO Support Process: The Children’s Guardian highlighted the need for high levels of support to this placement and a full SGO support plan was also prepared. This covered all the important aspects of Child J’s life, but did not include expected outcomes, timescales or proposed reviewing mechanisms. The Court agreed the SGO and in addition a FAO24. The FAO does not come with a clear set of guidance regarding the expectations of support, what sort of plan should be developed or what the reviewing mechanisms should be. Cafcass have developed their own guidance25 but no Local Authority has done this. This meant that there were three potential plans for Child J, the Children’s Guardian recommendations, the SGO Support Plan and the FAO. In the event the former two were not implemented and no support plan for the delivery of the FAO was developed. This was hugely influential in the provision of support which followed, which lacked aims and a clear purpose, had no reviewing mechanisms or contingency arrangements. Most crucially there was a lack of a coordinated multi-agency approach. Researchxxxiii highlights the importance of good quality plans to support new placements and to ensure their success, particularly where children have complex needs. 24 A Family Assistance Order is intended to provide focused short-term help to a family. The nature of the help to be provided will normally be in the assessment or case analysis provided by Cafcass to the court. The order requires that a local authority is to make an officer of the authority available, “to advise, assist and (where appropriate) befriend any person named in the order” (section 16(1)). 25 https://www.Cafcass.gov.uk/media/6572/FAO%20guidance%20300312.pdf Serious Case Review Final Report 13.04.2017 Page 55 of 74 4.68 The transition process: The SGO guidance does not stipulate how the process of transition for a child from any current placement to the Special Guardian should be managed. This is largely because the assumption is that the child may be already living with the person who is applying to be the Special Guardian, or the child is moving to live with someone who is well known to them and with whom they already have an established relationship. Local Fostering and Adoption processes26 and researchxxxiv makes clear that good transition arrangements are imperative to the success of new placements. 4.69 A timetable was put together for Child J’s move from the foster carer to Aunt. This was practical in nature and was well managed and supported by the foster carer. There was not enough focus, however, on the emotional transition and although some direct work was done with Child J, it was not sufficiently focused on her desire to return home, or stay with the foster carer, or her worries about her Mother’s health. Child J needed an opportunity to think about these issues in the context of life story work – something mentioned in the SGO support plan, but was never started. 4.70 One of the essential elements of life story workxxxv is to help children understand their recent history and decisions that have been made about their lives. It also enables memories to be captured. It is unclear, for example, what Child J brought from her Mothers’ home to the foster carer’s home and what she brought from there to her home with Aunt. There is no sense of her likes and dislikes, what she was good at, what toys she liked to play with, what television programmes she liked, who were her friends and did she have a favourite toy/object that she used for safety and security. These may all have been discussed informally between the foster carer and Aunt, but should have been part of a more formal transition plan. Finally, research around transitions xxxvi highlights the importance of foster carers staying in contact with children for a period of time after they have moved to a new permanent home. This was not formally planned for, but happened informally in the first few weeks after Child J moved to live with Aunt. 4.71 Contact arrangements: The SGO guidance does not provide any specific guidance regarding contact arrangements, and there is a presumption that this happens more easily within a family context. The lack of a support plan meant that there were unclear expectations regarding contact between Mother and Child J. The need for this to happen was outlined in the SGO support plan, and contact did take place. It was initially supervised by a contact worker and then by Aunt. There is very little information about the contact sessions or arrangements and they were never subject to formal review. Mother has said as part of the review process that she shared concerns about Child J and her wellbeing with the contact supervisor, but there is no record of this. Aunt raised concerns about the contact between Child J and her Mother, suggesting that it was disruptive to Child J. Although there are sometimes difficulties in contact between children and their birth families, it is important that these links are 26 http://nottinghamcitychildcare.proceduresonline.com/chapters/p_place_adop.html#plan_place Serious Case Review Final Report 13.04.2017 Page 56 of 74 maintained, and efforts are made to resolve problemsxxxvii. Contact was made with Mother, but there was no assessment of whether the contact was really having an impact and decisions to alter arrangements should have been made in a more considered way. 4.72 There is also little information about contact between Child J and Sibling 1. A number of concerns had been raised about the relationship between Child J and Sibling 1 and Child J’s feelings of jealousy. Research suggests that these relationships need clear assessments and planning if contact is to be successful and helpful to allxxxviii. 4.73 The SGO support plan also highlighted the importance of Child J having contact with her wider family. There was no plan regarding this, and the concerns raised by Mother about the extended family were not addressed. Again there is a national assumption, which appears to have influenced local practice, that families are able to sort these arrangements out themselves. This position does not take account of complex and difficult family arrangements and this was a significant issue for Child J. Recent researchxxxix regarding SGO’s has highlighted that children placed with relatives actually have less contact with the birth family and more needs to be done to formalise arrangements. No recommendation has been made given the work undertaken by Nottingham City Council to respond to these issues. Information regarding this is set out in the response document. This work has been further strengthened by national developments in relation to the use of Special Guardianship Orders. The NCSCB will need to seek reassurance this this work is making a difference to the issues raised in this report Finding 10: The importance of effective plans, assessments and effective multi-agency processes 4.74 The SGO process influenced planning when Child J came to live with her Aunt, particularly because the FAO had created some confusion about planning processes and Child J’s status. It was clear that she was not considered to be a child in need and was not subject to child in need regulations. The absence of any guidance regarding the FAO did not help – but over the whole period there was an absence of what would be considered routine family support practice in response to a child with complex educational and health needs. The process of assessment, planning, provision of support and services, review and multiagency planning is embedded into services for children for a reason. It supports children’s safety and wellbeing and the absence of such processes is consistently highlighted in Serious Case Reviews and child abuse inquiriesxl. 4.75 Absence of plans to address need: There were historical concerns about the absence of a coordinated plan to address Child J’s needs and circumstances; when her Mother Serious Case Review Final Report 13.04.2017 Page 57 of 74 was struggling to care for her and Sibling 1, support was offered, but not in a coordinated way. There was no clear articulation of the nature of the family’s difficulties, a plan to address them and a reviewing process to see how successful the support had been. 4.76 This was a similar picture when Child J came into the care of her Aunt, as has already been discussed there was an SGO plan and the Childrens Guardian recommendations when the SGO was granted, but neither were implemented and the FSW was left to provide support without any clear aims or focus, and without knowing exactly what was to be achieved. It should be a core requirement that all children in receipt of services from Children’s Integrated Services (as the lead agency) should have an individual plan tailored to meet their needs and focused on the precise nature of support and service provision and with a clear reviewing mechanism built in. 4.77 Unclear multi-agency processes: The absence of any plan for the placement with Aunt meant there was a lack of a multi-agency approach, and no professional or agency questioned this. Neither health nor education were included in the SGO assessment or support planning and so were unaware of what the implications of the SGO were for their provision of services to Child J. There was further confusion caused (unintentionally) by the first meeting held after Child J had moved to live with Aunt being the CAMHS consultation. CAMHS made clear the nature of this consultation process, and their minutes sent out to all reiterated that they were there to provide support and reflection and that usual planning and case work processes would continue outside of the meetings. However, this was the only meeting where different agencies got together, and in the first case consultation was described as a “review” of Child J’s circumstances. The CAMHS consultation sessions were held regularly from six months into the placement and with the exception of school, they were the only place where members of the multi-agency group came together. This was not a consistent group of people, and only short term plans were made at these meetings, in response to the concerns raised. There was one meeting described as a multi-agency meeting and this was held at school when CSC were to close the case in July 2014. This was in fact a meeting of school and the FSW and no plans were made. There was no process which took take an overview of Child J’s circumstances and considered what she needed. 4.78 Assessment practice when children’s circumstances change: Child J was subject to a core assessment when she came into foster care, but there were no other assessments undertaken over almost a two-year period. This is despite there being a number of times when concerns were raised about Child J’s wellbeing and circumstances. These concerns should have prompted a further assessment to explore and understand the nature of the problems and to form the basis of further interventions and support. 4.79 Lack of a chronology: Despite the many concerns raised, each incident of concern for Child J was treated as an isolated issue, and there was no reflection of the overall Serious Case Review Final Report 13.04.2017 Page 58 of 74 picture, no chronology of events and no assessment to step back and try and understand what was happening. No recommendation has been made in relation to this issue in recognition of the work undertaken by Nottingham City Council to address this issue. This is set out in the response document. 4.80 Working with discrepancies: There were many examples highlighted through the case review where professionals were working with discrepant information, but did not notice this or further analyse its meaning. Examples include Aunt complaining about finding it hard to deal with some aspects of Child J’s behaviour, but not attending the appointments organised to support her. There were many occasions when the information provided by Aunt regarding concerns for Child J was inconsistent and discrepant. This was not noticed, and not addressed. 4.81 Poor recording practices: There were many examples of poor recording practice across the review. For example, the Team Manager for the FSW did not fully record their supervision discussions about Child J. The CAMHS minutes did not include the challenges made to Aunt about her punitive parenting approaches, and the FSW did not record the many play sessions she had with Child J. It is important that professionals have time to spend with the children and adults they work with, but these were all important issues that should have been more clearly recorded. 4.82 Confusion regarding roles and tasks: Across the period when Child J lived with her Aunt there was confusion about roles, responsibilities and tasks. This was exacerbated by the lack of a plan or multi-agency process, and were unintended by all involved, but often meant that professionals thought action was being taken when it was not. Professionals were unclear about the role of CAMHS and saw them as the lead agency. The role of the meetings and the tasks they were meant to fulfil was not well understood and there was a misconception that Child J herself was receiving services because of her difficulties. This was fuelled by Aunt, but never clarified, and many professionals were reassured that something was happening to address concerns. The provision of intensive support by CAMHS created further reassurance and confusion. Professionals believed this was a highly specialist service intended to address the significant concerns about Child J’s disturbed behaviour. In fact, it was a specialist parenting support programme intended to address positive disciplinary approaches and improve relationships. The role of the FSW was not always clear. She was allocated to fulfil the requirements of the FAO, which was to befriend and support. A new social worker was brought in when there were concerns regarding safeguarding. She had no existing relationship with either Child J or the Aunt and her role was never really made clear to other professionals. 4.83 The specialist nurse for continence was clear about her role, but unclear about her place in the multi-agency network. This confusion meant that there was a muddled response across the professional network, and despite the many professionals who were involved with Child J and their commitment to her, the response was much less Serious Case Review Final Report 13.04.2017 Page 59 of 74 effective than it could have been. Aunt manipulated professionals and caused divisions between people; this should have been recognised and seen as a cause for concern. 4.84 Differences in professional opinion: There were some differences of professional opinion that remained unacknowledged and unaddressed. The school were marginalised early on, and Aunt suggested that the school concerns were indicative of poor parent-school communication which led to these concerns being discredited. This was in essence a difference of opinion about the nature of the problem. The belief that Aunt was struggling to manage Child J’s behaviour was the dominant professional view. Some members of the school staff held the professional view that Aunt was hostile and abusive, other believed that she was being unfairly targeted. These differences were never fully aired or discussed and ultimately it was Aunt who dominated most meetings and the analysis of concerns. This was particularly apparent in the months leading up to Child J’s death, where the Class Teacher was challenged in the school meeting for making a safeguarding concern directly to the FSW. The school and CSC took the position that this issue was conflict between a member of staff and a parent/carer rather than step back and reflect on the meaning of this significant difference of opinion. 4.85 Working with complex and fragmented families: At the start of this review process it was anticipated that this case would shed light on the complexity of working with complex and fragmented families. Child J was part of an extended family, which included her Father having a number of families and meaning she had many siblings, some of whom she had no contact with. Very little was known about the role that Father played in Child J’s life; this was in part because he was in prison for some of the time. PGM was known briefly to professionals, but was not seen as part of Child J’s life. There were early opportunities to connect parts of the family together, but it was hard to make sense of the nature and influence of family relationships. This case highlights the importance of viewing children in the context of their wider family, however complex this is. No recommendation is made regarding these issues about routine casework practice in recognition of ongoing work being completed by agencies and outlined within the action plan. Finding 11: The influence of fixed views and confirmatory bias 4.86 A key feature of the work in this case is the extent to which a number of professionals formed a fixed view about Child J and her circumstances, and despite professional differences of opinion this view did not change. One of the key purposes of supervision is to provide professionals with the opportunity to critically reflect on their practice and explore the wide range of influencing factors that might be affecting their decision making, including biases, assumptions, and attitudes to parents/carers and working relationships. It is through this type of supervision that practitioners can slow down Serious Case Review Final Report 13.04.2017 Page 60 of 74 and carry out the analytical thinking for the complex task of working with children and their families. This was a complex case and required the opportunity to take a step back and think about the professional task. There was little evidence of consistent reflective supervision for any professional involved. Some professionals received no supervision, others sought advice from their safeguarding supervisors, but agreed no actions and some professionals attended supervision regularly but did not use the time to explore the circumstances of Child J in any detail. The paradox is that the fixed view that this was not a safeguarding case stopped professionals from seeking supervision to explore if this was a correct analysis and to have their decision making challenged. 4.87 This fixed view was to some extent a consequence of the deficiencies in the multi-agency response. This was exacerbated by the impact of confirmatory bias. Researchxli and Serious Case Reviewsxlii have highlighted the tendency of professionals in the safeguarding arena to develop fixed ideas about a child’s situation (whether that is positive or negative) and to stick to this notion, taking account of information which supports the existing hypotheses and rejecting any information which appears to contradict it. This pressure comes in part from the emotional nature of the safeguarding task and in part from the complexity and contradictory nature of the information being evaluated. 4.88 The view of a number of agencies was that Aunt was struggling to manage in a difficult situation, but was doing her best when faced with complex issues such as self-harm and disturbed behaviour. The over reliance on Aunt’s own self-report of the circumstances tended to reinforce this view and therefore she was not challenged or questioned about inconsistencies in her explanations of what actually happened. In fact, because she often pre-empted enquiries about bruising, this tended to reinforce the largely positive view held. She was also extremely articulate and presented as a credible source of information. 4.89 Some members of the school staff found Aunt aggressive and obstructive, and were clear that the bruises were of concern. Aunt managed to discredit their view, alleging that they did not communicate well with her, and had falsely accused her of child abuse. This “splitting” of the professional group was not reflected upon in a professional context and the fixed view remained. 4.90 Confirmatory bias needs to be addressed by professionals having the opportunity for good quality reflective supervision, the space to reflect on cases and to have ways of “playing devil’s advocate”. There were organisational pressures that made this more difficult for some agencies, and it did not happen. This also highlights the need for multi-agency meetings where differences in professional opinion about the needs and circumstances of children can be openly discussed, and strategies to address differences of professional opinion formulated. Major differences in professional opinion in a network of professionals who are charged with meeting the needs of a child or group of children are indicative that no one agency has fully understood the needs of the child or family, and a new approach is required. Serious Case Review Final Report 13.04.2017 Page 61 of 74 Recommendation 7: The Safeguarding Children Board should seek assurance from partner agencies about: • The criteria they use to determine how reflection and critical thinking is embedded within their organisation in order to enable practitioners to consider the information they hold, what additional information they need, who would hold this information and how this process addresses the potential impact of confirmatory bias. • Why they are content that this is working well • Any steps that need to be taken to improve this aspect of safeguarding practice. Finding 12: Lack of focus on the child and her lived experience 4.91 The Nottingham City Children Safeguarding proceduresxliii, underpinned by Working Together 2015xliv makes clear that one of the core principles of effective safeguarding and support practice is a child centred approach which is focused on the needs and views of children. This is reinforced by the United Nations Convention on the Rights of the Child (UNHCR CRC), which recognises a child’s right to expression and to receiving information. This right is also reinforced by Article 10 of the Human Rights Act 1998 and the Children Act 1989, which requires a Local Authority to ascertain the ‘wishes and feelings’ of children and to give consideration to these when determining what services to provide or what action to take (taking into account the child’s age and understanding). 4.92 Despite this mandate, evidencexlv shows that children nationally are not being routinely fully included in safeguarding and support work. The consistent finding from Serious Case Reviews is that professionals did not speak to the children enough; a report by Ofstedxlvi on the themes and lessons to be learned from Serious Case Reviews across the country highlighted that child were not seen frequently enough by the professionals involved in their lives, professionals focused too much on the needs of the parents and overlooked the implications for the child. Many of these issues were present for Child J. 4.93 Child J was not always consulted about matters that affected her. She was not formally consulted as part of the looked after reviewing process (being described as too young) and her views were not included in the SGO assessment. She was seen regularly during the court process by the Social Worker and the Children’s Guardian; her views were incorporated into court reports. She was not always asked about injuries and bruises, although the school and the FSW did seek to ask her regularly about what had happened to her. However, when she was asked her inconsistencies, changing of story and assertion that she had lied or harmed herself were accepted as either fact, or indicators of her behavioural and emotional difficulties which were as described by Aunt. These were accepted far too readily and were not sufficiently explored or Serious Case Review Final Report 13.04.2017 Page 62 of 74 analysed. There was no sense that professionals considered that she might either be afraid or have been told not to tell the truth. Professionals did not know that this was the case but they should have considered it. 4.94 Child J was reported on a number of occasions to have reported “harming herself”, but her exact words are not recorded, and so it is hard to evaluate what this meant. There is little evidence across agency records of what Child J actually said herself about her circumstances and there are insufficient reflections on her lived experiences, what was everyday life like for her. 4.95 Although professionals were concerned about the harsh, critical and punishing approach taken by Aunt and this was often discussed, there is no recorded view of what this might mean for the day to day lived experience of Child J. 4.96 There were many occasions that Child J made disclosures about the harsh and critical care she was receiving from Aunt and she made a direct allegation of abuse about her Aunt’s friend who was looking after her. These incidents were enquired about and a pattern emerged where Child J would then withdraw the disclosure either saying she had lied or had self-harmed. This happened on many occasions, but the lack of a chronology of incidents, or appropriate reflective supervision for the professionals hearing these disclosures meant the pattern was not recognised. When Child J made a direct allegation of being hit by her PGM and another adult she was asked to discuss this in front of Aunt and again said she had lied. There was never any discussion regarding why a child of 6 or 7 might lie, what this might mean about her wellbeing or how this might impact on her own help seeking behaviour. When children make disclosures they are asking adults for help. If they are being abused they are taking a risk, as the disclosure might lead to further abuse. It is essential that professionals handle these disclosures sensitively, that children are reassured that they are right to talk to adults, that they will receive help, that being harmed is wrong and that in the short term the adult responsible will be asked to repair any damage. The onus here was on Child J to prove what had happened to her, rather than on Aunt being asked to take responsibility for what was clearly emotionally abusive care. 4.97 All children deserve sensitive caregiving, where secure and loving attachments are fostered, where love and care is provided and children are enabled to experience empathy and are treated fairly and justly. Parental attitudes to children which are about blame, harsh and critical care and scapegoating are recognised as a key indicator of emotional abusexlvii. Emotional abuse has the capacity to impact negatively on children’s development in the short and long termxlviii and thus needs addressing urgently. Aunt was recorded as saying many negative things about Child J, including that she was remorseless, wilful and knowingly difficult. These very negative views, expressed about a child of six were wholly inappropriate, and in terms of the records available do Serious Case Review Final Report 13.04.2017 Page 63 of 74 not seem to be accompanied by a sense of empathy by Aunt for Child J and her circumstances. Aunt should have been challenged regarding this, and these very negative views should not have been recorded as facts. In addition, there were concerns in school regarding how downcast Child J looked in the presence of her Aunt, and how unhappy she seemed. This was not consistently recorded and not reported to any professional. There was confusion regarding what could be asked about, and what constituted a fact regarding safeguarding issues. The Class Teachers and Teaching Assistants were rarely asked by other professionals about how Child J seemed – and this information was not reflected upon during the school safeguarding meetings, when safeguarding concerns were being discussed or during the CAMHS consultations. This meant that the lived experience of Child J was not really known. They were Aunt’s view and there was rarely corroboration for them from any professionals. It is of concern that Aunt made use of her friends and church members to substantiate her claims about this child. Professionals wanted to support Aunt, and allow her to air her feelings whilst working with her to develop her attachment but too often the self-report of Aunt about Child J became seen as fact, not opinion. 4.98 It is essential that all professionals recognise and empathise with the lived experience of children and use this as the cornerstone for plans, assessments and decision making. They also need to recognise when adults attempt to divert attention from the child and be challenging of this. This requires good reflective and challenging supervision and management oversight. Recommendation 8: The NCSCB should seek assurance from all partner agencies about the quality of child focussed practice and draw on any current work, such as audits, to consider whether there is any other evidence regarding poor child focussed practice which requires action. Finding 14: Partnership practice and the importance placed on engagement with parents/ carers can mistakenly lead to both a lack of challenge and collusion leaving children at risk Recommendation 7 addresses this issue. Finding 15: Awareness that parents/carers may be covertly recording meetings. 4.101 The trial and inquest process has meant that it became known that Aunt covertly recorded many meetings and telephone calls, as well as discussions after meetings Serious Case Review Final Report 13.04.2017 Page 64 of 74 with Child J. These recordings highlighted some unprofessional behaviour and unguarded comments which could have been seen as collusive by Aunt. This raises the importance of professionals being aware that this can happen, and to also ensure that they behave in a professional way at all times. Recommendation 9 : The NCSCB recognises the significant issue of staff being recorded and will seek reassurance from partner agencies that they provide staff with clear guidance about this matter. Serious Case Review Final Report 13.04.2017 Page 65 of 74 5 CONCLUSIONS 5.1 This is an extremely sad case and the death of Child J has caused a great deal of pain to all those who knew her. 5.2 Child J was removed from her Mother's care and although this was a difficult decision, the available evidence suggests that it was appropriate given the information at the time. This was a hard decision for professionals to make and they truly believed that placing Child J in her family network would ensure that her cultural needs would be met and that she would remain in the orbit of her family network. This decision was made without knowledge of the complex or corrosive nature of some of the family relationships or that Mother would be able to overcome her poor early experiences; she has worked hard to create a new and settled life for herself whilst always holding Child J in mind. This is very sad and the thoughts of all those involved in the Serious Case Review are with her. 5.3 Child J spent over a year with a loving and caring foster family who did their best for her. They were not sufficiently prepared for the task of caring for a traumatised child, but after seeking advice they found a way of forming a relationship with her which was beneficial to all. The whole foster family are left with the loss of her. 5.4 It is a huge responsibility for professionals to ensure that children who cannot live with their birth families have secure and permanent families for life. They are only too aware of the damage that is caused to children by lack of certainty, and insecure placements. Aunt presented as an adult who was committed to Child J and wanted to provide her with a home in the long term. She did not tell the truth about her past family life, or her personal circumstances, and she provided information that suggested she was a mature and able individual. There was no available evidence in the context of the SGO that suggested she would not be an appropriate carer. 5.5 It has become clear as a result of the criminal trial, the inquest and the end of the Serious Case Review, that Aunt was harsh, cruel and abusive to Child J. She manipulated and deceived professionals, and incorporated friends into this process of deception. 5.6 The level of Aunt’s cruelty was glimpsed, but not fully known. It was the absence in this case, caused in part by the granting of a FAO, of routine processes such as ongoing assessments, plans which make clear the nature of a child’s needs and good multi-agency working arrangements, effective reviewing arrangements, clarity of task and role alongside an awareness that parents/carers who are abusing children create divisions and diversions so they are not found out. This was not recognised in this case. Most professionals lost sight of the need to keep the child and her lived experience in mind. Serious Case Review Final Report 13.04.2017 Page 66 of 74 5.7 Although there was no clear evidence that Child J would die (and the trial did not make clear who was responsible for this) it was possible to recognise that she was being harmed by Aunt and in the last few months of her life concerns about bruising known at school were not shared with other professionals because of a mistaken belief that these were false allegations. The lack of awareness of escalation processes meant that those who were concerned felt they could take no further action to ensure that she was safeguarded. This points to the need for all professionals to recognise their responsibilities to take action, even when faced with hostility and reluctance from others, using either the escalation processes or whistle blowing processes in place. 5.8 It is essential that all professionals working with children and their families do so in a respectful and open way. This is the cornerstone of partnership practice as embedded in the Children Act 1989 and subsequent guidance and legislation. However, research and Serious Case Reviews emphasise the importance of not taking at face value what parents or carers say when asked about the possible abuse of children. The Munro review commented that adults in this situation have a number of motives for not always providing a full picture of their or their children’s circumstances. The task of professionals is to remain in a position of “respectful uncertainty” and display “healthy scepticism” which in practice means: checking the validity of information provided by parents/adults by cross referencing/triangulating with other sources testing out the level of parental care and concern for children and the extent to which parents feel a sense of responsibility for their children and their well-being 5.9 It has become clear as a result of the covert recording of meetings by Aunt that she dominated much of the professional response and brought in friends strategically to support her view and this meant that Child J’s needs and lived experience got lost in the process. 5.10 In the last few months before Child J died the divisions in the school provided further opportunity for Aunt to play professionals off against each other. When the Class Teacher became increasingly concerned, Aunt was able to characterise this as poor communication and unfair targeting. DSL2 believed this and a taped telephone conversation showed how much she sought to reassure Aunt that the school did not believe that she was abusing Child J and would ensure that communication improved. This position was further reinforced when the Class Teacher was asked to communicate better during a meeting with Aunt in attendance. The lack of any supervisory processes in the school, and absence of leadership or management oversight of the school safeguarding response meant that the differences of opinion were not addressed appropriately and unintentionally served to enable this collusion with Aunt against another member of staff. 5.11 The FSW was not always provided with a clear picture of concerns regarding bruising and injuries by school, but was aware that school staff were concerned. The covert recordings show that in an attempt to maintain a partnership approach with Aunt, the Serious Case Review Final Report 13.04.2017 Page 67 of 74 FSW sought to reassure Aunt and to take her side against the school. This collusion by one professional with a parent/carer in the context of safeguarding concerns is a feature of many case reviews, and should never happen. Professionals should seek support through local processes to resolve professional disputes, and although parents/carers have the right to discuss concerns they have about how they are treated this should be managed in a professional and non-collusive way. 5.12 All the findings point to the importance of good quality reflective supervision and complex case processes for the multi-agency group. There was evidence that the FSW had supervision, but there was little case discussion and little reflection regarding emerging and new information. CAMHS workers did not access supervision during the time under review, and so were not able to reflect on some of the discrepancies and worrying information they were hearing. The continence nurse did seek safeguarding supervision, but did not act on the advice given. There is no routine of safeguarding or reflective supervision in schools and the complex picture that has emerged about the chaos and lack of leadership, lack of action and at time collusion with Aunt shows the need for it. 5.13 There was no indication to professionals that Child J would be killed, and this is also the conclusion of the inquest. However, a more authoritative approach to the harsh and cruel parenting, bruising and injuries and very negative attitudes of Aunt to Child J should have been adopted. The lack of a full understanding of Child J as a child who had been traumatised and the likely impact on Aunt who was herself someone with a traumatic and complex background meant that Aunt was considered to be struggling with the task of parenting. This was an inaccurate conclusion which was fuelled by fixed views and an adult focus, but also by what is now clearly known to be Aunt’s deliberate manipulation and splitting of professionals. Serious Case Review Final Report 13.04.2017 Page 68 of 74 Recommendations to the Nottingham City Safeguarding Children Board 1. The NCSCB should seek assurance that the implications of parental mental ill-health are understood and fully addressed in plans for children and young people. This will include an evaluation of the availability of therapeutic support needs of parents, how this is prioritised and the implications this has for local commissioning arrangements. 2. The NCSCB should highlight the importance of recognising and understanding early childhood trauma when communicating the learning from this Serious Case Review. It should seek assurance from partner agencies that this issue has been reinforced through internal communication and training routes. 3. The NCSCB Practice Guidance regarding self-harm should be updated to address the needs of children aged 5- 10. This update should make clear that professionals should not accept the term self-harm in children under 10 without consideration of potential emotional well-being or safeguarding concerns. 4. The NCSCB should ensure that all professionals who are working with children with continence issues are aware of the national guidance regarding this. The NCSCB should seek assurance that agencies are clear about what action to take when parents/carers adopt a significantly punitive approach and recognise the need for a coordinated response to these issues. 5. The NCSCB should review the guidance for all professionals regarding the assessment of potential non accidental injury and ensure it is compliant with the existing NICE Guidelines regarding child maltreatment. This revised guidance should also include Guidance for all professionals about child centred disciplinary approaches. A mechanism for ensuring relevant information about a child’s known psycho-social history and history of previous concerns/injuries is completed in preparation for a child protection medical and that this is recorded where it is not possible to do this in advance of the medical, this information must be considered alongside the outcome of the examination. Serious Case Review Final Report 13.04.2017 Page 69 of 74 6 APPENDIX 1 Agencies who provided a Chronology and Appraisal NHS Nottingham City CCG Nottingham CityCare Partnership 6. The NCSCB should reinforce the need for all professionals to recognise the important role played by schools in the support and safeguarding of vulnerable children and promote a multi-agency approach to all aspects of assessment and planning for vulnerable children. This action should include ensuring that: Schools routinely follow up referrals to children's social care in writing including details of all concerns that have been recorded by staff within the school. Nottingham Education to work with head teachers to establish consistency in the way that “soft” information that raises concerns about a pupils wellbeing is collected and reviewed both directly during staff supervision sessions and through recording processes 7. The NCSCB should seek assurance from partner agencies about: The criteria they use to determine how reflection and critical thinking is embedded within their organisation in order to enable practitioners to consider the information they hold, what additional information they need, who would hold this information and how this process addresses the potential impact of confirmatory bias. Why they are content that this is working well Any steps that need to be taken to improve this aspect of safeguarding practice. 8. The NCSCB should seek assurance from all partner agencies about the quality of child focussed practice and draw on any current work, such as audits, to consider whether there is any other evidence regarding poor child focussed practice which requires action. 9. The NCSCB recognises the significant issue of staff being recorded and will seek reassurance from partner agencies that they provide staff with clear guidance about this matter. Serious Case Review Final Report 13.04.2017 Page 70 of 74 Nottingham University Hospitals NHS Trust Nottingham City Council: Children’s Integrated services Nottinghamshire Healthcare NHS Foundation Trust Cafcass DLNR CRC Nottinghamshire Police Nottingham City Council: Education Service Serious Case Review Final Report 13.04.2017 Page 71 of 74 References i Department of Health, Department for Education and Employment and Home Office (2015) Working Together to Safeguard Children: a guide to interagency working safeguard and promote the welfare of children: London: The Stationery Office. ii Department of Health, Department for Education and Employment and Home Office (2015) Working Together to Safeguard Children: a guide to interagency working safeguard and promote the welfare of children: London: The Stationery Office. iii Department for Education (2005) Special guardianship guidance: https://www.gov.uk/government/publications/special-guardianship-guidance v NOCTURNAL ENURESIS: the management of bedwetting in children and young people – FINAL VERSION https://www.nice.org.uk/Guidance/QS70 vi Department for Education (2016) Keeping children safe in education: Statutory guidance for schools and colleges: London: The Stationery Office. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/550511/Keeping_children_safe_in_education.pdf vii Farmer, E., et al (2008) The Reunification of Looked After Children with their Parents: Patterns, interventions and outcomes, Report to the Department for Children, Schools and Families, School for Policy Studies viii Biehal, N. (2006) Reuniting looked after children with their families: A review of the research, London: National Children’s Bureau ix Fahlberg, V. (2004) A Child’s Journey through Placement, London: BAAF x Fahlberg, V. (2004) A Child’s Journey through Placement, London: BAAF xi Brown, R and Ward, H. (2013) Decision-making within a child’s timeframe: An overview of current research evidence for family justice professionals concerning child development and the impact of maltreatment: Childhood Wellbeing Research Centre https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/200471/Decision-making_within_a_child_s_timeframe.pdf xii Elliot, A (2013) Why Can’t My Child Behave? Empathetic Parenting Strategies that work for Adoptive and Foster Families: JKP xiii Elliot, A (2013) Why Can’t My Child Behave? Empathetic Parenting Strategies that work for Adoptive and Foster Families: JKP Serious Case Review Final Report 13.04.2017 Page 72 of 74 xiv Cairns C (2006) Attachment, Trauma and Resilience: Therapeutic Caring for Children. London: BAAF xv NSPCC (2010) Disguised compliance: An NSPCC factsheet https://www.nspcc.org.uk/globalassets/documents/information-service/factsheet-disguised-compliance1.pdf xvi NICE guidelines [CG16] (2004) Self-harm in over 8s: short-term management and prevention of recurrence. www.nice.org.uk/guidance/CG16 xvii NOCTURNAL ENURESIS: the management of bedwetting in children and young people – FINAL VERSION https://www.nice.org.uk/Guidance/QS70 xviii Department of Health, Department for Education and Employment and Home Office (2015) Working Together to Safeguard Children: a guide to interagency working safeguard and promote the welfare of children: London: The Stationery Office. xix Kemp AM, Dunstan F, Nuttall D, et al. Arch Dis Child Published Online First: /archdischild- 2014-307120 xx NICE guidelines (2009) Child maltreatment: when to suspect maltreatment in under 18s: NICE http://pathways.nice.org.uk/pathways/when-to-suspect-child-maltreatment xxi NSPCC Scotland, Children 1st, Barnardo’s Scotland and the Children and Young People’s Commissioner Scotland (2015) Equally Protected? A review of the evidence on the physical punishment of children https://www.nspcc.org.uk/globalassets/documents/research-reports/equally-protected.pdf xxii Children’s Aid Society (2003) What is Discipline and What is Abuse? Children Aid Society xxiii Gershoff ET (2010): More harm than good: A summary of scientific research on the intended and unintended effects of corporal punishment on children. Law and Contemporary Problems, 73, 33-58. Gershoff ET (2013): Spanking and Child Development: We Know Enough Now to Stop Hitting Our Children. Child Development Perspectives, 7(3), 133-137. xxiv United Nations (1989): United Nations Convention on the Rights of the Child (UNCRC). Geneva: United Nations. http://www.ohchr.org/en/professionalinterest/pages/crc.aspx xxvi DoE (2014) and (2015) Keeping children safe in education Statutory guidance for schools and colleges: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/447595/KCSIE_July_2015.pd Serious Case Review Final Report 13.04.2017 Page 73 of 74 xxvii Elaine Farmer and Sue Moyers (2008) Kinship Care: Fostering Effective Family and Friends Placements (Jessica Kingsley). xxviii Research in Practice (2015) Special guardianship: qualitative case file analysis Research report: London: Department for Education https://www.gov.uk/government/publications xxix Research in Practice (2015) Special guardianship: qualitative case file analysis Research report: London: Department for Education https://www.gov.uk/government/publications xxx DoH (2000) Framework for the Assessment of Children in Need and their Families: http://webarchive.nationalarchives.gov.uk/20130401151715/https:/www.education.gov.uk/publications/eOrderingDownload/Framework%20for%20the%20assessment%20of%20children%20in%20need%20and%20their%20families.pdf xxxii Shemmings, D and Shemmings Y (2011) Understanding Disorganized Attachment: Theory and Practice for Working with Children and Adults, London: Jessica Kingsley xxxiii Hunt J (2009) ‘Family and Friends Care’ in Schofield G and Simmonds J (eds) The Child Placement Handbook: Research, policy and practice. London: BAAF xxxiv Argent, H (2008) Top Ten Tips: Placing Children: London: BAAF xxxv Lauerman, M (2015) Life Story work – the wider context. Care Knowledge Special Report 100: https://www.careknowledge.com/life_story_work__the_wider_context_ xxxvi Schofield G and Simmonds J (eds) (2009) The Child Placement Handbook: Research, policy and practice. London: BAAF xxxvii Morgan R (2009) Keeping in Touch. A report of children’s experience by the Children’s Rights Director for England London: Ofsted xxxviiiLord J and Borthwick, S (2009) ‘Planning and Placement for Siblings Groups’ in Schofield G and Simmonds J (eds) The Child Placement Handbook: Research, policy and practice. London: BAAF xxxix Research in Practice (2015) Special guardianship: qualitative case file analysis Research report: London: Department for Education https://www.gov.uk/government/publications xli Burton, S et al (2010) (Effective practice to protect children living in ‘highly resistant’ families: C4EO http://archive.c4eo.org.uk/pdfs/6/Safeguarding%20knowledge%20review%20edit%20250310final%20lo-res.pdf Serious Case Review Final Report 13.04.2017 Page 74 of 74 xlii Brandon, M., Bailey, S., Belderson, P., Gardner, R., Sidebotham, P., Dodsworth, J., Warren, C. and Black, J. (2009) Understanding Serious Case Reviews and their Impact: A biennial analysis of Serious Case Reviews 2005-07, London: Department for Children, Schools and Families, DCSF-RR129. xlv Willow, C. (2009), ‘Putting Children and Their Rights at the Heart of the Safeguarding Process’, in Safeguarding Children. A Shared Responsibility, Cleaver, H., Cawson P, Gorin S, et al., pp13–37, Chichester, Wiley -Blackwell; xlvi Ofsted, (2010) The voice of the child: learning lessons from Serious Case Reviews. A thematic report of Ofsted’s evaluation of Serious Case Reviews from 1 April to 30 September 2010 (available online at: http://www.ofsted.gov.uk/content/download/12180/141321/file/The%20voice%20of%20the%20child.pdf) xlvii Barlow, J. and Schrader McMillan, A. (2010) Safeguarding children from emotional maltreatment: what works? London: Jessica Kingsley. xlviii Gavin, H. (2011) Sticks and stones may break my bones: the effects of emotional abuse. Journal of Aggression Maltreatment and Trauma, 20(5): 503-529. |
NC047171 | Death of 10-day-old baby of Black and Asian British descent in August 2013. Father had lain on top of B1 while in bed. He was convicted of neglect in 2015. B1 and two older siblings were the subject of child protection plans under the category of emotional abuse. Both siblings had been on a plan before and had been looked after in 2010, placed with their maternal grandmother. Family were well known to agencies, including children's services and police, because of parental alcohol misuse, domestic abuse, concerns about neglect and father's, sometimes violent, criminal behaviour. Parents did not engage with health services resulting in delayed immunisations for B1's siblings and dental neglect. Uses a systems based approach based on the SCIE framework to identify issues for learning. Issues discussed include: professional focus on domestic abuse as an anger management issue; parental fear of statutory intervention; manipulative and obstructive parental behaviour; delays in follow-up to incidents; lack of recognition of indicators of neglect such as dental cavities; the limited use of assessment tools or frameworks; and the impact of excessive workloads and reconfiguring of services on the capacity of professionals. Includes a multi-agency action plan.
| Title: Serious case review: Child B1: Overview report. LSCB: Manchester Safeguarding Children Board Author: Peter Maddocks Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Manchester Safeguarding Children Board A Serious Case Review ‘B1’ The Overview Report September 2014 This report has been commissioned and prepared on behalf of Manchester Safeguarding Children Board and is available for publication on the 11th February 2016 Page i Child B1 SCR Final Report published 110216 Index 1 Introduction and context of the review.................................................................1 1.1 Rationale for conducting a serious case review ............................................2 1.2 The methodology of the serious case review................................................2 1.3 The scope of the serious case review............................................................3 1.4 Particular issues identified by the serious case review team for further investigation by the key lines of enquiry:..................................................................4 1.5 Membership of the case review team and access to expert advice .............5 1.6 Independent lead reviewers..........................................................................6 1.7 Parental and family contribution to the serious case review........................6 1.8 Time scale for completing the serious case review.......................................7 1.9 Status and ownership of the overview report...............................................7 1.10 Cultural, ethnic, linguistic and religious identity of the family......................7 2 Summary of agency contact and involvement ......................................................9 3 Appraisal of professional practice in this case.....................................................16 3.1 In what way does the case provide a window into the local systems for safeguarding children?.............................................................................................24 4 Analysis of key themes from the case and description of findings for learning and improvement ........................................................................................................25 4.1 Cognitive influence and human bias in processing information and observation ..............................................................................................................26 4.2 Family and professional contact and interaction ........................................27 4.3 Responses to information and incidents.....................................................29 4.4 Tools to support professional judgment and decision making ...................31 4.5 Management and agency to agency systems..............................................33 4.6 Issues for national policy .............................................................................35 APPENDIX A: Multi agency action plan........................................................................36 APPENDIX B: Procedures and guidance relevant to this serious case review.............41 Legislation ................................................................................................................41 The Children Act 1989..........................................................................................41 The Children Act 2004..........................................................................................41 Safeguarding Procedures.....................................................................................42 The local safeguarding children procedures........................................................42 Other local procedures relevant to this serious case review ..................................42 National guidance....................................................................................................42 Working Together to Safeguard Children (2010) and (2013)..............................42 Framework for the Assessment of Children in Need and their Families 2001....43 Common Assessment Framework (CAF)..............................................................43 Safe sleeping for infants 2009 .............................................................................44 Page 1 of 44 Child B1 SCR Final Report published 110216 1 Introduction and context of the review 1. In early August 2013 the regional ambulance service were contacted by a 26 year old mother requesting an ambulance for her ten day old child (B1) who was not conscious or breathing at the family home in Manchester. The call was logged at 07.48 and by 07.49 a rapid response vehicle (RRV) was allocated along with a fully crewed ambulance. At 07.50 a further crewed ambulance that was already mobile had arrived at the family home at 07.53 along with the RRV. The original ambulance crew was stood down. 2. On arrival the paramedics found B1 in a bedroom on a bed with the 29 year old father lying beside the child. Mother informed the paramedics that father had lain on top of B1. The paramedics found B1 with no signs of life although initiated their basic life support treatment protocol with B11. The ambulance left the property with B1 and mother for the local hospital arriving at 08.03 where B1’s death was confirmed. 3. The police were notified of the incident through the emergency operations centre (EOC) at 08.00. The two older siblings (Sibling 1 and Sibling 2) were made the subject of police powers of protection (PPOP). A strategy meeting took place later the same day to plan statutory enquiries and assessment and to agree arrangements for the continuing protection of the surviving siblings. 4. Sibling 1 was aged ten at the time of the death and Sibling 2 was aged six. The two siblings had been the subject of a child protection plan from January 2009 until September 2010. They had also been looked after with the agreement of their parents from June 2010 until November 2010 when they were placed with their maternal grandmother. The involvement of children’s social care services was then closed in April 2011. 5. There had been further involvement following referrals in January and June 2012 after a repeat of domestic abuse and the two older children were again subject of a child protection plan because of emotional abuse from March 2013. B1 was also the subject of a child protection plan following birth and therefore all children were identified as being at risk of significant harm. 6. The reasons for statutory involvement were centred on the domestic abuse and the use of alcohol and the neglect of the children. Father was convicted of neglect in early 2015 following the death of B1. 1 The protocol covers continuous chest compression and ventilation, use of bag-valve mask to deliver oxygen, and insertion of a tube into the airway. An electro cardiogram applied to establish heart rhythm showed no activity. The paramedic continued their efforts throughout the journey to the hospital. Page 2 of 44 Child B1 SCR Final Report published 110216 1.1 Rationale for conducting a serious case review 7. Regulation 5 of the Local Safeguarding Children Board Regulations 2006 requires a Local Safeguarding Children Board (LSCB) to undertake a review of a serious case in accordance with the procedures that are set out in chapter four of Working Together to Safeguard Children (2013). 8. The LSCB should always undertake a serious case review when a child dies or has been seriously harmed and abuse or neglect is either known or is suspected and there is cause for concern as to the way the authority, the Board or other relevant persons have worked together. 9. The reason for undertaking this review is that B1 may have died as a result of neglectful parental care. The death was reported to the Manchester Safeguarding Children Board (MSCB) and was reviewed by the serious case review sub-group on the 17th September 2013 who recommended to the independent chair of the MSCB that the circumstances of B1’s death met the criteria for a mandatory serious case review. 10. The review was commissioned by Ian Rush, the independent chair of the MSCB on the 17th September 2013. 11. The commissioning meeting for the serious case review was on the 11th October 2013 and confirmed the scope and methodology for the serious case review. 12. The purpose of the review is to establish what lessons are learned from the case for improving safeguarding services, to improve inter-agency working and better safeguard and promote the welfare of children in Manchester. 1.2 The methodology of the serious case review 13. A serious case review team was convened of senior and specialist agency representatives to oversee the collation and analysis of information and outcomes of the review. The review was co-ordinated and managed by two independent lead reviewers with appropriate experience and training. Further information is provided in section 1.6. 14. The review team that oversaw the serious case review decided to build on the learning that had been developed from previous serious case reviews in the city; one of those had been wholly conducted using the SCIE (Social Care Institute for Excellence) framework and other serious case reviews had used the framework to present the findings from the review. 15. This review uses a systems based approach to analysing information and presenting the findings in the final chapter using recommended best practice in identifying improvement and learning. Page 3 of 44 Child B1 SCR Final Report published 110216 16. Work began on compiling a multi-agency chronology in December 2013. From the collated chronology the initial meeting of the review team identified the initial key lines of enquiry. 17. The review team also identified information for individual agencies to provide to the review. This included almost 100 documents and reports from services working with the family in regard to assessments (DASH and children’s social care services statutory) and multi-agency meetings (strategy meetings, child protection conferences and core groups) and child protection plans and working agreements. There were reports from professionals to the child protection conferences and midwifery records. The review also had copies of the domestic violence prevention notice (DVPN) and the domestic violence prevention order (DVPO). 18. The review team identified the services and individual practitioners that would provide information and participate in the review. A briefing was held in early January 2014 which was followed by a programme of individual conversations with seventeen practitioners which were facilitated by members of the review team and lead reviewers. 19. The review team used the information from the conversations and other evidence to identify the following as key practice episodes for particular learning in this serious case review: a) The incident of domestic abuse in June 2012 and referral to the police public protection and investigation unit and children’s social care services; b) Use of the domestic violence prevention notice (DVPN) and domestic abuse prevention order (DVPO); c) Core assessment in March 2013; d) Core assessment in June 2012; e) Reassessment of father’s level of risk by the probation service in August 2012; f) Pre-birth assessment and child protection conference in May 2013; g) The hospital discharge planning meeting in July 2013 after B1’s birth. 20. The findings in the final chapter of this report use an adaptation of the framework developed by SCIE to present the key learning within the context of the local arrangements. 1.3 The scope of the serious case review 21. The period under review is from the 10th June 2012 (date of an incident of domestic abuse which initiated a multi agency intervention leading to the second episodes of the older siblings being subject of a child protection plan up to the date of the strategy meeting in mid August 2013. 22. All agency chronologies included detailed information about when the children were seen or observations were made about them. Page 4 of 44 Child B1 SCR Final Report published 110216 23. The following agencies have provided information and contributed to the serious case review in accordance with Working Together to Safeguard Children (2013), Chapter 4 and the associated LSCB guidance and relevant learning and improvement frameworks. � Health services in Greater Manchester that include: o Central Manchester Foundation NHS Trust (CMFT) (acute, maternity and community services) o Pennine Acute Hospitals NHS Trust (provided midwifery services during the pregnancies); o Manchester NHS general practitioner services under the clinical commissioning group; o North West Ambulance Service. � Manchester Education Services (primary education for Sibling 1 and Sibling 2) � Manchester Community Alcohol Team (Manchester City Council and Manchester Mental Health and Social Care NHS Trust) � Greater Manchester Police (GMP) (in respect of responding to incidents of domestic abuse and investigation of the death of B1) � Manchester Children and Families Services providing children’s social care services in respect of statutory assessments, management of the child protection plan and arrangements for the two older children to be looked after (LAC) by their grandmother � City South Housing Trust � Greater Manchester Probation Service Trust � NSPCC (did not provide any services to the family). 24. Information sought from the family is described in section 1.7. 1.4 Particular issues identified by the serious case review team for further investigation by the key lines of enquiry: 25. In addition to analysing individual and organisational practice the review considered: a) The quality of the assessment of risk to B1 including; the adequacy of the child protection plan, the functioning of the core groups, the oversight and challenge of the child protection case conferences; b) The recognition and assessment of neglect; c) Were Public Law Outline arrangements ever considered in this case? d) The extent to which domestic abuse and alcohol abuse and the associated impact on parents were recognised and assessed; Page 5 of 44 Child B1 SCR Final Report published 110216 e) Was there evidence of a resistant family or disguised compliance. Failure to recognise the risks associated with their behaviour and no willingness to change; f) Voice of the child, were the children spoken / listened to? Were their views, wishes and feelings taken into consideration? g) Race, ethnicity, culture and economic circumstances. Mother and Father were of different ethnic origin. What impact did this have on the family circumstances? Were there any tensions? What impact did this have on the children/subject? 1.5 Membership of the case review team and access to expert advice 26. The case review team that oversaw this review comprised the following people and organisations from Manchester: Position Organisation Head of Safeguarding and Improvement Unit Children and Families Directorate (children’s social care) MCC Locality Manager Children and Families Directorate (children’s social care) MCC Detective Sergeant Greater Manchester Police Designated Doctor Manchester Clinical Commissioning Group Deputy Designated Nurse Manchester Clinical Commissioning Group Named Nurse Central Manchester Foundation NHS Trust (CMFT) Acting Operations Manager Greater Manchester Probation Trust Head of Service Community Alcohol Team Director of Resources City South Housing Trust Education Case Manager Education and Skills Directorate MCC Team Manager NSPCC Business and Performance Manager MSCB Business Support Officer MSCB 27. The independent lead reviewers attended every meeting of the review team and case group meetings. One of the reviewers took lead responsibility for facilitating meetings and overseeing documentation and liaison in regard to family contact. The other lead reviewer took principle responsibility for drafting the report. Both of the independent reviewers participated in conversations and meetings with case group members and collating evidence and information. 28. The review team had access to legal advice from a solicitor in the council’s legal service. The team also had access to other specialist advice if it had been required. Page 6 of 44 Child B1 SCR Final Report published 110216 29. Written minutes of the review team meeting discussions and decisions were recorded by a member of the MSCB business unit. 1.6 Independent lead reviewers 30. Valerie Charles works as an independent consultant and is registered with the Health and Care Professions Council (HCPC). Valerie has been qualified since 1991 and has a professional social work qualification and MA. She has extensive experience of working in children’s services in both the local authority and voluntary sector. She was a senior manager for NSPCC from 2006 to 2012. Valerie has worked in different roles within local safeguarding children boards, including chairing serious case reviews and has experience in systems methodology case reviews. Valerie has undertaken training for independent reviewers. 31. Peter Maddocks has over thirty-five years experience of social care services the majority of which has been concerned with services for children and families. He is the author of the report. He has experience of working as a practitioner and senior manager in local and national government services and the voluntary sector. He has a professional social work qualification and MA and is registered with the HCPC. He undertakes work as an independent consultant and trainer and has led or contributed to several service reviews and statutory inspections in relation to safeguarding children. He has undertaken independent agency reviews and has provided independent overview reports to several LSCBs in England and Wales as well as work on domestic homicide reviews. He has undertaken work as an overview author on two previous serious case reviews in Manchester. Apart from this, he has not worked for any of the services contributing to this serious case review. He has also participated in training for overview authors and independent reviewers including the application of systems learning. 1.7 Parental and family contribution to the serious case review 32. In view of the separate investigation by the police as well as the coroner’s enquiry the serious case review team had to ensure that all contact with the family was the subject of appropriate consultation and advice. The review team used the national guidance agreed between chief police officers, the Crown Prosecution Service and the Directors of Children’s Services in England2. 33. The parents were made aware of the serious case review when it was commissioned, in a letter sent to them on the 7th February 2014. At the time of the review being conducted there was an ongoing investigation by the police. Both parents were summoned in June 2014 to appear in court. Father was charged with offences 2 A Guide for the Police and the Crown Prosecution Service and Local Safeguarding Children Boards to assist with liaison and the exchange of information when there are simultaneous chapter 8 serious case reviews and criminal proceedings; April 2011 Page 7 of 44 Child B1 SCR Final Report published 110216 relating to child neglect and was convicted in early 2015. He was sentenced to eight months in prison suspended for two years. 34. In view of the legal proceedings it was not possible to seek any direct evidence or information from either parent until after the criminal proceedings had been completed. 35. Mother took up the offer of a meeting with the independent reviewers after father’s conviction. Mother acknowledged that at the time of the events examined by the review she had been unable to see the impact of domestic abuse and alcohol use on the children. She acknowledged that she had been unwilling accept the concerns of professionals. 36. Since the review was completed mother has undertaken courses that have helped her see the impact of such behaviour on children. She says that this would make her behave differently now. She says that she could now see things from the child’s perspective and would be more open to the concerns and advice of professionals. 37. Mother found some professionals more helpful than others. She could not identify anything specific that could have helped at the time although was keen that the review helped learning. 1.8 Time scale for completing the serious case review 38. The case review team met on five occasions between December 2013 and April 2014. The review findings were presented to the MSCB in August 2014. 1.9 Status and ownership of the overview report 39. The overview report is the property of the Manchester Safeguarding Children Board (MSCB) as the commissioning board for the serious case review. 40. Since June 2010, all overview reports provided to LSCBs in England are expected to be published in full. This overview report provides the detailed account of the key events and the analysis of professional involvement and decision making in relation to B1 and family. 41. An executive summary is not required by the revised national guidance set out in Working Together to safeguard Children 2013. The MSCB will determine how and what further information is provided to the family at the conclusion of the review and following the submission of the overview report to the Department for Education. 1.10 Cultural, ethnic, linguistic and religious identity of the family 42. Child B1’s mother is Black British and father is Asian British. Mother’s first and only language is English. Father spoke Urdu and English. There is no recorded physical or Page 8 of 44 Child B1 SCR Final Report published 110216 learning disability. There is no information about any religious or cultural affiliation over and above the fact that father was celebrating the Islamic festival of Eid the evening before Child B1 died. Father has been long term unemployed. Mother has worked in a series of casual or short term jobs although very limited detail is provided in any assessment or reports. The family were in receipt of housing and other benefits and rented a two bedroom property. 43. The father was living with his parents while the children stayed with their mother in the family home. Although the parents had daily contact father was not supposed to be staying overnight because of concerns about his use of alcohol and the potential for domestic abuse. 44. B1 was living in an area of Manchester that is amongst the ten per cent of the most deprived areas in England. 45. The area has a higher concentration of people from a Black or ethnic minority background compared to the city’s overall population profile. The area has higher levels of children living in poverty, with ill health and also experiencing crime. The area has a higher concentration of adults who have no educational qualifications. 46. The north west of England has a higher rate of teenage pregnancies; there are also higher concentrations of families living in social housing and a lower proportion of children are living in two parent households. 47. There are 115,910 children and young people aged 0-19 years living in Manchester according to the 2009 mid-year population estimate. This accounts for 24 per cent of the city’s total population of 483,830. Manchester has been growing at over 1 per cent a year since 2001, twice the average rate of growth in England and Wales. The number of children aged five to 14 years has decreased during this period, but there has been an increase of over 20 per cent in the number of children aged under five. 48. The 2007 Index of Multiple Deprivation ranked Manchester as the fourth most deprived local authority area in England. In 2009, 77 per cent of pupils lived in one of the 20 per cent most deprived areas in England. The area in which Child B1 lived is one of the 10 per cent most deprived areas in England. In 2010, 37 per cent of primary school pupils and 34 per cent of secondary school pupils were eligible for free school meals, significantly more than nationally. In the 2001 census, 31 per cent of children and young people aged 0 to 19 years were from minority ethnic groups compared with 26 per cent for the total population. According to the January 2010 school census, 35 per cent of primary school pupils and 30 per cent of secondary school pupils spoke English as an additional language, well above other areas of the country. Over 170 languages are spoken across schools in Manchester. 49. In Greater Manchester, domestic abuse accounts for six per cent of calls to the police for assistance. Of these calls, 16 per cent were from repeat victims. Greater Manchester recorded 905 assaults with intent to cause serious harm, of these 154 were domestic abuse related. This is 17 per cent of all assaults with intent to cause Page 9 of 44 Child B1 SCR Final Report published 110216 serious harm recorded for the 12 months to end of August 2013. The force also recorded 12,953 assaults with injury, of these 4,478 were domestic abuse related. This is 35 per cent of all assaults with injury recorded for the 12 months to end of August 20133. 2 Summary of agency contact and involvement Historical context 50. This summary of professional contact with B1 provides an account of the most significant events and decisions from the different services involved with B1 during the timeframe established for the review. It does not give an account of every contact with an individual professional or service. 51. Mother and father first met when they were teenagers. The family have been known to several services over many years. Both parents have longstanding problematic use of alcohol that certainly for father began in adolescence and this has been a significant factor in the aggravation of domestic abuse, antisocial behaviour and neglect of the children. 52. Mother had been permanently excluded from school. She first came to the notice of the police for a robbery as a 12 year old. She has been arrested 26 times between 1996 and 2012. The father also had a disrupted education. He first came to the notice of the police as a 15 year old in relation to robbery. He has had numerous contacts with the police since then; on two occasions it was in relation to driving offences. He has a record of verbal and physical violence including arguments and assaults on at least 15 occasions to mother and assaults on at least two males. He was convicted and sentenced to 30 months imprisonment in March 2010 following an assault on a neighbour with a hammer in 2009. 53. There was an incident of domestic abuse as early as 2002 and a year before the first child was born in 2003. The parents separated very briefly in May 2004 when mother told the father to leave the home due to his drinking, constant arguing and lack of support in parenting the children. There were further reports of domestic abuse in June 2004 that involved a new partner that mother had. Both adults refused to give statements. 54. The parents were reconciled during 2004. There was further domestic abuse involving both parents. There were five incidents of domestic abuse involving a police response between the birth of the first child in August 2003 and the birth of the second child in March 2007. In October 2008 father was cautioned for two common assaults on mother and Sibling 2 during an incident of domestic abuse. The subsequent referral to children’s social care services led to the first initial child 3 Source: HMIC data collection. Crime figures are taken from police-recorded crime submitted to the Home Office. Page 10 of 44 Child B1 SCR Final Report published 110216 protection conference. There were 15 recorded incidents of domestic abuse between August 2002 and June 2012. 55. Children’s social care services have known the family since December 2003 due to the recurring concerns about domestic abuse, both parent's alcohol abuse and the lack of their insight into the impact of these factors on their children. 56. There is a history of poor maternal and paternal engagement with health services. There were attendances at the hospital emergency service for the older siblings; there were eight for Sibling 2 between April 2007 and September 2011. There were missed appointments with primary health workers such as health visitors and delays in completing routine health assessments. Both older children had a history of delayed immunisations and missed dental appointments; this resulted in severe dental caries (tooth decay) for one of the older siblings and the extraction of nine teeth. Sibling 1 had delayed development of speech and language. 57. The older siblings were made the subject of child protection plan under the category of neglect between 16th January 2009 and the 22nd September 2010. Mother was referred three times to the community alcohol team (CAT) between May and October 2009 and again on two more occasions in 2010 but did not attend any appointments. She acknowledged drinking heavily but asserted that it was ‘only at weekends’ and when the children were with their maternal grandmother. The involvement of CAT ended in January 2010 when it was apparent that mother was unwilling to engage with any of the advice and support being offered4. 58. The children subsequently became looked after children under section 20 of the Children Act 1989 and were placed with their maternal grandmother between 14th June 2010 and again on the 17th November 2010 after their mother had reportedly gone to the shops and the police used their powers of protection; when they were returned to mother’s care the father was still in prison. During the time that the children were looked after it appears that mother had daily and extensive contact and remained effectively in control of contact and interaction with the various professionals. The case was closed in April 2011. 59. Children’s social care services received further referrals in January and June 2012 owing to further incidents of domestic abuse and the two older children again became subject of child protection plans on the 7th March 2013 under the category of emotional abuse. 60. The family had significant levels of debt including being in arrears with the rent. The landlord had secured a Possession Order but had not initiated any eviction proceedings. 4 Outside the time frame for the SCR she was referred again in October and November 2013 and did not engage, and then a social worker referred again in January 2014. On that referral it states that mother denies that she has a problem with alcohol although her presentation suggests otherwise. Page 11 of 44 Child B1 SCR Final Report published 110216 Incident of domestic abuse and response by services 61. On the 10th June 2012 in the late afternoon the police were summoned by mother who had been assaulted by father. The police arrived and mother began to shout and scream about father hitting her in the face and that he had also broken her jaw the previous month. She said that she was fed up with him and wanted to be rid of him. Mother was intoxicated. 62. The officers interviewed the parents separately. Mother had been out all night and had returned to the house with three men. There had been an argument between mother and father and during the argument father had punched mother to the side of the face; there was no mark visible to the officers. Mother slapped father in the face while the officers were still present. Both parents were arrested in relation to the respective assaults although it was subsequently decided that neither would be prosecuted on the basis that it would not be in the public interest. 63. The officer completed a DASH (domestic abuse, stalking and harassment) assessment that graded the circumstances as reflecting medium risk.5 A referral was made to children’s social care services and a strategy meeting on the 27th June 2012 took place between the police and children’s social care services. The meeting acknowledged that there had been a core assessment completed in March 2012 following previous incidents of domestic abuse which had concluded that there were no concerns in regard to the children and that mother was able to safeguard them. The children were reported to be up to date with immunisations and the school did not have concerns. The case had been closed to children’s social care services. The police understood that a further core assessment would be completed by children’s social care services; in the event an initial assessment was completed on the 27th June 2012. 64. The initial assessment was completed outside timescale and concluded that the pattern of domestic abuse had been ongoing for several years and that further assessments were required to ensure that the children were not at risk. The assessment notes that mother did not want to allow social workers into the house to speak to the children alone. The assessment also noted that mother showed no insight or understanding about the negative impact on the children. The initial assessment recommended that a core assessment would be completed. Report of domestic abuse in August 2012 and use of the domestic violence prevention notice (DVPO) 5 ACPO (association of chief police officers) council accredited the DASH (Domestic Abuse, Stalking and Honour Based Violence) to be implemented across all police services in the UK from March 2009. The DASH is a risk identification, assessment and management framework and means that most police services and a large number of partner agencies across the UK are using a common checklist for identifying and assessing risk, with the intention to save lives. Page 12 of 44 Child B1 SCR Final Report published 110216 65. Mother made a 999 call to the police to report father having punched her to the face and was refusing to leave the property. Police officers went to the house and arrested father. Mother told the arresting officers that she did not wish to make an allegation of assault or to make a statement. Father was subsequently interviewed under caution during which he declined to make any comment. The CPS advised that due to insufficient evidence they would not authorise a prosecution. The incident was the seventh since the beginning of the year and the police constable made report to the public protection investigation unit recommending that further action and support was required because there were two children in the household. The sergeant in public protection investigation unit initially allocated the case for follow up referral to the MARAC and to seek a strategy meeting. It was subsequently reassessed before going to MARAC and graded as medium risk and therefore not for MARAC. 66. Father was issued with a domestic violence prevention notice (DVPN) and the domestic violence prevention order (DVPO) issued by the magistrates6. This was delivered to the paternal grandparents’ home on the 9th August 2012 where father was living although he was not in. The DVPO was left with his father. The order prohibited father from going to the family home or to assault, harass or molest mother. The order was for 28 days. 67. A police referral was made to children’s social care services on the 16th August 2012 to inform them about the further domestic abuse and the issuing of the DVPN and DVPO and requesting a strategy meeting given the concern that father would be allowed back into the family home. Coincidentally father’s prison licence came to an end on the 19th August 2012 and bringing the involvement and supervision of father by a probation officer to an end7. 6 A DVPN was initially piloted in three police areas from June 2011 and is the ‘go order’ issued to a perpetrator and is the initial notice issued by the police to provide emergency protection to an individual believed to be the victim of domestic violence. This notice, which must be authorised by a police superintendent, contains prohibitions that effectively bar the suspected perpetrator from returning to the victim’s home or otherwise contacting the victim. A DVPO (domestic violence prevention order) is issued by a magistrate upon the application through notice of the police and lasts for 28 days. 7 Prisoners who qualify for parole are released from prison ‘on licence’. This means that although they are not serving their sentence in prison they are still required to adhere to certain conditions whilst serving the remaining part of their sentence in the community. Time spent ‘on licence’ in the community is supervised by the probation service. There are six standard conditions for prisoners serving determinate sentences (a custodial sentence with a fixed length). The prisoner should: behave appropriately and not commit further offences or undertake any activity that may undermine their attempts to resettle in the community; maintain contact with their supervising probation officer and do what is asked of them; allow their supervising probation officer to visit them at home if they need to; live at an address approved by their probation officer and keep them informed of any changes of address (even if only for one night); only do work, paid or unpaid, that has been approved by their probation officer and keep them notified of any changes in employment; not travel outside of the United Kingdom. If the conditions are breached the prisoner is sent back to prison to complete their original sentence. Page 13 of 44 Child B1 SCR Final Report published 110216 68. In the event, a strategy meeting did not take place; a joint home visit to mother by a detective constable from the public protection investigation unit and the social worker on the 29th August 2012 explained that unless the domestic abuse was resolved it might be necessary to refer the children back to a child protection conference with a view to making them subject of a child protection plan. Mother did not want this to happen and said that she was now prepared to take counselling and mediation (which in any event would not have been an appropriate strategy and response to domestic abuse). She also made it clear that she did not agree with the DVPN. Completion of core assessment October 2012 and multi agency meeting discuss domestic abuse 69. The core assessment had been agreed following the incident of domestic abuse in June 2012 and was therefore significantly outside the national and local timescales for completing a statutory assessment. The assessment concluded that ‘case planning should occur’ and that the children would be spoken to alone at school to ascertain their wishes and feelings. The assessment also recommended counselling for both of the parents. 70. On the 16th November 2012 a multi agency meeting at the school chaired by the social worker and attended by the mother, head teacher and school nurse discussed the incidents of domestic abuse. Sibling 1’s school attendance was just over 90 per cent whilst Sibling 2 had managed almost 97 per cent attendance. Both children had been discharged from the dental clinic at the local health centre after two appointments had been missed. Further domestic abuse in late 2012 and evidence of significant debts 71. In November and December 2012 the police followed up two 999 phone calls that were abandoned by the caller. On the 9th December there was third call that was also abandoned and again the police followed up with a visit to the home. On this occasion the police found mother upset that the police were in the house. Both parents were unwilling to speak with the police officers who had noticed several letters thrown around the kitchen floor and that indicated that the family owed several thousand pounds to various companies. Father agreed to leave the property. Confirmation of third pregnancy, evidence of neglect and further domestic abuse and second use of the DVPN 72. On the 17th December 2012 mother made the first contact with the midwifery service at the local health centre in regard to her pregnancy with B1. She did not attend the antenatal booking appointment made with the community midwives for the 24th December 2012. 73. Mother attended for the ante natal booking appointment on the 7th January 2013. The booking confirmed details about the parents including the fact that they both Page 14 of 44 Child B1 SCR Final Report published 110216 smoked and were willing to accept specialist support regarding this. Information about substance misuse was only recorded in relation to mother who reported that she did not misuse alcohol or drugs. There is confirmation that routine enquiries were made about domestic abuse and that no disclosure was made. She was booked for midwifery led care during the pregnancy8. 74. On the 9th January 2013 five year old Sibling 2 had nine teeth removed due to dental cavities at the hospital paediatric dental service. The GP was routinely notified by letter. 75. On the 12th January 2013 mother contacted the police in the early afternoon to report that father had assaulted her. Mother stated that she was too busy to make a statement but would do so at a later time. Father was arrested but declined to answer any questions. 76. A multi agency child in need (CIN) meeting on the 15th January 2013 was chaired by the social worker at the school. The meeting was advised that mother was pregnant and that there had been further incidents of domestic abuse. No minutes were recorded and no CIN plan was agreed. A further meeting was scheduled for the 5th March 2013. There is no record of the midwifery or health visiting service being alerted to the CIN meeting or invited to participate. Section 47 enquiries and initial child protection conference 77. On the 23rd January 2013 father was issued with a second DVPN after both parents had declined to co-operate with the police in regard to the domestic abuse incidents. A referral was made to children’s social care services on the 1st February 2013. 78. A strategy meeting was held three weeks later on the 22nd February 2013. The meeting agreed that the police and children’s social care services would complete enquiries. On the 25th February 2013 the decision was taken to convene an initial child protection conference which took place on the 7th March 2013. 79. The initial child protection conference discussed the pattern of domestic abuse, the dental cavities and use of alcohol by both parents. The initial child protection conference agreed that both children would be subject of a child protection plan under the category of emotional abuse, that a core assessment would be completed and that the school nurse would coordinate a health assessment of both children. 80. The first core group meeting on the 21st March 2013 was told that the family were on the verge of eviction due to the rent arrears; this appears to have been an assumption rather than based on fact as the landlord service has never initiated any 8 The booking form asks for details about the birth father in regard to their name and date of birth and a box for proposed contact with the baby although the space to provide information is minimal and in this case was completed with just ‘father’. Although the form recorded information about smoking for both parents the subsequent questions about substance use focussed completely on the mother. Page 15 of 44 Child B1 SCR Final Report published 110216 eviction procedure. The social worker had produced a ‘working agreement’ that was challenged by mother in relation to the proposed restrictions on her contact with father. Father was to be referred to alcohol services. 81. The second core group meeting on the 25th April 2013 was attended by mother but not by father. The landlord had organised involvement from the FIP service. The social worker had made a referral to women’s aid; counselling at Relate was also discussed. The social worker advised the group that the case would be allocated to a different social worker (SW3). The case was transferred later that day. 82. The first review child protection conference on the 8th May 2013 was told that mother would separate from father because she wanted to put her children first. However father wanted to return to the family by the time that B1 was born. He claimed that he was no longer drinking alcohol. The core assessment remained unfinished and a pre-birth assessment was required for B1 within the following five weeks. The children remained subject to the child protection plan. The chair of the child protection conference advised that the ‘working agreement’ needed to included a ‘firm agreement that father will self refer to the community alcohol team’ and that failure to adhere to the child protection plan should result in ‘legal consultation’. Initial child protection conference and post birth contact 83. On the 3rd July 2013 the initial child protection conference in regard to the unborn B1 agreed that the baby would be subject of a child protection plan because of the risk of emotional neglect. The child protection plan was opposed by mother. B1 was born at the end of July 2013 at 38 weeks gestation but with a low birth weight of 2.19kgs. 84. A discharge planning meeting at the hospital was told that father was not living at the home address but stayed overnight a couple of nights a week. The postnatal discharge planner was completed confirming that there had been a discussion about reducing the risk of cot death with the parents and that written information had been provided9. The planner recorded that mother stated that she was not a smoker which was contradictory to the information recorded at the booking of the pregnancy. 85. The first visit by the midwifery service was done without knowledge of the child protection plan. B1 was making good weight gain. 86. Less than a week after being discharged from hospital B1 died. 9 The post natal discharge planner is a discrete document that is a list of actions to be completed prior to discharge from hospital and includes a section on ‘discharge information discussed’ such as post natal exercise, contraception and reducing the risk of cot death. Page 16 of 44 Child B1 SCR Final Report published 110216 3 Appraisal of professional practice in this case 87. B1’s parents and siblings were well known to agencies and there had been a high level of involvement for over ten years. During this time there had been persistent concerns about domestic abuse and consumption of alcohol. Father was convicted in 2009 following an assault on a neighbour. Although the parents separated for a few weeks in 2004 and again during father’s imprisonment between March 2010 and May 2011, they have continued their relationship ever since they were teenagers. 88. The family lived in a small and settled community. Although they had rent arrears and there had been reports of anti-social behaviour the family had not been regarded as particularly problematic by the landlord service relative to other tenancies. The senior manager in the landlord service had not been made aware of them until the serious case review signifying that they were not a family that were attracting a high level of concern from a housing and community perspective. If any safeguarding issues arising from B1’s birth had been clearly identified then the housing officer could have requested the Director to consider waiving the rent arrears control that blocked the application from being progressed; this would have restarted the application process and moved the family up the re-housing application list. This was not done. 89. Mother was in employment intermittently; this disrupted housing benefit which contributed to some of the difficulties in rent arrears although the family were known to have significant levels of debt although the extent and nature of debt was never established by any service. The children regularly attended school where they participated well and received good support and education at an outstanding school (as judged by Ofsted). 90. Although there had been child protection plan’s in place for the two older siblings for several months between January 2009 and September 2010 and again from March 2012, there had been a collective inability to recognise and respond to the parent’s attitude, behaviour and lifestyle that was detrimental to the children’s emotional health and well being. 91. The parents have a long history of minimising concerns about their children’s emotional well being and were unwilling to engage with any professional unless it was on their terms or to postpone any threatened action to have the children removed from their care. 92. The parents made little effort to disguise their ambivalent or hostile attitude to professionals raising concerns about the children and mother in particular proved to be very effective in hijacking the conduct of some important meetings such as the child protection conferences or reviews when she felt threatened and was not prepared to acknowledge or accept inconvenient or uncomfortable evidence about how the behaviour of both parents would damage their children. Page 17 of 44 Child B1 SCR Final Report published 110216 93. Several of the professionals talked about how emotional and challenging some of the meetings had been and commented on how the minutes did not reflect that dimension of the interaction. 94. Mother consistently refused to allow professionals to speak to the children on their own or at school; both of the older siblings were very guarded in their interaction with teaching and support staff for example. She did not participate in core groups and nor did father. 95. Mother was reluctant to allow any service into the house including the family intervention project (FIP) that had been organised through the landlord service when they knew about the child protection plan from March 2012. Mother was especially opposed to children’s social care services and saw any other service as a route for information to be fed back. Mother was very concerned to not give any reasons for the children to be removed from her care. The reluctance to engage contributed to a ‘softly softly’ strategy being used to try to gain confidence and trust and undermined a more assertive approach that some professionals including one of the child protection conference chairs felt should have been pursued. 96. The FIP worker made a total of 29 visits to the home of which only 15 were successful in getting access to the house; five visits were cancelled by mother at short notice. The FIP worker had the most success in getting access to the house. There was never an explicit rejection of the contact; more usually if an excuse was given it was because there was a clinic appointment or a need to go to a job interview. Ironically, the FIP worker was never given a copy of the child protection plan or the working agreements although did attend meetings and was in contact with the social workers. 97. Mother’s repertoire of strategies for dealing with professionals ranged from being warm and friendly (at least initially until challenged such as with the midwife), ingratiation (such as baking cakes for school), being argumentative through to outright confrontation and attempted intimidation and could adapt her behaviour to the circumstances of particular situations. Some professionals understood the behaviour for what it was although crucially this was not the case for everybody and especially for people coming new to the case and giving mother in particular the benefit of new starts. 98. The initial booking for the pregnancy with B1 with the community midwife involved a routine discussion of history. Mother denied any domestic abuse, drinking alcohol and said that she did not have a social worker involved with the family. She was already 15 weeks late when making the initial booking; the late booking represented neglect of both mother’s and her baby’s health. She had already missed the first screening that is routine during early pregnancy. 99. The use of alcohol and incidents of domestic abuse were often linked. This does not mean that alcohol was the cause of the domestic abuse but it certainly exacerbated the verbal and physical violence and on at least one occasion was a significant contributor to one of the children being struck during an incident. The assault for Page 18 of 44 Child B1 SCR Final Report published 110216 which father was convicted and sentenced to 30 months imprisonment also took place after he had consumed several alcoholic drinks (vodka and cokes). 100. The parents’ lifestyle around alcohol and some use of cannabis had implications in terms of how much of the family’s limited income was used to fund this as well as the behaviour that resulted from it. The family have very significant levels of debt and have considerable rent arrears. Although much of the drinking appeared to take place in the home there were times when mother was out all night and on one occasion returned with unknown men to the house. 101. The police were summoned frequently to deal with incidents of domestic abuse. Almost on every occasion both parents declined to make statements. Mother refused to participate in the DASH assessment. Although the police had latterly used new legal powers to manage the risk of domestic abuse through for example issuing a DVPN and following this up with a DVPO this only addressed short term action and there was insufficiently co-ordinated and concerted follow up action by other services. Collectively, there was insufficient attention to the underlying reasons for the domestic abuse or to the cumulative impact on the children. 102. The DVPO was not served in person on father but to his father who agreed to make sure his son received it. The procedures do not require the notice or order to be served in person but merely delivered to their address. 103. Although the sergeant in the public protection investigation unit had issued instructions that a strategy meeting was required because of the frequency of incidents and concerns about the impact on the children the instruction was not followed through. Instead the home visit by the social worker and a police officer said that a child protection conference would be required if there was a repeat of the incidents. Not only does this miss an opportunity to explore what has been happening in this household by sharing information across agencies and checking what further action was required, it also provided an incentive to the parents to not involve any agency in future incidents. 104. It was in February 2013 when a strategy meeting was held leading to a child protection conference and was after further incidents of domestic abuse. The trigger in February was the realisation that mother was five months pregnant. It was the March child protection conference when mother was dismissive of the history of domestic abuse and its impact on the children in spite of the chair of the child protection conference being very assertive and clear about the extent of the history and the implications for children’s emotional and physical safety. 105. Although alcohol misuse has been a longstanding concern, neither of the parents has been known to the local specialist alcohol service. Although advice had been given to seek help neither of the parents has done this through a self referral. Page 19 of 44 Child B1 SCR Final Report published 110216 106. Whilst father was in prison he had participated in a number of programmes such as healthy relationships and alcohol awareness10 although information about this was not shared with the probation officer and the post programme report was not reviewed in the community and indicates a lack of continuity in the offender management for father. He was not motivated to do any further work upon release, reflected in his non engagement with any community alcohol treatment. The programmes in prison were not designed to provide the level of therapeutic or intensity of intervention to address the extent of alcohol dependency, violent behaviour or the domestic abuse. Additionally, the index offence for which he had been convicted would not have met the threshold for entry on to a structured and intensive programme such as IDVA. The child protection conference in March 2012 was led (not by probation) to believe that the domestic abuse work in prison had been part of an IDAP programme which was not the case11. 107. Upon father’s release from prison on licence in May 2011 he was assessed by the probation service as being a low risk source of serious harm; that assessment was based on looking narrowly at the crime for which he had been convicted and making a judgement about whether it for example was life threatening, had caused serious physical injury or psychological harm. He had been convicted of striking an adult male on the head with a hammer. The case was subsequently transferred to another probation officer who became aware of the domestic abuse and along with other factors such as the substance misuse reassessed the level of risk to be medium (to the family and to the public) when the licence was completed in August 2012. This reflected a more holistic approach to understanding the nature of risk and wanted to alert any subsequent offender managers to the history to father’s use of violence to gain control and his excessive use of alcohol that was an aggravating factor. Significantly, the probation officer was not included as a member of the core group. 108. As part of the prison release and planning father had been assessed for suitability to participate in a thinking skills programme which is a cognitive behavioural therapy. He was assessed as functioning at a higher level than the thresholds set for the programme and he therefore only had access to work preparation. His problematic and violent behaviours were therefore not subject to any concerted intervention. 10 The alcohol awareness programme is not accredited and therefore there is limited evidence about efficacy. The healthy relationships is accredited by psychologists. The group work was not reviewed by the probation officer. 11 IDAP (integrated domestic abuse programme) is a nationally-accredited community-based group work programme in the UK designed to reduce re-offending by adult male domestic violence offenders. It is based on the domestic abuse project developed in Duluth, Minnesota, USA, which led to a comprehensive overhaul of the criminal justice agencies’ response to these cases and the development of an integrated community approach. For it to be effective, it requires good communication and co-operation between services that consistently focus on the safety of women and children who have been subjected to the domestic abuse and that the perpetrator acknowledges and takes responsibility for their behaviour through the programme. The programme is not suitable for men who have mental health or severe substance misuse problems that undermine their capacity to achieve the learning outcomes of the programme. In this case father, as well as mother, had chronic and long term dependency on alcohol. Page 20 of 44 Child B1 SCR Final Report published 110216 109. There had been evidence of neglect over many years and this was the focus for the involvement of services. Mother neglected her own health during the pregnancies and there have been many missed appointments for routine health check ups for herself and for the children. The dental cavities that contributed to one of the children having nine teeth extracted is evidence of neglect over an extended period of time. The significance of this did not appear to be understood by the core group or by the dental practitioners. 110. Although some professionals had longstanding concerns about the children and have had a clear insight about the extent to which neither parent has been prepared to acknowledge concerns, this was not explicitly discussed. 111. There have been frequent changes and reallocations of social workers that had led to inconsistency in knowledge and developing a strategy for the case. Very little was known about the individual history of either parents or of the family. Assessments have not been adequate, all have been delayed and none have contained information about direct views wishes and feelings of the children or collated information from other services. 112. The pre-birth assessment for B1 in May 2013 was late, contains inconsistent spelling of children’s names, and is very superficial in summarising information or providing analysis. There is high reliance on the parents’ assertions that for example they have stopped drinking and that mother would report father to the police if he drank alcohol. The assessment asserts that mother had prepared for the pregnancy but provides no evidence over and above that a pram had been purchased; there is no reference to any other preparation and significantly given the circumstances of B1’s death, there is no reference to proposed sleeping arrangements or whether a cot had been acquired. 113. There is no information either from the older siblings in terms of their views wishes and feelings about the pregnancy and general circumstances and no information from other professionals. This reflected the fact that mother obstructed professionals from having opportunity to talk with the children on their own as well as key professionals such as social workers not being sufficiently assertive and focussed on pursuing such contact especially as part of statutory enquiries, assessment and child protection plan. 114. Issues such as overcrowding after B1 was born are mentioned in the assessment but there is no indication of any discussion with the landlord service. 115. The team manager realised that the assessment was inadequate but because of the extent of other workload personally and across the team felt that that it was better for an inadequate assessment to go forward rather than risk further delay. 116. Mother’s pregnancy with B1 was the subject of multi agency pre-birth risk identification and B1 was subject of a child protection plan from birth. Paradoxically, professionals such as the head teacher and the school nurse were initially invited to Page 21 of 44 Child B1 SCR Final Report published 110216 attend but this was rescinded. It is believed that this was because the chair who was allocated the child protection conference was on leave when the allocation took place and support staff mistakenly believed that the child protection conference should only involve people who would be involved with B1 rather than the siblings. The consequence was that two professionals who had extensive and historical knowledge and understanding about the family’s circumstances were not able to contribute information and assist with analysis about risk. Other professionals such as the probation officer who had such a good understanding about father’s risk was also not involved in discussion involving B1. 117. Although B1 was therefore regarded as at risk of harm from neglect it is clear that the full extent of risk was not sufficiently understood. For example the fact that mother had continued to smoke and to use alcohol through the pregnancy and B1’s low birth weight were factors associated with sudden infant death syndrome (SIDS). This is in spite of the well developed local strategies that have reduced the incidence of SIDS in the city. 118. There was confusion in regard to arrangements for co-ordinating multi agency contact with B1. The birth was three weeks earlier than expected and the hospital midwife had to be very assertive about convening a discharge planning meeting after the birth and before B1 and mother returned home. The pre-birth assessment had been subject of delay and had already reduced the amount of time to assess and plan a multi-agency child protection plan. 119. The child protection conference in March 2012 was told that there were no education or health concerns that would indicate neglect; this was in spite of one of the children having very severe dental cavities that had contributed to the extraction of nine teeth. 120. The two older children appear to be very resilient in spite of their exposure to abuse and neglect. They have a close bond with each other and are sociable and bright and participate well at an excellent school. The apparent absence of neglect in regard to the children’s physical appearance and presentation may have led some professionals to think the risk from the parents’ behaviour was less severe. The older siblings also appear to have a good relationship with members of the extended family such as grandmother and an aunt. 121. B1 was made the subject of a child protection plan in the category of emotional abuse prior to birth at a conference held on the 3rd July 2013. All children were still subject of plans at the time of B1’s death. The pre-birth assessment that had been completed provided an incomplete evaluation of historical abuse of the older siblings and probably contributed to an overly optimistic assessment of risk. 122. The assessment did not take enough account of the known history and did not take account of the risk factors at birth in regard to the dangers of sudden infant death. The pre-birth child protection conference only received a verbal update from a social Page 22 of 44 Child B1 SCR Final Report published 110216 worker who was taking responsibility for the case from the social worker who had undertaken the assessment. 123. The property was overcrowded with the arrival of B1. It had been assumed that because of the rent arrears there would be no prospect of the family being offered an alternative and larger home. In fact the landlord had a policy of considering housing need that involved a senior manager considering individual family circumstances and making a decision as to whether to approve a transfer while there were rent arrears. This was not done in this case. 124. The work of the core groups was underpinned by a series of working agreements that were in addition to the outline child protection plan agreed at the child protection conference. Significant parts of the working agreements were disregarded by the parents. For example the requirement for the parents to live in separate households was ignored and by the time that the birth of B1 was imminent the mother was determined to have the father in the family home in order to provide support. This was not known about by several members of the core group who were involved or in contact with the older siblings. 125. The agreements had no provision for dealing with non compliance and there were no consequences when important aspects of an agreement were simply ignored. Some professionals such as the social worker and chairs of conference felt isolated in trying to tackle the parents’ attitudes and behaviour. Other professionals felt not enough was being done and that there was not enough of an assertive grip on case management. 126. The duty system of allocating the independent chairs for child protection conferences contributed to a change in the chair between the child protection conference that decided to make the older siblings subject of a child protection plan and the pre-birth initial child protection conference that made the decision in regard to B1. The chair of the earlier child protection conference in respect of the older siblings had a long term involvement in the historical child protection conference and had used this historical knowledge to be assertive in his approach with mother’s minimisation of concerns in particular. He knew of the domestic abuse and its significance along with the substance abuse. He was sceptical about mother’s efforts to divert attention. The next chair did not have that level of knowledge and had limited time to read them self into the case prior to the child protection conference. As a consequence there was less opportunity to challenge and manage the attitude and behaviour of mother in particular. 127. There was further loss of historical oversight when the decision was taken to exclude professionals such as the head teacher and school nurse from the B1 child protection conference on the basis that they had no direct contact or input in respect of B1. The head teacher had been originally invited but was then removed from the list of professionals to participate. Page 23 of 44 Child B1 SCR Final Report published 110216 128. The workload of all the services had varying implications for how aspects of the case were managed. There was significant reorganisation of children’s social care services that coincided with an increase in referrals and allocation of complex work. There were three social workers allocated at different times between March and September 2013. The team manager at the time of B1’s pre-birth child protection conference was managing a team that was responsible for 92 statutory assessments. It was against this background that an inadequate assessment was allowed through to the pre-birth conference to avoid further delay. 129. The child protection conference chairs also had a busy workload that reflected increases in the numbers of children subject of a CPC; there are currently over 900 children subject of a child protection plan in Manchester. The police have also made changes to their work practice in respect of attending CPC. One of the sergeant positions in the public protection investigation unit was vacant between December 2012 and July 2013. The public protection investigation unit can be dealing with as many as 140 incidents of varying urgency. The school nursing service has been re-configured resulting in school nurses working with larger clusters of schools. 130. The person with the longest and most consistent contact with the family was the head teacher who had a good understanding about the circumstances and issues in the family. The head teacher had tried to get more consistent and intensive involvement from other services in response to issues such as domestic abuse; more than once there was a delay of several weeks and moments of opportunity had passed such as when mother had bruising to the face. The head teacher no longer has parent support advisors and this has implications for the personal capacity of the head teacher and work with vulnerable families. 131. The heavy workloads of several professionals led to some corners being cut in respect of assessment, quality assurance and follow up on the implementation of plans and agreements. There is little capacity for professionals to talk with each other and to develop clearer strategies for managing uncooperative and resistant parents. Reports to child protection conferences are frequently delivered on the day of a child protection conference. Discussions about the release of parents from prison and returning to families are often postponed until after the release rather than before to plan any assessment or support. 132. The probation officer was the only professional to report having a more manageable workload at the time that had allowed more extensive contact with the family and other professionals and provided capacity to do a more extensive final assessment; that workload has since increased. 133. For the professionals who had the longest contact with the family there was a general consensus that father had very little motivation to work or to engage with professionals and that mother was also dismissive of professional advice. People who had longer term contact with the family felt that some of the professionals who were either younger or had less contact or involvement with the parents were susceptible to mother’s tactics and disruptive behaviour and her ability to create collusive Page 24 of 44 Child B1 SCR Final Report published 110216 alliances that for example allowed father back into the household without enough monitoring of arrangements. 134. The frequent changes in social workers had a negative impact on the quality of co-ordination of multi agency work. Plans and agreements were not routinely circulated. A written record of discussions and decision of core groups was often left to individual professionals to make their own note. 3.1 In what way does the case provide a window into the local systems for safeguarding children? 135. The extent to which the quality of risk assessment and responding to the attitude and behaviour of two parents who were unwilling to acknowledge how it represented risk to the emotional well being of their children was insufficiently managed and co-ordinated is concerning. The parents remained in control of professional interaction and influenced decision making and were effective in preventing meaningful intervention. Personal and organisational capacity is a significant factor in how the case was managed. 136. Both of the parents were aware that their lifestyle and abusive relationship was a concern for professionals. Mother in particular was very concerned about children’s social care services being able to remove the children from her care. This appeared to be a major factor in her minimisation of concerns either in multi agency meetings or dealing with the frequent call outs to the police. At no stage does anybody appear to have really explored the quality of attachment and emotional care that the older siblings have had over many years. The fact that both children are at the same school, have a close relationship with each other and are in a setting that provides outstanding education and pastoral support have been important sources of resilience for them. In other words, in spite of the neglect and emotional abuse at home they have managed to show remarkable ability to develop social relationships with peers and to make progress at school. 137. The case has revealed some good examples of assertive practice. This has included the clear challenge by one of the chairs of the child protection conference in March 2012 in regard to mother’s history of minimising concerns about domestic abuse and the referral made by the police officer in June 2012 and recommendation that co-ordinated action was required to address the concerns about the children. There were other referrals from the police which in February 2012 led to the latest child protection plans being put in place. The use of the DVPN and DVPO was evidence of using new powers for a more proactive approach to domestic abuse. Unfortunately it did not translate into enough of a multi agency strategy or take enough account of mother’s unwillingness to recognise the threat of the abuse for the children. 138. The level of obstruction and unwillingness to engage by the parents was never discussed and the response from key agencies such as children’s social care services was not adequate. The response was too often inconsistent and lacked enough purpose. In large part this probably reflected the behaviour of individual Page 25 of 44 Child B1 SCR Final Report published 110216 professionals feeling overwhelmed by their workloads and disruption in the lines of management and professional support. 4 Analysis of key themes from the case and description of findings for learning and improvement 139. Meaningful analysis of the complex human interactions and decision making processes that are involved in multiagency work with vulnerable children and troubled families needs to understand why things happen and the extent to which the local systems (people, work processes, organisational arrangements) help or hinder effective work locally within ‘the tunnel’12. 140. This chapter sets out the key findings designed to offer challenge and reflection for the MSCB and partners. The emphasis is not on the more traditional formulation of SMART recommendations that tend to call for ever more procedure or protocol. 141. The key findings are framed using a systems based typology developed by SCIE to identify some of the underlying patterns that appear to be significant for local practice in Manchester: a) Cognitive influence and human bias in processing information and observation; b) Family and professional contact and interaction; c) Responses to significant incidents and information; d) Tools and frameworks to support professional judgment and practice; e) Management and agency to agency systems. 142. The remainder of this report aims to use this particular case to reflect on what this reveals about gaps or areas for further development in the local child protection system. 143. In providing the reflections and challenges to the MSCB there is an expectation that there will be a response to the key findings in regard to the following: a) An indication as to whether the MSCB accepts the findings; b) Information as to how the MSCB will take any particular findings forward; c) Information about who is best placed to lead on any particular activity; d) An indication of the timescales for responding to the findings; e) Information about how and when it will be reported. 144. The MSCB will determine how this information is managed and communicated to relevant stakeholders. The formal response should form part of the publication of the serious case review. 12 View in the Tunnel is explained by Dekker (2002) as reconstructing how different professionals saw the case as it unfolded; understanding other people’s assessments and actions, the review team try to attain the perspective of the people who were there at the time, their decisions were based on what they saw on the inside of the tunnel; not on what happens to be known today through the benefit of hindsight. Page 26 of 44 Child B1 SCR Final Report published 110216 4.1 Cognitive influence and human bias in processing information and observation Understanding domestic abuse as coercion and control rather than anger management; identifying and responding to parents not engaging with professional’s concerns about child welfare and safety; the influence of parental fear of statutory intervention and keeping possession of their children. 145. Evan Stark13 describes how domestic violence has to be understood more clearly as coercion in order to understand the impact on the adult victims (and their children) and to understand why these relationships so often endure for many years as it has in this case. 146. Being able to place information and observation of incidents and behaviour within good enough historical knowledge rather than treating events as individual or isolated is fundamental along with a good understanding about coercion, control the nature of abusive relationships. 147. The probation officer appeared to be the only professional to have a clear understanding about father’s use of violence to resolve conflict and to regain control and the risk it represented particularly given the habitual use of alcohol and the associated loss of inhibition. 148. Individual police officers were concerned about the frequency of the call outs to deal with incidents of domestic abuse although much of their effort to assess risk was undermined by the lack of co-operation from either adult. 149. In general the response from professionals was to see the domestic abuse as being poor behaviour that was insensitive to the needs of the children and that it required threats of action to make the parents change their behaviour. This reveals a misunderstanding about the nature of abusive relationships. 150. The domestic abuse was a longstanding and recurring concern for all the services. It provoked some of the clearest examples of where both parents were unwilling to engage with the concerns about the impact on and risk to the children’s emotional, psychological and physical well being. 151. There is no record of any discussion in single or multi agency settings about the extent and significance of the parents’ lack of engagement. Parents may present in a number of ways on a continuum from hostility, threats and violence through to superficial and ineffective engagement. Behaviours may include ambivalence, avoidance, confrontation, refusal and violence. 13 Coercive Control: How men entrap women in personal life Evan Stark: Oxford University Press 2007 Page 27 of 44 Child B1 SCR Final Report published 110216 152. Unless resistance and non engagement is recognised there will be a danger that effective intervention is compromised and control remains with the parent. It can influence how practitioners respond; they can become hesitant, be concerned about confrontation and focus on the parent’s agenda or concerns rather than on the child. Reference is made to adopting a softly softly approach in an effort to secure mother’s confidence. This is not a criticism of any individual practice; the point is that the absence of engagement was never discussed openly and therefore no agreed strategy and plan was put in place. 153. Any persistent displays of avoidant, hostile or resistant behaviour should be taken very seriously. Research shows that this behaviour can be a factor for fatal child abuse and neglect (Chance & Scannapieco, 2002)14. 154. Although some professionals expressed very clear feelings that neither of the parents was engaging or taking concerns seriously there was little or no discussion about this. The only example of recorded effort to deal with resistance was in the child protection conference in March 2012 when the chair clearly made a concerted effort to confront the lack of engagement with the concerns. However this was not followed up and chairing transferred to another chair for the child protection conference in relation to the unborn B1. 155. A key finding from a review of evidence on what works in protecting children living with highly resistant families was the need for authoritative child protection practice. Families’ lack of engagement or hostility hampered practitioners’ decision-making capabilities and follow-through with assessments and plans ... practitioners became overly optimistic, focusing too much on small improvements made by families rather than keeping families’ full histories in mind15. Issues for the MSCB to consider in regard to learning and improvement 1. Is the MSCB satisfied that there is sufficient understanding about domestic abuse and the dangers of professionals adopting inappropriate strategies such as conciliation or mediation in their intervention? 4.2 Family and professional contact and interaction The dangerous combination of busy and overloaded professionals combining with the manipulative and obstructive behaviour of adults resistant to services and professional contact; contact and interaction as the exercising of parental control over children and 14 Chance, T., & Scannapieco, M. 2002. Ecological Correlates of Child Maltreatment: Similarities and Differences Between Child Fatality and Nonfatality Cases. Child and Adolescent Social Work Journal. 15 Effective practice to protect children living in highly resistant families. London: Centre for Excellence and Outcomes in Children and Young People’s Services. C4EO (2010) Page 28 of 44 Child B1 SCR Final Report published 110216 challenging of professional authority; understanding manipulative and obstructive behaviour and having strategies in place to respond. 156. A consistent concern for mother was her fear that children’s social care services would remove the children from her care. This was a dominant factor in her interaction with all of the services. This was a reason for not wanting to participate in the police DASH risk assessments or to make any statements in relation to domestic abuse. It was a significant factor in her efforts to minimise or silence information and reports about domestic abuse and substance abuse. The older siblings were clearly encouraged not to give any information to the staff at the school and mother controlled and influenced all of the professional contact with the children. 157. Some of the professionals had a very clear insight and perspective about the nature of the parents’ interaction with professionals and that it was about control of information and managing the response of professionals. This involved a repertoire of different tactics and behaviour that have been described in earlier sections of the report. Some professionals felt that mother wanted to retain the contact with services for as long as she was able to extract the benefit that she wanted in regard to material support and assistance but this would always be on her terms. There was never any discussion between professionals about the interaction or motivation of the parents. 158. All of the people in contact with the family were managing complex and in some cases excessive workloads. Managers were also dealing with a large workload as well as having the additional challenges of working though a reconfiguration of services. In these circumstances there was little capacity for reflection. 159. Key roles such as the social worker were subject to changes and reallocation. Many of the professionals had no long term contact and involvement with the family and crucially those who did have long term involvement such as the head teacher were excluded from the child protection conference in regard to B1. 160. The combination of key professionals changing and the absence of any discussion between professionals meant that the effectiveness of meetings and discussion with the parents was not as effective as it could have been. The use of working agreements made little demand on the parents and were ignored when inconvenient for the parents; this included the use of alcohol and the requirement for father to not stay in the household for example. 161. There are a variety of reasons for families wanting to avoid a service, poorly engaging with a service, disengaging over time, or refusing a service. Families may also have different responses to different services or change over time in their response to services. Service fatigue is not uncommon, particularly in families with complex needs and the long term involvement of several different agencies or professionals. Page 29 of 44 Child B1 SCR Final Report published 110216 162. Families who display evasive or resistant behaviour can be challenging to work with. Examples of such behaviour include: a) avoiding home visits (often cancelling at the last minute) or not appearing to be home (curtains drawn and not responding to telephone calls or knocks on the door); b) children failing to attend school or child care (which was not a significant factor for school attendance although mother did not use any other out of school provision); c) parents not attending appointments, in particular prearranged meetings that involve the assessment of themselves or the children or are in denial about issues such as use of alcohol and domestic abuse; d) repeated excuses why the worker cannot see the child or young person, for example “they are at their grandparents” or are “sleeping” or as in this case downright refusal at times. 163. Any persistent displays of avoidant, hostile or resistant behaviour should be taken very seriously because of the association with fatal child abuse and neglect. 164. Non-compliance and disguised compliance by parents were common features in cases reviewed by Ofsted in their national report on professional responses to neglect16. The report found that although some multi-agency groups adopted clear strategies to manage such behaviour, this was not evident in all cases. Where parents were not engaging with plans, and outcomes for children were not improving, professionals did not consistently challenge parents. This was reflected in this case. Issues for the MSCB to consider in regard to learning and improvement 2. Is the MSCB satisfied that there is sufficient understanding and professional capacity in developing a sufficiently assertive and informed response to resistant families where there are concerns about the development or safety of children? 4.3 Responses to information and incidents Delays in the follow up to incidents through a multi agency and co-ordinated response; recognition of indicators and evidence of neglect such as dental cavities in young children; ensuring that the serving of the DVPN lead to follow up by other services and require the presence and direct engagement of the perpetrator; the reliance in the booking of pregnancies on the mother providing relevant health and social history; understanding the significance of low birth weight and the combination with other risk factors. 16 In the child’s time: professional responses to neglect; Ofsted; March 2014 Page 30 of 44 Child B1 SCR Final Report published 110216 165. Delay in referrals and passing of information between services has an impact on subsequent enquiry, assessment and intervention especially when responding to resistant families. This occurred for example between the police and children’s social care services. There were also delays in responding to the request from the police to convene a strategy meeting and follow up information. The head teacher saw facial bruising on mother’s face and reported this to children’s social care services in anticipation that enquiries and assessment would follow. This did not happen for several weeks by which time the opportunity for more focussed enquiry and intervention had passed. 166. The identification of neglect is seen increasingly to be important in work with vulnerable children. In a study completed in 201217 health visitors indicated that dental neglect is rarely an isolated issue that leads on its own to child protection referral however poor dental health in children is a marker of broader neglect. 167. Abused and neglected children have been found to have higher levels of tooth decay than the general population (Valencia-Rojas et al. 200818) therefore when primary health care workers such as health visitors are aware of the presence of dental neglect it should alert them to the potential for broader neglect and subsequent child protection and particularly in families that are resistant to professional advice and factors such as domestic abuse and substance misuse are factors. 168. In this case there was evidence of potential neglect in relation to the dental cavities that resulted in one of the children having nine teeth extracted. The fact that this appeared to have been allowed to be minimised is concerning. 169. A local survey has emphasised that dentists are well placed to notice signs of child abuse and neglect, yet research shows that UK dentists are unprepared for a role in protecting children at risk and there is under reporting of concerns19. 170. B1 had a birth weight of 2.19kgs. Low birth weight babies of 2.5kgs or less are subject of particular post natal observation and support. The local guidance in respect of SIDS identifies the cluster of factors that can increase the risk of death in an infant and there is a particular focus on safe sleeping practice for example. Although these risk factors are well understood in the health community it is not apparent that other key professionals including social workers have sufficient knowledge and understanding. Curiously, given the assertiveness from a health professional, this did not form part of an explicit discussion of the discharge planning 17 Health Visitors’ Role in Assessing Oral Health in Children: Investigating Dental Neglect Thresholds. Bradbury-Jones. C., Taylor, J., Innes. N., Evans, D. & Ballantyne, F. August 2012 18 Prevalence of early childhood caries in a population of children with history of maltreatment. Journal of Public Health Dentistry, 68(2), 94-101. Valencia-Rojas, N., Lawrence, H.P., Goodman, D. (2008) 19 Safeguarding children in dentistry: Do paediatric dentists neglect child dental neglect? J.C. Harris, C. Elcock, P. D. Sidebotham & R. R. Welbury British Dental Journal 2009:206, 465 - 470 (2009) Page 31 of 44 Child B1 SCR Final Report published 110216 meeting following the birth of B1 and was not part of any of the working agreements or plans. Issues for the MSCB to consider in regard to learning and improvement 3. How can the MSCB promote more co-ordinated and effective response to managing the behaviour and risk from perpetrators of domestic abuse in households with children when using measures such as the domestic violence prevention notices and orders? 4. Are the arrangements for pre birth assessment of risk to unborn children appropriate and fit for purpose? 4.4 Tools to support professional judgment and decision making The limited use of tools or frameworks to assess to identify the extent of domestic abuse and coercion, of neglect, risk or substance misuse; the compilation of assessments rely heavily on repeated narrative and incomplete information about history or the perspectives of all relevant professionals; the procedures for using measures to prevent repeat domestic abuse are complex and bureaucratic. 171. Indicators of neglect are many and varied and each on their own are unlikely to provide definitive evidence and is why it is important for professionals to have recognisable frameworks within which to collate and analyse the significance of information and observation. 172. Neglect can be indicated by the physical appearance of a child other than the dental cavities. By all accounts there was nothing to indicate concern about either of the children. This may have been a reason for neglect being missed; unless the child looks neglected will they be regarded as neglected? 173. There may be indicators in the child’s behaviour. There was nothing observed in the behaviour of these children to cause concern although the behaviour of the parents was a source of concern. Substance abuse is a significant factor in parents neglecting the emotional and physical needs of their children. It would have been advisable to have considered using tools such as the attachment style interview and graded care profiling that would have helped provide a more informed view about mother’s parenting capacity, motivation and insight regarding her children’s needs20. 174. The team manager referred to the availability of local resources such as the Bruce Thornton Risk Assessment Model and recent work on improvements to risk assessment. 20 There are other tools and frameworks that are available to professionals and some such as the attachment style interview require specific training. Page 32 of 44 Child B1 SCR Final Report published 110216 175. The third group of indicators in regard to neglect is the behaviour of adults. It is this third category of indicators that have greatest relevance in this case. It was the behaviour of both parents and their inability to understand how it had an impact on the emotional well being of the children that was recognised as far as agreeing to make the children subject of a child protection plan on two different occasions although lost both momentum and focus in regard to subsequent plans and work. 176. The quality of the assessments in this case was poor. There was a summary of concerns but there was insufficient exploration of history, attitude and motivation and no inclusion of detail from the older siblings regarding their wishes and feelings; this was in part due to the severe limits that mother put on any professionals having contact with the children on their own. There was no use of recognisable frameworks or tools to help collate and analyse information although children’s social care services have invested in some. 177. The assessments did not seek and therefore include information from other professionals some of whom had a long history of contact with the children and an insight about the circumstances of the children and the attitude of the parents. 178. The team manager had recognised at the time that the pre-birth assessment was inadequate but had felt unable to stop it going forward because of the consequences for delaying the pre-birth child protection conference and planning. The team manager was dealing with a backlog of other assessments and work at the time. 179. Priority has been given in children’s services to achieving improved quality in statutory assessments of children since the unannounced statutory inspection of contact, referral and assessment services in August 2011 that found that some assessments had lacked ‘rigour and offer insufficient analysis, resulting in a lack of clarity of children’s needs and vulnerabilities on which to base the provision of services’. This had been an area for development at the previous inspection and was also reflected in this case. 180. Some caseloads were also found to be high and this was leading in certain instances to delays in information being recorded on the electronic recording system. Some staff reported during the inspection as well as during conversations for this review of working excessive hours in order to meet the deadlines required to safeguard children. Additional posts have been created to address this issue. 181. Police and partners in Manchester had welcomed the use of the domestic violence prevention notices and orders although the recent HMIC inspection had found their use was inconsistent across the force and found that some staff described the application process as being complex and bureaucratic. A full evaluation of both pilot schemes has been undertaken by the Home Office that reported some concern from officers that the system was too complex for many officers to use without further training and that the bureaucracy associated with DVPOs was still an issue. The Page 33 of 44 Child B1 SCR Final Report published 110216 evaluation as well as inspections by HMIC emphasise the importance of the procedures being used in conjunction with other support services.21 Issues for the MSCB to consider in regard to learning and improvement 5. Does the MSCB have sufficient information about the availability and use of appropriate risk assessment tools and frameworks to support professional judgement and decision making with troubled families and vulnerable children? 6. Does the MSCB have sufficient information about the quality and outcome of assessments for vulnerable children and new born babies where there are concerns about parental behaviour and lifestyle? 4.5 Management and agency to agency systems Excessive workload and reconfiguring of services has an impact on the capacity of individual professionals; the system of duty allocation of chairs for child protection conferences disrupts independent continuity and oversight; screening and identifying higher risk pregnancies. 182. This review has highlighted the extent to which the performance and decision making of professionals is adversely affected by the functioning of other systems and organisational arrangements around them. 183. At the time of the review there were just over 900 children subject of a child protection plan. Manchester has a high rate of children who require protection; almost double the average for England and much higher than the rate for the north west of England22. 184. The government have acknowledged that there is a high turnover of social workers in the UK, a short working life (estimated as an average of just eight years in the UK), and perhaps in consequence a shortage of experienced social workers in England, which can result in newly qualified social workers dealing with complex cases too early in their career. A survey of local authorities in 2011 estimated a 9.1 per cent turnover rate for social workers in children’s services (equivalent to 1 in 11 workers leaving per year). The vacancy rate for children’s services social workers nationally was 6.1 per cent23. In this case there were three different social workers allocated to the case over a six month period between March and September 2012. 21 Evaluation of the Pilot of Domestic Violence Protection Orders Research Report 76 London Metropolitan University & Middlesex University: Liz Kelly, Joanna R. Adler, Miranda A. H. Horvath, Jo Lovett, Mark Coulson, David Kernohan and Mark Gray; November 2013; Home Office 22 80.6 children per 10,000 compared to an England average of 46.2 and a regional average of 53.1 in 2012/2013. (Characteristics of Children in Need 2012 to 2013 February 2014; DfE) 23 Child protection, social work reform and intervention: research priorities and questions; March 2014; DfE. Page 34 of 44 Child B1 SCR Final Report published 110216 185. The workload in other specialist units was also a factor in this case. For example the specialist police officers in the public protection investigation unit had implications for the speed and effectiveness of some risk assessment and communication in this case. The public protection investigation unit deal with child protection, vulnerable adults and domestic abuse. A large proportion of the work is child protection. There are three work streams, each work stream managed by a detective sergeant and are overseen by one inspector. Each team has approximately 22/23 constables. The volume of work becomes a particular problem if a team does not have a sergeant in post and have to cover the vacancy. One sergeant moved in December 2012 and the post was vacant without any back fill until July 2013. 186. There are a high number of incidents that have to be prioritised and risk assessed by officers on a daily basis. A log is created and the cases are ‘triaged’ each day; it is not always possible to triage an incident on the day or the following day, and it can take some time for some incidents to be triaged. The timescale for reviewing cases within public protection investigation unit varies, every morning there is a domestic abuse governance meeting noting the DA from the previous day. Incidents go in a queue which can be quite high (approximately 100 standard risk and 40 medium risk). 187. High workloads can also contribute to early departures from child protection work. The impact of these factors on practice and difficulties with retention is a concern in a number of developed countries, including Sweden, the USA and Australia. Research in this area indicated that interventions addressing organisational and administrative factors (rather than individual employee factors) produced stronger effects in preventing undesirable turnover. 188. The allocation of a chair to an initial child protection conference need to take sufficient account of previous contact or knowledge about a family. In this case, the initial child protection conference was allocated to another chair in order to meet timescales and a clash with previously scheduled commitments of the chair for the older siblings. In a case that had so much history and complexity, the allocation of B1 to a different chair was a significant loss of continuity. 189. National revisions to the midwifery self booking arrangements mean that pregnant women can go to midwifery services direct without reference to GP practices. The initial booking includes routine inquiries about social and other history from the parent(s) which inevitably relies heavily on the accuracy of the self reporting. In this case mother did not disclose any involvement from children’s social care services, did not disclose the history of domestic abuse or the history of significant alcohol use. Issues for the MSCB to consider in regard to learning and improvement 7. Does the MSCB have enough information about the workload of services working with the most vulnerable children? Page 35 of 44 Child B1 SCR Final Report published 110216 4.6 Issues for national policy 190. The use of DVPN and DVPNs are a welcome addition to the measures available to manage domestic abuse. The use of such measures in situations where children are living in the same household need to take account of the framework of law and guidance for safeguarding children. The evidence from this single case and from national evaluations reinforces the values of ensuring that DVPN and DVPOs are used in conjunction with other services and are underpinned by sufficiently effective interagency planning and intervention. Peter Maddocks MA, CQSW. September 2014 Page 36 of 44 Child B1 SCR Final Report published 110216 APPENDIX A: Multi agency action plan The finding identified by the serious case review Do MSCB accept the finding? If MSCB accepts the finding how will it be taken forward? Who is best placed to take this forward and in what timescale? Timescale for responding to the finding and how will it be reported? 1. Understanding domestic abuse as coercion and control rather than anger management; identifying and responding to parents not engaging with professional’s concerns about child welfare and safety; the influence of parental fear of statutory intervention and keeping possession of their children. Issues for MSCB to consider: 1.1 Is MSCB satisfied that there is sufficient understanding about domestic abuse and the dangers of professionals adopting inappropriate strategies such as conciliation or mediation in their intervention? Yes 1.1 MSCB is not satisfied that there is sufficient understanding about domestic abuse and the dangers of professionals adopting inappropriate strategies such as conciliation or mediation in their intervention and will take this forward by establishing links with the Community Safety Partnership (CSP) in relation to the ‘Delivering Differently’ approach to domestic abuse. 1.1.1 A letter in the name of the MSCB Independent Chair will be sent to the Chair of CSP requesting assurances that the new approach takes account of the learning from this review and will strengthen arrangements to safeguard children. 1.1.2 The Safeguarding Children Practice Develop Group (currently known as SPIG) will monitor the new arrangements ensuring that the safeguarding of children is strengthened. 1.1.1. Letter to CSP Chair. MSCB Business Unit by end of September 2014. (Business Manager AMC) 1.1.2 Safeguarding Children Practice Development Group monitoring by end of January 2015.(Chair tbc) 1.1 By the end of January 2015 via a report from the relevant group to MSCB. Page 37 of 44 Child B1 SCR Final Report published 110216 The finding identified by the serious case review Do MSCB accept the finding? If MSCB accepts the finding how will it be taken forward? Who is best placed to take this forward and in what timescale? Timescale for responding to the finding and how will it be reported? 2. The dangerous combination of busy and overloaded professionals combining with the manipulative and obstructive behaviour of adults resistant to services and professional contact; contact and interaction as the exercising of parental control over children and challenging of professional authority; understanding manipulative and obstructive behaviour and having strategies in place to respond. Issues for MSCB to consider: 2.1 Is MSCB satisfied that there is sufficient understanding and professional capacity in developing a sufficiently assertive and informed response to resistant families where there are concerns about the development or safety of children? Yes 2.1 MSCB is not satisfied that there is sufficient understanding and professional capacity in developing a sufficiently assertive and informed response to resistant families where there are concerns about the development or safety of children and will take this forward by tasking the Learning and Development Sub-Group (Currently known as the Workforce Development Sub-Group) to challenge agencies about the support given to staff. 2.1 Learning & Development Sub-Group by the end of January 2015. (L&D SG Chair AMc tbc) 2.1 The Sub-Group will report to MSCB no later than the end of February 2015. 3. Delays in the follow up to incidents through a multi agency and co-ordinated response; recognition of indicators and evidence of neglect such as dental cavities; Yes 3.1 MSCB will promote more co-ordinated and effective response to managing the behaviour and risk from perpetrators of domestic abuse in households with children when using measures 3.1 Superintendent South Manchester Division, GMP by the end of December 3.1 Report to MSCB by the end of December 2014. Page 38 of 44 Child B1 SCR Final Report published 110216 The finding identified by the serious case review Do MSCB accept the finding? If MSCB accepts the finding how will it be taken forward? Who is best placed to take this forward and in what timescale? Timescale for responding to the finding and how will it be reported? ensuring that the serving of the DVPN lead to follow up by other services and require the presence and direct engagement of the perpetrator; the reliance in the booking of pregnancies on the mother providing relevant health and social history; understanding the significance of low birth weight and the combination with other risk factors. Issues for MSCB to consider: 3.1 How can the MSCB promote more co-ordinated and effective response to managing the behaviour and risk from perpetrators of domestic abuse in households with children when using measures such as the domestic violence prevention notices and orders? 3.2 Are the arrangements for pre birth assessment of risk to unborn children appropriate and fit for purpose? such as the domestic violence prevention notices (DVPN) and orders by tasking the Superintendent South Manchester Division, GMP to liaise with the Head of the Public Protection Division in order to develop a protocol for the integrated approach to the use of DVPN’s and orders. 3.2 In order to ensure that pre birth assessments of risk to unborn children are appropriate and fit for purpose. MSCB will task Strategic Lead Children’s, children’s social care services to facilitate a review of pre birth assessments to include volume, quality, outcomes and tools used to complete them. 2014.(WC) 3.2 Strategic Lead Children’s, children’s social care services by the end of December 2014. (RP) 3.2 Report to MSCB by the end of December 2014. Page 39 of 44 Child B1 SCR Final Report published 110216 The finding identified by the serious case review Do MSCB accept the finding? If MSCB accepts the finding how will it be taken forward? Who is best placed to take this forward and in what timescale? Timescale for responding to the finding and how will it be reported? 4. The limited use of tools or frameworks to assess to identify the extent of domestic abuse and coercion, of neglect, risk or substance misuse; the compilation of assessments rely heavily on repeated narrative and incomplete information about history or the perspectives of all relevant professionals; the procedures for using measures to prevent repeat domestic abuse are complex and bureaucratic. Issues for MSCB to consider: 4.1 Does the MSCB have sufficient information about the availability and use of appropriate risk assessment tools and frameworks to support professional judgement and decision making with troubled families and vulnerable children? 4.2 Does the MSCB have sufficient information about the quality and outcome of assessments for vulnerable children and new born babies where there are concerns about parental behaviour and lifestyle? Yes 4.1 MSCB does not have sufficient information about the availability and use of appropriate risk assessment tools and frameworks to support professional judgement and decision making with troubled families and vulnerable children. Therefore through the Safeguarding Children Practice Development Sub-Group (currently known as SPIG) will call for evidence from GMP, Health and children’s social care services of risk assessments in place that reflect good practice? 4.2 To ensure that MSCB have sufficient information about the quality and outcome of assessments for vulnerable children and new born babies where there are concerns about parental behaviour and lifestyle. The Quality Assurance and Performance Improvement Group will audit relevant assessments and report back with findings and recommendations. Safeguarding Children Practice Development Sub-Group by the end of February 2015.( Chair tbc) 4.2 Quality Assurance & Performance Improvement Group by the end of March 2015.(SPIG Chair RW) Report to MSCB by the end of February 2015. 4.2 Report to MSCB by the end of March 2015. Page 40 of 44 Child B1 SCR Final Report published 110216 The finding identified by the serious case review Do MSCB accept the finding? If MSCB accepts the finding how will it be taken forward? Who is best placed to take this forward and in what timescale? Timescale for responding to the finding and how will it be reported? 5. Excessive workload and reconfiguring of services has an impact on the capacity of individual professionals; the system of duty allocation of chairs for child protection conferences disrupts independent continuity and oversight; screening and identifying higher risk pregnancies. Issues for MSCB to consider: 5.1 Does the MSCB have enough information about the workload of services working with the most vulnerable children? 5.2 Does the MSCB have sufficient enough information about contract arrangements for termination or withdrawal of services by any provider to resistant families including children subject of a CIN or child protection plan? Yes 5.1 In order to be sighted on the workload of services working with the most vulnerable children the Quality Assurance & Performance Improvement Sub- Group will ensure that the appropriate information is within the Performance Management Framework currently under development and scrutinised by the associated quality assurance framework. 5.2 In order for MSCB to have sufficient information about contract arrangements for termination or withdrawal of services by any provider to resistant families including children subject of a CIN or child protection plan it will require the Safeguarding Children Practice Development Sub-Group (currently known as SPIG) to ask in what circumstances will services be withdrawn in relevant agencies and to seek assurances about what alternative measures will be taken as a result. 5.1 Quality Assurance & Performance Improvement Sub-Group by end of January 2015.(SPIG Chair RW) 5.2 Safeguarding Children Practice Development Sub-Group by end of January 2015. (Chair tbc) 5.1 Report to MSCB by end of January 2015. 5.2 Report to MSCB by end of January 2015. Page 41 of 44 Child B1 SCR Final Report published 110216 APPENDIX B: Procedures and guidance relevant to this serious case review Legislation The Children Act 1989 Section 11 of the Children Act 2004 places a duty on the key people and bodies described in the Act24 to make arrangements to ensure that their functions are discharged with regard to the need to safeguard and promote the welfare of children. The application of this duty varies according to the nature of each agency and its particular functions. The Section 11 duty means that these key people and bodies must make arrangements to ensure that their functions are discharged having regard to the need to safeguard and promote the welfare of children and this includes any services that they contract out to others. Section 17 imposes a duty upon local authorities to safeguard and promote the welfare of children in need. Section 47 requires a local authority to make enquiries they consider necessary to decide whether they need to take action to safeguard a child or promote their welfare when they have reasonable cause to suspect that a child is suffering, or is likely to suffer significant harm. These enquiries should start within 48 hours. The local authority is required to consider whether legal action is required and this includes exercising any powers including those in section 11 of the Crime and Disorder Act 1998 (Child Safety Orders) or when a Baby Has contravened a ban imposed by a Curfew Notice within the meaning of chapter I of Part I of the Crime and Disorder Act 1998. Section 46 provides the Police with Powers of Protection to take children into police protection where a constable has reasonable cause to believe that a child would otherwise be likely to suffer significant harm. The Children Act 2004 Section 10 requires each local authority to make arrangements to promote co-operation between it, each of its relevant partners and such other persons or bodies, working with children in the authority’s area, as the authority consider appropriate. The arrangements are to be 24 Local Authorities, including District Councils, the Police, National Offender Management Service, NHS bodies, Youth Offending Teams, Governors/Directors of Prisons and Young Offenders Institution, Directors of Secure Training Page 42 of 44 Child B1 SCR Final Report published 110216 made with a view to improving the wellbeing of children in the authority’s area – which includes protection from harm or neglect alongside other outcomes. This section is the legislative basis for children’s trusts arrangements. Section 11 of the Children Act 2004 places a duty on the key people and bodies described in the Act25 to make arrangements to ensure that their functions are discharged with regard to the need to safeguard and promote the welfare of children. The application of this duty varies according to the nature of each agency and its particular functions. The Section 11 duty means that these key people and bodies must make arrangements to ensure that their functions are discharged having regard to the need to safeguard and promote the welfare of children and this includes any services that they contract out to others. Safeguarding Procedures The local safeguarding children procedures The procedures provide advice and guidance on the recognition and referral arrangements for children suffering abuse. This includes emotional abuse that involves causing children to feel frightened or in danger. The procedures also cover physical abuse of children. The procedures also describe abuse involving the neglect of children that includes failing to protect children from physical harm or danger or the failure to ensure access to appropriate medical care or treatment. This includes describing distinct action to be taken when professionals have concerns about a child, arrangements for making a referral, and the action to be taken. The procedures cover arrangements for the ACPC (now superseded by LSCB) to ensure there are effective arrangements that promote good interagency working and sharing of information and training. The procedures describe specific responsibilities for all agencies contributing to this serious case review. Other local procedures relevant to this serious case review National guidance Working Together to Safeguard Children (2010) and (2013) The national guidance to interagency working to protect children is set out in Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. The guidance includes safeguarding and promoting the welfare of children who 25 Local Authorities, including District Councils, the Police, National Offender Management Service, NHS bodies, Youth Offending Teams, Governors/Directors of Prisons and Young Offenders Institution, Directors of Secure Training Centres. Page 43 of 44 Child B1 SCR Final Report published 110216 may be particularly vulnerable. This guidance was extensively revised and republished in March 2013. The revised guidance placed greater responsibility on local areas to develop their own frameworks and standards. It abolished the national framework for assessment and instead no required local areas to have in place their own assessment arrangements. Framework for the Assessment of Children in Need and their Families 2001 The guidance in respect of the Framework for the Assessment of Children in Need and their Families was issued under section 7 of the Local Authority Social Services Act 1970 and was therefore mandatory until it was abolished with the publication of Working Together in 2013. . The framework set out the framework for ensuring a timely response and effective provision of services to children in need. It makes clear the importance of achieving improved outcomes for children through effective collaboration between practitioners and agencies. The framework set out clear timescales for key activities. This included making decisions on referrals within one working day, completing initial assessments within seven working days and core assessments within 35 working days. As part of an initial assessment children should have been seen and spoken with to ensure their feelings and wishes contributed to understanding about how they were affected. If concerns regarding significant harm were identified they had to be the subject of a strategy discussion to co-ordinate information and plan enquiries. Child protection procedures had to be followed. Assessments should be centred on the child, be rooted in child development that requires children being assessed within the context of their environment and surroundings. It should be a continuing process and not a single or administrative event or task. They should involve other relevant professionals. The outcome of the assessment should have been a clear analysis of the needs of the child and their parents or carers capacity to meet their needs and keep them safe. The assessment should identify whether intervention was required to secure the well – being of the child. Such intervention should have been described in clear plans that included the services being provided, the people responsible for specific action and describe a process for review. Common Assessment Framework (CAF) The CAF is a key part of delivering direct services to children that are integrated and focused around the needs of children and young people. The CAF is a standardised approach to conducting assessments of children’s additional needs and deciding how these should be met. It can be used by practitioners across children's services in England. The CAF remains in place. Page 44 of 44 Child B1 SCR Final Report published 110216 The CAF promotes more effective, earlier identification of additional needs, particularly in universal services. It aims to provide a simple process for a holistic assessment of children's needs and strengths; taking account of the roles of parents, carers and environmental factors on their development. Practitioners are then better placed to agree with children and families about appropriate modes of support. The CAF also aims to improve integrated working by promoting coordinated service provisions. All areas were expected to implement the CAF, along with the lead professional role and information sharing, between April 2006 and March 2008. Local guidance Safe sleeping for infants 2009 This is guidance published by the Obstetric Clinical Effectiveness Group and Division of Medicine and Community Services Clinical Effectiveness Group in Manchester through the Central Manchester University Hospitals NHS Foundation Trust. This guidance outlines the core principles of safe sleeping which are implemented nationally. To ensure a consistent message is given to parents in Manchester this guidance was written following a period of collaborative working between Manchester and Pennine (Bury, Rochdale and Oldham) Trusts. In 2002 Manchester had the highest infant mortality rate in the country. Examination of the SUDI by Manchester’s serious case review panel revealed some recurring features. A significant number of these deaths were associated with risk factors known to increase the risk of SUDI (sudden unexpected death of infants) and now more generally referred to as SID (sudden infant death). There is a plethora of evidence from long term studies of SUDI suggesting that some of the infant deaths associated with bed-sharing, co-sleeping and other risk factors could have been avoided. Parents/carers should be advised never to fall sleep with their baby: • If they or their partner smoke or smoked in the ante natal period, even if they never smoke in bed or at home. • If they or their partner have been drinking alcohol. • If they or their partner take medication or drugs (prescribed or otherwise) which cause drowsiness. • If they or their partner feel very tired. • If their baby was low birth weight (less than 2.5kg). • If their baby was premature (born before 37 weeks). |
NC047777 | Sexual and physical abuse of Child F and her younger brother, Child G, by their stepfather over several years; the family lived in Preston and Wigan. Child F made multiple disclosures to different professionals which were subsequently retracted. Their mother was sexually abused as a child and had consecutive relationships with 4 men who posed a risk to herself and her children; the stepfather was previously implicated in causing serious injuries to a 6-month-old child. Child G had a genetic medical condition which his mother struggled to cope with; Child F visited health professionals several times with head and back injuries and urinary tract infections. Both children were subjects of child protection plans. Following allegations of abuse by Child F in 2013, the stepfather was arrested; the investigation was closed because she was not deemed a credible witness. She was removed from home during the investigation and informally fostered afterwards. Child G had denied previous allegations, but disclosed abuse in February 2014. He and their younger siblings were taken into care. Key findings include: limited understanding of how and why victims of abuse disclose and withdraw allegations; the mother's parenting capacity was not formally assessed and no long term support plan was put in place; the voices of Child F and Child G were ignored or disbelieved on some occasions. Uses elements of the Social Care Institute for Excellence (SCIE) systems model to make recommendations, including: family history and genealogy should be used to identify and assess patterns of risk; the police should review evidence gathering practices in cases where a child has alleged abuse.
| Title: Child F and Child G: serious case review. LSCB: Wigan Safeguarding Children Board Author: Clare Hyde Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Child F and Child G SERIOUS CASE REVIEW AUTHOR: CLARE HYDE DATE: WEDNESDAY 10TH AUGUST 2016 COMMISSIONED BY: WIGAN SAFEGUARDING CHILDREN BOARD 1 Contents INTRODUCTION ....................................................................................................................................... 3 METHODOLOGY ...................................................................................................................................... 4 Independence ......................................................................................................................................... 7 Serious Case Review Panel ...................................................................................................................... 7 Confidentiality ......................................................................................................................................... 8 Family involvement ................................................................................................................................. 9 Staff involvement .................................................................................................................................... 9 Dissemination of learning ....................................................................................................................... 9 Race, Religion, Language and Culture ..................................................................................................... 9 BACKGROUND INFORMATION .............................................................................................................. 10 Family Background ................................................................................................................................ 10 ANALYSIS AND RECOMMENDATIONS ................................................................................................... 22 Sharing of information appropriately between partner agencies ........................................................ 23 The partnerships collective understanding of how and why victims of abuse disclose and withdraw allegations. ............................................................................................................................................ 26 Partnership planning around the Acquiring Best Evidence (ABE) interviews. ...................................... 29 The quality of partnership working and decision making at Strategy Meetings and Section 47 Enquiries ............................................................................................................................................... 30 The sharing / obtaining of historical information to inform current practice and service provision. .. 33 The process of transfer from another local authority and the appropriate reviewing of current protection plans. ................................................................................................................................... 34 Summary ............................................................................................................................................... 36 Recommendations ................................................................................................................................ 39 Multi Agency Recommendations .......................................................................................................... 39 Single Agency Recommendations ......................................................................................................... 40 Greater Manchester Police ................................................................................................................... 40 Children’s Social Care ............................................................................................................................ 41 Education .............................................................................................................................................. 41 Conclusion ............................................................................................................................................. 41 What has changed since this Serious Case Review began? .................................................................. 42 References ............................................................................................................................................ 43 2 3 INTRODUCTION 1.1 This Serious Case Review was conducted under the statutory guidance of Working Together to Safeguard Children 2015 which states (page 79) that a serious case review should take place “for every case where abuse or neglect is known or suspected and…a child is seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child”. 1.2 In this case Child F (who is now aged 18) told different professionals that she had been subject to many years of sexual and physical abuse by her stepfather (FS123). The first time that Child F told professionals that she was being physically abused by FS123 was in June 2004 when she was 6 years old. Child F retracted this allegation. 1.3 Child F made 2 further allegations of physical abuse against FS123 both of which she retracted. 1.4 In August 2011 Child F made an allegation of sexual abuse against FS123 which she retracted. 1.5 Child F made 2 further allegations of sexual abuse the third taking place in July 2013. 1.6 Child F lived with her mother MCFG, her stepfather FS123, her brother Child G and her half siblings S1, S2 and S3. 1.7 Following the allegation in July 2013 FS123 was removed from the family home whilst investigations were undertaken. 1.8 FS123 returned to the family home after five months. Child F remained in the informal foster care of a neighbour. 1.9 Two months after FS123 returned to the family home Child G who was then aged 14, told the police and social services that he had also been the victim of sexual and physical abuse perpetrated by FS123 (although during the investigation into Child F’s allegation he had denied this). 4 1.10 Child G described how the abuse continued after FS123 was allowed back into the home. 1.11 At this point steps were taken to protect Child G and the three younger children at home by placing them in foster care and starting care proceedings. 1.12 A brief summary of Child F and G’s family history: MCFG was 20 when Child F was born and 21 when Child G was born. The family lived in Preston, Lancashire. MCFG and FCF&G separated in April 1998, reunited in October 1998 and finally separated in November 1998. MCFG was a victim of domestic abuse in this relationship and one or both adults used drugs and alcohol. In April 1999 a Health Visitor queried MCFG’s learning abilities and carried out enquiries with MCFG’s former school and made a referral to the learning disability service. A paediatrician caring for Child G also made a comment that questioned MCFG’s cognitive ability. It was noted in June 1999 that MCFG had an eating disorder the behaviour of which was possibly being mimicked by Child F who was then aged 21 months. In January 2000 MCFG began a relationship with man who had several aliases, mental health issues and a personality disorder. This relationship ended Feb 2000. In February 2001 MCFG met and a married another man. He was on Police bail due to allegations of rape. This relationship broke down within 1 month of getting married. MCFG met FS123 in 2002 and moved to live with him in Wigan in March 2003. FS123 had previously been implicated (with other adults) in causing serious injuries to a 6 month old baby. FS123 and MCFG had 3 children together (in 2004, 2008 and 2013) METHODOLOGY 2.1 The government has indicated that it supports changes recommended by Professor Eileen Munro that serious case reviews should be conducted using systems based learning methodology and it was agreed that important learning could be gained by conducting a ‘whole system’ serious case review in order to conceptualise how services routinely operate and to identify what is working well or where there are problematic areas. 5 2.2 The WSCB Case Review Sub Group recognised that the review would need to be as robust and transparent as possible and should be identify the extent to which it would make a difference and improve Wigan’s multi-agency safeguarding response. 2.3 Consequently, the WSCB Serious Case Consideration Panel made a recommendation that WSCB should conduct a robust, transparent and participative serious case review with the emphasis upon professional involvement to address how agencies had worked together in this case, identify any learning, aggregate lessons from individual organisations and ensure that an improvement action plan was put in place. 2.4 The Serious Case Review was designed and led by Clare Hyde MBE, independent reviewer, from The Foundation for Families (a not for profit Community Interest Company). Ms. Hyde developed a review model that would enable participants to consider the events and circumstances, which led up to the point at which Child G made allegations against FS123. 2.5 The analysis in this report uses some elements of the framework developed by Social Care Institute for Excellence (SCIE) to present key learning within the context of local systems. This also takes account of recent work that suggests that an approach of developing over prescriptive recommendations have limited impact and value in complex work such as safeguarding children. For example, a 2011 study of recommendations arising from serious case reviews 2009 -2010, (Brandon, M et al), calls for a limiting of ‘self-perpetuating and proliferation’ of recommendations. Current thinking about how the learning from serious case reviews can be most effectively achieved is encouraging a lighter touch on making recommendations for implementation rather than over complex action plans. 2.6 A Serious Case Review Panel was convened and was made up of senior and specialist representatives from agencies involved with the family in the time covered, to oversee the conduct and outcomes of the review. All panel members were independent of the family and casework. The role of the panel was to assist the lead reviewer in considering the evidence, formulating the recommendations and quality assuring this report. 2.7 Agencies involved with Child F and Child G were asked to provide a chronology and these were integrated into a combined chronology by the Wigan Safeguarding Children Board Business Support Team. The following agencies provided a chronology: Child F and Child G’s High School Bridgewater NHS 6 Gateway GMP Lancashire Council NHS WBCCG Social Care W&L Homes Westfield Children's Centre WWL NHS 2.8 The author of this report considered the integrated chronology and designed and facilitated a learning event with the group of multi-agency professionals involved with Child F and Child G and their family to consider in detail the chronology of events and key practice episodes that underpinned those events. 2.9 It was agreed that the period of time covered by the SCR would be 18th September 1997 to 27th February 2014. The review considered intervention up to July 2013 there is no information regarding the action taken in 2014, subsequent care proceedings and planning which was implemented for the Child F and Child G (and their siblings) including the care plans developed to meet their needs. 2.10 The WSCB Case Review Group suggested terms of reference that provided the key lines of enquiry for the SCR in addition to the terms of reference described in national guidance. The key lines of enquiry included in the terms of reference were: A. Sharing of information appropriately between partner agencies with particular reference to how the Police shared information with Social Care B. The collective understanding of frontline practitioners of how and why victims of abuse disclose and withdraw allegations. C. Partnership planning around Acquiring Best Evidence (ABE) interviews. D. The quality of partnership working and decision making at strategy meetings. E. The sharing / obtaining of historical information to inform current practice and service provision. F. The process of transfer from another local authority and the appropriate reviewing of current protection plans. 2.11 The SCR aimed to provide an ‘whole system’ approach involving key front line practitioners (and their line managers) who worked with Child F and Child G and the adults of Child F and Child G’s family in a learning event. In this way, Child F and Child G’s ‘story’ was to be central to the Learning event. 7 Independence 2.12 The lead reviewer was Clare Hyde MBE. Ms Hyde is founder and Director of The Foundation for Families, a not for profit community interest company established in 2010. Ms Hyde was CEO of Calderdale Women Centre for 14 years (between 1994 and 2009) and developed nationally acclaimed, high quality services and support for at risk women and families. Ms Hyde was a member of Baroness Corston’s review team which was commissioned by the Government following the deaths of several women in custody. 2.13 Ms Hyde is currently working with local safeguarding children boards and their partners to improve safeguarding outcomes for children and young people living with domestic violence, substance misuse and parental mental illness and to support the development of a multi -agency response to children and young people at risk of sexual exploitation. 2.14 Ms Hyde also designed and facilitated the multi -agency learning review of child sexual exploitation in Rochdale in 2012. Ms Hyde is currently the Independent Chair / Lead Reviewer of several Serious Case Reviews and a Domestic Homicide Review and has designed and led several Learning Reviews on behalf of local safeguarding children and adults boards. Serious Case Review Panel 2.15 The Serious Case Review panel met on 4 occasions between October 2015 and July 2016. The overview report was ratified at the Wigan Safeguarding Children Board meeting on 18th July 2016. 2.16 The panel comprised of: Service Manager Safeguarding and Partnerships Wigan Safeguarding Children Board (WSCB) Business Manager Wigan Safeguarding Children Board (WSCB) Assistant Director Children and Families Wigan Council Social Care Enhanced Service Manager Targeted Services Wigan Council Social Care Principle Manager Targeted Services 8 Wigan Council Social Care Enhanced Service Manager Integrated Services Gateway Service Team Leader Borough Wide Vulnerable Team Gateway Service Senior Practitioner Referral Team Gateway Service Safeguarding Lead for Children, Young People, and Vulnerable Adult, Tenancy Service Wigan and Leigh Homes (WALH) Children’s Centre Co-ordinator Sure Start Children’s Centre Detective Inspector Greater Manchester Police Assistant Director Safeguarding Children/Designated Nurse Safeguarding Children & Looked After Children NHS Wigan Borough Clinical Commissioning Group (WBCCG) Named Nurse for Safeguarding Children Bridgewater Community Healthcare NHS Foundation Trust Specialist Nurse for Safeguarding Children Bridgewater Community Healthcare NHS Foundation Trust Named Nurse for Safeguarding Children Wrightington, Wigan, and Leigh Hospitals Foundation Trust WWL Named Midwife for Safeguarding Children Wrightington, Wigan, and Leigh Hospitals Foundation Trust WWL Assistant Principal and Designated Person for Child Protection High School Confidentiality 2.17 Working Together to Safeguard Children 2015 clearly sets out a requirement for the publication in full of the overview report from Serious Case Reviews: “All reviews of cases meeting the SCR criteria should result in a report which is published and readily accessible on the LSCB’s website for a minimum of 12 months. Thereafter the report should be made available on request. This is important to support national sharing of lessons learnt and 9 good practice in writing and publishing SCRs. From the very start of the SCR the fact that the report will be published should be taken into consideration. SCR reports should be written in such a way that publication will not be likely to harm the welfare of any children or vulnerable adults involved in the case.”1 Family involvement 2.18 The family were made aware that a Serious Case Review was taking place and Child F and Child G were invited to meet with the Lead Reviewer. 2.19 The Lead Reviewer met with Child G and Child G’s Social Worker on 11th May 2016 and with Child F on 30th June 2016. The SCR Panel Member from Greater Manchester Police joined this meeting for a period of time (at Child F’s request) as Child F wished to ask questions about the criminal proceedings. Staff involvement 2.20 The staff who were involved with Child F and Child G and their family participated in a whole day Learning Event in order to: Clarify the information contained in the combined chronology and to allow the lead reviewer to find out about Child F and Child G’s history and to develop hypotheses. Consider the terms of reference and other key lines of enquiry and consider possible lessons. Dissemination of learning 2.21 The learning from this review will be disseminated to the WSCB agencies via board and board sub group meetings in order to raise awareness and improve professional practice. 2.22 The WSCB will ensure that the learning from the report influences the planned multi-agency engagement and learning events such as the annual conference and locality briefings. 2.23 Specialist training around such areas as the impact of unresolved childhood trauma on the ability to parent and supporting young people who disclose and retract abuse will be commissioned. Race, Religion, Language and Culture 2.24 Child F and Child G are English White British. Religion is not considered to be a feature of their lives and they are described as working class. 10 BACKGROUND INFORMATION 3.1 What we know about Child F and Child G and their family raises a large number of practice issues, both for individual agencies and for WSCB, particularly in relation to families with complex and/or multiple needs and risk factors. 3.2 The review attempted to identify how agencies and individual practitioners responded to the needs of Child F and Child G and their family between 18th September 1997 and 27th February 2014. 3.3 In order to do this agencies carried out reviews of their records and materials including: Electronic records Paper records and files Patient or family held records 3.4 The time frame of the review covers a period of time when the family lived in both Preston and Wigan and agencies from both areas held historical information about the family which was highly relevant to the assessment of risk and need in this case. Family Background 3.5 Child F was born in September 1997. 3.6 MCFG was 20 years old when Child F was born. 3.7 In October 1997 MCFG and their father (FCFG) asked that Child F was removed from their care. Child F was one month old at the time. It is unclear from the records available to this review what the reasons were for this e.g. was this a one off incident of a young mother and father not coping with a new-born baby. 3.8 Child F remained with her parents however and Child G was born 12 months later. 3.9 MCFG was then aged 21 and had two children aged under 13 months. 3.10 In 1997 a Health Visitor shared concerns with Preston Social Services (the family lived in Preston at the time) regarding many extended family members being sexually abused or abusers. 11 3.11 Also in 1997 MCFG accused their father (FCFG) of sexually molesting other children. 3.12 One or both MCFG and FCFG were reported to be using drugs and alcohol. MCFG was a victim of domestic abuse in this relationship. (The couple separated in April 1998 reuniting in October 1998 and separating again in November 1998). 3.13 In 1997 MCFG disclosed that she had been sexually abused as a child and raped as an adult. It is not clear from the records available to this review what happened as a result of this disclosure. 3.14 MCFG took an overdose in 1997 which she survived. 3.15 As early as 1997 Child F and Child G’s maternal grandmother (MGCFG) raised concerns with professionals that MCFG could not look after the children properly. 3.16 This concern focused in particular on the management of Child G’s serious medical condition (PKU)* which required regular monitoring by health professionals and also that a very strict diet was followed. (*Phenylketonuria (PKU) is a rare genetic condition that is present from birth). 3.17 MCFG missed a number of medical appointments in relation to Child G’s condition and this led to concerns being raised by health professionals and MGCFG. 3.18 In 2000 a Health Visitor in Preston tried to establish if MCFG had learning difficulties by liaising with MCFG’s previous High School Head Teacher. The Health Visitor and was informed that MCF&G did not have a “special needs” file but it was considered that she was under achieving and was reported to be “prone to fantasy”. The Health Visitor made a referral to the Learning Disabilities service for an assessment, but was informed that the referral was not appropriate as it did not meet with their referral criteria. (MCFG’s cognitive abilities were queried on subsequent occasions but it does not appear that she has undertaken an assessment) 3.19 There were a significant number of visits to A & E with Child F (7 visits between the age of 10 months and 4 years) for head and back injuries. On one occasion the account of how Child F had sustained her injuries was inconsistent. 3.20 During one visit to A & E (in 1999) concerns were again raised by MGCFG about MCFG’s ability to care for the children. 3.21 In January 2000 MCFG began a new relationship with a man who had several aliases, mental health issues and a personality disorder. He was being managed by the Probation Service at that time. Child F and Child G were then aged 2 and 1. This relationship ended in February 2000 12 3.22 Also in January 2000 MCFG took Child F for a health appointment and reported that she had dark and offensive smelling urine. The health practitioner advised MCFG to collect a urine sample so that it could be tested for infection. It appears from the records available to this review that MCFG did not take a urine sample to be tested. 3.23 During this period of time MCFG and the children moved several times. 3.24 On 15th February 2000 an Initial Child Protection Case Conference took place and Child F and Child G became subject of a Child Protection Plan under the category of neglect. 3.25 In March 2000 MGCFG reported to a Health Visitor that Child F had simulated the movement and sounds of sexual intercourse. MGCFG reported that she believed Child F had witnessed MCFG’s sexual activity with her partner. 3.26 In February 2001 MCFG met and a married another man. He was on Police bail due to allegations of rape. This relationship broke down within 1 month of getting married. 3.27 At some point in 2001 MCFG met FS123 who lived in Wigan. 3.28 FS123 was implicated (along with other adults) in causing serious injuries to a 6 month old child. 3.29 An Initial child Protection Case Conference took place on 12th February 2002 in Preston. Child G was made subject of a Child Protection Plan under the category of neglect due to concerns about his mother’s management of the PKU. There were no other concerns raised during the CPCC and the focus was placed on the health needs. 3.30 This was Child G’s second period as the subject of a child protection plan. 3.31 Child F was not subject to a child protection plan at this time. 3.32 The family moved to Wigan to live with FS123 in 2003. 3.33 On 20th June 2003 a ‘transfer in child protection’ case conference was held in Wigan. Child G was already subject of a Child Protection Plan in Preston. A Social Worker and Health Visitor from Preston attended the conference. The outcome of transfer in conference was that both Child F and Child G became subjects of a Child Protection Plan under the category of at risk of physical abuse for both children and neglect in respect of Child G. 13 The risk of physical abuse was because of concerns that FS123 had been implicated in the non-accidental injury of a Child. It was agreed that FS123 should not have unsupervised contact with Child F and Child G. 3.34 At that point, Child F was 5 years old and Child G was 4 years old. 3.35 A risk assessment of FS123 was completed in September 2003 and he was assessed as ‘medium to low’ risk to the children and the Child Protection Core Group decided that the restrictions on FS123’s contact with Child F and Child G should end. It was noted at the Core Group meeting that Child F ‘did a lot of caring for Child G’ and a referral to a young carers service was discussed (it is not clear if this referral took place or what other outcome there was). Chid F had just reached 6 years of age at this point. 3.36 On 16th October 2003 a Child Protection Review Conference was held and Child F was deregistered but Child G remained on a Child Protection Plan under the category of neglect due to MCFG’s inability to meet his health needs. 3.37 Sibling 1 (S1) was born in January 2004. 3.38 The minutes of a Core Group meeting held on 15th June 2004 meeting in respect of Child G record that school reported concerns regarding a of physical assault on Child F who had attended school with a bruise and when asked said ‘I fell, my dad didn’t do it’. 3.39 Between June 2004 and October 2010 Child F made 3 allegations that FS123 physically assaulted her. She retracted her allegations on each occasion. 3.40 In July 2005 school staff witnessed a possible assault of Child G by FS123 and reported this to the police. Child G denied that this had been an assault. 3.41 On 9th September 2005 Child F, then aged 8, reported to the School Nurse that her back ached when she went to the toilet to pass urine and it “stung”. The School Nurse advised MCFG to take Child F to see her General Practitioner. It is not clear from the records available to this review if MCFG followed this advice. 3.42 On 22nd November 2005 despite the fact that MCFG was unable to manage Child G’s serious health condition a decision was made to de-register him and end the Child Protection arrangements. It was agreed to manage the case at a 14 ‘Child in Need’ level. The decision to end the CP plan at CPCC review was made on a multi-agency basis with the benefit of an independent chair to provide challenge and scrutiny if required. It was deemed that whilst there were identified needs Child G was no longer considered to be at risk of significant harm. Upon review of the minutes of the CP conference dated November 2005 there is a record of continued concerns specifically regarding health issues however there is no record that any professional challenged the decision for the period of registration to end. 3.43 Between 2005 and 2013 the management of Child G’s PKU remained a serious concern and MCFG repeatedly failed to meet his dietary and other health needs and failed to ensure that he attended medical appointments. 3.44 In summary the period of time between the family moving to Wigan in 2003 and Child F’s first allegation of sexual assault in 2011 was characterised by continuing significant levels of concern about neglect in respect of Child G’s health needs and by a pattern of allegations followed by retractions of physical abuse of the children carried out by FS123. 3.45 One allegation of physical abuse was made by Child F in October 2010. Child F told staff at her school that bruises had been caused by FS123 hitting her. This triggered a safeguarding referral and a social worker visited Child F at school. Child F retracted her allegation but told the social worker that physical chastisement was used by FS123 at times. Child F reported that this was only when she deserved it and that she needed to be hit as it was the only time she would listen. Child F reported that her FS123 lightly tapped her hand or bottom. During the same conversation the social worker noted that Child F ‘discussed home life fondly and raised no concerns’. Child F was aged 13 at this point. The assessment was closed with no further action. 3.46 During this same period MCFG gave birth to S1, S2 and S3 and lost another child at 18/19 weeks gestation in July 2007. 3.47 In summary it is apparent that MCFG had herself experienced significant and traumatic life events and had 4 consecutive relationships with men who each posed a potential risk to herself and her children. In addition, before Child F and Child G made an allegation of sexual abuse, the following issues were known: Persistent neglect of Child G’s health needs. Inability to manage Child G’s strict dietary needs. 15 Concerns raised by MGCFG that MCFG could not look after the children. Child F at the age of 6 was acting as a carer for Child G. Three recorded incidents which could have been indicators of sexual abuse (simulating sex and symptoms of urinary tract infections). Numerous A&E consultations for injuries to Child F; some of which were serious with, on one occasion an inconsistent account of what had happened. Reports by Child F that FS123 hit or injured her which were later retracted however Child F did confirm that FS123 used physical chastisement. Recorded concerns about MCFG and Child F and Child G having or developing eating disorders (MCFG was thought to have anorexic tendencies and Child F was observed with her fingers down her throat at a time when she was also losing weight. Child F was 21 months old at the time). 3.48 On 22nd August 2011 a friend of Child F told a taxi driver that Child F was being sexually abused by FS123. The taxi driver attended Wigan Police Station on the same day to report that a female juvenile passenger had disclosed to him that her friend, Child F, was being sexually abused by her father. The police identified the friend and she was visited and informed the attending officer that Child F had disclosed that FS123 was regularly abusing her. She described how FS123 would get drunk and sexually touch her. He had tried to have sex with her but had never actually done it. She stated that if she told anyone he would ‘take her to a nasty place and he would hang her over the banister by her feet’. 3.49 The police officer spoke with Child F who initially denied saying anything but then admitted to telling her friend this story to ‘fit in’. At this point FS123 approached the officer and enquired why he was speaking with Child F. Child F became upset and the officer arrested FS123 on suspicion of sexual assault. At this time MCFG approached the officer and was aggressive towards Child F. As a result the officer invoked a Police Protection Order (PPO) under the Children’s Act 1989. FS123 was taken to Wigan Police Station. Two police officers spoke to Child F alone. She continued to deny that anything had happened to her and stated that she had made up the allegation to ‘fit in’ as everyone else seemed to have been abused. 3.50 One police officer spoke with MCFG who stated that the family of 6 were struggling as there are only 3 bedrooms therefore Child F had to share with her younger brother. She also stated that Child F had a personality disorder and was self-harming. 16 The officers also received information that Child F had previous made a false allegation about FS123 physically abusing her. 3.51 The officers decided that they would remove the PPO from Child F and FS123 was released from police custody without being interviewed. The officer submitted a ‘Vulnerable Persons 1-8’ write up on the Police log and made a number of suggestions for Social Services to support the family. This information was not formally shared with social care at the time or in the strategy meetings held later. 17 3.52 At some point during 2012 (the exact date is not recorded) a note in Child F and Child G’s secondary school records states that students were calling Child F and G’s mother ‘disgusting’ and calling FS123 a paedophile following them hearing Child F stating that FS123 had raped her. Child F did not want FS123 to be informed or he would get angry and ‘start smashing plates’. Child G asked pastoral manager to speak to Child F ‘about the situation’. The note states that Child G is scared of FS123’s reaction when he gets home. It appears that Child F and Child G’s secondary school took no action other than to record this series of incidents and did not share this information with any other agency. 3.53 On 27th June 2013 a children’s charity contacted the police to inform them that an anonymous friend of Child F had called them to report that FS123 was sexually abusing her and this had been going on since the previous year. It was reported that he had taken her to the pub, bought her drinks and touched her inappropriately. 3.54 The anonymous caller had stated that MCFG was aware that the abuse was taking place. 3.55 At 10.20 pm two police officers attended Child F’s home and spoke to MCFG. She was informed that a report had been received in relation to Child F. 3.56 Child F was woken from her sleep and asked numerous questions, in the presence of MCFG. Child F denied confiding in anyone and that FS123 had not done anything. 3.57 MCFG believed that a female known to them was responsible for the rumours. She named this female as an ex-neighbour. MCFG reported that something similar was reported last year and that FS123 had been arrested. 3.58 At this time no crimes were confirmed and the police officers gave Child F contact details if she wanted to speak to them further. The police officers did not attempt to trace and speak to the ex-neighbour. 3.59 A Public Protection Incident (PPI) was created by the police but this was closed based on the information from the attending officer. A referral was made to Children’s Social Care by the police. 3.60 On 1st July 2013 Children’s Social Care were contacted by the police regarding information received from the children’s charity. The police reported that they had visited the home following the report and had spoken to MCFG and Child F within the family home and that they had taken no further action was taken by them. Upon receipt of the referral checks were undertaken and contact made with involved agencies. No safeguarding concerns were raised by the involved professionals; therefore no further action was taken by Children’s Social Care. 18 3.61 On 12th July 2013 the Children’s Social Care Duty team contacted the pastoral manager at Child F’s school to share information about the police referral and advised that as Child F was denying this was true no further action was being taken. 3.62 On 20th July 2013 Child F telephoned the police from a neighbour’s house and reported that FS123 had physically and sexually abused her since the age of 7. 3.63 Child F disclosed that the sexual abuse occurred on a regular basis and that previously she had refused to confirm the abuse as she was scared. 3.64 FS123 was arrested on suspicion of child sex offences. 3.65 A police officer (PO1) from the PPIU conducted the investigation. Child F was video interviewed and confirmed the report of sexual abuse from the age of 13. She also disclosed physical abuse from the age of 7 which included a number of assaults. 3.66 Child F said that she had told MCFG about this on the evening of 19th July 2013 however MCFG told her that she was a liar and she was going to kick her out of the house. 3.67 Child F disclosed that she had been physically abused by FS123 and recalled that when she was 5-6 years old he pushed her head into a kitchen cupboard until MCFG told him to stop. She also referred to another incident where he dragged her downstairs pushing her to the floor and kicking her. 3.68 FS123 was arrested for sexual assault, attempted rape and section 47 Assault. He denied all offences. 3.69 The police contacted Children’s Social Care on 20th July 2013 and informed them of Child F’s allegations and of FS123’s arrest. 3.70 Child F remained at the home of the neighbour and some days later went to live with the neighbour’s mother under informal fostering arrangements. 3.71 On 24th July 2013 Children’s Social Care were contacted by the police with additional information in respect of the reported disclosure by Child F. The information provided by the police highlighted that Child F had already attended an ABE Interview as part of police enquiries. The information was passed to the allocated worker with a recommendation for a strategy meeting to be held. 3.72 On 25th July 2013 Children’s Social Care completed a Child and Family Assessment with a recommendation for a strategy meeting to be held on 1st August 2013. 19 3.73 At the strategy meeting held on 1st August 2013 Child F’s allegations were discussed in the context of the family’s history of involvement with children’s social care, two recorded incidents of possible assault by FS123 of Child F and Child G and FS123 possible involvement in the serious assault of a 6 month old baby. 3.74 The strategy discussion noted that it was possible that MCFG was aware of the physical abuse. When Child F told MCFG of the sexual abuse it is alleged that MCFG stated that FS123 was her “only form of happiness”. Child F then apparently retracted the statement. It was also reported at the meeting that the family’s local community were aware of the allegations. 3.75 It was agreed during a strategy meeting that the threshold for a child protection conference to be held was not met as FS123 had left the family home. The meeting held was a multi-agency meeting; present at this meeting were representatives from social care, including a team manager and social worker, the investigating police officer, school nurse and health visitor. There is no record of any disagreement regarding the outcomes and actions made in the strategy meeting. 3.76 On 27th August 2013 Section 47 Enquiries were completed. These enquiries identified that the children were considered to have suffered significant harm however they were not thought to be at risk of continuing harm as FS123 had left the family home and his contact with the children was supervised. 3.77 On 15th September 2013 Child F completed a second video interview during which she alleged that FS123 had raped and sexually assaulted her. 3.78 Also on 15th September 2013 PO1 updated the PPI records with the following comments: “There are several issues with regards to this investigation and a history of Child F making allegations against FS123 and then retracting same. I am also aware after speaking with school that Child F has been accused of telling lies there over other incidents. They also confirm that Child F has been overheard by teachers telling classmates in school about the abuse; however she has denied doing this to me. Social services records have been obtained and show previous allegations made and comments made by Child F where she stated that she had lied. In light of this I will discuss this investigation with my Sgt to ascertain if this case meets the threshold test and whether there is any merit in taking this to CPS”. 3.79 On 23d September 2013 FS123 was further arrested for offences of Rape and Sexual Assault by Penetration. He denied the offences stating that the only reason he believes that Child F would make up this allegation is because on the night of the report he stopped her from going out to babysit. FS123 stated that Child F has been telling people about his arrest. He was bailed until 8th November 2013. 20 3.80 Also on 23rd September 2013 a second strategy discussion took place and Child F’s further allegation of rape and sexual assault against FS123 were discussed. 3.81 On 2nd October 2013 PO1 updated Child F in relation to the arrest of FS123. 3.82 On the 02/11/2013 a Detective Inspector at the PPIU made a decision to finalise the investigation stating that it did not pass the threshold test. He updated the report with the following rationale: “I have reviewed the investigation. Whilst Child F does give a clear account there are certain evidential difficulties and witness issues. Whilst we are not stating that the offence did not occur this will be a case of one against the other. The difficulty is that Child F has not been consistent in her disclosures, and this has been happening from a very early age. We have accounts of Child F stating that her father (sic) had bitten her in 2007. She later stated that she did this to get him into trouble. There was a further incident in 2010, where again she accused him of assault, when we have school records and friends testimony to state that this occurred whilst falling in a park. MCFG does not believe any of the reports made by Child F. Furthermore there is information to suggest that Child F has historically been found to be telling friends that she is pregnant, or has cancer. She is also currently stating she is having pregnancy tests despite also stating she is not in a sexual relationship with anyone. Whilst abused children can display these behaviours, it does make it difficult from a credibility point of view to overcome these issues. In this case I do not believe that she would come across as a credible witness, that there is no independent evidence to suggest a sexual offence has occurred, that there have been no other sexual disclosures by his other children and the child is not believed by her own family. I do not believe this offers a realistic prospection of conviction and should be filed as such”. 3.83 On 3rd October 2013 a Child in Need meeting was held in respect of Child F, Child G and S1, S2 and S3. 3.84 On 4th October 2013 a Child and Family Assessment was completed and finalised by a Children’s Social Care manager. The assessment made a recommendation for further social care intervention under a Child In Need plan. 3.85 Throughout September and October 2013, Child F and Child G’s secondary school sought information from Children’s Social Care and were included in some information sharing with the police and Children’s Social Care. A multi-agency strategy meeting was held in August 2013 when the school were on their summer break meaning school did not attend. Further to this, the first CIN meeting was held in October 2013 – this was attended by the school. As well as the school, Social Care alongside MCF&G, F&G, and the PG123 of F&G’s siblings were in attendance. The pastoral manager from the secondary school also attended the Child In Need meeting in November 2013 and December 2013. 21 3.86 The school staff put a ‘management plan’ in place for Child F following her disclosures which attempted to support Child F (and manage Child F’s relationship with Child G, and other students one of whom was a relative of FS123). 3.87 On 5th November 2013 Child F was informed of the decision and the investigation was finalised. 3.88 On 6th November 2013 a Child in Need meeting was held. Child F and Child G attended the meeting. Allegations of sexual abuse to Child F were reported as “no further action, not enough evidence to proceed with a prosecution”. MCFG was reported to be upset that FS123 was not yet back at home. 3.89 During the meeting MCFG was very hostile towards Child F. It was documented that the Social Worker needed to intervene during the meeting and request that MCFG was respectful of Child F’s feelings. Child F continued to live with the neighbour’s family. Child G reported that he did not want any contact with Child F. At this point, FS123 had not returned to the family home. 3.90 On 11th November 2013 Child F was seen by a School Nurse who carried out a comprehensive health assessment. The School Nurse recorded that Child F stated that she was feeling well, but emotionally “up and down”, reported that she missed contact with younger siblings, and would like to have time with MCFG without either of them arguing or shouting. Child F stated that she had poor concentration due to a poor sleep pattern, having nightmares and disturbed sleep. Child F reported that she gets angry about what was happening and tends to say too much to too many people including friends which had caused problems in school for Child F and Child G. Child F stated that she wanted contact with FCFG The School Nurse reported that emotionally Child F was struggling, currently waiting for referral for one to one support, Child F was awaiting counselling through school, and a referral to child and adolescent mental health services had been made. 3.91 On 5th December 2013 a Child in Need meeting was held. It was recorded that work with the family had been completed and that in light of the positive progress made and the work completed with the children which had raised no concerns it was agreed that FS123 would return to the family home. Child F continued to reside in the care of other adults and there were no identified plans in respect of a return to the care of MCFG. 3.92 It was agreed that the case would be closed at Child in Need level and that a referral to the ‘Gateway Service’ would be made in respect of Child F only as she remained outside the family home. The Gateway Service provides support to children and young people 0-19 years and their family at level 2/3 of the threshold of need. There is a step up/down process in place from Gateway to Wigan Social Care teams to ensure a positive transition to and from Wigan specialist services. 22 3.93 On 25th February 2014 a contact was received via the Out Of Hours Social Care department. The information was received from a professional reporting that Child F had informed them that her younger sibling Child G had made disclosures of sexual assault perpetrated by FS123. 3.94 On 26th February 2014 the police record states “This allegation was received from two sources; Firstly, a referral was made from Youth Leader. He said that Child F had attended the youth club and disclosed that Child G (15yrs) had be subject to sexual abuse by FS123 between 1.1.2004 and 26.2.2014”. 3.95 Police attended and spoke to Child F who said that Child G reported to her on 25th February 2014 that FS123 had been performing sexual acts on him. 3.96 On the 26th February 2014 Child G contacted the police directly and reported that he had been sexually abused by FS123. The report was made from a neighbours address. 3.97 A ‘Specially Trained Officer’ attended the address. Child G disclosed that he was victim of sexual abuse from the age of 6 involving touching and penetration. Child G disclosed that the last incident had occurred on 22nd February 2014 at his home address. 3.98 Child G told the police officer that everything that Child F had said in the past had been correct and that he had been lying. When asked why he didn’t disclose the abuse in the past Child G said it was because he was scared. Child G said that MCFG was not aware of any of the sexual abuse. Child G was asked if FS123 had ever hurt S1, S2 or S3 to which he said he had not. 3.99 Child G disclosed that, over the years, he and Child F were sexually abused by FS123 at the same time. 3.100 FS123 was arrested on 26th February 2014. 3.101 A Public Protection Order was issued and Child G, S1, S2 and S3 became looked after by the Local Authority. ANALYSIS AND RECOMMENDATIONS 4.1 This section sets out an analysis of key findings and associated recommendations that are designed to offer challenge and reflection for WSCB and partners. 4.2 The key lines of enquiry for the SCR were explored through the process of the Learning Event and considered together with the details submitted in individual agency chronologies: 23 Sharing of information appropriately between partner agencies 4.3 Information sharing between the police and social care in this case was poor. 4.4 Examples of poor information sharing between the police and social care include: 4.5 On 22nd August 2011 following the report by a taxi driver that a passenger had told him that Child F was being sexually abused by FS123 the police concluded their enquiries (FS123 was arrested but not interviewed) without contacting social care as part of their enquiries nor did they inform social care that this incident had taken place. 4.6 During this incident the attending police officers were told by MCFG that Child F self -harmed and had a personality disorder. They did not verify or share this information with any other agency. 4.7 On 27th June 2013 a police officer attended the family’s home in response to the anonymous phone call to the children’s charity. Although this incident led to a referral to Children’s Social Care the police officer did not contact Children’s Social Care to seek background information about the family or involve them in plans to speak to Child F in a neutral setting not in the presence of MFCG. This incident was not linked to the August 2011 incident. 4.8 The issue of the police sharing information before and after interviewing Child F and Child G is covered at paragraph 4.34 below. 24 4.9 Child F and Child G attended the same primary and secondary schools and school staff played a key role in a) being recipients of information and disclosures from Child F and Child G and b) attempting to manage and contain a very difficult tension between supporting Child F after her first allegation of sexual abuse against FS123 and Child F and Child G’s deteriorating relationship which was sometimes ‘played out’ in front of other pupils. Given the school’s crucial and difficult role they were not routinely invited to contribute to discussions or decision making and nor were they kept fully informed as events occurred. 4.10 The school however also knew at an unrecorded point during 2012 that Child F was telling her fellow pupils that FS123 had raped her and the school do not appear to have shared this information or acted upon it. 25 4.11 MCFG and FS123 were referred to a Children’s Centre shortly after the birth of S3 in April 2013. It was apparent from discussions during the Learning Event that the Children’s Centre did not have access to any information about the family’s history of contact with other agencies. Children’s Centres often play a crucial role in engaging with families who might not readily engage with other agencies and it is vital that they are party to historical information particularly when there have been safeguarding concerns. The issue of parental consent to access and share information is crucial in cases (such as this) where there is significant historical information. 4.12 There were several examples of good practice in information sharing for example between the Health Visitor in Preston and the Health Visiting Service in Wigan as MCFG and the children moved to Wigan. This transfer of care was well planned and would be seen both at the time and today as being best practice. 4.13 Another example of good practice in information sharing were the regular alerts and communications from Child G’s secondary care providers raising concern about the management of his health condition. 4.14 Participants in the Learning Event discussed information sharing at length and some participants observed that they were finding out some information for the first time during the Learning Event itself both from reading the integrated chronology and from discussions with other participants. It is probable that significant pieces of information had been shared appropriately in the past but the timescales of the review (19 years) would have impacted on who knew what from such a vast amount of information. 4.15 It was apparent that in some instances information was sought, gathered and shared but the information was not fully understood or contextualised. Examples include: 4.16 The police contacted Child F’s school following her allegation of sexual and physical abuse in July 2013 to ask for information about Child F. Specifically they asked if Child F told lies. The police officer who spoke to a member of staff from the school made the following note “There are several issues with regards to this investigation and a history of Child F making allegations against FS123 and then retracting same. I am also aware after speaking with school that Child F has been accused of telling lies there over other incidents. They also confirm that Child F has been overheard by teachers telling classmates in school about the abuse; however she has denied doing this to me. Social services records have been obtained and show previous allegations made and comments made by Child F where she stated that she had lied”. 26 4.17 This interpretation by the police officer of the school’s account that Child F sometimes told lies demonstrated a lack of understanding about the way in which children and young people disclose sexual and physical abuse and the pattern of denial and retraction which can follow such allegations. 4.18 Another example of information being shared but not being understood was the decision which was made by the CPS that the threshold was not met to proceed with criminal proceedings. This information was interpreted by some practitioners as confirmation that the abuse had not happened as some of the recipients of the information did not understand the different evidential thresholds. This issue was discussed by participants in the Learning Event. The partnerships collective understanding of how and why victims of abuse disclose and withdraw allegations. 4.19 Considerable focus was given to the pattern of disclosure by child victims of abuse during the course of the Learning Event. The participants were given the opportunity to explore recent and more established research and to reflect on their own understanding of why children and young people disclose and retract and how this affected judgement and practice. 4.20 Child F in particular disclosed both physical and sexual abuse on several occasions and then retracted her allegations. This pattern of retraction must be seen in the context of the child or young person’s family setting and also in the context of what evidence through research tells us. 4.21 Child F’s family history was complex and both she and Child G had been the subject of Child Protection Plans under the categories of neglect and physical abuse. The person that allegations were made against was FS123 a man implicated in causing serious injuries to a 6 month old baby and the reason that Child F and Child G had been made subject of the child protection arrangements in respect of physical abuse. 4.22 Child F and Child G’s mother had 4 consecutive relationships with men that posed a potential significant risk to herself and her children. 4.23 This current and historical family context should have afforded Child F’s allegations far more credibility and Child F’s retractions and Child G’s denials far less credibility than were given in this case. 27 4.24 Instead, Child F gained a reputation for lying and attention seeking and this had an impact on how she was responded to and vitally left herself and Child G exposed to further harm. 4.25 Personal and professional judgement were prejudiced by a lack of understanding of Child F’s retractions and Child G’s denials which were taken at face value. This impacted upon how the S47 and criminal investigations were conducted. 4.26 The following research was shared with Learning Review participants: 4.27 In an influential article, Summit (1983) described the disclosure process as the "Child Sexual Abuse Accommodation Syndrome" (CSAAS). “The CSAAS consists of five stages: (1) secrecy; (2) helplessness: (3) entrapment and accommodation; (4) delayed, unconvincing disclosure; and (5) retraction. According to Summit children retract their statements as part of a process of dealing with sexual abuse victimization”. Summit, R. C. (1983). The child sexual abuse accommodation syndrome. Child Abuse and Neglect, 7, 177-193. 4.28 A separate study carried out by Sorenson and Snow in 1991 examined 117 cases and found most disclosures of abuse were accidental (74%) and many victims (22%) recanted their statements only to reaffirm them later (93% of recantations). 72% of initially denied abuse, and 78% were reluctant to discuss the abuse”. Sorenson, T., & Snow, B. (1991). How children tell: The process of disclosure in child sexual abuse. Child Welfare, 70(1), 3 15. 4.29 A more recent study carried out by the NSPCC with 60 young people who have been physically and / or sexually abused showed that several of the young people described being pressured by their families to retract, through subtle threats that it would adversely impact on the family or that the young person would end up in care. We believe that in Child F’s case MCFG pressurised Child F to retract and indeed her overwhelming response when Child F finally refused to retract was extreme anger towards her. No One Noticed No One Heard: A study of disclosure of Childhood Abuse NSPCC 2013 4.30 The NSPCC study participants also highlighted positive and negative accounts of interactions with teachers, police and social workers emphasised that they wanted to be noticed. Police and social care professionals who were involved 28 with families for other reasons were often perceived as interested only in the matter at hand and not in the wider experiences of the young person. 4.31 In this case it was apparent both from Learning Event participants and from agency’s chronologies that Child F’s retractions and Child G’s denials were not recognised or understood in the context of the children’s family history or as part of a pattern of disclosure. 4.32 It was also apparent that Child F’s stories of, for example, having cancer or of being pregnant were viewed as attention seeking and this was not explored with her in a sensitive and ‘alert’ manner. 4.33 Rather than being viewed as a sign that Child F was distressed and may well have been trying to draw attention to herself because she needed help these stories were dismissed whilst at the same time contributing to the judgement that Child F told lies. 29 Partnership planning around the Acquiring Best Evidence (ABE) interviews. 4.34 The way in which the ABE interviews of Child F and Child G were conducted did not meet expected standards of best practice which are detailed in the Ministry of Justice guidance ‘Acquiring Best Evidence in Criminal Proceedings’. 4.35 This guidance outlines partnership planning thus “For children who have had past or current involvement with that local Children’s Social Care authority, useful information may already have been provided from different professionals or may be obtained from other adults who know the child (e.g. parents, carers, teachers, educational psychologists, youth workers, occupational therapists), and it may be that other individuals are offered a more active role in the planning process.” Ministry of Justice Achieving Best Evidence in Criminal Proceedings: Guidance on interviewing victims and witnesses, and guidance on using special measures 2013 4.36 Child F was ABE interviewed 3 times and Child G once and the police did not involve Children’s Social Care or any other agency in the planning for the interviews. In fact; Children’s Social Care only knew about the ABE interviews once they had taken place. 4.37 A joint protocol for information sharing in child abuse cases was published in 2013, whereby police and prosecutors are expected to share and seek appropriate information about vulnerable children with and from Social Services, schools and family courts in accordance with the protocol and a good practice model. There is no evidence that this protocol was used in this case. 4.38 A joint HMIC and HMCPSI inspection of how ABE interviews had been conducted in child sex abuse cases was published in 2014. The inspection concluded that there was poor compliance with the ABE Guidance and made several key recommendations some of which are pertinent to this case and are made as recommendations of this serious case review. 4.39 At the point of Child G’s disclosure Child F had already been interviewed twice and the officer in charge was aware of Child G’s disclosure of joint sexual abuse. An interview strategy should have been discussed with a ‘Tier 5’ interview advisor and consideration given to involve a child psychologist and a discussion with the CPS. 4.40 The quality of the ABE interviews which was compromised by the lack of planning led to the decision by the CPS that the threshold for criminal proceedings had not been met. This decision not to proceed with criminal proceedings compounded the belief of other agencies that Child F was not credible. This meant that the risk posed by FS123 to Child G and S1, S2 and S3 was not recognised. 30 4.41 The impact that this failure to strictly follow the ABE Guidance or refer to the protocol had upon Child F was that she was not treated by the police as a vulnerable child (and a potentially intimidated witness) but as an adult. This may well have re-victimised and traumatised Child F. The quality of partnership working and decision making at Strategy Meetings and Section 47 Enquiries 4.42 The partnership working and decision making at Strategy Meetings and Section 47 Enquiries was not always effective. Furthermore Section 47 Enquiries were not always instigated when it would have been appropriate to do so. 4.43 On 18th December 2003 the child protection plans in place for both children in respect of physical abuse ended. 4.44 Within 7 months of this decision Child F was seen with bruising at school and when asked said “I fell. My dad didn’t do it.’’ This was reported by the school to Children’s Social Care but did not prompt a Section 47 enquiry. 4.45 Within 12 months i.e. in December 2004, Child F was taken to the A & E department with an injury to her finger. The reason for the injury was given as ‘fighting with a sibling’. The injury was said to have happened 3 weeks prior to the A & E visit. Bruising, swelling and a slight deformity to the finger were noted. Within the context of this family’s recent history this injury should have prompted a safeguarding concern. 4.46 On 5th July 2005 Social Services were contacted by the Head Teacher at Child G’s school reporting that the previous day staff from the school had observed Child G (8 years old at this time) being dragged from the car by FS123 and then dragged into school by his hair. Concerns were raised by representatives from school that at some point Child G had been put in a car boot and that his sister had been using his blood testing kit. The police spoke to Child G, MCFG and FS123 who all denied that Child G had been assaulted and gave an alternate version of events. The matter was not taken further by the police. A S47 Enquiry was commenced by Children’s Social Care on the same day and Child G was seen at school and corroborated the version of events given by FS123 and MCFG i.e. that he had not been dragged into school by his hair(please see Appendix 1 in reference to this incident). 4.47 Given the family context and history this willingness to believe FS123 and MCFG and not view an 8 year old’s denial of an assault as questionable 31 (despite the perspective of the school staff that an assault had taken place) demonstrated lack of critical professional judgement and scepticism. 4.48 On 26th October 2007 Child F’s school contacted Children’s Social Care to report that Child F had been overheard (by a parent) saying that FS123 had bitten her finger to stop her touching the house alarm. This ‘accidental disclosure’ took place in a shop. 4.49 Section 47 enquiries were instigated on 2nd November 2007. The Family Support Investigation (FSI) states that Children’s Social Care did not obtain details of the parent or shop keeper. There is also indication on the FSI that three teachers had been made aware of the allegation. It is unclear if these teachers were informed by the parent together or separately and what they did with this information. The school was closed for half term and therefore the teachers were unavailable, it is unclear if the teachers were ever spoken to about this matter. A social worker attended at the family home and was told by Child F that she had bitten herself and that she had fallen. She had a faint mark on her finger and denied that FS123 had assaulted her. Given the minor nature of the mark on her finger a decision was made (although it is not clear by who) not to have Child F undertake a medical. 4.50 At the same time as speaking to Child F, children’s social care spoke with FS123 who also denied assaulting her. It was agreed that Child F’s parents would receive support via Child In Need arrangements and the Section 47 enquiries were concluded on 11th November 2007. 4.51 The willingness to believe the denials of FS123 and Child F without speaking to the parent who overheard the disclosure or any of the school staff who were recorded as having heard the parent’s report did not constitute a thorough enquiry and again demonstrated a lack of critical professional judgement and scepticism. 4.52 In October 2010 a referral to Children’s Social Care was made by Child F’s school. Child F had just turned 13 years of age. Child F had reported that bruising had been caused by FS123 hitting her. 4.53 The school’s concerns were that Child F had bruising and the explanation for how the bruises had been caused was inconsistent. The detail of the referral states that Child F’s demeanour was ‘shaking and nervously playing with things, not looking us in the face and asking that we didn’t tell social services’. Child F was also reported to state how much her Dad spends on her and how much he spoils her. In addition to this, she is reported to have stated that her mother has told her that ‘It is her last chance to be happy’. Additionally commentary within the school’s referral details as follows: 32 “I know Child F quite well and the behaviour she is exhibiting is unusual. I am worried about her and the way she presented herself, the nervousness, jittery and protesting about how well stepdad (FS123) treats her. My gut feeling is all is not well and that things are happening in the home.” 4.54 This triggered an initial assessment and a visit was undertaken to see Child F. Child F reported that the allegations were untrue and that she had not said this. Child F reported that she had sustained the injuries playing and falling off a roundabout. Child F did state that physical chastisement was used by FS123 at times. Child F reported that this was only when she deserved it and that she needed to be hit as it was the only time she would listen. Child F reported that her FS123 lightly tapped her hand or bottom. 4.55 Child F was recorded as having discussed home life fondly and raised no concerns. As a result of the information gathered the assessment was closed with no further action and no further enquiries were made. 4.56 This episode did not trigger a Section 47 enquiry however given the family history and context and the explicit concerns of Child F’s school there should have been a different response. Child F’s statement that her stepfather used physical chastisement including tapping her hand or bottom should, in itself, have prompted a different response especially given that Child F was 13 years old at this point. 4.57 On 1st July 2013 following the anonymous report to the children’s charity that Child F was being sexually abused by FS123 the police contacted Children’s Social Care. The information provided was that on 27th June 2013 the police had visited the family following a 3rd party anonymous report that Child F had confided in a friend that FS123 had been sexually abusing her. The police reported that they had visited the home following the report and had spoken to MCFG and Child F within the family home. Children’s Social care records indicate that “No further action was taken by the police records highlight that F had been spoken to by the police and denied the report stating that it had been made maliciously. Upon receipt of the referral departmental checks were undertaken and contact made with involved agencies. The police reported that they considered the report to be malicious, further contact with school identified that there were no safeguarding concerns however friendships were identified as an issue and school reported that F would tell friends information but when questioned by school would deny this. No safeguarding concerns were raised by the involved professionals; therefore no further action was taken by the department”. 33 4.58 Again, given the family context and history this episode added further to the likelihood that Child F (and potentially her siblings) were at risk of serious harm the decision not to enquire further is difficult to understand but could be attributed to the gaps in information sharing from the police and school and this may well have impacted on the decision making had this been provided. 4.59 Section 47 enquiries were instigated following Child F’s disclosure of sexual and physical abuse on 24th July 2013. The Section 47 Enquiries were completed on 27th August 2013. These enquiries identified that the children were considered to have suffered significant harm however were not thought to be at risk of continuing harm as FS123 had left the family home and his contact with the children was supervised. It was recorded however that when Child F told MCFG of the abuse it is alleged that MCFG stated that FS123 was her “only form of happiness”. This should have caused doubt that MCFG would protect Child F’s siblings from harm caused by FS123 and that she may not be honest about contact arrangements. 4.60 Given the conclusion that the children were considered to have suffered significant harm and given MCFG’s reaction to Child F and her suspected collusion with FS123 it is difficult to understand why a decision was not made, at this point, to make all of the children subject to child protection arrangements. The sharing / obtaining of historical information to inform current practice and service provision. 4.61 The obtaining and sharing of historical information to inform practice was critical to the safeguarding of the children in this case (as in many others). 4.62 Information was obtained and was shared and in some cases led to good practice and service provision e.g. the transfer of information from the Preston Health Visiting Service to the Wigan Health Visiting Service however please also see 4.77 below. 4.63 However on the whole historical information about MCFG and FS123 did not inform how risk and need were recognised, understood and responded to. 4.64 Agencies held information about the family which had built up (and continued to build) over a decade starting with the birth of Child F in 1997. This information came from a steady stream of contact with midwives, health visitors, A&E, nursery and schools, secondary health services, the police and Children’s Social Care. 4.65 This information which concerned the children and the adults in Child F and Child G’s family highlighted several complex and compounding issues which 34 meant that there were many ‘red flag’ indicators that extreme vigilance, scepticism and critical judgement were required when working with the family. These indicators included: MCFG’s relationships with males who posed a potential and proven risk to herself and her children. Ongoing neglect of Child F and Child G (the neglect of Child F was not explicitly identified as such as much of the focus was upon Child G’s serious health needs) Pattern of possible non accidental injuries. MGCFG’s concerns about MCFG’s ability to look after the children. MCFG’s mental health needs MCFG’s possible cognitive difficulties. FS123’s implication in the serious injury of a 6 month old baby. The children’s history of making allegations followed by retraction or denial which was not viewed as a pattern or a symptom of physical and/or sexual abuse by all agencies who were involved. The information held regarding MCFG’s knowledge that abuse was taking place and her reaction following Child F’s disclosure of sexual abuse. 4.66 Given this family history any allegation of physical and/or sexual abuse should have been responded to assertively. 4.67 There is little evidence that assessments or investigations at any time adequately analysed the interaction between these known risks and the protective factors within the family environment The process of transfer from another local authority and the appropriate reviewing of current protection plans. 4.68 Child F and Child G were subject of child protection arrangements in Lancashire in February 2000 because of neglect. 4.69 In June 2000 a decision was made to step down the arrangements and although there are no records of the rationale behind this decision the indications are that MCFG was still neglecting the needs of her children e.g. missing health appointments in respect of Child G. Furthermore Child F suffered bruising and injury (including a ‘black eye’) in June and December 2000 and March 2001. 35 4.70 Child G again became the subject of child protection arrangements in February 2003 because of neglect specifically focused around his health needs. Child F was not made subject of child protection arrangements. 4.71 In May 2003 during a Child Protection Review Conference concerns were noted about MCFG’s new partner FS123. 4.72 MCFG moved with the children to live with FS123 in Wigan in June 2003. 4.73 On 20th June 2003 an Incoming Child Protection Case Conference took place in Wigan and information was provided by Lancashire County Council highlighting concerns about MCFG’s ability to meet the health needs of Child G. In addition to this further concerns were raised regarding FS123. It had been disclosed to Lancashire County Council that in 2000 FS123 had been interviewed, alongside others in respect of serious injuries sustained by a 6 month old child. During the CPCC Lancashire County Council confirmed that written agreements were in place in respect of supervised contact between FS123 and the children whilst a further assessment was undertaken. 4.74 Both Child F and Child G were made subject of Child Protection Plans in Wigan. 4.75 Child G was subject of dual registration in respect of both neglect and physical abuse. 4.76 On 26th June 2003 the first Core Group Meeting was held. Records highlight that discussions were held about family activities however it was identified that at this time FS123’s mother (PGS123) could not be considered to supervise contact arrangements due to information linking her to the incident in 2000 where a number of adults including FS123 were considered as possible perpetrators of physical abuse. 4.77 It is not clear from the records available to this review if the transfer of child protection arrangements from Lancashire to Wigan included other highly relevant information for example: MCFG’s previous relationships with men who posed a risk to herself and her children. MCFG’s wider family connections with alleged perpetrators of sexual abuse. MCFG’s disclosure of childhood sexual abuse. MCFG’s overdose. 4.78 Much of the focus was on the possible risk to the children posed by FS123 and the neglect of Child G’s health needs. 36 4.79 In addition, when the family moved from Preston to Wigan the report provided by the Preston Social Worker stated that MCFG had “learning difficulties / a personality disorder”. It is not clear that this was qualified or quantified in respect of the impact on MCFG’s parenting capacity during the transfer of the child protection arrangements. 4.80 The handover of care from Preston Health Visiting Service to Wigan Health Visiting service was comprehensive and did include information about the historical context detailed above but it is not possible to conclude from the records available to this review that all of this information was shared during the transfer of child protection arrangements. Summary 4.81 This serious case review demonstrates the critical importance of a family’s complex history as an indicator of future risk and need and whilst complexity of risk and need is not always obvious within a family; in this case there were several long standing indicators that Child F and Child G were suffering neglect and physical and emotional harm. 4.82 Child F and Child G’s family history appears to have included inter and multi-generational abuse. This history was highly relevant to any assessment of MCFG’s need for therapeutic and other support as became a very young parent. 4.83 MCFG struggled to cope as a parent from the birth of Child F onwards. It may be that her own history of childhood abuse had compromised her parenting ability. Factors that are known to be associated with risk to babies and very young children (Ward et al 2012) include parents who have experienced abusive childhoods themselves and have not come to terms with the abuse. 4.84 Additional risk factors include domestic abuse and environmental stressors such as housing and we know that MCFG experienced domestic abuse and very unstable housing; moving several times when Child F and Child G were young infants. Significant protective factors are the presence of a supportive non-partner, wider family and informal support and parent’s insight understanding and capacity to change. Severe risk of harm is most likely where there is an absence of protective factors. Ward, H., Brown, R., and Westlake, D. (2012) Safeguarding Babies and Very Young Children. London: Jessica Kingsley Publishers. 4.85 Furthermore, children who have been sexually abused and exploited as MCFG may have been, are more likely than other children to be re-victimised both as 37 adolescents and adults. They are also more likely to have been targeted by the perpetrator specifically because of their particular vulnerabilities (Conte, Wolf, & Smith, 1989, Elliot, Browne, & Kilcoyne, 1995). This increases the likelihood that MCFG and by default, her children, would be vulnerable to further abuse. Conte, J., Wolf, S., & Smith, T. (1989). What sexual offenders tell us about prevention strategies? Child Abuse and Neglect, 13(2), 293–301. 4.86 MCFG’s consecutive relationships with 4 men who posed a potential risk to herself and her children (who were very young at the time) certainly indicated that this was the case. 4.87 MCFG’s parenting capacity and her possible learning or cognitive difficulties were an issue of concern from the birth of Child F onwards but there was no formal assessment of this and there were no plans put in place for any long term support or intervention to ensure that MCFG and her children were safe and thriving despite the fact that there were several significant indicators that her capacity to parent was compromised. 4.88 The family moved to Wigan in 2003 with agencies involved in the transfer of child protection arrangements. During the decade that followed there was a steady stream of contact with those agencies i.e. police, Children’s Social Care, health visitors, secondary care services which should have ensured that Child F and Child G remained on the safeguarding ‘radar’. 4.89 This steady stream of contacts however was not recognised as a pattern within the family context and the majority of incidents which caused the contact with agencies was dealt with as a single incident and was not ‘cross referenced’ with the other incidents or the family’s history. 4.90 Furthermore the established link between neglect and physical abuse was not considered despite the significant number of known injuries to Child F from the age of 10 months onwards. 38 4.91 An important theme that arises from many SCRs is how well professionals ensured that children were at the centre of the service delivered or at the centre of child protection or child in need plans. 4.92 Child F and Child G came into contact with a range of professionals throughout the period under review and they were, on occasion, asked direct questions about some of the alleged incidents of physical and sexual abuse. 4.93 In these circumstances any interaction with either child warranted careful planning and skilful and sensitive handling. The reality however was very different. For example Child F was spoken to by the police in the street outside her home and in front of her mother in relation to the anonymous reports that she was being sexually abused. 4.94 The voices of Child F and Child G were effectively ignored or not believed on some occasions 4.95 This serious case review also highlights the necessity of good reflective supervision and management scrutiny in all agencies to minimise the effect of common issues such as not recognising the pattern of retraction and denial, not recognising that Child F as well as Child G was experiencing neglect, not recognising the pattern of risk in MCFG’s relationships with males. The role of managers to stand back and help practitioners unpick and fully appreciate the complexities of a situation was missing in this case. 39 Recommendations Multi Agency Recommendations 4.96 Using the learning from this serious case review multi-agency training and awareness raising is required to ensure that practitioners demonstrate professional curiosity and scepticism around fathers and other males who are associated with high need or complex families particularly where there has been a potential history of sexual and other abuse. The LSCB partners should evidence how this training and awareness raising has impacted upon practice particularly in respect of risk assessments within an agreed timescale. 4.97 It is essential that the use of family history and genealogy to identify and assess patterns of risk should be embedded in practice. Single agencies should provide details to the LSCB of how they will monitor the use of family history and genealogy for example through supervision and case audits. 4.98 It is essential that the learning from this Serious Case Review is used by the LSCB partners to assess their practice approach to families with similar histories to Child F and Child G’s. In particular how practice and supervision are influenced by the understanding of the long term impact of unresolved childhood trauma and abuse, maternal mental illness and /or cognitive functioning on parenting capacity. For example practitioners should be able to evidence that risk and need assessments have taken account of these issues. 4.99 WSCB should use the learning from this Serious Case Review to ensure that neglect in all its manifestations is understood and responded to by multi agency practitioners and that the well evidenced link between neglect and physical abuse is considered in all cases and that evidence of this is recorded in case files and supervision records. 4.100 WSCB and partners should review what currently happens when there are concerns a parent or parents have a cognitive or learning difficulty which may impact upon their parenting capacity and ensure that there is a clear and accessible referral and assessment protocol between agencies. 40 4.101 WSCB and partners should, at the earliest opportunity, share the learning from this review concerning patterns of children and young people’s disclosure (including retraction and denial) in cases of physical and sexual abuse and commit to ensuring that all children and young people who make allegations of sexual or physical abuse receive a ‘gold standard’ response drawing from the very valuable research, studies and best practice guidance which are widely available. Evidence that children and young people have been listened to and their wishes and feelings have been understood, respected and taken into account in decision making and planning should be a core element of the ‘gold standard’ response. 4.102 Using the learning from this review WSCB and partners should prepare a briefing for practitioners to outline the difference between evidential thresholds in criminal and civil proceedings and what this may mean for the children and young people with whom they are working. Single Agency Recommendations Greater Manchester Police 4.103 Greater Manchester Police should ensure that the learning from this review is shared with the cohort of officers trained to carry out ABE interviews and reinforce the importance of pre-interview planning and the importance of consulting with and joint planning with partner agencies including children’s social care. 4.104 Greater Manchester Police should consider its ‘frontline’ response to children and young people who allege (or about whom there are concerns) that abuse is taking place and ensure that the learning from this review is shared and translated into improved practice. 4.105 Greater Manchester Police should review its practice of evidence gathering in cases where a child or young person has alleged abuse specifically in asking schools and other agencies whether or not a child or young person tells lies. This should be informed by research and best practice. 4.106 Greater Manchester Police should instigate a discussion with the Crown Prosecution Service in order to routinely receive feedback about the quality of ABE interviews particularly when a decision is made not to proceed with criminal proceedings and ensure that practice is reviewed accordingly. 41 Children’s Social Care 4.107 CSC managers should use every opportunity (induction, supervision, training) to embed the requirement for Social Workers to read and understand a child’s and family’s history, and for the worker’s manager to prioritise and protect the time needed to do so. This message should be supported by guidance about key documents and the use of chronologies, to support better understanding of family history and patterns. 4.108 A means of monitoring whether this has been done should be put in place for all children who are subject to a Child in Need Plan, Child Protection Plan, or Care Plan as a looked-after child. Education 4.109 The WSCB Education Sub Group should assure itself that safeguarding leads within each school in the Borough should ensure that they and other relevant staff have a good understanding of the important role that teachers and schools in play in the way in which children and young people disclose or attempt to disclose physical and sexual abuse. Conclusion 4.110 Child F and Child G suffered neglect from birth onwards. It is likely that Child F in particular also suffered physical abuse as a young baby onwards. The capacity of their mother to care for and safeguard her children was compromised but because she did not undergo a comprehensive parenting or cognitive assessment it is not clear whether this was because of her own childhood experiences of trauma and abuse, because she had a cognitive impairment and/ or mental health condition or a combination of all these factors. Whatever the cause the impact was that Child F and Child G suffered significant harm including exposure to domestic abuse, neglect and physical and sexual abuse. 4.111 This harm was compounded by the way in which agencies responded in particular to Child F’s disclosures of physical abuse and later of sexual abuse and also led to the continued abuse of Child G beyond the point at which Child F left the family home. 4.112 In conversation with the Lead Reviewer both Child F and Child G confirmed that they had been afraid of the consequences of telling the truth to agencies about the abuse (physical and sexual). These consequences were threatened by MCFG and FS123 and included physical punishments. The children were also told that the family would be split up if they told anyone what was happening. 42 4.113 Child G in his conversation with the Lead Reviewer confirmed that he was too afraid of FS123 to tell the truth about what was happening within the family. He said that the safest thing for him to do was to keep his head down and keep quiet. 4.114 Child F in her conversation with the Lead Reviewer said that she wanted professionals to understand that when a child or a young person tells them that some form of abuse is occurring, however confused or conflicting that disclosure may be, they should be believed. She also wanted professionals to understand that children and young people will be under huge pressure not to tell the truth and to change their story if or when they do. 4.115 The Lead Reviewer and the Serious Case Review Panel would like to thank Child F and Child G for their courage and their honesty in speaking to the Lead Reviewer. What has changed since this Serious Case Review began? 4.116 There has been a wide ranging response from social care; 4.117 Since 2013 there has been a full service review within the specialist assessment service; this identified a set of actions both immediate and long term to address service issues and ensure the provision of appropriate service. This included: Systemic supervision training has been accessed by social care managers Significant changes have occurred to the duty service in respect of management of information received. Chronology training has been provided to all social care staff to embed the importance of considering the holistic picture There has been a full audit of all social care cases to ensure the learning around the significance of chronologies on the child’s file has been implemented. Quality assurance meetings are held between Social Care and Health Colleagues in order to share information and address any problem areas. Arrangements are now in place to ensure all ABE interviews are attended or the evidence observed by social care staff 43 References Achieving Best Evidence in child sexual abuse cases - a joint inspection HMCPSI and HMIC December 2014 Conte, J., Wolf, S., & Smith, T. (1989). What sexual offenders tell us about prevention strategies? Child Abuse and Neglect, 13(2), 293–301. Ministry of Justice Achieving Best Evidence in Criminal Proceedings: Guidance on interviewing victims and witnesses, and guidance on using special measures 2013 No One Noticed No One Heard: A study of disclosure of Childhood Abuse NSPCC 2013 Sorenson, T., & Snow, B. (1991). How children tell: The process of disclosure in child sexual abuse. Child Welfare, 70(1), 3 15. Summit, R. C. (1983). The child sexual abuse accommodation syndrome. Child Abuse and Neglect, 7, 177-193. Ward, H., Brown, R., and Westlake, D. (2012) Safeguarding Babies and Very Young Children. London: Jessica Kingsley Publishers. Working Together to Safeguard Children 2015 |
NC045630 | Serious head injury of a 4-month-old boy in June 2013. Baby T had attended hospital 6-weeks prior to the incident with bruising, strongly suspected to be non-accidental. Mother and father did not live together and mother claimed to be the sole carer for Baby T leading up to this incident. A subsequent Working Agreement named father as the parent with supervisory responsibility for all contact with Baby T and his three siblings. All four children were the subjects of a child protection plan at the time of the incident. Mother and father were arrested and later admitted causing or allowing physical harm; they received a Community Order and suspended sentence respectively. Family were known only to universal services prior to the first incident. Father had a long history of mental health problems including chronic and severe anxiety and depression. The depth of father's mental health problems, as told to his GP, were not known by mother or children's social care. Identifies systemic learning and uses the Significant Incident Learning Process (SILP) model to pose questions relating to thematic learning, covering: low GP attendance at child protection conferences and the implications of a series of strategy discussions or conversations replacing formal, face-to-face strategy meetings. Makes various interagency and single agency recommendations.
| Title: Serious case review: re: Baby T: born: February 2013: overview report. LSCB: Gateshead Local Safeguarding Children Board Author: Paul Tudor Date of publication: 2014 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. GATESHEAD LOCAL SAFEGUARDING CHILDREN BOARD SERIOUS CASE REVIEW RE: Baby T Born: February 2013 OVERVIEW REPORT Lead Reviewer P Tudor August 2014 Baby T SCR - Final anonymised version CONTENTS 1. INTRODUCTION 1.1. Introduction to Serious Case Reviews 1.2. Introduction to SILP 1.3. Introduction to the circumstances 1.4. Introduction to the family 2. PROCESS 3. BACKGROUND AND CONTEXTUAL INFORMATION RELATING TO MOTHER AND CHILDREN 4. KEY PRACTICE EPISODES 5. INITIAL CHILD PROTECTION CONFERENCE (3 May 2013) 6. PROFESSIONAL INTERVENTIONS WITH FATHER 7. SYSTEMIC LEARNING 8. THEMATIC LEARNING 9. FINDINGS FOR THE BOARD 10. SINGLE AGENCY RECOMMENDATIONS Appendices i. Terms of Reference and Project Plan ii. Agency Authors Template Baby T SCR - Final anonymised version 1 1. INTRODUCTION 1.1. Introduction to Serious Case Reviews Serious Case Reviews have operated for many years, until recently under 2010 guidance “Working Together to Safeguard Children”. This guidance contained mandatory and discretionary thresholds and prescriptive advice on processes with IMR and Overview Report templates. In April 2013 new guidance was issued and Chapter 4 emphasises the importance of a Learning and Improvement Framework, of which reviews on cases is one element. Regulation 5 (2)(a) of the LSCB Regulations 2006 still requires Serious Case Reviews to be undertaken in defined circumstances; but the new guidance stipulates that reviews should be completed in a way which: - recognises the complex circumstances in which professionals work - seeks to understand the reasons that led individuals and organisations to act as they did - seeks to understand practice from the viewpoint of individuals and organisations at the time - is transparent about the way in which data is collected and analysed. (Chapter 4, para. 10) The guidance also advises that any learning model may be used, consistent with the principles contained in the guidance. 1.2. Introduction to SILP In 2010 Paul Tudor and Leicestershire & Rutland Safeguarding Children Board devised a methodology entitled Significant Incident Learning Process (SILP). The key principles of SILP are: - proportionality Baby T SCR - Final anonymised version 2 - learning from good practice - the active engagement of practitioners - systems methodology. These principles and the SILP methodology are entirely consistent with the 2013 Working Together to Safeguard Children guidance. 1.3. Introduction to the family It is understood that for a long time parents had lived separately whilst remaining in a relationship. 1.4. Introduction to the circumstances Aged seven weeks, Baby T was presented at hospital with bruising below his shoulder blades and around the armpits and also to the buttocks. Non-accidental injury was strongly suspected and this led to Children’s Social Care and Police investigations. An Initial Child Protection Conference placed his name and those of his three siblings on Child Protection Plans. The Working Agreement and Child Protection Plan was that his Father would be the parent with supervisory responsibility for all contact with Baby T’s mother because she claimed to be the sole carer for Ty leading up to the injuries. Just over six weeks after the Initial Child Protection Conference and resulting Child Protection Plan Baby T was again presented at hospital; and on this occasion with symptoms of being floppy and unresponsive and then having seizures. X-rays and a CT scan revealed a fractured skull. “Mother” 36 “Father” 39 “Baby T” 4 months “Baby E” 16 months “Brother K” 11 “Brother C” 14 Baby T SCR - Final anonymised version 3 Both parents were arrested and charged. Care Proceedings were issued and the children were placed with relatives. Subsequently Father admitted the charge of “Causing or allowing physical harm” and received a suspended sentence. The mother admitted the same charge and received a Community Order. The two older children have returned home to their Mother under Supervision Orders. The two younger children have been made the subjects of Special Guardianship Orders and placed with relatives. 2. PROCESS At a meeting of the Gateshead Local Safeguarding Children Board (LSCB) Case Review Sub Group on 3 October 2013, the decision was taken to recommend to the Independent Chair of the Board that the criteria for a Serious Case Review were met. Following peer consultation with another LSCB Independent Chair, the Gateshead LSCB Chair endorsed the decision to initiate a Serious Case Review on 21 October 2013. A further decision was taken shortly thereafter to use an alternative methodology rather than the “traditional” SCR process; and the company operating SILP (Review Consulting Ltd) were approached. Paul Tudor attended another meeting of the Case Review Sub Group on 13 November 2013 and explained the SILP process and methodology, from which the sub group were willing to proceed. Thereafter Terms of Reference, a Project Plan and an Agency Authors’ Template were approved (see Appendices [i] and [ii]) and the agency reports were commissioned. A Learning Event was held on 4 February 2014 and was very well attended (30+) including several Consultant Paediatricians, Designated Doctors, representatives of Community Health, GPs, Nursing, Police, Children’s Social Care, Education, Barnardo’s, Mental Health. The agency reports had been circulated a few days in advance so that the participants had comprehensive Baby T SCR - Final anonymised version 4 material in order to generate productive and challenging discussion, analysis and debate. A first draft of this report was then circulated a few days ahead of a Recall Event (3 March 2014) and again a large number of participants (25+) debated the issues. This process helped to formulate the final version which was presented to the Gateshead LSCB on 26 March 2014. Whilst the final version was accepted and endorsed by the Gateshead LSCB (after a few minor amendments), it was decided to postpone submission and publication until after the criminal trial (in case new information emerged); and to invite parents to contribute (which could not take place until after the trial). Invitations were sent out, to which Father did not respond; but Mother expressed an interest in speaking to the Lead Reviewer and LSCB Business Manager. An interview was set up and held on 1 August 2014, at which Mother was supported by an Advocate. Her views have been woven into the text at the appropriate places. Advice was taken in respect of involving Brother C and Brother K in the review and it was felt by a number of professionals that they would find the process very distressing and would be upset by any approach as they were upset by everything that had happened and did not wish to talk to anyone about it, therefore they were not contacted. Baby T himself is too young to have been consulted as part of the SCR process. The process has been very efficiently administered by Linda Conroy, to whom my sincere thanks. 3. BACKGROUND AND CONTEXTUAL INFORMATION RELATING TO MOTHER AND CHILDREN As an introduction to this section it is noteworthy that the family had very little contact with agencies prior to the scoping period. Baby T SCR - Final anonymised version 5 General Practitioner Mother has been registered with the same GP all her life; no concerns for her welfare or parenting skills have been identified. For the children, no significant events or safeguarding issues emerged prior to the scoped period. Routine consultations and appointments were conducted (i.e. immunisations, common health concerns). Community Midwife Mother had attended all her antenatal appointments for her pregnancy with Baby E (born February 2012) and she had continued work (a Production Administrator) throughout both pregnancies. She was breast-feeding Baby E throughout her pregnancy with Baby T. Child Health All the children received universal health visiting and school nursing. They attended A&E for minor illnesses and injuries; no safeguarding concerns were ever raised. Education For Brother C, attendance has been something of an issue throughout his school career, dropping to 62% in his first year at secondary school. In Year 7 it was always his father who rang the school to inform them of absences and the school had little contact with his mother. After two failed appointments (when parents had been invited to discuss attendance), a Letter of Concern was sent by the Education Welfare Service and his attendance improved the following year. The Education Welfare Service has established a staged response to managing attendance problems which is more proactive. The Education Welfare Service has established weekly allocation meetings and monthly Baby T SCR - Final anonymised version 6 supervision sessions allowing for a robust approach to individual case management. There have been some low level behaviour issues with Brother C which the school have dealt with by verbal reprimands and loss of privileges only. Academically he is achieving within his abilities. Brother K presents very well and is making good progress. He is popular and no significant behaviour issues are reported. Police and Children’s Social Care Neither parent nor the children were previously known. 4. KEY PRACTICE EPISODES This section acknowledges a style promoted by Learning Together (SCIE). 4.1. Antenatal Visit At the 13 August 2012 booking appointment by the Community Midwife, no presenting problems or concerns were identified (i.e. Mother and Father were both non-smokers, Mother stated that she did not use alcohol or substances, did not disclose any domestic violence and no mental health issues were disclosed), however she did suffer gestational diabetes with her last pregnancy. Antenatal clinic appointments were completed on 5 September 2012, 9 December 2012, 3 October 2012, 12 December 2012, 19 December 2012, 4 January 2013, 30 January 2013, 6 February 2013 and 21 February 2013, i.e. all her appointments. Throughout, no safeguarding concerns were identified though Mother became very tired (she was still working and breast-feeding Baby E). Baby T SCR - Final anonymised version 7 4.2. Baby T’s birth in February 2013 A planned induction took place at 37 weeks due to a large baby, increased amniotic fluid and gestational diabetes. No resuscitation was required immediately, but after 15 minutes some breathing difficulties were noted and therefore Baby T had a short admission to Special Care Baby Unit (SCBU) at HOSPITAL 2. Father was present at the birth. Mother’s Comment She feels the midwives were not as observant as they could have been and that it was she who drew their attention to the baby’s breathing difficulties. Baby T returned from SCBU after a day; Mother commenced breast-feeding and it went well; they were discharged the following day. 4.3. Postnatal Three routine home visits were conducted by a midwife in late February/early March 2013. Mother required injections daily for 6 weeks as she was at increased risk of thrombosis. A record states “technique shown to partner” (2 March 2013), thus confirming that Father was present at the home on that occasion – see Section 6 of this report. Mother’s Comment In fact Father felt unable to administer the injections (as did Mother herself) and so it was her sister who administered them. A primary visit was made by the Health Visitor on 8 March 2013. The issue of co-sleeping was discussed and Mother was aware of the risks and knew that it was not advisable. Application of the Early Warning Assessment showed the lowest level score, i.e. universal intervention. Baby T SCR - Final anonymised version 8 Father was not living with the family but staying over to help; Mother was tired; still breast-feeding Baby E (who is only 12 months older) but denied she was feeling down. The Health Visitor continued this visit on 8 March 2013 with Baby E’s 9-12 month assessment and there were no concerns about her development. Further home visits were made by the Health Visitor on 15 March 2013 and 22 March 2013. Baby T had a steady weight gain and the reviews were due to him being jaundiced. On advice to the Health Visitor from a Paediatric Senior House Officer, Baby T was taken by his mother to HOSPITAL 1 on 22 March 2013 where he was assessed by the medical team regarding his jaundice. On 28 March 2013, Baby T was taken by his mother to the hospital with a history of poor feeding and vomiting. He was admitted for a few hours; blood tests were taken and he was discharged within the day because the tests were normal and he fed well whilst on the ward. The diagnosis was of an early viral upper respiratory tract infection. Baby T’s GP received notification of the 28 March 2013 hospital presentation; and he was seen again on 11 April 2013 by his GP for a routine 6-8 week examination. Baby T’s head circumference was taken, testicular and hip examinations were conducted, there was no cardiac murmur; and there was good parental eye contact. No concerns were noted and there was no evidence of a viral infection. Mother’s postnatal examination was conducted at the same time and again no concerns were noted. 4.4. Bruises 14 April 2013 Mother presented Baby T at the Walk-in Centre, concerned that a rash on his nose might be an abrasion or possible meningitis. The Walk-in Centre referred him to the HOSPITAL 1 Paediatric Team. Baby T SCR - Final anonymised version 9 On examination, there was bruising on his buttock (no explanation), a small area on his lip looked infected and was crusting; a lesion on his nose; bruising on left and right sides of his back under the shoulder blades within the armpit. Mother could offer no explanation and reported that there were no other carers other than “dad at home” (meaning that Father was at home at the current time, but it was established that he did not live there on a permanent basis). She was not aware of the other children causing any injury to him other than his 14 month old sister having nipped him and left a bruise previously on his leg. The first examining doctor was a Paediatric Trainee and she appropriately considered non-accidental injury as part of her differential diagnosis. Therefore she drew it to the attention of the Consultant Paediatrician on call that evening, who also reviewed Baby T and initiated some blood tests. These blood tests were normal. Again Mother was unable to provide any explanation for the bruising. Mother was told by the Consultant Paediatrician that Baby T would need to stay in hospital overnight for further tests and that the Duty Social Worker, the Health Visitor and the GP would be spoken to. The following day, CT scans and X-rays showed no subdural haemorrhage or fractures. 4.5. Investigation The Consultant Paediatrician duly phoned Children’s Social Care Emergency Duty Team (EDT) at 21.00 hours and the EDT Social Worker informed the Police at 22.30 hours. Between them they confirmed that there was no previous knowledge or information in either Police or Children’s Social Care records. A Strategy Discussion took place confirming that Baby T needed to remain in hospital overnight. As Mother was breast-feeding both Baby T and Baby E, it was arranged by Children’s Social Care, with the agreement of the Police, that Baby E would be brought to the hospital and a childminder was organised to chaperone Mother’s care and breast-feeding of both children; leaving Father to look after the two older boys overnight. Baby T SCR - Final anonymised version 10 Comment This represents good early information sharing between Hospital/Police/Children’s Social Care; and very good, imaginative and sensitive practice by Children’s Social Care and ward staff in keeping a mother and young children together. However, Mother’s view is that this arrangement was more about checking Baby E than supporting her and the two children staying together. As that Consultant Paediatrician was on leave the following day, a colleague Consultant Paediatrician agreed to take over the management of the case; and did so by reviewing Baby T on the morning of 15 April 2013 and meeting Mother. The only explanation she could offer for the bruising below his shoulder blades and around the armpits was lifting him when she was breast-feeding and carrying him. A CT head scan, skeletal survey, and ophthalmology review were all conducted and later in the afternoon reported as normal. Baby T remained well on the ward (see Section 8). Mother confirmed in her interview that it was explained to her that the baby’s eyes had to be checked and she understood that possible shaking might be suspected. The Consultant Paediatrician consulted the GP, who reported no concerns or abnormalities at the 6-8 week check on 11 April 2013 (Key Practice Episode 4.3). The Consultant Paediatrician also reviewed Baby E and confirmed normal development and no signs of injury. 4.6. The Plan In addition to a joint visit to the hospital by Police and Children’s Social Care to see Baby T and Mother, and also to meet the Consultant Paediatrician, there were a number of telephone conversations between the Consultant Paediatrician, the allocated Social Worker, who was at the hospital, the Baby T SCR - Final anonymised version 11 Assistant Team Manager who was at an office and the Police during the afternoon of 15 April 2013. These comprised Strategy Discussions confirming that the bruising to a non-mobile infant was concerning and unexplained; that Mother had been the sole and consistent carer for Baby T; and she reported that Father had never cared for Baby T alone, although he visited the family home daily. Checks made with the Police and with the Local Authority (in relation to the two older boys at school) were all unremarkable. Therefore a written agreement was devised whereby Mother would move out of the family home and reside with her grandmother, and Father would move in. He would take over the care and responsibility of all four children, but Mother would visit a lot to breast-feed Baby T and Baby E and to share the care of the children, but under his supervision. She was indeed at the family home most of the time, as she described that there were no time constraints. Analysis of systems in relation to strategy discussions/strategy meetings, and of the practice relating to the plan are discussed at Sections 7 and 8. 4.7. Section 47 enquiries by the Social Worker The following activities took place: • Liaison with the schools for the two older children • Liaison with Health Visitor and School Nurse • Liaison with Police and Consultant Paediatrician • Legal consultation • Liaison with the children’s and Mother’s GP • Two announced and two unannounced visits • The two older boys seen and spoken to away from the family home • Childminding support was offered to Father but he declined Baby T SCR - Final anonymised version 12 • A referral to Barnardo’s Family Support service • The family did not want any other extended family members involved Comment This represents very comprehensive and efficient practice of a high standard. However, the obvious gap is that no contact was made with Father’s GP – see Section 8. 4.8. Other interventions At a Health Visitor home visit on 16 April 2013 – Baby T appeared well and his jaundice had resolved. Mother was feeling down and low (tearful) and attributed this to Children’s Social Care involvement. On 19 April 2013 Mother contacted the Health Visitor regarding new marks on Baby T’s face. They both considered them to be milk spots and the Health Visitor advised Mother to seek medical attention if they got worse. Comment The Health Visitor should have consulted her Safeguarding Nurse Advisor and it would have been appropriate to inform both the GP and the Social Worker. At a review by the Consultant Paediatrician on 1 May 2013, Baby T was well; there was no further bruising; and repeat X-rays were taken and proved normal. 4.9. Initial Child Protection Conference See section 5. 4.10. Challenge and Escalation The Consultant Paediatrician sought supervision with the Designated Doctor on 7 May 2013 and they agreed that from the history this was likely to be non-Baby T SCR - Final anonymised version 13 accidental injury. The supervision arrangements were discussed and there was concern that the plan may not ensure safety within the family home. On 8 May 2013 the case was also discussed at a Regional Consultant Paediatric Peer Review meeting at HOSPITAL 2 and this was attended by the Consultant Paediatrician. The conclusion was that non-accidental injury was likely and that the vulnerable infant may be at risk in the home with this current supervision plan. The following day (9 May 2013) the Consultant Paediatrician relayed this view to the original Referral and Assessment social worker who agreed to pass it on to the newly allocated Safeguarding and Care Planning social worker (see 4.11 below). The Consultant Paediatrician has recorded the views of the Peer Review and his contact with the social worker in the hospital records. Another Consultant Paediatrician who chairs the Peer Group at HOSPITAL 2 contacted the Designated Doctor on 9 May 2013 by email (which was read on 10 May) expressing concerns about the care arrangements and raising whether breast-feeding had been given a greater priority than safety. The Designated Doctor was unable to speak to that Consultant Paediatrician on 10 May. She then spoke to the previously allocated Social Worker who confirmed that the concerns of the Peer Review had been passed on. The newly allocated Social Worker was not available and therefore the Designated Doctor spoke with their Team Manager later that same day (10 May 2013). The Team Manager satisfied the Designated Doctor that the plan had been agreed at the Child Protection Conference; it would be monitored by the Core Group; and during the preceding three weeks there had been no indication that the parents were not cooperating. Therefore there was no real reason to remove Baby T from the household. Additionally, Police checks were being undertaken on the maternal aunt so that she could offer additional support. The Designated Doctor confirmed in the Learning Event that she was satisfied with this explanation. Baby T SCR - Final anonymised version 14 In the Learning Event and the Recall Event the Team Manager again reinforced that breastfeeding had not been given undue prominence; and certainly had not overridden the need for a safe plan for the children. Indeed the original plan had been that Mother would express milk and it was only when she was unable to do so that she came to the house for all the feeds. A third discussion on this case took place at a local Peer Review (at HOSPITAL 1) on 21 May 2013 with four other Consultant Paediatricians present, including the Designated Doctor. The previous concerns about the safety of supervision were reiterated but no further action was recorded. Comment The Regional Group is a forum for paediatricians across the region to access peer support and advice on the management of Safeguarding cases. Challenge is healthy. It has been reported for this Serious Case Review that for the Chair of the Peer Group to make contact with the Designated Doctor is unusual and emphasises that they thought the situation was a risky one. 4.11. Ongoing investigations Meanwhile, immediately after the Initial Child Protection Conference the case had transferred from a Referral and Assessment Social Worker to a Safeguarding and Care Planning Team Social Worker. They made a joint home visit to introduce the new worker to the family on 8 May 2013 and then she made a further home visit on 14 May 2013. The case was allocated within Barnardo’s to a named Project Worker on 9 May 2013. 4.12. Core Group 15 May 2013 The allocated Social Worker was unavailable at short notice to chair the Core Group meeting; and the chairing was therefore undertaken by a Duty Social Worker who had very limited knowledge of the case. Baby T SCR - Final anonymised version 15 Parents were present, and during the meeting the other professionals (School Nurse, School and Health Visitor) expressed concern that the two older children did not need to be on Child Protection Plans; and having their mother residing out of the family home may be having a detrimental emotional effect. There was a recorded view that the safety plan should be reviewed regarding Mother not having unsupervised contact with the two older children. Comment There is a systemic flaw in that no Social Worker or Team Manager with any knowledge of the case was present. Whereas the Core Group was considering a relaxation of the Child Protection Plan, no input is recorded describing the escalation and challenge from Paediatricians (see Section 4.10). No changes were actually made by this meeting as the Chairing Social Worker said she could not agree to them. The Children’s Social Care Team Manager did know of the challenge; and the issues of safe supervision were so important that ideally the Core Group should either have been rearranged, or another meeting called urgently when the Social Worker and/or Team Manager could be present. However, there is a very real dilemma about Core Groups going outside of prescribed timescales (10 days from the Initial Child Protection Conference) as these are set out in Working Together to Safeguard Children (2013). Therefore there is a very real pressure to keep within timescales. 4.13. Ongoing interventions • Health Assessments on Brother K and Brother C by the School Nurse on 15 May 2013 revealed no concerns. Baby T SCR - Final anonymised version 16 • A 3-4 month check by the Health Visitor during a home visit on 21 May 2013 confirmed that Baby T’s development and height and weight were fine and there were no concerns. • A second immunisation by the GP on 28 May 2013. • An initial home visit by Barnardo’s Project Worker on 29 May 2013 and then a subsequent visit on 30 May 2013, to complete paperwork. • Mother presented to the GP on 3 June 2013 with low mood (crying, not sleeping, poor concentration) but she declined counselling. • A Child Protection visit was undertaken by the Social Worker on 4 June 2013 and all the children were seen. Although Mother was tearful, both parents were still agreeing to follow the plan. • Parenting Assessment visits by the Barnardo’s Project Worker on 5 June 2013, 6 June 2013, 13 June 2013 and 17 June 2013. 4.14 Second Core Group Meeting 10 June 2013 Again the parents attended and the Social Worker, but only one school was represented; and the Health Visitor and the Barnardo’s Project Worker both tendered apologies. This time the concerns expressed by the HOSPITAL 2 Peer Group were discussed; but the conclusion of the Core Group was that there did not need to be a change of plan, as parents were cooperating. Indeed, as there had never been any safeguarding concerns regarding the two older boys, there was in fact a change in the plan, i.e. that they no longer needed to be supervised in their day to day contact with their mother. Also the Police checks on the aunt had come back clear so she could act as a supervisor of Mother’s contact, to relieve some of the pressure on Father. Comment On reflection, agencies are saying that there should have been more challenge to the sustainability of the supervision arrangements and the Baby T SCR - Final anonymised version 17 stress they were causing. Children’s Social Care hold the view that the plan was an integral part of the assessment and was never envisaged as a long-term arrangement. It would be constantly re-evaluated up to the Review Child Protection Conference and members of the extended family were being brought in to offer additional support. Mother suggested that she did not receive Core Group minutes from either the first or second Core Groups. 4.15. Second presentation to hospital 14 June 2013 Baby T was brought to HOSPITAL 1 by his mother and aunt early morning (5.22am). He was seen by a Trainee Doctor and then by a Consultant Paediatrician. Mother reported to the doctors that Baby T had woken up screaming and very distressed, breathing fast and snuffly; then he had a floppy episode and then brought up some blood-stained phlegm. Mother was very open with the Consultant Paediatrician about previous child protection issues and that Baby T was subject of a Child Protection Plan. On examination there was no sign of bruising and there seemed to be appropriate mother/child interaction; but “he does not look happy” (Doctor’s notes) and three non-blanching red spots to the right leg were recorded. Blood tests revealed a raised platelet count and a white cell count; and Baby T was diagnosed with a probable viral infection. He was discharged later that afternoon with a plan to repeat the blood tests in two weeks. Children’s Services EDT and the GP were notified (in the form of a discharge summary). Comment A systemic issue – the notes from the Designated Doctor’s discussion with the Children’s Social Care Team Manager were not in Baby T’s hospital records at this point as the Designated Doctor is based on another site. Therefore the examining Consultant Paediatrician did not have access to this dimension. Baby T SCR - Final anonymised version 18 4.16 Second Injuries Baby T was brought back into HOSPITAL 1 at 15.23 hours on 18 June 2013 by his parents, who reported a history of short episodes which looked like seizures while they were travelling in the car. At A&E staff noted further seizures and treatment to stop the seizures was commenced. He was transferred to a ward where further seizures were observed. Therefore he was later transferred to HOSPITAL 2 for ongoing care and further investigations. Meanwhile, a CT scan had revealed a skull fracture. Children’s Social Care and the Police were informed; and an EDT social worker attended at 20.10 hours. The Police also attended and therefore there were conversations between Police/EDT and medical staff. It was quickly arranged that one maternal aunt would stay with Mother, and another maternal aunt would look after the three remaining children at home. A Strategy Meeting was held on 19 June 2013 and it was confirmed that the three children would remain in the care of the maternal aunt after a Regulation 24 Connected Person’s Assessment was completed and approved. The other aunt was also assessed in order to assume responsibility for caring for Baby T upon his discharge from hospital. All contact by parents would be supervised by Children’s Social Care. Section 47 enquiries by the Police and Children’s Social Care were commenced and subsequently both parents were arrested and interviewed under caution. Baby T was discharged from hospital to the maternal aunt on 26 June 2013 following a Discharge Planning Meeting earlier that day. Discharge communication was sent to the GP and follow-up arrangements with the Consultant Paediatrician at Gateshead were clearly documented. Baby T SCR - Final anonymised version 19 4.17. The Services Offered The involvement of General Practitioner, Hospital, Police, Children’s Social Care, Health Visiting, Schools, etc. have all been described in some considerable detail in the text of Sections 3 and 4 above. The other service to the family was a commissioned one, i.e. Barnardo’s. Based on a telephone referral on 2 May 2013, the request for work from Barnardo’s Sungate service was specifically to undertake an observational role and to report on family functioning and attachments to inform the social worker’s assessment. On 22 May 2013 the Project Worker met with the Social Worker to gain background information; and the outcome was a request for 2 x 2 hourly visits per week within an 8-week timeframe for the Social Work Assessment to be completed. Within these visits, in addition to observation, the Project Worker would report on parenting ability and offer both parents emotional support. During the appointed six visits (see Section 4.13) the worker made detailed observations of child care, family functioning, child development and identified no issues to cause concern, other than parents’ anxiety about the circumstances. The case was discussed thoroughly in supervision. 5. THE INITIAL CHILD PROTECTION CONFERENCE (3 May 2013) As per Gateshead LSCB Inter-Agency Child Protection procedures, the Social Worker used Form CF62 to request to arrange an Initial Child Protection Conference and emailed it to the Safeguarding Unit on 18 April 2013. At that time invitations were mainly sent by hardcopy letter through Royal Mail postage. The Social Worker had not identified Father’s GP and therefore they were not invited, the significance of which is discussed at Section 8. The invitations were not sent until 29 April 2013 (11 calendar days after receipt of the request) and only 4 working days prior to the conference (i.e. Monday to Friday 3 May 2013), but this time scale was within the 15 days Baby T SCR - Final anonymised version 20 from the Strategy Discussions on 15 April 2013. Nevertheless, there was a more than adequate attendance (representing Children’s Social Care, Police, Hospital Doctor, Health Visitors, School Nurse, Schools) though the Chair should have highlighted the absence of GPs. There was also a wide range of reports tabled (Children’s Social Care, Paediatric Assessments, Health Visitor, School Nurse, Schools, Police). Comment This number of reports from all participants represents very good practice. Both parents had received invitations and both attended, but on their own and without support. The Health Visitor and School Nurse reports had been shared with them prior to conference; they were unable to fulfil the appointment which the Social Worker offered to go through the conference report the day before but the conference report was posted through their letterbox. Moreover, they arrived early in order to go through the report with the Social Worker beforehand. They also had a half hour meeting with the Chair prior to conference. The Chair made attempts to facilitate their involvement in the conference but reportedly they did not make much contribution or challenge in the conference. Although Referral and Assessment Team Social Workers always prepare a chronology when opening a case, on this occasion the conference did not receive a stand-alone chronology as the interventions and timescale were very limited; but a chronological sequence was contained in the text of the Social Work report. There is no recorded evidence of any discussion about inviting the two older siblings or asking an advocate to represent their views or to participate in some other form. Neither they nor an advocate attended or participated in any way. However, the Social Worker informed the Recall Event that Brother C had been asked if he wanted to attend or participate in some other way and Baby T SCR - Final anonymised version 21 he declined. Nevertheless, their views did assist in formulating the plans, i.e. they wanted their Mother to return but they supported their Father’s role in caring for all four children. The content and process of the conference (as represented by the minutes and as analysed by an independent author preparing a report for this Serious Case Review) gives no information or insight into Father’s background, his current circumstances, his relationships with Mother and the children, or his parenting capacity. There should have been. In the absence of this dimension, a requirement to satisfy this should have been clearly spelled out in the Child Protection Plan; “parenting assessment” is too vague. (Gateshead does have a specified format for a parenting assessment and most professional conference attendees would be aware of the prescribed format). Similarly, the Outline Child Protection Plans have vague timescales “as soon as possible”, “ongoing”. There was a further missed opportunity to explore Father’s role when the Child Protection Plans were being formulated and Father talked of “the house is up all night and it is very distressing for everyone”. This could – and should have – opened up discussion about the family functioning and his role in it. There are two process issues reflected in the minutes of the Initial Child Protection Conference. It was very good practice for the Consultant Paediatrician to present published journal evidence to support his views; but this is not recorded in the minutes. Neither is there a record of the break in the conference at which point parents were asked to leave for a few minutes while the conference received confidential information. The standard for the distribution of the decision for conference and the Child Protection Plans is 24 hours. In this instance the distribution took place on 14 May 2013 (11 calendar days and 7 working days later). The explanation was a technical issue with CareFirst (the electronic recording system) which was reported to the CareFirst Helpdesk. Baby T SCR - Final anonymised version 22 The standard for the distribution of the Chair’s report is 20 working days which would have fallen on 3 June 2013. In fact they were distributed on 2 September 2013, i.e. 3 months out of timescale and 4 months from the conference. The delay was caused by operational issues. These issues are now being addressed and 96.4% of Child Protection Plans are now distributed in timescales. Work continues to take place to ensure that Child Protection Chair’s Reports are distributed on time, which is monitored on a weekly basis. Comment Not only is the record of the conference a crucial working document for the professionals and the family, but it also makes it very difficult for a Chair to confirm the accuracy of the minutes from memory three months previously. 6. PROFESSIONAL INTERVENTIONS WITH FATHER NB: His first name is sometimes spelt differently. This discrete section is necessary, partly because there is a lot of missing information in the management of the case because no checks were made with Father’s GP; and partly because there is such a contrasting and discrepant history. Father has known his current GP since 2000 and by 2003/04 this GP was the only doctor that he would see. Father has been known to the practice since 1993 for anxiety symptoms. Over the course of the next few years he was considered to have chronic anxiety with social and agoraphobic symptoms and obsessional thoughts. He was referred to a psychiatrist in 1993 for anxiety and depression from which he was referred to an anxiety management group. There were hospital presentations in 1994 (panic attack; persistent nausea; depression and feelings of self-harm); and he called an ambulance after taking an overdose. He was then seen by a number of professionals within Baby T SCR - Final anonymised version 23 mental health (Psychiatry, Psychology, CPN, OT) and all reported non-compliance with medication and missing appointments; he lacked motivation to engage in therapeutic work. Low mood led to referrals in 1998/99 but he continued to fail appointments. Again in 2006 with the same outcome. The Psychology service was involved 2007-09 and Father made reference to his two boys whom he saw at weekends. They were assessed as a protective factor in relation to his mental health. At a multi-disciplinary team meeting in July 2009 it was considered that Father did not have a serious mental health problem, but he lacked motivation to change and was unwilling to accept support and the psychological work ended in November 2009. With his GP, Father remained on antidepressant medication. In a report for Benefit purposes the GP noted: “He is a man whose life is severely affected and restricted by his mental health problems but he rejects help and is difficult to engage. His strategy is avoidance of life to reduce anxiety. His problems are chronic and stuck”. (August 2010) Within the scoped period (July 2012-June 2013), Father saw his GP monthly and this is corroborated in the chronology for this Serious Case Review. He was being treated for depression by regular antidepressant medication and his condition appeared stable and he declined offers of intervention such as counselling. I now quote some of the General Practitioner entries and have left them in note form as they appear in the records: Baby T SCR - Final anonymised version 24 Appointment date Entry in records 2 August 2012 6 September 2012 Continues in his very small, safe world with no real motivation to change. 8 October 2012 8 November 2012 A range of mental health options declined; a young recluse really, a terribly small life, in some ways content with it, not a risk to himself, no thoughts of self-harm, no harmful behaviours, but not normal or good for his two sons to visit, i.e. not stimulated or engaged by him, but no safeguarding concerns. He saw the boys at his father’s house. 6 December 2012 8 January 2013 5 February 2013 Went to his ex-wife’s house for Christmas and enjoyed seeing the children 4 March 2013 Sees kids occasionally at his dad’s house, spends time between his dad’s and his brother’s. (NB: In the light of this 4 March 2013 entry, the midwife reported showing him an injection technique for Mother at a home visit on 2 March 2013.) 11 April 2013 Zero motivation; content in a very restricted lifestyle 16 May 2013 Reported that his father was in hospital and he was staying with his brother. (NB: Section 4.6 of this report. From 16 April 2013 he has been the supervising parent under a Working Agreement and responsible for all four children.) In summary, the GP knew nothing of the two younger children, nor of Father having contact with the boys’ schools (Section 3), nor of the information shared in the conference that Father visited the family home 3 or 4 times per week including staying overnight. The observations of the Barnardo’s Project Worker (and reinforced by Health Visitor) was that when Father was in the supervisory/caring role for the children; he was very passive; he needed prompting from Mother to play with and distract Baby E when Mother was breast-feeding Baby T. Also, that Baby T SCR - Final anonymised version 25 Father felt he had been forced into this role, rather than taking it on by choice; and he needed to learn a lot about day to day care, of which Mother was still undertaking the majority. Father showed an interest in the process by asking many questions and generally he presented quite well. However, he remained in the background, eg. sitting in the kitchen leaving Mother to undertake the main care (Health Visitor record of a home visit on 16 April 2013). In the interview with the Lead Reviewer and LSCB Business Manager, Mother was able to provide some background context to her relationship with the children’s father. He had lived at the home of his grandparents; Mother and Father met on a night out in Newcastle and she became pregnant with the eldest boy within four months. However, Father chose not to move in with her, though he visited regularly. He never wanted to commit to sharing a mortgage; though he did offer her some financial support. With the two boys they spent time together as a family at Christmas, birthdays and went away on holidays together. On occasion, they attended Parents’ Evening at school together. He had several jobs and was always in work, often at Call Centres. Mother attributes his depression to suffering two close bereavements in quick succession; but she had no knowledge of the depth of his mental health problems as described in his GP’s statement in the criminal proceedings. She stated that she was shocked when she read the report from his GP; and she reflects that if she had been given any such knowledge or insight, she would not have agreed to the supervision arrangements discussed earlier in this report. Author’s Comment It has already been fully discussed in previous sections of this report that Children’s Social Care also did not have or obtain this insight. The analysis for this Serious Case Review has constantly been struck Baby T SCR - Final anonymised version 26 by the great disparity between the GP’s description of Father’s mental health history, and Mother having no inkling of this history, despite them being together for 15 years. Maybe he was deceptive towards his partner; maybe he exaggerated his symptoms to his GP; but he has declined an invitation to meet the Lead Reviewer, and so this disparity cannot be explored any further for this Serious Case Review. Finally, Mother describes Father as quiet and he always liked to be in quiet areas (e.g. in restaurants) and she confirmed that he used to wear headphones quite a lot, for peace and quiet. Nevertheless, after Baby E was born, Father came through every day to help and they were talking seriously about him moving in on a permanent basis (prior to the events under review). 7. SYSTEMIC LEARNING a. This Serious Case Review has identified some good practices and systems: - The roles and responsibilities were clearly identified and communicated between clinicians at HOSPITAL 1 and HOSPITAL 2. - For the investigation of the second injuries, while the Police were interviewing the parents, the Consultant Paediatrician made herself available by phone so that they could discuss the explanations that were being given. This allowed the Consultant Paediatrician to consider and discount them which, in turn, enabled the Police to effectively challenge the parents during the interviews. This process included taking items mentioned by the parents to show the Consultant Paediatrician for her consideration. - The GP was consulted by the Consultant Paediatrician during the investigation of Baby T’s first injuries on 15 April 2013. - The GP received discharge summaries and handovers from A&E, Walk-in Centre, Cause for Concern, Special Care Baby Unit (5 March, Baby T SCR - Final anonymised version 27 22 March and 28 March 2013, 14 April and 18 April 2013, 14 June and 17 June 2013). - Hospitals are now sending copies of Immediate Response forms to GPs rather than them waiting for delayed Discharge Forms. - The use of the Information-sharing form from Health Visitors to GPs. - A provisional proforma describing injuries and examination given to the Social Worker and Police Officer whilst at the hospital and then a copy emailed later. - Strategy Meetings and Pre-discharge meetings held in hospital to provide the opportunity for clinicians and professionals to attend with least interruption. - Health Visitor and Safeguarding Nurse attended 19 June 2013 Strategy Meeting and the Health Visitor attended the Discharge Planning Meeting on 26 June 2013. b. This Serious Case Review has also identified some issues which have been put in place recently, some of which have arisen directly from this process: - Distribution of Child Protection Plans within 1 working day of the conference is currently 100%. - Child Protection Conference invitations and minutes are now distributed electronically by secure email with “read/receive” facility. - Within Children’s Social Care for Section 47 enquiries an additional mandatory section has been included in the documents detailing checks have been undertaken with the parents’ GP and that they may be two different GPs. Social Workers have been briefed. - A Health Visitor contact antenatally is now a standard expectation (but it was not so at the time). Baby T SCR - Final anonymised version 28 - Children’s Social Care Team Managers have been advised of the importance of the first Core Group and of ensuring that it is chaired by the allocated Social Worker or Team Manager. c. Nevertheless, there remain some outstanding issues: - GP attendance at Child Protection Conferences remains very low (approximately 2%) and the incidences of GP reports to conference is still only approximately 20%. These figures are being monitored regularly by the Safeguarding Unit and the CCG and are being raised in GP Newsletters and in training sessions for GPs. - The issue of regular meetings between Health Visitors and GPs was a recommendation from a previous Serious Case Review. There is a Link Health Visitor allocated to each GP practice and they should meet at least quarterly; but not wait for scheduled meetings when there are urgent case issues to be discussed and information to be shared. In this case meetings took place with the Practice Manager which is not acceptable, as the Practice Manager does not have clinical authority. - Notes of any discussion with a Designated Doctor must be placed on the child’s hospital records at the earliest opportunity. - There is another practice issue which Mother raised in her interview. She considered that there were several examples in which the Police and hospital staff lacked discretion, eg. the Police were in uniform accompanying her between wards; the curtains were not drawn when photos were being taken, so that other parents could see what was happening. 8. THEMATIC LEARNING Contained in the agency reports and debated at the Learning and Recall events, a number of key areas have emerged; and they are best posed as questions. Baby T SCR - Final anonymised version 29 8.a. Did Paediatricians convey and explain their thinking on how significant the first injuries were? Implicit in the fact that an Ophthalmology Review and CT head scans were ordered during the investigation of the first injuries on 14 April 2013, was that “shaken baby” was being considered; particularly in the light of the siting of the bruises. The Police confirm that the first Paediatrician they dealt with did explain that she was considering “shaken baby”, but in the absence of other features discounted it. None of the Children’s Social Care staff involved in this investigation ever heard the phrase being used or the condition being considered. The Consultant Paediatrician who took the lead on the investigation and the Designated Doctor have explained to this Serious Case Review that in the light of the positioning of the bruises they had to consider “shaken baby” even at a low level, in order to try to prevent such behaviour escalating to a serious “shaken baby syndrome”. In order to gain Baby T’s mother’s consent for the tests, the Consultant Paediatrician and/or nursing staff must have explained their thinking to a greater or lesser extent to her. However, such explanation and clarification was not made to the investigating Social Worker or Police Officer; and the issue of Strategy Discussions rather than Strategy meetings comes into play at this point (see Section 8b below). Whilst the phrase “shaken baby” does not appear in the Initial Child Protection Conference minutes, and the Chair of the conference who attended the Learning Event has no recollection of the term being used, there is no doubt that the conference members did understand the significance of the injuries to such a young baby. This is evidenced by the Consultant Paediatrician bringing to the conference journal literature; and also by the outcome of all four children being placed on Child Protection Plans. In particular, the investigating Social Worker and Police Officer, both of whom attended the Learning Event, confirmed that they Baby T SCR - Final anonymised version 30 understood and accepted the seriousness and significance of the injuries to a non-mobile baby. 8.b. Did the process of a number of conversations and strategy discussions on 15 April 2013 compensate for the lack of a formal Strategy Meeting? There is clear evidence that the investigating Social Worker and Police Officer were at the hospital during the afternoon of 15 April 2013; and they were speaking to both parents and the Consultant Paediatrician; and they were also consulting with the Team Manager back at the Children’s Social Care office. As a result, a Working Agreement Plan was put in place (see 8.3 below). However at the Learning Event, the Consultant Paediatrician described the process in hindsight as “a series of conversations in motion” and he doesn’t consider that he contributed to the plan or was party to the decision; the plan was presented to him and he accepts that he did not make a challenge to it. The dynamics of a series of conversations are very different to those of sitting down for a face to face meeting where ideas can be thoroughly explored. Rather than a series of bi-lateral communications, “the whole is greater than the sum of the parts”. A recommendation has emerged from this dimension. 8.c. Was the decision to allow Father to take over the care of the children and to supervise Mother’s contact a wise and defensible one? The Children’s Social Care stance is that this was a proportionate decision and plan, on the grounds that Mother was stating that only she had had sole care of Baby T and therefore she appeared to be taking responsibility. There were no identifiable concerns regarding Father (to whom the Social Worker had spoken at some length); and it gave all four children the stability of remaining at home. Moreover, birth fathers would not normally be routinely assessed in order to care for their own children; and both Mother and Father signed a Working Agreement. Baby T SCR - Final anonymised version 31 As a pragmatic and short-term solution, it can be concluded that the decision was a reasonable one. 8.d. Were there opportunities to review that decision and the plan; and were those opportunities utilised? The position of Mother taking responsibility at the time of Baby T’s first injuries and therefore Father not being considered as a perpetrator was accepted by everyone and never revisited or reconsidered. He was consistently seen as the safety factor. There were significant members of the respective extended families, notably Father’s father and Mother’s mother and sisters. Mother and Father made it known that they did not want their extended families to be informed or involved. However, once Children’s Social Care were into Section 47 enquiries, there is a strong argument that it would have been justifiable to pursue contact and enquiries with the extended family as, inevitably, members of the extended family often hold vital information. Structurally there were two major opportunities to gain very valuable information. Whilst the Section 47 enquiries were generally very comprehensive (see Section 4.7), the significant omission was not to identify and subsequently contact Father’s GP. Secondly, (and similarly), not to identify this GP to the Safeguarding Unit so that they would receive an invitation to the Initial Child Protection Conference. Equally, this should have been picked up by the conference. Also, there is an important reference in the minutes of the Initial Child Protection Conference “Mother said this means Father is literally up 24 hours. Father advised the whole house is up every night and it is very distressing for everyone”. This throws light on the future sustainability of the plan. Thereafter, of the three Peer Review and Supervision discussions, the first was relayed by the Consultant Paediatrician to the Social Worker, the first and Baby T SCR - Final anonymised version 32 second were relayed by the Designated Doctor firstly to the Social Worker and then to the Team Manager, and the third was not relayed. However, by then the Working Agreement which was endorsed by the Child Protection Plan had been in operation for over three weeks, with no indication that it was being breached, i.e. the parents appeared to be cooperative. 8.e. If Children’s Social Care and the professionals at the Initial Child Protection Conference had been given the information from Father’s GP and from Mental Health Services which appears at Section 6 of this report, would it have made a difference to the plan? Father’s GP and representatives from Mental Health Services attended both the Learning Event and the Recall Event and made it clear that if they had been approached by Children’s Social Care and/or invited to and attended the Initial Child Protection Conference, they would have shared all the information contained in Section 6; even if this meant overriding Father’s consent, as he was being put in charge of the children. The Children’s Social Care position is that Father’s mental health problems emanate from a period a long time ago, and the only current medication is antidepressants. This in itself would not necessarily preclude him from assuming care of the children; and the plan and working agreement could still have gone ahead, albeit with more discussions with him, perhaps more support and analysis, and perhaps more intervention based on his apparent limited experience for caring for the two young babies. The GP’s position is that Father was barely able to look after himself or meet his own needs; he would have no ability to look after the children. Moreover, he was “leading a double life” and/or being significantly dishonest with his GP. This “double life” and dishonesty certainly needed to be rigorously exposed and explored before putting him in a supervisory and responsible role, eg. the GP states that he could not stand noise and was constantly wearing headphones, whereas this was never seen at the family home. Baby T SCR - Final anonymised version 33 The Children’s Social Care agency report states: “Further checks into Father’s health history would have revealed the extent of his psychiatric history, now fully evident and it is likely that if this information had been known at the time that the children would not have been placed in his care.” This aspect also impacts on Father not being given the opportunity to make an informed choice or decision. Collectively, the conclusion from this Review is that it is very unlikely that the plan would have been agreed in its current form if this information had been known and shared with a professional group (Strategy Meeting, Initial Child Protection Conference, Core Group, etc.). 8.f. Does Baby T’s presentation on 14 June 2013 represent a missed opportunity to protect him? Mother and her sister (Baby T’s aunt) presented him to hospital with a history of him having woken up screaming, breathing fast and then having a floppy episode and bringing up some blood-stained phlegm. The Consultant Paediatrician attended the Learning Event and explained that whilst the possibility of non-accidental injury was considered, given the non-blanching spots on his legs, vomiting and evolving diarrhoea, likelihood of infection was a priority that had to be ruled out. Hence the baby had blood tests and was observed on the ward; with no suggestion of any witnessed bleeding from any site and improving observations, he was diagnosed to have a viral illness and subsequently discharged. As a part of safety netting, the family were offered 48 hours open access return to the ward, and repeat blood tests appointment given for two weeks. NICE Guidelines suggest that the presentation as described would be highly suspicious of non-accidental injury; the more so as it was known that Baby T was already on a Child Protection Plan based on non-accidental injuries four Baby T SCR - Final anonymised version 34 weeks earlier. With the benefit of hindsight it is easier to reflect and consider NAI as the closest differential. However, at the time, given the information available, risk of life threatening infections remained the priority. 8.g. Were there other missed opportunities? There should have been more “respectful curiosity” (Laming), eg. at the hospital during the first investigation when Mother stated that Father had no independent contact with the children. Although the investigating Social Worker did speak to both parents individually and did explore the family circumstances, there should have been more challenge about the practicalities of the 24 hour supervisory care and responsibility. Nursery Nurse intervention could have been considered/provided to assist regarding Baby E’s jealousy and disruptive behaviour; and/or should a nursery placement have been considered for her? A physical assessment of the baby should have been undertaken at the Health Visitor’s primary visit. The Health Visitor should have explored Mother’s emotional health, eg. tearful at Primary visit having undergone a traumatic birth; and later tearful regarding Children’s Social Care intervention. 8.h. What were some of the uncertainties, dilemmas and ambiguities identified in this Serious Case Review? It is a very real dilemma for Social Workers on the one hand to respect the family’s right to confidentiality by not contacting members of the extended family; yet on the other hand balancing the need to gather information for enquiries and also to establish support networks for the children, which might mean that parental consent is overridden. Whilst injuries to a non-mobile child may be highly suspicious of non-accidental injury,that suspicion can rarely be translated into a definitive confirmation or certainty, without an explicit admission, eg. the absence of any Baby T SCR - Final anonymised version 35 findings from X-rays and CT scans doesn’t rule out a diagnosis of non-accidental injury. In this case the uncertainty was compounded by Mother presenting so openly and honestly. One record states “Mother’s openness is perplexing”; indeed she was perhaps almost over-compliant, e.g. during the investigation of Baby T’s first injuries she consistently stated that she was the only person who had sole care of him. With hindsight, this might be regarded as a form of disguised compliance. 9. FINDINGS FOR THE BOARD a. The Board will want to oversee the following specific recommendations which are of a multi-agency/joint agency nature. 9.1. For significant injuries to children there must always be a Strategy Meeting rather than Strategy Discussions. As such Strategy Meetings may need to be called at very short notice and sometimes out of office hours, invitations to Health Visitors, GPs, Named Nurse, etc. may not be possible; and/or their attendance may not be possible. The core attendance should remain as Children’s Social Care/Police/Doctors. 9.2. For Strategy Meetings where the decision to progress to a section 47 enquiry has been agreed, copies of the Strategy Meeting record must be circulated to the respective GPs and Health Visitors/School Nurses, whether or not they have attended, in order that they are kept informed of the circumstances. 9.3. After the Child Protection Conference there will be circumstances in which professionals will take a keen interest in the case and may want to make further contributions even though they have not been named as members of the Core Group (eg. Police, Paediatricians, etc.). The keyworker should consider making specific wider invitations to Core Group meetings; equally, those professionals should Baby T SCR - Final anonymised version 36 proactively make it known to the keyworker that they wish to contribute/attend. 9.4. Challenge/escalation of the Child Protection Plan should be directed to the Safeguarding Unit in general and the Conference Chair in particular, as the Child Protection Plan is a multi-agency process and responsibility. 9.5. At the time of any professional enquiries or investigations or bookings, seek the identity of parents’ GP, and try to ascertain whether each parent and the children are registered at the same or different GP practices. b. There is much systemic and practice learning contained in this Serious Case Review and the LSCB will want to ensure that the learning is disseminated through briefing sessions, newsletter, etc. 10. SINGLE AGENCY RECOMMENDATIONS These recommendations have been identified by the agency authors in their own reports and have been signed off at a senior level within the respective agency. The Board accepts responsibility for overseeing and ensuring their implementation. 10.1. Hospitals a. The Peer Review process needs to be robust and with clear outcomes from discussions, recorded by the doctor bringing the case to supervision in the child’s hospital records at the earliest opportunity. b. The current Safeguarding Children Supervision Policy (OP75b) should be followed with use of the discussion sheets and minuted records and action points. It will be amended to state that in addition to other supervision, consultants should seek specific supervision prior to attendance at ICPC. c. It is recommended that Consultant Paediatricians attend a minimum of 6 Peer Review sessions per year. Baby T SCR - Final anonymised version 37 d. Paediatric medical staff to ensure that they have access to the child’s full set of medical records when a child about whom there is a safeguarding concern presents. e. There needs to be sufficient capacity to offer in-house Peer Review on a fortnightly basis. f. Paediatric medical staff to document that they have read and understood the nature of safeguarding concerns when dealing with a child who is the subject of such concerns. g. All staff to be trained in the use of the colposcope in the Bluebird suite to take photographs of injuries with parental consent. h. When reports are disseminated for conference and a body-map has been used to document injuries then copies of the body-map should be included with the report. 10.2. General Practitioners a. When a patient is known to suffer from a diagnosis of depression their family circumstances should be explored and documented in the medical record to ensure any risk to children in their care is fully appreciated. 10.3. General Practitioners/Health Visitors a. General Practice needs to have robust arrangements to review children and their families. When a child/children become subject to a Child Protection Plan a discussion of these cases should take place with the Safeguarding Lead GP and the Health Visitor and GP Practice team members at an agreed date and time. This must be seen as a priority. A record of these discussions must always take place, and scanned onto the patient record. Baby T SCR - Final anonymised version 38 10.4. Consultant Paediatricians/Designated Doctor a. Consideration should be given to formally recording discussions which take place during a medical supervision meeting where concerns are identified and how these concerns are taken forward and where they are documented. 10.5. Health Visiting a. When advice is requested by a practitioner from the Safeguarding Team and actions agreed, the practitioner is required to adhere to the plan unless they become aware of new information which makes the plan invalid. 10.6. Safeguarding Children Unit a. Chairs of Initial Child Protection Conferences must immediately write to the designated professional lead (or, for health provider organisations, named professionals) for safeguarding of the agencies who do not attend or present a report to an Initial Child Protection Conference and request a report is completed within five days and sent to the Chair of the Initial Child Protection Conference and the Lead Social worker to enable the information to be shared within the first core group. b. Chairs must ensure when fathers are registered with a different GP and reside at a different address their GP practice is notified in writing by the Safeguarding Children Unit, within 24 hours of the Initial Child Protection Conference, his children are the subject of child protection plans. The GP practice must also be invited to attend all future Review Child Protection Conferences so that this can be logged in the patient’s records and flagged for the GP to action to ensure they can contribute to the future risk assessment of the child/children involved. Baby T SCR - Final anonymised version 39 10.7. Children’s Social Care a. For Section 47 enquiries add a mandatory section in the documentation confirming that checks with parents’ GP have been undertaken and that they may be two different GPs. NB: This has been actioned and social workers have been briefed. b. Team Managers must emphasise the importance of first Core Groups and ensure that they are chaired by the allocated Social Worker or a Team Manager. NB: This has been actioned. Appendix (i) Terms of Reference and Project Plan GATESHEAD LOCAL SAFEGUARDING CHILDREN BOARD TERMS OF REFERENCE & PROJECT PLAN SUBJECT : BABY T D.O.B. xx.2.13 Appendix (i) Terms of Reference & Project Plan 1. Introduction Baby T presented to a Walk-in Centre on 14 April 2013 with bruising which was considered to be non-accidental. (He was then aged 2 months.) A resultant Child Protection Conference placed Baby T and his three siblings on Child Protection Plans, and all contact with his mother had to be supervised. On 18 June 2013 (then aged 4 months) Baby T presented at hospital after he had been brought in “floppy and unresponsive”. He was found to have a fracture to his skull. Police investigations are proceeding and Care Proceedings have been instigated. The Independent Chair of Gateshead Safeguarding Local Children Board, in consultation with members of the Case Review Sub Group, has decided to invoke a Serious Case Review (21 October 2013). The Department of Education and Ofsted have been advised accordingly. It has also been decided to use SILP methodology. 2. Purpose The purpose of a SILP remains the same as that for a Serious Case Review, namely: • To establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children • To identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and • Improve intra- and inter-agency working and better safeguard and promote the welfare of children. (Working Together to Safeguard Children, March 2010) Appendix (i) Terms of Reference & Project Plan 3. Framework Serious Case Reviews and other case reviews should be conducted in a way which: • Recognises the complex circumstances in which professionals work together to safeguard children; • Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • Is transparent about the way data is collected and analysed; and • Makes use of relevant research and case evidence to inform the findings (Working Together, para. 10, March 2013) 4. Specific Scope The subjects: • “Baby T” (subject child) • both parents – “Mother”, “Father” • the three siblings – “Baby E”, “Brother K”, “Brother C” The time period – from 10 July 2012 (the antenatal booking) to 26 June 2013 (Baby T’s discharge from hospital after the serious injury). Appendix (i) Terms of Reference & Project Plan 5. In addition Agencies are asked to review and report on significant events and safeguarding issues on both parents and children prior to July 2012. This material will be used primarily to provide a background context and therefore should be concise and summarised, highlighting any particular learning points. 6. Agency Reports (see template document) Agency reports within the scoping period will be commissioned from: • Gateshead Council Children’s Social Care • Gateshead Safeguarding Children Unit • Five heath agencies • Two NHS Foundation Trusts in relation to acute services – Gateshead Health NHS Foundation Trust and Newcastle Hospitals NHS Foundation Trust • South Tyneside NHS Foundation Trust in relation to community based health services • Two GP practices – the practice that Leona and the four siblings were registered with in Gateshead and the practice that Lee/Leigh were registered with in Northumberland • Northumbria Police • Education (including two named schools) In addition: • Northumberland Tyne and Wear NHS Foundation Trust (mental health); a free-form narrative as background information and involvement re: Father • A brief note from Gateshead Council Legal and Corporate Services • A summary of the school careers of the two older siblings in free-form narrative Appendix (i) Terms of Reference & Project Plan All of these to be used as background context. 7. Analysis 1. Critically analyse and evaluate the events that occurred, the decisions made and the actions taken or not. Were there missed opportunities or episodes when there was sufficient information to have taken a different course? Were assessments conducted effectively and appropriate conclusions drawn? 2. Where judgements were made or actions taken which indicate that practice or management could be improved, try to get an understanding not only of what happened, but why. 3. Demonstrate whether your agency/service heard and responded to the child’s voice. 4. Identify and explain if your agency/service believes that other agencies/services should have been sought and/or provided. 5. Identify good practice. 6. Were professionals proactive in escalating concerns and effecting challenge where appropriate? 7. From an inter-agency perspective, were processes and communication effective? Did services operate in silos rather than being “joined up” with each other? 8. Engagement with the family A letter will be sent from the Chair of the LSCB informing parents of this Review and its purpose. A little while later Independent Author will write to them again as a follow-up and invite them to participate in the form of a home visit/ interview/correspondence/telephone conversation. Their contribution will be woven into the text of the Overview Report; and they will be given feedback at the end of the process. Consideration will be given to the two older siblings. Appendix (i) Terms of Reference & Project Plan Hopefully any interviews will take place prior to the Learning Event so that their voice will be heard at the Learning Event. 9. Documentation The “bundle” for the Learning Event will comprise: • Integrated Chronology • Agency reports • Child Protection and Core Group minutes (copy for PT; participants invited to bring their own copies) 10. Timetable Commissioning letters to agencies for Authors 25 November 2013 Agency reports back by 21 January 2014 Quality assurance of the reports by PT 23 January 2014 Distribution of agency reports 27 January 2014 Learning Event 4 February 2014 Recall Day 3 March 2014 Presentation to LSCB 26 March 2014 Appendix (ii) Agency Report GATESHEAD LOCAL SAFEGUARDING CHILDREN BOARD AGENCY REPORT TEMPLATE (Name of the agency) SIGNIFICANT INCIDENT LEARNING PROCESS SUBJECT : BABY T D.O.B. xx.2.13 Appendix (iii) Single Agency Recommendations 1. Please see Terms of Reference and Project Plan document for: • Introduction • Purpose • Framework 2. Specific Scope The subjects: • “Baby T” (subject child) • both parents – “Mother”, “Father” • the three siblings – “Baby E”, “Brother K”, “Brother C” The time period – from 10.7.12 (the antenatal booking) to 26.6.13 (Baby T’s discharge from hospital). 3. In addition Agencies are asked to review and report on significant events and safeguarding issues on both parents and children prior to July 2012. This material will be used primarily to provide a background context and therefore should be concise and summarised, highlighting any particular learning points. 4. Within the Scoping period (10.7.12-26.6.13) a. Summarise in narrative form the key information on the child and parents from your agency/service. b. Summarise the services offered and/or provided to the child and parents; and the decisions reached. Appendix (iii) Single Agency Recommendations 5. Analysis 5.1. Critically analyse and evaluate the events that occurred, the decisions made and the actions taken or not. Were there missed opportunities or episodes when there was sufficient information to have taken a different course? Were assessments conducted effectively and appropriate conclusions drawn? 5.2. Where judgements were made or actions taken which indicate that practice or management could be improved, try to get an understanding not only of what happened, but why. 5.3. Demonstrate whether your agency/service heard and responded to the child’s voice. 5.4. Identify and explain if your agency/service believes that other agencies/services should have been sought and/or provided. 5.5. Identify good practice. 5.6. Were professionals proactive in escalating concerns and effecting challenge where appropriate? 5.7. From an inter-agency perspective, were processes and communication effective? Did services operate in silos rather than being “joined up” with each other? 6. Key Learning Points 6.1. What did we do well which we need to keep doing? 6.2. What didn’t we do so well that needs to stop? 6.3. What things need to be done differently to lead to improvements and how should this be done? 6.4. What is to be learnt about improving multi-agency working? Appendix (iii) Single Agency Recommendations 7. Recommendations You may make in-house/single agency recommendations (but are not obliged to do so). If you are making recommendations please make them SMART, i.e. Specific Measurable Achievable Realistic Timely 8. Sign-Off (Neither the reviewer nor senior sign-off person has had any direct involvement with this case prior to the death of the child.) Agency Reviewer: Date: The reports of all reviews must be signed by the relevant senior officer, indicating that the review has been: • carried out to the required standard and • the learning points are accepted by the organisation • the recommendations/action plan will be implemented The Senior Officer accepts that: • The review has been carried out to the required standard. • The learning points reached in the review are accurate. • The recommendations/action plan will be implemented. Appendix (iii) Single Agency Recommendations Senior Officer: Job Title: Date: On completion, please send or deliver the completed report by 21 January 2014 at the latest. |
NC52462 | Arrest and conviction of a 13-year-old boy for a serious violent crime. Learning includes: children and young people with special educational needs and disabilities (SEND) need to be understood, and local capacity improved so that these specialist needs can be met; the quality of information sharing when a child or young person with an education health and care plan (EHCP) changes schools is crucial; new pathways are required for young people with complex needs if exclusions from school are to be reduced; there is a need to develop a culture of safeguarding within front line staff to improve the service offered to young people by Thames Valley Police. Recommendations include: develop new procedures for the early review of EHCPs when a child or young person moves local authority area at the same time as transitioning from primary to secondary school; develop new information sharing procedures when students with an EHCP change schools, including professional meetings attended by the relevant schools, the agencies working with the young person, and the parents/ guardians; Thames Valley Police should produce new policy and guidance in relation to children and young people who are identified as suspects in a criminal investigation and develop a culture of safeguarding and partnership working, with training delivered to all police officers and police community support officers; update policy and guidance for the review of referrals and contacts that involve children and young people with SEND.
| Title: Local child safeguarding practice review (Wokingham): ‘Harry’. LSCB: Berkshire West Safeguarding Children Partnership Author: Mark Power Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Local Child Safeguarding Practice Review (Wokingham) ‘Harry’ Commissioned By: Berkshire West Safeguarding Children Partnership Lead Reviewer and Author: Mark Power (Mark Power Safeguarding) Date of Publication: 13th December 2022 2CONTENTS Section Page 1. Introduction and Methodology 3 2. Case Summary and Key Events 4 3. Views Of Harry’s Family and the Wider Context 8 4. Critical Analysis and Learning 9 a) Finding 1: The Provision of Services for Children and Young People with Special Educational Needs (SEND). 9 b) Finding 2: Educational Establishments – Information Sharing and Planning 11 c) Finding 3: The Police Response to Young People and Suspected Criminality 13 d) Finding 4: Children’s Services – Response to Safeguarding Concerns 13 e) Finding 5:- Early Help Services for Children and Young People with SEND Needs 14 5. Conclusion and Summary of Recommendations 17 31. INTRODUCTION AND METHODOLOGY Background In February 2021, the Berkshire West Safeguarding Children Partnership (BWSCP) considered the case of Harry, a young person who had been arrested, and later convicted, for a serious violent crime. Harry had been known to a number of services over a lengthy period and at the time of the incident was being supported by the Wokingham Integrated Early Help Service1. The safeguarding partnership recognised the potential to improve the way agencies worked together to safeguard young people and commissioned this Local Child Safeguarding Practice Review (LCSPR)2. The review aimed to use the experiences of Harry and his family, to identify learning and to continually improve the way that agencies work together to safeguard children and young people. A wide number of agencies from the safeguarding partnership took part and five key findings were identified. These are outlined in this report as follows: a) The Provision of Services for Children and Young People with Special Educational Needs and Disabilities (SEND). b) Educational Establishments – Information Sharing and Planning. c) The Police Response to Young People and Suspected Criminality. d) Children’s Services – Response to Safeguarding Concerns. e) Early Help Services for Children and Young People with SEND Needs. Methodology An independent lead reviewer was appointed to undertake the review, working alongside a panel of local professionals. Terms of reference were provided, identifying the key date parameters as July 2018 to January 2021. Chronologies and single organisation reviews were provided by each agency, analysing events and considering how changes to practice may deliver future improvement. The independent reviewer met with Harry’s family on a number of occasions to ensure that their views were fully considered, and that Harry’s voice could be captured. The BWSCP is very grateful for their participation and valuable contribution. Practitioners and senior representatives from each agency met for a further analysis of events and to identify the systemic reasons as to why better outcomes were not achieved. All were then involved in identifying potential improvements for consideration by the safeguarding partnership. This overview report summarising the analysis and findings of the review panel was then prepared, having passed the BWSCPs quality assurance process. About This Report This report outlines the recommendations in a concise format. It is written with the intention of publication and as such does not contain information which may identify those involved. The document aims to be as succinct and practical as possible and therefore does not contain a detailed chronology of events, or the ‘working out’ process for the review findings. The detailed analysis of events and the evidence underpinning this report are held in additional documents retained by the BWSCP. 1 Integrated Early Help and Youth Offending services. Now restructured into two separate services. 2 https://www.berkshirewestsafeguardingchildrenpartnership.org.uk/scp/professionals/child-safeguarding-practice-reviews 42. CASE SUMMARY AND KEY EVENTS Harry – An Overview At the age of 13, Harry was involved in the commission of a serious violent crime, in which he used a knife in the assault of another young person. He was subsequently convicted of the offence and was sentenced to a lengthy period of youth detention. Prior to his arrest he had been living in the Wokingham area with his mother and younger sibling. Whilst his parents are estranged, he regularly saw his father who remained active in the children’s lives. During his early childhood Harry was diagnosed with a developmental disability. This condition affected his understanding of what behaviour was socially acceptable, his understanding of consequences, and his assessment of risk. Despite this Harry was determined to be treated the same as his friends and felt a strong need to ‘fit in’, both at school and with his peers. To support his academic ambitions, Harry was supported by the local authority with an Education and Health Care Plan (EHCP)3. Despite Harry’s enjoyment of education and his desire to do well, his schools found it difficult to manage his behaviour and this led to a number of exclusions. This caused considerable distress to Harry, increasing feelings that he was different and that he could not be accommodated in school. The exclusions led to him spending considerable time outside of full-time education, during which he became vulnerable to criminal exploitation. Criminal exploitation may take many forms4 and in Harry’s case this risk came from peer groups, with whom due to his developmental disability he felt a need to fit in. This risk of exploitation was identified a number of times and was demonstrated by his involvement with different groups of young people. All were older than him and had been suspected of crime and disorder before his association with them began. Whilst involved with these groups Harry went on to become involved in criminality, which became more serious as time went by. During 2020, concerns about exploitation continued to increase and Harry became involved in a number of incidents which were reported to the police. Despite being supported by a number of agencies his involvement in criminal incidents escalated, culminating in the offence leading to this safeguarding review. Key Events 1) For the majority of his time at primary school, Harry was living in Reading and his EHCP was supported by Reading Borough Council. His school describe how they found it extremely difficult to support his needs and how there was a need to provide one to one supervision. They felt that Harry would struggle to succeed in a mainstream secondary school and expressed these views to the local authority. In February 2018, Harry was required to select his secondary school in accordance with the school admission calendar. He was keen to attend the same school as his friends and selected a mainstream school near to his home. 2) In March 2018, Harry and his family moved to Wokingham, at which time Wokingham Borough Council assumed ownership of his EHCP. As the secondary school had already been selected, and in accordance with procedures, there was no family engagement at this time and the EHCP was not reviewed. Future reviews were inconsistent in their timing and quality. 3) In July 2018, Harry’s primary school made a child safeguarding referral to Reading Children’s Services, after Harry’s sibling had disclosed that he had threatened to harm them with a knife. Following an assessment, early help5 support was offered to the family. The early help service did 3 https://educationadvocacy.co.uk/what-is-a-ehcp/ 4 https://www.nspcc.org.uk/what-is-child-abuse/types-of-abuse/gangs-criminal-exploitation/#criminalexploitation 5 https://learning.nspcc.org.uk/safeguarding-child-protection/early-help-early-intervention 5not succeed in engaging the family and it was recorded that Harry’s mother declined any support. The case was closed. 4) In late July 2018, the school made a second referral to children’s services following an incident at school. Harry had threatened another pupil with a cutlery knife and the school became concerned about Harry and his risk to others. A referral was also submitted to the Child and Adolescent Mental Health Services (CAMHS) who had previously worked with Harry. CAMHS determined that this was not a mental health issue and referred it to children’s services. 5) Both referrals6 were received by Wokingham Children’s Services and reviewed by the Referral and Assessment Team, a department providing the single point of access to children’s services for all referrals and contacts7. This review considered the previous involvement of Reading Children’s Services but did not involve any discussions with the referring agencies. Whilst it was assessed as proportionate to offer early help services, this was recorded as being declined by Harry’s mother as she had found previous offers ineffective. The case was closed. 6) In September 2018, Harry started at his secondary school where concerns about him quickly developed with frequent episodes of disruptive behaviour. Attempts to support Harry did not result in any improvement and the school, along with Harry’s mother, concluded that it may not be possible to support his needs in a mainstream school. The school made attempts to discuss these concerns with the Wokingham Specialist Education Needs (SEN) service8, however they did not receive any reply to correspondence. 7) On 26th November 2018, Harry’s secondary school submitted a safeguarding referral to Wokingham Children’s Services, following information that he had been making bombs at home and was threatening to hurt his sibling. At this time Harry’s behaviour had escalated to assaulting other pupils and making threats to injure others with a pair of scissors. A child and family assessment9 was completed, which resulted in a recommendation that the family should be supported by the provision of early help ‘family coach’ services. An early help visit to the family did not take place until March 2019, at which time it was recorded that Harry refused to engage and that his mother declined any support. The case was closed. 8) On 9th January 2019, Harry received a fixed term exclusion from school, the first of eight short term exclusions between January and July 2019. Whilst these did little to support Harry, the head teacher felt they had little option as there was a need to safeguard other pupils. 9) During March 2019, both the school and Harry’s mother raised concerns about the provision of his schooling with the SEN service and requested an emergency review of his EHCP. Despite delays in responding to these requests, the SEN service did attend two emergency reviews during April and May. Representations were made that a specialist school placement was required, however this was not facilitated by the local authority. Further specialist services were provided to the school to help in supporting Harry, however this had little effect in improving his situation and the exclusions from school continued. 10) On 18th May 2019, Harry’s school submitted a referral to the PREVENT10 scheme as concerns about Harry escalated. This was received by Thames Valley Police, who shared the information with children’s services. Following a review of this contact it was determined that a multi-agency strategy discussion to share information was not required and that an offer of early help would be proportionate. It was recorded that Harry’s mother declined any support and the case was closed. 6 Working Together 2018 (Para17) outlines that any person, or agency, may make a safeguarding referral and that the local authority should have published measures in place to receive and manage referrals. 7 ‘Contacts’ – A term used by Children’s Services to describe information passed to them by other agencies concerning child safeguarding concerns. Often described as a referral by the agencies passing the information. 8 Provided by the Wokingham Borough Council 9 Under the provisions of Section 17 Children’s Act 1989 10 https://www.thamesvalley.police.uk/advice/advice-and-information/t/prevent/prevent/ 611) On 5th July 2019, a further emergency review of Harry’s EHCP took place. The SEN service was represented at the meeting and whilst they agreed that a specialist placement was now required, it was explained that this may not be possible as such placements were not readily available. The school was offered additional financial resources to meet Harry’s needs, although when challenged by the school the local authority was not clear as to how this would help. 12) On 15th July 2019, the SEN team received a letter from the head teacher requesting that a new school placement was found for the September term and two days later Harry was permanently excluded from school. It was explained that staff were no longer able to manage his behaviour and that the head teacher did not believe his needs could not be delivered in a mainstream school. The SEND panel11 subsequently met to consider the provision of a new school placement, concluding that Harry’s educational needs had not changed since starting at his previous school and that with a better use of resources they could be met in a mainstream setting. As a result the request for a specialist school was not approved. 13) In September 2019, Harry started a temporary placement at a specialist pupil referral unit which aimed to help young people re-engage with education. This was a temporary arrangement whilst a permanent school placement was sought, and Harry was only offered a part time timetable (mornings) with a limited curriculum. Whilst at the college Harry’s behaviour improved with the provision of clear routines and boundaries. It was however noted that Harry felt a need to be accepted by others and at times would respond to encouragement to behave in an inappropriate way. It was recognised that his educational and health needs made him at risk of exploitation. 14) In December 2019, Harry started at a new secondary school. The school had originally declined to offer a placement as they didn’t believe that they could meet Harry’s needs, however one was subsequently provided following encouragement by the local authority. Concerns quickly emerged about Harry’s behaviour towards staff and other pupils and upon later receiving his education records, which were incomplete, the school identified that they had not been fully informed of Harry’s needs and the previous concerns in relation to him. Both the school and Harry’s mother quickly formed the opinion that he was unable to manage in a mainstream school and that a specialist provision was required. 15) During February and early March 2020, Harry was identified by Thames Valley Police as being involved in two crimes. Whilst it was policy to submit a safeguarding referral for a young person involved in crime, this was not done. 16) On 10th March 2020, Harry’s mother contacted children’s services to express concerns that Harry was the subject of criminal exploitation and to seek support in managing his behaviour. Harry’s mother explained to the review that this was the moment that she had become extremely worried for Harry and also for the safety of her family. In her words this was a cry for help. The outcome of this contact was to make a further offer of early help, however upon them contacting Harry’s mother she was recorded as saying that she no longer needed assistance. The case was closed. 17) On 16th March 202012, due to the worsening COVID-19 pandemic, the UK government issued public guidance to stop all unnecessary personal contact and to avoid unnecessary travel. On 23rd March the first ‘lockdown’ period commenced. Public sector organisations continued to provide services, which included face to face contact where necessary and the introduction of mobile and remote working practices for non-essential services. The lockdown period also involved a reduced attendance at schools, with a move to remote learning for most students other than those who were vulnerable or children of key workers. Due to Harry’s vulnerability and his mother’s occupation, he was entitled to continue attending school and on a number of occasions was invited to attend by the school. 11 A panel of experts who meet to support the local authority’s decision making in respect of EHCP and the resourcing of educational need. 12 UK Govt COVID-19 Timeline - https://www.instituteforgovernment.org.uk/sites/default/files/timeline-lockdown-web.pd 718) On 1st April 2020, an emergency review of Harry’s EHCP took place with the SEN service at the request of his school. It was agreed that his needs could not be met in a mainstream school and the process to commission a specialist placement commenced. 19) On 1st June 2020, having made her own enquiries to find Harry a specialist school placement for the new September term, Harry’s mother received a provisional offer from a nearby school subject to completion of the commissioning process. The school was located in an adjoining local authority area, it specialised in supporting young people with special educational needs. This was not approved by the SEN service which continued to seek a school within the Wokingham area, eventually securing a placement in October 2020. Harry was not attending any educational setting between the start of the September term and him starting at the new school in November. This gap in education was not reported to the SEN service, nor was it identified by them despite it being highlighted to children’s services in a subsequent safeguarding referral. 20) On 14th July 2020, the police submitted a safeguarding referral to children’s services following an incident involving Harry. The referral outlined that his mother was unable to cope with his behaviour, that she was concerned about increasing risks of criminal exploitation, and that he had no schooling provision for the September term. She had asked the police to submit the referral as she had been unable to receive any support with his schooling. Following review an offer of early help was made, which was recorded as being declined as previous offers had not delivered positive outcomes. The case was closed. 21) On 28th September 2020, Harry’s mother contacted children’s services after finding cannabis in his room. She expressed concerns about exploitation, his escalating behaviour, and the fact that she was struggling to cope. She also explained that Harry was being verbally aggressive to her and to his younger sibling. She was advised to contact the police to report her concerns and an offer of early help was made. An exploitation screening tool was completed, which concluded that whilst some indicators of exploitation existed there was not any evidence of it actually happening. 22) On 29th September 2020, Harry’s mother contacted the police to express concerns that Harry was being exploited by a County Lines criminal drugs network13. The police shared this information with children’s services. No further action was taken in respect of this contact, as children’s services felt that his had already been addressed with Harry’s mother when she had contacted them herself. 23) On 7th October 2020, the police made a second safeguarding referral and requested a multi-agency strategy discussion. A meeting was held on 9th October, with a decision that the Section 47 threshold to determine if Harry was suffering or likely to suffer significant harm had not been met. It was determined that a single agency response by children’s services was appropriate, with a rationale that Harry’s mother was protective, and little could be gained from multi-agency involvement. This was not a unanimous decision, with the meeting participants equally split as to whether a more robust child protection response was required. A child and family assessment commenced. 24) During September and October 2020, Harry was involved in the commission of three violent crimes against other young people. Each case was investigated by a different police officer, and each involved a significant delay between him being identified as a suspect and being interviewed. During the period of delay, neither Harry’s mother nor children’s services were informed of his involvement in the crimes. Information was not shared with children’s services until February 2021 when the investigation concluded. 25) During September and October 2020, a number of incidents were also reported to the police, where Harry had threatened to stab other young people. These were not investigated as crimes but treated as reports of potential disorder. Information was not shared with children’s services and his mother was not informed of the incidents. 13 https://www.nationalcrimeagency.gov.uk/what-we-do/crime-threats/drug-trafficking/county-lines 826) On 3rd November 2020, Harry started at his new school which specialised in supporting young people with complex needs. When the school later received his school records it was evident that they had not been fully informed about the concerns for Harry. They were unaware of concerns relating to criminal exploitation, an involvement with gangs, and his involvement in knife crime. During the safeguarding review, it also became apparent that Harry’s previous educational establishments were unaware of the extent of these concerns and there was a pattern of information not being effectively shared with the schools. 27) On 11th November 2020, the child and family assessment was completed and a decision was made to allocate the case to the Integrated Early Help Service, which encompassed both early help and youth offending services (YOS). A YOS worker was appointed to conduct prevention and intervention work. 28) On 30th November 2020, Harry’s new school submitted a safeguarding referral about his suspected involvement in violent crime, threats to kill others with a knife, and Harry claiming to have associates with access to weapons and a firearm. As Harry was now being supported by YOS, a decision was made that no further action was required. A multi-agency strategy discussion was therefore not held. 29) On 3rd December 2020, the YOS intervention work commenced, and Harry was described as engaging well and making a positive contribution. Incidents of Harry threatening to harm others with knives continued and this was reported to his YOS worker by Harry’s mother. A decision was made to discuss this with Harry at the next intervention session on 15th December, however during this session Harry disengaged and no further work was completed. 30) In early 2021, Harry was involved in a violent crime when he assaulted another young person with a knife. He was subsequently convicted for this offence and sentenced to a period of youth detention. 3. VIEWS OF HARRY’S FAMILY AND THE WIDER CONTEXT Views of Harry’s Mother Harry’s mother actively contributed to the review and presented views as to why she felt that better outcomes were not achieved for Harry. Her key issues and views are summarised as follows: 1. At the time of Harry transitioning to secondary school, she did not have an understanding of what his educational needs were and that they may not be met in a mainstream school. She feels that at the time of selecting the school greater support from the SEN service and an informed discussion about options would have made a difference. 2. When it became apparent that a specialist placement was needed, she felt that the SEN service would not listen to her views. Things went wrong quickly after the permanent exclusion, and had a specialist placement been commissioned at this time, she feels that outcomes would have been very different. Harry spent a considerable time outside of full-time schooling and on a limited curriculum. He felt that he was not wanted in school, and this pushed him away from supportive figures to ones who were able to exploit him. Whilst outside of full-time schooling, he drifted into criminality. 3. During the assessments of safeguarding concerns she felt that the focus was placed upon her and not Harry’s needs. She felt that she was seen as a fellow professional by children’s services staff, who were often overly optimistic about her ability to support and meet Harry’s needs (especially his educational needs), rather than being seen as a mother of a child in need of additional support. 4. She felt that the early help pathways were ineffective, and that the worker was not aware of what support could be offered, placing the onus on her to suggest what she would like. When she was unable to outline what she needed, the cases were closed. At no time did she withdraw consent for early help services or say that she did not need support. 95. She was not aware of the extent of information known to the police and the concerns about Harry’s involvement in disorder whilst away from home. This affected her ability to protect Harry. Further Local Child Safeguarding Practice Reviews During 2021, the BWSCP considered learning that had been obtained from a case unrelated to Harry’s. Whilst not connected, it provides useful context as a number of similar learning themes were also found in Harry’s review. These include: a) The family did not feel that they were listened to and did not feel that agencies were able to provide practical and emotional support. b) A focus on repeated early help offers and not escalating to section 47 child protection. c) Professionals not understanding criminal exploitation and a lack of pathways to provide effective outcomes. This included the lack of mechanisms for cross border working. d) Police information and intelligence was not shared with other agencies. During 2022 the issues of exploitation and violent crime will be explored through wider work commissioned by the BWSCP, which will include how capabilities may be developed to reduce crime and protect young people. To avoid duplication, Harry’s safeguarding review does not explore the wider issues of violent crime and exploitation. COVID 19-Pandemic The time period for this safeguarding review included a significant period during 2020 when services in England were affected by the COVID-19 pandemic. It was important for the review to consider how this may have impacted upon Harry and how this may have affected the ability of professionals to support him. Whilst the pandemic will have impacted upon the way key services were delivered across the country, it was not a relevant issue in Harry’s case. The ability to provide him a suitable educational provision was an issue that pre-dated the pandemic and due to his EHCP he was still able to attend school even when they were closed to many other young people. None of the key events that affected Harry took place in the lockdown periods and there was no evidence to say that he was at greater risk of exploitation during them. The lengthy period of time he spent outside of education during 2020 was between September to November and was not COVID related. 4. CRITICAL ANALYSIS AND LEARNING Finding 1: The Provision of Services for Children and Young People with Special Educational Needs Learning: There is a requirement for the local authority to develop new ways of working to ensure that children and young people with special educational needs and disabilities are understood. There is also a requirement to improve local capacity so that these specialist needs may be met. The issue that would have made most difference to Harry, providing the opportunity for improved outcomes, would have been the early involvement and intervention of the local authority in his education provision. This did not happen as his needs were not understood by the SEN service and due to the lack of provision in Wokingham to support children with specialist needs. Shortly before transitioning from primary to secondary school, the governance of Harry’s EHCP transferred to Wokingham as his family moved home. As it is not policy to review education plans when a young person moves between authorities, the SEN service did not hear the concerns of Harry’s primary school and did not have an understanding that his needs may not be met in a mainstream secondary school. It also meant that Harry’s mother did not benefit from an informed discussion to 10understand his schooling needs and to properly consider their options. Had a review taken place, a school able to support his needs may have been selected and a different course followed by Harry. The transition from primary to secondary school is a significant adjustment in a young person’s life, with a very different method of education and a less intensive level of supervision. Whilst it may not be practicable to review every EHCP when a young person moves local authority area, there would be great benefit in doing so when it also involves transition from primary to secondary education. This was highlighted as good practice by the SEN service at the review panel and as such this change of process forms one of the recommendations in this review. The quality of education plans and the support provided to schools by the SEN service, were also identified as key issues during this review. Harry’s written plan was not updated within statutory time frames and when it was done it did not reflect the changes in his life. Of significant concern was the fact that multi-agency information and child protection concerns were not included in the plan. When concerns about Harry were raised by the schools, there was a lack of response by the SEN service which did not have the capacity to reply or to attend review meetings. This lack of capacity meant that they were unable to provide any quality assurance as to how the school planned to deliver Harry’s needs. When a specialist school placement was eventually authorised, the lack of provision in Wokingham caused a significant delay in providing Harry a school and meant that he was outside of education for a number of months. By the time he started at this new school, he had been exposed to exploitation and had become involved in the commission of serious crime. At this stage it was simply too late for the new school to make a difference. In April 2019, OFSTED conducted an inspection of SEND provision in Wokingham and identified a number of areas for improvement, including all of the themes highlighted in this review. In response the local authority has developed an ambitious strategy14, with a focus on early intervention and engagement with young people and their families. Since 2020 an improvement board has been in place to oversee progress of the improvement plan, supported by an implementation team commissioned until the end of 2022. Whilst improvements have been made, those working within the system explain that there is still much to achieve, a view supported by performance documentation considered in the review. Due to the extent of the improvements required the difficulty in delivering this new strategy should not be underestimated. It is therefore recommended that the local authority develops arrangements with the Children’s Safeguarding Partnership, to provide ongoing assurances that the improvement board is effective in the delivery of change and that it is able to evidence how improvements are delivering better outcomes for children and young people. Recommendation 1: The local authority should develop new procedure for the early review of EHCPs when a child or young person moves local authority area at the same time as transitioning from primary to secondary school. Recommendation 2: The Local Authority should develop arrangements with the BWSCP, to provide ongoing assurances that the improvement board is effective in the delivery of change and that it is able to evidence how improvements are delivering better outcomes for children and young people. 14 Wokingham SEND Strategy 2021-2025 11Finding 2: Educational Establishments – Information Sharing and Planning Learning: There is a need to improve the quality of information sharing when a child or young person with an EHCP changes educational establishments. If exclusions from school are to be reduced, then new pathways are required for young people with complex needs. When a young person changes school, the established process for sharing information is confined to the exchange of written records. The information is often received and reviewed after the student has joined the new school and does not include the richness of information which may be presented by a previous member of staff who knew the young person well. Whilst this may work for the majority of pupils, it was not effective in Harry’s case, and this is likely to be the same for many young people in his situation. The new schools were not aware of key information known to the previous schools, or the involvement of partnership agencies who were working with Harry and his family. This lack of information meant that Harry was not fully understood, and this had two effects: a) During the admission process the schools could not properly assess whether they were able to meet Harry’s needs. This led to placements failing, causing significant distress to Harry and the disruption of his education. b) In not understanding Harry, effective planning to deliver his needs could not be achieved from the outset of his school placement. In examining the reasons as to why information was not effectively shared, the review identified the following: Firstly the lack of an enhanced process for the sharing of information about pupils with complex needs; and secondly that following an exclusion there is often pressure to find any school placement, rather than the correct placement. To address both of these issues, the experts on the review panel recommended that a professionals meeting should be held when a young person with an EHCP changes educational establishments or when a new placement is sought by the local authority. Whilst the required attendance list should be flexible to reflect the circumstances of the young person, it should where possible include parental representation and any relevant agencies working with the family. Should the meeting identify the necessity to change the EHCP, then the SEN service may be requested to arrange and attend an emergency review meeting. This new procedure would make a difference to many children and young people and therefore forms a recommendation of this review. Whilst examining the quality of the school planning for Harry, it was recognised that the high number of exclusions had a negative impact upon him. Not only did this affect his mental wellbeing, it also pushed him away from supportive figures and made him more susceptible to exploitation. The schools explained that exclusions were used as a last resort, however there was a need to safeguard other pupils and maintain school discipline. It was further explained that resources and options available to the schools are limited and that if the use of exclusions was to be reduced then new pathways and resources would need to be developed and made available to them. Reducing the use of exclusions for children and young people with an EHCP is already an ambition for the local authority and if this is to be delivered then it would be helpful to use the expertise of school staff in any future development plans. It is therefore recommended that the local authority develops the pathways and resources available to schools, aiming to reduce the use of exclusions. In order to achieve this it would be desirable to form a working group involving head teachers and special educational needs staff, ensuring their expertise and professional views are captured. The findings may then form part of a new strategy to reduce exclusions from school or may be incorporated into the current Wokingham SEND Strategy 2021-2025. 12Recommendation 3: New information sharing procedures should be developed in the Berkshire West partnership area, to provide an enhanced level of information sharing for students who have an EHCP at the time of changing education establishments. This should include professional meetings attended by the relevant schools, the agencies working with the young person, and the parents/ guardians. Recommendation 4: The local authority should review the provision of resources and pathways available to schools, in order to reduce the use of exclusions for children and young people with EHCP. This should be delivered by a working group that involves headteachers and specialist staff from both maintained and non-maintained schools. Finding 3: The Police Response to Young People and Suspected Criminality Learning: If Thames Valley Police are to improve the service provided to young people, there is a need to develop a culture of safeguarding within front line staff. This needs to be supported through organisational strategy that clearly sets safeguarding as a priority and a strategic aim. Whilst participating in this review, Thames Valley Police conducted a detailed analysis of their processes and identified a number of opportunities to improve the service delivered to young people and their families. This was an excellent piece of self-reflection and has resulted in a significant number of improvement recommendations. As these are mainly ‘single agency’ actions they are not fully presented in this report, which instead focusses on a smaller number of key issues that have the potential to improve multi-agency working. There would be great value in Thames Valley Police presenting details of their action plan to the BWSCP, so that the implementation of change and the outcomes may be assessed during the existing annual Section 1115 quality assurance processes. In Harry’s case there were two key areas of police practice that directly affected how the police and the partnership agencies were able to safeguard him. These being: a) Safeguarding referrals were not consistently submitted and information was not shared. This directly affected the quality of subsequent multi-agency decision making and planning. b) There were significant delays during the investigation of offences and incidents, during which time the risk to Harry and other young people was not proactively managed. The police had requested the October 2020 strategy meeting and made representations that a multi-agency response was required. Following the decision to follow a single agency children’s services response, the police did not take any further action in relation to the risks and concerns that they had originally identified. In examining the reasons for this, the review identified the following: There was a culture of police officers and staff only seeing Harry as an offender and not seeking to understand why he may have become involved in such serious crime and disorder. For example within one official document was the wording, “Harry’s main danger is himself and his attitude. He has no respect for authority and will not be told what to do”. In cases of exploitation a young person may be both a victim of crime as well as preparator, however this did not appear to be understood by those who came into contact with him. 15 Section 11 of the Children Act 1989 13 There was a pattern of crimes and incidents being dealt with in isolation and by different officers. Police information systems were not researched at the time of offences being investigated and offence were not connected. The pattern of escalating incidents was not identified and therefore risk was not properly assessed. There was a lack of priority placed upon the investigation of crimes and incidents, leading to a significant delay in which risk was not proactively managed. There was a lack of understanding in relation to child safeguarding and the benefits of partnership working. This was demonstrated by the failure to quickly inform Harry’s mother and partnership agencies of incidents, so that Harry could be safeguarded and deterred from criminality. Whilst it was policy to submit a child safeguarding referral as soon as a young person came to notice as a potential suspect, it was common practice for this not to be done until the end of an investigation, or in many cases not at all. Thames Valley Police has identified a need to develop a safeguarding mindset and culture, and an organisation wide training programme has already been agreed. Whilst this is a positive step, it will need to be supported through strong policy and guidance. It is therefore recommended that the police produce new operational guidance in relation to children and young people who are identified as suspects in a criminal investigation. This should be underpinned by an annual training programme to develop a culture of safeguarding and partnership working. The training should be delivered to all frontline police officers and police community support officers. Recommendation 5: Thames Valley Police should produce new policy and guidance in relation to children and young people who are identified as suspects in a criminal investigation. This should be underpinned by an annual training programme to develop a culture of safeguarding and partnership working, delivered to all police officers and police community support officers. Finding 4: Children’s Services – Response to Safeguarding Concerns Learning: Whilst reviewing safeguarding referrals and contacts, Wokingham Children’s Services did not understand the needs of Harry or his family. The understanding of SEND needs requires specialist knowledge and this is not currently held in the Referral and Assessment team. Throughout 2018 to 2020, a significant number of safeguarding referrals and contacts from partnership agencies were received by Wokingham Children’s Services. This should have provided the opportunity for positive outcomes delivered within a multi-agency plan, but instead a pattern developed in the repeat tasking of early help services. On a number of occasions it was determined that a referral did not meet the threshold16 to hold a multi-agency strategy discussion, to share information and to consider multi-agency planning. These decisions have been subject of review by the children’s services review panel representative, who agrees that at times circumstances met the threshold for a social care assessment and that opportunities to engage with Harry and his family were missed. The pattern of referrals assessed as not meeting the threshold for an enquiry under Section 47 of the Children’s Act17, was not only evident in the referral and assessment practices, but also in the decision making at the October 2020 strategy meeting, where a decision was taken that a single agency response led by children’s services was appropriate. This missed the opportunity to develop a robust 16 https://www.berkshirewestsafeguardingchildrenpartnership.org.uk/scp/wokingham/wokingham-threshold-guidance 17 Where a child is suspected to be suffering, or likely to suffer, significant harm - https://www.legislation.gov.uk/ukpga/1989/41/section/47 14multi-agency plan, which should have included a role for the police to proactively address the ongoing issues of violent crime and disorder. Opportunities for early and effective interventions were missed and in examining the reasons for this the following key issues were identified: a) An understanding of Harry’s situation and his needs was never fully developed, particularly how his special educational needs increased the level of support that he required and how it made him more vulnerable to exploitation. b) The review of referrals and contacts did not fully consider the outcome of previous offers of early help. Particularly why they had not delivered successful outcomes and whether the further offer of early help was an effective option. c) There was a focus on Harry’s mother, rather than the needs of Harry and his sibling. There was too much optimism about the ability of Harry’s mother to meet his needs without a more robust multi-agency response. Wokingham Children’s Services has since introduced a new trauma informed approach for the initial review of all child protection referrals and contacts. This is reported to have improved the outcomes for children and young people, however it does not specifically aim to improve the understanding of young people with special educational needs and disabilities. There would be great benefit in complementing the trauma informed approach with a specific policy in relation to children and young people with such needs. The SEND Codes of Practice18 recognises the importance of this and requires local authorities to develop policy and guidance to ensure that this is achieved. Currently Wokingham does not have clear guidance for staff working in the referral and assessment team. Had policy and procedure been in existence and understood by staff, then this may have greatly improved the chance of providing better outcomes for Harry. Recommendation 6: Wokingham Children’s Services should update policy and guidance for the review of referrals and contacts that involve children and young people with special educational needs and disabilities. Finding 5: Early Help Services for Children and Young People with SEND Needs Learning: Harry’s mother felt that the Early Help offer was ineffective in providing the emotional and practical support that she and Harry needed. There is an opportunity to use this review to improve the services offered to young people and their families, making a greater use of different agencies and community organisations. The Early Help service19 was tasked to support Harry and his family on several occasions, however up until November 2020 this was unsuccessful in securing any effective engagement. Referrals were closed with a rationale that Harry’s mother had declined support or withdrawn her consent for services. Harry’s mother explained that she was desperate for support and had in fact contacted children’s services on more than one occasion to seek support. In her opinion she had never declined services but had just not been offered anything that met her and Harry’s needs. She provided examples of this, indicating that there is potential to improve the services offered to children and young people with special educational needs and disabilities. One of the key things needed by Harry’s mother was additional support in addressing Harry’s schooling and whilst this was identified by Early Help workers, there was no support offered in relation 18 https://www.gov.uk/government/publications/send-code-of-practice-0-to-25 19 Wokingham Integrated Early Help Service 15to this. Whilst it is accepted that the schooling should have been progressed by the SEN service, this had not happened. After being tasked to support Harry’s family it would have been beneficial for the Early Help service to have taken a multi-agency approach, holding a Team Around the Family (TAF) meeting to ensure that Harry’s needs were fully understood and acted upon within a coordinated multi-agency plan. This could have included his schools and the SEN service. Such a multi-agency plan would have helped to secure the engagement of Harry’s mother, providing her a greater level of emotional support whilst providing the opportunity to address Harry’s early signs of offending behaviour. A local outreach service is a key pillar of support offered to young people with a developmental disability and signposting the family to this service, or making a referral for focussed 1-1 support, would have been supportive. This was not however offered to Harry’s mother, who was left to discover the existence of the service herself and then self-refer. Following the October 2020 strategy meeting, a child and family assessment was completed, and Harry’s case was ‘stepped down’ for early help. At this time two things should have occurred to ensure that Harry’s needs were understood and that partnership agencies were considered in the response. a) A formal step-down meeting between the social worker completing the assessment and the relevant early help staff. b) A ‘Team Around the Family’ meeting, to consider the involvement of partnership agencies and to develop multi-agency planning. Neither of these things was done, illustrating how whilst providing services to Harry the early help service worked in isolation. The children’s services representative informed the review panel, that since Harry’s case a number of improvements have been made to the early help and youth justice20 services, including a performance framework that measures the quality and outcomes of interventions. The improvements relevant to Harry’s case include: a) An enhanced Early Help Hub, involving a greater number of partnership organisations and groups, to provide additional pathways of support for young people and their families. b) Early help multi-agency processes include holding an early Team Around the Family meeting where a case is led by the Early Help service, ensuring that a multi-agency support plan can be developed. c) Improved youth justice service pathways, including targeted intervention for young people who display offending behaviour, including a specific referral process for schools. d) A new exclusion prevention programme that is currently being trialled within a number of schools in Wokingham, offering targeted 1-1 support for a young person instead of the use of exclusion. Should the trial prove to be successful then there is an intention to apply for funding from the Office of the Police and Crime Commissioner so that the service may be expanded and opened to all young people living and attending school in Wokingham. e) The Children with Disabilities Service has developed a continuum of need document, outlining the support that may be offered to young people. This includes the ASSSIT service, with clear referral pathways that may be used by other departments within children’s services and partnership agencies. It also includes methods of self-referral for use by families. Whilst this development is positive and encouraging, there would be great value in reviewing how this has been embedded into routine practice, to ensure that an effective multi-agency approach is consistently achieved and that families are receiving the type of help they need. It is therefore recommended that children’s services, supported by the wider safeguarding partnership, conducts a multi-agency audit of cases where the Early Help service has recently been assigned to support young 20 During 2022 the Wokingham youth offending service has been rebranded to the Prevention and Youth Justice Service. 16people with special educational needs and disabilities. This should include direct representation of the families involved in the cases, to ensure that services are delivering their needs and that the safeguarding partnership understands how it feels to be in receipt of early help services. School exclusion was a key issue that affected Harry and for this reason the new exclusion prevention programme is an exciting development that has the potential to make a significant difference to young people in the future. Whilst Harry lived in Wokingham, he went to a school in an adjoining local authority area and as the intention is to deliver this scheme at schools in Wokingham it is not clear if he would have benefitted fully from this initiative. Should the trial be successful, and a decision taken to implement it fully, then consideration should be given as to how the full benefits are provided to young people in Harry’s situation. Due to local capacity of suitable school placements, it is likely that other young people living in Wokingham will attend schools in adjoining local authority areas and it is essential that they are not denied the full benefits of the exclusion prevention scheme due to their disability. Recommendation 7: Wokingham Children’s Services, with the support of the BWSCP, should conduct a multi-agency audit of cases where the Early Help service has been tasked to support young people with special educational needs and disabilities. This should include direct representation of the families involved in the cases, to ensure that services deliver their needs, and that the safeguarding partnership understands how it feels to be in receipt of early help services. Recommendation 8: Wokingham Children’s Services should consider how the full benefits of the Exclusion Prevention scheme may be provided to young people who live in Wokingham, whilst attending school in a different local authority area. These arrangements should be included in any future policy and procedure that is developed to support the scheme. 17 5. CONCLUSION AND SUMMARY OF RECOMMENDATIONS Concluding Comments This child safeguarding practice review has identified key learning for both single agencies and for the development of partnership working. The Berkshire West Safeguarding Children Partnership should now consider the recommendations and consider how they intend to deliver improvements to safeguarding practice. In addition to addressing multi-agency recommendations it should hold individual agencies to account for delivering the single agency recommendations. Summary of Recommendations Recommendation 1: The local authority should develop new procedure for the early review of EHCPs when a child or young person moves local authority area at the same time as transitioning from primary to secondary school. Recommendation 2: The Local Authority should develop arrangements with the BWSCP, to provide ongoing assurances that the improvement board is effective in the delivery of change and that it is able to evidence how improvements are delivering better outcomes for children and young people. Recommendation 3: New information sharing procedures should be developed in the Berkshire West partnership area, to provide an enhanced level of information sharing for students who have an EHCP at the time of changing education establishments. This should include professional meetings attended by the relevant schools, the agencies working with the young person, and the parents/ guardians. Recommendation 4: The local authority should review the provision of resources and pathways available to schools, in order to reduce the use of exclusions for children and young people with EHCP. This should be delivered by a working group that involves headteachers and specialist staff from both maintained and non-maintained schools. Recommendation 5: Thames Valley Police should produce new policy and guidance in relation to children and young people who are identified as suspects in a criminal investigation. This should be underpinned by an annual training programme to develop a culture of safeguarding and partnership working, delivered to all police officers and police community support officers. Recommendation 6: Wokingham Children’s Services should update policy and guidance for the review of referrals and contacts that involve children and young people with special educational needs and disabilities. Recommendation 7: Wokingham Children’s Services, with the support of the BWSCP, should conduct a multi-agency audit of cases where the Early Help service has been tasked to support young people with special educational needs and disabilities. This should include direct representation of the families involved in the cases, to ensure that services deliver their needs, and that the safeguarding partnership understands how it feels to be in receipt of early help services. Recommendation 8: Wokingham Children’s Services should consider how the full benefits of the Exclusion Prevention scheme may be provided to young people who live in Wokingham, whilst attending school in a different local authority area. These arrangements should be included in any future policy and procedure that is developed to support the scheme. |
NC047789 | Serious, non-accidental head injuries to a 10-week-old baby, Child AA, whilst in the care of parents. The parents were arrested and bailed pending further investigation and Child AA and an older sibling were taken into care. Sibling was subject to a Child in Need plan which continued following Child AA's birth. Team around the child and professionals meetings were also convened following Child AA's birth. Concerns about the family included: young age and immaturity of parents; lack of support from family or friends; dependence on professionals for money, food and equipment for the children; poor living conditions. Mother was a young carer for her mother, was subject to a Child in Need plan and received services from CAMHS. Issues identified include: the differences of opinion between children's social care and the community health services, which were compounded by a lack of clear and current assessment and co-ordinated planning. Recommendations include: guidance for social workers on assessment should include joint visiting with other professionals to share perceptions and views; risks to new born babies should be fully understood with the expertise of community health professionals in this area acknowledged; inclusion criteria for the Family Nurse Partnership should be revised to include young parents who have a second or subsequent child.
| Title: Overview report on the serious case review relating to Child AA. LSCB: Surrey Safeguarding Children Board Author: Ruby Parry Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Overview report on the SERIOUS CASE REVIEW relating to Child AA Ruby Parry Senior Consultant Reconstruct www.reconstruct.co.uk 2 Contents: Page 3 Introduction Page 4 Purpose of review Page 4 – 6 Review process, scope and methodology Page 9 Context of Report Page 10 Family culture and identity Page 11 – 13 Summary of events Page 13 – 34 Analysis Page 34 – 37 Lessons Learned Page 37 – 38 Recommendations to Surrey Safeguarding Children Board Page 39 – 40 Single Agency Recommendations Page 41 Appendix: Terms of Reference 3 1. INTRODUCTION 1.0 Background to the review 1.1 This serious case review has been carried out as a result of serious injuries to a 10 week-old baby, Child AA, whilst in the care of young parents, who were living in a hostel for the homeless. Child AA was the younger of 2 small children, being born prematurely at 31 weeks gestation. The older sibling aged 13 months, had been subject to a Child in Need Plan with Children’s Social Care, and this continued following Child AA’s birth. In the 6 weeks leading up to the injuries, there had been many concerns raised about Child AA by the health professionals, but the level of these concerns was not fully understood by social workers. A professionals meeting was held on the 6th of June 2014 to seek to resolve differences of opinion between the two agencies and a full parenting assessment was agreed. Unfortunately this was overtaken by an incident on the 15th of June 2014, when Child AA was taken to A&E by ambulance. Child AA was described as being floppy and unresponsive, and a CT scan revealed “…bilateral subdural blood from different ages, meaning there has been more than one incident”1. This was considered to be non-accidental injury and both parents were subsequently arrested by the police and bailed pending further investigation. 1.2 At the time of writing, Child AA and the older sibling are in foster care, and Child AA’s health is improving, though the child has suffered significant brain damage, the long term effects of which are still being assessed. 1.3 Criminal proceedings concluded in September 2016. Care proceedings in relation to both of the children concluded in December 2014. 1.4 In line with government requirements, the incident was referred to the Independent Chair of the Surrey Safeguarding Children Board (SSCB), who, following peer review, determined that it met the criteria for a serious case review, as set out in Working Together 2013. 1.5 One of the key questions for the review has been to consider whether the poor inter-professional communication and relationship between Children’s Social Care and health visiting services in this case had an identifiable impact on the safety of the children. In addressing this it is important to note that the time scale from the discharge of Child AA home from hospital, four weeks after birth, to the serious injuries that resulted in this review was a matter of only 6 weeks. Events moved very quickly, and there was a huge level of visiting and support offered to the family in that period. However, there was no full assessment carried out following the birth of Child AA and professionals continued to work to an earlier social work assessment that did not draw fully on the history of the family. This meant that they did not have a full picture about the potential risks and stresses faced by the parents. It is possible that, had there been such an assessment at this time, there would have been a better shared understanding and a clearer focus on the emerging risks. However, it is impossible to conclude whether this would have resulted in a different 1 SSCB Notification of Serious Incident Form 17/6/14 4 outcome, in preventing the injuries to Child AA, given the very short timescale in which action could have been taken. 1.6 It is also important to acknowledge that whilst hindsight enables us to learn from these events, staff involved at the time could work only with what they knew. The emotional impact of working with the family and of the events that resulted in this review, have been significant, and it is important to acknowledge that there was evidence of good practice, as well as areas from which LSCB partners can learn. 2.0 PURPOSE OF THE REVIEW 2.1 Working Together to Safeguard Children 2013 was the statutory guidance in force at the time of the review2, provided by governments to Local Safeguarding Children Boards and their constituent agencies, and setting out how agencies should work together. It states that Serious Case Reviews must be held for: “…every case where abuse or neglect is known or suspected and either: • a child dies; or • a child is seriously harmed and there are concerns about how organisations or professionals worked together to safeguard the child.” 3 2.2 The purpose of a serious case review is: To establish lessons to be learned from the case To look at what actions and procedures may need to be changed To improve inter-agency working and better safeguard children 2.3 The guidance is clear that: “Reviews are not ends in themselves. The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children.” 4 3.0 THE REVIEW PROCESS 3.1 The review process reflected the principles set out in Working Together 2013 and aimed to contribute to learning and improvement through consolidating good practice and identifying where practice could be improved. 2 This has subsequently been updated in 2015 3 “Working Together to Safeguard Children: A Guide To Inter-Agency Working To Safeguard And Promote The Welfare Of Children.” Page 68 HM Government March 2013 4 “Working Together to Safeguard Children: A Guide To Inter-Agency Working To Safeguard And Promote The Welfare Of Children.” Page 68 HM Government March 2013 5 3.2 These principles are as follows: There should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works and promote good practice; The approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined; Reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed; Professionals should be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith; Families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring that the child is at the centre of the process. Final reports of SCRs must be published, including the LSCB’s response to the review findings, in order to achieve transparency. The impact of SCRs and other reviews on improving services to children and families and on reducing the incidence of deaths or serious harm to children must also be described in LSCB annual reports and will inform inspections; 3.3 The review will recognise the complexity of safeguarding children and seek to understand not only what happened but why individuals and organisations acted as they did. 4.0 SCOPE OF THE REVIEW 4.1 The principal focus of the Review was the period from 01.09.2012 to 22.06.2014 4.2 However, the SSCB asked agencies to provide a summary of all significant events and relevant family history outside the specific scope and timescale, where this would help to inform the overall analysis. 5.0 THE FOCUS OF THE REVIEW 5.1 The SSCB agreed that the review should focus on the following questions: 1). Did agencies communicate effectively and work together to safeguard and promote the children’s welfare? 2). Was the level and extent of agency engagement and intervention with the family appropriate? Were assessments undertaken in a timely manner, was the quality adequate and did they include fathers, extended family and all historical information? 3). Was any information known by any agency about parental mental health issues, domestic abuse, substance misuse or parental antisocial behaviours or concerns 6 re neglect? If so was appropriate consideration given to how these impacted on parenting capacity and were appropriate referrals made? 4). Was there sufficient consideration of the vulnerability of this family in relation to their housing situation and the impact on their parenting capacity and what support was provided? 5). Were the decisions and actions that followed assessments appropriate and were detailed plans recorded and reviewed? 6). Were the children’s views and wishes sought and taken account of in assessments and planning? Did this include the presentation of these young non-verbal children being fully considered? 7). Were any safeguarding issues in respect of the children identified and acted on appropriately and in a timely way by all agencies? 8). Were missed appointments and failure to engage considered as indicators of neglect? 9). Was race, religion, language, culture, ethnicity or disability a factor in this case and was it considered fully and acted on if required? How was the uniqueness of this particular family recognised? 10). Were there any organisational or resource factors which may have impacted on practice in this case? 11). Were appropriate management/clinical oversight (supervision) arrangements in place for professionals making judgments in this case? 6.0 THE METHODOLOGY 6.1 The SSCB has a well-established methodology which this reviewer agreed to adopt. This reflects good practice in that it seeks to ensure that those most involved in the incident which resulted in the review are fully engaged and supported to reflect on their practice and to contribute to the recommendations from the review. 6.2 Governance of the review was provided by the Surrey Safeguarding Children Board Strategic Case Review Group, chaired by the Independent Chair of the LSCB, Alex Walters. The other group members were: o Director of Rehabilitation and Deputy Chief Executive - Kent, Surrey and Sussex Community Rehabilitation Company o Consultant Designated Nurse Safeguarding Children - NHS Guildford and Waverley Clinical Commissioning Group o Designated Doctor Safeguarding Children - NHS Guildford and Waverley Clinical Commissioning Group o Deputy Director, Children's Schools and Families - Surrey County Council (Children, Schools and Families Directorate) o Head of Youth Support Services - Surrey County Council (Children, Schools and Families Directorate) 7 o Assistant Director - National Probation Service, South East and East Division o Detective Superintendent, Public Protection - Surrey Police o Director of Quality and Executive Nurse - NHS Guildford and Waverley Clinical Commissioning Group o Assistant Director for Schools and Learning - Surrey County Council (Children, Schools and Families Directorate) o Acting Principal Solicitor - Surrey County Council 6.3. The author met with the group on three occasions: 25th November, 2014; 23rd January 2015, and 26th March 2015, and had a telephone conference with them on 21st May 2015. 6.4. The methodology required that the relevant agencies provide details of their involvement, which was drawn together in to an integrated chronology. This was then supported by individual agency Internal Management Review reports - IMRs 6.5. The following agencies were asked to contribute IMRs; o Surrey Hospital o Community Health provider o Surrey and Borders Partnership Foundation Trust o Surrey Children's and Safeguarding Service o Surrey GP o The District Council (housing) 6.6. The following agencies had less direct involvement and were therefore asked to provide a briefing report rather than a full IMR: o South East Coast Ambulance Service o Surrey Police o Surrey Early Years Service o Surrey Schools and Learning o St George’s Hospital NHS Foundation Trust o The Housing Support Agency 6.7 A neighbouring Children’s Social Care service were also asked to provide information, which they did in the form of an email about their brief involvement with the family, before the birth of Child AA. 6.7 The reviewer attended a meeting of the strategic case review group on 25th November 2014, at which all of these reports were tabled and discussed. The IMR authors 8 were also present at this meeting and had the opportunity to present their reports and to discuss their findings with each other, with the group and with the reviewer. 6.9 Practitioners were then invited to meet with the reviewer in order to discuss their contribution and to reflect on learning and recommendations for change. Given that the chronology evidenced some clear differences of opinion between social care and primary health care professionals it was agreed that each of these groups of staff would be invited to meet with the reviewer separately prior to any larger multi-agency practitioners event. 6.10 The reviewer met with the four health practitioners from Community Health on 10th December 2014, and with the social care professionals on 9th January 2015. The delay between these meetings was due to the Christmas and New Year break and professionals leave arrangements over this period. Unfortunately, only 3 staff from social care, out of the 8 who were invited, were able to attend. These were the student social worker who had held the case from April 2014 (now a qualified social worker), the family support worker, and the social worker who managed the initial court proceedings following the injury and removal of the children from their parents. Unfortunately no managers were able to attend this session. The supervising manager for SW2 was on maternity leave, and the others were unable to attend due to operational pressures, although they did give apologies. There appears to have been a breakdown of communication in that some of the social work participants who did not attend had misunderstood the nature of the meeting, and therefore did not appreciate its importance to the review. 6.11 A discussion subsequently took place between the reviewer and the Area Manager for the Children’s Social Care teams involved in the review on March 4th 2015. This has been enormously helpful in clarifying the context of the structural changes within the service and the overall system, and the learning for the social care service. 6.12 There was clearly a great deal of distress for staff about these events and both the reviewer and the serious cases group were keen to manage the review and the involvement of those staff with as much sensitivity as possible. This meant accepting that there would be a delay in completing the review to allow for staff to be properly debriefed and to comment on the draft report in a timely way. The draft report was circulated for comment and the responses incorporated into this final version. 6.13 The serious cases group have agreed to hold a further learning event engaging with the staff involved to give them time to debrief and to reflect, before any wider scale rollout of the learning. 7.0. HOW FAMILY MEMBERS WILL BE INVOLVED 7.1. Whilst it is the commitment of the Board and the reviewer to fully engage with the family, the parents have not responded to letters sent to them in October 2014 inviting them to be involved. 7.2 They will be contacted again prior to publication of the report to discuss their experiences of working with agencies. 9 8.0 THE REPORT AUTHOR 8.1 The report author is Ruby Parry, who is a senior associate consultant for Reconstruct, a children’s services company which provides training and development and consultancy to children’s services professionals, and advocacy and participation services to children and young people as well as serious case review expertise. Ruby is a registered social worker and former Assistant Director of Children’s Social Care, an experienced author and reviewer, and meets the criteria for independent authors of serious case reviews. 9.0 PUBLICATION OF THE REVIEW 9.1 As previously stated, Working Together requires that Local Safeguarding Children Board’s maintain a learning and improvement framework of which serious case reviews are part. The guidance states that there should be: “….transparency about the issues arising from individual cases and the actions which organisations are taking in response to them, including sharing the final reports of Serious Case Reviews (SCRs) with the public.” 5 9.2 This report is therefore written with full publication in mind. That means that the names of the adults and the children, as well as some of the facts in this review have been changed to protect identities and to respect individual rights to confidentiality in relation to personal information. The report therefore contains only that information which will ensure that the facts can be understood in order for lessons to be learned. 10.0 DISSEMINATED LEARNING AND HOW CHANGE WILL HAPPEN AND BE MONITORED The Board has a well-developed learning and improvement framework and the learning from this review will be incorporated into existing training, as well as being the subject of specific workshops with the practitioners and managers concerned. The action plan will be monitored by the Board. 11.0 CONTEXT OF THE REPORT 11.1 At the time that Child AA was expected and then delivered into the world, Children’s Social Care (CSC) was undergoing a significant restructuring which had been phased in across the authority and was being implemented in the area responsible for the care of Child AA’s family from April 2014. This was outlined in a paper to Surrey Children Safeguarding Board in January 2014, and involved a restructuring of the Area social care teams Assessment and Child in Need Teams to support the developing Surrey wide Early Help Strategy and the local authority's responses to the revised Working Together 2013 statutory guidance including the introduction of the single assessment process. 11.2 Staff state that they had been well prepared for this through a series of inclusive consultation and information events. The key changes in relation to Child AA and the way in which the case was managed, were in relation to the former Children In Need (CIN) Team within which SW1 and SW2 worked, being disbanded, and moving into a different model of 5 Working Together, Op cit Page 65 10 working as an Assessment and Intervention Team sitting within the area Referral, Assessment and Intervention Service. The focus of the work within that team was, from 1st April, to provide an assessment and short term intervention to families, and then on the basis of this to make a decision about whether the case would be closed, stepped down in to the multi-agency Early Help system (with or without a social worker as lead professional, depending on need) or move into the specialist child protection (social work) team. Children in need who have been assessed and provided with a social care intervention through the single assessment process that remain vulnerable with unmet need or the family being in need of continued support would be supported by the Early Help System or a lead professional from the Referral, Assessment and Intervention Service. The management of Child AA’s case however, did not reflect these new arrangements, and was managed as an existing Child In Need case. 11.3 Whilst there was no wholescale movement of staff, with only 5 social workers posts across the County moving in to the new Multi-Agency Safeguarding Hub, the health practitioners stated that this meant that some of the positive relationships previously built up with social workers were broken down as there was initial confusion about who they should contact about what. They were also aware of some morale issues as some social workers shared their concerns and anxieties with them. 11.4 The Community Health service staff described a positive and ‘can do’ culture in their own organisation where health professionals feel well supported and able to discuss concerns and to take creative action to support families. Their working context was therefore stable, and very different from the day to day experience of the social workers involved at the time of these events. 12.0 FAMILY CULTURE AND IDENTITY 12.1 The Oxford English Dictionary defines culture as being “the ideas, customs, and social behaviour of a particular people or society’6. The experience of family ‘culture’ can shape the way in which we as adults then view the world and seek to parent our own children7. 12.2 The mother’s family is White British and she was born and grew up in Surrey. She was known to CSC from an early age due to her mother’s alcoholism and dementia, and she was a young carer. Her family life can be said to have been lacking in emotional nurture and care for her as a child in her own right, whilst her parents struggled with their own considerable health needs. She was bullied at school because of her mother’s condition, and her school work and attendance suffered as a result. She became pregnant at 16 years old, and a mother at 17. 12.3 The children’s father described himself to the health visitor as ‘half Romany/Gypsy’. Culturally, this may have resulted in fixed ideas about the roles of men and women, most notably, that the men provide for their families, and the women take care of the 6 Oxford English Dictionary 7 See, for example, The Child’s World, Jan Howarth, 2010 11 children – certainly the professionals records of father’s behaviour suggest that this was the case. 12.4 There is little evidence of any extended family network or support to the couple and their children, and they appear to have been very isolated in this respect. 13.0 SUMMARY OF EVENTS 13.1 The integrated chronology which tells the detailed story of agency involvement with the family runs to 341 pages, and this is not reproduced here. Instead the following is a brief summary of events which provides the background to the analysis to enable connections to be made between these events and the learning arising from the review, without compromising the anonymity of the family concerned. 13.2 As above, Health and Children’s Social Care records indicate that the mother had been known to Children’s services from 2003, when she was 8 years old, until 2011 when the case was closed. Her own mother was admitted to hospital with alcohol induced dementia in 2008, and subsequently diagnosed with Korsakoff’s’ Syndrome – a form of early dementia associated with alcohol abuse. CSC subsequently started a Children In Need8 (CIN) plan, and a referral was made to Child and Adolescent Mental Health Services (CAMHS) for the mother due to the emotional impact of her home life which manifested itself in physical palpitations. She then suffered a miscarriage at age 16. 13.3 The mother then moved areas to live with her partner and again became pregnant, presenting to her GP seven times through the pregnancy with abdominal pain, including once at 23 weeks when she complained of hip pain due to a fall. 13.4 Her first baby was born in June 2013, and she attended A&E with the baby 2 weeks later, worried that the baby was unsettled. During this period mother also indicated to hospital staff that children’s social services had been called by neighbours due to shouting in the home, and the local Children’s Social Care service has subsequently confirmed that they carried out both an Initial and Core assessment in July 2013, following allegations that the mother had been shouting at the baby and had tried to smother it with a pillow. However, they quickly closed the case following the assessment. 13.5 By September, 2013, the mother had presented to A & E eleven times, with anxieties about the baby but with no medical issues being identified. She was also at one point prescribed anti-depressants. On 6th October 2013 the GP received an NHS 111 notification that the mother had called because her 3 month baby had rolled off of the sofa and had a bump on the back of the head. She was advised to call her GP, but went to A & E instead, leaving before being seen. A&E therefore sent a safeguarding form both to the health visitor and to the local Multi-agency Safeguarding Hub, as well as asking the police to complete a welfare visit, which they did. This did not result in any further action, although the police report noted that the house was “incredibly messy and with obstacles all over the 8 The Local authority has a duty to provide services to Children who are in Need as defined within Section 17 of the Children Act 1989. At this time, this was provided in Surrey as part of a CIN plan, which children’s social care managed to coordinate help to families who met the Section 17 criteria 12 floor”9 and that mother seemed to be struggling to get into a routine with the baby. In October the mother’s GP prescribed anti-depressants and noted that she had thoughts of self- harm, but the family then moved out of the area. 13.6 In December 2013 the mental health social worker visiting the mother’s parents noted that the couple had moved in with their baby, and made a referral to Children’s Social Care due to concerns about “cramped, chaotic and unhygienic conditions in the flat and the possible risk posed by the grandparents10”. The worker also expressed concerns that neither parent was in receipt of the appropriate benefits. The mother was also again pregnant. 13.7 By January 2014, the local health visiting service had been informed about the couple’s circumstances, and made a series of visits in which they provided food parcels and advice, and also referred the family to Children’s Social Care (CSC) due to concerns about the conditions the couple were living in, and their capacity to manage the baby safely due to overcrowding and the mess in the flat. 13.8 CSC subsequently allocated a social worker who carried out an assessment, and recommended a Children in Need plan to support the family in finding accommodation and caring for the baby. A team around the child (TAC) meeting was agreed, but did not happen before the mother was admitted to hospital in early April 2014, and Child AA was born prematurely at 31 weeks gestation. The baby was transferred to the Neo-Natal Infants Unit (NNIU). The mother was discharged home as she said that she found it difficult with all the other babies crying and she wanted to be with her older child who was being cared for by the father and grandfather. 13.9 CSC had at that point decided to close the case, but calls from the mother and the named health visitor (NHV1) changed this decision, and CSC agreed to support mother with money for transport to the hospital to see Child AA. As the case holding social worker was a locum who had now left the service, the case was transferred to a student social worker, SW2, on 28th April, and she made plans for the family to move into a hostel for the homeless when the baby was discharged. A family support worker (FSW) was also allocated to help the mother manage the needs of her 2 small children, and the local Children’s Centre also provided a support worker and invitations to ‘drop in’ and parenting groups to reduce the mother’s isolation. 13.10 Between 6th May, 2014, when Child AA was discharged home to her parents at the hostel, and June 15th, 2014, when she was re-admitted to hospital by ambulance, there were almost daily visits by professionals who were trying to support the family to manage the babies and to sort out their finances and housing situation. 13.11 There were very early concerns highlighted by the health visiting service to SW2 about what they saw as being very poor conditions in the rooms the family was living in, which they described as dirty and messy, with many hazards left unattended and which they considered to present a danger to the children. Both the named health visitor (NHV) and the health visitor for the homeless (HVH) recorded and expressed a high level of anxiety about 9 Police IMR 10 ICS recording, integrated chronology 13 the mothers ability to cope, about her young age and immaturity and her dependence on professionals for money, food and equipment for the children. They continued to provide food parcels, equipment and toys to the family. 13.12 SW2 and the Family Support Worker (FSW) did not understand this level of concern and sought to support the mother and the father to take responsibility for their children and their circumstances. They quickly formed the view that the family were being overwhelmed by the level of professional visiting and requested that health reduce this. SW2 therefore convened a team around the child (TAC) meeting on 19th May to discuss the concerns, but the HVH who attended the meeting, did not consider that this meeting had addressed her concerns, and she continued to raise these with her colleagues and with her manager. 13.13 Between May to June 2014 there were 2 minor injuries to the older baby – small bruises which the mother brought to professionals attention, and one of which resulted in the child being admitted overnight to hospital for observation. Doctors were satisfied that these were not safeguarding concerns, as were CSC, although the health visiting service saw these as significant and indicative of neglect, and so now sought to escalate their concerns to the manager of SW2. 13.14 Child AA was at that time also admitted to hospital overnight with suspected sepsis (infection) but released home with a cannula inserted for antibiotics to be administered the next day. This was then removed as the infection had resolved. 13.15 A professionals meeting was held on 6th June at which the differing opinions of the health and social work professionals were aired, and a plan was agreed for a full parenting assessment to be undertaken by SW2, along with unannounced visits by SW2. However, before this plan could be put into action, Child AA was admitted to hospital with severe brain trauma, associated with Non Accidental Injury. 14.0 ANALYSIS 14.1 The following considers these events in relation to the questions raised in the terms of reference. This includes reference to research evidence and the procedures that were in place at the time. However, the Terms of Reference lists 11 questions to be addressed, which are interlinked and inevitably overlap with each other. To avoid unnecessary repetition the analysis is very brief in response to some, where this has already been covered elsewhere. 14.2 As stated in the introduction, it should also be noted that the period between the birth of Child AA and the injuries that resulted in this review is very brief – a matter of 10 weeks, 4 of which were spent in hospital in the NNIU, with only 6 weeks at home in the parents care. This provides important context in relation to the level of professional involvement and visiting and the timeliness of professional understanding of, and response to, concerns – it is not much time in which to fully understand and respond to complex and dynamic family circumstances. 14.3 There is also a lack of detailed information in relation to the social work involvement with the family prior to the allocation of SW2, compared to the very full health visiting records. This is reflected in the IMRs from both agencies, so that the level of concern 14 being recorded by the health visitors is very clear, and can easily skew analysis as there is less detail available in the IMR about the social services response. This in turn reflects the different cultural, professional, procedural and practical contexts within which these professionals were working, and which are further explored in the lessons learned section of this report. 1. Did agencies communicate effectively and work together to safeguard and promote the children’s welfare? 14.1.1 There is evidence of appropriate referrals being made in relation to the older sibling of Child AA, during 2013, when health professionals noted the vulnerability of the mother due to her youth, and previous history with social care. However, she moved twice during this period – once to be with the baby’s father, and then back into her home area – and these referrals and the information about her many visits to A&E in the neighbouring authority do not then seem to have been picked up and understood as possible indicators of safeguarding concerns when she returned to her home area. This includes an incident on 6th October 2013 when the older sibling was 3 months old and according to mother hit its head rolling off the sofa. Mother attended A&E but did not wait to be seen. This information was appropriately passed to the local MASH on a Safeguarding Form, and there was a police welfare check carried out at the hospital’s request – an example of good safeguarding practice. Information about the core assessment undertaken by the local Children’s Social Care in July 2013 however, was not accessed as part of the 2014 assessment, and this is further commented upon later in this report. 14.1.2 On the 15th of October 2103, whilst still in the neighbouring authority, the mother is recorded to have visited her GP who prescribed anti-depressants due to her low mood, and wrote in the notes that mother was: “Panicky, thoughts of self-harm but not enacted due to baby.”(Integrated chronology GP Records) 14.1.3 The family are noted to have moved shortly afterwards, but this head injury in a 3 month old baby in the care of a very young mother who is noted to be considering self-harm, is of concern. Unfortunately this information does not appear to have informed any later assessment, or to have been known to the health visiting service that became responsible for the care of the children when the family moved back into the area. The 0-19 team from the Community health service did follow the ‘transfer in’ procedure but were informed by the previous team that there were no concerns, which is surprising given the history. The information appears in the GP notes, but these do not appear to have been transferred over at this point. The current process for GP records passing from one practice to another is triggered by the patient registering at the new practice. This then starts the process of the records being requested from the original practice, and subsequently being forwarded to the new practice. However, the family did not register with a new GP until after the birth of Child AA, by which time the receiving health team already had significant concerns based on their observation and interaction with the family, but without this historical information which may have increased their evidence base in discussing risk with CSC. 14.1.4 There are many examples of immediate communication from Surrey health professionals with each other and with children’s social care following visits to, and contact with the family. For example, NHV1 appropriately communicated with other agencies when she was made aware of the family, and arranged for a food parcel and essential equipment 15 for them. She contacted the health visitor for the homeless (HVH) and did a joint visit with her, and then appropriately referred into Children’s Social Care on 4th February 2014 by telephone, and followed this up with a detailed FAX. The HVH also telephoned to give her support to the referral, and the social care records are clear that this listed a number of safeguarding concerns, including the history of the mother, whom HVH had known previously, having been her school nurse. 14.1.5 Following this there was then a great deal of communication between health professionals and children’s social care, and between social care and the other helping agencies, particularly following the allocation of SW2 to the case at the end of April 2014. There was also good communication in most instances between health professionals across the health community and information was shared with CSC about ambulance call out and hospital admissions in relation to Child AA and the older sibling – although not on every occasion. This is discussed in the next section in relation to safeguarding. 14.1.6 SW2 communicated effectively with housing to advocate for the family, and with the Children’s Centre to engage additional support. 14.1.7 However, it is clear that there was a very difficult relationship between the health visiting service and children’s social care in relation to this case, and unfortunately this meant that they did not work together, but in parallel. There is evidence of a wide difference of opinion about the level of concerns about the parents’ capacity to provide safe care to their children from the outset, and it appears that as events unfolded professionals become further entrenched in their relative positions, with growing frustration on both sides. 14.1.8 Communication appears to have been problematic from the start. In February 2014 NHV1 arranged a joint visit to the family with SW1. The Assistant Team Manager recorded a recommendation that such a visit should take place. However, the social worker did not turn up to the visit and gave no explanation for this. When the health visitor phoned she was told that the social worker was ‘out’, and there was no further discussion with her about this failed visit. This would inevitably have had a negative impact on the ongoing relationship between these two core agencies and unfortunately served as a baseline for the poor communication which is a feature of the case going forward. 14.1.9 The ICS records then show one visit from SW1 to the family on 11th February, and a phone call with the mother, and with NVH. On the 19th February the social workers assessment was signed off by the ATM, with a recommendation for short term support. 14.1.10 NHV1 and HVH continued to visit and record their concerns, and were under the impression that SW1 was undertaking a core assessment. RIO health records outline many concerns from both health visitors about the crowded and unsuitable living conditions, and note on 4th March a telephone call to NHV1 from SW1 in which it was agreed that a Team around the Family would be arranged and NHV1 would complete the Family Health Needs Assessment. 14.1.11 Neither the Team around the Family meeting, nor the Family Health Needs Assessment occurred however, and SW1 left the service in April 2014. This was not communicated to the health visitors, who learned about the change of social worker when NHV1 contacted the department to talk about the discharge planning meeting for Child AA on 1st May. NHV1 also then moved to a new post and handed over to NHV2. This meant that 16 there was no effective cross agency handover of the case and a real potential for misunderstanding and miscommunication between the two agencies was created, which became evident very quickly thereafter. 14.1.12 Following the discharge of Child AA from hospital into the care of the parents at the hostel, there were a series of difficult telephone calls between SW2 and NHV2 and between SW2 and HNH about the provision of equipment to the family and about who was responsible for what. The tone of the communication deteriorated quickly, and began to reflect professional differences about whether the level of concerns actually reflected safeguarding concerns. SW2 was clear that she had been allocated the case on the basis that this was a short term piece of work with children in need, and although she recognised that “the arrival of baby AA increased the level of support that would be needed” she still viewed this as a ‘Child in Need’ case and was supported by her manager in this view. 14.1.13 This view does not appear to have changed at any point, and on the contrary, escalated to the point where CSC workers were of the view that health visiting professionals were undermining mother and the progress that she was making with their help. Health visiting professionals records evidence a number of internal discussions where the risks as they saw them are outlined and the advice of the lead nurse for safeguarding is sought. 14.1.14 This difference in opinion was unfortunately communicated to the parents and there are examples in the records of parents complaining about professionals to each other. On 12th May, the mother told the HVH that the social worker had told her to ‘just get on with it’, and on 14th May the father told the EDT worker that he was going to make a complaint about the health visitor. 14.1.15 On 16th May, SW2 then recorded a telephone call to mother “She (mother) believes the pressure from professionals visiting is causing her and (the father) to argue.” The social workers response to this was to try to get health visiting reduced. She also the same day recorded a conversation with father: “I informed I had spoken with the HV and acknowledged their concerns and reiterated that to father. Also that I felt we were not helping but hindering the situation with so many people telling them what to do, without practical help and informed him of Homestart.” (ICS record - integrated chronology) This made it very clear to the parents that the social worker did not share the health visitors concerns and that these professionals were not working effectively together. 14.1.16 There were 2 professionals meetings held to try to resolve these issues. 14.1.17 The first was on 19th of May, which is recorded in the social care record as “Professionals meeting to co-ordinate services” and this is what HVH stated that she thought she was coming to. However, what transpired was described by the health visitor as a TAC11 meeting with mother present, which was chaired by SW2. HVH stated that it was difficult to articulate her concerns with mother present throughout this meeting. There was also another person present who was not introduced to her. This later turned out to be SW2s tutor, who was there to observe her practice. 11 Team Around the Child in which family members discuss and agree their needs and the plan to meet these with professionals 17 14.1.18 The Housing Support service did not attend the meeting, but noted that: “The meeting closed without appearing to make any recommendations about future inter agency contact arrangements, or if they were, then they were not documented on the minutes of the meeting circulated on 20/5/14.” 14.1.19 This meeting did not therefore resolve the professional differences, and the next day, the sibling of Child AA was admitted to A&E via the GP with bruising to the ear which was queried by the hospital as possible Non Accidental Injury. On the 21st May SW2 recorded a telephone call from HVH in which she expressed her concerns and suggested that the mother required a fostering placement with her babies. SW2 requested that these concerns be put in writing to her, and the named nurse for safeguarding followed up this with a telephone call and an email outlining health’s concerns the following day, the 22nd May. 14.1.20 SW2 subsequently made a joint visit with her manager on the 28th May. However this visit, which is briefly recorded on ICS, does not contain any assessment or report on the outcome of that visit, and it does not appear to have been communicated to the health visitor, so that the relationship and communication between health visiting staff and children’s social care remained difficult, with health professionals continuing to believe that their concerns were not being taken seriously. 14.1.21 This can clearly be seen in the recording in RIO on 4th June, of a disagreement between SW2 and HVH, concerning the mouldy Moses basket: “The HVH then contacted the SW2 and ……asked that the FSW visited to support mother to get a new Moses basket. SW2 advised that mother had cancelled the FSW visit and that she would have to get her own Moses basket. HVH asked how this was possible with no transport, no buggy and 2 babies. SW2 is recorded as telling HVH that she should source one as she has no capacity or FSW available to help. HVH informed SW2 she was equally busy but that she would source and supply a carrycot as a temporary option on the basis that the present Moses basket presented a significant safety issue for a premature baby” 14.1.22 As a consequence, the next day, the Lead Nurse for Safeguarding appropriately sought to use the escalation procedure and to discuss the case with the Service Manager, who was not available. She spoke instead with the Assistant Team Manager, who agreed to convene a professionals meeting to discuss her concerns. 14.1.23 This was held on 6th June, chaired by the Assistant Team Manager. By this point SW2 had received information from Housing about the couples impending eviction, the strong suspicion that father was using cannabis, and concerns that the couple were not following up their benefits application. The meeting resulted in a plan to include unannounced visits from CSC and a parenting assessment. It also agreed that health visiting would reduce. This was of course, very quickly overtaken by events. 14.1.24 SW2 regularly discussed her perceptions with the FSW, who had started work in the new team in April 2014. FSW agreed with SW2 and was clear that she saw mother as gaining in confidence and that in her view mother was feeding the baby properly and sterilising her equipment well. Interestingly, the police IMR contains the following statement: “The crime report records that hospital staff noticed that the baby’s feeding bottles looked unhygienic” (para.7.5) which appears to support the health visiting staff’s assessment, and which adds confirmation that the thresholds and expectations of health and social care were 18 very different. What the health professional saw as being unhygienic, the social care professionals thought was ‘good enough’. 14.1.25 What is key here is that health professionals in interpreting risk will include infection risks, whereas social care training focusses more on a social model of parenting capacity. The important factor is the ability of different professionals to understand and engage with the professional expertise of others – a basic requirement of Working Together to Safeguard Children. What would have been helpful therefore in these circumstances would have been a joint visit between SW2 and HVH at an early stage in order to identify and discuss their differing professional perspectives and further joint visits or regular TAC meetings thereafter to explore any continuing points of disagreement. 14.1.26 The chronology confirms that the meeting of the 19th May was originally intended to seek to explore and resolve this difference in threshold and understanding. However, this unfortunately did not turn out to be the forum that the health visitor expected, and it is also clear that SW2 did not understand the depth of health concerns at this point, hence her use of the meeting to provide an opportunity for her tutor to observe her practice. 14.1.27 SW2 did then request that these concerns be set out in writing to her, but is not clear what she then did with the e-mail she subsequently received from HVH. HVH and the Named Nurse then appropriately escalated their concerns to the team manager of SW2 when HVH realised that the notes of that meeting did not reflect the level of anxiety that she felt she had expressed to SW2. 2. Was the level and extent of agency engagement and intervention with the family appropriate? Were assessments undertaken in a timely manner, was the quality adequate and did they include fathers, extended family and all historical information? 14.2.1 Following Child AA’s discharge from hospital into the care of her parents, until the incident just under 6 weeks later, according to the chronology there were 11 recorded visits by health visitors, and 9 by the social worker, plus 5 by the family support worker and children’s centre worker. The Housing Support service also visited 7 times between the 1st of May and the 12th of June. On some days, mother was visited twice – by health visitors and by the family support worker, and she also attended the Children’s Centre with both babies. 14.2.2 It is easy therefore to understand that the mother may have found this level of intervention somewhat overwhelming at times, and it clearly also resulted in her being given conflicting information. For example, the health visitors were unhappy about the buggy which they considered to be unsafe and told the SW2 this on 7th May, but SW2 visited on 12th May and recorded that the buggy was “a little scruffy, however, suitable and safe” (ICS recording – integrated chronology) As above, this conflicting approach was apparent to the parents and they complained to the professionals about each other. 14.2.3 What was lacking in this level of activity was a full assessment leading to a clear plan of purposeful action, including joint visiting so that professional opinions could be discussed, differences highlighted, agreement reached, and resources coordinated. As outlined below, neither CSC nor health undertook this task and the plans from the hospital discharge meeting and then from the TAC meeting on 19th May, were not informed by any updated assessment that took account of all the known risks and stresses. 19 14.2.4 The CSC IMR acknowledges that the initial assessment “was not undertaken in a timely way and was delayed due to the absences of the worker who was a locum and who was challenged by …the managers…in relation to performance.” It also goes on to say that: “However the “quality of the assessment was acceptable”. (p7) 14.2.5 The CSC IMR author however also states that ‘there were gaps in the assessment….. The father did not feature greatly in the assessment and throughout the lifetime of the case prior to the critical incident very little was known about his history. (The manager) had requested that enquiries should be made of the London Borough of The local as to the reasons for the family’s departure and whether they were known to Children’s Services. This was not followed up and that gap in the knowledge remained.” 14.2.6 The chronology only records one visit to the family by this social worker to undertake the assessment, in February 2014, and none thereafter, so that the expectation of the health professionals and the couple, that a full 45 day assessment was being undertaken, was inaccurate. The manager of SW1 had also asked that a joint visit with the referring health visitor be undertaken, and, as above, this was arranged but the social worker did not turn up, without any explanation. 14.2.7 On the 7th April the manager of SW1 recorded: “I am unable to approve this assessment due to inconsistencies between the analysis and the recommendations. The analysis identifies that (the baby) could get 'physically hurt' due to clutter whilst it also mentions that parents provide close supervision and act appropriately to keep safe.”. On 9th April the manager then records: “ As per previous oversight, please amend analysis of 'risk that the baby (sic) can get physically hurt' as this has not been evidenced and remove the recommendation for CAF as no specific issues identified for CAF to address, then close.” 14.2.8 Therefore, despite the paucity of assessment the decision was made to close the case in early April, and the identified risk was to be removed, rather than further explored, to enable this to happen. 14.2.9 The neighbouring authority has subsequently provided the following information to the Board as part of this SCR: “Our involvement was in respect of (the sibling of Child AA)…..who was subject to both an Initial and Core assessment in July 2013 following concerns being raised by a neighbour and the midwife about mothers treatment of (the baby), shouting at (the baby) and alleged to have smothered (the baby) with a pillow”. 14.2.10 This information and the details of the assessments would have been helpful information, although without having sight of these it is impossible to determine what impact they would have had on the planning around Child AA. However, it is also clear that this information was known to the previous midwife, who had made the referral, but it was not passed on to the case- holding health visiting service when the couple moved back into the area. As stated previously neither CSC nor the Community Health service in fact followed up on the historical records, so that neither had the full information about the family background. Whilst the health visitors nevertheless acted quickly to refer on their concerns to CSC, the additional history may had some impact on the response from CSC in terms of the level of risk they understood to be present. 20 14.2.11 Although the mother’s own history of being parented was known to both CSC and health services, the impact of poor early childhood experience on the mother’s ability to parent her own children was not explored in the social work assessment. Indeed, many assumptions were made by CSC about her ability to parent despite her young age and the lack of familial support networks available to her. The medical history of repeated A&E visits, and the injury to the older baby at 3 months old would also have been important in highlighting vulnerability and the risk factors already present in the situation. 14.2.12 There was also little known about the father and there was no attempt to access any information about his history. The CSC IMR notes that this lack of information was strangely also translated by SW2 into seeing father as a positive influence. This had no bearing in fact, and indeed the mother had told the health visitors that father did not help her. SW2 was made aware of this but considered that she had addressed this by “making my expectations clear” and that he had subsequently “made more of an effort”. (ICS recording, integrated chronology) Unfortunately, this was not borne out by fact. It was not until the meeting with mother on the 5th of June that they discussed the possibility of domestic violence and mother shared that the father was controlling of her. However, events then moved very quickly and overtook the decision at the professionals meeting to start a full parenting assessment, before this could begin. 14.2.13 As above, the IMR author goes on to explain that the case was allocated to SW2, who was a student social worker, on the basis of the initial assessment that this was a Child in Need case, and that the role of the worker was to “focus on housing, finances, and self-esteem for the mother”(IMR p8) and this is what she did. The premature birth of Child AA was viewed by her as being an indicator that the family would be in need of more support, but was not interpreted as an additional stressor which might heighten risk to either of the children. 14.2.14 In this context – that is, that this was a short term CIN case - the provision of support to the family to enable them to move out of the maternal grandparents home and into a hostel for the homeless was appropriate, and SW2 engaged the help of a family support worker to “engage with the mother in a six week programme of regular visiting to offer support with the family’s practical needs and emotional support for the mother”. (ICS recording integrated chronology) 4.2.15 However, at the point that Child AA was born, there were already a number of risk factors in place: 1). Both parents were very young – mum was 18 and dad was 19 2). Mother already had a young baby about whom she had sought reassurance from health professionals on many occasions, including repeated presentations at A&E 3). Mother had a difficult childhood where she was a young carer and had lived with an aggressive alcoholic parent 4). The family were living in cramped and unsuitable conditions with the maternal grandparents – one of whom suffered from alcohol related dementia 21 5). This also meant that the mother did not have access to familial support and the couple were quite isolated 6). The reasons for the move from their previous tenancy were unclear 7). The couple had financial problems which they did not appear to be managing despite repeated advice from professionals and had required several food parcels as well as basic equipment for their older child 8). Experienced health professionals were very concerned about mother’s ability to manage her baby and also about her awareness of dangers in the physical environment she provided the baby 9). Mother talked about having a low mood, had a history of depression and was very thin, presenting to the duty social worker as ‘unkempt’. 10). Fathers background was unknown 11). Child AA was premature and as such was likely to require a high level of parental care in the first few months 14.2.16 Working Together to Safeguard Children, 2013 sets out the aim of an assessment as being to “use all the information to identify difficulties and risk factors as well as developing a picture of strengths and protective factors.”12 This statutory guidance also states that: “Assessment should be a dynamic process, which analyses and responds to the changing nature and level of need and/or risk faced by the child”13 14.2.17 The change of worker should have resulted in a requirement to revisit and review the existing assessment, and the birth of the new baby clearly indicated that the family circumstances had changed and that there were new and increased stresses on the parents. This should have triggered an assessment, as should the increasing concerns being raised by the health professionals, particularly following the professionals meeting on 19th May, when these concerns were put in writing. 14.2.18 However, as above there was no further formal assessment at any point pulling together the above factors as the situation deteriorated, with the family being threatened with eviction, the allegations about father’s cannabis use, and his unemployment. Many of these are known risk factors, and new born babies, particularly those who are premature, are known to be highly vulnerable to injury.14 14.2.19 Prior to the professionals meeting on 6th June all of the social work visits to the family were by appointment, whereas the majority of the health visits were opportunistic. This may account for some of the differences noted on these visits, as the parents may well have tidied up in preparation for the social worker. SW2 and SW3 advised the reviewer that there was a culture in the department at that time that one “did not do unannounced visits on 12 Op Cit. paragraph 42, p.21. 13 Ditto p.28 14 Biennial Review of Serious Case Reviews, 2008-10, Brandon et al 22 Children in Need cases”, as this was seen as not working in partnership with those parents, and only possible as part of a child protection plan. This is ill advised as social workers, drawing together and reviewing their evidence about the needs of children must do so on the basis of the child’s whole context, including their home environment at different times of day and not always by appointment. 14.2.20 Within this lack of updated or in depth assessment, SW2 and FSW appear to have remained focussed on their initial task and perceptions, and expressed a great deal of frustration about the health professionals, whom they saw as not understanding children’s social care thresholds and responsibilities. This was compounded by the suggestion from HVH at the May 19th meeting that a mother and baby fostering placement should be sought, an option which was very much out of the scope of the existing plan and would have required a very high level of assessed risk to have been identified. 14.2.21 There are conflicting views about the provision of the health chronology and the photos of the Moses basket as evidence and this remains unresolved, as SW2 believes that these had been requested at the meeting on 6th June, but that HVH “was not prepared to hand them over.” (SW2 in interview) The HVH is of the view that she had agreed to provide the chronology when it had been completed and that she was not asked for the photos. This difference of opinion about events suggests that the professional differences which are an unfortunate feature of this case still need to be resolved in order to move professional practice and working relationships forward. 14.2.22 Unfortunately, the failure to carry out an up to date assessment was mirrored within the health visiting services, and the Community Health IMR acknowledges that “a Family Health Needs Assessment was never done even though this is a standard assessment and is in the appropriate guidelines. The FHNA is also a means of gathering evidence and supporting referrals made to Children’s Services. However it does appear that though attempts were made to book appointments to complete this, events overtook each time.” (p13. 8.2) 14.2.23 This would have been incredibly helpful in setting down the concerns and risks in a structured way that may have assisted social care to fully understand the level of concern being experienced by the health visiting staff and the evidence base against which they were forming their judgments about risk. 3. Was any information known by any agency about parental mental health issues, domestic abuse, substance misuse or parental antisocial behaviours or concerns re neglect? If so was appropriate consideration given to how these impacted on parenting capacity and were appropriate referrals made? 14.3.1. In terms of parental history, the reasons why the couple had left their previous tenancy were unclear, and the Housing IMR contains the following information: “With the support of The Housing Support Agency, (the couple) submit a letter ..which…lists an unattended fire in garden that led to some external damage to their property, neighbours asking for money/complaining when the baby was crying, a recent gas inspection which highlighted a need for a mechanical part and that they felt unsafe. These were unsubstantiated reasons and, as such, would be considered fairly weak cause for leaving a tenancy…..the file showed that (the father) had written to say that he had to leave the 23 property because he was being threatened. There was no record on file of anti-social behaviour, either towards or from (the father). There were rent arrears and Council tax arrears at this property, and the tenancy was terminated by …(the father) The local.” 14.3.2 The source of these threats and whether they were linked to father being in debt, or to drug use, was never explored. The ATM in CSC had asked SW1 to follow up the history of the family with The local, and it is unfortunate that this did not happen, as it may have provided important context to the family circumstances. Certainly there is reference in the health records from 4th July 2013 to the mother talking about some disturbance at the property which she said had resulted in a visit from a social worker.(EMS record – integrated chronology) 14.3.3 There was information about the father’s use of cannabis. The first time this appears in the chronology is on 7th April 2014, when Child AA was born. When the family arrived on the ward to see Child AA, the delivery suite midwife noted “a strong smell of cigarettes and cannabis on partner”. (ESH notes, integrated chronology) This was not shared with the community health service. 14.3.4 The chronology also records a police stop in relation to father smoking cannabis on 12th April, but this was not referred on as there was no information to the police that this was the father of vulnerable children. 14.3.5 This issue was referred to again on 16th May when HVH and NHV1 did a joint visit to the mother and the 2 children at the hostel. They had a discussion with her about finances and she shared that she had to give money to her partner “.. to pay ‘someone’. Mother did not think this was for drugs referring to past payments” (RIO – integrated chronology) 14.3.6 The CSC IMR records that “On 5th of June the housing manager contacted SW2 and informed her that he had met with dad and noted that he smelt strongly of cannabis. On the same day the SW2 had met with mother who told her that a neighbour had made a similar allegation. The SW2 visited and challenged the father who denied it. SW2 recorded that she had never smelt cannabis or seen any other evidence of drug use during any of her visits and there were no complaints from neighbours or the staff at the hostel. The FSW further confirmed this and noted that she had seen that the ashtrays did not have any evidence of cannabis use in them” 14.3.7 This appears to have satisfied both workers that the allegation was unfounded, and the fact that all of their visits were announced, and could therefore be prepared for, was not considered. 14.3.8 The Housing Support Agency worker visited a few days later and was “told that the applicant’s partner was smoking cannabis. It was understood that other agencies had also been made aware of this…” (The Housing Support Agency report to SCR) The worker did not therefore follow this up. 14.3.9 Cannabis use can contribute to parental neglect15 and for this family may also have had a bearing on their financial circumstances. Certainly money management was a 15 Insert reference 24 real problem, and as above, when the HVH visited one evening with bedding and a cot, the father was playing with a new x-box, so appears to have given his own needs priority over those of the children, another potential indicator of neglect. 14.3.10 Mother’s alleged low mood and depression and apparent need to be told how to do things several times before she grasped this was also a source of considerable concern to the health visiting professionals, who as above, made many attempts to raise the level of concern in CSC to that of child protection. In this they were unsuccessful. Mother’s mental health and the dynamics of the parental relationship would have been crucial factors to understand in relation to their parenting capacity, but the agreement that CSC would undertake a parenting assessment after the meeting of 6th June was, sadly, too late. 4. Was there sufficient consideration of the vulnerability of this family in relation to their housing situation and the impact on their parenting capacity and what support was provided? 14.4.1 Resolving the family housing situation was the primary focus of the work by CSC and by the Housing Support Agency, and there is clear evidence that professionals from all agencies worked to support the couple in attempting to sort this out. There were visits from many professionals giving advice and practical support in relation to housing and managing the necessary day to day tasks involved in looking after 2 young babies in cramped and temporary living conditions. 14.4.2 The initial referral into CSC from NHV1 concerned the cramped and unsuitable conditions in which the family were living. The couple had moved into the mother’s parents 2 bedroomed flat in November 2013, and according to the District Council IMR, the grandfather “appears to be surprised at the length of their stay as he says that GS had rung to say that she would be leaving their home in The local for a few days due to a gas leak, but they had moved in and had never left.”(Section 6) 14.4.3 The NHV and the HVH both expressed safeguarding concerns to CSC about the conditions in the flat which they saw as unsuitable for a young baby, and also about the vulnerability of the mother, who did not seem to be able to understand basic safety issues. The grandmother’s dementia and father’s alcohol use meant that they were not able to give practical support, and on the contrary, medication and overflowing ashtrays were left in the reach of the baby, who was starting to pull up on the furniture. 14.4.4 SW2 agreed with this perspective that the flat was overcrowded and unsuitable, and she supported the couple to make a homelessness application, supported by a letter from the grandfather evicting them from the flat, in order to provide a case for the District Council to regard them as urgent for rehousing. 14.4.5 The hospital was also made aware of the plan to try to rehouse the family prior to the discharge of the baby into the parents care, and held on for longer than they normally would in order to support this. The hospital had noted no concerns about the parent craft of the mother, and had received no information to suggest that there were any issues other than the practicalities of finance and accommodation. The fact that Child AA had been on the NNIU for 30 days at the point of discharge also meant that there was no outreach offered to support the parents in the hostel with any aspect of the care of a premature baby. This was to be provided by the health visiting service instead. 25 14.4.6 The couple were interviewed by housing officers on 6th May, where they explained that they had to leave the mother’s parent’s flat due to overcrowding, and that “Social Services felt that household would not be conducive to a new-born and premature baby”. (District Council IMR) 14.4.7 SW2 also then telephoned that day to support the application. Although the officer considered that it would have been helpful to have had more information, he was able to offer them temporary hostel accommodation the following day, which was incredibly fortunate as it was rare for there to be empty accommodation without any waiting. 14.4.8 In addition, the couple were fortunate enough that the hostel was not full, so they were able to have an area to themselves for most of the time, and did not have to share bathroom or toilet facilities. They were allocated a “double-room unit which is of sufficient size considering both children were very young.” (DC IMR) 14.4.9 SW2 and the FSW from CSC then helped the couple to move their things into the hostel and to unpack, and the next day took the mother to the hospital to collect Child AA. The FSW then visited regularly with a view to helping the mother to keep the rooms clean and tidy and to support her in the parenting task. The Children’s Centre had also made a referral to the Housing Support Agency who visited quickly to risk assess and then provided regular visits to focus on the housing situation and future options. 14.4.10 However, as discussed above, there were professional differences of opinion about the level of vulnerability of the couple, and therefore of their children. SW2 was also aware of the level of rent arrears that the couple had already incurred in their previous property, which by early June meant that the family were facing eviction. This related in part to the couple’s failure to apply for housing benefit and to provide the necessary paperwork to support their application and this was a source of considerable frustration to the housing officer as he expected this to be resolved quickly. This failure to follow through on advice about finance had continued from the time when the couple had been living with the maternal grandparents, and was indicative of a degree of immaturity which does not appear to have been fully understood and taken into account in relation to the couple’s parenting capacity. 14.4.11 As already discussed, there was also an ongoing difference of opinion about how well the couple managed the tenancy, with the health visitors concerned about how dirty and untidy it was, and about mould and damp affecting the babies bedding. CSC considered that the mother was doing her best in the cramped conditions. The District Council IMR however states the following: “However their rooms were poorly kept. The hostel warden had cleaned up the condensation mould but said the room was in a mess. He recalled how one of the other residents helped (the mother) clean up a couple of times, but then commented that she had stopped because she wasn’t going to keep going in to clean up after them.” 14.4.12 This appears to support the health visitors’ view, but was not understood by SW2 until 5th June when she emailed housing about the ‘mould’ and received an immediate response that this was due to poor cleaning and the couple’s poor management of the property. 26 14.4.13 The District Council IMR also refers to the change in the family circumstances when the father lost his job. “…..he was around at the hostel a lot more and was seen smoking more frequently. There were then more arguments between the couple.” 14.4.14 Again, this evidence that the father’s unemployment was increasing stress on the mother did not appear to factor into any CSC understanding about the increasing vulnerability of the children in these circumstances. There is no recording about this in the chronology so it is likely that the social worker did not know about it, as the ICS recording is very full on all other matters. 14.4.15 The IMR concludes that the homelessness staff did not see the family as any different from the others they work with. However, the author goes on to say that “They were perceived as chaotic and exceptionally difficult to engage with….. (the couple) received more than the average input and support from the homelessness team as they were failing to pay towards the cost and rent of accommodation. There were frequent calls and shared frustrations between professionals regarding the difficulty in getting (them) to engage or carry through any actions that only they could complete. Council officers were concerned that the family were realistically looking at the prospect of being evicted from the hostel due to rent arrears and consequently their housing options would be severely restricted.” 14.4.16 It therefore appears that professionals were doing everything possible to support the family with their housing need, but that this was likely to fail in the light of the couple’s immaturity and inability to follow through with the important life skills of budgeting and the practicalities of day to day living. 14.4.17 Housing confirmed to SW2 on 6th June that the couple had lost their previous tenancy in their previous authority due to rent arrears, and SW2 met with mother that day and worked out the money the family had coming in. Mother agreed to pay £1000 off the arrears (this seems to be a misprint in the records as this would have been nearly all the money they had) at the end of the month and SW2 appears to have managed to get an extension on the eviction. However, there does not seem to have been a contingency plan for the likelihood of eviction, which may well have resulted in the children coming into care. 14.4.18 The professionals meeting on 6th June did not include a member of the housing team, so that their information about how the couple functioned within the hostel was relayed to the meeting by the HVH, and the importance of these observations appears to have been somewhat undermined by the focus on the professional disagreements between CSC and community health services. Part of the plan from this meeting was therefore that the Housing Support Agency worker was to be asked for her observations of how the family were coping in the hostel. 14.4.19. Again, what would have been helpful at the outset was a clear and focussed assessment, leading to a realistic plan and recognition of the risks to the children given the mounting pressures on the young adults who were caring for them. 5. Were the decisions and actions that followed assessments appropriate and were detailed plans recorded and reviewed? 14.5.1 The CSC IMR author concludes that the plan resulting from the initial assessment was followed through in relation to the housing and social needs of the family. 27 The CIN plan was reviewed at a Team around the Child meeting on 19th May, which was chaired by SW2. 14.5.2 However, as outlined above, there was no further assessment, and a lack of agreement between the key professionals working with the family about the level of risk and the amount of support required. This resulted in a significant amount of visiting which lacked coordination and purpose. 14.5.3 Given the guidance in Working Together 2013, it would be reasonable to expect that SW2 would have been required to complete a new assessment on allocation of the case, given that the family circumstances had changed significantly with the birth of the premature baby. This would also have been a good learning vehicle for a student social worker. 14.5.4. However, as previously stated, this did not happen, and whilst there was a plan arising from the discharge planning meeting held at the hospital on 1st May, this focussed on the practicalities of obtaining alternative accommodation for the family so that the baby could be discharged home. This did not include any further assessment, and there was no detailed plan co-ordinating the work with the family, resulting in numerous professionals visiting, sometimes on the same day, and no resolution to the very different views being expressed between health and CSC. 14.5.5 The first real plan, to which all of the professionals appear to have given their agreement, was the one that resulted from the professionals meeting on 6th June. Unfortunately this was too late for Child AA. 6. Were the children’s views and wishes sought and taken account of in assessments and planning? Did this include the presentation of these young non-verbal children being fully considered? 14.6.1 The recording of both health and social care staff contains many references to the presentation of the children. As above, they paint different pictures. What they do have in common is the positive relationship between the mother and her older baby, prior to the birth of Child AA, albeit within a context of basic safety concerns expressed by health. 14.6.2 The fragility of Child AA is commented on frequently by health visitors, but the IMR acknowledges that “There is evidence that on many occasions the health visitors were overwhelmed by the maternal concerns that were apparent” (Community Health IMR p15, 8.6) 14.6.3 The Social Care IMR records that “Both children were too young to be able to formulate and express a considered wish. Observations of them were recorded in ICS. (The sibling) always presented as well cared for, appropriately dressed and as a happy little (baby)The interactions between (the baby) and both parents were reported and observed by SW12 and FSW to be warm and affectionate…..Child AA was also seen to be clean and appropriately dressed”(p11 para 8.6) 14.6.4 These observations, as previously discussed, did not always correspond with those of other professionals. 28 7. Were any safeguarding issues in respect of child AA and sibling identified and acted on appropriately and in a timely way by all agencies? 14.7.1. There is evidence from the records that potential safeguarding concerns were identified by the midwife in 2013 when mother was booked for maternity care for her first child. A referral was made to Children’s Social Care due to the fact that this was a teenage pregnancy and there was previous involvement with children’s services as a child herself. However, she moved out of the area a few days later before this could be activated. 14.7.2 There were then a high number of hospital attendances during pregnancy with unspecific stomach pains, and these attendances continued after the baby was born. In July the mother is noted as saying that a social worker had visited her in response to arguing reported by neighbour. Taken together, this is suggestive of possible domestic abuse, as there is some research evidence that unspecific stomach problems in pregnancy are a possible indicator16. A safeguarding form was completed, but as the case was not open to The local social care, there was no further action taken. 14.7.3 As discussed previously, there was a timely and appropriate response when the mother attended A&E with her 3 month old baby who had rolled off the sofa, and left without being seen. This resulted both in a police welfare check and a second information form to the The local MASH. 14.7.4 The first visit from any professional to the family on their return to the area was by NHV1 In January 2014 who appropriately identified potential safeguarding concerns and made a referral to Children’s Social Care. She also provided a travel cot, bedding, sheets and clothing for the baby, and followed up with a joint visit with the health visitor for the homeless. This health visitor shared her colleagues concerns and both described in the practitioners meeting their horror at the living conditions. They describe the mother as being very thin and frail, child-like, and not taking in what they were saying about the presence of full ashtrays, medication, and rubbish at a level that was accessible to the baby, who was crawling around in the mess. NHV1 faxed her referral to CSC after this visit. 14.7.5 SW1 visited the family the following week and did not share the safeguarding concerns. As above, this difference of opinion became a serious issue between the two departments over the next few months, with the health professionals becoming increasingly concerned about the couple’s failure to sort out their finances and to take control of their circumstances. Health professionals describe the mother as being very much like a child herself, who was not able to take on advice, and who repeatedly ran out of money and asked for help to sort out food and basic equipment. They felt that this deteriorated hugely after the birth of Child AA and they became increasingly frustrated in their attempts to raise the level of concern in CSC. 14.7.6 The safeguarding issues arising during this time are well documented above. However, further exploration of the injuries to the sibling and the first hospital admission of Child AA is warranted. 16 NHS England website – Domestic abuse in pregnancy 29 14.7.7. There were two (further) reported injuries to the sibling whilst in the care of the parents - on 5th May and 20th May. 14.7.9. Child AA’s father called NHS 111 on 4th May (recorded as 5th in the chronology, and 4th in the Ambulance Service IMR) and was advised to contact 999 and an emergency ambulance was dispatched. The IMR from the Ambulance Service records that “AA’s sibling was described as having become more drowsy than usual and seemed to have an unexplained bump on the head. (The baby) was treated at scene and not transported to hospital. A vulnerable person (VP) form was completed in line with (local ambulance service) procedures as staff felt that the family may need extra support with the child having an unexplained bump on (the) head and the Father also disclosing that he believed the child may have a worm infestation. The VP form was shared with children’s social care.”(p2 – 3) 14.7.10 This was good practice by the paramedics, and this referral was considered by a CSC manager on 8th May, who determined that this was not a safeguarding concern. 14.7.11 The second (third) injury to this child was self-referred by the mother on 20th May – the day after the TAC meeting she had attended with CSC and HVH. The mother visited her GP to show him a small bruise at the top of the child’s ear, which she was unable to explain, but said she was worried was indicative of leukaemia or meningitis. The chronology notes that the GP made an immediate referral to the Children’s Assessment Unit at the hospital, and “In view of unexplained bruise, GP asked for non-accidental injury to be excluded.” (integrated chronology Hospital Notes 20th May 2014) The baby was admitted overnight to hospital and was noted to be “a happy smiling (child) who was well kept and interacting well with (the) mother. There were no other bruises seen”.(Surrey Hospital IMR p8) The mother was very open about her involvement with social services. The IMR goes on to say “The decision was made to contact social services and not to request a CT scan or skeletal survey at that time until more information was available”. 14.7.12 This seems an appropriate decision given that it was now late evening, and contact was made with EDT who confirmed that the child was not subject to any child protection plan. A Safeguarding Information Sharing form was completed for the liaison health visitor and also for CSC. The form stated that “(Mother) was tearful and thought she had post- natal depression. She stated that her partner is supportive but works a lot and she feels lonely, is scared to be alone, and is worried that she is a bad mother.”(p9) 14.7.13 SW2 telephoned the ward the next morning for an update and confirmed that “Social Services would be happy for (the child) to be discharged if doctors were happy”(Surrey Hospital IMR p9.) 14.7.14 The child was seen by a consultant paediatrician on the ward that morning who noted that “this is not a safeguarding issue” and discharged the child home. The IMR notes that there is no explanation given on the record for this conclusion, though no other bruises or concerns were noted in relation to the child, and the parent child interaction was noted to be positive. Given that the social worker had not raised any concerns with the doctor, it was then reasonable for the child to be discharged. 14.7.15 The next safeguarding concern was when Child AA was admitted to hospital, via the GP, with a suspected sepsis. This manifested itself as “a spreading, non-blanching 30 petechial rash, apparent on forehead, arm and left leg”.(Surrey Hospital IMR p10) However, Child AA had no sign of a temperature. 14.7.16 The mother’s story was that she had “left AA with (the) dad in the morning who said AA had been vomiting and scratching at (the) head. Mother said on her return AA’s ears appeared a darker colour..” (p10) 14.7.17. Child AA was admitted overnight and started on IV antibiotics. 14.7.18 The hospital then appropriately contacted CSC to share this information and on request faxed a copy of the safeguarding information form to SW2, who telephoned the next morning. The IMR notes that this conversation was not recorded in the notes, but that “SW2 shared nothing of concern”. 14.7.19 Child AA was not at any point examined by a consultant paediatrician during this admission. The SSHT IMR points out that the consultant on the ward was off sick that day, and that the ward was being covered by another doctor who was also covering the SCBU...”(This doctor) was to see all children who had not been seen by a consultant (in line with children being reviewed by a Paediatrician in 12 hours). The doctor believed that Child AA had been seen by a consultant the previous evening on CAU, whereas the CAU consultant had been contacted by phone to discuss AA but had not seen her in person.”(p15) 14.7.21 The IMR author notes that whilst AA was not seen physically by a consultant, there is no suggestion that there would have been any changes to the management plan had this happened as there were no safeguarding concerns. 14.7.22 However the IMR then goes on to say that “the mother shared that she suffered from anxiety and depression, she also shared about their living circumstances and LBs job loss and financial difficulties..” 14.7.23 These statements are somewhat contradictory given that this was a 2 month old premature baby. The hospital appears to have been very reassured by the fact that SW2 was not raising safeguarding concerns. Historically, the ‘child protection register’ was discontinued partly because of the risk of ‘false positives’ – that is, the belief that if a child was not on the register, professionals could assume that there were no risks to the child. Whilst Child AA was of course not subject to a child protection plan, the same ‘false positive’ must also be guarded against when social workers give an opinion that they have no concerns. Other professionals must consider whether this reassurance is sufficient for them to also have no concerns in their own right – that is, they must make their own considered and professional judgement based on the facts before them. The IMR author acknowledges that this episode may well have been a ‘cry for help’ as mother was so forthcoming about her anxieties. However, she was discharged home with a cannula in the baby’s arm that would have increased those anxieties. 8. Were missed appointments and failure to engage considered as indicators of neglect? 31 14.8.1 There is no evidence that this was the case, and indeed the mother is noted to have been in regular contact with professionals and to have missed appointments only when there were valid reasons. 9. Was race, religion, language, culture, ethnicity or disability a factor in this case and was it considered fully and acted on if required? How was the uniqueness of this particular family recognised? 14.9.1 As discussed previously, very little was known about the father, though he did tell the NHV1 that he was half ‘Romany/gypsy and also had ADHD. These would have been significant factors in relation to his cultural identity and expectations of family life. 14.9.2 The lack of any full assessment meant that this was not considered or addressed, and indeed the CSC IMR author remained unaware of this cultural heritage, assuming from the records that the family were ‘White British’. The IMR notes that the professionals were aware of the mothers’ background and her own parents’ mental health issues, but that “Her own experience of being parented and of how this may impact on her ability to parent was noted, although not explored in great depth. However all the professionals working with her commented on her apparent frailty and vulnerability and her low mood at times.” (p14, 8.9) 14.9.3 There was therefore an unrealistic expectation from CSC about the mothers’ ability to parent, given her vulnerability as a young person who was responsible for 2 very young children and who clearly lacked the life skills to manage budgets, housing, and independence without considerable support from professionals. She was in fact herself still a child as defined in the Children Act 1989. The social care professionals did note that the mother seemed to struggle to take in instruction and advice, and in interview pondered whether she had a mild learning disability, but this did not trigger any assessment of her parenting capacity at the time. 10. Were there any organisational or resource factors which may have impacted on practice in this case? 14.10.1 In terms of community health services, there was good information sharing and support and the staff reported feeling that they work within a supportive organisational culture in which creativity is encouraged and staff feel valued. The IMR for the Community Health service notes that there may have been a lack of clarity around the role of the HVH and the NHV which is being addressed through the action plan arising from this review. 14.10.2. The social workers referred to the major restructuring that had been taking place across Surrey and which was being implemented in the area where the family lived in April 2014. As previously discussed this involved the disbanding of the Children in Need Team and the creation of an Assessment and Intervention Team into which SW2 transferred. 14.10.3. The FSW shared that she had been interviewed for a post in February 2014 in the CIN Team, but that by the time she started in April 2014 the post had moved to the Assessment Team. Similarly, the student social worker, SW2, had moved from the CIN team to the Assessment Team and taken her CIN cases with her. 32 14.10.4. SW3 described the new arrangements that the Assessment Team would undertake all assessments and that CIN work would now be stepped down into the Early Intervention Service after a maximum of 45 days when other agencies would in many cases be required to take the role of lead professional. She acknowledged that other agencies were expressing concerns about this and that this has been creating a backlog in the Assessment Team. 14.10.5. The Area Manager for the service has acknowledged that the scale of the changes has been enormous, and that not all staff appear to have fully grasped the model. This may have resulted in some misinterpretation of the way in which cases are to be managed, and certainly the social workers in the practitioners event gave an impression that there was a clearer ‘cut off point’ for social work support to children in need than the strategy suggests – although this may in fact be an issue of interpretation. There is no evidence that this change in approach had any direct significant impact on the management of the case, but it does provide a context within which SW2 and her manager would have been operating. However, it is all the more surprising that, given the move to an Assessment and Intervention team, no assessment was actually undertaken when the case transferred to SW2. 11. Were appropriate management/clinical oversight (supervision) arrangements in place for professionals making judgments in this case? 14.11.1 The Community Health IMR notes that NHV1 had only been qualified for 3 months when this family arrived on her caseload and so did have limited experience. She did not appear to have sought advice from a safeguarding supervisor or her clinical team leader though she did liaise regularly with her peers and the HVH. It is also noted that there was a delay of 3 weeks by the CNN1 to record her visits on the electronic records. This will be disseminated to the practitioners involved and their line managers. 14.11.2 It is clear from the notes in the chronology that both NHV2 and HVH regularly consulted with the safeguarding team and advisors as required within their procedures and policy guidance, and they documented these conversations on RIO. 14.11.3 In relation to Children’s Social Care, the management of SW1 is not fully explored in the IMR but there is reference to performance concerns and a lack of recording and visiting. The poor quality of this social workers assessment is noted in the chronology and commented on previously, but this does not appear to have informed the plan for SW2’s intervention, and surprisingly she was expected to work with the family using this assessment as her basis for planning. As outlined above, SW2 explained that she had very little handover and that she had no reason to doubt the assessment of the previous social worker, and neither should she. However, her manager did have this information and it would be reasonable to expect that the re-allocation of the case would have been accompanied by an instruction to SW2 to revisit the assessment so that the plan for Child AA was not undermined by previous poor quality of work. Given the significant change in family circumstances as a result of the birth of Child AA, this was even more important. 14.11.4 The ATM provided a minimum of 2 weekly supervision to her student, and the CSC IMR records that “…..there was in addition a considerable amount of ad hoc supervision. There is evidence of management oversight on the case notes although only 33 one record of formal supervision. SW2 felt that she was listened to by (ATM), that her views were respected and that she was supported in relation to her assessments (p15. Para 8.11). 14.11.5 This lack of recorded supervision is not good practice and makes it difficult to evidence the degree of challenge being offered to the student. It also means that there is no record of the rationale for decision making in the light of concerns being expressed by community health professionals. The chronology for example, indicates that there were points at which the student social worker clearly felt very threatened and challenged by HVH. Whilst the nature of this challenge was a professional one, the CSC IMR makes reference to “….one particularly difficult telephone conversation between SW2 and HVH in which SW2 had felt somewhat intimidated and(the manager) had offered her peer support following this” (p6 8.1) Given the confident presentation of SW2 described by the health visitors, they may have underestimated the emotional impact of professional challenge on a student who was still in a position of learning and being assessed on her competence. 14.11.6 SW2 was subsequently offered a great deal of support by her supervisor to deal with what was seen as ‘over-anxiety’ by health colleagues. The approach seems to have been one of nurturing and supporting the student, and this meant that she was supported in her views about the cases she was working with. What might have been more helpful at this point was a direct conversation between the manager and HVH to address this apparently ‘threatening’ approach, both in terms of better understanding the dynamic between the student and HVH, but more importantly, to follow up the difference in professional opinion and its impact on the management of the case. There appears have been an over emphasis on the part of social care on the personal impact of the disagreement between SW2 and HVH, rather than on the professional viewpoint which underpinned it, and which should have been the main focus. This was not a personal challenge, but a professional one. 14.11.6 Eileen Munro, states that: “The single most important factor in minimizing errors (in child protection practice) is to admit that you may be wrong”17. For this to happen requires that “all processes that support and inform practice foster a questioning approach or a spirit of inquiry as the core professional stance of the child protection practitioner”18. This enables the practitioner to separate the personal from the professional and to consider the facts in a different light. 14.11.7 Similarly, Working Together 2013 states that: “It is a characteristic of skilled practice that social workers revisit their assumptions in the light of new evidence and take action to revise their decisions in the best interests of the individual child” and that: “The social work manager should challenge the social worker’s assumptions as part of this process”19 14.11.8 These are key lessons for a student practitioner and the absence of written supervision notes makes it difficult to fully understand the quality of supervision being given to her and whether this degree of challenge was present. 17 Munro, E. (2008). Effective child protection (2nd Edition). London: Sage 18 Turnell, A Signs of Safety, A comprehensive briefing 2010 19 Op cit. paras 41 and 43. 34 14.11.9 As above, the context of organisational change may also have undermined the capacity of the supervisor to present this necessary degree of challenge. Unfortunately the manager was absent on maternity leave for the duration of the review so it was not possible to further pursue this line of enquiry. 14.11.10 Finally, as also noted previously, there was no further assessment, and SW2 was not asked to explore the family history, which would have been good practice in student learning, as well as providing important information about the family with whom she was working. 15. LESSONS LEARNED 15.1 The key issue arising from the review is that of inter professional trust and collaboration, without which children will not be well protected or their needs fully understood. There is a clear theme running through the chronology and the IMRs about the differences of opinion between children’s social care and the community health service in relation to this case, which were further compounded by the lack of clear and current assessment and co-ordinated planning. 15.2 The Community Health IMR concludes that: “Working with families where there is chronic neglect highlights the need for practitioners to work together in a supportive way, each understanding the difficulties faced in approaching the family. Joint supervision sessions may have helped all concerned to focus entirely on the safeguarding concerns for the children”. This is an important consideration, as there were several points where a joint approach in terms of visiting and/or supervision would have been helpful and may have resolved some of the professional differences so that there was a united and well informed approach to the growing risks in this situation. 15.3 Within Community Health it is noted that “professionals showed considerable tenacity and combined together to cover key visits, meetings and make full reports. They were each managing the emotional demands of this family and making individual assessments at contact. Group supervision sessions when teams are managing such complex cases would be useful and this will be suggested as an action. This is a helpful analysis and highlights also the heightened emotions that appear to have been a feature of this case. Good reflective supervision is a foundation stone of safe practice, and shared supervision, as suggested, may have helped to identify and to resolve the underlying differences of opinion. 15.4 It should also be noted that the HVH had prior knowledge of the mother, having been her school nurse, and that she therefore felt a huge degree of compassion for a young woman whom she described as “still a child herself”. This undoubtedly shaped her view and ongoing relationship with the family, and it is important that where such a prior relationship exists, there is an acknowledgment in supervision of the potential impact, both on the professional and on the management of the case. 15.5 Robert Dingwall20 states that: “ Professionals (sic).. have to make difficult decisions with imperfect, limited and fragmented information. An inter-agency system 20 The Rule of Optimism – Thirty Years On: Robert Dingwall | Published: September 18, 2013 35 creaking under resource pressures and lacking public support for a more interventionist approach necessarily has to find ways of bounding its work. Sometimes the result is that children die (or suffer serious harm). There are no quick fixes to a complex – and, in a technical sense, wicked – problem.” 15.6 This is a reference both to the complex and imperfect systems within which professionals work, but also to the notion of children’s social care thresholds. There is repeated evidence in this review that social care did not believe that health professionals understood social care roles and responsibilities, and that the needs of the children did not meet the ‘threshold’ for child protection. This inter professional difference of opinion is a national issue which is highlighted time and again in serious case reviews, as a failure in multi-agency working21. National statistics show a steady increase in numbers of referrals in recent years, which social workers are finding problematic to manage.22 In addition, some practitioners argue that the reluctance of other agencies to share safeguarding responsibility clogs the system up with inappropriate referrals. ‘Thresholds’ therefore become higher to manage demand, and social workers can develop a ‘siege mentality’ in which they become less open to the concerns of others, and protective of their own resources and skills in order to cope with the stress of the work23. 15.7 This is compounded by the way in which children’s social care services are traditionally organized: the Munro report offers examples of good practice in multi-disciplinary arrangements for dealing with enquiries and referrals.24This includes reference to the creation of a Multi-Agency Safeguarding Hub as a means of managing the ‘front door’ in a multi-agency way and Surrey has implemented this approach. 15.8 However, whilst there is clear evidence that the quality of local partner relationships is key to effective joint working, it is also clear that structures and systems alone are unlikely to make a significant difference25. The Surrey Early Help Strategy acknowledges that the existence of a MASH will not in itself resolve all of the issues, and the strategy seeks to take a bold step in changing the whole system in Surrey from a traditional early intervention and child protection system to one of “Early Help, Safeguarding and Well-being”26. 15.9 This requires significant culture change and the success of such a system will be strongly dependent on the development of effective collaborative shared ways of working, precisely the opposite of what has been demonstrated here. What is needed to support this is a move away from the narrow professional perspectives in which social workers and others have been trained, and which are compounded by traditional structures and systems 21 Brandon et al, 2008 22 See Department for Children, Schools and Families (2009) Referrals, Assessments and Children and Young People who are the Subject of a Child Protection Plan, England – Year Ending March 31 2009 (www.data.gov.uk/dataset/ referrals) and Department for Education (2010d) Children in Need in England, including their Characteristics and Further Information on Children who were the Subject of a Child Protection Plan (2009–2010 Children in Need Census, Final). London: Department for Education. 23 Tunstall, op cit. and Munro,E 24 Munro, E. (2010) The Munro Review of Child Protection. Part One: A Systems Analysis. London: Department for Education 25 Audit Commission, Are we there yet? Improving governance and resource management in children’s trusts.(2008) London. The Stationery Office. 26 Surrey Early Help Strategy, op cit. 36 for dealing with child concerns, to one which is based on an open and facilitative approach rooted perhaps in a model of appreciative inquiry27 in which professionals are able to engage in positive dialogue with each other and with families. In its purest form appreciative inquiry "advocates collective inquiry into the best of what is, in order to imagine what could be, followed by collective design of a desired future state that is compelling and thus, does not require the use of incentives, coercion or persuasion for planned change to occur." 28 15.10 Examples of this model in action in protecting children can be seen in the application of the system wide ‘Signs of Safety’29 model for example, which is gaining prominence in many local authorities in England, although there are other evidence based models, such as strengthening families, and solution focussed intervention, which also have promising results. 15.11 Regardless of what model is adopted, successive studies support the need for professionals to train together, and if possible to be co-located and working to a common understanding and agenda, in order for a shared culture to develop which will deliver the intended changes in the Surrey Early Help Strategy, that is, “Shared values and principles, common methodology and approach towards working with children, young people and/or within their families”. This will not develop on its own. 15.12 Some of the learning from this review therefore is about the management of this transition, and the need to ensure that cultural change is supported at every level within the services, cutting across supervision, assessment, and work allocation, particularly in the case of trainee and newly qualified or inducted staff. 15.13 Within this current context however, there are elements of good practice, which need to be highlighted and celebrated. For example, the health visiting staff demonstrated a huge commitment to ensuring that the situation was as safe as they could make it, including one health visitor shopping for the family out of hours with her own money, to ensure that they had food and equipment, and visiting in the evening to check that the children were ok. The ambulance service followed up some concerns about the children as the result of their call outs, referring into social care, and the GP practice registered the family locally without question or historical paperwork. The GPs also responded quickly, and in a protective manner to potential safeguarding concerns about both babies. SW2 made huge efforts to get alongside the mother and to understand her perspective. The District Council offered immediate homeless hostel accommodation and sought to avoid eviction, despite the couples’ failure to complete necessary paperwork. All of these are examples of putting the needs of the children first, and understanding safeguarding responsibilities. 15.14 Surrey has also now adopted the Family Nurse Partnership model which specifically targets vulnerable parents, including young parents, for intensive assessment and support. Child AA’s family would clearly have met the criteria for this had it been in place at time of the birth of her older sibling. However, the FNP criteria do not extend to a second child, which is unhelpful, as this approach may well, through its focus on risk assessment, 27 Bushe, Gervase (2012). "Foundations of Appreciative Inquiry". Bushe's website. Appreciative Practitioner. 28 ditto 29 A. Tunstall, et al, op cit. 37 have provided an additional safety net for this family. Consideration of the extension of the criteria for FNP to include a second or subsequent pregnancy to vulnerable young parents is therefore a recommendation arising from this Review. 15.15 All professionals have recognised the need to work more openly and jointly. The introduction of joint assessment visits and joint supervision, as well as co-location and integration were mentioned by all of the staff interviewed. 16. RECOMMENDATIONS 16.1 No professional wants to work in a way or in a system that fails to protect children, and there is no doubt that there was both good practice and practice which fell short of the level that Surrey SCB would want to promote. The Surrey Early Help strategy presents a brave attempt to change the current prevailing approach in which children are not well served nationally, to a local solution in which there is shared understanding about risks and needs. Clearly, whilst there is still some way to go in terms of joint training, risk focussed assessment and interagency communication, if the vision set out in the strategy is to be realised this review has identified some helpful learning to inform progress. 16.2 I support the single agency recommendations from the IMRs to the Surrey Safeguarding Children Board, and also recommend the following: 16.2.1 That Children’s Social Care reports back to the Board that the guidance for social workers on assessment includes the following requirements: o Joint visiting with other professionals to share perceptions and views o clear ‘triggers’ for reassessment when circumstances change in families, o a focus on history and chronology o understanding the role of fathers, o challenging assumptions and producing clear evidence for professional opinion o identifies risks as well as needs and strengths, regardless of whether the case is CIN or CP o that, where children are subject to Children in Need Plans, social work visits are both announced and unannounced in order that the child’s whole context can be understood 16.2.2 Surrey Safeguarding Children Board should also satisfy itself through its learning and improvement framework and a system of audit that: o the risks to new born babies and premature babies are fully understood and the expertise of community health professionals are acknowledged in this area, and o the Family Nurse Partnership arrangements are improving the focus on the needs of very young parents, and in particular the focus on the parents as Children in Need themselves, and therefore improving outcomes for them and their children 38 16.2.3 Surrey Community Health services should consider revision of the criteria for inclusion in the Family Nurse Partnership programme to include young parents who have a second or subsequent child. 16.2.4 Surrey Safeguarding Children Board should also ensure that the Escalation policy is brought to professionals attention and in particular the urgency in the case of very young children 16.2.5 Surrey Safeguarding Children Board should consider how best to support joint training and consideration of the appreciative inquiry or a similar model as a means of promoting common dialogue and developing positive shared practice. 16.2.6 The Safeguarding Children Board of the neighbouring authority should also assure itself through audit that policies and procedures reflect the requirement to vigorously pursue and share information and concerns, where there are families with additional vulnerabilities who move between health practices. This would include the health practitioner following up by telephone with the receiving practice any issues that indicate vulnerability direct with the new practice in order that safest and best practice is assured. 16.2.7 The Safeguarding Board should also ensure that a full de-brief is held between the health and social care staff involved in this Review. Ruby Parry Ruby Parry Independent Consultant, On behalf of Reconstruct, July 2015 39 SINGLE AGENCY RECOMMENDATIONS Community Health 1. Definition and Clarity of roles between different health visitors. Though it is felt that all the health visitors concerned identified the risks and were clearly working together to improve the situation for these children it is apparent that too many were involved. There needs to be a clearer definition of the role of the Health Visitor for the Homeless and for the 0-19 teams to understand where their responsibilities lie in conjunction with this post. 2. Improved links with Children’s Services. There were clear differences of opinion between Children’s Services and health and a degree of not understanding what the different roles were. Measures are already in place to improve this working relationship and managers from the 0-19 team, the safeguarding team and children’s services are now meeting regularly to liaise about complex cases. Shadowing between the agencies is actively being encouraged. 3. Improved Assessment and Record Keeping. The annual record keeping audit will include a deeper audit of safeguarding records and supervision records including risk assessment and action plans evidenced by the effective use of chronologies and the use of the Family Health Needs Assessment. 4. Clinical managers are to update all 0-19 team members on record keeping issues via service meetings and team leaders. 5. The Family Health Needs Assessment should be used as a continuing document assessing risks, strengths and resilience and it will be recommended that practitioners should be given more training on its use in universal practice assessments and how it can be used to provide objective evidence to support referrals and concerns. 6. Group Supervision. As has already been documented there were a large number of health professionals and professionals from other agencies involved with this family. Group supervision and joint supervision would have been a useful way for all individuals concerned to meet together and discuss the concerns that they had and decide in a more organised way exactly what support each practitioner or agency could provide. District Council 1. Ensure that the regular liaison and visits (as described in the good practice example) between the SHO, health visitor and Children’s Services outreach worker are sufficiently resourced and prioritised so that they continue. 2. Ensure that staff continue to receive and update their training on safeguarding and child protection as this clearly engenders confidence for staff in dealing with difficult situations. Children’s Social Care 1. A chronology to be started at an early point in the life of the case and to be a piece of ongoing work and a tool for analysis and supervision 40 2. Where a parent of a child referred to children’s Services has themselves been known to the Local Authority as a consequence of Child Protection concerns, has been on a Child Protection Plan, Looked After or a child in need, their own early history should be examined with a view to an assessment of their own patterns of childhood attachment. 3. For supervision notes to address each aspect of the plans and record the risks and to outline a clear plan of work 4. For assessments to include fathers and the wider family. 5. Where there are difficulties between agencies in their understanding of the case for consideration to be given to early joint meetings and supervision. 41 APPENDIX TERMS OF REFERENCE 1. Did agencies communicate effectively and work together to safeguard and promote the children’s welfare? 2. Was the level and extent of agency engagement and intervention with the family appropriate? Were assessments undertaken in a timely manner, was the quality adequate and did they include fathers, extended family and all historical information? 3. Was any information known by any agency about parental mental health issues, domestic abuse, substance misuse or parental antisocial behaviours or concerns re neglect? If so was appropriate consideration given to how these impacted on parenting capacity and were appropriate referrals made? 4. Was there sufficient consideration of the vulnerability of this family in relation to their housing situation and the impact on their parenting capacity and what support was provided? 5. Were the decisions and actions that followed assessments appropriate and were detailed plans recorded and reviewed? 6. Were the children’s views and wishes sought and taken account of in assessments and planning? Did this include the presentation of these young non verbal children being fully considered? 7. Were any safeguarding issues in respect of the children identified and acted on appropriately and in a timely way by all agencies? 8. Were missed appointments and failure to engage considered as indicators of neglect? 9. Was race, religion, language, culture, ethnicity or disability a factor in this case and was it considered fully and acted on if required? How was the uniqueness of this particular family recognised? 10. Were there any organisational or resource factors which may have impacted on practice in this case? 11. Were appropriate management/clinical oversight (supervision) arrangements in place for professionals making judgments in this case? |
NC050517 | Death of a 3-month-old girl in October 2020. Freya was found in an unsafe sleeping position co-sleeping with her parents. Learning themes include: information sharing arrangements between agencies and professionals; the handover of care during the ante and post-natal periods between NHS trusts; the local safeguarding children's board's referral arrangements; policies related to patients who 'do not attend' (DNA); the knowledge and understanding of sudden unexpected death in infants (SUDI) among professionals; and the information provided to parents and carers around co-sleeping. Recommendations include: ensure the roll out and use of the Badger Notes system for maternity records supports and promotes information sharing, so that referrals are documented, visible and communicated to appropriate professionals; include all the information about a patient when they are referred to any service, especially information that might suggest an increase safeguarding risk or heightened vulnerability for children or parents; the local police force ensures all officers understand the purpose and importance of sharing information through the public protection notification process, especially when that information indicates substance misuse or violent behaviour by parents or carers; ensure that hospital trusts have an effective communication pathway between acute and community services in respect of babies under 1-year-old who are being treated in an acute setting; paediatric clinicians should have access to parental information, such as maternity liaison forms, so they can properly assess children's vulnerability when making clinical decisions or decisions to discharge; ensure that all professionals understand the maternity DNA escalation procedure for mothers who miss midwifery appointments.
| Title: Rapid child safeguarding practice review – Freya. LSCB: Portsmouth Safeguarding Children Partnership Author: Graham Bartlett Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. PSCB Rapid Child Safeguarding Practice Review – Freya Final Report 1 Portsmouth Safeguarding Children Partnership Rapid Child Safeguarding Practice Review – Freya By Graham Bartlett January 2022 PSCB Rapid Child Safeguarding Practice Review – Freya Final Report 2 Table of Contents 1. INTRODUCTION ................................................................................................. 3 2. REVIEW ARRANGEMENTS .............................................................................. 3 3. PRACTICE EPISODES ...................................................................................... 4 4. ANALYSIS ........................................................................................................ 10 5. CONCLUSION .................................................................................................. 21 APPENDIX A – SCHEDULE OF RECOMMENDATIONS ....................................... 22 APPENDIX B – SCHEDULE OF GOOD PRACTICE ............................................... 24 PSCB Rapid Child Safeguarding Practice Review – Freya Final Report 3 1. Introduction 1.1 Applying Working Together to Safeguard Children (2018)1, on 16 November 2020, the Portsmouth Safeguarding Children Partnership (PSCP) determined it was appropriate to conduct a Rapid Child Safeguarding Practice Review examining agency involvement with a sixteen-week-old infant and her parents, who for the purposes of this report will be known as Freya2. 1.2 Freya died having spent the first eight weeks of her life in hospital following a prenatal diagnosis of gastroschisis and health concerns arising from that. The cause of death was unascertained, however she was found in an unsafe sleeping position co-sleeping with her parents, who are now under criminal investigation on matters connected with her death. 1.3 The aim of the review is to capture areas of learning to inform service improvements around interagency working, information sharing, and practice in raising awareness of babies at heightened risk from unsafe sleeping. 2. Review Arrangements 2.1 The PSCP appointed Graham Bartlett to lead the review, drawing from the combined scoping to which all agencies contributed, additional material requested, a learning event and the considerations of the Learning from Cases subgroup, acting as the Panel 2.2 Graham Bartlett is the Director of South Downs Leadership and Management Services Ltd. He independently chairs the East Sussex and Brighton and Hove Safeguarding Adults Boards and was previously the Independent Chair of the Brighton and Hove Local Safeguarding Children Board. He has significant experience of chairing and writing Domestic Homicide Reviews, Serious Case Reviews and Safeguarding Adults multi agency reviews. He is a retired Chief Superintendent from Sussex Police latterly as the Divisional Commander for Brighton and Hove. He had previously been the Detective Superintendent for Public Protection. He retired in March 2013. He has had no involvement or responsibility for any policing or safeguarding services in Portsmouth or Southampton. 2.3 The agencies contributing to the review were • Portsmouth Children and Families Services • Hampshire Constabulary • Portsmouth Clinical Commissioning Group • Portsmouth Hospital NHS Trust • Solent NHS Trust • University Hospitals Southampton NHS Foundation Trust • Freya’s General Practitioner 2.4 The specific terms of reference for the review were established as: • To examine the effectiveness of information sharing arrangements between all agencies and professionals (including whether PPN1 forms are used accurately and effectively) and whether these could have been improved • To explore the arrangements which support handover of care during the ante and 1 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Working_together_to_safeguard_children_inter_agency_guidance.pdf 2 ‘Freya’, ‘Hannah’ and ‘Ryan’ are pseudonyms. PSCB Rapid Child Safeguarding Practice Review – Freya Final Report 4 post-natal periods between NHS trusts, especially when one or more trust is out of the Portsmouth area. • To examine the effectiveness of new birth and post-natal visiting and care arrangements, especially when one or more on the trusts involved is out of the Portsmouth area • To examine the Portsmouth safeguarding referral arrangements and the threshold for Multi Agency Safeguarding Hub (MASH) decision making • To explore the effectiveness of policies and protocols related to patients who ‘do not attend’, children who ‘were not brought’ to health appointments and around disguised compliance during the ante and post-natal periods. • To examine the Healthy Child Programme Health Visiting thresholds in operation in Portsmouth, the status' of 'Universal / Universal +' as used by Health Visitors (including the criteria for escalation or step down through these), what they mean in practice and whether partners have a good understanding of what this looks like. • To explore the knowledge and understanding of Sudden Unexpected Death in Infants (SUDI) risk factors among professionals and how these influence assessment and decision making • To examine the nature, range and effectiveness of information and support provided to parents and carers, by health and social care agencies, around co-sleeping and reducing the risk of SUDI • To examine the impact of organisational and operational change as a consequence of the Coronavirus pandemic on the provision of health and social care in the ante and post-natal periods • To examine the nature and quality of bereavement support offered and/or provided to parents in the period following a SUDI, including in cases when parents are under investigation for alleged criminal offences • To consider any equality and diversity issues (e.g. age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief, sex and sexual orientation) that appear pertinent to the family and any consequent service provision. 2.5 The timeframe under review was from 1 January 2020 - 23 October 2020 (the day of Freya's death) although for the purposes of examining bereavement support, this period was extended. 2.6 It was not possible to involve the parents in this review for some time as they were under police investigation. They no longer are and many efforts have been made by the lead reviewer and their social worker to encourage them to contribute to and review the report but, other than to one text message confirming an email address, they did not reply. It was felt by the lead reviewer and the Safeguarding Partnership that the review should take this as them not wishing to be involved so this report is written without their direct perspective. As a result the pseudonyms used have been chose by the lead reviewer rather than the parents. 3. Practice Episodes 7 January 2020 – 1 July 2020 – Ante Natal Period 3.1 On the 7 January 2020, Hannah – Freya’s mother –, accompanied by Ryan (Freya’s father) –, presented at Queen Alexandra Hospital (QAH), Portsmouth (part of Portsmouth Hospitals University NHS Trust [PHUT]) for maternity care and was booked by an allocated midwife. During this she disclosed a history of pre-pregnancy alcohol use (20 units per week) and cocaine use, two years previously. PSCB Rapid Child Safeguarding Practice Review – Freya Final Report 5 3.2 Hannah’s GP did not become aware of the pregnancy until early April as women are able to self-refer directly online by completing an online booking form. On receiving the completed form, the usual process is that PHUT Maternity Services contact the GP by letter informing them their patient is pregnant and has presented for maternity care, requesting any relevant health related and social information be returned. The GP surgery has no record of receiving this notification until after Hannah’s sixteen-week scan. 3.3 Hannah attended QAH for a routine ultrasound scan on 23 January 2020 and gastroschisis3 was identified in the unborn baby so Maternity Services contacted the Fetal Medicine Unit (FMU) at Princess Anne Hospital (PAH) in Southampton (part of University Hospital Southampton NHS Foundation Trust [UHSFT]) for Hannah to be reviewed. A Parental Substance Misuse Assessment was completed by the midwife four weeks later and no ongoing support was identified as necessary. 3.4 It is unclear whether any of the history known to PHUT Midwives was shared with UHSFT as, initially, the referral was for a fetal medicine opinion rather than a booking. 3.5 On 7 February 2020, at fourteen weeks gestation, Hannah was reviewed in FMU Outpatients at PAH. The investigations confirmed prenatal gastroschisis, a complex diagnosis requiring the baby at birth to have surgical input in a specialist FMU in the immediate postnatal period. A plan for this was established and Hannah’s antenatal care and birth was then to be led by the FMU at PAH. 3.6 On 20 February 2020, Hannah attended a PHUT community midwife antenatal appointment. A PRAM (substance misuse proforma) was completed due to her previous self-disclosed alcohol consumption, however she reported she had ceased drinking in pregnancy. The PRAM revealed a low risk score and it was planned to be revisited later in the pregnancy. 3.7 The same day, during a PHUT maternity safeguarding supervision around this case, domestic abuse and mental health were discussed and there was no evidence of either, but it was decided to re-visit Hannah’s lifestyle and drinking at subsequent appointments. There was also a discussion regarding Hannah’s attendance at antenatal appointments. 3.8 On 14 April 2020, during a routine ultrasound at PAH, it was noted that the baby was small for her gestational age and had shortened long bones. Clinicians discussed with Hannah whether she would consent for an amniocentesis but there appeared to be no further discussion regarding this, therefore it is unclear if she declined it or, clinically, it was decided against. 3.9 The same day Hannah was booked for pregnancy care and birth at Princess Anne Hospital by the FMU midwife. Routine enquiry was made during regarding substance misuse, mental health, previous social care involvement and domestic abuse. Hannah responded that there were no such issues. FMU remained unaware of the history reported to PHUT. 3.10 On 23 April 2020, Hannah was due to attend a PHUT midwife appointment but did not. The midwife made two calls and left messages on each. It seems PHUT maternity services did not know that Hannah had been booked in to UHSFT for pregnancy care and birth. 3.11 On 30 April 2020, again Hannah did not attend a PHUT midwife appointment. Two telephone messages were left on Hannah’s answerphone, and a letter sent to her home. Within the letter, a new appointment date was provided and Hannah was informed if she did not attend the third appointment a referral to children’s social care would be made. Again, it seems PHUT did not know that Hannah had been booked in to UHSFT for pregnancy care and birth. 3.12 Hannah attended PAH for ultrasounds on seven further occasions between 28 April 3 An abdominal wall defect whereby a child’s abdomen does not develop fully while in the womb causing the intestines to develop outside the abdominal wall PSCB Rapid Child Safeguarding Practice Review – Freya Final Report 6 2020 and 29 June 2020. At this last appointment, due to continued concerns over the baby’s growth and gastroschisis, a decision was made to induce labour. 3.13 In addition to the ultrasound appointments, given concerns around fetal growth which remained on the 5th centile, there was a plan for the baby’s heart to be regularly monitored by a non-invasive continuous cardio-tocograph (CTG). The frequency of these increased from twice weekly to alternate days. 3.14 On 14 May 2020, for the third time Hannah did not attend a PHUT midwife appointment. A telephone call was again made and message left together with a letter being hand delivered to her address. 3.15 On 21 May 2020, PHUT made a MASH referral due to her missing the midwifery appointments. The referral contained information relating to alcohol and cocaine use (including information from the PRAM of 20 February 2020) and adverse childhood experiences. The referral stated that no mental health or domestic abuse issues had been reported. 3.16 Given the referral did not meet threshold it was returned to PHUT Maternity Services for more information. It seems that it was from this that PHUT safeguarding first became aware that Hannah was receiving her care in Southampton and that some appointments there clashed with theirs. UHSFT were satisfied that Hannah was engaging well with them and had no concerns regarding her keeping appointments. This was also the first time that PHUT Maternity Services discovered Hannah’s ante natal and birthing care would be delivered by UHSFT. 3.17 As a result of this information, on 2 June 2020 the case was reviewed by PHUT Safeguarding Team resulting in a request to the community midwife that all relevant information and the maternity hand-held record be sent to PAH and to formally hand over care. The Community Midwife confirmed this had already been done. 3.18 On the same day a health visitor attempted a remote (due to Covid) antenatal home visit but there was no reply. The health visitor left a voicemail asking for a call back. 3.19 Given the referral did not meet threshold and was returned, the fact that Hannah had been a victim of domestic harassment from a previous partner and that Ryan had been subject of three Multi Agency Risk Assessment Conferences (MARAC) between 2013 and 2015 in respect of another partner, was not highlighted. The police held this information but it would not have been expected for PHUT to enquire of them once the referral had been returned. 3.20 On 8 June 2020 Solent NHS undertook a remote antenatal health visit and noted that Hannah would require additional post-delivery support for maternal mental health due to her anxiety. She was given comprehensive safe sleeping advice and signposted to electronic resources. The health visitor also discussed domestic abuse with her but no immediate action was required. They did discuss the frequent appointments at PAH but Hannah said her wider family friends were very supportive. 3.21 On 10 June 2020, a maternity safeguarding liaison form was raised and reviewed by maternity safeguarding at UHSFT in response to the earlier MASH decision as it seems this was the first time PAH were aware of the previous alcohol and cocaine misuse as Hannah had not reported that to them. 3.22 Hannah did miss two consecutive CTG appointments in the week commencing 8 June 2020 and advice was given to continue to monitor and review if further appointments were missed. 2 July 2020 – 28 August 2020 – Birth and Post-Natal Hospital Care 3.23 On 2 July 2020, due to a delay in the first stage of labour, Freya was born by Emergency Caesarean Section at thirty-five weeks. Her birth weight was 1.585kg, she was in good condition and needed no neonatal life support. She was transferred to the Neonatal Unit PSCB Rapid Child Safeguarding Practice Review – Freya Final Report 7 (NNU) to allow immediate treatment for her gastroschisis. She required some support with breathing but was weaned off this quickly and was self-ventilating by eight hours old. 3.24 During the initial postnatal period Hannah made a routine recovery and was keen to mobilise and visit her daughter. There is no documentation regarding her partner during this period but Hannah visited her daughter regularly. Due to Covid restrictions, visiting by partners was severely restricted. 3.25 The following day, Hannah was discharged to midwifery-led care. Ordinarily she could have lodged at the Ronald Macdonald House but as this was closed due to Covid, she was discharged to Bramshaw ward to enable her to spend time with Freya. 3.26 Following birth, the gastroschisis was confirmed and the bowel was gradually reduced back inside and the abdominal opening was closed. She was fed intravenously until her bowel started to work and she was able to establish full breast feeds, then she transitioned to a prescription formula because of poor growth. She also had symptoms of gastro-oesophageal reflux disease There were no family concerns noted during the inpatient stay. 3.27 Having been notified of the birth on the 3 July 2020, the health visitor congratulated Hannah by text. She asked to make a home visit in July but as Hannah was still in hospital this was delayed. During this time, Freya was under Universal Plus health visiting. 3.28 On 6 July 2020 the health visitor text Hannah to set an appointment for 13 July 2020. Hannah text back to say that that Freya will not be with her so it was agreed they would talk over the phone then and plan a subsequent face to face appointment. This conversation happened as planned and communication was maintained regarding Freya’s hospital stay and to discuss discharge. 3.29 In the early hours of 19 July 2020 police were called to a report that a drunk driver had crashed into a fence in Portsmouth. When they arrived, witnesses described to police how the driver had driven off from the scene. Before doing so the driver had assaulted a security guard who had challenged him. 3.30 Police went to the owner of the vehicle, Ryan’s, address and found him and a woman (believed to be Hannah, as comments were made about her breastfeeding and having a baby in hospital) in the address. Both were described as drunk. Ryan refused to come to the door and threatened the officers himself and with two dogs who were in the house. Whilst officers spoke with him he barricaded the door and screwed it shut. A senior police officer declined permission for officers to force entry to make an arrest or to ‘save life or limb’ under Section 17 Police and Criminal Evidence Act 1984. This incident was not reported to other agencies through the police PPN1 referral form. 3.31 Later in July 2020, Hannah was in Neonatal Intensive Care Unit (NICU) with sickness. The health visitor advised Hannah to liaise with the GP regarding contraception and to let her know when Freya was discharged. 3.32 By 10 August 2020, Hannah was becoming frustrated with Freya’s hospital stay. She sent her health visitor a text saying she wanted to take Freya home as some of the staff do not listen when Freya has got wind and do things that are making her vomit which doesn’t happen when she feeds her. The health visitor quickly replied, offering to complete weekly weight checks but said Freya should stay in hospital to be monitored. The health visitor offered to liaise with the hospital but it is unclear whether she did. 3.33 On 18 August 2020, Freya’s weight was 2.7kg and she was discharged home. Her discharge medication was Omeprazole, Iron and Vitamin supplements. The discharge checklist was completed which included a one to one discussion regarding ICON4 and safe sleep and a pack containing information5 covering these risks. Because of Covid it was not 4 A method to avoid abusive head trauma in babies. https://iconcope.org/for-professionals/ 5 https://www.lullabytrust.org.uk/wp-content/uploads/Safer-sleep-for-babies-a-guide-for-parents-web.pdf PSCB Rapid Child Safeguarding Practice Review – Freya Final Report 8 possible to discuss these with Ryan at the same time and no steps were taken to do so subsequently. 3.34 As well as seemingly not being notified of Hannah’s booking, the GP surgery maintain they did not receive a discharge summary or birth notification from Southampton regarding Freya, despite UHSFT records showing they were sent. After being registered with the surgery on 21 August 2020 she was never seen in the surgery. She did not have a 6-8 week check, nor did she attend for either her first or second immunizations. 3.35 On 24 August 2020, Hannah contacted the surgery following discharge from UHSFT to re-prescribe Alfamino powder for Freya. The missed child immunizations were picked up from the child health report and, after being unsuccessful in contacting Hannah by phone, the surgery sent a text message in October asking her to contact them to arrange an appointment. 3.36 On 25 August 2020 Hannah took Freya for a NNU routine post-discharge review. The surgical nurse specialist noted some concerns regarding Freya’s physical health so, in accordance with protocol, sought advice from the consultant in charge of Freya’s care and arranged for her to be reviewed by the paediatric surgical team in based in the Emergency Department (ED). Staff escorted Hannah and Freya to ED where Freya was initially reviewed by a consultant paediatric surgeon who recommended an overnight stay on PAW for observation and monitoring of input and output as she was mildly dehydrated. 3.37 That evening a surgical register further reviewed Freya as Hannah wanted to go home. They explained the risk of Freya deteriorating and offered a referral to the Paediatric Unit at QAH. Hannah declined this and told the surgical registrar she had a health visitor appointment the next day. This was not checked. A plan was made for Freya to be discharged home with a follow up call the next day, a review by the health visitor and a ward review on the 27 August 2020. 3.38 The paediatric surgeons would have preferred not to have discharged Freya but did so given the plan they put in place. As UHSFT paediatricians do not have access to maternity liaison forms they would not have been aware of the parental history and therefore any additional vulnerabilities. They only access maternal records in cases regarding children open to Children’s Services where they have concerns and with maternal consent. 3.39 Hannah had cancelled the appointment with the health visitor. It is unclear whether this was before or after she took the decision to self-discharge. In either case, she would have known before or shortly after the discharge plan was set that she would not be seeing the health visitor before 8 September 2020. 3.40 On 27 August 2020, following a review by a surgical registrar, when the fact of the cancelled health visiting appointment was realised, Freya was admitted to the children’s surgical ward. Hannah completed and signed the nursing assessment form stating there was no current or historical alcohol misuse, drug misuse, domestic violence or mental health issues with anyone living in home. Hannah remained with Freya during her stay. 3.41 The following morning, after a gastroenterology opinion and review, Freya’s feeds were changed to a high energy formula, with paediatric dietetic supervision. During the review, a plan was made to discharge that day. There is no record of whether a discussion took place regarding the potential risk of early discharge or the impact on Freya. It is noted on the discharge paperwork that ‘mother would like to go home.’ A period of observation to see if the change in formula improved feeding and reduced vomiting episodes had been requested, but this appears to have been changed, probably as there was no evidence of vomiting at the time of discharge. A discharge letter was sent to primary care but seems not have been received. Following discharge from UHS, Hannah had ongoing telephone support with the paediatric dietician. 4 September 2020 – 23 October 2020 Post Discharge Period in Community 3.42 On 4 September 2020 an outpatient review with the Neonatal Dietician revealed that PSCB Rapid Child Safeguarding Practice Review – Freya Final Report 9 Freya was gaining weight and was now 3.02kg. Hannah had no other concerns and said she had a review with the health visitor planned for the following week. 3.43 On 8 September 2020 the health visitor tried to contact Hannah to arrange a visit. Her call and text were returned the following day when Hannah said Freya was gaining weight with the new milk. A plan was made for a home visit on the 21 September 2020. 3.44 On 21 September 2020, Hannah text the health visitor to cancel the appointment as she had too much on. The health visitor text back offering to weigh Freya but Hannah did not reply. The health visitor waited for Hannah to rebook an appointment. 3.45 On 30 September 2020 during an outpatient review with a consultant paediatric gastroenterologist, there were no clinical concerns and Freya’s weight was now 4.05kg. She was reported to be on no medications and the plan was to review her in 4 months. 3.46 On 1 October 2020, the health visitor tried to call Hannah and sent her a text but received no reply. By now Freya had been stepped down to Universal Health Visiting. That was the last contact attempted between the health visitor and Hannah. The effect of this is that Freya was not seen for a new birth visit since her discharge from hospital on 18 August 2020. 3.47 On 15 October 2020, Hannah’s MATB1 (Statutory Maternity Pay form) was collected from the GP surgery, the same day the surgery sent her a reminder to book Freya’s immunisations. 3.48 At 06:00 on 23 October 2020, Hannah awoke to find Ryan asleep on top of Freya in their double bed. Ryan was on his side partially covering Freya with his body. Hannah woke Ryan and picked up Freya who was cold to touch and her body felt stiff. Hannah commenced CPR however she could not open Freya’s mouth fully. At 06:08 Hannah contacted the ambulance who were dispatched immediately, arriving within seven minutes of the call. When they arrived Freya was unresponsive and pale. 3.49 She was taken straight to QAH but sadly pronounced dead at 07:10. Given the circumstances, Hannah and Ryan were arrested on suspicion of causing or allowing the death of a child. During the search of their house a number of cannabis plants were found in the loft. Subsequently, both parents were further arrested for cultivation of cannabis. 3.50 The house was described as cluttered and untidy – indicating that some level of support required due to a degree of neglect. There was baby equipment present in the house, although not being used. There was evidence of old food in the kitchen, compost in the house as well as cannabis and drugs paraphernalia. There was a cot present in the parents’ room but appeared to be used for storage and had some evidence of posseting and animal hair on the sheet. There was blood on the sheets in the bed. 3.51 There were appropriate clean bottles and clothes in the house and a Calpol bottle which indicated minimal use. Freya’s red book was found, but there were no written contacts inside, and safe sleep information was found in a wardrobe. The pet dogs and fish appeared well cared for 3.52 The Child Death Review Process6 was instigated straightaway. 3.53 During interview, Hannah confirmed that she drank four pint cans and a small can of Heineken the previous evening. She drank the first one at around 8pm and the rest over a three to four hour period. Eight empty cans were found. She said when she went to bed she was drunk but not ‘wasted.’ She also said she had ‘two tokes’ of cannabis at about 9pm. 3.54 Hannah confirmed Ryan drank about the same amount as her and maybe a few extra smaller cans of Heineken. He also had ‘two tokes’ of cannabis. She said she went alone to bed about midnight, leaving Ryan alone with Freya. The last time she saw Freya alive, she 6 https://hipsprocedures.org.uk/assets/clients/7/HIPS%20Child%20Death%20Review%20Process.pdf PSCB Rapid Child Safeguarding Practice Review – Freya Final Report 10 was asleep in her highchair. 3.55 At 06:00 she awoke and Ryan was lying on his side facing the wall away from Hannah. Freya was under him just below his shoulder blades with her face in his back. Hannah could see one side of her face, one arm and a leg. The rest of her, including her face, was squashed against Ryan’s back. 3.56 Hannah said Freya would normally co-sleep with them despite knowing that they should not. She admitted to being aware of safe sleep guidance and was told not to co-sleep but her friends did it so she thought it would be OK. Hannah said Freya usually slept on her side of the bed, up by her face between her and Ryan, and she moves a pillow to allow room. 3.57 During his interview, Ryan said he and Hannah drank two pints cans of Heineken each. He said he did not consume any other alcohol nor had he smoked cannabis or taken any other illegal substance. 3.58 He said he, Hannah and Freya went to bed together at midnight and that 80% of the time Freya sleeps in her cot. He said that she was in her cot when they all went to bed and the first time he knew she was in the bed was the following morning when Hannah woke him shouting. He then saw Hannah pick Freya up from the centre of the bed and confirmed that Freya had been tucked under his back. He had not known she was there and at no time did he feel her. 3.59 He added that Freya was being given Calpol as she was teething and that he and Hannah had not discussed co-sleeping but had been given leaflets on safe sleep. 3.60 Freya and Ryan are still under investigation. 4. Analysis 4.1 This review has highlighted a number of learning opportunities and areas of good practice. The learning opportunities, good practice points and the recommendations they lead to are organised by the terms of reference they refer to. To examine the effectiveness of information sharing arrangements between all agencies and professionals (including whether PPN1 forms are used accurately and effectively) and whether these could have been improved. 4.2 There were a number of examples where information broke down in this case, specifically: 4.3 Hannah’s care was transferred from PHUT to UHSFT given the fetal abnormality which was discovered in January 2020. A decision was made shortly after that all Hannah’s ante natal care, and the birth, would be led by UHSFT. UHSFT’s monitoring regime of Hannah was intense and, by and large, she engaged with it. 4.4 However, despite the referral the communication between PHUT and UHSFT was poor. The midwifery service seemed unaware Hannah was being looked after in Southampton and made many attempts to see her during the period she was making the forty five mile round trip for fetal scans. In accordance with their policy7, they were tenacious in following up what they considered to be episodes of non-engagement, to the point that they made a MASH referral under the safeguarding arrangements. Had they been aware that Hannah’s care had been transferred, they say they would have realised she was engaging elsewhere and not considered her missing their appointments a safeguarding issue. 4.5 The MASH referral, which was not accepted, was not discussed with the Named Midwife for Safeguarding nor shared with the GP, which reduced the opportunity for fuller information to be considered. Had the referral met threshold, Ryan’s and Freya’s domestic 7 Missed Antenatal and Postnatal Appointments – Guideline – PHUT 2020 PSCB Rapid Child Safeguarding Practice Review – Freya Final Report 11 violence history with previous partners would have been revealed as police information would have been requested. However, as it did not, PHUT were asked to gather more information which led them to realise that Hannah was being treated at Southampton. This exercise would not reasonably have included a request for police information. 4.6 Practitioners explained that the initial referral to FMU was for a review only and made over the telephone. When that became a booking to manage the gastroschisis, the FMU did not communicate that with PHUT Maternity Services so they remained oblivious. The review was told that routinely FMUs communicate with each other and then expect the recipient to cascade the information to their wider teams as appropriate. The PHUT Antenatal Transfers Out to External Trusts Standard Operating Procedure (SOP)8 does not explicitly cater for these transfers as it is more focused on transfers consequential to mothers’ choice. Since these events, the review has been told that the practices have been addressed and now FMUs would ensure they refer to the originating maternity services department. 4.7 The review understands the introduction of Badgernet9, a perinatal data management system, across all the trusts involved in this review will significantly improve the information sharing in these situations. As it is new to many trusts, its efficacy in this region has yet to be shown but the Child Death Overview Panel co-ordinator reports promising improvements already. Access to this system will not only be by maternity services but FMUs too. Although the signs are good, its important that professionals review records otherwise, despite the information being available, they may remain unaware of key events. Recommendation 1 That PHUT and UHSFT assure themselves that the introduction, roll out and use of Badgernet supports and promotes information sharing so that referrals are documented, visible and communicated to appropriate professionals. Also that the outcome is available to the referring department, and any other clinical services the patient is currently under, so that continuity of care is clear and primary responsibility assured. 4.8 When the FMU referral was made, the relevant information around Hannah’s increased vulnerability, primarily to do with her self-reported historical alcohol and substance misuse, was not included so the receiving hospital were unaware of these factors. Also, information regarding Ryan having a history of domestic violence with a previous partner, and Freya previously being a victim was unknown to all health professionals so, in respect of any future risk, all they had to rely on was Hannah’s self-report that domestic abuse was not an issue. There is nothing to suggest there was domestic abuse between her and Ryan, but the previous history combined with her alcohol/ substance misuse disclosure would have highlighted an increased vulnerability around her and her unborn child than was assumed. Recommendation 2 PHUT ensure that when referring patients to any service, whether within or out of the Trust, they include all information regarding that patient, especially such that might suggest an increase safeguarding risk or heightened vulnerability for the child or parent(s). 4.9 The police did not share the details of the road traffic collision during which it was revealed that Freya, who was in the house that Ryan barricaded, was breast feeding. This oversight meant that critical information was kept from other agencies and, particularly around the time Freya was seeking to discharge Hannah from hospital, might have prompted a stronger response to safeguard her. The police acknowledge they should have shared, and 8 Antenatal Transfers Out To External Trusts Standard Operating Procedure (SOP) – PHUT 2020 9 https://www.badgernotes.net/ PSCB Rapid Child Safeguarding Practice Review – Freya Final Report 12 this was an oversight by the officers concerned. 4.10 Had they shared this event, they would have identified the previous domestic history Hannah and Ryan had with previous partners and this would have been significant in assessing risk, especially with a new born baby adding to the family pressures. 4.11 Hampshire Constabulary have recently launched a major initiative, ‘Child Centred Policing10’, a program to embed six key principles of taking a Child Centred approach to all aspects of policing so as to improve the quality of policing for children and young people by acknowledging their differences, recognising their vulnerabilities and meeting their needs. 4.12 The oversight in this case was an individual error but it is intended the principles of Child Centred Policing will reduce such occurrences in the future. Recommendation 3 Hampshire Constabulary, as part of the Child Centred Policing programme, ensure all officers understand the purpose and importance of sharing information through the PPN/1 process which might indicate that children or vulnerable people are, or could be, at risk especially when that information indicates substance misuse or violent behaviour by parents and/ or carers. 4.13 The communication between the UHSFT and the health visitor could have been improved. Hannah voiced frustrations to the health visitor about the way NNU were treating Freya and the health visitor said they would speak with the ward yet there is no evidence they did. Then, against medical preference, Hannah wanted to discharge Freya from PAW. One of the factors that seemed to reassure the registrar that discharge was safe was Hannah saying she had a health visitor appointment the following day, but she had cancelled it. Given this conversation took place in the evening it might have been difficult for the registrar to check, but had they been able to, they would have discovered the truth, a truth that was only realised subsequently upon which Hannah returned Freya to hospital for a pre-arranged appointment. However, as UHSFT were unaware of any concerns, as they had not been shared, there were no concerns regarding Freya’s safety. Recommendation 4 Solent NHS Trust and UHSFT should assure themselves that the communication pathway between acute and community services in respect of babies under one year who are being treated in an acute setting is effective. This should ensure improved information exchanges regarding shared patients/ service users so as to provide better continuity of care and ensure that the parents’ voice is heard regarding their child’s treatment. 4.14 Greater access to maternity liaison forms might have allowed the clinicians to better understand the risk and vulnerability of a child under their care. Whilst UHSFT did not know the domestic violence background, nor Ryan’s recent alcohol related offending, they would have known of the historic substance misuse concerns which would have painted a fuller picture than Freya’s disclosure offered. The introduction on Badgernet should improve this, as well enabling inter-trust maternity information sharing. The effectiveness of this should be reviewed when the system is established and operating. 10 https://www.safe4me.co.uk/wp-content/uploads/2018/10/CYP-strategy-2017-01-update.pdf PSCB Rapid Child Safeguarding Practice Review – Freya Final Report 13 Recommendation 5 UHSFT should ensure that paediatric clinicians have access to parental information, such as maternity liaison forms, so they can properly assess children’s vulnerability when making clinical decisions or decisions to discharge. 4.15 Hannah’s GP have no record of hearing about the pregnancy, birth and discharge. The discharge letter is on the hospital system as being sent but it remains unclear why it was not received by the GP. Recommendation 6 The GP surgery, PHUT and UHSFT should review their systems to ensure notifications of pregnancies, births and discharges are sent and received as expected and to establish whether this is a case specific issue or whether other patients are affected too. To explore the arrangements which support handover of care during the ante and post-natal periods between NHS trusts, especially when one or more trust is out of the Portsmouth area. 4.16 The referral from PHUT to UHSFT was clinically appropriate given Freya’s gastroschisis but it does not seem to be underpinned by any holistic process to ensure that all the relevant information about expectant mothers and their unborn babies is shared. 4.17 For example, in this case the historical information regarding Hannah’s previous alcohol and drug misuse, which was captured at her midwifery booking, was not passed on to the UHSFT and were only picked up by UHSFT when they responded following the rejected MASH referral. They then raised their own Maternity Safeguarding Liaison form but this was not subsequently passed on to the clinicians. This meant that when Freya was admitted to PAW and the surgical ward in late August, Hannah’s assertion that there was no current or historical substance misuse was accepted as there was nothing to cross check this against. These concerns are addressed by Recommendations 1, 2 and 5 and should be resolved by Badgernet. 4.18 It appears also that Solent NHS were similarly not informed of the previous substance misuse until the rejected MASH referral was followed up. This is also addressed by Recommendation 2. 4.19 Despite PHT referring Hannah to UHSFT for Freya’s gastroschisis to be managed, it seems PHT midwifery were unaware as they escalated Did Not Attend (DNA) episodes to safeguarding. They also did not know that her antenatal care and the birth would be led by UHSFT. They were oblivious that Hannah was attending PAH very regularly and that they had no concerns. 4.20 There did not seem to be any protocols between the two trusts to ensure relevant information was shared when patients are referred for tertiary treatment. The review was told that there are arrangements when a formal referral is made but not, it seems, when transfers of care happen through these less formal routes. Badgernet should ensure that all relevant information is shared and all those previously providing services notified. This is also addressed by Recommendation 1. To examine the effectiveness of new birth and post-natal visiting and care arrangements, especially when one or more on the trusts involved is out of the Portsmouth area. 4.21 From the information provided, Solent NHS, who provide the Health Visiting Service in Portsmouth were aware of Hannah as the health visitor was quick to congratulate her on Freya’s birth and was in regular phone and text contact with her during the hospital stay. PSCB Rapid Child Safeguarding Practice Review – Freya Final Report 14 4.22 It was not possible for PHUT to undertake a new birth visit as is standard, given that Freya was still in hospital for the first six and a half weeks of her life. Given that, responsibility fell on Solent NHS to undertake the new birth visit. This was very much on the health visitor’s radar while Freya was in hospital with attempts to predict when she might be discharged and therefore a visit possible. When she was discharged various appointments were made with the health visitor and cancelled by Hannah. The effect of this was that the health visitor never did visit Freya and therefore never saw her or Hannah in their home setting. 4.23 After the neonatal contact the HV was not afforded the opportunity to discuss previous or current concerns with Freya, the conversations being of a more general nature to arrange a birth visit. Despite efforts, there was no appropriate opportunity to continue conversations around safe sleep after discharge from hospital. 4.24 Whilst it would be easy to point to the Covid pandemic for the reasons the post-natal care was not as continuous as it would otherwise be, it seems it was more connected with Freya’s extended hospital stay coupled with Hannah cancelling appointments or not returning calls. Every effort was made but thwarted. Good Practice Point 1 The tenacity of the health visitor on keeping in touch with Hannah while in hospital and seeking to visit her on discharge was impressive. Whilst she did not have all the information regarding Freya’s vulnerability, the health visitor was determined to keep in touch, notwithstanding less enthusiasm from Hannah. To examine the Portsmouth safeguarding referral arrangements and the threshold for MASH decision making. 4.25 The PSCP Safeguarding Children Procedures11 are accessible, clear and compliant with national standards and expectations. They are easy to use and have clear appendices on Threshold Guidance12 and the Inter Agency Referral Form13. 4.26 Section 3.2 of the procedures links to “Principles and Guidance for Secondary and Tertiary Health Care When a Child Is Not Brought or Misses an Appointment.14” This relates to missed ante-natal appointments (DNAs), as well as post-birth consultations. 4.27 This document suggests that referring episodes of “Was Not Brought” (WNB) to social care through the Inter Agency Referral Form should be in cases where there is “high concern due to a persistent pattern of non-attendance or non-engagement, on-going medical or mental health condition and/ or known parental mental ill health, drug or alcohol misuse or domestic abuse or known looked after child or subject to child in need (CIN) or child protection (CP) plan.” There are a number of suggested steps for the professional to go through before making the referral including discussing with the health visitor, school nurse, or other professionals. 4.28 Unsurprisingly the MASH referral was returned for the referrer (in this case PHUT midwifery) to undertake further enquiries as to the reasons for the DNA. It was at this point they became aware that Hannah had been attending her appointments in Southampton. Had they been aware of this the situation would have been better understood, professionals’ time saved and the impact of multiple clashing appointments on Freya and her unborn baby considered in a more appropriate fashion. PHUT acknowledge that they would not have made the referral had they have known this. 4.29 The previous domestic abuse history was not revealed during the PHUT information 11 https://hipsprocedures.org.uk/ 12 https://hipsprocedures.org.uk/assets/clients/7/PSCP%20Threshold%20Document%20v5%20March%202021.pdf 13 https://hipsprocedures.org.uk/okyyzl/appendices/threshold-documents-and-inter-agency-referral-forms 14 https://hipsprocedures.org.uk/assets/clients/7/Child%20and%20Family%20Engagement%20Guidance%20for%20secondary%20and%20tertiary%20care%20March%202017.pdf PSCB Rapid Child Safeguarding Practice Review – Freya Final Report 15 gathering process following the referral nor was the GP informed. The former is understandable as the referral was not at the threshold which would have permitted wider information sharing. The latter is more concerning as, in all cases, information should be sought from primary care. The GP might have had health or social information that would add to the safeguarding considerations. They did not but that was not known nor checked. Recommendation 7 The PSCP should assure itself that the information gathering and sharing processes between partners, when completing a referral, are thorough and inclusive so, where permitted, relevant information is gleaned and shared with others following each and every request so that risk-based decisions and interventions can be considered, backed by all available information. To explore the effectiveness of policies and protocols related to patients who ‘do not attend’, children who ‘were not brought’ to health appointments and around disguised compliance during the ante and post-natal periods. 4.30 The PHUT process for prospective mothers who miss midwifery appointments is clear and escalates effectively from telephone calls through to hand delivered letters. This was followed but notification of the third DNA to the GP and to the Named Midwife, as set out in the Safeguarding Procedures for Safeguarding, did not happen. This suggests that staff are unfamiliar with the process and the levels of information gathering expected before onward referrals are made. Engaging the Named Midwife for Safeguarding and the GP might have highlighted more opportunities and possibly even that Hannah’s care had been transferred. Recommendation 8 PHUT should ensure all professionals understand the maternity DNA escalation procedure for mothers who miss midwifery appointments so they engage with appropriate safeguarding and primary care colleagues before making a MASH referral. 4.31 In terms of Hannah’s disengagement from health visiting, Solent NHS Trust’s Guideline15 is clear and seems to have been broadly followed. The difficulties the health visitor had in engaging Hannah were discussed at regular supervision. As it was clear Hannah was taking Freya to regular appointments in Southampton, the Guideline did not need to be instigated. 4.32 Health visiting is not a mandatory service so if Hannah said she did not want it or a home visit, the health visitor would have strived to make other arrangements such as meeting in a family hub, albeit these were closed due to Covid. Hannah’s refusal might have triggered some concern but as it is not statutory to engage; ultimately the choice lies with the parents. The Guideline has been updated around new birth visits now, so if the health visitor has not been able to engage or visit they would escalate their concerns. To examine the Healthy Child Programme Health Visiting thresholds in operation in Portsmouth, the status' of 'Universal / Universal +' as used by health visitors (including the criteria for escalation or step down through these), what they mean in practice and whether partners have a good understanding of what this looks like. 4.33 The Healthy Child Programme16 has four stages: Universal, Universal Plus, Universal Partnership Plus and Enhanced Health Visiting Offer (ECHO). 4.34 At birth, due to her medical condition, Freya was under Universal Plus, which is defined as short term targeted response for specific concerns and provides: 15 Guideline for Family Disengagement & Children Not Brought for Appointments - Children’s Service Solent NHS Trust 16 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/167998/Health_Child_Programme.pdf PSCB Rapid Child Safeguarding Practice Review – Freya Final Report 16 • Extra support with breast feeding • Evidence based programmes for behaviour, post-natal depression, attachment, sleep programmes, healthy eating and exercise • Targeted parenting programmes such as Parent Child Game • Lifestyle interventions such as for smoking or oral health • Additional interventions for infants and children with developmental delays • Help to access other support or information to reduce social isolation and improve interactions for children 4.35 By the 1 October 2020, Freya had been stepped down to Universal, which is defined as routine family health assessment and delivery of the core healthy child programme and provides: • Antenatal visit • New birth visit • 6-8 week maternal mood screen • 9 – 12 month developmental review • 2 – 2.5 developmental review • Offer to attend child health clinic and breast-feeding groups • Text messaging and website access to service 4.36 The health visitor had yet to see Freya by this point, and she had relatively recently been discharged from hospital having been readmitted following what appears to have been a discharge against clinical preference, and with incomplete information. 4.37 Freya was on Universal Plus due to being in hospital for her gastroschisis and Hannah requiring additional support. When Freya was discharged, she was moved to Universal seemingly for that reason, although the rationale was not documented. The new Guideline says that if the health visitor cannot visit the family in their home for a new birth visit they cannot now be stepped down. In this case Covid would have prevented the visit but Hannah was not engaging anyway. The review was told that she should not have been stepped down and would not in the future. It was suggested that had the health visitor been able to visit then Freya may have been escalated rather than stepped down, given what is now known. To explore the knowledge and understanding of Sudden Unexpected Death in Infants (SUDI) risk factors among professionals and how these influence assessment and decision making. To examine the nature, range and effectiveness of information and support provided to parents and carers, by health and social care agencies, around co-sleeping and reducing the risk of SUDI. 4.38 In the Child Safeguarding Practice Review Panel thematic report, ‘Out of Routine: A Review of Sudden Unexpected Death in Infancy (SUDI) in Families Where the Children are Considered at Risk of Significant Harm (2020)17’, a range of pre-disposing risk factors were identified in the forty notified cases. These are in keeping with the well-established evidence base for the risk factors associated with SUDI: • Unsafe sleep position (prone or side) 17 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/901091/DfE_Death_in_infancy_review.pdf PSCB Rapid Child Safeguarding Practice Review – Freya Final Report 17 • Unsafe sleep environment: –co-sleeping in the presence of other risks (including bed sharing), overwrapping, soft sleep surfaces • Tobacco exposure • Alcohol and drugs (during pregnancy and when co sleeping) • Poor post-natal care - late booking and poor ante natal attendance • Low birth weight (< 2.5kg) and preterm birth <37 weeks’ gestation) 4.39 Whilst this case involved all of these factors, professionals were aware of just the final two as, so far as they knew, Freya no longer drank, did not smoke or take drugs and did not co-sleep or expressed a desire to do so. As previously explained, it was not possible for the health visitor to see the home environment and therefore get a sense of whether Hannah and Ryan smoked, drank, took drugs and what the sleeping arrangements were, although she would have seen a cot (albeit cluttered) had she been able to access. She was also unable to have detailed remote conversations around this too as the bulk of the phone calls were to do with planning for Freya’s discharge to arrange the new birth visit. 4.40 During a remote ante natal visit by the health visitor in June 2020, Hannah was anxious about post-delivery and they advised her on the best sleeping position for the baby and that the safest place was for the baby to sleep in a room with their parent/carer for the first six months. They also spelt out the risks associated with co-sleeping, advised around no hats in the house as the baby would overheat and on bedding. The notes also say she was signposted to electronic resources, but it does not indicate which. 4.41 When Freya was discharged in August 2020, UHSFT recorded they discussed safe sleep in some detail with Hannah. Both the Neo Natal ward and the health visiting service say that the notes reflect that Freya’s heightened vulnerability was recognised, hence the detailed discussions they had. They also say that professionals impressed on Hannah that Freya was in a higher risk category than the general population so the advice they were giving was particularly pertinent. 4.42 Applying Figure 1, further information would have placed the family in the middle category (Predisposing vulnerability and risk) and on the night Hannah died, into the bottom category (Situation risks and out-of-routine incidents). Applying the proposed ‘prevent and protect practice model for reducing the risk of SUDI (Figure 2), there are a range of recommendations for working with parents of children with heightened risk. These seem to have been applied in this case. Figure 1 Source - Child Safeguarding Practice Review Panel Report, ‘Out of Routine’ (2020). PSCB Rapid Child Safeguarding Practice Review – Freya Final Report 18 Good Practice Point 2 The recognition of SUDI risk factors that were known (accepting some had not been shared) was strong and the bespoke advice and guidance given to the mother was clear to the extent that she could recall it when interviewed by the police. 4.43 In 2019, Southampton LSCB (now Safeguarding Children Partnership) published a thematic review on co sleeping deaths18. This examined four deaths, two of which were also reported as serious case reviews. In that review, the four deaths were compared against recognised risk factors similar to the Out of Routine Report (Figure 3). Freya is added for comparison. 4.44 This shows Freya to be more vulnerable on the night she died than the other babies, the difference being that given the lack of information, social care and non-universal provision in this case many of those factors or risks were unknown in this case. 4.45 Hannah said that she was aware of the risks of co-sleeping and had been told not to do it but as her friends did, so did she. She described how she would usually sleep with Freya. Ryan said, as far as he was aware Freya was in her cot and it was rare for them to co-sleep. Hannah admitted consuming alcohol and cannabis on the night. Ryan said their alcohol consumption was modest and neither consumed drugs. Despite the varying accounts, what is clear is that Hannah heard and understood the safe sleep messaging and chose to co sleep anyway. 4.46 The Southampton review noted from a 2017 US study19 that all mothers in one focus group admitted to bedsharing even though they knew the risks. In this study they cited exhaustion as being the reason but equally there could be other drivers for parents to make this choice in the face of advice. Figure 2 Source - Child Safeguarding Practice Review Panel Report, ‘Out of Routine’ (2020). 18 Southampton LSCB Thematic Review on Co Sleeping Deaths (2019) 19 https://web.wpi.edu/Pubs/E-project/Available/E-project-121217-163202/unrestricted/WPI_Infant_Sleep_Safety_CPSC_17_Report.pdf PSCB Rapid Child Safeguarding Practice Review – Freya Final Report 19 Figure 3. Source Southampton LSCB Thematic Review on Co Sleeping Deaths (2019) 4.47 Co-sleeping is common-place, even widespread in many cultures, so the universal message regarding safe sleeping should reflect unsafe co-sleeping rather than co-sleeping per se. In the Out of Routine report, all the cases reviewed unsurprisingly involved co-sleeping but nearly all also involved drugs or alcohol. The risk factors are episodic and contextual so while in this case, Hannah’s friends had reported co-sleeping and presumably did so with no adverse effects on their babies, unlike Hannah they may not have had any predisposed or situational risks. If the messaging is universal and does not focus on heightened risks, parents could compare their sleeping arrangements with others and see no problem, not recognising the differences. 4.48 It seems that in this case the extra risk was recognised hence the more focused guidance. The Safeguarding Children Procedures gives clear messages too20. Given the Covid restrictions on visiting, UHSFT did not give the same messages to Ryan and did not seek to do so subsequently. On reflection it would have been better if they had so there would be a common understanding between both parents of the risk and how to avoid them so they could support and regulate each other. To examine the impact of organisational and operational change as a consequence of the Coronavirus pandemic on the provision of health and social care in the ante and post-natal periods. 4.49 All but the first two months of the period under review took place during Covid restrictions, most of it during the first lockdown when services and the whole population were coming to terms with an unprecedented pandemic and the arrangements to stem its spread. 20 https://hipsprocedures.org.uk/qkypxo/children-in-specific-circumstances/safe-sleep-for-babies-and-infants. Risk Factor Reece Child A Child B Billy Freya Not in a cot by parents’ bed X X X X X Sleeping with baby on a sofa X Sharing with a smoker X X X X Sharing with person who has consumed alcohol X Sharing with person who has taken drugs (legal or illegal) X Parents in low socio-economic groups X X X Parents currently abuse alcohol or drugs X Young mothers with more than one child X Premature infants and those with low birthweight X X X X PSCB Rapid Child Safeguarding Practice Review – Freya Final Report 20 4.50 Surprisingly, the organisational impact this brought was not considered to have affected Hannah’s and Freya’s services in any significant way. There were staffing shortages across all sectors due to shielding but, in the main, the services Hannah accessed operated as normal. The only exceptions were that staff were unable to see parents together, so missed the opportunity to observe the dynamic they would normally see and health visits were remote, but as Hannah stopped engaging this was not a factor. Portsmouth had closed all family hubs so there were no drop-ins but, again, Hannah had disengaged so probably would not have used them in any case. To examine the nature and quality of bereavement support offered and/or provided to parents in the period following a SUDI, including in cases when parents are under investigation for alleged criminal offences. 4.51 Given Hannah and Ryan did not wish to engage with the review, it was not possible to speak to them around the bereavement support they received following Freya’s death. Whatever their suspected criminal culpability, Hannah and Ryan have suffered an unimaginable loss and their grief may well be aggravated by a real sense of guilt given the police investigation, necessary as it was. 4.52 The Joint Agency Response minutes of 23 October 2020 and 9 November 2020 reveal a decision that the police Family Liaison Officer21 (FLO) act as the Keyworker for the family. The SIO confirms that contact has been maintained but at this stage, how that has been received by the parents cannot be judged. The GP had also written offering support but received no reply. 4.53 The Bereavement Support Manager at PHUT says they have had no contact from Hannah and Ryan and she was barred from contacting them due to the investigation. 4.54 The Child I Serious Case Review (PSCP 2020)22 highlights the lack of clarity over staff contacting parents under investigation to provide them bereavement support. The Lullaby Trust provides advice on how to offer support23 but not where there is a criminal investigation ongoing. There appears to be no guidance on this so parents are left in limbo to grieve alone with no professional support other than through the FLO whose independence they might doubt. Recommendation 9 Hampshire Constabulary and NHS providers involved in the Joint Agency Response Procedures should develop guidance to allow parents of children who have died unexpectedly to receive appropriate independent bereavement support in a way that does not adversely affect the criminal justice processes but also recognises their need for support. To consider any equality and diversity issues (e.g. age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief, sex and sexual orientation) that appear pertinent to the family and any consequent service provision. 21 https://profdev.college.police.uk/professional-profile/family-liaison-officer-flo/ 22 https://www.portsmouthscp.org.uk/wp-content/uploads/2020/07/Child-I-report-V8-Final-for-publication-1.pdf 23 https://www.lullabytrust.org.uk/bereavement-support/family-and-friends/ PSCB Rapid Child Safeguarding Practice Review – Freya Final Report 21 4.55 Throughout the analysis for this review there was nothing identified to indicate that Freya, Hannah or Ryan received a differential or detrimental service based on any equality factors. Unfortunately, as Hannah and Ryan chose not to speak with the review, their perspective on this remains unknown. 5. Conclusion 5.1 It is clear from this tragedy that health providers recognised Freya’s increased risk of SUDI and provided enhanced one to one guidance to Hannah to impress on her the heightened vulnerability. 5.2 However, the information sharing arrangements between and within acute trusts and from the police had shortcomings which meant there was confusion as to who was leading on services for Hannah, a lack of information about her alcohol and substance misuse and incidents of alcohol related violence and domestic abuse not being shared. Had the information sharing arrangements been clearer and applied, professionals elsewhere in the system would have had a fuller understanding of the environment Freya was being discharged into and might have engendered additional support to safeguard her. 5.3 The impact of Covid restrictions meant that only Hannah, not Ryan, was given safe sleep guidance, and that was regrettable, but given she understood it there were no omissions or errors which had they not have occurred, would have prevented Freya dying. However, had agencies worked together there might have increased vigilance which might have encouraged safer sleeping arrangements, which might have led to a less tragic outcome. PSCB Rapid Child Safeguarding Practice Review – Freya Final Report 22 Appendix A – Schedule of Recommendations Recommendation 10 That PHUT and UHSFT assure themselves that the introduction, roll out and use of Badgernet supports and promotes information sharing so that referrals are documented, visible and communicated to appropriate professionals. Also that the outcome is available to the referring department, and any other clinical services the patient is currently under, so that continuity of care is clear and primary responsibility assured. Recommendation 11 PHUT ensure that when referring patients to any service, whether within or out of the Trust, they include all information regarding that patient, especially such that might suggest an increase safeguarding risk or heightened vulnerability for the child or parent(s). Recommendation 12 Hampshire Constabulary, as part of the Child Centred Policing programme, ensure all officers understand the purpose and importance of sharing information through the PPN/1 process which might indicate that children or vulnerable people are, or could be, at risk especially when that information indicates substance misuse or violent behaviour by parents and/ or carers. Recommendation 13 Solent NHS Trust and UHSFT should assure themselves that the communication pathway between acute and community services in respect of babies under one year who are being treated in an acute setting is effective. This should ensure improved information exchanges regarding shared patients/ service users so as to provide better continuity of care and ensure that the parents’ voice is heard regarding their child’s treatment. Recommendation 14 UHSFT should ensure that paediatric clinicians have access to parental information, such as maternity liaison forms, so they can properly assess children’s vulnerability when making clinical decisions or decisions to discharge. Recommendation 15 The GP surgery, PHUT and UHSFT should review their systems to ensure notifications of pregnancies, births and discharges are sent and received as expected and to establish whether this is a case specific issue or whether other patients are affected too. PSCB Rapid Child Safeguarding Practice Review – Freya Final Report 23 Recommendation 16 The PSCP should assure itself that the information gathering and sharing processes between partners, when completing a referral, are thorough and inclusive so, where permitted, relevant information is gleaned and shared with others following each and every request so that risk-based decisions and interventions can be considered, backed by all available information. Recommendation 17 PHUT should remind professionals of the maternity DNA escalation procedure for mothers who miss midwifery appointments so they engage with appropriate safeguarding and primary care colleagues before making a MASH referral. Recommendation 18 Hampshire Constabulary and NHS providers involved in the Joint Agency Response Procedures should develop guidance to allow parents of children who have died unexpectedly to receive appropriate independent bereavement support in a way that does not adversely affect the criminal justice processes but also recognises their need for support. PSCB Rapid Child Safeguarding Practice Review – Freya Final Report 24 Appendix B – Schedule of Good Practice Good Practice Point 3 The tenacity of the health visitor on keeping in touch with Hannah while in hospital and seeking to visit her on discharge was impressive. Whilst she did not have all the information regarding Freya’s vulnerability, the health visitor was determined to keep in touch, notwithstanding less enthusiasm from Hannah. Good Practice Point 4 The recognition of SUDI risk factors that were known (accepting some had not been shared) was strong and the bespoke advice and guidance given to the mother was clear to the extent that she could recall it when interviewed by the police. |
NC52464 | Thematic review of cases involving serious non-accidental injuries and death of three babies aged 6-10-weeks-old in 2018, focusing on common issues regarding non accidental injury to babies whose parents are teenagers or young adults. Learning themes include: the importance of recognising parents as children/recently children themselves; the need for comprehensive assessment of parenting skills and risk to the unborn baby; the importance of support for young parents. Recommendations include: ensure that professionals working with young parents are aware of the need to recognise that in the first instance parents under 18-years-old are children themselves; wherever possible the life history of fathers, including their own childhood experience of parenting, needs to be documented and shared with all professionals involved in working with young, vulnerable parents; police to continue to recognise that domestic abuse can occur in teenage relationships; police officers attending incidents of domestic abuse where children are present should be reminded of the crucial importance of professional curiosity; consider reviewing as a matter of urgency the appropriateness and safety of the service currently provided to young parents and babies living in supported housing accommodation; ensure that the seriousness and significant risk of substance and alcohol misuse on the ability of young parents to care for and safeguard their baby/child is fully understood by all professionals; agencies to be made aware that where a baby is not registered with a GP Practice by the time of their six week developmental check professionals need to consider this as a safeguarding concern.
| Title: Serious case review: overview report: a thematic review concerning the non-accidental injury of Three Infant Children. LSCB: Southampton Safeguarding Children Partnership Author: Moira Murray Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 | P a g e Serious Case Review Overview Report A Thematic Review Concerning the Non-Accidental Injury of Three Infant Children Lead Reviewer Moira Murray November 2021 2 | P a g e Contents Page No Introduction 3 Who were the three babies? 3 Serious Case Review Process 5 Scope and Terms of Reference 5 Analysis Issues 6 Developing a picture of the lives of: Baby Connor, Baby Danny and Baby Ethan 6 Key themes and analysis of practice 20 Key Learning Arising from the Review 36 Good Practice 38 Conclusion and Recommendations 38 - 40 Appendix 1 Scope and Terms of Reference for the Review Appendix 2 The Process of the Serious Case Review Appendix 3 The Serious Case Review Author/Lead Reviewer 41 44 46 3 | P a g e 1. Introduction 1.1.1 On the recommendation of the Serious Case Review Group, a decision was taken in March 2018 by the Independent Chair of the Southampton Safeguarding Children Board (hereafter referred to as the Southampton Safeguarding Children Partnership) to commission a Serious Case Review into the death of one baby and serious injuries to two others. All three cases were considered individually by the Serious Case Review Group, which decided that they met the criteria for Serious Case Review under Working Together 20151. 1.1.2 All the babies were male and at the time of the injuries and death, were aged between 6 to 10 weeks. Because there were similarities in the age and background of their parents, and due to all three incidents occurring within a two-month period, in order to maximise the opportunity for learning and improvement of professional practice, it was decided that it would be appropriate to consider all three cases together. Purpose 1.1.3 This Serious Case Review2 is a thematic review with an analysis of common issues concerning non-accidental injury to babies whose parents were teenagers or young adults. The review is presented as one report, which will also include an assessment of particular circumstances pertinent to each individual case. 2. Who were the three babies? Circumstances leading to the commissioning of this Serious Case Review 2.1.1 For the purposes of anonymity, the three babies subject to review are known as: • Baby Connor • Baby Danny • Baby Ethan 2.1.2 Baby Connor was born in December 2017 and died at the age of six weeks in February 2018. 2.1.3 At the time of Baby Connor’s death, he was living with Mother in a flat, which was part of a supported, independent living unit for parents and babies. It was not a Mother and Baby Unit and was not staffed 24 hours a day. Partners were allowed to visit 3 nights a week, however it is known that Father may have been residing at the flat with Mother. The Unit where Baby Connor was living was well known to Police because of concerns about residents engaging in parties, drug and alcohol use and anti-social behaviour. 1 All three incidents occurred in January or February 2018. 2 Known as Child Practice Safeguarding Reviews, Working Together 2018 4 | P a g e 2.1.4 Police were called by ambulance staff attending Baby Connor early in the morning of 11 February 2018. On arrival Baby Connor was not breathing and paramedics were undertaking CPR. Bruising was noted to his legs and arms, but primarily to his thighs and under his arms. Baby Connor was taken to Southampton General Hospital but was declared deceased. A post-mortem examination found that he had suffered bilateral and complex fractures to the skull, as well as other fractures to his leg and collar bone. 2.1.5 On 21 December 2018, Father was convicted of murder and sentenced to life imprisonment. Mother was convicted of child cruelty and sentenced to 30 months imprisonment. Father was aged 17 at the time Baby Connor died and Mother was 19 years old. 2.1.6 Baby Danny was born in October 2017. When he was 10 weeks old, on an evening in early January 2018 Police were contacted by Children’s Social Care Out of Hours Service to inform them that they had been called to attend Southampton General Hospital. Baby Danny had been brought into the hospital that morning by ambulance. Father reported that he had given Baby Danny his feed early in the morning and shortly afterwards he had struggled to breath and became floppy. 2.1.7 On arrival at hospital Baby Danny was no longer floppy and presented as a well-baby, however further examination revealed swelling to the fontanel, which indicated swelling to the brain. A CT scan revealed bi-lateral retinal haemorrhaging and a subdural hematoma. There were no other signs of external injuries. 2.1.8 Prior to his birth Baby Danny was subject to Child Protection Planning under the category of neglect. He was deemed to be at risk of significant harm due to concerns in relation to Mother’s mental ill heath, self-harm, volatile behaviour and unpredictability. 2.1.9 Baby Danny is now placed with foster carers on a Special Guardianship Order. The CPS decided that no charges should be brought against his parents. 2.1.10 Baby Ethan was born in October 2017. In January 2018, when he was 10 weeks old, he was taken to the GP Surgery by his parents. During a medical examination, Baby Ethan was found to have bruises and marks all over his body (25 in all). These injuries were considered to be non-accidental. Police and Children’s Social Care attended the surgery and Mother and Father were arrested. 2.1.11 On arrival at Southampton General Hospital, in addition to the bruising, a skeletal survey revealed that Baby Ethan had suffered fractures to the proximal and distal metaphyses of the left tibia. 5 | P a g e 2.1.12 On discharge from hospital Baby Ethan was placed with foster carers. His parents were charged with causing or allowing serious injury to a child. Father was convicted of this offence and was sentenced to a term of imprisonment. Mother was acquitted. 3. The Process of the Serious Case Review 3.1.1 The Terms of Reference, purpose, methodology for the review and details of the Lead Reviewer can be found in Appendices 1 - 3. Practitioner Event 3.1.2 A practitioner event was held on 3 April 2019. Prior to arranging the event, the Police and Crown Prosecution Service were contacted to ensure that by holding such an event any outstanding criminal proceedings would not be compromised. Confirmation was received that the event could proceed, and 20 practitioners attended. The purpose of the event was to consider key questions and themes arising from the review and to provide an opportunity for those attending to reflect on events, professional practice and to assist the Lead Reviewer in forming her analysis of the issues arising from this case. 3.1.3 The event proved helpful to the Lead Reviewer and the consensus from those attending was that it proved useful and beneficial to their understanding of the cases and events leading to the death and serious injury of the three babies. 3.1.4 The Lead Reviewer would like to express her thanks to all those who attended the event and who contributed to this Serious Case Review. Most especially, the assistance provided by the Southampton Safeguarding Partnership support staff, which ensured that the event and the review process as a whole was smooth, efficient and professional. 3.2 Scope and Terms of Reference 3.2.1 The full Terms of Reference and Scope for the Review can be found at Appendix 1. 3.2.2 The time period under review for each child is: Baby Connor: 11/05/2017 -11/02/2018 Baby Danny: 10/03/2017 – 6/01/2018 Baby Ethan: 4/04/2017 – 10/01/2018 3.2.3 The start date for each review is the date the Mother’s pregnancy became known to agencies. The end date is the date of the death/injury to the child. 6 | P a g e Analysis issues 3.2.4 This review will consider the issues that could have a bearing on the circumstances of these cases and will include: • Support offered to young parents • Assessment of parenting skills and risk to the unborn baby • Impact of mental health issues, self-harming behaviour and substance misuse on parenting capability • Impact of lack of good parenting experiences on young parents • Impact of homelessness • Anger management and domestic abuse • Robustness of decision making concerning the child protection process • Evidencing of the child’s lived experience within the family • Over optimism on the part of professionals as to the parents’ capacity to care • Involvement of Police and Criminal Justice. 3.3 Involvement of the Families 3.3.1 Statutory Guidance: Working Together to Safeguard Children (2015), requires that families should be invited to contribute to a Serious Case Review. Southampton Safeguarding Children Partnership informed the families in October 2018 that a Serious Case Review was being undertaken. Only Baby Danny’s parents met with the Lead Reviewer. Due to the Covid Pandemic the meeting took place virtually in November 2020. The meeting proved helpful to the review and the views of the parents are reflected in the report. The Lead Reviewer would like to thank the parents for taking the time to meet with her and for talking about Baby Danny. Developing a picture of the lives of Baby Connor, Baby Danny and Baby Ethan 4.1.1 The purpose of this section of the review is to provide a background history of each baby and his parents. Key events for each child are included and evidence of their lived experience within the family. Relevant information concerning the background of each family, which falls outside the period under review is also included. 4.1.2 The information included in the report is taken from documentation provided by agencies participating in the review. Baby Danny is an exception, as when interviewed, his parents provided their views to the Lead Reviewer on the way in which agencies worked with them, as well as some additional information concerning themselves and Baby Danny. The views of Baby Danny’s parents are reflected in the sections of the report concerning this child. 7 | P a g e Baby Connor Mother 4.1.3 It is believed that Baby Connor’s parents had been in a relationship when Mother was almost 17 and Father was just 16. When she became pregnant, Mother was living at home with Maternal Grandmother and her two younger siblings. Maternal Grandmother was supportive of the pregnancy. 4.1.4 There had been some previous concerns about Mother, however, Children’s Social Care’s main focus of involvement was with Mother’s younger sibling, who had special needs. 4.1.5 When Mother was 12 years old, she attended the Emergency Department (ED) having taken an overdose following an argument with Maternal Grandmother. She was admitted overnight and assessed as not having mental health concerns. Six months later, in April 2012, Mother attended the ED again. She was drunk and was admitted overnight. A safeguarding proforma was completed by the hospital and having been assessed by a paediatrician and CAMHS, Mother was discharged. 4.1.6 In April – June 2014 Mother was not attending school due to bullying and low self-esteem and there was also concern that she may have been subject to grooming for the purpose of Child Sexual Exploitation. This was investigated by Children’s Social Care and Maternal Grandmother gave assurance that this was not the case. A Strategy Discussion took place, but no further action resulted. 4.1.7 Children’s Social Care was contacted by ED staff in March 2016, when Mother and Father were admitted with smoke inhalation following a house fire at Paternal Grandmother’s flat, whilst she was not in attendance. They escaped serious injury having been rescued by firefighters. At the time of her admission to hospital, it was noticed that Mother had a large bruise to her upper left arm and multiple bruises to lower legs. When asked about the bruising Mother said she couldn’t remember how it had happened and that all was fine. Maternal Grandmother expressed her concern about the relationship with Father. 4.1.8 Mother’s relationship with Father was volatile and there were concerns that she was subject to domestic abuse. Police had recorded three incidents in 2016 which were domestic abuse related involving Mother and Father. They were all recorded as verbal domestic arguments and a Child and Young Person Report (CYPR), safeguarding notification was submitted on each occasion. 4.1.9 In 2017, Maternal Grandmother and the family were an open case to Children’s Social Care. This was because of concerns about the significant special needs of Mother’s 13 year old sibling, and had at times been violent towards herself and Mother. 4.1.10 When she was 7 weeks pregnant Mother booked for midwifery care and it was recorded that it was “an unplanned pregnancy but happy, Boyfriend supportive, will live at home.” (Source: Primary Care IMR). Due to the age of the parents, care 8 | P a g e was completed by East NEST (Needing Extra Support Team) and a referral was made to both the Family Nurse Partnership (FNP) and the Hospital Maternity Safeguarding Team. During the antenatal period there were no missed appointments and no concerns were raised concerning Mother’s presentation or appropriateness at appointments. Father was present for some of the antenatal appointments. Mother was said to be emotionally well during pregnancy and in the postnatal period. 4.1.11 In August 2017, the first visit was undertaken by the Family Nurse. At the time Mother and Father were living with Maternal Grandmother, her stepfather and siblings. Children’s Social Care had supported a referral to housing for Mother to secure her own accommodation, because of the risk presented to Mother and her unborn child from her sibling. The FNP recorded excellent engagement by Mother throughout her pregnancy and both she and Father appeared to be excited about the baby, had prepared well for the arrival, showed good insight into the risks that Mother’s younger sibling might pose and was keen to secure her own accommodation, although they were also aware that this was a ‘big step’. (Source: Solent NHS Trust) 4.1.12 By mid-November 2017, Mother was residing at a supported accommodation unit for young parents. Father was noted to be considering an apprenticeship. In mid-December two appointments with the Family Nurse were cancelled and when a meeting did take place in January 2018, 4 days after Baby Connor’s birth, at the parents request, it was in a café. It was known by the Family Nurse that Father was residing at the young parent accommodation unit. 4.1.13 During the following weeks until the death of Baby Connor, the Family Nurse attempted six visits, but only managed to gain access to him and the parents on three occasions. The last visit taking place just over a week before he died, by which time the family had moved to another supported, independent living unit for parents and babies. Visits were cancelled by Mother, or the Family Nurse could not gain access to the property, nor could contact be made with Mother by phone. When the Family Nurse did gain access, no concerns were recorded about Baby Connor’s care. During the last visit, it was noted that Mother was tired, Baby Connor was more unsettled at night and that there was decreased contact with Maternal Grandmother. By the time he was 6 weeks old Baby Connor had not been registered with a GP. Father 4.1.14 There was a long history of involvement by statutory agencies with Father and his family. Father and his siblings had been subject to Child Protection Plans for emotional and physical abuse and were under a Public Law Outline (PLO) process for a number of years. There were also concerns about neglect. Paternal Grandmother had a history of alcohol and substance abuse, with periods of severe intoxication, as well as being subject to domestic violence. 9 | P a g e 4.1.15 Father’s school attendance was poor, and his behaviour became increasingly violent when he reached adolescence. He was referred to CAMHS in 2017 but was not considered to meet the criteria for the provision of service. 4.1.16 Until the death of Baby Connor, Father had no previous convictions. However, Police were in receipt of nine incidents concerning Father from January 2017 until February 2018. These concerned reports of criminal damage at Paternal Grandmother’s home, (which was reported to the Multi-Agency Safeguarding Hub (MASH) on 23/01/2017); domestic disputes between Father and Paternal Grandmother, and between Father and Mother; being present when Mother was assaulted by her sibling, being under the influence of alcohol and substance misuse, noise complaints and aggressive behaviour whilst staying at the independent living unit for parents and babies. 4.1.17 There was a notification of Father being involved in an aggressive incident, 6 days after Baby Connor’s birth, when Police were called to Southampton General Hospital because of his behaviour towards ambulance staff. Father was under the influence of prescription drugs at the time. Baby Connor’s lived experience within the family 4.1.18 Baby Connor was born in hospital without complication. Mother had attended antenatal appointments and the parents were said to be excited about his birth. Whilst Mother engaged with midwifery appointments and the FNP when living with Maternal Grandmother, this began to deteriorate once she moved out of the family home. During the first weeks of his life Baby Connor lived with Mother in supported accommodation unit for mothers and babies. Father visited regularly and was staying overnight. 4.1.19 Whilst at this supported unit, Mother and baby were not considered to be at risk and, following the completion of the unit’s ‘My Safety and Support Plan’ Mother and Baby Connor moved to an Independent Living Unit, which offered less support to parents. Once there, Mother began to fail to attend review sessions and concerns began to be raised with staff by other residents about arguments between her and Father. 4.1.20 Little is known about the quality of Baby Connor’s short life. When the Family Nurse visited in late January 2018 Mother was described as ‘slightly tearful’ due to tiredness as Baby Connor had not slept for two nights. Father had been staying over to offer support. Money was a problem, as appropriate benefits had not been received and the FNP issued a ‘Basics Voucher’. The Family Nurse noted that Father handled Baby Connor well, was gentle and caring and supported his head appropriately. There is, however, no description available to the review of whether Baby Connor was well fed and dressed, or whether he was generally a contented baby. The review has learnt that is it not usual for a Family Partnership Nurse to record such information, as only concerns about a baby’s care is noted. (NB Practice has changed since the review was commissioned). 10 | P a g e 4.1.21 When the Family Nurse made her last visit before Baby Connor died, she noted that Mother said he was becoming more unsettled at night and she was increasingly tired. Mother reported that a complaint had been made by another resident about the noise from her flat and that she was having decreased contact with Maternal Grandmother. 4.1.22 By this time, Baby Connor was five weeks old, but had not been registered with a GP. There is no information available as to whether Baby Connor’s six to eight-week check had been arranged, nor whether it was questioned as to why he had not been registered with a GP. 4.1.23 At the end of January 2018, Police Officers attended an incident which concerned another resident at the unit. It was during the arrest of this resident that the officers were told that Baby Connor had been seen with blood coming from his mouth. Banging and shouting was heard coming from Mother’s flat. Mother requested that Father leave, which he did at the request of the officers. The flat appeared clean and tidy and no further concerns were reported. Although Father was arrested, he was then de-arrested and returned to the accommodation. Unfortunately, the concerns expressed by the resident about Baby Connor seen bleeding from his mouth were not investigated at the time by the attending officers. See Para 5.1.20. 4.1.24 At the practitioners event, information was shared that on the night that Baby Connor died, there had been a party involving drugs and alcohol. There had been an argument between Mother and Father relating to jealousy, which resulted in domestic violence and then violence to Baby Connor. 4.1.25 At the criminal trial of both parents, distressing evidence was given of the injuries which Baby Connor suffered and the actions resulting in his death. Father confirmed that he had taken ecstasy and drunk vodka and lager shortly before his son’s death. 4.1.26 The picture which emerges from the limited information available about Baby Connor’s short life is one of domestic arguments between young and inexperienced parents, living in an environment where alcohol and drugs were prevalent. Little is known about his day to day experience, but given the toxic mixture of immature parents, limited engagement with professionals, substance misuse and violence, Baby Connor was a vulnerable child who was seriously at risk of harm, which tragically resulted in his violent and painful death. Baby Danny Mother 4.2.1 Mother was 18 years old when Baby Danny was born. 4.2.2 When she was 10 years old, Maternal Grandmother died. Mother had experienced a traumatic childhood. She was placed with Maternal Great Grandmother, until 2013 when Mother became a Looked After Child by another authority. Mother had 11 | P a g e numerous foster care placements and was first admitted to hospital when she was 12 years old, because of self-harming behaviour, which was to continue throughout her teenage years. Concerns began to emerge about Mother being at risk of Child Sexual Exploitation. Mother was placed in secure accommodation and subsequently admitted to a hospital for children with mental health needs. 4.2.3 Mother became known to Police, in the main for assaulting care staff and serious self-harming behaviour. As a Looked After Child she had experienced 35 different placements. Mother was sectioned under the Mental Health Act, 1983, on numerous occasions because of the serious risk she presented to herself, as a result of extreme self-harming behaviour 4.2.4 In March 2017 a referral was made to Southampton Children’s Social Care from the Children’s Services Care Leavers Team in the local authority where Mother had been looked after. Mother was now residing in Southampton having been recently discharged from hospital having been Sectioned under the Mental Health Act. She had been diagnosed as having a personality disorder, complex PTSD which manifested itself through flashbacks, dissociative episodes, feelings of hopelessness, low mood, anxiety and suicidal thoughts. Mother was in the early stages of pregnancy. 4.2.5 Mother had met Father via the internet. Within 8 weeks of knowing each other, Mother became pregnant, and they had moved in together. Mother was seen by midwifery services in March 2017, where further concerns were raised about her being overweight, cannabis use, cigarette smoking and high alcohol consumption. Mother was on medication for her mental illness, which was reviewed throughout her pregnancy. It was noted on the midwifery assessment form that Father had mental health and substance difficulties. Mother was referred to the Specialist Midwife. (Source: Solent NHS Trust Scoping document). 4.2.6 There were also concerns about the condition of the accommodation in which the parents were living. 4.2.7 On 24 November 2020, the parents met with the Lead Reviewer and when asked whether she had any anxieties or fears about being pregnant, Mother agreed that she felt frightened about having a baby. ‘She didn’t feel she was ready for a baby but as the pregnancy progressed, she started to feel ready for it.’ Mother explained that she had only just left care when she found out she was pregnant with Baby Danny. Given her experience of being a Looked After Child, Mother did not trust Children’s Social Care to become involved with her pregnancy. 4.2.8 Prior to and throughout her pregnancy, the Care Leavers Team was involved with Mother and visited her and Father regularly. They were also part of the Child Protection and Discharge Planning Meetings. During the meeting with the Lead Reviewer, Mother explained that at this time she was having to learnt to trust different people in a way that she had never done so before. Mother said she had moved to Southampton to live with Father and had been asked by Children’s Services to register with a new GP Surgery and request a referral for local Perinatal Mental Health Services. Mother told the Lead Review she had done so but was told that she did not 12 | P a g e meet the criteria for the service. At a Child Protection Conference, Mother said it was inferred that she refused to go to the GP to seek this referral. 4.2.9 The Lead Reviewer asked if Mother had challenged this suggestion, and Mother explained that she ‘struggled with communication at the time and when she did manage to communicate it probably did not come across in the most articulate way.’ Mother went on to say that she felt she was never really listened to by professionals and that she was seen as argumentative rather than trying to make a point. Mother told the Lead Reviewer that she was ‘a lot calmer now and has worked on her communication.’ 4.2.10 In May 2017 Mother attended the Emergency Department because of self-harming behaviour, however, she did not stay to be seen and Father said he was dressing the wound at home. A week later, the Family Nurse undertook a recruitment visit and was advised by Mother that she had not self-harmed recently. 4.2.11 In June 2017, Mother and Father came under the care of the FNP. Mother was expressing anxiety about her ability to care for the baby. Concerns were also noted about the condition of the flat. It was considered that Mother was engaging well with the FNP. Mother was referred to the Perinatal Mental Health Team by the midwife. 4.2.12 In the first two weeks of July the Family Nurse visited Mother at home. Father was at work. Mother said she found it difficult to get up and walk around the flat before 3pm. The flat was described as cluttered and untidy. At the second visit the flat was described as cluttered, and Mother was smoking heavily. The Family Nurse noted concerns that Mother was struggling to meet her own needs and questioned the level of support needed after the baby was born. She planned to follow up with the Social Worker. 4.2.13 In mid-July the Perinatal Mental Health Team visited Mother at home. It was concluded that there was nothing that could be additionally offered, which was not already being provided by the FNP. 4.2.14 At the end of July 2017, an Initial Child Protection Conference (ICPC) decided that the unborn baby should be subject to a Child Protection Plan. A Legal Planning Meeting was held, which recommended: further perinatal assessment, non-negotiable mental health assessment of Mother and a capacity to care assessment of the parents. 4.2.15 The GP informed the Social Worker in early August 2017 that the Adult Mental Health Team would not consider Mother appropriate for their service as she had already been seen by Perinatal Mental Health Team, who had concluded that she was not mentally ill. The Social Worker made a telephone call to the Perinatal Mental Health requesting that Mother was offered support, as had been recommended in the parental assessment, however, the response was that this could only be offered if Mother was deemed to be mentally ill during her pregnancy. 13 | P a g e 4.2.16 Although Mother engaged well with the FNP, during the later stages of her pregnancy, there appears to have been little contact with Father, who was working. Toxicology tests relating to mother proved negative for alcohol and substance misuse. Mother had also stopped smoking. Child Protection visits were undertaken, and home conditions were considered ‘good enough.’ At a Core Group meeting in September 2017, the parents advised that Paternal Grandmother would be staying with them for two weeks after the baby was born to support with his care. 4.2.17 Baby Danny was born by emergency caesarean section in October 2017. He spent 4 days on the neonatal unit for observation as he was showing signs of withdrawal and was jittery, potentially as a result of Mother’s mental health medication. 4.2.18 Following Baby Danny’s birth, midwifery staff were concerned that Mother was regressing to childlike behaviour and was not caring for herself. There were also concerns about her high level of dependency on Father and what would happen when he returned to work. During the meeting with Baby Danny’s parents and the Lead Reviewer, Mother denied this was the case. 4.2.19 On 30 October 2017, a discharge planning meeting was held. Concerns were raised about the hostile manner in which the parents communicated with staff and there was also a report of a smell of cannabis in Mother’s room, which the parents denied. This was something which the parents also strenuously denied when they met with the Lead Reviewer. At time Mother agreed to a toxicology text, the results of which were negative. Father was not tested. 4.2.20 It was noted at the planning meeting that Mother and Father were responding well to Baby Danny and Father was caring for him overnight as Mother was drowsy due to medication. Because of Mother’s mental health, Father was allowed to stay with her and Baby Danny overnight3. 4.2.21 Baby Danny was discharged to his parents care on 30 October 2017, on the basis of them signing a contract of expectations drawn up at the Planning Meeting. The contract stipulated that Mother was not to have unsupervised contact with Baby Danny and that Father was to be the main carer. It also stated that professionals would visit every day for the first two weeks. From information provided to the review, it is not known who the professionals were, nor whether the visits took place. A Family Group Conference was to be arranged and pre-proceedings plans were to commence. A further assessment of Mother by the Perinatal Team was to be undertaken to assess risk. Father gave up his job to care for Baby Danny. 4.2.22 When meeting with the Lead Reviewer, Father stated that ‘he thought it was outrageous that professionals expected him to be awake 24/7. He felt he couldn’t go to the toilet unless he took Baby Danny with him and felt that it was unmanageable for him to have eyes on 24/7 as he needed to sleep.’ Mother agreed that it put ‘unnecessary strain on Father and that he had to give up work pretty much overnight’. Both parents considered they had no choice but to sign the agreement if Baby Danny was to come home with them. They explained that Father was earning a good wage 3 The Trust occasionally allows partners to stay overnight, where mothers are experiencing difficulties. 14 | P a g e and once he began caring for Mother and Baby Danny, the family faced severe financial difficulties. They had to wait six weeks for benefit payments to come through and were reliant on the Family Nurse who organised a food parcel from the local church. The Support Worker from the Care Leavers Team also gave them a voucher for a food bank. 4.2.23 The Lead Reviewer asked Baby Danny’s parents whether the allocated Social Worker was aware of their financial situation at that time. Both said that the Social Worker told them to ask Paternal Grandmother for financial assistance and said that ‘they needed to make ends meet or Baby Danny wouldn’t be allowed to go home with them.’ Mother explained that this came across as ‘threatening.’ Father said he had some holiday pay owed to him but both parents had to borrow money to ensure they had a roof over their heads and to pay for gas and electricity. They had to ask ‘family for help to get nappies, baby milk and food as Christmas presents.’ 4.2.24 A Child Protection Review Meeting in mid-November 2017 was not quorate and the Social Worker was not in attendance. It was noted at the meeting that Mother became agitated when holding Baby Danny and that Father was responsible for the entirety of the baby’s care. A Home Visit and Core Group Meeting at the end of November 2017 decided that the parents were showing signs of good parenting. They appeared to be ‘providing good enough care to Baby Danny and were attentive and responded to his cues.’ Baby Danny remained subject to a Child Protection Plan, and PLO and Family Group Conference procedures. By this stage Father was not working and there had been a breakdown in the relationship between his brother and partner, which meant the support offered to Father by the couple in caring for the baby whilst he had some respite was no longer available. Financial pressures were also recognised, given that Father was now the main carer. 4.2.25 Until 6 January 2018 when Baby Danny was injured, visits by the Family Nurse and Social Worker continued. He was brought to his 6 week check with the GP and on Christmas Eve 2017 was taken to the Emergency Department when the parents were worried about him being unwell following his immunisations and that his head had a ‘sunken soft spot’. On examination no concerns were noted, and the parents were reassured. 4.2.26 The Family Nurse last saw Baby Danny on 27 December 2017, when he was alert, kicking and had been fed. His fontanel appeared normal. Father 4.2.27 Father was 27 at the time of Baby Danny’s birth. Little information is available about Father’s background. He was working at the time he and Mother met and claimed to be a paramedic. It is known that he lied about this. Prior to moving in together into privately rented accommodation, Father was facing homelessness. Father was seen to be supportive to Mother during her pregnancy and cared for her when she had episodes of self-harm. At the practitioners event it was stated that no assessment was undertaken of Father and his suitability to care for a baby (and for Mother). 15 | P a g e 4.2.28 Apart from what was registered at the time Mother had her midwifery assessment, there is no information available concerning Father’s mental health. Some concerns have been noted as to the relationship between the parents. Following Baby Danny’s injury and removal from his parents, the Care Leavers Team shared with mental health services that Mother was considering moving to a refuge due to Father’s controlling and coercive behaviour. Mother also stated that Father was disappointed that the baby was not a girl, as ‘he likes young girls’ and that he had girlfriends aged 14/15 before he met Mother. This information was shared with police. 4.2.29 Prior to being arrested for the injury to Baby Danny, Father had no previous allegations or convictions against him. Baby Danny’s lived experience within the family 4.2.30 Baby Danny was born at full term via emergency caesarean section. His weight was within normal parameters. No concerns were noted by the Family Nurse when she visited him and the parents for the first time in hospital, after his birth. 4.2.31 When meeting with the Lead Reviewer, Father described Baby Danny as ‘fantastic.’ Mother said ‘he was so easy that she worried she was doing something wrong. He was so tiny that she was initially terrified. Mother felt she was being constantly watched in hospital and everything she did with Baby Danny seemed to be wrong. When they got home, everything was so much better. Father explained that ‘Baby Danny loved cuddles, he loved holding him and he was a little bundle of joy. Baby Danny made him smile and he would sit and cuddle him. Baby Danny was so easy to look after’. Mother commented that she felt ‘a lot of judgement from her family about her holding the baby too much’. 4.2.32 When Baby Danny returned home it was on the premise that Father would be supervising his care 24 hours a day. Initially, Father’s relatives were offering support with his care and consideration was given at the Family Group Conference in early November 2017 as to who, from the wider family, would be able to care for him if his parents could not do so. Three extended family members attended this meeting. 4.2.33 The new birth visit by the Family Nurse found that all appeared ‘normal’. Baby Danny had good tone and reflex and was feeding well. Mother was gaining confidence and appeared gentle and caring. Father was doing the night feeds as Mother was not waking, because of her medication. 4.2.34 A home visit a week later in mid-November by the Family Nurse found Baby Danny thriving and Mother caring for him in a gentle manner, with support from Father. Baby Danny was also being cared for one day a week by Father’s brother’s partner. This was a recommendation of the Family Group Conference and was with a view to the couple being assessed to offer future overnight care to Baby Danny. This arrangement broke down after a family disagreement. 4.2.35 The home conditions in which Baby Danny spent the first weeks of his life were described as ‘cluttered and untidy’, but good enough. Finances were a problem, given 16 | P a g e that Father had resigned from his job, but apparently plenty of baby clothes and equipment had been bought in preparation for his birth. 4.2.36 It is known that often the curtains were drawn in the flat and Mother did not like to leave the property. Thus, unless Baby Danny was taken out by Father, he spent most of his days inside the flat with his parents. When speaking with the Lead Reviewer both parents denied that his was the case. 4.2.37 By the end of November 2017, Mother told her Personal Adviser from the Care Leaver’s Team that she was very happy, that Baby Danny was making a squeaky noise when he was happy and was sleeping better at night time. She was taking her medication and not self-harming. 4.2.38 Given Mother’s history of self-harm, mental illness, trauma, alcohol and substance misuse and her lack of experience of positive parenting herself, it was more than optimistic that at the age of 18 she would be able to protect and care for her baby. The reliance on Father as a 24 hour a day, 7 day a week carer for Baby Danny, whilst also having to supervise Mother, was unrealistic. Such a task would have been difficult, if not impossible for most new parents, however, given the lack of background information concerning Father, particularly knowledge of his own childhood experiences, the risk of Baby Danny being at risk of significant harm was greatly increased. Baby Ethan Mother 4.3.1 In March 2016, when Mother was 15, a referral was received by Children’s Social Care after she disclosed being hit by Maternal Grandmother following a verbal argument. Mother’s attendance at school was poor. At this time Mother was living with Maternal Grandmother, Stepfather and her younger sibling who was disabled. 4.3.2 In November of the same year, a further referral was made to Children’s Social Care by the school as Mother was refusing to return home and was living with Father’s family. 4.3.3 By February 2017, Mother was 16 and was known to be pregnant with Baby Ethan and in May 2017, Children’s Social Care allocated the case for a single assessment of the unborn baby. Following the single assessment, a S.47 investigation was recommended. During this time, Mother was living with Father and his extended family. 4.3.4 In June 2017, Mother and Father moved to live with Maternal Grandmother. Shortly afterwards, Father moved back to Paternal Grandmother’s home and it was said that the relationship with Mother was over. By September 2017, the parents were back together. 17 | P a g e 4.3.5 A pattern developed throughout Mother’s pregnancy and after Baby Ethan’s birth of the parents moving between Maternal and Paternal Grandmother’s home. At the time of Baby Ethan’s injuries, he was living with his parents in a flat, the tenancy of which had been secured with the help of Paternal Grandmother. 4.3.6 During her pregnancy Mother was booked for maternity care with the Needing Extra Support Team (NEST). Regular visits were undertaken by the same NEST midwife and on the whole Mother’s attendance at antenatal appointments was good. A referral was made to the FNP by midwifery staff in early April 2017. The Family Nurse managed to complete 8 antenatal visits to Mother, Father was present at 3, and 3 home visits postnatally, at which Father was present at one. There was a lack of engagement with the FNP by both parents and at times it was apparent that when they were living with Paternal Grandmother, she would falsely deny that Mother was available when the Family Nurse telephoned. 4.3.7 During her pregnancy Mother presented to hospital on five occasions for reduced foetal movements. Although nothing abnormal was found, on one of these occasions when she attended a hospital outside Southampton whilst visiting Paternal Grandfather, staff raised concerns about Father smelling of cannabis. A referral was made to Children’s Social Care and a professionals meeting was convened in September 2017. 4.3.8 Following the professionals meeting in September 2017, when concerns were also expressed about the parents lack of engagement with agencies, and their capacity to deal with the needs of a new born baby, an Initial Child Protection Conference (ICPC) was recommended. 4.3.9 The ICPC in October 2017 decided that Child Protection Planning was not required, and a Child in Need Plan was agreed. This was on the basis that Mother stated she was no longer in a relationship with Father. The case was allocated to a Student Social Worker and the FNP was involved. After Baby Ethan was born in October 2017, Mother took her own discharge on 31 October, against medical advice. Clinicians wanted her to remain in hospital to monitor her and baby. 4.3.10 There was a lack of engagement with agencies including the FNP by Mother following Baby Ethan’s birth. He was not brought for his 6 week check and hearing test. By the end of November, it was known that Mother was back with Father, whom it was believed influenced her contact with agencies. Concerns were raised by Children’s Social Care about this development and a single assessment was to be completed with the likely outcome that the case would return to ICPC. 4.3.11 During December 2017, Mother did not return calls from the Student Social Worker and Baby Ethan was not seen until 22 December. A Duty Social Worker made a home visit to Paternal Grandmother’s home. Home conditions were described as good and Baby Ethan was seen and appeared well, although asleep for most of the visit. 4.3.12 The next time Baby Ethan was seen by a professional was 10 January 2018, when he was brought to the GP Surgery. 18 | P a g e Father 4.3.13 Prior to Mother becoming pregnant with Baby Ethan, Father and his family were known to Children’s Social Care and Police. 4.3.14 Father was 15 years old when Mother became pregnant with Baby Ethan. 4.3.15 In 2012 Father suffered a brain injury following a road traffic accident. This had left him with anger management problems, which at times resulted in him displaying aggressive behaviour. School attendance was poor and Children’s Social Care was aware that Father had caring responsibilities for his stepfather, Paternal Grandmother’s partner, who was terminally ill. 4.3.16 In January 2017, when Father was 15, the school, which both he and Mother attended contacted Police as neither had attended school since the beginning of December 2016. Father and Mother were later found at Paternal Grandmother’s home and had been hiding in the loft when teachers had previously visited. Mother was living at the address. 4.3.17 Police were called to Paternal Grandmother’s address in February 2017 when Father was threatening Paternal Grandmother with a knife and threatening to harm himself. Father had been drinking, which had exacerbated his behaviour. A referral was made to Children’s Social Care. A single assessment was completed in April 2017, which identified Father taking on caring responsibilities for Paternal Step-Grandfather, poor school attendance, self-harm and lack of care provided by Paternal Grandmother. Father was made subject to a Child in Need Plan. 4.3.18 Following Father’s brain injury, attempts were made by CAMHS to identify specialist services for his condition, however he did not engage. 4.3.19 In September 2017, Children’s Social Care closed Father’s case (as a Child in Need) due to non-engagement. However, other agencies continued to be involved because of Mother’s pregnancy. Baby Ethan’s lived experience within the family 4.3.20 It was reported by the Midwifery Team at a discharge planning meeting following Baby Ethan’s birth that Mother was coping well with him. The parents were not together, but Father and Paternal Grandfather had visited. Following their discharge, Mother and Baby Ethan lived with Maternal Grandmother. Mother was seen by the Family Nurse and was said to be loving and caring towards Baby Ethan. He was alert and starting to smile, formula feeding well and thriving. At this time Mother was engaging with professionals. 4.3.21 Once Paternal Grandmother provided the means for Mother and Father and Baby Ethan to live independently, unsupported in private rented accommodation, contact with professionals deteriorated and monitoring of Baby Ethan proved increasingly difficult. Mother cancelled a visit by the Family Nurse at the beginning of November 19 | P a g e 2017 and two further visits were met with no reply. Baby Ethan was seen by the Family Nurse on 15 November 2017 and was noted to be smiling and appeared well. 4.3.22 Access was gained by the Family Nurse on 28 November 2017 when both parents and Baby Ethan were present. Mother was handling Baby Ethan with care, but Father became angry when contraception was discussed. 4.3.23 By mid-December 2017 the Family Nurse escalated her concerns with the Student Social Worker and with the Named Nurse for Safeguarding that the baby had not been seen for three weeks. A further visit was attempted, but although the Family Nurse could hear a baby crying there was no reply. 4.3.24 Children’s Social Care had experienced similar problems to the FNP in gaining access to Baby Ethan and were planning to undertake a single agency assessment with a view to proceeding to an ICPC. Baby Ethan was not brought for his 6 week check with the GP and neither was he brought for two hearing test appointments. (He was subsequently discharged from the service). On 13 December 2017, the GP was very worried about Baby Ethan missing his 6 week check and informed the Student Social Worker of these concerns. 4.3.25 A Duty Visit was arranged by Children’s Social Care after contact from the GP, the Family Nurse and the Safeguarding Midwife had all raised concerns about Baby Ethan not being monitored. The first visit was not successful and Maternal Grandmother was told that Police would be requested to assist if the baby was not seen. 4.3.26 On 22 December 2017 a Duty Social Worker gained access to Baby Ethan at Paternal Grandmother’s address. Home conditions were described as good, Baby Ethan was sleeping but appeared well. The Family Nurse attempted two home visits after this visit, but without success. 4.3.27 By 8 January 2018 Children’s Social Care decided that the case required progression to ICPC. However, on 10 January 2018 the GP contacted the Student Social Worker to say that Baby Ethan had arrived for his 6 week check, now 4 weeks late, and was seen with bruising, thought to be Non-Accidental Injuries (NAI). The GP considered that baby Ethan could wait for child protection medical, however the Team Manager insisted that an ambulance was called to transport Baby Ethan to hospital. The Police also arrived at the Surgery and arrested both parents. 4.3.28 On arrival at hospital, Baby Ethan was found to have 25 bruises to his body and a broken tibia in two places. 4.3.29 The age, immaturity and volatile nature of the parents relationship put baby Ethan at risk of significant harm. The lack of engagement and refusal to allow access by professionals to their baby meant that little was known of what life was like for Baby Ethan whilst in his parents care. When he was seen, it was said that he was well cared for and thriving. However, these occasions were very much dependent on the parents and members of both extended families agreeing to allow Baby Ethan to be seen. It is disturbing, that Mother and Father brought Baby Ethan to his delayed 6 week check when he had sustained substantial bruising and a broken tibia. Whether they 20 | P a g e considered that the injuries would raise professional concern is not as yet known, however, it is fortunate that Baby Ethan was seen and the risk of him sustaining further injury was eliminated. 5 Key Themes and Analysis of Practice 5.1.1. At the time the Southampton Safeguarding Children Partnership made the decision to commission a thematic Serious Case Review, it was apparent that there were a number of significant similarities in the three cases. These can be summarised as: • All were young parents • All had experienced childhood trauma and/or Adverse Childhood Experiences • All the babies were male and of White British ethnicity • All three babies had received significant injuries, which resulted in the death of one child • All of the incidents occurred within the same two-month period • At least one of the parents of each of the children had exhibited violent behaviour in the past • Alcohol and cannabis misuse featured in all three cases • All the young parents had experienced homelessness 5.1.2 Having reviewed the information provided and constructed a narrative, it is evident that there are a considerable number of key themes emerging from this Serious Case Review, which are important to the improvement of practice. This section of the review will consider each of the themes in turn and will comment on professional practice at the time. The importance of recognising parents as children/recently children themselves 5.1.3 Recent research4 shows that the brain continues to develop through childhood and adolescence, even into the late 20s and 30s in some brain regions. White matter increases, grey matter decreases. These changes are thought to be caused by important neurodevelopmental processes that enable the brain to be moulded and influenced by the environment. When a risk is taken the brain’s positive reward system gets activated. In adolescents, that activation is higher during risk taking than in adults. 5.1.4 These findings are particularly important when considering the events which led to the serious injuries sustained by these three very young babies. In all of the cases the parents engaged in risk taking activities, for example alcohol and substance misuse, risk of sexual exploitation and lack of stable accommodation. In the case of Baby Connor his parents were living in accommodation where parties, alcohol and drug use were prevalent features of the lives of the young parents living in the unit. 5.1.5 It is important for professionals to be aware of research findings concerning the workings of the adolescent brain if an informed understanding is to be developed and 4 Blakemore Sarah-Jayne Inventing Ourselves: The Secret Life of the Teenage Brain, 2018 21 | P a g e maintained of the additional risk posed to young parents themselves and, more importantly to their babies and children. 5.1.6 It is also important for professionals to consider adolescent decision making with regard given to the Mental Capacity Act, 2005. The Act states clearly that mental capacity does not mean a young adult needs to make good decisions and indeed should be permitted to make decisions, even if others feel such decisions are not in their best interests. However, when a young adult is caring for another child as their parent safeguarding procedures will always be paramount in any decision making made by professionals. 5.1.7 Such findings are of particular significance when considered in light of the vulnerability, immaturity and limited life experience of all of the parents of the three babies. This is evidenced by the following: • In two of the three cases the mother of the baby was a child herself when she became pregnant and in the third, the mother of Baby Danny, had only just reached 18. • The fathers of the children, with the exception of Baby Danny’s father, were under the age of 18. Baby Connor’s father was 16 and in the case of Baby Ethan, Father was 15 when Mother became pregnant and had been a Child in Need himself until a month before Baby Ethan was born. • All of the mothers, and from what is known, two of the fathers, had experienced difficulty at school and their attendance had been poor. Given the number of placements Baby Danny’s mother had as a Looked After Child, together with her admissions to psychiatric hospital, with the resulting disruption to her education, it is surprising, and to her credit that she was literate. • Two of the mothers had engaged in self-harming behaviour and in the case of Baby Danny’s mother she had experienced a traumatic childhood prior to becoming a Looked After Child, which was further compounded by having 35 placements and being Sectioned under the Mental Health Act, 1983 on three occasions. • The susceptibility of the parents to child exploitation featured in two of the three cases. Baby Connor’s Mother was thought to be at risk of child sexual exploitation whilst at school and the mother of Baby Danny had been subject to sexual exploitation and violent sexual assault, not least because of her vulnerability due to her mental ill health. • Although support was offered to the mothers throughout their pregnancy by midwives and the FNP, the reality of giving birth at such a young age and becoming a parent when still a child, can be and is a difficult, traumatic and frightening experience. It is not clear from the information provided to the review that this was fully explored with the mothers. 22 | P a g e • Baby Connor’s parents expressed excitement on learning that they were going to have a child, however, the consequences of looking after a baby independently, in accommodation with limited support, proved to be tragic for Baby Connor and for his parents. • Prior to the birth of Baby Danny, Mother had displayed childlike behaviour and after his birth midwifery staff were concerned about Mother holding onto a comfort blanket when she required treatment following a caesarean section. Whilst recognising that Baby Danny’s Mother had suffered significant trauma for most of her life, her experience as a young person of giving birth and the aftermath of having a caesarean section cannot be underestimated. The concerns of the midwifery staff on the postnatal ward were shared and known by professionals prior to Mother and Baby Danny being discharged from hospital, they went home. • The heightened anxiety which can be experienced by a young, pregnant mother was illustrated by baby Ethan’s mother attending the Emergency Department on five occasions, fearful that she could not feel a foetal heartbeat. Whilst anxious and concerned about her unborn child, once Baby Ethan was born, Mother ceased to engage with professionals, to the detriment of her baby’s health, wellbeing and safety. 5.1.8 All of the above highlights the need for professionals working with young teenage parents to recognise that in the first instance they are children themselves. This is not always easy, given the difficulty, which is so often encountered when attempting to engage with young people. However, this review has attempted to illustrate that if this fundamental principle is not embedded in professional practice the risk to the babies and children of young parents is severely heightened and can lead to tragic consequences. The need for comprehensive assessment of parenting skills and risk to the unborn baby 5.1.9 In none of the three cases is there evidence of comprehensive assessment of parenting capability and the risk presented to the unborn baby. 5.1.10 In the case of Baby Connor, no assessment was undertaken of either parent by Children’s Social Care. The focus of social work involvement was on Mother’s younger sister who had special needs. There had been referrals prior to Mother’s pregnancy to Children’s Social Care about Mother’s lack of school attendance, risk of child sexual exploitation, and in 2016, contact had been made by hospital staff from the ED when both Mother and Father were admitted with smoke inhalation following a house fire. None of these resulted in an assessment, although information from Solent NHS suggests that Mother was an open case to Children’s Social Care (see below para.5.1.15) 5.1.11 Baby Connor’s Maternal Grandmother had said that she would offer support to her daughter and given the involvement of the FNP, it seems to have been assumed that 23 | P a g e an assessment by Children’s Social Care was not required. This decision was made in the knowledge that the family was well known to statutory agencies, with Father and his siblings having been subject to Child Protection Plans in the past, due to neglect. At the time Mother became pregnant, Paternal Grandmother and her children were an open case to Children’s Social Care. Paternal Grandmother had a history of alcoholism, substance misuse and suspected drug dealing. It was known that Father was Mother’s partner and the father of her unborn child, but there was no sharing of these concerns between the Social Worker for Paternal Grandmother and the FNP. 5.1.12 Both Father and Paternal Grandmother were well known to Police. When Police attended Paternal Grandmother’s home, a Child and Young Person Report (CYPR, subsequently replaced by PPN1) was submitted on each occasion. The incidents included arguments between Mother and Father, excessive alcohol consumption on the part of Paternal Grandmother and Father, and violent behaviour between Paternal Grandmother and Father. 5.1.13 Whilst Police Officers attending these incidents followed procedure by submitting CPYRs/PPN1s, there was “no assessment of the recent history nor family context and an apparent lack of understanding as to why they were submitting a PPN1……..an ongoing theme with PPN1s is that officers are frequently assessing incidents in isolation and not considering the context when assessing risk or considering exactly what the actual risks are…..There is also the potential that officers are not considering older teenagers as children at risk.” (Source: Police IMR) 5.1.14 When Baby Connor’s Mother was first seen by midwives at the antenatal booking in June 2017, social risk factors were noted, and a concerns form was sent from the Community Midwife to the Maternity Safeguarding Team. However, it was not reviewed by the Maternity Safeguarding Team until mid- September 2017. The reason for the delay is not documented. It was at this booking that a referral was made to the FNP. 5.1.15 Further information was requested by the Maternity Safeguarding Team from Children’s Social Care in September 2017. This showed that the case was open because of the special needs of Mother’s sibling, but the Team Manager had requested that Mother’s case be closed. Information concerning Father was shared with midwifery, which should have been recognised as increasing the risk to the unborn baby. A referral to MASH should have been considered but this did not happen. The recommendation from the Maternity Safeguarding Team was for Mother to remain under enhanced midwifery care, to offer an Early Help Assessment and to liaise with the FNP. However, the Early Help Assessment referral was not made. 5.1.16 Mother and Father were registered at different GP surgeries and no information was shared about Father’s childhood history between practices. The GP Practice for Mother was aware of the risk presented by Mother’s younger sibling and that it was initially proposed that Mother would reside at Maternal Grandmother’s home. There was however no exploration of the safeguarding risk presented to the unborn child or to Baby Connor had Mother continued to live at the family home. The GP knew that Mother was under the care of the FNP and there was little involvement with the Practice thereafter. 24 | P a g e 5.1.17 Information provided to the review from the FNP states that: “there is evidence of excellent engagement throughout the pregnancy with the Family Nurse. [Mother] and [Father] appeared to be excited about the baby, prepared well for the arrival, showed good insight into the risks that [Mother’s] younger sister might pose to her and her unborn baby and was keen to secure her own accommodation although aware this was a big step.” There is no information from the IMR of a formal risk assessment of parenting capacity or risk to the unborn baby undertaken by the Family Nurse. This is particularly concerning. Once Mother moved into her own accommodation and contact with the Family Nurse significantly decreased, Baby Connor was not monitored, he was not brought to appointments and was not registered with a GP at the time of his death. 5.1.18 The assessment made of Mother, when she was pregnant, for her suitability for admission to the supported accommodation unit, showed that the only risk identified was that of her younger sibling. No risks concerning Father were identified, however it is not known to the review as to what the assessment consisted of. Once resident at the unit, the ‘My Support Plan’ for Mother, used at the time, was completed by staff as there was no engagement by Mother. No information is available as to whether Mother’s non-engagement was questioned or whether it was usual practice for staff to complete a form on behalf of a mother. 5.1.19 Based on the assessment by the housing provider, Mother was deemed suitable to move to the independent living unit 18 days after she gave birth to Baby Connor, scoring the lowest possible risk score on the ‘My Safety and Support Plan.’ Once there, Mother attended three out of the five support sessions offered and at the last meeting in February 2018, before Baby Connor died on 11 February 2018, the arguments between Mother and Father were discussed. There is no indication that the risk to Mother and Baby Connor was considered to be increased because of the parents arguing. 5.1.20 There is no reference in the IMR submitted to the review by the provider of the supported Independent Living Unit, to Police visiting the Unit in January 2018 after 3am having received a complaint about noise involving another resident and Mother. Whilst investigating the incident, officers heard banging coming and shouting coming from Mother’s flat. Mother and Father were arguing, and Mother requested that Father left. A PPN1 was completed for Baby Connor and the DASH5 risk assessment completed with Mother. She answered no to most questions and therefore the incident was assessed as ‘standard risk’. It was during the arrest of another resident that the officers were informed that on two occasions Baby Connor had been seen with blood coming from his mouth. This disclosure was not investigated by the officers attending and is the subject of further investigation, by the Independent Office for Police Conduct (IOPC). 5.1.21 Information provided to the review explains that when one of the two officers attending the incident returned to the flat of Baby Connor’s parents to complete a domestic risk assessment with Mother, he found Father in the flat, holding Baby 5 DASH risk assessment: Domestic Abuse Stalking and Honour Based Violence used by Police 25 | P a g e Connor. Father was drunk and his behaviour argumentative. The Officer was concerned about how Father was holding Baby Connor who was crying. Father said: ‘he hadn’t done anything’ and thought the officer was implying he had hurt the baby. The Officer was not concerned for Baby Connor’s wellbeing and put Father’s behaviour down to inexperience. Unfortunately, none of this information was recorded in the PPN1, which with the information provided by the other resident about Baby Connor bleeding from his mouth was a significant omission. If this information had been included in the PPN1, it could have possibly resulted in a Grad A assessment by MASH (‘unexplained injuries or suspicious injuries to a child under 4) which would have resulted in a referral to the Child Abuse Investigation Team (CAIT). (Source: Police IMR) 5.1.22 The need for professional curiosity by Police Officers visiting premises because of domestic abuse, is paramount. The importance of careful exploration, documentation and the reporting of concerns is crucial if children are to be safeguarded. The incident detailed above required further investigation and was a missed opportunity. It is a lesson learned arising from this review and is reflected in Recommendation 3. 5.1.23 Throughout her life as a Looked After Child the mother of Baby Danny had been subject to assessment. The concerns about her mental health, history of severe self-harming behaviour, alcohol and cannabis misuse were well documented and known when Mother moved to Southampton within weeks of becoming pregnant. Once the pregnancy was confirmed as viable, a Social Worker from Southampton Children’s Social Care visited the offices of the local authority where Mother had been looked after to read their care records. Information was shared between the two local authorities. The care records were not reviewed by Social Workers subsequently involved in Baby Danny’s case, so it is not clear how much of this detail was known to them. 5.1.24 In July 2017, a Section 47 assessment was initiated which resulted in the convening of an ICPC. The outcome of the ICPC, was for the unborn Baby Danny to be subject to a Child Protection Plan, category neglect. Legal advice was taken at the meeting. 5.1.25 A report concerning Mother was presented at the ICPC by the South East Care Leavers Team, which included the following: 5.1.26 “I have concerns about Mother’s ability to parent a child and keep herself and a child safe…….. [Mother] will need to be assessed very carefully and fully assessed once the baby arrives to ensure [she] is able to meet the child’s needs and keep him safe. [Mother] will need to attend parenting workshops to ensure her child’s developmental needs are being met.” 5.1.27 In August 2017, a legal planning meeting followed the ICPC, which requested a further mental health assessment of Mother. A Review Child Protection Conference was due to take place at the end of October 2017 but was cancelled as Baby Danny arrived early. A pre-discharge meeting was held on 30 October, at which concerns were expressed by the South East Care Leavers Team about Mother being able to manage with a child, to which Mother nodded her agreement. 26 | P a g e 5.1.28 Concerns were also expressed by the midwife as to how Mother would manage a baby and the midwifery staff from the ward explained the difficulty in obtaining Mother’s cooperation with Baby Danny’s care, that she smelt of cannabis when returning from smoking outside, having left him without a blanket and he was cold. Mother disputed this, however the midwife attending the meeting advised that she had concerns about Mother being able to provide any care to her baby. 5.1.29 The decision to allow Baby Danny to be discharged home into the care of his parents was made on the basis of Mother signing a contract of expectations, confirming that she was not to care for Baby Danny without supervision from Father. Mother was not happy about this but signed the agreement. Children’s Social Care confirmed that further assessments would be completed in respect of Mother and Father, and that the legal planning process would continue. 5.1.30 However, it is evident that there was no further assessment undertaken of either parent’s ability or capacity to care for Baby Danny. Little was known of Father’s background. What is known is that he and Mother met on-line and within days of meeting, they were inseparable. Father lied about his profession, claiming to be a paramedic, and quickly assumed caring for Mother when she self-harmed. Yet he was deemed to be the protective factor for Baby Danny, having sole responsibility for his care and supervision. 5.1.31 Prior to Baby Danny’s birth and on his discharge from hospital, the Family Nurse recorded that the parents engaged well with the Programme. However, it is evident from the information provided to the Serious Case Review that there was a lack of comprehensive, informed assessment of the parenting abilities of Mother and Father. The Family Nurse was aware that Mother was not engaged with the Perinatal Mental Health Team; that there were serious concerns about whether Mother had ceased drinking and using cannabis; that she did not like to go out of the flat and thus Baby Danny remained inside with Mother; that there were financial pressures on the family due to Father giving up his employment to care for mother and baby and that Father was expected to supervise Mother and ensure that Baby Danny was not put at risk. 5.1.32 Whilst Mother did co-operate with a mental health assessment late in her pregnancy, with regular input thereafter from the Community Mental Health Team (CMHT), there is no documented evidence of liaison between the Family Nurse and CMHT, or the GP. It appears that the content of the CMHT assessments was not shared or discussed either at the Child Protection Conferences or outside of meetings in multi-agency liaison. It is questionable whether the Mental Health Worker was invited to the Child Protection Conferences as she did not appear on the list of attendees. 5.1.33 Given Mother’s history of chronic self-harm, mental illness, lack of parenting in her own childhood and recognition that she herself could not look after a baby, it could be argued that further assessment of Mother was not necessary to decide whether it was safe to discharge Baby Danny into her care. Given that so little was known about Father, for a decision to be taken at the pre-discharge planning meeting that he was a suitable parent, with the skills and capability to care for his child and supervise 27 | P a g e Mother, without an evidence-based assessment of him, was not only poor but also dangerous practice, which sadly proved to be the case when Baby Danny was found to have sustained a serious head injury. 5.1.34 In the case of Baby Ethan, no comprehensive assessment was undertaken of the parents ability to parent, nor was there an assessment of the risk posed to their baby. 5.1.35 Father had been subject to a Child in Need Plan a month prior to Baby Ethan’s birth, due to lack of school attendance and anger management issues as a result of a brain injury. An ICPC was convened in October 2017 because of concerns about the lack of agency engagement by the parents and questions about their ability to care for a new born baby. The decision was taken that as Mother was no longer involved in a relationship with Father, the case did not warrant a Child Protection Plan and was suitable for Child in Need procedures. 5.1.36 The case was then allocated to a student social worker. Given the known history of concerns about both Mother and Father, not least Father’s controlling and volatile mood and behaviour, greater consideration should have been given to an assessment of parenting ability, which also involved a comprehensive exploration of the relationship between Mother and Father. This required qualified social worker involvement and the case should not have been allocated to a student. The fact that Mother was living with Maternal Grandmother prior to Baby Ethan’s birth, whilst maintaining that her relationship with Father was over, meant that there may have been an element of complacency that the risk to the unborn baby was low. Insufficient consideration was given to the probability of the couple resuming their relationship, and what in turn, this meant for the safety and well-being of their child. The importance of support for young parents 5.1.37 The IMR concerning Baby Connor submitted to the review by the provider of the supported Independent Living Unit states that: “[Mother received support from a Family Nurse practitioner. She had no Social Services involvement. Our role was to assess [Mother] for housing and to provide her with suitable accommodation based on her tenancy readiness.….We do not provide parenting skills but support clients to access parenting skills where needed….Our staff did not raise any concerns relating to [Mother’s] parenting skills and [Mother] and [Father] appeared to be attentive and caring parents”. 5.1.38 This statement not only raises serious concerns as to the responsibilities and expectations of the housing provider to young parents, it also brings into focus the nature of the ‘support’ offered to the parents and by which agencies. It is evident from information submitted to this review, that there was a perception on the part of professionals referring young parents to this service provider that the support offered was more substantial than it was in reality. The unit in which Baby Connor’s mother was first placed was not a Mother and Baby Unit, with staff on duty 24/7. It was staffed during office hours, and limited support was offered. Once Mother moved into the Independent Living Unit, the support available was as described above in para 5.1.37. 28 | P a g e 5.1.39 The need for agencies to work together, as well as having a clear understanding of the context of the support offered and responsibility held by each agency for the safeguarding and well-being of young, vulnerable parents and their children, is a fundamental finding of this review. It is clear that there was a higher expectation of the provider by agencies using this facility of the care, monitoring and support available to young parents. 5.1.40 Whilst there was Children’s Social Care involvement in the lives of Baby Danny and Baby Ethan, there was none in the case of Baby Connor. There had been Children’s Social Care involvement with Baby Connor’s extended families, but once Mother was pregnant and after the baby was born, the only support which the parents received was from the FNP. 5.1.41 Information provided by Solent NHS Trust to the review, describes the FNP as follows: “The FNP is a voluntary home visiting programme, standard contacts are offered weekly for 4 weeks initially then fortnightly until the child is born. Then weekly contacts are offered for 6 weeks followed by fortnightly contacts until the child is 21months then monthly contacts until 24 months. FNP is structured - in that the tools it uses and the nature and number of visits is prescribed, based on years of research, evidence, successful implementation and constant evaluation - but it is also flexible. Within this structure, nurses deliver a highly personalised intervention based around the specific strengths and needs of each client. As part of FNP delivery facilitators which cover a wide range of topics including lifestyle and positive health changes, relationships, communication skills, medical information, life plans and goal setting, becoming a parent, focusing on the child’s care and development, cues and responsiveness are shared with clients (and partners if present) during contacts. These are kept by the clients for their own records and for them to use as a resource. [In the case of Baby Connor] these have not therefore been available to form part of this review within the SystemOne records. Family Nurse Partnership is a voluntary home visiting programme, by focusing on their strengths, FNP aims to enable young parents to: • Develop good relationships with and understand the needs of their child • Make choices that will give their child the best possible start in life • Believe in themselves and their ability to succeed • Mirror the positive relationship they have with their family nurse with others”. 5.1.42 During the course of their engagement with Baby Connor’s parents the two Family Nurse Partnership nurses involved in the case, assessed that they engaged well before and after the baby’s birth. An appropriate number of appointments were kept, until Mother moved to the Independent Supported Housing Unit. 29 | P a g e 5.1.43 No pre-birth referral to social care was felt necessary as both parents were considered to be making appropriate choices, engaging with services and showed good signs of preparing for their baby both emotionally and physically. 5.1.44 Mother was seen to be keeping herself safe from her sister by moving into supported accommodation. The parents observed care of Baby Connor during contacts after delivery was loving and caring and he was thriving. The Family Nurse was aware of a little of Father’s background but was not aware of the lengthy involvement of Children’s Social Care, and the history of Child Protection concerns with Paternal Grandmother, and this was not disclosed by Father. The Family Nurse could only access information on the electronic recording system for health professionals (SystemOne), if there was an open referral, (as was the case for Mother). Father did not have an open referral, which meant that the Family Nurse was not aware of his history of violent outbursts. Since the death of Baby Connor, where is it is known that a partner is living with a pregnant mother, a form has been devised and used by FNP, which seeks to ascertain with consent access to a father’s medical history. 5.1.45 It has also emerged in the course of this review that the provider of the Independent Living Unit, would only ascertain information concerning the father of a baby, if he was known to be living with the mother. If he was only visiting, such information would not be sought. The service provider has recognised this as an area which requires attention if safety for mothers and children living in their accommodation is to be improved. 5.1.46 The FNP was informed of Baby Connor’s father arriving at the hospital Emergency Department drunk, violent and under the influence of Paternal Grandmother’s medication, but the Family Nurses involved did not realise that the medication was prescribed and if taken by anyone other than the patient was an illicit drug. The incident was discussed with Mother on the telephone, who said she was aware that Father was drunk and had banged his head. It was planned to discuss the matter with Father, but Baby Connor died before this happened. 5.1.47 The Family Nurse was aware that Father had caused a disturbance at the independent living unit and in the two weeks up until Baby Connor was fatally injured, it was apparent that Mother was less engaged. When Mother was seen, she complained of feeling increasingly tired and that she was having decreased contact with Maternal Grandmother since moving into the unit. 5.1.48 Whether the Family Nurse assessed that Mother was in need of additional support in the care of Baby Connor is not known. Her next visit to the family was due to take place the week beginning 12 February 2018, by which time Baby Connor had already died. 5.1.49 It is evident that the FNP was not aware of the details of Father’s background, nor was sufficient information shared by the housing provider about the arguments between Mother and Father and of the complaints made by other residents. The Police PPN1 submitted at the time of Police attendance at the end of January 2018, lacked detail of the alleged injury to Baby Connor’s mouth. If this had been included, a more concerning picture would have been presented of child protection issues related to 30 | P a g e Baby Connor. The sharing of all information concerning the safety and well-being of children, particularly in respect of very young vulnerable babies, between agencies is fundamental if children are to be protected from significant harm. Unless information referred into the MASH results in a Section 47 investigation, such information would not be reviewed by Children’s Social Care. This is a lesson learnt from many Serious Case Reviews and sadly this review is no exception. See Recommendation 10 5.1.50 The assessment by the housing provider that Mother and Baby Connor were suitable to move to the Independent Living Unit has already been addressed above. However, how the decision was reached that Mother did not require additional support and supervised care, within 18 days of arriving at the supported living unit, is subject to question. It would seem from the information provided to the review that there was a lack of robust assessment of the support needs of mothers and the risk presented to babies by staff undertaking such assessments, none of whom were qualified social workers or health professionals. This finding is concerning and is reflected in Recommendation 4. 5.1.51 Baby Danny was subject to a Child Protection Plan, but how much support was offered to his parents by Children’s Social Care is not clear. The plan was that Child Protection visits were initially to be undertaken on a daily basis by the Social Worker, however, this level of monitoring was not maintained after the first days of Baby Danny’s discharge from hospital and was soon reduced to weekly and then fortnightly by mid-December. From information available, Baby Danny was not seen by a Social Worker after 14 December 2017, nor was there any contact until 6 January 2018, when the hospital contacted Children’s Social Care to inform them that Baby Danny had been brought to hospital by ambulance in an unresponsive condition and that NAI was a possibility. 5.1.52 Given the known history of Mother and the pressures placed on Father having to care for Baby Danny and supervise Mother, the level of involvement by Children’s Social Care was unacceptable, and is a lesson learned from this review. See recommendation 2(a) 5.1.53 There were regular and frequent visits by the Family Nurse to Baby Danny and his parents. The engagement by the FNP has already been explored in detail. Whatever support was being offered to Father, given the enormity of his responsibilities to Mother and Baby Danny, it would not have been sufficient to meet the requirements to keep Baby Danny safe. This was confirmed when Baby Danny’s parents met with the Lead Reviewer, given they stated that whilst they received support from the Family Nurse, little if any assistance was provided to them or Baby Danny by their allocated Social Worker. 5.1.54 Whilst Baby Ethan was on a Child in Need Plan, the case was allocated to a student social worker. Given the complexities of Father’s family history, his violent and aggressive behaviour resulting from a serious brain injury; that he had been a Child in Need himself just a month prior to baby Ethan’s birth; the concerns noted about Father’s cannabis use; the pattern of Mother moving from Maternal Grandmother’s home to Paternal Grandmother’s home and the lack of engagement with the Family 31 | P a g e Nurse after Baby Ethan’s birth, should have resulted in the case being escalated to one of Child Protection. It is evident that it was inappropriate for a student social worker, on placement to be given a case of this complexity and risk and is a lesson learned from this review. See recommendation 8. Recognition of the risk posed by fathers in the lives of babies and children 5.1.55 In all three cases the importance of the risk of father’s behaviour to the wellbeing and safety of these very young babies can be said to have been underestimated or was unknown by professionals. 5.1.56 In the case of Baby Connor and Baby Ethan the volatility of father’s behaviour was known to Children’s Social Care and to CAMHS professionals. This information was not known to the Family Nurses when they began working with the family and was not sufficiently explored once it was known that father was a constant in the life of the mother and baby. The need for professional curiosity, as well as information sharing concerning the childhood and life experiences of fathers, together with concerns about anger management, substance misuse and mental health is a pre-requisite if children are to be protected from significant harm. 5.1.57 Unlike Baby Connor and Baby Ethan, little was known about the background of Baby Danny’s father. This was a concern in itself, given the way in which the parents met on-line and the immediacy of them moving into together when Mother became pregnant. The decision of the pre-discharge planning meeting and the subsequent Child Protection Conference to allow Father to assume, what was essentially, sole responsibility for caring for Baby Danny and Mother, 24/7 was misguided and inappropriate. To place such an expectation on any parent would be difficult, however, given Mother’s behaviour and mental health needs, it proved to be dangerous to the health and well-being of Baby Danny. The impact of mental health issues, self-harming behaviour and substance misuse on parenting capability 5.1.58 All of the parents engaged in using cannabis, some to a greater extent than others. Alcohol use by parents also featured in all three babies lives. This is a theme, which is prevalent throughout this review. 5.1.59 In the case of the father of Baby Connor, the Police IMR makes an important point, in that “upon analysing the information within Police systems there was a general absence of recognition of alcohol misuse. Evidence is that officers may [emphasis of IMR author] have assumed, because Father was 16, this type of alcohol use was perhaps the norm. What is concerning is that Father was putting himself at risk of harm i.e. laying in the road, being out during the very early hours of the morning and displaying violent and aggressive behaviour. Crucially there was a real absence of the risk alcohol misuse posed to Baby Connor.” 32 | P a g e 5.1.60 Cannabis misuse by parents has become a feature of the day to day work of social care and health professionals. Such use and misuse cannot be treated with complacency. Cannabis misuse by parents is also increasingly featuring in Serious Case Reviews. The importance of professionals taking account of the impact of alcohol and substance misuse on the capacity of parents to care for their children, but also on the well-being of the children themselves, must not be underestimated. See Recommendation 5. 5.1.61 The review has highlighted that the brains of adolescents are usually still developing until the age of 25 and in some instances until 30. It is known that risk taking is more prevalent in adolescents. This lack of maturity combined with alcohol and substance misuse had a profound effect on the ability of these young parents to safeguard and care for their babies. 5.1.62 Similarly, self-harming behaviour is another feature of this review. Two of the three mothers were known to self-harm. The propensity to self-harm by the Mother of Baby Connor, was not a dominant feature of her behaviour, however, the degree of self-harm perpetrated by Baby Danny’s mother was chronic and extreme. Her vulnerability to self-harm and the subsequent impact on her ability to care for her baby was not given sufficient significance by professionals, because Father was seen as the protective factor. 5.1.63 The mental health of parents featured in all three cases and is a theme arising from the review. For all three babies the mental health of Father was a concern. What little was known about Baby Danny’s father included information that he had experienced depression, but no detail was known as to when, its extent or severity. If an assessment had been undertaken of Father’s ability to parent, this aspect could have been explored and a risk assessment made of his capacity to keep Baby Danny safe. 5.1.64 Neither the father of Baby Connor nor Baby Ethan, both of whom had anger management issues, engaged with CAMHS professionals, although in the case of baby Ethan, CAMHS staff were aware that he was about to become a father/was a father. As a result of non-engagement both cases were closed. The need to take account of the mental health of fathers when assessing the parenting capacity and abilities of parents is an important theme arising from this review and is a recommendation. (Recommendation 2). 5.1.65 The mental health of Baby Danny’s Mother has been documented throughout this review. What is surprising, is that despite being sectioned three times, during her pregnancy and was on medication for her mental health, Mother did not meet the criteria for a mental health assessment or intervention. Whilst there was some dissent, most notably by the South East Leaving Care Team and midwifery staff on the postnatal ward, the decision of the pre-discharge meeting to allow Baby Danny to return home with his parents from hospital raises real and serious concerns for the Lead Reviewer. In essence by taking such a decision, the NAI to this baby was predictable and preventable. 33 | P a g e The impact of a lack of good parenting experiences on young parents 5.1.66 The history of a lack of good parenting experienced by at least five of the six parents has been evidenced throughout the review. 5.1.67 The absence of a stable, caring home environment, coupled with poor school attendance had a profound effect on all the young parents featured in this review, and in turn their ability to parent their own children. Because of the lack of good parenting by Maternal and Paternal Grandparents, there was in turn an absence of support from extended family members. This essentially meant that apart from the provision of the FNP service, all the parents were left to parent the babies themselves. There is no evidence of parenting classes and child development information being made available. Over optimism on the part of professionals as to the parents’ capacity to care 5.1.68 The review has found that there was over optimism on the part of the majority of professionals involved with these young families and is evidenced in detail in previous sections of the report. A lack of robust, comprehensive parenting assessment in all of the cases is at the centre of why these small, vulnerable babies were seriously injured and, for one resulted in his tragic death. Impact of Homelessness 5.1.69 All of the parents experienced homelessness and it is a theme of this review. The lack of a safe, stable caring environment for all three babies increased their vulnerability and risk of significant harm. Anger management and domestic abuse 5.1.70 The propensity for violence and lack of anger management by a parent was prevalent in all three cases. For Baby Connor and Baby Ethan, it was father who presented the most risk and in the case of Baby Danny, there was a long history of aggressive and dangerous behaviour on the part of mother. These factors were well known to Children’s Social Care and should have been given greater significance at the IPCPs, Core Groups and Review Conferences. 5.1.71 In the case of Baby Ethan, the Police IMR author makes a very important finding concerning the need for professionals to be cognisant of identifying the risks of coercive and controlling behaviour. Father’s behaviour was highlighted at the ICPC. However, the risk to the unborn baby was seen as reduced because the couple were no longer in a relationship and resulted in unborn Baby Ethan being made subject to a Child in Need Plan. Once the case became one of Child in Need, Police were no longer represented at the Core Group meetings. “Bearing in mind concern regarding [Father’s] mental health, [Mother’s] description of being alienated from friends due to his behaviour, the fact it was understood that he influenced her to miss school and not engage with ante-natal provision”, should have prompted the police conference attendee to submit a fresh PPN1 identifying the risks of coercive and controlling 34 | P a g e behaviour highlighted at the ICPC. “Furthermore, there needed to be consideration as to how the presence of this may impact [Mother’s] capacity to remain out of a relationship with[ Father], which in turn could make it difficult for her to adhere to the outline Child in Need plan. In addition, consideration could have been given to the police proactively completing a DASH risk assessment (Mother was over 16 years old at this point) as a part of this PPN1 to enable a full assessment by MASH sergeants of the potential risk with consideration as to whether a criminal investigation was required”. 5.1.72 The University of Bristol's research findings on violence in teenage relationships6 undertaken between 2005 – 2009 clearly show that physical, sexual and emotional forms of teenage partner violence constitute a major child welfare issue. More recent information provided by Dr Christine Barter7 makes reference to teenage partner violence in two Serious Case Reviews. “In 2016 two serious case reviews occurred due to the deaths of ‘Lucy’ and ‘Jayden’, aged 16 and 17 respectively, who were murdered by their partners. The reviews showed that both young women experienced very high levels of coercive control alongside other forms of intimate violence. The review into the death of ‘Lucy’, who was pregnant at the time, documented a relationship which started when she was 15 and quickly became controlling and abusive, with her teenage partner banning her from going out alone or seeing friends and family, stopping her wearing make-up and telling her how to dress, accompanied by incidents of physical violence. Jayden’s abusive relationship followed a similar path.” “The serious case reviews also highlight that Lucy and Jayden experienced additional vulnerabilities and challenges. However, professionals in both cases failed to see them as children requiring protection with significant risks in their lives and instead positioned them as difficult adolescents. Research has identified a range of risk factors which increases a young person’s vulnerability to relationship abuse including: domestic violence and child abuse; attitudes which normalise violence including gender roles; anti-social peers; psychological factors – including low-self-esteem; bullying; early sex, and alcohol and drug use”8. 5.1.73 Whilst the controlling behaviour of the fathers in this Serious Case Review did not result in the death of their partners, the concerns highlighted by the Police IMR author concerning the behaviour of the Father of Baby Ethan resonate with the two Serious Case Reviews described above. As Dr Barter asserts “Professionals need to recognise the impact of these risk factors and understand that being in a controlling and abusive relationship will have an impact on a young woman’s ability to recognise the abuse, and affect their decision making”.9 6 Conducted by Christine Barter (Senior Research Fellow 2005-present), Professor David Berridge (Professor 2005-present), Dr Melanie McCarry (Research Associate/Lecturer 2004-2013), Ms Marsha Wood (Research Associate 2003-present) and Ms Kathy Evans (Research Associate 2006-2009). 7 February 2017 Dr Christine Barter is a Reader in Young People and Violence Prevention in the Connect Centre for International Research on New Approaches to Prevent Violence and Harm, at the University of Central Lancashire http://www.safelives.org.uk/practice_blog/violence-young-people%E2%80%99s-relationships-%E2%80%93-reflections-two-serious-case-reviews 8 ibid 9 ibid 35 | P a g e 5.1.74 Information has been provided to the review as to current Police practice, which shows that Hampshire Constabulary is delivering Safelives Domestic Abuse Matters training to all frontline officers and staff, which provides information relating to the identification of coercive and controlling behaviour. Police conference attenders have attended this training. This is learning for all agencies involved in this review and is reflected in recommendation 2, which also explores the establishment of a DASH system and checklist for young people under 16. Robustness of decision making concerning the child protection process 5.1.75 This review has highlighted the lack of robustness of decision making concerning the protection of these three babies and is a theme arising from this Serious Case Review, as illustrated below. 5.1.76 There was no child protection process for Baby Connor and thus no involvement by legal services. This was despite Father being subject to Child Protection procedures in 2015, followed by a Child in Need Plan. The lengthy history of safeguarding concerns in relation to Father should have alerted Children’s Social Care, as the lead agency for Child Protection to undertake a Section 47 investigation, once it was known that Father was going to be a parent. Unfortunately, this did not happen, and the focus of social work involvement was in securing accommodation for Mother away from the family home due to the risk presented by her younger sibling. This demonstrated a lack of professional curiosity on the part of agencies about Father’s background and the risk his behaviour may have presented to the unborn baby. 5.1.77 The lack of robustness, if not naivety, of the Child Protection Plan for Baby Danny has already been the subject of lengthy discussion in this review. Given Mother’s known history and vulnerability, and the significant lack of information concerning Father, consideration should have been given to having a Legal Gateway Meeting prior to Baby Danny’s discharge from hospital. Whilst Public Law Outline (PLO) meetings did take place, (the purpose of which is to obtain advice as to whether the 'threshold criteria' for a care order under section 31 Children Act 1989 have been met), once Baby Danny had been discharge to the care of his parents, the parents agreed to continue to engage with the Child Protection Plan, with mental health services, parenting courses, capacity to care assessments, assessments of family members and with the FNP. It was recorded that the parents were engaging with all professionals, that the family was visited regularly by different professionals and attended regular review meetings. Thus, it would appear that the threshold criteria were not met. What is not documented is an assessment of risk presented to Baby Danny and consideration given to his lived experience in the care of his parents. It is apparent from information provided to the review that the frequency of visits undertaken by the social worker fell short of expected statutory child protection practice and the monitoring of Baby Danny was left essentially to the Family Nurse. 5.1.78 In the case of Baby Ethan, the decision of the ICPC to make the unborn baby a Child in Need was based on Mother residing with Maternal Grandmother and the ending of the relationship between the parents. The Police ceased to be involved once the case was no longer one of Child Protection. The Child in Need Plan made no consideration 36 | P a g e of any involvement of Father, assessment of him in case of future contact, arrangements for future contact or medical information concerning his mental health. There was no consideration given to the possibility of the couple reuniting; nor was there any understanding of the pressures on Maternal Grandmother and the previous poor relationship between Mother and Maternal Grandmother. The case was allocated to a student social worker and management oversight was by a temporary manager whilst the permanent manager was on leave. Legal advice was not sought during the ICPC or the Child in Need process. 6 Key Learning arising from this Serious Case Review 6.1.1 The need for professionals to recognise adolescent parents as children themselves, whose brains are still developing, is an important lesson arising from this review. Training focusing on brain development, risk taking behaviour by adolescents and the impact of these factors on their parenting ability would be beneficial to professionals working with young parents. The review has been informed that adolescent brain development is a key element of FNP evidence based training. Thus, those Family Nurses working with young parents, should have been equipped with such understanding. Recommendation 1. 6.1.2 Comprehensive, robust assessment of risk factors, in addition to the parenting abilities of young parents, is key if children are to be protected from significant harm. This is particularly important when decisions are made to move mothers and babies from supported accommodation to independent living units where there is a lack of monitoring by staff and substantial support to residents. 6.1.3 The need for suitably qualified staff working with young parents in independent housing is a pre-requisite if the risk posed to young babies by immature, vulnerable parents is to reduce. It is not sufficient for the current service provider to state that their responsibility is to offer intermediate accommodation and to simply signpost young parents to appropriate support services. 6.1.4 The review has been made aware that significant concerns have been raised by Police about the number of times and the reasons why they are required to attend the independent living unit provision in Southampton. If a tragedy such as that of Baby Connor is to be prevented in future, the provision of independent living accommodation needs to include professionally qualified social care staff to support the parents and babies residing at this unit. 6.1.5 Recognition of the need for appropriate support to young parents is a finding from the review. In all three cases the involvement of the FNP was seen as the main support to the parents. Additional social work support and Early Help intervention was also required. 6.1.6 Cases involving vulnerable parents of young babies should not be allocated to student social workers. 37 | P a g e 6.1.7 The propensity for domestic abuse, controlling and violent behaviour in teenage relationships has been highlighted in the review. Professional awareness needs to be raised about these issues and consideration needs to be given to introducing a DASH risk assessment and checklist for under children under 16 years old. 6.1.8 The review has illustrated that informed, evidence based decisions and challenge, as well as professional curiosity and robust child protection planning, with advice from legal services, is required at ICPCs and Child Protection Conferences. 6.1.9 As is a finding in so many Serious Case Reviews, it is also the case in this review that the need for comprehensive information sharing amongst agencies is fundamental if professionals working with families are to be fully conversant with and understand the risk of significant harm presented to children. This did not happen in the three cases subject to review. 6.1.10 It is however, recognised that is three years since the review was commissioned. Since then, it is important to note that improvements to information sharing have taken place across the partnership. The review has been informed that the FNP now has a stronger relationship with the MASH and an information sharing agreement is in place for MASH practitioners to request information concerning fathers/partners where there are concerns. (Recommendation 2). 6.1.11 FNP also now ask fathers and involved partners if they will agree to having records open on System 1 (health recording system) to link with the baby. Whilst this is dependent on gaining the permission of those concerned, if it is provided, then the FNP has access to information across the health economy, e.g. CAMHS, GP records where System 1 is used. Solent Trust are also involved in conversations with Children’s Social Care, Police and Information Governance Teams as to how the sharing of PPN1 can be more robust with health, whilst fulfilling their statutory and Information Governance requirements. Such changes in practice are to be commended and should improve information sharing between agencies, which can only serve to benefit the protection of children. 7 Good Practice 7.1.1 The following good practice has been identified in this review: • The decision of the Southampton Social Worker to visit the offices of Children’s Social Care in another local authority to review their records concerning the past history of Baby Danny’s Mother was good practice. • The dissent by representatives of the Leaving Care Team and midwives from the postnatal ward with the decision of the pre-discharge meeting to allow Baby Danny to go home with his parents was good practice. • The decision of the Team Manager to overrule the view of the GP that Baby Ethan could wait for a child protection medical and insist that an ambulance was called to transport him to hospital, was good practice. 38 | P a g e 8. Conclusions 7.1.2 The decision of the Southampton Safeguarding Partnership to adopt a thematic approach when commissioning the review has enabled the readers of this report to gain an insight into the difficult and often complex situations, which professionals from different disciplines face on a daily basis when working with young, vulnerable parents. 7.1.3 The report has highlighted significant themes which run throughout all three cases subject to review. These have been discussed in detail, but for the purposes of clarity can be summarised as: • The importance of recognising parents as children/recently children themselves; • The need for comprehensive assessment of parenting skills and risk to the unborn baby; • The importance of support for young parents; • The impact of mental health issues, self-harming behaviour and substance misuse on parenting capability; • Over optimism on the part of professionals as to the parents’ capacity to care; • The impact of a lack of good parenting experiences on young parents; • Recognition of the risk posed by fathers in the lives of babies and children; • Impact of Homelessness; • Anger management and domestic abuse; • Robustness of decision making concerning the child protection process. 7.1.4 It is hoped that the findings of this review will provide a useful reflection of practice for all those working with young parents. However, it is fundamental to any professional when working with such parents to ensure that the safety, welfare and well-being of vulnerable small babies remains their first priority. 8 Recommendations for consideration by Southampton Safeguarding Partnership Due to the thematic nature of this review, there are more recommendations than would normally be anticipated. Recommendation 1 (a) All agencies to ensure that professionals working with young parents are aware of the need to recognise that in the first instance parents under 18 years of age are children themselves. (b) This would be achieved by the provision of training concerning the research findings into the brain development of adolescents, risk taking behaviour and the impact of these factors on their parenting ability. Recommendation 2 (a) Whilst dependent on the information parents may wish to share, agencies are to be reminded that wherever possible the life history of fathers, including their own childhood experience of parenting, needs to be documented and shared 39 | P a g e with all professionals involved in working with young, vulnerable parents. Use of the information sharing agreement between the FNP and the MASH is to be encouraged. (b) The research findings of the University of Bristol (as referenced in this report) on violence in teenage relationships and its consequences for the welfare of mothers and babies should be disseminated to all agencies working with young parents. (c) Police to continue to recognise that domestic abuse can occur in teenage relationships and use the DASH (Domestic abuse, stalking and harassment) risk assessment, as well as the child at risk element of the safeguarding notification, to assess and share that risk with the relevant partner agencies. Recommendation 3 Police Officers attending incidents of domestic abuse where children are present should be reminded of the crucial importance of professional curiosity; as embodied in careful exploration, documentation and the reporting of concerns, to ensure that children can be protected from significant harm. Recommendation 4 The Safeguarding Partnership should consider reviewing as a matter of urgency the appropriateness and safety of the service currently provided to young parents and babies living in supported housing accommodation. Recommendation 5 Assurance needs to be provided to the Safeguarding Partnership that the seriousness and significant risk of substance and alcohol misuse on the ability of young parents to care for and safeguard their baby/child is fully understood by all professionals by: (a) Providing training which emphasises the risk of parental substance misuse (especially cannabis) to young babies, and the potential impact on them. (b) Reviewing the Threshold Assessment Framework so that cannabis/substance use is included. (c) When undertaking any assessment, cannabis/substance use by a parent is taken into account. Recommendation 6 The FNP should be required to review standards of record keeping, ensuring inclusion of the development of babies and children and not simply a focus on concerns. This will ensure a complete picture of a child’s lived experience in the care of their parent/s is captured. Recommendation 7 Agencies to be made aware that where a baby is not registered with a GP Practice by the time of their six week developmental check professionals need to consider this as a safeguarding concern. 40 | P a g e Recommendation 8 Careful consideration should be given to which cases are allocated to Student Social Workers. Good quality supervision needs to be provided to the student to ensure that where concerns that a baby/child may be at significant risk of harm, the case can be reallocated when such concerns arise. Recommendation 9 Chairs of Pre-discharge meetings and Initial/Review Child Protection Conferences should be reminded of their responsibility to ensure that any decision made needs to be evidence based, open to challenge and professional curiosity, and results in robust child protection planning, with advice from legal services. Recommendation 10 The Safeguarding Partnership to ensure that all agencies recognise their responsibility to partners to share information concerning the safety and well-being of children, particularly in respect of very young, vulnerable babies if they are to be protected from harm. This can be achieved, by ensuring that once received by the MASH, the pathway already in place for such information to be shared with other agencies is utilised, even if the criteria for a Section 47 referral is not met at the point of initial grading. 41 | P a g e Appendix 1: Terms of Reference: Non Accidental Injury in Infants - Thematic Review Reason for review This thematic review has been commissioned due to three cases involving serious non accidental injury/death of babies aged between six to ten weeks. All three incidents occurred within a two month period. Each case was considered by the SCR Group and met criteria for Serious Case Review under Working Together 2015. Purpose This will be a thematic review and analysis of common issues regarding non accidental injury to babies whose parents are teenagers or young adults. The review will be presented as one report which will also include an assessment of particular circumstances pertinent to each individual case. Period under review The review will reference the three cases, known as Baby Connor, Baby Danny and Baby Ethan. The period under review for each child is: Baby Connor is 11/05/2017 – February 2018 Baby Danny is 10/03/2017– January 2018 Baby Ethan is 4/04/2017 – January 2018 The start date for each review is the date the Mothers’ pregnancy became known to agencies. The end date is the date of the injury/death of the child. This review will request relevant background and contextual information regarding key factors and significant events about the family that was known or knowable by the agency at the start of the review period. However, it is also important to include any relevant agency knowledge outside of the period of review. To include the time prior to the review period regarding the family background and any other important and relevant information. The lead reviewer is Moira Murray. The lead reviewer will work with a panel of agency representatives. Members to include: • Police • Social Care • CCG • Solent NHS • UHS • Education • Housing • Legal Services Analysis issues 42 | P a g e This review will consider all issues that could have a bearing on the circumstances of these cases and will include: • Support offered to young parents • Assessment of parenting skills and risk to unborn baby • Impact of mental health issues, self harming behaviour and substance misuse on parenting capability • Impact of lack of good parenting experiences on young parents • Impact of homelessness • Anger management and domestic abuse • Robustness of decision making concerning child protection process • Evidencing the child’s lived experience within the family • Over optimism on the part of professionals as to the parent’s capcity to care • Involvement of Police and Criminal Justice Involvement of staff The lead reviewer will consider from summary information provided the involvement of relevant staff in this case to ensure any possible learning opportunities are identified and acted upon. Involvement of families The lead reviewer will notify the family members of the review and they will be invited to participate as and when appropriate. Methodology The methodology for this review will consist of: • Proportionate IMRs for each individual case (specific template for IMR authors to follow) • A panel of representatives from relevant agencies • A review of relevant multi agency policies, procedures and processes that are in place • Facilitation of multi-agency learning event, to explore key themes arising with partner agencies • This will be chaired by an Independent Reviewer who will produce a report outlining key findings and multi-agency recommendations. This will be presented to the LSCB. • The Independent Reviewer will request details and further information where necessary to support analysis and scope of the review. This may involve minutes of meetings, written assessments made and other relevant information. • Learning from the review will be disseminated with multi agency partners. Addendum – Analysis questions for IMR When answering the following questions, please try to take into account how and why decisions were reached at the time, as well as what decisions were made. Parents Was appropriate assessment made of: 43 | P a g e • The parents’ capacity and capability to care for an unborn baby? (to include consideration of their own parenting experience) • Their needs as young people? • What support was put in place to enable them to care for their baby? (to include the role of the Family Nurse Partnership, Mother and Baby Unit). Was this sufficient? Was sufficient consideration given to and assessment made of: 1. The mental health needs of Mother and/or Father? 2. Self-harming behaviour and suicide ideation? 3. Disengagement/withdrawal from education? 4. The effect of alcohol and substance misuse on their ability to parent? 5. The seeming acceptance by professionals of the use of cannabis by the parents, and the effect this had on their ability to parent? 6. The possible involvement of young parents with a network of older adults misusing/dealing drugs? 7. The effect of homelessness? 8. Criminal activity? 9. Domestic abuse? Were the views of the parents listened to when their own doubts may have been expressed about their ability to care for their unborn baby? Voice of the Child • Was there appropriate, robust pre-discharge planning after the baby was born? • What was a typical day like for a baby in the household? • Was there appropriate engagement with professionals to ensure that the baby’s health and wellbeing was monitored and promoted? • Was there disguised compliance on the part of the parents? Child Protection and Legal Processes • What were the reasons for the unborn baby/baby (and where appropriate, siblings of Mother and Father) to be made subject to a Child in Need Plan, rather than a Child Protection Plan? • Where appropriate, why was the baby ‘stepped down’ from a Child Protection to a Child in Need Plan? • Was there sufficient escalation of concerns? • Was the Child Protection/Child in Need Plan robust, monitored and reviewed? • Was the involvement of Legal Services, i.e. PLO process, timely and appropriate? Could intervention have been earlier? General • Was the case looked at holistically, from the perspective of the child? • Were professionals over optimistic in the belief that the baby could be safely and well cared for by the parents? • What are the criteria for ’good enough’ home conditions? • Was there good information sharing between and within agencies? • What do we learn from this case? 44 | P a g e Appendix 2 The Process of the Serious Case Review The mandatory criteria for carrying out a Serious Case Review as set down in Working Together to Safeguard Children (2015), is as follows: (a) abuse or neglect of a child is known or suspected; and (b) either: (i) the child has died; or (ii) a child is seriously harmed and there are concerns about how organisations or professionals worked together to safeguard the child. The purpose of a Serious Case Review is to undertake an independent appraisal of practice, whilst also recognising the complex circumstances in which professionals are working. A review also seeks to understand the role of all agencies involved with a family, to identify improvements which are needed and to consolidate good practice. It is not about apportioning blame. A Serious Case Review seeks to encourage: • a culture of continuous learning and improvement across organisations that work together to safeguard and promote the welfare of children, and that • the approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined. For the purposes of transparency all Serious Case Reviews are required by the Department of Education to be published. The Lead Reviewer is aware of the sensitivity of the information contained in this report and the distress that it may cause to family members. There has been an attempt to balance the need for agencies to learn lessons from this review and the need to manage the distress of the families concerned. All personal information has therefore been anonymised, and pseudonyms have been used to refer to key family members and those connected with the three babies. It is expected that Southampton Safeguarding Children Partnership will translate the findings from this review into programmes of action, leading to sustainable improvements and the reduction of risk of death, serious injury or harm to children. Some agencies have already taken steps to improve practice as result of the untimely death and injury of these babies. The review acknowledges and references where this has happened. 45 | P a g e Agency IMR Reports The following agencies were requested to contribute to this review: Baby Connor Baby Ethan Baby Danny • Police • Local Authority Children and Families Service • GP • Hospital NHS Foundation Trust including maternity • 0-19 Services; Health Visiting, FNP • Secondary School • Local Authority Education Welfare • Ambulance Service • Local Authority Housing and Homelessness Team • Commissioned Housing Provider • Police • Local Authority Children and Families Service • Secondary School • Hospital NHS Foundation Trust including maternity • Local Authority Housing and Homelessness Team • GP • 0-19 Services; Health Visiting, FNP, CAMHS • Police • GP • Mental Health Services: perinatal mental health and Adult Mental Health Team • Local Authority Children and Families Service including Care Leavers Team • Local Authority Adult Social Care • Hospital NHS Foundation Trust including maternity • 0-19 Services; Health Visiting, FNP, CAMHS • Local Authority Housing • Local Authority Education • Local Authority Legal Services The Serious Case Review Panel included members of the following agencies: • Police • Social Care • Local Clinical Commissioning Group including Primary Care • Solent NHS Trust • Hospital NHS Foundation Trust Southampton • Education • Housing • Legal Services • Integrated Commissioning Unit 46 | P a g e Appendix 3 The Serious Case Review Author/Lead Reviewer Moira Murray is a social worker by training and has been the chair and author of numerous Serious Case Reviews over the past eleven years. She has also undertaken safeguarding audits for local authorities, the NHS, the Foreign & Commonwealth Office and the BBC. She was a non-executive board member of the Independent Safeguarding Authority for five years and in 2012 was appointed Safeguarding Manager for children and vulnerable adults for the London Olympic and Paralympic Games. Most recently she was the Senior Casework Manager for the Church of England National Safeguarding Team. In the past, Moira Murray has been commissioned by Southampton Safeguarding Partnership to undertake several Serious Case Reviews. As a result, she has had previous professional contact with some of the SCR Panel Members and IMR authors involved in this review. However, she has had no involvement with any of the three cases subject to review, and had no knowledge of, or prior involvement with the babies of their families, before her appointment as the review independent author. |
NC52440 | Life-threatening injuries to a boy in August 2020. Child N fell from a second-floor window and sustained serious injuries. Learning includes: work with families should demonstrate an understanding of the impact race, culture and religion can have on parents' behaviour; agencies should obtain contact details of a parent not living in the household and should engage them in important decisions regarding their child, unless there is a reason not to do so; practitioners require the knowledge and skills to promote engagement with families who are resistant to co-operating with services offered; for children experiencing neglect there can be a range of factors which mean that incidents have some element of forewarning; the category of harm should reflect the risks to the child, which should be articulated in the child protection plan; statements for family court proceedings should articulate all the risks of harm to a child. Recommendations include: consider how agencies can develop practitioners' knowledge and skills in working with resistant families; when a section 47 enquiry is initiated all circumstances should be reviewed to ascertain if the threshold is met for a joint agency investigation; undertake a review of safeguarding training to ensure that cultural awareness and sensitivity is promoted; the child protection service should undertake an audit of the categories of harm identified for children who are subject to child protection plans to ascertain if the categories reflect the identified risks.
| Serious Case Review No: 2022/C9604 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. 1 Local Child Safeguarding Practice Review Child N SILP Lead Reviewer: Adrienne Plunkett A Local Authority Safeguarding Board Commission Approved by the Safeguarding Board 31.5.22 2 CONTENTS: PAGE: 1. Statutory Framework 3 2. Significant Incident Learning Process 3 3. Process for LCSPR 3 4. Family Engagement 4 5. Background information 4 6. Scoping Period 4 7. Analysis: KLOE 11 8. Good Practice identified 27 9. Key Learning 28 10. Recent Developments 30 11. Conclusion 31 12. Recommendations 32 Appendix A: References 33 3 1. Statutory Framework: 1.1. This Local Child Safeguarding Practice Review (LCSPR) was commenced in 2021 and undertaken in accordance with the guidance contained in Working Together to Safeguard Children 2018 1 which outlines reviews should be completed in a way which: ▪ Reflects the child’s perspective and family context. ▪ Is proportionate to the case under review. ▪ Focuses on potential learning. ▪ Establishes and explains the reasons why events occurred. ▪ Invites families to contribute. ▪ Fully involves practitioners. 1.2. Working Together 2018 encourages Local Safeguarding Partnerships (LSPs) to use a variety of models for undertaking LCSPRs, including the systems approach. The Significant Incident Learning Process (SILP) is one such model. 2. Significant Incident Learning Process (SILP): 2.1. The SILP methodology reflects on multi-agency work systemically and focuses on why those involved acted in a certain way at that time. The SILP methodology adheres to the principles of: • Involvement of families • Active engagement of practitioners and frontline managers • Systems methodology • Proportionality • Learning from good practice 2.2. SILPs are characterised by practitioners, managers and Agency Report Authors coming together for a Learning Event, where the perspectives of all those involved are discussed and valued. The same group considers the draft Overview Report at a Recall Event, ensuring practitioners contribute to the key learning. 3. Process for this LCSPR: 3.1. In 2020, the authority’s Safeguarding Children Board’s Independent Chair made the decision to undertake a LCSPR in respect of Child N. Furthermore, a decision was taken that this would be undertaken using the SILP methodology. The Terms of Reference were prepared, and the Agency Report Authors’ Briefing held in February 2021. 3.2. The Scoping Period for the Review covers the period from when Mother and Child N moved into the local area in 2015 to N’s serious, life threatening, injuries in 2020. 1 Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children, Department for Children, HM Government July 2018. 4 3.3. Two SILP Learning Events were held, one for Practitioners and one for managers, in April 2021 and the Recall Event was held in September 2021. Events were attended by practitioners, managers and Agency Report Authors from Education, nurseries and schools, NHS Foundation Trusts, Clinical Commissioning Group (CCG), GP Practice and Children’s Social Care, 3.4. An application was made to the Family Court for the Reviewer to have access to court documents and a court hearing was arranged. This led to the timescale for the review being extended. 4. Family Engagement in the LCSPR: 4.1. Both parents were informed that the LCSPR was being undertaken and that they would be invited to participate in due course. 4.2. Advice was sought from practitioners working with the family about how best to engage with the parents and obtain their views about the services offered. Despite this advice being followed, unfortunately it has not been possible to meet with the parents and incorporate their views into the review. 5. Background Information: 5.1. N’s Mother is of Black African heritage and grew up in countries experiencing civil war and genocide. Her parents are deceased; she was cared for by an aunt and received a good education. N’s Father is white British. The parents have never shared a home together. 5.2. N is described by practitioners as a bright, happy and affectionate child, ’a little star’, who loves buses and trains. N’s verbal communication skills are limited, but can understand non-verbal cues, and has the ability to learn, being fascinated by numbers and enjoying phonics and songs. N responds well to the structure and routine at school. 5.3. The Scoping Period evidences long-term concerns regarding the neglect of N, but practitioners acknowledge Mother and N’s close relationship. 6. Scoping Period: 6.1. Mother and N moved to the local area in December 2015, to be nearer Father. At the age of two and a half years, N commenced at Nursery 1, where attendance was irregular for 10 months. Mother’s attitude towards the nursery staff was inconsistent; sometimes co-operative and at others irritable and hard to engage. Some days she was happy to leave N but on other days found this difficult, which affected N’s behaviour. N left the nursery as Mother chose to change provision. 6.2. The Health Visitor identified concerns about N’s development and behaviour early in 2016. N was referred to the Child Development Centre (CDC) and in November 2016, at the age of three years, was diagnosed with autism spectrum disorder (ASD) by the multi-disciplinary Team Around the Child (TAC), including the pre-school provision, Speech and Language Team (SALT) and the Community Paediatrician. 5 Mother and N attended the meeting, and it was noted that she had some difficulty accepting the diagnosis and was not receptive to the support services offered. 6.3. Follow up support was offered by the Community Paediatrician at CDC, SALT and the National Autistic Society, with a review planned after 6 months. Mother and N sporadically attended the support sessions at the CDC and three SALT post diagnosis group meetings. The Health Visitor was informed of the diagnosis. 6.4. The CDC 6 months review did not take place and, although there was considerable communication between professionals, a multi-agency plan was not put in place. 6.5. Mother’s lack of acceptance of the support services offered impacted significantly on N as a child with special needs, in the development of key skills, notably communication and language. Agencies involved with the family are of the view that Mother was looking for a ‘cure’ for N and she was disappointed when practitioners could not offer this which affected her engagement. The family were isolated, without the support of family or friends 6.6. In March 2017 Mother contacted the GP surgery as she was having difficulty managing N’s behaviour. An appointment was arranged with the GP, who suggested further input from Paediatrics may be helpful. Mother became angry and left the consultation. Following further discussion, it was agreed Mother would follow up with N’s school. 6.7. In May 2017, N commenced at Nursery 2, with Mother hoping that the new provision would ‘cure’ him. Mother’s approach towards the nursery staff was again inconsistent and she did not engage with professional advice. refusing to give agreement to SALT involvement. N left 9 months later due to the non-payment of fees. • Child in Need (CIN) Plan: 6.8. In June 2017, the family were evicted due to rent arrears and deemed to be intentionally homeless. There were reports from neighbours of N being left unattended, ‘hanging out’ of windows and running into the road. A single assessment was undertaken by Children’s Social Care and a CIN Plan recommended. Mother did not engage, and the plan ceased in October 2017. However, further concerns were raised by Housing, including N being locked in a room whilst Mother went shopping/into communal areas causing distress, N being disruptive throughout the night and several moves of B & B accommodation due to the complaints. 6.9. In October 2017, the Police and Fire Service received a report that Mother had forgotten her key and N was locked in their room. The Fire Service assisted with unlocking the door. The Police dispatched a unit one hour after the report but did not check on N’s welfare. Given the concern that such incidents were escalating, a Strategy Meeting was held between CSC and the Police. The decision was that CSC should undertake single agency Section 47 enquiries; the outcome was that Mother agreed to engage with the CIN Plan. 6 6.10. Further unsuccessful attempts were made to engage Mother in the CIN Plan. Using the Signs of Safety Scoring, the level of risk was assessed as 3 – 5. 2 The safety scale 0 indicates the child is highly likely to be harmed and 10 indicates there is sufficient safety to cease involvement. The CDC, SALT, OT and Health Visitor were not aware of the CIN Plan until informed by the Family Intervention Team in February 2018, neither were they informed the family had been evicted and were living in B & B accommodation. • Child Protection Planning: 6.11. The CDC Manager referred the family to CSC in February 2018; concerns included the Education, Health and Care Plan (EHCP) not progressing, N not attending nursery or receiving SALT, N presenting as anxious and fretful and showing signs of developmental delay. Mother was not engaging with the services offered, and concerns were expressed about her mental health, parenting capacity and lack of a support network. The family were experiencing frequent house moves and following another eviction, had been placed in a Travelodge. CSC took the view that the threshold of significant harm 3 to trigger child protection procedures was not met. 6.12. However, due to continuing concerns, following a CIN review in March 2018 when there was a ‘recalibration’ of approach to better reflect the level of need, a single agency Section 47 investigation was agreed. This was undertaken by a specialist Social Worker from children’s social care (CSC) who recommended an Initial Child Protection Conference (ICPC), held in April 2018. Both parents attended the ICPC. The unanimous decision was that N was at risk of significant harm and required a Child Protection Plan (CPP) in the category of neglect. Mother had not engaged with services (SALT, CDC, Nursery) and the family were experiencing frequent accommodation moves. There was discussion as to whether the difficulties of engaging Mother were related to possible ASD. The CPP included an assessment of Mother’s cognitive abilities, support with housing, an EHCP and assessment by SALT. The Pre-Proceedings Public Law Outline Process 4 was initiated, and the Local Authority commenced care proceedings. 6.13. In May 2018 Police reported to CSC that N had been found alone at a railway station, nearly one mile from home, having crossed a busy road and before Mother had reported N missing (after approx. 45 minutes). N was found ‘by chance’ by a Police Officer leaving the Railway Station; the Officer reported to the Supervisor and discussed assuming Police Powers of Protection. When Mother came to collect N, she 2 Signs of Safety: The Signs of Safety approach is a relationship-grounded, safety-organised approach to child protection practice, created by researching what works for professionals and families in building meaningful safety for vulnerable and at-risk children. https://www.signsofsafety.net/ 3 Significant Harm: “Harm” is the “ill treatment or the impairment of the health or development of the child”, Section 31, Children Act 1989 (England and Wales). Harm can be determined “significant” by “comparing a child’s health and development with what might be reasonably expected of a similar child”. 4 The Pre-Proceedings Public Law Outline (PLO) process takes place when the S31 Children Act 1989 Threshold Criteria are met and the Local Authority is concerned about a child’s wellbeing and unless positive steps are taken to address and alleviate those concerns, the Local Authority may consider making an application to the Court. The PLO process is therefore the last opportunity for parents to make improvements to their parenting before care proceedings are issued. Family Law Group, July 2020. 7 explained she had left N in the living room whilst in the kitchen. She denied any involvement with CSC and Police records were not checked, which would have provided the information that N was subject to a Child Protection Plan. The Police Officer did not confirm the details or visit the family home to ascertain further information about N’s welfare and full details of the incident were not recorded. (Police: Single Agency Learning Point) 6.14. The Local Authority applied for an Interim Care Order; this was granted, and N and Mother were placed in an out of area foster placement. The CPP ceased in June 2018 as N was a Child Looked After (CLA) and the reviewing process then became the planning mechanism. • Child Looked After (CLA): 6.15. There were concerns at the first placement about the lack of routine and boundaries for N, as well as Mother’s mental health. Her behaviour towards the foster carer became suspicious and threatening and the placement was considered no longer viable. Following an Emergency Planning Meeting in July 2018, when the legal advice to the Local Authority was that there was insufficient evidence to separate N and his Mother, they moved to a residential placement in London. 6.16. There were early concerns in the second placement about the lack of boundaries for N, road safety and Mother undoing the safety catches on the windows. Mother appeared to ‘baby’ N and was dismissive of support. At the CLA Review in October 2018 new safety concerns from the placement were noted and a ‘danger statement’ was issued as Mother had again unlocked the window restrictors. The CLA Review reinforced the need for close supervision. 6.17. In November 2018 N commenced at School 1 where he attended regularly for six months whist in the residential placement. An EHCP was in place and support was provided by the SENCO and Headteacher. N had 1:1 support and, though non-verbal, communicated using gestures. The Educational Psychologist visited the school on three occasions to complete an assessment, but each time N was not in school, so tried to complete the assessment without seeing the child. However, dissatisfied with this, returned for a fourth visit and was able to observe N. Whilst regularly attending School 1, the Social Worker noted that N ‘blossomed’, reading, and playing with other children. There were concerns for Mother’s mental wellbeing as she presented as suspicious and critical of the school. 6.18. Following a report of N being left unattended in the family’s room for thirty minutes, a Strategy Meeting was held in February 2019 and Section 47 enquiries were undertaken by the Local Authority in London. There was a further incident when N ran out of the property and along the street before being stopped by Mother. It was decided that the ICO negated the need for an ICPC. 8 • Return to the community: Placement of Child with Parents Regulations 6.19. At the court hearing in April 2019, the court did not agree that the test for the interim separation 5 of N was met and the family moved back to the Local Authority area into temporary accommodation under the Placement with Parent Regulations 6. Extensive supervision was arranged by a local children’s home, the social worker and agency staff. Mother did not consent to the involvement of SALT and OT for N. 6.20. N received tuition from the Virtual School and commenced at School 2 at the end of July 2019. A large number of schools were considered by Mother before a decision was reached. At School 2 N received 1:1 support and supervision. Mother was anxious about leaving N and worried about removal by the Local Authority. Despite continued attempts to gain consent for SALT, this was not given. Father was invited into school in September 2019 to support N in school, but N did not attend that day. N did not attend School 2 for more than four consecutive days. 6.21. School 2 describe N as a happy child with ‘huge potential’. At the age of 5 years, N’s language and communication skills were those of a much younger child but N understood non-verbal cues and used hand signals. Mother found N’s progress difficult to accept. She did attend a local parenting course for children with autism. 6.22. N made progress with counting and phonics, evidencing his potential. School staff were confident that with regular attendance N would meet milestones. School continued to try and progress referrals to SALT and CDC, but Mother declined consent. • Final Family Court Hearing: 6.23. At the Final Hearing in August 2019, the Local Authority requested a Care Order and a Placement Order, with a plan to place N for adoption. The Local Authority’s view was that Mother would be unable to support any other permanency arrangements, e.g., with contact. This plan was supported by the Independent Reviewing Officer (IRO) and the Children’s Guardian and had been supported by the Independent Social Worker until the day of the hearing. It was opposed by the expert Psychologist who had been jointly instructed by the parties. 6.24. The threshold of significant harm was met, but the Local Authority’s application for Care and Placement Orders was dismissed by the Judge and no orders were granted. The IRO recommended the Local Authority appeal and the CLA Nurse and SALT raised concerns about whether Mother could safely meet N’s long-term needs. The Care Plan did not have a contingency plan should the Local Authority’s recommendation not be accepted by the court. (Child Protection Conference Team Recommendation) 5 Interim removal of children from their parents: In approaching the issue of interim removal, the court must consider whether the risk to the child's safety demands immediate separation (per Thorpe LJ in Re H (A Child) (Interim Care Order) [2003] 1 FCR 35) and is such an action proportionate (Article 8, Human Rights Act). 6 Placement of children with Parents etc Regulations 1991 provide for the accommodation of children in the care of a local authority with a parent, person who is not a parent but has parental responsibility. The Children Act 1989. Amended by Care Planning, Placement and Case Review Regulations 2010 9 6.25. The advice to the Local Authority was that there were no legal grounds to appeal the decision, as due process had been followed. 6.26. On the final day of the hearing N was seen to run into the road by a member of CSC staff. A Strategy Meeting was held, and the decision taken that there would be no further action in view of the outcome of the court proceedings. 6.27. In October 2019 CSC referred Mother to the Common Point of Entry, Mental Health Service, due to concerns about paranoid thoughts. The Crisis Team rated the referral red, and a joint visit was undertaken by the Social Worker and the Mental Health Worker. (Good practice) The assessment concluded there was no evidence of mental disorder or impairment, and she was discharged to the care of the GP. 6.28. In mid-October, a month after N commenced fulltime at School 2, after many attempts to engage Mother and improve N’s school attendance, a referral was made to the Education Welfare Service (EWS) due to poor school attendance (40%). This was followed, after 6 weeks of chronic school attendance, by a Child Missing Education (CME) 7 referral in December. School 2 were in frequent contact with the Education Welfare Officer and when necessary, made referrals to Children’s Social Care. 6.29. In October 2019, the duty to accommodation the family was accepted under the homelessness legislation, and they were offered a two-bedroom second floor flat which Mother initially refused. The Housing Department sought advice from an organisation providing housing medical advice as to the flat’s suitability, which was also assessed by the Social Worker, Team Manager, Housing Officer and Occupational Therapist prior to Mother accepting the tenancy in November. Safety modifications were agreed, i.e., window restrictors, removal of bath glass panel, securing boiler cupboard and fuse box, and completed. The Contractor and Housing Department ensured that the window restrictors were securely in place. 6.30. Housing’s surveyor undertook an inspection of the property in November 2019. He identified one of the window restrictors in the living room had become detached and returned a few days later with the contractor to refit this and check all the others. In addition, a slide bolt was fitted to the front door, out of N’s reach. There was concern about how the window restrictor had become detached, as this would be ‘virtually impossible’. Mother told the surveyor that the social worker had pulled it off. The surveyor was concerned about Mother’s lack of coherence and reported this to the Housing Department which triggered a ‘safeguarding concern’ to CSC. The contractor was confident this would not recur. • Child Protection Planning: 6.31. Following a Strategy Meeting in November 2019, an ICPC was held in December 2019 due to concerns about N’s poor school attendance (30%), the lack of consent to SALT and Mother’s mental health. The decision was that N was at risk of significant harm and required a CPP in the category of emotional abuse. The plan included: N to attend school, a health review by the School Nursing Team, Mother to seek help with her mental health needs and to engage with community resources. There was 7 Child Missing Education: Statutory Guidance for local authorities: September 2016. DFE 2016. 10 also a decision to seek legal advice and consider initiating the Pre-Proceedings Public Law Outline Process for the second time. The decision to use the category of harm of emotional abuse, rather than neglect, represented a shift in safeguarding priorities. N’s lack of boundaries and supervision and risks to his physical safety, which had consistently been previous concerns, were not referenced in the plan. (Learning Point) 6.32. Mother contacted the GP Practice three times between December 2019 and June 2020 requesting support with N’s sleeping, eating, nocturnal enuresis. Onward referrals were made with her consent. 6.33. In the three months before the RCPC in March 2020 concerns continued about N’s safety and wellbeing. Mother had not consented to the health review by the school nursing service, poor school attendance continued and, following 6 weeks of chronic non-attendance, a CME referral had been made and a Fixed Penalty Notice (FPN) issued. A home visit by the EWS to discuss the FPN ended due to Mother’s ‘intimidating verbal response’. 6.34. Social Worker 2 had seen N run across the windowsills and finger marks were noted on the windows. Whilst the restrictor on the living room window had been repaired earlier in November, by mid-November another of the restrictors was observed by the social worker to be broken. This was reported to Housing, but there is no evidence that any action was taken in response. In January N was observed to run into the road, whilst in Mother’s care, causing a car to swerve. 6.35. Monitoring N’s safety at home and outside was not a part of the CPP. Additionally, whilst there is an expectation that children’s bedrooms should be seen during child protection visits by the Social Worker, N’s bedroom was not seen as Mother denied access. 6.36. At the RCPC in March 2020 it was agreed that the CPP should continue; the category of harm was changed to neglect, but the CPP, i.e., actions and timescales, was unchanged. PLO had been initiated and, after three cancelled meetings, the Legal Planning Meeting had been held in mid-February. 6.37. Early in March EWS Officers made an unannounced home visit, they could hear N in a bedroom but did not see him. (Recommendation for the Education Welfare Service) 6.38. When schools closed due to the Pandemic, due to being the subject of a CPP, N was offered a school place and attended occasionally. Mother explained that there was no requirement for N to attend. School and EWO maintained contact and tried to encourage N’s attendance. CSC prioritised cases according to a traffic light system; N was given the highest priority and rated as red which meant home visits continued. The family were given the same priority by the Foundation Trust. 6.39. Early in June 2020, School 2’s Family Support Advisor (FSA) contacted Mother to encourage N’s attendance at school. Mother did not want N to attend and was aware she would not face prosecution. The same day Mother made a request for a change of school, stating that N was not happy. This request was accepted without 11 any communication with the Social Worker or members of the Core Group, and a place was allocated at School 3. (Learning Point) 6.40. In July 2020 there was a further referral to Mental Health Service by the Social Worker. Mother was presenting as paranoid, worried she was being watched by Eastern European men. The referral was rated amber; Mother was contacted by the Mental Health Service but did not respond and was discharged. 6.41. The EWO maintained weekly telephone contact with Mother, who shared that N had got into the bath twice fully dressed and turned on the taps. The EWO advised a lock should be fitted on the bathroom door and informed the Social Worker, but there is no evidence any action was taken to safeguard SC. Further attempts to gain Mother’s consent to SALT, through the EWO, were unsuccessful. • Legal Proceedings: 6.42. As the Child Protection Plan was not progressing, the Local Authority again initiated care proceedings in June 2020, and applied for an ICO with interim separation and placement in foster care. Mother did not attend the Case Management Hearings in July and August or instruct a solicitor. The Children’s Guardian and the Judge considered that the test for interim separation was not met, and the case was adjourned for assessments until October 2020. • Incident August 2020: 6.43. Tragically, whilst unsupervised, N fell from a second-floor bedroom window and sustained serious, potentially life threatening, injuries. A passer-by called emergency services. The Local Authority obtained an ICO, the test for interim separation was met and, following discharge from hospital, N was placed in foster care and has made good progress. A criminal investigation was commenced. Concerns have subsequently increased about mother’s mental health needs. 7. Key Lines of Enquiry (KLOE) 7.1. Is there evidence of consistent child-centred practice and consideration of the voice of the child within risk assessments and the crucial decision-making and planning processes, and was consideration given to promoting the welfare and safeguarding a child with a disability? ‘This child centred approach is fundamental to safeguarding and promoting the welfare of every child. A child centred approach means keeping the child in focus when making decisions about their lives and working in partnership with them and their families.’ 8 7.1.1. The Agency Reports and discussions at the Practitioner and Manager SILP Learning Events evidence that practitioners kept N very much at the forefront of their thinking and interventions with the family. Practitioners from Early Years provision, Schools, SALT, Educational Psychology and CSC spoke of N with understanding, 8 Working Together to safeguard children: A guide to inter-agency working to safeguard and promote the welfare of children. HMG 2018. 12 knowledge, concern and warmth. They were distressed by N’s fall and the injuries sustained, having felt that they had strived to prevent such a serious event. 7.1.2. Practitioners recognised that Mother and N had a close attachment and worked to maintain this relationship. The concerns were that Mother was denying N access to schooling and the services essential to support the development of abilities and skills for a child with a disability. 7.1.3. There was a good understanding of N’s needs as a child with a disability and practitioners worked hard to offer the appropriate services to promote development and to support Mother in meeting these needs. The need for stimulation, play and supervision to promote N’s development and ensure safety were recognised. The services recommended by the Specialist Team (CSC), were appropriate for a child with special needs, e.g., play centre and support groups. 7.1.4. The CCG Agency Report Author notes that the GPs were child centred and recognised N’s individual needs in the context of the diagnosis. Appointments were routinely offered and GP records evidence attention to N’s presentation, e.g., appearance, behaviour and interaction with Mother. 7.1.5. Nursery 1 promptly identified N’s developmental delay, raised this with the CDC and contributed to the multi-agency assessment. The Education Psychologist was persistent in attempts to see N whilst undertaking the assessment and at the fourth attempt was successful. The Special Educational Needs Service encouraged mother to visit a special school for N, as this provision may be most suitable. School 1 focussed on developing N’s life skills, e.g., toilet training. When N commenced at School 2, Mother was concerned that N did not want to attend and would be upset when she left. School staff worked hard to provide evidence that N was settled, and suggested Mother come to school and reassure herself, but she declined. 7.1.6. The SALT assessed N as having ‘limited functional language’ and wanted to support the development of N’s social and communication skills, with strategies and the utilisation of aids, which would also promote inclusion. SALT was keen for sessions to be held in N’s home environment, but Mother wanted them outside the home. She tended to focus on N’s speech development, did not recognise the wider need to promote communication skills and was dismissive of aids and strategies. There appeared to be a change in Mother’s attitude towards speech therapy; prior to the move from the Local Authority area she wanted more speech therapy sessions but following their return would not consent to the service. 7.1.7. Health services encouraged sessions at educational settings to promote a co-ordinated approach to N’s needs, with workers present as well as Mother. They were aware the impact of not having a secure home and not attending nursery/school regularly would have on N as a child with a disability, exacerbated by the family’s isolation and limited social support. 7.1.8. The Housing Provider paid considerable attention to N’s safety when a property was allocated to the family. There was a joint assessment by Housing, CSC and OT as to the suitability of the property and Housing were advised by an independent medical organisation. The property was surveyed carefully, and steps were taken to make it safe for N, e.g., window restrictors, lock on front door. This was followed up by 13 the surveyor undertaking a property check in November 2019, which identified that a window restrictor had been damaged. 7.1.9. The CPP in April 2019 did not reference that N had a diagnosis of ASD and the long-term impact of neglect on a child with special needs. However, the CPP in December 2019 was more explicit, referring to N’s special needs and the concerns about Mother’s ability to understand and meet these needs. The Review and Planning Agency Report notes that N’s voice was heard through practitioners’ observations and interactions with N. The Social Worker’s descriptions of N were well observed; she was able to state N’s preferences and interests and recognised the affection shown towards mother. N’s special needs were an important factor in determining the level of risk as high and the decision that the CPP should continue. 7.1.10. In summary, there is good evidence of child-centred practice and practitioners demonstrated an understanding of the heightened risks posed by neglect for a child with a disability 7.2. What was practitioners’ understanding of the role of the father in family life and of his relationship with N and of what part he might play in promoting/securing N’s wellbeing? Did managers and practitioners demonstrate an awareness of the concern nationally about agencies’ lack of engagement with fathers? Has any training been provided for staff regarding this? 7.2.1. For some time, concern about agencies’ lack of engagement with children’s fathers and the focus on mothers has been highlighted in research and reviews of serious case reviews. This equally applies to a parent with parental responsibility not living in the household with the child and to significant others, e.g., wider family members. 7.2.2. It is understood that N’s parents’ relationship was short-term, and they had never shared a home together. The Health Visiting records note that when N and Mother moved into the area Father had a ‘significant role in N’s life’, with contact taking place every weekend. However, it appears that this pattern did not continue, with contact becoming more sporadic. None of the practitioners observed N with Father. 7.2.3. Records indicate that Father’s view changed during the Scoping Period, initially believing that Mother should be supported to care for N, but in the second set of family court proceedings he did not consider she could safely parent N. On occasions Father expressed a wish to be considered as a carer but subsequently withdrew the offers. 7.2.4. The overall picture is that most of the Health and Education agencies, apart from School 2, had not requested or recorded Father’s details and made little or no attempt to involve him in their work with N and Mother. They were not aware if he held parental responsibility. There is no evidence that he was involved in the development of the Education, Health and Care Plan or included in any meetings outside of those arranged by CSC. (Learning Point) 7.2.5. Health agencies: The Foundation Trust has little information regarding Father. No information has been provided as to whether he was invited to the Trust appointments, e.g., multi-disciplinary meeting to share the diagnosis of ASD, but he 14 did not attend any. His involvement was not considered when there were difficulties with gaining consent to SALT/OT involvement. Could Father have given consent for this? The GP records did not contain details of N’s Father; these were not recorded in the ante or post-natal records. (Single agency recommendation: Clinical Commissioning Group) 7.2.6. Education: Records evidence there was little involvement with Father. The exception being School 2 which contacted father when there were concerns about N’s attendance and difficulties engaging with Mother. He was invited to the school and did so on one occasion but unfortunately N was not in school that day. The School understood that whilst father wanted to be part of N’s life, this was difficult due to the nature of the parental relationship. Requests for school placements were made solely by Mother, notably the change from School 2 to School 3 which would have had a detrimental impact on N. Despite the Education Welfare Service being very concerned about N’s school attendance, the Service did not contact Father. This suggests that consideration was not given as to whether Father or other members of the paternal family might be able to support N’s school attendance. Hence this was potentially a missed opportunity. 7.2.7. Children’s Social Care: There is evidence that the Social Worker endeavoured to maintain contact with Father and keep him informed of developments. He was invited to participate in the Child Protection and CLA Planning and Review processes and attended some of these meetings. Greater engagement by Father might have identified other family members who could have offered N support and protection. 7.2.8. In summary, agencies’ lack of involvement with Father, particularly in the early stages, indicates a lack of consideration of his role in N’s life and the support and protection he and his family, e.g., a paternal grandparent, may have been able to offer N. Does this attitude devalue the role of fathers (and parents not living in the household)? What about his rights, given he had parent responsibility for N, e.g., did he have the right to know about the action being taken by the EWS? 7.2.9. The First Annual Report of The Child Safeguarding Practice Review Panel,9 highlighted the continued concern about the lack of information regarding fathers, noting that the ‘primary focus of health professionals and social workers continues to be on the need, circumstances and perspectives of the mother’. The Panel is concerned that ‘such a lack of curiosity in fathers and partners not only leaves women and children vulnerable, it can also leave fathers feeling alienated and forgotten and their role in bringing up the children dismissed’. It argues that services need to find ways to become more male friendly to encourage the involvements of men in the lives of their children. This finding has resonance for this LCSPR, as there were missed opportunities to engage Father in working alongside services in meeting N’s needs. This approach also applies to any parent with parental responsibility not living with the child and to significant others in the child’s life, e.g., grandparents, aunts and uncles. 9The Child Safeguarding Practice Review Panel Annual Report 2018 to 2019: Patterns in practice, key messages and 2020 work programme. 15 7.3. What understanding was achieved of the reasons for mother’s rejection of professional opinion and of services to promote N’s wellbeing (including the impact of culture, ethnicity and her lived experience) and what action was taken to promote her engagement? Was this identified as a risk factor for N? 7.3.1. It is apparent from Agency Reports and discussions at the Practitioner and Manager SILP Learning Events that Mother was a complex personality, mistrustful of professionals, fearful of losing her son, and there were challenges for practitioners in engaging with her. On occasions Mother would ask for help in managing N’s needs and behaviour but either decline services when offered, e.g., GP’s referral to Paediatric Dietitian, or only be prepared to accept services on certain conditions, e.g., SALT. 7.3.2. Mother’s behaviour towards professional staff was inconsistent and at times could be confrontational and intimidating. Social Worker 2 received a hostile response from Mother when she asked to see the bedrooms and similarly the Education Welfare Officer when she made a home visit to discuss the fixed penalty notice. Evidence would indicate that this resistance to professional engagement increased after the outcome of the first set of family court proceedings. It is noted that local procedures do not contain guidance for Working with Resistant Families, as other Safeguarding Partnerships have, and this would be helpful for practitioners. (Recommendation 1) 7.3.3. Mother is Black African and was cared for by a relative after the deaths of her parents. Despite growing up in a country experiencing a violent civil war, Mother has told practitioners that her childhood was happy, and her family were unaffected. The family are believed to be of some social standing and Mother received a good education. Mother has no family in UK. She is described by Health professionals as a ‘proud and private woman’. Despite attempts to do so, practitioners, including the Children’s Guardian, have been unable to explore Mother’s background in any depth, but it is known that for many people whose countries experienced genocide there has been a long-term impact with some experiencing mental health difficulties, including post-traumatic stress disorder. 7.3.4. Discussion at the Learning Events suggested that Mother had certain attitudes and values that presented challenges in securing services. There are indications that she preferred to deal with people with some status, e.g., Headteacher at School 1, GP. Also, that she did not treat practitioners of different ethnicities in the same way, e.g., not accepting services from Asian and Italian staff. This created challenges in building working relationships, but the CSC Report Author suggested these were not explored. 7.3.5. It is evident that during the period under review, a number of practitioners were concerned about Mother’s mental health. Two assessments were undertaken by mental health services, due to her paranoid thoughts. These concluded that Mother did not have a diagnosable psychiatric condition, but there were indications that her mental health was fragile at times. The Independent Reviewing Officer and Children’s Guardian recognised the need for a psychiatric assessment in the care proceedings. This assessment similarly concluded that Mother was not suffering with a depressive or other mental illness, nor did she have a personality disorder. 16 7.3.6. Mother had difficulty understanding and accepting N’s diagnosis of ASD and practitioners are of the view that she hoped N would be ‘cured’. It is evident that following the diagnosis, a considerable amount of support and specialist services were offered to N and Mother by the CDC, SALT, nurseries and CSC. Some of this she engaged with, however, it was difficult to gain her sustained co-operation. The underlying reason for this appears to be a reluctance to accept the diagnosis and it is not clear from the reports and discussions what actions were taken by practitioners to understand the reasons behind this reluctance and to encourage Mother’s understanding and acceptance. 7.3.7. There are two particular areas for reflection and learning. Firstly, whilst there was a lot of professional activity and inter-agency communication, there is a question about whether this was effectively planned and co-ordinated. It was planned to hold a review meeting six months after the diagnosis in October 2017, but this did not take place and there were no further multi-disciplinary meetings arranged by health agencies. This would have provided the opportunity to co-ordinate the activities of the range of health professionals and to consider how best to engage with Mother and encourage her understanding. Although the Paediatrician at the CDC was the lead professional, a ‘key worker’ was not identified who could have taken the lead in building a relationship with N and Mother. It is understood that in similar circumstances the CDC would now convene multi-disciplinary meetings to discuss any difficulties in engaging with a family and what action could be taken. (Learning Point) 7.3.8. Practitioners from health agencies and N’s nursery were not informed of or engaged in the Child in Need plan in 2017. Hence, this was another missed opportunity to coordinate the work of the large number of practitioners working with N and Mother, even if she had declined to engage in this. The lack of co-ordination of Child in Need plans for children with disabilities was identified in Ofsted’s Thematic Inspection, highlighting that many CIN plans were not detailed or focused on outcomes and reviews did not always include all professionals working with the children. 10 (Learning Point) 7.3.9. Secondly, there is limited evidence that Mother’s ethnicity and culture were considered in understanding her response to N’s ASD diagnosis, hence practice lacked cultural awareness and sensitivity. There is a lack of evidence that Mother’s background was considered in the support offered following diagnosis, which could be seen as a crucial time for the family. The Practice Guidance, Safeguarding Disabled Children, 11 highlights the potential for double discrimination and that children with a disability from Black and minority ethnic groups can receive services that are ‘not sensitive to their culture and language or relevant to their needs’. This lack of awareness was mirrored in the Agency Reports where, despite this aspect being included in the KLOE, it was not addressed. The Education Report Author recommends that the impact of a family’s ethnicity and culture should be addressed in safeguarding training and clinical supervision. (Education Single Agency Recommendation) 10 Protecting disabled children: Thematic Inspection. Ofsted 2012. 11 Safeguarding disabled children: Practice Guidance. DCSF 2009. 17 7.3.10. It should be noted that The Children’s Specialist Support Team did recognise the impact of Mother’s ethnicity and culture and allocated an experienced, skilled, French speaking Social Worker to work with the family, evidencing an attempt to reach out to Mother and put her more at ease. A Black social work student also supported the work. The Social Worker attempted to discuss the cultural aspects but had difficulty in establishing a dialogue with Mother. There is a view that this may have been due to underlying psychological issues. 7.3.11. An acknowledgment of the need for a further specialist assessment to understand the barriers to Mother’s engagement and her dismissal of professional opinions was noted at the Child Protection Conferences. The Child Protection and Review Agency Report Author highlights the need for practitioners and managers to routinely consider the impact of culture and ethnicity within assessments and planning. (Recommendation 3) 7.3.12. There is a body of literature that references the challenges for parents of African origin in accepting the diagnosis of ASD and that their child has special needs. Involving African families in the education of their autistic children, published by The National Autistic Society (NAS), 12 highlights the need to be aware of cultural differences in working in partnership with parents. The paper suggests that there remains a stigma attached to having a child with autism within African families, some may believe that autism is a result of adultery or witchcraft. Parents can fear the label and family and friends knowing that their child has autism. The NAS recommends that if professionals show some understanding of the family’s culture, parents will respond positively and feel more comfortable to work in partnership. 7.3.13. Autism in Black, Asian and Minority Ethnic Communities, the Report on The First Autism Voice UK Symposium 13 highlights that culture plays an important role in how people view autism and recommends that service providers need to broaden the support menu currently available to include a culturally sensitive approach to diagnosis, family-specific care and support services. At the Learning Event the Foundation Trust’s Safeguarding Lead noted that there is no word for autism in many languages spoken within the BAME community and parents might well not understand the nature of autism. (Learning Point and recommendation) 7.3.14. It is difficult to know whether a more co-ordinated approach to supporting the family and providing services to N, combined with increased cultural awareness, would have made a difference to Mother’s engagement with services, particularly in view of what appears to be her fragile mental health, but certainly there are important lessons here for working sensitively with BAME families from the point of diagnosis of a child’s special needs/a disability. 7.3.15. An additional factor to consider in respect of Mother’s engagement with agencies is the outcome of the family court proceedings in August 2019. No orders were made, and Mother had agreed to co-operate with a Child in Need Plan. However, there is no evidence that she did so and by December 2019 N was again the subject of a Child Protection Plan. 12Bankole, Olatokunbo, Involving African families in the education of their autistic children, National Autistic Society, 4 April 2016. 13Autism in Black, Asian and Minority Ethnic Communities: A Report on The First Autism Voice UK Symposium. 2020. 18 7.3.16. Throughout agencies engagement with the family, there had been difficulties gaining Mother’s consistent co-operation and concerns had been escalated appropriately through Child in Need and Child Protection Plans to family court proceedings. Discussions at the Learning and Recall Events indicated that post-proceedings practitioners felt undermined, lacking in authority, and were at a loss as to how best to work effectively with the family to safeguard N. 7.4. What impact did Ms K’s lack of engagement have on practitioners and on the effectiveness of the safeguarding network? 7.4.1. Despite the challenges for practitioners working with the family, it is evident that many made real efforts to work together and engage with Mother, e.g., School 2, the Social Worker and Education Welfare Officer. They recognised the adverse impact of her lack of engagement on N as a child with special needs and on his global development. There is a view that Mother’s non-engagement increased on the family’s return to the local area in 2019 and following the family court hearing. This was recognised as a risk factor in the return to an ICPC in December 2019. 7.4.2. The Education and Children’s Support Services Report Author notes that there was a consistent theme across provisions of N’s Mother being ‘defensive and suspicious’ towards staff, of expressing the need for help, but refusing this when arrangements were made. Mother appeared to be worried that professionals would take her son away and hence kept him away from professional sight. 7.4.3. SALT was persistent in attempts to gain mother’s consent to a service for N, sought advice from the Safeguarding Team and shared the information at the Strategy Meeting. 7.4.4. The nurseries and schools worked hard to find ways to engage with Mother. School 1 supported Mother to encourage N’s attendance, which led to good progress, e.g., with toilet training, widening diet, and academically with numbers and phonics. The school was confident that this good progress would have continued if N’s attendance had been regular. 7.4.5. The Educational Welfare Officer had weekly telephone contact during the pandemic to try and encourage N’s school attendance, as did School 2’s Family Support Worker. However, Mother was angered by this contact and as a result requested a change of school. This was agreed with the Special Needs Officer without consultation with other agencies and without consideration of the impact of a further change, to a third school, on a young child diagnosed with ASD for whom this would be difficult and may well have hindered any progress made. 7.4.6. During the initial child protection proceedings and the care proceedings the allocated Social Worker specialised in working with children with disabilities and their families. The Social Worker was experienced in communicating with children and was French speaking. There is evidence that the Social Worker persisted in trying to establish an effective relationship with Mother and support her in understanding and meeting N’s needs. This was recognised in the Family Court Judgement, which noted the obvious commitment of the family’s Social Worker and that she had exhausted all her skills in trying to engage with Mother, 19 7.4.7. The CSC Report Author highlighted that Mother’s lack of engagement left workers feeling ‘frustrated and drained’ whilst trying to manage what was perceived as a high-risk case. Practitioners ‘knew something was going to happen’. This was particularly noticeable during the period when N was the subject of an Interim Care Order and placed with Mother under Placement with Parent Regulations with intensive supervision. There is evidence that the impact on practitioners was recognised and the CSC put support processes in place with weekly Team Briefings to update the Team and ensure that both practical and moral support was available. The Head of Service and Assistant Director were well informed. 7.4.8. This professional fatigue was recognised by the LCSPR Panel, highlighting the importance of regular, reflective, safeguarding supervision and the value of multi-agency group supervision in such cases. (Learning point) 7.4.9. The CAFCASS Children’s Guardian notes the significant efforts that practitioners made at various stages during the care proceedings to work collaboratively with mother, e.g., at the residential placement. There would be ‘brief positive changes by mother’ and investment in care plans but these were short-lived. 7.4.10. There is also evidence that Mother’s hostility led workers to not pursue matters, including those relating to risk to N. The EWO felt threatened on the visit to discuss the fixed penalty notice. The social worker was refused access to the bedrooms, which meant they were unable to check the window restrictors. Therefore, Mother’s behaviour prevented the practitioner taking protective action. 7.4.11. Agencies recognised that Mother’s lack of engagement with services, which led to N’s lack of attendance at health appointments and inconsistent attendance at school, impacted adversely on N’s wellbeing and development, particularly social and intellectual development, which was magnified for a child with a disability. The lack of access to SALT hindered the important development of N’s communication skills and must have increased any sense of isolation. It was this inability to promote N’s welfare and safety that led to the Local Authority’s decision to initiate care proceedings twice. 7.4.12. In summary, Mother’s lack of engagement hindered agencies in providing services which would support N and promote his development, physically, socially and intellectually, and this position was exacerbated following the outcome of the family court proceedings in August 2019. It also prevented the social worker undertaking the necessary checks of safety in the home. Currently the Safeguarding Board does not have guidance for practitioners on working with resistant families and with disguised compliance.14 This would be an important addition to the Multi-Agency Safeguarding Arrangements Procedures. (Recommendation 1) 14 Working with families who display disguised compliance: Guidance for Professionals. Wirral safeguarding Children Board, December 2017. 20 7.5. What assessments were undertaken of the protective factors and risks to N and did the categories of abuse identified in the Child Protection Plans fully address the risks to N? Was sufficient consideration given to the risks of physical and emotional harm associated with long term neglect? 7.5.1. N was the subject of several Strategy Meetings and Section 47 enquiries. The Police Agency Report Author raises the question of whether joint police & CSC enquiries, rather than single agency enquiries by CSC, could have been considered, as it would be with concerns about physical and sexual abuse. When there are serious concerns about neglect, notably a history of children being left unattended, Police Officers can make house-to-house enquiries, identify witnesses and collect statements, e.g., from neighbours, which would provide evidence for child protection procedures as well as family court proceedings. Officers could also advise neighbours of the action to take when they have concerns, which would allow for protective action when appropriate. 7.5.2. The Agency Report Author suggests that there could have been greater consideration of whether there was a role for the Police to establish whether Mother should be held criminally responsible for her lack of care/neglect of N, i.e., a proactive role for the Police. There were such significant concerns that the Local Authority was seeking removal, a criminal investigation may not have resulted in charges being brought, but it could have supported the court proceedings and demonstrated to the court the gravity with which Mother’s actions were viewed by the Police Force. (Learning Point & Recommendation 2) 7.5.3. The Police were not represented at any of the CPCs, including the ICPCs. Due to insufficient staff to attend all ICPCs, attendance has to be prioritised. An Internal Review in 2020 noted that attendance had fallen below the expectations of the Local Authorities (ICPCs 63% and RCPCs 5%)). Steps are being taken to address this, with remote attendance and requests for officers involved with a criminal investigation relating to the family to attend. MASH Police staff review the minutes of RCPCs 7.5.4. There were two periods when N was the subject of a Child Protection Plan. The first short period being from April to May 2018, when an Interim Care Order was granted to the Local Authority and N became a child looked after (CLA), and the second being from December 2019 until September 2020 when N again became a CLA following the serious incident. 7.5.5. At the ICPC in April 2018, the decision was that N was at risk of significant harm and required a CPP in the category of neglect 15. The danger statement noted that Mother’s sporadic engagement with professionals meant N was not receiving the support required to aid development. Additionally, Mother’s difficulties in managing 15 Neglect: The persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to: a. provide adequate food, clothing and shelter (including exclusion from home or abandonment) b. protect a child from physical and emotional harm or danger c. ensure adequate supervision (including the use of inadequate caregivers) d. ensure access to appropriate medical care or treatment It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs. Working Together to Safeguard Children: A guide to interagency working to the safeguard and promote the welfare of children HMG, 2018. 21 her finances meant the family did not have a stable home and N was not attending nursery, The CPP included: parenting assessment and expert assessment of Mother’s functioning, N to attend school for further assessments, SALT and OT support for N and support for Mother in relation to housing. The Local Authority were to take legal advice. The risks to N were well recognised by agencies and the category of harm, i.e., neglect, was appropriate. 7.5.6. Following the final hearing in the family court in August 2019, when no orders were made, concerns about the risks continued. N’s school attendance was poor, Mother did not give consent for SALT involvement and there were concerns about N’s safety, e.g., being left unattended, observed to be in danger on the roads, damaged window restrictors. An ICPC was held in December 2019 and again it was agreed that N was at risk of significant harm and required a CPP, in the category of emotional abuse. 16 7.5.7. There have been discussions at the LCSPR Panel and the Managers’ Learning Event about the choice of category of harm and whether emotional abuse was appropriate. Evidence would indicate that the wider definition of neglect fitted more closely with the risks to N and emotional abuse less so, The Named Professional for Safeguarding for the NHS Foundation Trust had suggested at the Conference that neglect would encompass the risks to N’s physical, social and emotional needs. 7.5.8. At the Learning Event, the Conference Chairs’ Manager suggested that this decision may have been made because parents can find the term ‘neglect’ difficult to accept so ‘emotional abuse’ was used as this may have been less distressing for Mother. Additionally at the Panel, it was suggested that, given the outcome of the family court proceedings and the ongoing difficulties engaging with Mother, professionals were ‘bewildered’ and trying to find different ways to engage with her post the care proceedings, i.e., a sense of what else can we do? 7.5.9. Whilst it is perfectly understandable that professionals were looking for ways to engage with Mother, this thinking meant that the decision was based on Mother’s needs and not on the day-to day-experiences and risks to the child. Neglect is much closer to what N was experiencing, e.g., a failure to meet N’s physical and psychological needs, likely to result in impairment of the child’s health or development, to protect a child from physical and emotional harm or danger and to ensure adequate supervision. (Learning Point) 7.5.10. The significance of the category of abuse is that it highlights the greatest risks to the child and sets the focus for the development of the CPP. The danger statement 16 Emotional Harm: The persistent emotional maltreatment of a child such as to cause severe and persistent adverse effects on the child’s emotional development. It may involve conveying to a child that they are worthless or unloved, inadequate, or valued only insofar as they meet the needs of another person. It may include not giving the child opportunities to express their views, deliberately silencing them or ‘making fun’ of what they say or how they communicate. It may feature age or developmentally inappropriate expectations being imposed on children. These may include interactions that are beyond a child’s developmental capability, as well as overprotection and limitation of exploration and learning, or preventing the child participating in normal social interaction. It may involve seeing or hearing the ill-treatment of another. It may involve serious bullying (including cyber bullying), causing children frequently to feel frightened or in danger, or the exploitation or corruption of children. Some level of emotional abuse is involved in all types of maltreatment of a child, though it may occur alone. Working Together to Safeguard Children: A guide to interagency working to the safeguard and promote the welfare of children HMG, 2018. 22 noted that N was not attending school and lacked structure and routine, which would impact on his learning and emotional development, and the impact of the Mother’s lack of a support network and isolation on her mental wellbeing. There is no reference to the concerns about N’s lack of boundaries and supervision and risks to physical safety. The actions in the CPP include an updating of Mother’s psychological assessment, N to attend school, Mother to access social and community resources and consistent arrangements for contact with Father. However. there is no action in respect of the physical risks to N, e.g., promoting road safety and checking the door locks and window restrictors are functioning. (Learning Point) 7.5.11. The CPP was reviewed at the RCPC in March 2020; a decision was taken to continue with the plan but, appropriately, the category was changed to neglect. There had been a further incident of N running into the road with cars needing to swerve and concerns about N running on the flat windowsills. However, there were no changes to the actions in the CPP or to the timescales for the completion of these. Therefore, there is a question about how effective this CPP was in providing a working tool for practitioners in protecting N. (Learning Point) 7.5.12. The gap in the CPP relates to the lack of recognition of the risk of physical harm; there had been reports of N being left unattended, running into the road whilst in mother’s care and concerns about the window restrictors becoming detached. These serious risks should have been addressed in the plan, so that practitioners remained mindful of them. An appropriate action would have been that the Social Worker and a representation from Housing should undertake checks of the safety features in the family home every 4 weeks. 7.5.13. There were two incidents during this period of child protection planning which were not followed up sufficiently robustly. Firstly, the Social Worker observed a broken window restrictor and secondly, the EWO was informed by Mother that N had got into the bath twice and turned the taps on. The lack of focus on the physical risks may be the explanation for this, which highlights the importance of CPPs clearly identifying risks to children. 7.5.14. Each of the agencies represented at the CPC has responsibility for drawing together an effective CPP. Questions for the Board are whether the fact that the CPP was not refreshed at the RCPC is common practice and whether attendees at CPCs see themselves as having an active role in the formation of the CPP. (Recommendation 4) 7.5.15. The research paper ‘The Role of Neglect in Child Fatality and Serious Injury’ 17 has relevance for this review. It ‘offers ‘a re-analysis of neglect in serious case reviews’ from four consecutive government commissioned national two-yearly studies. The study explored ‘how circumstances came together when neglect has a catastrophic impact on the child’ in six difference ways, one of which was ‘accidents with elements of forewarning’. Accidents are sudden, unexpected, events without forewarning, but for these children there were a range of factors which meant that the incident, although not directly predictable, offered some element of forewarning. Similarly, the 17 Brandon, Bailey, Belderson and Lasson: The Role of Neglect in Child Fatality and Serious Injury. Child Abuse Review Vol 23: 235 – 245 (2014) Wiley Online Library. 23 NSPCC Briefing (2015)18 suggests that attention should be paid to frequent accidents and injuries as these may be an indicator of poor-quality parenting through the lack of supervision or of living in an unsafe home. This was certainly true in respect of N’s fall from the window; there had been concern about N’s safety in the home and in the street and about the level of supervision N received for some years. The practitioners ‘knew something was going to happen.’ There was an ‘element of forewarning’. (Learning Point) 7.5.16. In respect of N, there is evidence that there was concern about immediate risk of harm and a sense of urgency in the work, hence the Local Authority initiating two sets of care proceedings. However, there is evidence that the child protection planning from December 2019 to September 2020 was not effective and did not address the serious and enduring risk of physical harm to N. 7.5.17. In summary, it was recognised that N was at high risk, and it was appropriate that child protection procedures were initiated, and N was made the subject of a CPP. However, there are questions about whether the category of harm in December 2019 reflected the nature of the risks and whether the plan was effective in protecting N, both in its actions and timescales. Evidence would also suggest that the fact that physical ham was not referenced in the CPPs meant this was then not highlighted in the Local Authority’s evidence for the second set of proceedings, potentially undermining the case for immediate removal of N for his safety. 7.6. Were there barriers that prevented agencies taking timely measures to safeguard N and, if so, do these have an impact on partners’ ability to safeguard children with a disability more generally? 7.6.1. The additional vulnerability of children with disabilities and that neglect will have both a short-term and long-term impact on their development and wellbeing is understood. There were several factors which undermined agencies’ ability to promote N’s welfare and put safeguarding measures in place. 7.6.2. Firstly, the family moved frequently and were not always living in suitable accommodation, e.g., B & B, Travelodge. Additionally, the two placements when N was a CLA were outside the Local Authority area, and it took time to trigger local services. These changes of accommodation and placements presented challenges for services in gaining access to and providing timely services for N. The family were registered at three GPs, which the CCG’s Report Author considers affected continuity of care. 7.6.3. Secondly, Mother’s presentation was extremely changeable, at times appearing to want help but not accepting this when offered. The Foundation Trust’s Report Author suggests that where there is a lack of parental consent to treat a child, despite strong evidence of the clinical need, consideration should be given to escalation to senior managers and discussion with CSC. (Foundation Trust: Learning Point and Recommendation) 18 NSPCC learning: Neglect: Briefing summarises the risk factors and learning for improved practice around neglect. September 2015. nspcc.org.uk/learning. 24 7.6.4. Thirdly, there appears to have been a delay in the progression of the second set of family court proceedings. The Local Authority initiated care proceedings in June 2020, the case was adjourned at the Case Management hearings in July and August, and a hearing date was set for October 2020, four months later. This was a significant delay given there had been serious concerns about N’s welfare and safety since December 2019 when the CPP had not progressed and was not safeguarding N. 7.7. To what extent has the Covid-19 pandemic impacted either on the circumstances of the child or family or on the capacity of the services to respond to their needs? 7.7.1. Information presented to the LCSPR provides evidence that undoubtedly the restrictions imposed by the pandemic increased the family’s social isolation and vulnerability and presented additional challenges for agencies in providing services to safeguard and support N’s wellbeing and development. The Foundation Trust’s Author suggests that Mother’s lack of engagement with services to meet N’s needs was ‘masked by the pandemic’. However, the risks to N were such that his needs were prioritised by agencies during the pandemic. 7.7.2. CSC operated a traffic light system for evaluating cases and N was consistently rated as red, which meant that home visits continued. A school place was available, although Mother took the decision not to access this. Both the school and the EWS maintained regular contact and endeavoured to encourage N’s attendance. The lack of attendance at school increased risks to N’s development as well as to physical safety, 7.7.3. Health agencies also rag rated N as red due to the significant risk, which was likely to increase due to more time spent at home during lockdown. The GP continued to offer face to face appointments for more vulnerable patients, including N. 7.7.4. The one service area where there appears to have been an impact was in the family courts. The Local Authority instigated care proceedings in June, at a hearing in July the court did not agree that the test for interim separation was meet. There was a case management hearing in August and a date was set in October 2020 for an interim removal hearing, i.e., four months later. It is understood that there were two reasons for this delay, firstly the difficulty with providing Covid safe courts and secondly, the shortage of judges. 7.8. Learning in respect of the family court proceedings: ‘Plans and interventions for disabled children suffering neglect should be time-limited, with a focus on measuring whether sufficient change has occurred to secure the safety and well-being of the child.’19 7.8.1. With the consent of the Judge, various court documents have been made available to the Lead Reviewer. These include the reports of the expert Psychologist and the Judgement in the first set of proceedings which concluded in August 2019. The Psychologist had been provided with documentation and met once with N and 19 Kennedy and Wonnacott: Neglect of Disabled Children. Chapter 13: Child Neglect: Practice issues for health and social care. Jessica Kingsley Publishers, 2005. 25 Mother, once with N and Father and briefly with both parents prior to preparing the first report in May 2018. He had met with them once more before preparing an update in May 2019. Also made available to the Lead Reviewer were statements from the Mother, Local Authority and Children’s Guardian in the second set of proceedings, which commenced in July 2020, 7.8.2. First set of family court proceedings: There are a number of factors to take into account: • The Judgement noted that the decision of the Court was ‘finely balanced’. • Within the proceedings an application had been made by the parties to jointly instruct an expert Psychologist. This was found by the Court to be ‘necessary’ to resolve the proceedings. • The Judge was highly complementary of the work undertaken by the Social Worker and acknowledged the commitment made to trying to find ways of engaging positively with Mother. • The Local Authority and the Children’s Guardian, CAFCASS, did not concur with the assessment of the jointly instructed Psychologist. • Within the proceedings there was robust challenge to the evidence of both the Psychologist and the Social Workers, to the extent that the Independent Social Worker, instructed by the Local Authority to undertake a parenting assessment, reconsidered and no longer supported the Local Authority’s plan for a Placement Order. • The Court found that the threshold criteria for significant harm were met. • When considering the welfare stage, the Judge did not find, when applying the welfare checklist 20, that the Local Authority’s Care Plan, which was to separate mother and child and place N for adoption, was in N’s best interests. The test for severing the parent/child relationship, where the care plan is adoption, is very strict and should only happen when there is no other option, when ‘nothing else will do’ (this is a welfare test). 7.8.3. The Psychologist’s position was that there was a positive attachment between N and Mother, and this should not be discarded lightly; separation would be psychologically damaging to N, more so for a child with autistic spectrum disorder. Mother could provide good enough care and the family required an appropriate education placement for N and suitable housing. The Psychologist recognised that Mother’s lack of autistic specific knowledge and skills were party due to not attending sessions rather than a psychological difficulty and she needed to learn autism specific management techniques and develop better ways of co-operating and negotiating with others. Mother risked alienating the very people offering to help, but if she was given appropriate training, therapy and support she could manage to care for N long term. Mother had stated a willingness to take part in the programmes recommended. 20 Welfare Checklist: Children Act 1989, Section 1 (3) and Adoption and Children Act 2002 Section 14. 26 7.8.4. No orders were made, and the Judge anticipated that, following the conclusion of the proceedings, N would become the subject of a Child in Need Plan and receive support and services through this route. 7.8.5. The findings and recommendations of the Report of the Public Law Working Group, published in March 202121 may be relevant for this LCSPR. The Report noted the increase in the number of experts being approved by the courts in public law proceedings. It highlighted that such applications should not be made unless the opinion of an expert is necessary and such an instruction can lead to delays in proceedings. This was judged to be ‘necessary’ in the case under review. 7.8.6. The report also highlighted that ‘Professionals who know the family and the child should feel confident about reporting to and advising the court’ and made the following recommendation regarding this. • Recommendation 33: There should be a shift in culture and practice away from early instruction within proceedings of experts. Social workers and Children’s Guardians are expected to have the expertise to make professional judgements and assessment both generally and particularly in respect of the assessment of siblings and parental relationships/bonds and commenting upon attachments. 7.8.7. It is interesting to note that this recommendation for the family justice system reflects discussions that have taken place in the course of this LCSPR, notably the value that courts place on the evidence of social workers, who may know a family well, and the Children’s Guardian, who is appointed by the court to represent the rights and interests of the child, to be the child’s voice. Recommendation 33 recognises the expertise that social workers and Children’s Guardians bring to the family court proceedings. 7.8.8 Since the conclusion of the proceedings, there has been a case in the appeal court which may also have relevance for the review, The N (Children: Refusal of Placement Orders) 22 where the Family Court Judge had refused the Local Authority’s application for care and placement orders despite ‘severe difficulties’ and the Local Authority appealed. Lord Justice Peter Jackson concluded that ‘the Judge was entitled to decide that it might be possible to reunite the children with their mother’. However, • He should not have dismissed the local authority’s application without first ensuring that reunification was underpinned by clearly understood court approved arrangements. • Accordingly, the appeal will be allowed to the limited extent that the local authority’s application is remitted to the Judge so that he can consider and endorse such arrangements or, if they cannot be devised, redetermine the application. 21 Public Law Working Group: Recommendations to achieve best practice in the child protection and family justice systems. Final Report (March 2021). 22Case no: b4/2021/1517: N (children: refusal of placement orders): In The Court of Appeal (Civil Division) on appeal from The Family Court at Liverpool 27 7.8.9. This Judgement indicates that there is now an expectation placed on Family Court Judges to ensure that there are realistic plans in place to support a child’s rehabilitation and hence refuse a local authority’s application for a placement order. 7.8.10. Second set of family court proceedings: These proceedings were initiated in July 2020 and the Local Authority made an application for an Interim Care Order with a plan for immediate separation and N’s placement in foster care. The Judge and the Children’s Guardian considered that the Local Authority had not provided sufficient evidence to show that N was at immediate risk of harm requiring separation. The Judge refused the application, on the basis that the test for immediate separation was not met, and a hearing date was set in October 2020. 7.8.11. The statements of the Social Worker provided evidence of the impact of Mother’s continued lack of co-operation on N’s development, e.g., education, speech and language therapy, and highlighted the risks in the lack of road safety. However, there is no reference to concerns about safety in the home. The Local Authority and the Housing Provider had taken substantial steps to ensure that the flat was safe for N, e.g., fitting window restrictors, an additional lock on front door, but there had been concerns about the window restrictors becoming detached. 7.8.12. An explanation for the absence of this evidence in statements may be due to the lack of attention to the physical risks in the child protection planning, as referred to in 7.5.7/7.5.10. As this risk had not been highlighted in the Child Protection Plan, it is not surprising that its significance was not brought to the attention of the court in the evidence presented. If this information had been included. it would have provided more evidence in respect of the immediate risk of harm to N. 7.8.13. The review has highlighted the importance of practitioners from all agencies having sufficient time to prepare statements for court and for them to be provided with management oversight and reflective supervision when undertaking this important task. (Learning Point) 8. Good Practice Identified: • Evidence of child centred practice: Many of the practitioners spoke very warmly of N, they knew him well and understood his needs. • Practitioners demonstrated an understanding of the impact of long-term neglect on a young child with a disability and this informed the assessment of risk and escalation of concerns. • The Social Worker showed commitment, understanding and tenacity in trying to establish a working relationship with Mother in order to support her in meeting N’s needs. The Judge complimented the work of the social worker and commented that if there was any other means of engaging with the family, she would have tried this. • CDC did not accept the response to concerns about Mother’s lack of engagement with the services offered, escalated this internally and contacted CSC to ensure the extent of the concerns were fully understood. 28 • Educational settings worked hard to engage with N’s mother and to promote N’s development, socially and academically. School 2 engaged with Father to support N in school. • SALT recognised the impact on N of not receiving therapy and were tenacious in seeking consent. • The Educational Psychologist showed determination to see N to undertake the assessment and did so on the fourth attempt. • The EWO maintained weekly contact with mother during the pandemic to try and encourage N’s attendance at school. • Housing ensured that the necessary safety modifications were made to the family’s flat prior to them moving into the property. • The Children’s Specialist Services Team held weekly team briefings to ensure that all workers in the team were kept up to date with developments, intervention with the family was well co-ordinated. and practical and moral support was offered to the practitioners. • GPs records flagged CPP, CLA and diagnosis of ASD. Routinely offered Mother a face-to-face appointment at the surgery following telephone consultations. 9. Key Learning: 1. Multi-disciplinary working: Following the diagnosis of a child’s disability by the Child Development Centre, support for the family should be co-ordinated through multi-disciplinary team meetings and plans that are reviewed regularly. 2. Cultural awareness and sensitivity: Work with families should demonstrate cultural awareness and sensitivity and an understanding of the impact that race, culture and religion can have on parents’ behaviour and reactions and how best to offer support and encourage engagement with a view to promoting the child’s best interests. (Recommendation 3) 3. Engagement with the Father/a parent not living in the household: All agencies should obtain the names and contact details of a child’s father/parent not living in the household, importantly those with parental responsibility, and as a matter of course inform and engage them directly in important decisions and discussions regarding their child, e.g., formulation of Education, Health and Care Plan (EHCP), unless there is a reason not to do so. Where parents are not living in the same household, agencies should not rely on one parent to share this information with the other parent. Practitioners need to be aware of the potential support and protection that can be offered to the child by the parent not living in the household and their wider family. (Single agency recommendations) 4. Working with resistant families: Practitioners require the knowledge and skills to positively promote engagement with families who are resistant and hostile to 29 co-operating with services offered, whilst understanding the inherent risks to the wellbeing and safety of children. (Recommendation 1) 5. Professional fatigue: Managers need to be alert to professional fatigue and ensure that regular reflective supervision is in place for practitioners and give consideration to the use of multi-agency group supervision where this is appropriate. 6. Child in Need Planning: The importance of the involvement of all practitioners and agencies working with a family being involved in the development and implementation of a Child in Need plan, notably health agencies. This is particularly vital when a child has a disability. 23 7. Investigation of neglect: When a strategy meeting is held and a section 47 enquiry initiated where serious concerns for cruelty/neglect of a child are identified, all circumstances should be reviewed to ascertain if the threshold is met for a joint agency investigation. If it is deemed that, on the balance of probabilities, the cruelty/neglect is likely to amount to a criminal offence then the crime will be recorded by police in accordance with NCRS/HOCR. Where a joint investigation is agreed Children’s Social Care and Police should then ensure that all available evidence is collated and analysed. (Recommendation 2) 8. Neglect & Accidents: Accidents are sudden, unexpected, events without forewarning, but for children experiencing neglect there can be a range of factors which mean that incidents, although not directly predictable, have some element of forewarning. 9. Child Protection Planning: The category of harm should reflect the risks to the child and these risks should be articulated in the Child Protection Plan (CPP), with actions to address them within specified timescales. CPPs are dynamic documents and should be updated after every Review Child Protection Conference to reflect the current position and identified risks. All agencies represented at the CPC and Core Group have a responsibility to ensure that the CPP is an effective tool in safeguarding the child. 24 (Recommendation 4) 10. Family Court Proceedings: ➢ Statements for Family Court proceedings should articulate clearly all the risks of harm to a child. ➢ Importance of social workers and practitioners, who are providing reports to courts, having sufficient time to prepare the analysis, together with reflective discussions in supervision. Recommendations to the court should be clear about the impact on the child if the recommended course of action is not agreed. ➢ Consideration should be given as to how partners can inform the family 23 Protecting disabled children: Thematic Inspection. Ofsted 2012. 24 Protecting disabled children: Thematic Inspection. Ofsted 2012. 30 court process to ensure the best evidence is made available and to promote the value of evidence available from professionals who have had significant involvement with a child and family over a period of time, e.g., health, education. 10. Recent Developments: Education Welfare Service: • Since 2020 staffing levels have Improved, including the appointment of Children Missing Education (CME) and Elective Home Education (EHE) Officers. • February 2020 Elective Home Education and Children Missing Education Groups established to provide strategic oversight of the development of services. • Relationships with schools strengthened. Housing: • In line with best practice, Local Authority Housing no longer places families in B & B accommodation. Whenever possible, homelessness is prevented, and a planned move secured to self-contained accommodation. • When CSC accepts a duty to accommodate a household, Housing and CSC work collaboratively and Housing provides support in sourcing suitable accommodation. Police: • In response to a previous LCSPR, Thames Valley Police have produced a training package around providing a service to individuals with neuro developmental conditions, which is mandatory for operational Police officers/staff. • This training is being implemented within the vulnerability training for all new intake officers as part of their introductory training. • Operational guidance is being reviewed to establish if it requires amendment for Police Officers. Children’s Social Care: • Child Protection Conference Team: ➢ Training on developing SMART Child Protection Plans, which are child centred and outcome focused, and on identifying the category of harm. ➢ Child Protection Conference Manager undertakes quarterly quality assurance activity, including audits of child protection plans and 31 observations of child protection conferences. ➢ Child Protection Chairs routinely audit any repeat child protection plans. Learning is shared with the Heads of Service. • Social work staff (Including the Child Protection Conference Team): ➢ Motivational Interviewing Training to promote the values of Family Safeguarding: valuing strengths, solution focussed, high support/high challenge. ➢ Mandatory cultural competence training, ensuring cultural and identity needs are considered in the development of safety plans. ➢ Training in working with difficult to engage with parents, practical ways to creatively look at resistance and how to break down barriers and improve communication. 11. Conclusion: 11.1. This local child safeguarding practice review concerns N, a young boy diagnosed with autism spectrum disorder, who fell from a second storey window and sustained serious, life-threatening injuries. At the time N was the subject of a child protection plan and the Local Authority had, for the second time, initiated care proceedings, two months earlier. The fall cannot be considered an accident, it was an incident ‘with an element of forewarning’.25 11.2. LCSPRs routinely identify concerns about the robustness of risk assessments, the quality of communication between agencies, the timeliness of action taken by agencies and crucially a lack of focus on the needs of the child. Whilst some important learning has been identified in this LCSPR, none of the above perennial concerns are evident in the intervention by agencies, individually or on a multi-agency basis. 11.3. The increasing risks to N, a child with additional needs, from neglect were recognised and the level of intervention was escalated appropriately, through a Child in Need Plan, a Child Protection Plan and Family Court proceedings. Importantly, the focus was maintained on N’s individual needs and protection, on the impact of the lack of services, including specialist services, being accessed by the family, as well as the serious concerns about N’s safety and wellbeing. 11.4 The key learning relates to the need for cultural awareness and sensitivity in agencies’ work with families, the importance of engaging with a parent not living in the household to assess the potential for support and protection from the wider family, the need for practitioners to develop the skills in working with resistant individuals and the value of robust child protection plans, which clearly identify the key risks, how these will be managed and the timescale for doing so. 25 Brandon, Bailey, Belderson and Lasson: The Role of Neglect in Child Fatality and Serious Injury. Child Abuse Review Vol 23: 235 – 245 (2014) Wiley Online Library. 32 11.5. There has been careful consideration of the evidence presented to the review and it appears that the outcome of the Family Court proceedings in August 2019 was a significant point. The Judgement was that no orders would be made by the court and that services to N and the family would be offered through a Child in Need Plan. 11.6. There was substantial evidence indicating that Mother was likely to have difficulty in co-operating with a Child in Need Plan and this would impact on N’s wellbeing in the short and long term. It appears that the outcome of the court proceedings somewhat undermined the authority of agencies working with the family and impacted on the Local Authority’s Children’s Social Care practitioners who faced challenges in creating any positive change for N. 11.7. N became the subject of a further Child Protection Plan and, as referred to above, some of the key learning from the review relates to the effectiveness of this process, notably the recognition of the risks to N’s physical safety, which had implications for the quality of evidence presented in the second set of family court proceedings. 11.8. The learning from this LCSPR will be disseminated by the Safeguarding Board. The recommendations below are already being taken forward and these, together with the single agency recommendations, will be closely monitored by the Board. 12. Recommendations: 1. The Safeguarding Board should consider how agencies can develop practitioners’ knowledge and skills in working with resistant families, including developing guidance for inclusion in the multi-agency safeguarding arrangements procedures and promoting training and reflective supervision. 2. When a strategy meeting is held and a section 47 enquiry initiated where serious concerns for neglect of a child are identified, all circumstances should be reviewed to ascertain if the threshold is met for a joint agency investigation. If it is deemed that the neglect is likely to amount to a criminal offence, then Children’s Social Care and Police should ensure that all available evidence is collated and analysed. 3. The Safeguarding Board’s partners should undertake a review of their safeguarding training to ensure that cultural awareness and sensitivity is promoted and report on the findings of the reviews to the Board. 4. The Child Protection Service should undertake an audit of the categories of harm identified for children who are subject to child protection plans to ascertain if the categories reflect the identified risks and these are addressed in the actions and timescales agreed. The findings and any recommendations of the audit should be presented to the Board’s Quality Assurance Subgroup. In addition, the Child Protection Conference Service’s Annual Report should routinely be presented to the Board to ensure this receives multi-agency scrutiny. 33 5. The report of the LCSPR should be shared with the Local Family Justice Board and with the President of the Family Division, as advised in the President’s Guidance Judicial Cooperation with Serious Case Reviews 26. 26 President’s Guidance Judicial Cooperation with Serious Case Reviews. Sir James Munby, President of the Family Division, 2 May 2017. 34 Appendix A References: • Bankole, Olatokunbo, Involving African families in the education of their autistic children, National Autistic Society, 4 April 2016. • Autism in Black, Asian and Minority Ethnic Communities: A Report on The First Autism Voice UK Symposium. 2020. • Brandon, Bailey, Belderson and Lasson: The Role of Neglect in Child Fatality and Serious Injury. Child Abuse Review Vol 23: 235 – 245 (2014) Wiley Online Library. • NSPCC learning: Neglect: Briefing summarises the risk factors and learning for improved practice around neglect. September 2015. nspcc.org.uk/learning. • Safeguarding disabled children: Practice Guidance. DCSF 2009 • Protecting disabled children: Thematic Inspection. Ofsted 2012. • The Child Safeguarding Practice Review Panel Annual Report 2018 to 2019: Patterns in practice, key messages and 2020 work programme. • Working with families who display disguised compliance: Guidance for Professionals. Wirral safeguarding Children Board, December 2017. • Case no: b4/2021/1517: N (children: refusal of placement orders): In The Court of Appeal (Civil Division) on appeal from The Family Court at Liverpool. • Public Law Working Group: Recommendations to achieve best practice in the child protection and family justice systems. Final Report (March 2021). • President’s Guidance Judicial Cooperation with Serious Case Reviews. Sir James Munby, President of the Family Division, 2 May 2017. |
NC050401 | Serious injury of a 9-year-old child in October 2016 from burns caused by a scalding hot bath. Both parents were charged with neglect and were given suspended sentences. Family, which consisted of mother, father and 6 siblings, was of Roma heritage and moved from Slovakia to the UK in 2015. Family was known to health visitors, police, schools, fire service, children's services, housing services and doctors. Parents intermittently engaged with professionals but on occasions children were not taken to health appointments. Younger children were often left home alone with older siblings. Children were often absent from school and showed challenging behaviour. Following this incident concerns were also raised about the care of the youngest sibling who showed signs of significant neglect and all the children were placed in foster care. The children have since returned to Slovakia to live with their grandparents. Learning includes: the importance of obtaining a family history when a family moves to a new country and concerns are raised; importance of being able to communicate with families without sufficient interpreting services. Recommendations include: all agencies should ensure that their staff understand the impact of culture, race, and heritage when identifying neglect and they should not condone practices and beliefs that are not in accordance with practice in England.
| Title: Serious case review overview report in respect of: Child FD17. LSCB: Derby Safeguarding Children Board Author: Glenys Johnston Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Final Version Derby City Safeguarding Children Board Serious Case Review Overview report in respect of: Child FD17 FINAL Glenys Johnston OBE Director Octavia Associates Limited 1 Final Version Contents Page 1.0 Introduction 2 2.0 The Serious Case Review Process 2 3.0 Context 4 4.0 Summary of background and events 4 5.0 Feedback from the practitioners’ and managers’ events 10 6.0 The engagement of the family 16 7.0 Diversity and cultural issues 16 8.0 Analysis and learning 17 9.0 Conclusion 27 10.0 Recommendations 28 Appendix 1 The Serious Case Review terms of reference 31 2 Final Version 1.0 Introduction 1.1 On 25th November 2016 Derby City Council decided that the criteria for a serious incident notification to Ofsted were met and they notified Ofsted on 27th November 2016. The Derby Safeguarding Children Board serious case review panel considered the serious incident notification at meetings on the 12th December 2016 and the 16th January 2017. 1.2 On 30th January 2017, Christine Cassell, the Independent Chair of Derby Safeguarding Children Board, commissioned a serious case review into the involvement, care, and support of agencies in relation to a child, referred to in this report as Child 1, to identify any learning that may arise. 1.3 The concerns that led to this review were in relation to severe burns to the legs of nine-year old Child 1, thought to be caused by scalding from hot water in a bath or shower and the failure of his parents to seek medical attention, which resulted in severe and life-threatening infection. 1.4 Following the incident which led to the serious case review, several concerns were also identified about the care of the youngest child, Child 6, who had signs of significant neglect. 1.5 All the children were made subject to Interim Care Orders in favour of Derby City Council until 25th August 2017, by which time, the children had been returned to Slovakia to the care of their grandparents; at that point the Interim Care Orders were discharged. 1.6 On 13th July 2017 at Derby Crown Court the child’s mother and father were charged with the neglect of Child 1 and his brother Child 6 to which they pleaded guilty, they were given 20-month prison sentences, suspended for two years. 2.0 The Serious Case Review Process 2.1 Derby Safeguarding Children Board decided that the most appropriate method of conducting the review was by using the extended Child Practice Review Model set out in Protecting Children in Wales; Guidance for Arrangements for Multi-agency Child Practice Reviews (Welsh Government 2012) as permitted by Department for Education (DfE) guidance. This model includes a multi-agency chronology, individual agency initial case summary and analysis reports and multi-agency meetings with the practitioners and managers involved in the case, to seek their views of what happened and why, and secure the most comprehensive information from a number of perspectives. The process also includes consultation with the family. 2.2 The purpose of the review is to: Determine whether decisions and actions in the case complied with the policy and procedures of named services and Derby Safeguarding Children Board. Examine inter-agency working and service provision for the child and family. Determine the extent to which decisions and actions were child focused. 3 Final Version Seek contributions to the review from appropriate family members and keep them informed of key aspects of progress. Take account of any parallel investigations or proceedings related to the case. Hold a learning event for practitioners and identify required resources. To protect the identity of the family, the following pseudonyms have been used Father Mother Child 1, the subject of the review, born July 2007 Child 2, born March 2002 Child 3, born February 2004 Child 4, born July 2005 Child 5, born April 2014 Child 6, born August 2016 Child 7 oldest sibling (date of birth unknown) lives in Slovakia The full terms of reference are included at Appendix 1 2.3 I, Glenys Johnston OBE, Director, Octavia Associates Limited am the independent author of this report. I have extensive experience in social work practice, chairing Local Safeguarding Children Boards, reviewing and inspecting children’s services and carrying out serious case reviews, I have previously undertaken serious case reviews for Derby Safeguarding Children Board, but I have had no involvement with this case. 2.4 A serious case review panel was established to provide oversight of the process and support me, as the overview author, this Panel met regularly and was made up of: Children’s Social Care, Derby City Council – Service Director of Early Help and Children’s Safeguarding Derbyshire Police - Detective Chief Inspector Learning and Skills Department, Derby City Council - Head Teacher of Virtual School for Looked After Children Derby Teaching Hospitals NHS Foundation - Trust Safeguarding Lead Derbyshire Healthcare Foundation Trust – Head of Safeguarding Children’s Service Housing - Tenancy Sustainability and Safeguarding Manager Designated Doctor Southern Derbyshire Clinical Commissioning Group Designated Nurse Southern Derbyshire Clinical Commissioning Group 2.5 Each agency that was involved with the family was asked to undertake an internal review by a member of staff who had not previously had involvement in the case and provide an individual agency initial case summary and analysis report. These were critically reviewed by the Panel and further information was sought where necessary. 4 Final Version 3.0 Context 3.1 Derby City is a multi-cultural city in the Midlands of England. Approximately 59,400 children and young people under the age of 18 years live in the City, this is 23.2% of the total population of the area. Of these children, approximately 25%, aged under 16 years, are living in low-income families. The proportion of children entitled to free school meals in primary schools is 16% (the national average is 14%) and in secondary schools it is 14% (the national average is 13%). 3.2 Children and young people from minority ethnic groups account for 24.7% of all children living in the area, compared with 21% in England. The largest minority ethnic groups of children and young people are (Asian/Asian British) Pakistani and (Asian/Asian British) Indian. The proportion of children and young people with English as an additional language, in primary schools is 27.6% (the national average is 20%) and in secondary schools it is 21% (the national average is 16.2%). 3.3 On 31st March 2017, there were 2,742 children in need in the City, this figure includes children subject to child protection plans and children in care, which equates to a rate of 461.6 per 10,000, which is higher than the comparator average in 2015-16 which was 385.3. 3.4 On 31st March 2017, 368 children in Derby had a child protection plan, this equates to a rate of 61.9 per 10,000 children, of these 2.3% were in relation to children from Roma families. This is higher than both the national (43.1) and comparator (50.7) averages in 2015-16, due to an increase of 54 plans being open at the end of the year. 3.5 Roma families in Derby tend to live closely together, so their children attend the same schools, where they represent a significant percentage of the total pupil numbers, 32% of children attending School A are from Roma families and 16% attend School B. 3.6 Ofsted inspected children’s services in 2017 and judged the service to be ‘Good’ and the Derby Safe Guarding Children Board to be ‘Outstanding’. 4.0 Summary of Background and Events 4.1 Child 1, the subject of the review was born in 2007; he lived with his parents and five siblings who are, at the date of this report, between fifteen and almost one years of age. Child 1, his four siblings and his parents came from Slovakia to live in Derby City in October 2015, Child 6 was born in Derby in 2016. The family are of Roma Slovakian heritage. 4.2 A combined chronology of the involvement of all agencies was produced from which the following key events have been extracted: 08/01/2016: An assistant health visitor practitioner and Derbyshire Fire and Rescue Service visited the property to see another family, they met mother and her five children on the doorstep of the family home and she explained that they were the new occupants of the house. Mother would not allow entry to the property and 5 Final Version appeared worried, saying her husband was at work. She said the family, four school-aged children and a toddler, had been in Derby for three months but she was reluctant to give the children’s names. The family were not previously known to the health team, but mother agreed they could return for a health visit when her husband was at home. 21/01/2016: Child 1 and CH 4 were enrolled at School A. 24/01/2016: The Police were informed that a young child had been seen walking alone on the street near the family home. None of the child’s siblings were at school. 10/02/2016: School A completed a non-verbal ability test on Child 1 and identified the lowest score ever recorded in school, he was eight years and seven months old on the day of test and had a score of a child under five years of age. 15/02/2016: The health visitor and the assistant health visitor practitioner undertook an initial home visit, the family were found to be living in a four bedroomed, privately rented house, sparsely furnished, in need of decoration, without smoke alarms and the front entrance needed to be repaired. Mother's brother-in-law stated that the children were registered with a GP and the health visitor discussed the need for the family to register with dentists and opticians. Mother reported no current concerns regarding the children, who were seen appropriately dressed, although a little unkempt, happy and sociable. No growth checks were completed as the children went outside to play during the visit. Mother and the other adults present were given advice about the children's safety including road safety. Mother gave her consent for information about the family to be shared with other professionals. 19/02/2016: An unannounced, opportunistic visit was made by the assistant health visitor practitioner and Derbyshire Fire and Rescue Service, mother declined a home safety check; several issues about the condition of the house were identified and a referral was made to Housing Standards. 22/02/2016: Child 2 and Child 3 were enrolled at School B. 3/03/2016: The assistant health visitor practitioner visited to complete GP registration forms which were not completed as mother was unable to remember the family’s previous address. Child 1 and Child 4 absconded from school and were collected and returned to school by staff 09/03/2016: The assistant health visitor practitioner assisted mother to complete GP registration forms. Child 5 was noted to be at home, having been left there alone whilst mother accompanied the other children to school. School A contacted Children’s Social Care to inform them and were advised to offer the family an early help assessment which was declined by the parents. Mother was advised to contact the New Communities Achievement Team for support and advice but this was not followed up by her. 10/03/2016: Child 5 aged two, was left at home, as it was raining, whilst mother accompanied her other children to school. The New Communities Achievement 6 Final Version Team support worker advised mother that this was unacceptable, and Children’s Social Care and the Police were subsequently informed. 17/03/2016: Police were informed by school that Child 3 was not in school and had been seen trying to sell a bicycle, which it was thought he did not own. 21/03/2016: Child 4 was not in school, having been left at home to look after Child 5. Mother was again warned about the inappropriateness of leaving children at home alone. 05/04/2016: Children’s Social Care convened a Section 47 strategy discussion with the Children’s Social Care manager and the named nurse, the Police were not invited, and the children were not seen the same day. 07/04/2016: Housing visited the family home, all the children were seen at home without their parents, no referral was made to Children’s Social Care however, a home visit was made by a Children’s Social Care reception social worker who used Language Line to discuss the concerns about leaving the children alone, with the parents. 11/04/2016: The children did not return to school, following the Easter holidays and were not in school for the following two weeks. 13/04/2016: Father informed New Communities Achievement Team that his family had moved to Dover; he refused to provide their address. 14/04/2016: Children’s Social Care decided to undertake a single assessment, although allocation of this work was delayed until 24th April as the social worker was on leave. The family were seen in Derby, so they were not in Dover, as father had stated on the previous day. 15/04/2016: Child 2 and Child 3 were not in school. 22/04/2016: Information from Children’s Social Care records indicate that it became known that mother was pregnant, with Child 6. 27/04/2016: Children’s Social Care visited and discovered the family were not registered with a GP, mother was advised to access ante-natal care. The education welfare officer (EWO) advised Children’s Social Care of the children’s poor school attendance. 28/04/2016: Children’s Social Care became aware that the family had been known to move around Bradford and Derby, no information was sought from Bradford Children’s Services. Children’s Social Care asked School A to complete an early help assessment and arrange a team around the family meeting to develop a plan, no network meeting was held to discuss the level of support being provided by New Communities Achievement Team or how effective monitoring would take place. 29/04/2016: Children’s Social Care closed the case. 7 Final Version 04/05/2016: Child 5 was left at home alone. The family were still not registered with a GP. Children’s Social Care requested a Section 47 strategy meeting with health and the Police, no referral was made to New Communities Achievement Team for support. 05/5/2016: Section 47 strategy discussion held, there was no involvement of schools or New Communities Achievement Team 26/05/2016: An initial child protection conference was held, the children were made subject to child protection plans under the category of neglect. A week later the case was allocated to a new social worker. 07/06/2016: The first Core Group meeting did not take place as an interpreter had not been arranged. 10/06/2016: Family GP registration was completed. 14/06/2016: The re-convened first core group was not held as the social worker was unavailable. 30/06/2016: A core group was held but incomplete as the parents did not attend, however, concerns were shared with those present. 11/07/2016: Children’s Social Care contacted the Slovakian Authorities for information about the family. Significant information was subsequently provided (on 13th December) about previous concerns of neglect. Child 3 had sustained significant burns after falling in a fire and the family’s first child, Child 7, was removed by the authorities and remained in Slovakia. All the children were given immunisations at the GP surgery, with support from an interpreter. 13/07/2016: A safeguarding GP practice review meeting was held to consider the concerns about the children, agreement was made to share information between the GP and the Derby Integrated Family Health Service health records. 27/07/2016: A pre-birth assessment was completed on unborn, Child 6. 03/08/2016: The health visitor visited the home and completed a growth and development review for CH5 and an antenatal contact for mother. The assessment identified that Child 5’s needs were being partially met although the skin could have been cleaner; the family were registered with a GP and were accessing services with support. There was evidence of emotional warmth between Child 5 and mother. 16/08/2016: Child 1 and Child 4’s names were deducted (removed) from GP registration as mother and father had not responded to letters sent to them. The GP practice was not aware that the children were subject to child protection plans. 17/08/2016: A review child protection conference was held, schools were represented by an education welfare officer, teaching staff provided reports but did 8 Final Version not attend due to school holidays; the children were stepped down to ‘child in need’ plans. 24/08/2016: Child 5 was seen alone on the street. 31/08/2016: Child 6 was born; maternity staff became aware of the involvement of Children’s Social Care from mother who said this was due to non-school attendance. Police visited the family due to theft of bicycles, damage to a car and Child 1 urinating in public. 05/09/2016: Child 4 did not attend the first day at School B. 06/09/2016: All three older boys attended School B but with no uniform or equipment; on the same day, Child 3 left school without permission and Child 2 and Child 3 stole a bicycle from the school bike shed, the Police were informed. 12/09/2016: Child 2 and Child 3 left School B without permission, Child 4 swore at a member of school staff, Child 6 was not taken for a hearing test, and the social worker observed Child 6 to have a pillow and a quilt and explained the inappropriateness of this to mother. 14/09/2016: Child 3 left School B without permission. The health visitor completed a new born hearing test on Child 6, the records note that the baby’s needs were being met by the family, no nappy rash was noted but safe sleeping would need to be reviewed in the next visit. 15/09/2016-4/10/2016: The older children’s behaviour became increasingly challenging, they variously left school without permission and on one occasion Child 3 was returned to school by an unknown man and they were found smoking in school. 03/10/2016: Child 1 and Child 4 were re-registered at the GP practice. 05/10/2016: A child in need network meeting was held; concerns were raised about the older children’s poor academic attainment and their anti-social behaviour. School B asked about escalating the concerns to child protection. Father was told that unless he and mother engaged with services by the next child in need meeting the children’s names would be returned to a child protection plan. 06/10/2016: Child 2, aged 14, touched a female student’s bottom. 06/10/2016-09/11/2016: School A attempted to meet the needs of Child 1 with a part-time timetable etc. The older children continued to be challenging in school, leaving the premises without permission and smoking. The Police received information that Child 2 and Child 3 were believed to be part of a gang and were carrying knives and stealing bicycles. Mother and father intermittently engaged with professionals but on occasions, the children were not taken to health appointments. 12/10/2016: The health visitor made a six-eight week visit to Child 6, the records comment that the baby’s basic needs were being met; Mother was seen to be an 9 Final Version experienced parent who appeared to have a good level of support available locally, but the health visitor was slightly concerned about her level of understanding of the information she provided. Child 6’s weight gain had slowed a little and would require review in two weeks; the nappy area was sore with an inflamed rash on the buttocks but also extending down legs from the groin, the health visitor prescribed 1% Clotrimazole cream, its appropriate use, when to stop and when to seek a GP review. No further concerns were recorded. 27/10/2016: Home visit by the health visitor, who recorded her observations; Child 6 was an alert active baby and there was good weight gain, following the 9th centile, some remaining skin inflammation on the abdomen, under the axilla and to the head and neck. The health visitor advised mother to increase the strength of Child 6’s feeds and gave advice on hygiene, bathing and the use of the skin cream. 31/10/2016: Last visit by health visitor to see Child 6 and complete an assessment of needs review, she recorded that the baby’s needs were being partially met. She discussed the missed GP appointment which mother had asked to be made and the importance of not leaving the baby on sofa with only the younger children to supervise. 07/11/2016: Child 1 was seen by the social worker; this was the last time CH1 was seen by a professional before the injury to CH1 was found. 09/11/2016: Child 1, who had not been in school since term resumed after the autumn half-term holiday on 31/10/2016, was reported to New Communities Achievement Team by his father to have scalded his feet in the bath and was being treated with ‘gels’ from the GP, and as a result, he would not be in school for a few days. It is therefore considered likely that the burns occurred on or just before this date. The information was noted in the safeguarding records of School A but not referred to Children’s Social Care by them or New Communities Achievement Team. 10/11/2016: Child 2, Child 3 and Child 4 were on reduced timetables at school and at this point they were attending as follows: Child 2: 76%, Child 3:63% and Child 4: 71%. 11/11/2016 (a Friday): An email was sent to Child 1’s social worker from the care and guidance team leader (C>L) at School B, raising, amongst other issues, his being off school because of burns to his feet. A visit was carried out by the care and guidance team leader to discuss a sibling who had truanted from School B. Child 1 was not seen and was reported by mother to be at his aunt’s house. The care and guidance team leader was told that Child 1 would not be in school for a further four weeks, due to the burns. This additional detail was also communicated by email to the social worker. 15/11/16: The social worker undertook a home visit, but no one answered the door and it is not known if anyone was at home. The social worker picked up the email which had been sent on the 11th November, but not seen by her, as she was out of the office and had no mobile ‘phone on which to access email. 10 Final Version 16/11/16: A child in need network meeting was held at School A, following which, the social worker made two unsuccessful attempts, to see Child 1 at home. At the first visit, no one answered the door. On the second occasion, the social worker was told by mother and a sibling, that Child 1was in Slovakia with his father. 17/11/16: The social worker visited again but was there was no response. The education welfare officer subsequently told the social worker that father had been seen in Derby that day, so he was not in Slovakia as reported. 18/11/16: The social worker saw the older siblings in school with an interpreter who confirmed Child 1 was still at home, as a result, the social worker visited the home and gained access. She found Child 1 in extreme pain and visibly shaking. He had burns on his legs which had not been treated and appeared infected and he could not walk. The social worker took him to hospital immediately and he was then transferred to the Nottingham Burns’ Unit. 18/11/16: Following Child 1’s admission to hospital, the Police obtained Police Protection Powers to safeguard all five siblings. 18/11/2016: Derby Teaching Hospitals Foundation Trust completed a child protection medical on Child 6 which identified significant indicators of neglect. 18/11/2016: A Section 47 strategy meeting was held. 19/11/2016. Child 2 and Child 3 left their foster home and made their way home overnight. Child 3 was later discovered to have significant self-harm marks on his body and said he took drugs to reduce the pain caused by his self-harm. 21/11/2016: Child 1, Child 5 and Child 6 were made subject to Interim Care Orders in favour of Derby City Council and remained in foster care. Child 3, Child 4 and Child 5 were made subject to Interim Supervision Orders and remained in the care of their parents. 22/11/2016: Child 5 was examined by the GP. 23/11/2016 Child 5 was examined by a Community Paediatrician. 4/12/2016: An invitation to an initial child protection conference was received by agencies. 5.0 Feedback from the practitioners’ and managers’ events 5.1 On the 5th June 2017, a practitioners’ event was held as part of the serious case review. Professionals from a wide range of services who had been involved with the case attended, except for the social worker, due to ill health; she was seen separately by me on 22nd August 2017, her views are largely consistent with the practitioners at the meeting on the 5th June and any different points have been incorporated. Attendees were provided with the key events from the multi-agency chronology and the discussion addressed the key issues in the terms of reference. 11 Final Version 5.2 Derby Safeguarding Children Board and I are very appreciative of the way practitioners engaged in the discussion and sought to identify why things did or did not happen. Their reflectiveness and focus on learning is commendable however, please note that the views summarised below, are theirs and are not necessarily shared by me. Assessment Was previous relevant information or history about the child and/or family members known and considered in assessment, planning and decision-making? The capacity to seek previous relevant information about children who come into Derby City was identified as ‘challenging’. Practitioners found the parents reluctant to share their history and information with them, this was said not to be unusual with Roma families who are anxious about what use will be made of the information, i.e. will it lead to their children being removed from their care? Schools are unable to see children for whom places are applied for, if they do not live in Derby before they join the school; schools are reliant on families informing them that their children attended a previous school and where, there is no national database to check where children have attended, and GPs do not have the capacity to see every new patient for an introductory meeting and gather background information. New Communities Achievement Team has learned that families from the Roma community are sometimes reluctant to engage with them because they see them as part of the community and therefore they leave families to seek information, when they are ready to do so. It was difficult to use New Communities Achievement Team to fully support the family as the worker’s hours did not coincide with father’s, who worked night shifts. The social worker did not contact the Slovakian Welfare Authorities, although she wanted to, as she did not receive advice on how to do so by her managers. The information once acquired was significant. Midwifery services tried to find out information about the family from Children’s Social Care, whose response focussed on the school attendance rather than broader concerns about neglect; this is not accepted by the social worker who is sure she would have shared information about neglect and children being left unsupervised. However, the midwife should have been invited to child protection and child in need meetings. It was noted that there does not seem to be a good system for making sure community Police are aware of addresses and the names of families, where there are child protection plans in place. There was a lot of contact with them via the Safer Neighbourhood Team but in this case, it was unclear what they knew of the concerns about the family; had they done so this would have helped in gathering a more informed view of the poor supervision of the 12 Final Version children and neglect issues. It was noted that local intelligence officers brief the team on a weekly basis and this should be checked to ensure the right information is getting through to officers. How effective was the assessment of mother’s understanding of professional concerns and her ability and willingness to address these? Professionals recognised that there was not a shared understanding of mother’s capacity to understand the concerns of professionals and if she did, whether she could address them. They felt that the ability to get a parenting assessment at an early stage, particularly when language difficulties are a factor is limited, unless this is secured as a part of care proceedings and ordered by the Court. Professionals were of the view that the family were not isolated as mother’s sister was living on the same street and another sister was around for a while, professionals assumed that this would provide some additional parenting support. Romanes is a distinct language with different dialects however, there are a limited number of qualified Roma interpreters as Romanes is not a language for which interpreter services have been commissioned in Derby City. Practitioners felt that father could communicate in Slovakian and he had a reasonable command of English. Mother’s behaviour also indicated that she had some limited understanding of Slovak. Some practitioners held the view that there was a “selective” understanding of Slovak by the parents, depending on the context of what was being discussed. How effectively were agencies able to contribute to the analysis of risk and safeguarding concerns both at the point of the decision to remove the children from child protection plans and in the period following the de-escalation from child protection plan to child in need status? School A staff observed that although appropriate issues were included in the child protection plan, there was insufficient consideration of the difficulties and effectiveness by the core group and the implementation of the plan was not monitored or updated, as events changed, and concerns increased; they did not think the children should have been stepped down to children in need. They reflected that whilst they had submitted information to the review child protection conference, they did not escalate their concerns on hearing, when the summer holidays ended, that the children’s names had been removed from child protection plans and should have done so. They reflected that the learning from this case has made them clearer about escalation and their responsibility to do so. The Police did not attend the review child protection conference and this is usual in Derby City. However, a question was raised about how the Police should be informed if their attendance is required. The Police did attend the child in need network meeting. 13 Final Version Neither the GP or midwifery service received an invitation to be involved in the pre-birth assessment of the un-born baby, Child 6 There was some unfamiliarity with the Derby Safeguarding Children Board process of raising a case with a Child Protection Manager either about a child protection concern or to bring forward a child protection conference. Practitioners reflected that discussion about this case had emphasised the need for everyone to take responsibility for escalating concerns and satisfying themselves that actions have been taken. Some attendees were not aware that when they pass concerns verbally to Children’s Social Care or leave a message, these should always be confirmed in writing. In respect of the incident where Child 5 was found on the street, after the children’s names had been removed from the child protection plan, there was recognition that leaving a message for a social worker is not the same as making a written referral, and this is something that would be done in future. There were views from professionals at the review child protection conference, that the points of views of attendees were listened to and informed the decision to remove the children’s names from child protection plans however, there was insufficient recognition that there had been deteriorations by that point. Plans Practitioners thought that the child protection and child in need plans seemed to be very responsive on a day to day basis but did not capture the wider picture. It was suggested that had there been more monitoring of the overall aims and tasks for the plans, this may have led to better engagement. Roma Complex Case meetings no longer occur. Previously they had provided the opportunity for multi-agency discussion about families who needed support and or monitoring. It was felt that this has had an impact on the ability of practitioners to liaise and discuss concerns about local families and make sure the right plans and links are established between relevant agencies. Practitioners felt that the decommissioning of the Specialist Health Visitor role (including the Assertive Outreach Team for New and Emerging Communities), the Language Centre and the Roma Complex Case Meetings had collectively made the job of engagement with the Roma community more difficult. Barriers, Staff Support and Supervision Health practitioners felt that their staff support and supervision arrangements are in place and effective, in their organisation, there are criteria for mandatory discussions of priority cases in supervision, for example children who are the subject of a child protection plan. 14 Final Version There was a question about whether all other agencies have identified those categories of risk that must be discussed at every supervision meeting. The schools involved in this case had weekly meetings at which the designated safeguarding lead was present, and they were therefore able to discuss the concern emerging in school, including in relation to this case. It was noted that awareness raising events are in place for parents and families in the community. This is to help them understand the services that are available, as well as the expectations of their living in the UK, if they are new to the country Given all the difficulties that had occurred, practitioners felt that it was a testament to the good work done with the family that they had stayed in the area There was a view that there were some positive relationships with the family with a determination to work with the family and improve school attendance and attainment and access to services School A has invested in support from New Communities Achievement Team with a member of staff available to parents every day to try and help them with a diverse range of needs and requests. Practitioners noted that this case illustrated the challenges of supporting one family with several children which meant children could not easily be spoken to alone, and there are many others with similar complex needs, hence previous comments about the significant impact of the decommissioning of specialist services for families and professionals working with new, emerging communities Feedback from the Managers’ event 5.3 On 5th June 2016, a separate event was held to gather the views of managers involved in this case. A wide range of agencies, including Children’s Social Care was represented. Again, the engagement of all attendees was commendable and their reflectiveness in identifying why actions happened has led to good learning. The Derby Safeguarding Children Board and I are fully appreciative of their contribution. 5.4 The following points were noted from the discussion; they are not all endorsed by me. Assessment Children’s Social Care did not gather information from the Slovakian Authorities when child protection concerns emerged and therefore significant information, subsequently gathered during the proceedings in the family court was not known to them. Clearly the new and additional information about the neglect of the children in Slovakia has a bearing on the assessment and the “culpability” of the parents. 15 Final Version The single assessment was not routinely shared with other agencies. This is contrary to the Children’s Social Care guidance for staff. There is an issue as to whether this should be included in Derby and Derbyshire Safeguarding Children Board Safeguarding Children Procedures. In respect of the Specialist Health Visitor role (as part of the Assertive Outreach Team for New and Emerging Communities), it was suggested that the previous post holder had made a significant contribution to the support of Roma families in Derby and the loss of this post has had a detrimental impact. In terms of the assessment of needs, it was suggested that arrangements are in place for new arrivals to Derby and that school admissions are being managed with contact being made with parents. How effective was the assessment of mother’s understanding of professionals’ concerns and her ability and willingness to address these? There was a view that mother did have capacity but that she needed things explained to her in a simple and straightforward way, for example she had difficulty telling the time by looking at a clock, but could manage to attend appointments on time, when she wanted to. Whilst Roma is the family’s main language, both schools felt that both mother and father had been left in no doubt about the need for the supervision of Child 5 and that it was not acceptable to leave her on her own. Plans There was a general view that, on reflection, the right issues had not been in the child protection and child in need plans and that the core group had been ineffective. There was agreement that it would be helpful to obtain an update of the frequency of visits by the health visitor and midwife between the end of the child protection plan and the incident that gave rise to the serious case review, to assess whether this had been appropriate. It was hypothesised that the review child protection conference’s decision to remove the children’s names from child protection plans, may have been interpreted by agencies as the end of the concerns and led professionals to be less worried. Barriers, Staff Support and Supervision On reflection, it was noted that in this case there may have been the need to support the social worker more fully and that they may have felt isolated and unfamiliar with Roma culture and the complex and challenges presented by families like this: this view was not shared by the social worker who said she had worked with several Roma families and was familiar with their culture and 16 Final Version beliefs, although the number of children in the family made it difficult to see them separately. There were opportunities to co-work closely with schools who have many Roma families and draw on their understanding of this community and the community’s confidence and familiarity with schools in Derby. 6.0 The engagement of the family 6.1 From the outset of the serious case review, Derby Safeguarding Children Board were committed to seeking the views of the family and two carefully planned meetings were convened by the social worker for me to meet them. Mother and father attended the first meeting on time but were unable to stay for more than a few minutes, they did not attend the second meeting and when an interpreter telephoned father, he said neither he nor his wife would be attending the meeting and they did not want any further meetings with me to be arranged. 6.2 It has therefore not been possible to gather the views from the family about the services they received. 7.0 Diversity and cultural issues 7.1 To understand the events that took place, it is helpful to understand the beliefs and culture of Roma Slovakian people. The following is extracted from “Project Education of Roma children in Europe” http://www.coe.int/education/Roma. Slovakian Romas are not a homogenous group, many will have similar beliefs, but some may have changed these over time, nevertheless some aspects of the following explain why Roma Slovak parents may still have deeply held cultural beliefs, even though they seek to adapt to the culture in the UK. 7.2 Roma society is based around the group of close kin, which in most traditional Roma communities forms a single household, in settled communities, members of the extended family share living quarters with the nuclear family. Roma people tend to live a segregated life, apart from the surrounding society through generations and centuries of exclusion and suspicion. 7.3 Traditional Roma families educate their children at home by allowing them to participate in all family activities, including economic activities; children observe, participate, and gradually assume a share of responsibility for the extended household. School is a Gadže institution, it represents everything that outsiders stand for and everything that separates Roma from outsiders: rigid rules, obedience toward a person in authority who is not part of the family, oppression of children’s own initiative and withholding responsibility from them, imposition of arbitrary schedules, and perhaps the most difficult of all, the separation of children from the rest of their family, for long hours. 7.4 School is thus seen as potentially, interfering with everyday Roma life. Indeed it is seen as a threat since it removes children from their parents’ sphere of influence, and weakens their confidence in the ways and traditions of the Roma household, the school situation thus conflicts with Roma morality, with its protection of the family 17 Final Version unit. Finally, mixing with non-Roma children in adolescence carries with it the danger of liaisons with outsiders that threaten to alienate Roma children from their homes and traditions, and even to separate them from their families permanently through permanent relationships or marriage. 7.5 In many countries of Central and Eastern Europe, integration with other children was limited because of the almost automatic referral of Roma children to special needs schools. Such schools only contributed, however, to the stigmatisation of the Roma, while still disrupting traditional family life and weakening parents’ ability to act as successful role models. In most Roma communities, it is now recognised that school cannot be avoided for young children and families reluctantly send their children to primary schools, hoping at least that they will benefit from the opportunity to acquire some key skills such as basic literacy, which can prove useful to the family. Many Roma families recognise the relative freedom of school attendance but may encourage their children to miss school occasionally as a way of signalling that loyalty to the family and participation in important family events has precedence over anything else. 7.6 Parents will attempt to maintain respectful but distanced relationship with the school, always siding with their children in the event of conflict, as yet another way to teach their children the value of mutual support and reciprocal loyalty. Most Roma parents withdraw their children from school before they reach puberty. Parents often give several reasons for this, most commonly cited is the fear of drugs, violence and other threatening behaviour that is often associated with secondary schools especially in deprived areas, another is the fear of alienation from their home environment, and a further, more specific reason is the fear that boys and girls might be called to participate together in sex education classes, which, in the Roma context, would shame them and require much effort to restore their honour in the eyes of others within the Roma community. 7.7 The parents in this case were reluctant to share their views or provide important information, as commented elsewhere, this limited the opportunity for professionals to understand their experience of services, to understand their child rearing practice and their own experience of being parented. This information could have included whether they had any reservations about engaging with services or concerns about the children attending school. Their unwillingness is an important learning point to be understood within some of the broader experiences of Roma Slovakian families. 7.8 The children in this family behaved differently to many of their peers in school, who adapted and settled well, Child 1 was clearly unprepared for school, even being in a building and required intensive 1:1 supervision and support. The older children began leaving school premises or not attending. Professionals who worked with many Roma children in Derby highlighted the difference between this family and many others. 8.0 Analysis and learning 8.1 The following information has been extrapolated from the detailed scrutiny of multi-agency involvement and reflection by practitioners, managers and Panel members. The serious case review panel and I have identified some areas of good 18 Final Version practice and the learning that can be equally derived from these. However, several areas have been identified where multi-agency practice could be improved to provide better safeguarding arrangements across agencies in Derby. The following section addresses the key questions posed in the terms of reference. Was previous relevant information or history about the child and/or family members known and considered in professionals' assessment, planning and decision-making in respect of the child the family and their circumstances? The period from January to March 2016. 8.2 The family were known to the Police, Housing, the Fire Service, School A, the Health Visiting Service and the New Communities Achievement Team at times between the 8th January and the 9th March 2016 during which concerns about the very young children being left at home alone, being found alone in the street, living in poor housing with no smoke alarms, and not being registered with a GP were noted. None of these were reported to Children’s Social Care until the 10th March and the agency reports provided for this review do not include comments as to whether on reflection, and with the benefit of knowing what subsequently happened, this should have happened. In my opinion, the thresholds for referring to Children’s Social Care for exploration with partners, were met and the children should have been referred as the incidents occurred. It may be that concerns were seen as issues common to other Roma families, but this was not acceptable, professionals should make decisions about referrals on the basis of each individual child, rather than their view of other families in an area or from a different culture. 8.3 The family first became known to Children’s Social Care on 10th March 2016 when School A reported that the previous day, Child 4, aged 10, had stayed at home to look after his two-year old sister and this happened again on the 21st March; the school were advised to complete an early help assessment and the following day New Communities Achievement Team raised concerns and the school were advised by Children’s Social Care to speak to the parents which they did, appropriately using an interpreter to explain to the parents that this was not acceptable practice. It was assumed that this action was thought by Children’s Social Care to be sufficient as no further action was undertaken until, following a reported concern by housing on the 7th April 2016, that two of the older children and a young girl had been found unsupervised at home and their parents were not expected to return until 7.00 pm, Children’s Social Care progressed the case to a referral, and visited the family and the following day, started a single assessment. 8.4 When the single assessment was undertaken some information was provided by schools in relation to the children’s poor school attendance; the behaviour, distress and attainment of Child 1, the behaviour and attainment of Child 4 and some of the children being left alone at home. However, the fullest possible information was not sought by Children’s Social Care to provide a comprehensive picture. No information was sought from the Authorities in Slovakia, I understand that this is not always requested unless the case is in proceedings; it is perceived as an onerous task, information takes time to be provided and it is more difficult if the parents provide limited 19 Final Version information. However, had information been sought from Slovakia previous information about the care of the children i.e. that the eldest child has special needs and is in the care of the Slovakian Authorities, due to concerns about the parents’ capacity to cope, (despite additional family support) and their relationship with the child and that Child 3 also experienced significant burns by ‘falling into a bonfire’, would have been made known. Professionals cannot force parents to reveal information about themselves, but they need to maintain a respectful uncertainty/healthy cynicism about what is being said or withheld, even in the face of resistance from them. No information was sought from Bradford where at least Child 2 and Child 3 lived around December 2009 and June 2010, when they were aged seven and five, as GP appointments were made. It is not known whether they attended school in Bradford during this period, but subsequent checks confirmed they were not known to Bradford Children’s Social Care. No information was sought from the authorities in Dover where they were also thought to have lived. The Police held information about previous concerns, an incident of domestic abuse with another woman and alcohol use by Father and low level criminal activity by both parents but disclosure was not sought from the Police by Children’s Social Care at the outset, when the first single assessment was being undertaken. 8.5 The single assessment was completed on 26th April 2016, within 20 working days, in accordance with required the timescales of 35 days, Children’s Social Care records show that the social worker found it difficult to engage the parents to produce a family history and the language barrier was a constant difficulty throughout. 8.6 The content of the assessment was deemed to be of an acceptable standard by the Children’s Social Care author of the individual agency initial case summary and analysis report to this review, although this is debatable given the lack of the above information. It concluded that as there had been no further reported incidents of the children being left unsupervised at home the case would be closed to Children’s Social Care and School A would be asked to monitor the situation and support the family through a team around the family, although it was not known whether the family were in agreement with this. By the time the single assessment was completed Children’s Social Care were aware that mother was pregnant and had not received any ante-natal care, the family were not registered with a GP and school attendance remained an issue. I support the view of the Children’s Social Care author of the individual agency initial case summary and analysis report that these outstanding actions should have been referred to the Vulnerable Children’s Meeting for further consideration and the identification of a named professional to lead the monitoring of the situation. 8.7 There is no record that the single assessment was shared with the family or other agencies although Derby City procedures state that: “The outcomes of the assessment should be: 20 Final Version - discussed with the child and family and provided to them in written form. Exceptions to this are where this might place a child at risk of harm or jeopardize an enquiry; - taking account of confidentiality, provided to professional referrers and; - given in writing to the agencies involved in providing services to the child with the action points, review dates and intended outcomes for the named child. 8.8 No further assessment was commissioned to inform the Children’s Social Care report to the initial child protection conference and no further work was undertaken with Child 1 who was said to have ‘anxious eye contact’ and the Children’s Social Care conference report was not shared with mother. 8.9 During the period before the initial child protection conference, Children’s Social Care and Primary Care knew that mother was pregnant however, no information was shared with the midwife and there was no invitation to attend the conference. How effective was the assessment of parental learning disability? What impact was there on the effectiveness of engagement with the family arising from communication issues and the specific dialect of Romany used by the family? How did that knowledge contribute to the outcome for the child? 8.10 There was no formal assessment of mother’s learning ability and this was said to be due to her reluctance to participate in an assessment. During the early involvement with this family it would probably not have been feasible to provide an assessment of her learning ability or her parenting capacity by someone without appropriate language skills. 8.11 There appear to be differences of professional opinion as to whether mother had learning difficulties, lacked the capacity to parent effectively, did not understand or share the concerns raised by professionals, was dominated by her husband, or was influenced by her previous experience of a child being removed from her in Slovakia. At the practitioner’s event, it was mentioned that some professionals thought her understanding of Slovak, as opposed to Romanes, was better than it appeared. 8.12 Effective engagement with the family was affected by their reluctance to share information about their history and the false information they provided, particularly in relation to the care they were giving Child 1 after he was burnt and his whereabouts. This cannot be fully attributable to language difficulties although this was a factor. The Romanes language includes several dialects, there are difficulties securing interpreting support from people with the appropriate skills despite the significant number of Roma families living in parts of the city. Although some Roma people speak Slovak their understanding may not be sufficient for them to fully understand. 8.13 As previously stated, practitioners felt that the decommissioning of the Specialist Health Visitor role, the Language Centre and the Roma Complex Case Meetings had collectively made the job of engagement with the Roma Community more difficult. There was reduced liaison between agencies and awareness of the difficulties within some very complex families. The lack of specialist services meant 21 Final Version that practitioners were less able to draw on expertise and help to ensure that the right services were getting to and were understood by the Roma community. 8.14 The valuable contribution of the New Communities Achievement Team attached to School A must be included in this section, they have excellent knowledge of Roma culture and families in Derby learn to trust them and value the advice and support they give to obtain benefits and find out about services. Whilst they understand the different child rearing practices in the UK and by Roma families they have pointed out that most Roma families do accept the practices in the UK and most do not neglect their children. 8.15 The number of children in the family and the capacity of the social worker made it difficult for the social worker to establish individual relationships with each child. It would have been helpful if the challenge had been raised with the social worker’s manager or the assistance of other professionals had been enlisted by co-working and joint visits. Were the child protection plan and subsequent child in need plan robust, and appropriate for that child, the family and their circumstances? Were all agencies effectively involved in the child protection plan? Were the plans effectively implemented, monitored and reviewed? Did agencies contribute appropriately to the development and delivery of the multi-agency plans? How effective was the core group/network group? What aspects of the plans worked well, what did not work well and why? How well were the plans understood by the children and parents and what evidence is there to demonstrate this? What oversight was there of the plans and how effectively were they reviewed? To what degree did agencies challenge each other regarding the effectiveness of the plans, including progress against agreed outcomes for the child? Was the protocol for professional disagreement invoked? 8.16 The initial child protection conference was held within timescales, on the 26th May 2016, and was attended by: the social worker, two Children’s Social Care managers, a Police researcher, School A and School B, the school nurse, the assistant health visitor practitioner, mother, father and a Slovakian interpreter. Invitations were not sent to the GP, the community midwife or New Communities Achievement Team, and they did not receive the outcome or minutes of the meeting, although mother was pregnant and not accessing ante-natal care. 8.17 In their individual agency initial case summary and analysis report Children’s Social Care highlight that a Graded Care Profile, which is required for neglectful families, was not completed so it could not be used to inform the discussion and decisions. Those professionals who did attend the meeting have confirmed that they felt they had effectively contributed information that informed the child protection plan. 8.18 The child protection plan included the main concerns and the need for continued support to the children and family, but the actions were confused with outcomes and there were no agreed timescales to ensure actions were completed on time. 22 Final Version 8.19 The child protection plan was ineffectively implemented due to the core groups not taking place as required i.e. the lack of an interpreter at the first core group meant it could not go ahead; the second core group was cancelled as the social worker did not attend (due to competing priorities) and the parents were not able to attend the last core group before the review child protection conference. 8.20 At the review child protection conference on the 17th August 2016, there were views expressed by attendees, although not by the school who had submitted a report, that the child protection plan was working; the children were attending school; the family had moved to a different house and home conditions were improving; there had been no recorded incidents of the children being left unattended; the family had registered with a GP; and mother was receiving ante-natal care. Nevertheless, the situation deteriorated in the school summer holidays; seven days after the review child protection conference. Child 5 was seen alone on the street and a further week later, the Police were involved with the family as the older children had been stealing bicycles and Child 1 was seen urinating in the street, so the impact of the child protection plan had not been sustained nor had it remained in place long enough to monitor the impact on the family following the birth of the new baby Child 6. This indicates an over-optimism about improvements and an acceptance that the children’s care was part of their culture. 8.21 The effectiveness of a child protection plan is dependent on the engagement and commitment of the family however, the language used in the plan was inaccessible, it used professional jargon (e.g. “parents to engage with advice from professionals”) and was inappropriate for someone whose first language was not English, caring for a family of five children and the possibility of insufficient parenting skills and a learning difficulty. The individual agency initial case summary and analysis reports do not state whether it included the consequences of not complying with the plan or whether it included the views of the children. 8.22 The Police have reflected, appropriately in my view, that a written agreement was not an appropriate way to ensure the parents complied with the plan and this would have been more appropriately addressed and enforced by considering a criminal investigation of neglect. How effectively were agencies able to contribute to the analysis of risk and safeguarding concerns both at the point of the decision and in the period following the de-escalation from child protection plan to child in need status? 8.23 The pre-birth assessment was completed on the 27th July 2016, one month after all the children had been made subject to child protection plans due to neglect, it is unclear who contributed to the assessment. The community midwife was not informed of child in need or child protection processes and when she asked how the issues identified in the child protection plan might affect the care of a new-born baby she was informed the concerns were about the older children and school attendance despite the known issues of the youngest children being left alone; one child being found wandering in the street and mother’s limited engagement in ante-natal care, It would, in my view, have been more appropriate for the plans for the unborn baby to 23 Final Version have been included in the child protection plan and an ongoing assessment being made by health professionals as part of the plan. 8.24 The individual agency initial case summary and analysis reports do not provide much detail on the review child protection conference, what was discussed and how the risks were weighed but given the above; the decision to remove the children’s names from the child protection plan was premature, in my opinion. The child in need plan 8.25 A Children’s Social Care manager completed an audit of the child in need plan; she believed the threshold for child in need support was met and the family needed close monitoring, she concluded that the child in need plan was too general and contained no timescales for the completion of tasks. This was not escalated to more senior management. 8.26 From 31st August 2016 until the 18th November 2016, several concerns emerged in relation to the care, neglect and supervision of the children. Network meetings took place on two occasions, but the concerns continued, Derby City’s principal solicitor has subsequently confirmed that the thresholds for another initial child protection conference were met. Were the respective statutory duties of all agencies working with the child and family fulfilled? Were there obstacles or difficulties in this case that prevented agencies from fulfilling their duties? This will include consideration of both organisational issues and other contextual issues? This will include analysis of responses by all agencies to safeguarding concerns and the effectiveness of communication? 8.27 The agencies who contributed to this review were robust in their analysis of this issue, some going further than simply evaluating whether they had complied with statutory duties by exploring whether good professional practice was adhered to. 8.28 Children’s Social Care set out the duties of local authorities in respect of children under the Children Acts of 1989 and 2004. They comment that the team manager appropriately allocated the case for single assessment on the third occasion the children were left unsupervised and on the fourth occasion the team manager acted appropriately by convening a Section 47 strategy meeting with the Police and the child protection manager, although I note that health were not involved as required and schools were not included, which was significant given their daily contact with the children. They state that there was a lack of liaison with other local authorities and the Slovakian Authorities but explain that this would not be feasible unless clear safeguarding issues were identified. 8.29 They also state that on some occasions, there were safeguarding concerns which the locality manager did not discuss with the child protection manager to determine whether thresholds for child protection enquiries had been met: Following the review child protection conference, when the school nurse found Child 5 inappropriately unsupervised in the street, it is accepted by 24 Final Version Children’s Social Care that a Section 47 enquiry should have been undertaken and in all probability, would have led to an updated Single Assessment and an initial child protection conference. In September 2016, there were two further occasions when the social worker found Child 6 to be covered by a blanket with a pillow under his head and although this had been addressed by the health visitor and the social worker as being unsafe sleeping practice, it was being disregarded by mother who did not understand the risks; but no further action was taken. Child 1 was not seen by professionals from the 7th November 2016 until the 18th November 2016, despite concerns that he had burns to his feet and was not in school. The social worker should have seen Child 1 on the 17th November 2016 or asked the team manager to send a colleague and if necessary secured the support of the Police in so doing. 8.30 It must be recognised and commended that when the social worker did see the child she acted appropriately and took emergency action by taking the child to hospital and may have saved his life. 8.31 Derbyshire Healthcare Foundation Trust stated in their individual agency initial case summary and analysis report that their statutory duties were not completely fulfilled as although two safeguarding referrals were made when Child 5 was deemed to be at harm, these were not followed up with a written referral in accordance with procedures, they are of the view that staff believed that because the case was already open to Children’s Social Care this was not necessary, despite this being a requirement in Derby and Derbyshire Safeguarding Children Board procedures and covered in training. 8.32 They also state that the team did not consider using the Derby and Derbyshire Safeguarding Children Board Escalation Policy when on the second occasion Child 5 was unsupervised and Children’s Social Care took no action and there was no consideration of completing a graded care profile or an early help assessment despite this being covered in training. 8.33 The Police were fully engaged with the initial child protection conference and acted appropriately when Child 1 was found with injuries and the siblings were removed under Police Powers of Protection. However, as previously stated, they did recognise that earlier consideration of investigating the parents for neglect should have been undertaken. 8.34 School A and School B both made considerable efforts to meet the educational needs of the children, they describe how unprepared Child 1 was for school and spent the first few days crying inconsolably, they changed his timetable and provided him with nurturing support, they provided daily contact with the family through New Communities Achievement Team and support with a range of non-educational welfare issues, housing and benefit concerns and advice and support regarding the payment from the hospital for the bill for the delivery of Child 6. 8.35 They reported when the children were absent or had left school without permission, they ensured the EWO followed up continued absences and challenged the parents about the children’s behaviour and being left alone. They shared 25 Final Version information regularly and have maintained a comprehensive file of safeguarding actions. 8.36 They have reflected that although they made every effort to meet the needs of Child 1, based on their extensive experience of working with Roma children, they needed to revise their induction policy. They also reflected that they could have measured the impact and effectiveness of the plans for the children and stood back and considered what life was actually like for them. 8.37 Derby Teaching Hospitals Foundation Trust provided ante and post-natal services appropriately but they did not have any involvement in the child protection and child in need processes because they were not invited to them. They were fully compliant with procedures when Child 6 was admitted to hospital with neglect. 8.38 The practice of the health visitor was good. Following the birth of Child 6 a primary birth visit was undertaken in accordance with the Healthy Child Programme (2009). Concerns were raised by the health visitor about mother’s ability to read. 8.39 A visit was arranged a month later to complete Child 6’s six-eight-week review. Following this visit the family were offered a higher level of support and regular visits were made to the family and missed visits, when there was no response to the door, were promptly followed up. 8.40 The health visitor had noted nappy rash, she prescribed Clotrimazole cream but was not overly concerned and another visit was planned in two weeks’ time to review. At the next visit the health visitor reported that the nappy rash looked better, but she was concerned about some areas of the baby’s skin and an appointment was made with the GP which the parents did not take the baby to; mother later stated she did not know about the appointment even though the health visitor was with her when it was arranged. 8.41 The health visitor was concerned about the parents’ apparent lack of understanding and inability to act on advice; she therefore shared her concerns with the social worker and with the GP and attended relevant multi-agency meetings about the family. 8.42 The GP practice commented that insufficient information was shared with them. They did hold safeguarding practice meetings and the family was discussed and agreed plans were recorded and open sharing of information was agreed with the 0-19 family health services to ensure electronic records could be equally accessed. Were there obstacles or difficulties in this case that prevented agencies from fulfilling their duties? This will include consideration of both organisational issues and other contextual issues? This will include analysis of responses by all agencies to safeguarding concerns and the effectiveness of communication? 8.43 Much of this question is covered within the other key questions and is not repeated here in full, the impact of working with Roma families with complex needs and challenges around communication have been highlighted by agencies 26 Final Version throughout this review, as has the impact of the withdrawal of some specialist support which made a real difference for example; The Derby City Language Centre which Child 2 and Child 3 attended before joining School B, was established to help develop student’s language acquisition to enable them to function in mainstream schools, although a review of the service concluded that it did not meet the needs of young people, nor did it promote their inclusion in schools or wider society and as a result, the service was closed. 8.44 Overall, although professionals were carrying complex cases and found that the need to secure interpreters made working with them took longer, organisations did not raise issues of difficulties in staff shortages or in recruiting and retaining staff, (except for health visiting and school nursing services in the locality area, this was raised as a significant issue by the health visitor with her manager on 20th July 2016 and was formally recorded as a risk for the Derbyshire Healthcare Foundation Trust) they appeared to be reasonably resourced and have considerable professional experience. However, the additional demands of working with Roma families and the loss of some specialist Roma services, particularly the specialist health visitor for Roma families, which not only provided support directly but were a source of advice for professional, was repeatedly mentioned in reports and discussions, as being of significant concern. Were the practitioners involved in the case have appropriate safeguarding training and management supervision/support specific to their role? 8.45 It is evident from the information provided that staff in all agencies have been provided with a range of safeguarding training, both their own agency training and that provided by the Derby Safeguarding Children Board, with the exception of Children’s Social Care who state that although the social worker, team manager and deputy head of service had received mandatory training the social worker and team manager had not received training on completing effective plans and the use of the Graded Care Profile which was being rolled out at the time they were involved in this case; this has been subsequently addressed. 8.46 Supervision processes, both individual and in groups and access to safeguarding advice from lead professionals in all agencies has been effectively established. 8.47 In relation to supervision, Children’s Social Care have reflected that during the summer of 2016 it took time for the new team manager to gain oversight of the 160 cases held by the team and given the complexity of this case, more frequent supervision would have been helpful, although this would have had to have been balanced with the need to closely supervise several more complex cases. 8.48 There is little evidence of use of effective professional challenge or Derby and Derbyshire Safeguarding Children Board’s escalation policy to resolve professional disagreements, apart from the schools who on returning from the summer holiday and discovering that the children had been removed from child protection plans, raised this with the social worker at the network meeting. 27 Final Version 8.49 Practitioners who contributed to the review reflected that they had been unclear about when, and to whom concerns should be raised or escalated but the review had enabled them to understand this better. 9.0 Conclusion 9.1 This was a complex and challenging case; a family with many children, parents who came from a Roma heritage and culture, who were not always open and honest with professionals in sharing information and may not have understood or agreed with the concerns raised with them. 9.2 Not only was it difficult to obtain information from the family, there was no contact made with the Slovakian Authorities for information about the family, had they been it would have become known that Child 7 had been removed from the care of their parents and that Child 3 had fallen into a fire and suffered significant burns to his body and enabled practitioners to identify potential risk at an earlier stage. 9.3 Communication between the family and agencies was challenging as the family speak a Romanes dialect and interpreting services for this language were insufficiently available and there has been a loss of some significant support arrangements to help professionals understand and meet the needs of Roma families in the city. 9.4 Overall, the information gathered for this review evidences strenuous efforts by professionals to respect the heritage of the family, to work with them in meeting their needs and to respond to the plethora of daily events that required a response. 9.5 There was not a shared view as to whether mother had learning difficulties, was illiterate or was reluctant to accept the need to care for the children in accordance with the culture in which they lived. Father was the main point of contact with several agencies as he had some command of English and the Slovakian language for which interpreters were available, it was unclear whether he dominated his wife or was simply the more articulate and responsive parent or whether he appeared to comply but in practice did not. It should be noted that the children always appeared happy in the care of their parents until the events that triggered this review. 9.6 There was a lack of consensus on what the focus of concerns was, was it about; non-school attendance; the children’s challenging and anti-social behaviour; the children being left alone at home and being unsupervised and allowed to wander outside in the street or; the care given to them at home? The decision to remove the children’s names from the child protection plan undoubtedly had an impact on the focus of concerns which were no longer on neglect and led some professionals to believe they had reduced. This lack of clarity and lack of appropriate focus is not uncommon in cases of neglect where the demands of the family are responded to by professionals but divert them from monitoring what is actually happening and stepping back and reflecting on what the real issues are, i.e. is the care given to this child ‘good enough’? 9.7 Some of the characteristics and challenges of neglect contained in the DfE Research report of 2014, ‘Missed opportunities; indicators of neglect, what is 28 Final Version ignored, why and what can be done’ are paraphrased below as they are relevant to this case: - neglect can, in some cases, be challenging to identify because of the need to look beyond individual parenting episodes and consider the persistence, frequency, enormity and pervasiveness of parenting behaviour which may make them harmful and abusive; - there is a reluctance to pass judgement on patterns of parental behaviour particularly when deemed to be culturally embedded (e.g. the Traveller community) or when associated with social disadvantages such as poverty. 9.8 Although agencies responded well to events on an almost daily basis and communicated reasonably well with each other, there were some exceptions, for example, there were missed opportunities to gather all the information which was held by different agencies and produce effective plans that were clearly understood by everyone, rigorously monitored and revised as new information became known and challenged when agencies had concerns. 9.9 Practitioners were very sensitive to the fact that the family were from a different culture but they, the social worker, the school and the health visitor did challenge the parents’ care and supervision of their children. 9.10 After the injuries to Child 1 a medical examination of Child 6 was undertaken and identified some significant concerns and indicators of neglect for which the parents were prosecuted and admitted their guilt. Since birth, most contact with Child 6 was by the health visitor, who made regular assessment visits, identified and addressed concerns but also emotional warmth and that the baby was thriving and active, they liaised with professionals from other agencies. The health visitor’s last contact with Child 6 was on the 31st October 2016 by the 18th November 2016 medical examination, the baby’s condition had deteriorated. 9.11 Communication between professionals was in person, by ‘phone, by leaving ‘phone messages and by email. All verbal concerns should be followed up in writing immediately, responded to in writing and if the sender does not receive a response they should pro-actively contact the addressee’s manager. In this case the reliance on communication by email had a significant impact on how quickly the social worker was made aware of Child 1’s burns. It was not appreciated that social workers do not have mobile ‘phones on which they can access emails, when they are out of the office. 10.0 Recommendations 10.1 The following recommendations are predominantly directed at Derby Safeguarding Children Board, they do not include those identified by agencies in their individual agency initial case summary and analysis reports and provided for this review. However, two additional recommendation for Children’s Social Care are made and one for all agencies. 1. Derby Safeguarding Children Board should ensure that a strategic multi-agency needs assessment in relation to Slovak families and families from new, emerging communities in Derby City is undertaken to ensure there is a 29 Final Version sufficient range of services to meet identified need. This should include consideration of the reinstatement of the complex case meetings for Roma and new, emerging communities and other previous arrangements. 2. Derby Safeguarding Children Board should assure itself that single assessments are always shared with other agencies and the family. They should always include checks with previous local authorities in the UK and with authorities abroad. 3. Derby Safeguarding Children Board should satisfy itself that where cognitive and parenting assessments are part of a plan, they are completed at an early stage to assist in effective planning. 4. Derby Safeguarding Children Board should satisfy itself that reports to child protection conferences, at which the agency is not represented, should be referred to at the meeting, to inform decision making. 5. Derby Safeguarding Children Board should satisfy itself that plans, whether child protection or children in need should be translated for families where appropriate and be explicit about who will do what by when and what must be evidenced to demonstrate that things have improved, invitations should always include all agencies involved with the child including GPs and midwives. If the plans are not being implemented or there are other professional concerns, these must be escalated, using the Derby Safeguarding Children Board’s Escalation Process. In January 2015, similar recommendation was made in another Derby Safeguarding Children Board review - “Derby and Derbyshire LSCBs should ensure partner agencies remind all frontline staff of the Escalation Process which is there to support them in cases where there is difference of professional opinion”. 6. Derby Safeguarding Children Board should satisfy itself that agencies have assured themselves that their staff follow up verbal referrals in writing and if no response is received, have escalated this to the relevant manager in accordance with the Derby and Derbyshire Safeguarding Children Board Escalation Policy. 7. All agencies should ensure that their staff understand the impact of culture, race and heritage, when identifying neglect and significant harm and ensure that assumptions are not made about the practice and beliefs of newly emerging communities, nor should they condone these if they are not in accordance with practice in England 8. Children’s Social Care should remind social workers of the memorandum of understanding that Derby City Council has with Slovakian Authorities in terms of obtaining and sharing information and ensure staff do so at an early stage of their assessments. 30 Final Version 9. Derby Safeguarding Children Board should monitor the implementation of these recommendations and those identified by individual agencies. 10. Derby Safeguarding Children Board should offer the Slovakian Authorities, where the family and the children live, a copy of this report and they accept the offer, they should be asked to share it with the family on behalf of Derby Safeguarding Children Board. 31 Final Version Appendix 1 The purpose of the review is to Determine whether decisions and actions in the case comply with the policy and procedures of named services and Local Safeguarding Children Board. Examine inter-agency working and service provision for the child and family. Determine the extent to which decisions and actions were child focused. Seek contributions to the review from appropriate family members and keep them informed of key aspects of progress. Take account of any parallel investigations or proceedings related to the case. Hold a learning event for practitioners and identify required resources. The extended child practice review will have regard to the following: Was previous relevant information or history about the child and/or family members known and considered in professionals' assessment, planning and decision-making in respect of the child the family and their circumstances; How effective was the assessment of parental learning disability? What impact was there on the effectiveness of engagement with the family arising from communication issues and the specific dialect of Romany used by the family? How did that knowledge contribute to the outcome for the child? Was the child protection plan and subsequent child in need plan robust, and appropriate for that child, the family and their circumstances? Were all agencies effectively involved in the child protection plan? Were the plans effectively implemented, monitored and reviewed? Did agencies contribute appropriately to the development and delivery of the multi-agency plans? How effective was the core group/network group? What aspects of the plans worked well, what did not work well and why? How well were the plans understood by the children and parents and what evidence is there to demonstrate this? What oversight was there of the plans and how effectively were they reviewed? To what degree did agencies challenge each other regarding the effectiveness of the plans, including progress against agreed outcomes for the child? Was the protocol for professional disagreement invoked? How effectively were agencies able to contribute to the analysis of risk and safeguarding concerns both at the point of the decision and in the period following the de-escalation from child protection plan to child in need status? Were the respective statutory duties of all agencies working with the child and family fulfilled? Were there obstacles or difficulties in this case that prevented agencies from fulfilling their duties? This will include consideration of both organisational issues and other contextual issues? This will include analysis of responses by all agencies to safeguarding concerns and the effectiveness of communication? Were the practitioners involved in the case have appropriate safeguarding training and management supervision/support specific to their role? |
NC50571 | Death of an 11-year-old girl in a road traffic accident in December 2014. Child M and her mother were not wearing seatbelts; Child M's 2-year-old sibling was appropriately restrained and did not sustain any injuries. Criminal action was deemed not in the public interest. Mother was born in mainland Europe, moving to England at age 19 after a family disagreement. Mother of Sri Lankan/Christian heritage; father's heritage Sri Lankan/Hindu. Family known to children's social care since May 2013; maternal history of: child sexual abuse; domestic violence; mental health problems. Findings: although Child M was subject to a child protection plan at the time of death, the fatal accident could not have been predicted; help to the family could have been more focused, better coordinated and impact of plans reviewed more thoroughly; over optimism regarding Mother's capacity to sustain changes needed to provide safe care to the children; inconsistent provision of management or supervision arrangements to promote critical reflection and analysis. Recommendations: to ensure that all relevant professionals are included in child protection conferences; develop a statement of expectation regarding safeguarding supervision and undertake a multi-agency audit of the quality of safeguarding practice; consider whether the voice of the child is adequately heard within assessments; the housing association should review internal communication pathways where a family is in arrears; and the Diocesan Safeguarding Team should develop and communicate with churches the process for obtaining advice where there are safeguarding concerns relating to members of the local church community.
| Title: Serious case review: Child M. LSCB: Hampshire Safeguarding Children Board Author: Jane Wonnacott Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. FINAL FOR LSCB Serious Case Review Child M 17.8.16 Hampshire Safeguarding Children Board Serious Case Review Child M Report Author Jane Wonnacott MSc MPhil CQSW AASW FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 2 of 37 Contents INTRODUCTION ........................................................................................................... 3 1. REVIEW PROCESS ...................................................................................................... 3 2. BACKGROUND PRIOR TO REVIEW PERIOD ............................................................ 4 3. CASE SUMMARY ......................................................................................................... 4 4. NARRATIVE / EVALUATION OF PRACTICE .............................................................. 6 5. FINDINGS AND RECOMMENDATIONS .................................................................... 21 6. APPENDIX ONE: THE REVIEW PROCESS .............................................................. 33 7. APPRENDIX TWO: PRCTITIONER DISCUSSIONS ................................................. 36 8. FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 3 of 37 INTRODUCTION 1.1.1 Child M died at the age of 11 in a road traffic accident in a neighbouring local authority. Her mother (known throughout this report as “Mother”) was driving the car and evidence presented at the inquest suggests that Mother and Child M were not wearing seatbelts at the time of the accident. Child M’s two year old sibling was appropriately restrained in a car seat and did not suffer any injuries. The Crown Prosecution Service was consulted by the neighbouring police force regarding any potential criminal action against mother for driving offences but they decided that such action was not in the public interest. 1.2 The reason for this serious case review is that at the time of her death, Child M and her sibling were both the subject of child protection plans. The family had been known to children’s social care since May 2013 and Mother had also been in contact with a number of organisations, including mental health services. REVIEW PROCESS 2.2.1 Jane Wonnacott, an experienced lead reviewer, was appointed to lead the review and write the final report. For full details of the review process and further details of the lead reviewer please see appendix one. 2.2 The lead reviewer worked with a small team of senior professionals from within Hampshire who represented the organisations who had contact with Child M and her family. Each organisation prepared a chronology and outline of their involvement and the review team agreed questions that would need to be considered by the review. 2.3 The review aimed to understand events from the point of view of practitioners working with the family and the lead reviewer arranged to talk to individual practitioners with the member of the review team representing their organisation. It was possible to speak to all key practitioners with the exception of the social worker in the community mental health team who was on extended leave throughout the review period. These individual discussions were followed up by a group meeting of all practitioners to check the accuracy of the case narrative and discuss the emerging findings of the review. 2.4 Mother and her children had been involved with the local church and the lead reviewer spoke to the vicar and his partner in order to understand more about the church’s involvement. As a result of these discussions, a member of the local diocesan safeguarding team joined the review team. 2.5 Child M’s mother was asked by letter and verbally whether she wished to contribute to the review but did not feel able to do so. Child M’s father, who lives some distance from Hampshire, was also invited via two letters to contribute. Neither parent expressed a wish to contribute to the review. FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 4 of 37 2.6 Although the serious incident took place in December 2014 this review has not been completed until the summer of 2016. The reasons that lay behind the length of time taken to complete the review were: The complexity of the case including the large number of organisations and professionals who had been involved with the family, The identification of organisations only becoming clear as the review progressed. BACKGROUND PRIOR TO REVIEW PERIOD 3.3.1 Mother was born in mainland Europe and moved to England at the age of 19, following a family disagreement. GP records note mental health problems in her home country and a significant issue in Mother’s history is that she alleges that she was sexually abused by a close family member from the age of 10 to 17. This allegation has not been investigated as mother has not given specific details to any of the professionals working with the family. 3.2 Mother’s heritage is Sri Lankan/Christian and she met the father of the children whilst living in the UK, his heritage being Sri Lankan/Hindu. There are allegations that Father was violent towards Mother and they separated, with Mother moving to Hampshire. At first Mother lived in privately rented accommodation, later moving into social housing provided by a housing association. 3.3 Prior to Mother’s pregnancy with Child M’s sibling, in February 2011 a local family support team (FST1) managed by a local schools partnership, received a referral from the primary school expressing concerns about Child M and the mental health of her mother. This led to a CAF2 and a team around the child meeting. Support from the family support team continued until September 2011 when it was agreed that support structures were in place through school and universal services. At this point Mother was enrolled in parenting classes but she missed the first session, attended the second and did not complete the course. 3.4 Mother was involved with the local church community and from the time that she was pregnant with Child M’s sibling they became very involved in providing support to Mother. This support included developing a rota to visit the home every morning to give breakfast to the children as well as taking and picking up Child M from school. CASE SUMMARY 4. Jan 2012 Child M’s sibling born. (Child M was age 8). Family support team support started again. 1 An early intervention service 2 A CAF is an early help assessment using the Common Assessment Framework. FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 5 of 37 March 2013 Mother was referred by the GP to the community mental health team. Regular support from the team social worker started. May 2013 GP referred to children's social care: children at risk of neglect. Health visitor referred to Home-Start3. June 2013 An initial legal strategy meeting took place. July 2013 Initial child protection conference – both children made subject of a plan under the category of neglect with a second category of emotional abuse. A Public Law Outline letter (first stage of legal proceedings) was sent to Mother. Aug 2013 Assessment by consultant psychiatrist; recommended counselling and emotional coping skills group. Sept 2013 Mother started emotional coping skills group. (Three out of six sessions were fully completed). Oct 2013 A review child protection conference recommended that both children should remain subject of a plan. Nov 2013 A legal strategy meeting requested a parenting assessment and a psychological assessment of Mother. A strategy discussion agreed single agency Section 47 enquiries by children's social care following an allegation by Child M that her uncle had attempted to hit her. The outcome of these enquires was no further action (NFA). Home-Start visits finished as Mother had a job Dec 2013 A “notice of seeking possession” was issued by the housing association due to rent arrears. Jan 2014 Debt advice given by the Housing Association. Mother started counselling at a sexual abuse counselling service. A third legal strategy meeting took place: the parenting assessment had been completed but no psychological assessment. No conclusion could be reached until the assessment had been discussed with Mother. Feb 2014 A fourth legal strategy meeting agreed that the Public Law Outline 3 Home-Start is a family support charity who work with families and young children through a network of volunteers. FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 6 of 37 process should be ended and the threshold for legal proceedings no longer deemed to be met. Good progress noted in community mental health team and Mother to be discharged. March 2014 A review child protection conference removed both children from child protection plans. June/July 2014 Further concern noted by housing association about rent arrears and court action pending: support offered and payment plan agreed. Deterioration in home conditions noted by health visitor. Sept 2014 Referral by school to children's social care concerned about Child M as young carer and Mother’s mental health. Oct 2014 A child protection conference made both children subject of a child protection plan under the category of neglect. A legal strategy meeting deemed that the threshold for legal proceedings was not met. Recommendation from the meeting was that report should be obtained from Mother’s private counsellor in London. Father should also be contacted. Dec 2014 Child M died in a road traffic accident. NARRATIVE / EVALUATION OF PRACTICE 5.5.1 The main purpose of a serious case review is to improve services to children and their families. Much of the forthcoming section therefore focuses on the services provided to Child M and her family and in line with the requirements of a report which is expected to be in the public domain, personal details have been kept to a minimum. Where family details including aspects of Child M’s life, these are included, this is because they are relevant to an evaluation of professional practice. This approach does mean that when many services are primarily focused on the adult, it may seem that a focus on the child has been lost. This is not intention of this report and it should be read with the understanding that Child M and her sibling are at the heart of this review. From birth of Child M’s sibling in 2012 to child protection conference in July 2013 5.2 After the birth of Child M’s sibling, in January 2012, (when Child M was age 8) Mother requested further help from the family support team and records note that she was having difficulties with her relationship with Child M. The home was chaotic and routines were not in place. It is not clear from the records what support was offered, FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 7 of 37 although the health visitor referred Mother to baby massage to encourage attachment with the baby. Mother attended only one session and did not return. 5.3 In October 2012 at a home visit by the family support team worker, Mother shared concerns regarding Child M’s “controlling behaviour” and it was arranged for a parent support adviser to visit the home. The records show visits from the adviser between November 2012 and February 2013. 5.4 In March 2013 the GP referred Mother to the community mental health team (CMHT) noting concerns which included Mother’s poor relationship with Child M and problems relating to Mother’s past experience of sexual abuse. (This assessment took place on 10th June). 5.5 In May 2013 the GP was contacted by a friend/neighbour of Mother, who was concerned about the children. The concerns included physical neglect that could have compromised the children’s safety and the GP took proactive action and referred to children’s social care the same day. 5.6 The case was allocated within the referral and assessment team with a S17 assessment4 being carried out by a student social worker. With hindsight and the benefit of experience, this social worker (now qualified) believes this should have been treated as a child protection enquiry (S47)5 from the start. At that time decisions regarding thresholds were made within local social work teams whereas current practice is that the decision would be made within the Multi Agency Safeguarding Hub (MASH) and be based on full consideration of information from a multi-agency perspective. Whilst it cannot be said with absolute certainty that the decision by MASH today would be different, the application of consistent thresholds across the county combined with multiagency discussions means that that decision making at the point of referral would be more defensible and robust. 5.7 An additional issue at this point is the allocation of the case to a student social worker. Discussions with Hampshire workforce development team have clarified that historic and current practice is that the team’s policy, supported by instructions from senior managers, is that cases involving statutory assessments (child in need or child protection) must be allocated to a qualified worker even though tasks may be carried out by the student. In this case the social worker who was a student at the time recalls being “allocated“ the case and that usual practice in the team was that it would have only been allocated to a qualified worker if it had involved child protection enquiries. This was not in line with expected practice and importance of clarity in relation to the role of students within social work teams is discussed further in paragraphs 6.20 – 21. 4 This is an assessment of a Child in Need; where the child is not believed to be a risk of significant harm. 5 This is an enquiry under section 47 of Children Act 1989 where there is cause to suspect that a child is suffering or is likely to suffer significant harm FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 8 of 37 5.8 There were occasions during this assessment period where information was shared between practitioners working with the family: The health visitor had referred Mother to Home-Start and following an initial visit the Home-Start co-ordinator completed a record of concern and called the student social worker. Concerns included Mother’s mental health, chaotic home, disorganisation and difficulties in caring for the children. On 10th June 2013 there was a clinic assessment by a social worker at the CMHT which explored both social and mental health history. This assessment noted an answer of “yes” to whether there were any actual or potential risks to children, with a note that there were two children in the house and concerns of neglect and emotional abuse. As a result there was liaison with the student social worker in children's social care. 5.9 On 11th June there was a joint visit to the home by the student social worker, health visitor, parent support adviser from the school and a supporter from the local church. The student social worker recalls Mother saying that she had recently fallen asleep on the sofa while cooking and only woke up when the fire alarms were going. No practitioner challenged Mother about the implications of this for the children’s safety and it is to the student social worker’s credit that they did recognise the risks to the children and after the visit appropriately recommended that the case should be escalated to S47 (child protection) enquiries. At this stage the focus of others on supporting Mother appears to have detracted attention from a focus on the impact of her behaviour on the children. 5.10 The lack of challenge to mother by more experienced professionals meant that the student had not felt confident to query Mother’s behaviour in the meeting. Due to staff sickness, there was no supervisor from the team accompanying the student social worker on this visit which would have been expected practice. The visit was observed by the student’s practice educator but they did not have a background in children’s services6. 5.11 The case was immediately allocated to a qualified social worker who had responsibility for child protection enquiries and carried out a further visit with the student social worker on the same day. Mother was offered s207 accommodation for the children but declined this offer and the social worker arranged for all the family to stay with the local vicar and his wife over the weekend. Following the weekend, Mother’s sibling (Child M’s uncle) came to stay with the family on a longer term basis to support Mother. The focus of social work at this point was on helping the family to stay together with support. The risk of harm was managed through recommending that there should be a multiagency child protection conference. 6 Practice educators are responsible for a student social workers overall learning and assessment and do have line management responsibility for specific cases. 7 This accommodation provided with parental consent under section 20 Children Act 1989. The local authority and the parent share parental responsibility for a child accommodated under this section of the Act. FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 9 of 37 5.12 On 13th June the Home-Start volunteer was introduced and as they arrived, the social worker was leaving the home. This is indicative of many people involved in helping Mother, but little sense of a coordinated planned approach at this stage. 5.13 During this period (June 2013) Mother was living in a property owned by a housing association which was working with Mother to agree a repayment plan for rent arrears. The association were not contacted during the child protection enquiries and was unaware of any children's social care involvement. As a result there is no evidence that the implications of financial stressors including arrears were considered during assessments prior to the conference. 5.14 On 14th June 2013 the access and assessment team within the Community Mental Health Team referred Mother to the community treatment team, as her “needs appear to be complex and long-standing”. It was hoped that the community treatment team would provide emotional coping skills and medical input. 5.15 GP records for 24th June 2013 note anxiety with depression, and that Mother was not allowed to be alone with the children so was staying with a volunteer with the church. Mother’s brother was noted to be returning soon. 5.16 On 25th June 2013, there was a joint meeting at the home attended by the student social worker, two qualified social workers, the health visitor, two supporters from the church, the family support worker and the outreach worker from the local Children’s Centre. (This meeting had been called by the student social worker to review the situation, and Mother had invited several people to the meeting herself). The student social worker recalls that a view from others at the meeting that they were not in agreement with concerns of children’s social care and thought that children’s social care was being negative towards Mother. 5.17 At school Child M was receiving support from the ELSA (Emotional Literary Support Assistant) and notes from this period state that Child M was worried about her Mother and that she ‘cared for her sibling whilst Mum sleeps’. Child M also worried that, “her Mum was given away and hurt by people and this might happen to her. Dad can’t come to the house until he stops hurting Mum”. 5.18 It is clear that there were significant concerns about risks to the children at this point as on 25th June, a legal strategy meeting was held to discuss whether the threshold had been met to issue proceedings under the Public Law Outline. This meeting agreed that the threshold had been met and minutes note that a letter would be sent to Mother after the child protection conference on 4th July. The review team have not been able to understand the rationale for the letter being delayed until after the conference other than the conference was taking place nine days later and it would take longer than this for a letter to be prepared. 5.19 0n 1st July, Home-Start completed another record of concern following a visit to Mother. Child M was apparently sleeping on the floor of the bedroom so her Uncle could use the bed, and Mother commented on thoughts about hurting the children, FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 10 of 37 such as pouring hot oil on Child M’s sibling when cooking. Home-Start records note that the “social worker aware of these thoughts”8 and there is a record of the coordinator having a conversation with the social worker on 4th July 2013. During this conversation Home-Start queried why they had not received an invitation to the child protection conference (see paragraph 5.20 below). Summary: from birth of Child M’s sibling in 2012 to child protection conference in July 2013 During this period, risks to the children associated with Mother’s parenting capacity were recognised and resulted in a number of organisations and individual practitioners helping Mother and her children. These included: the family support team the community mental health team social workers in children's social care the GP the church the housing association the health visitor home-start school (particularly the ELSA). This was indicative of an enduring pattern of work in this case whereby a combination of Mother’s vulnerability and quest for help combined with the concerns of others about the children, led to a wide range of services being involved. Almost inevitably this presented challenges in ensuring that services were coordinated in the most effective way possible. The following issues affected the overall effectiveness of work with the case. 1. There were tensions between the church/neighbours and children's social care regarding the extent to which the community should be involved in providing day to day support. This was underpinned by a lack of clarity from staff in children’s social care about how far statutory services should/could involve informal networks in formal child protection processes. 2. The initial decision that this was a child in need referral resulted in allocation of the case to a student social worker who did not receive adequate case management supervision for a period of time due to the practice supervisor9 being on extended leave. The student’s practice educator10 did not have children’s experience and in any case did not have line management responsibility for work with the family. The student social worker was rightly worried about the children but lacked confidence to express these concerns in a meeting with more experienced professionals although the student did escalate once they had returned to their office. 3. The supervision of the health visitor did not provide sufficient time for individual oversight of cases and critical reflection regarding the dynamics of this case: the health visitor believes that the group format for safeguarding supervision 8 This was the student social worker although referred to as a social worker in Home-Start records 9 The practice supervisor is a member of the team responsible for case management 10 The practice educator is not a member of the team but has overall responsibility for assessment of the students practice. FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 11 of 37 contributed to this issue, Child protection conference and plans July 2013 – March 2014 5.20 An initial child protection conference was held on 4th July 2013 and both children became the subjects of a child protection plan under the category of neglect, with a second category of emotional abuse. The list of those invited to the conference did not include Home-Start, the housing association or the community mental health team (although the CMHT social worker sent a written report). The lack of attendance by Home-Start or a written report meant that significant information was not available to the conference; for example there is no record in the conference minutes of Mother’s comment to the Home-Start volunteer that she had thoughts of harming the children. The Home-Start records show that Mother had asked the Home-Start volunteer to accompany her to the child protection conference, but Home-Start were informed by the “social worker”11 that this was not possible as Home-Start had not been with the family long when the invitations were sent out. This appears to have been an individual error as the review team have received confirmation from Home-Start that they are usually appropriately invited to child protection conferences. 5.21 Members of the church also asked whether they could support Mother at the conference. Mother was supported by her sibling and sister and the conference chair recalls receiving a message that the church members were neighbours who wished to understand the conference process. In the light of this information, the decision of the chair not to agree to admit them to the conference was entirely appropriate. 5.22 It is of note that there is no reference in the conference minutes to the fact that children's social care had started legal proceedings. Whilst the detail of actions taken in this regard would not be appropriate to share at the conference, the multi-agency group would expect to be informed that a legal strategy meeting had taken place which deemed the threshold for proceedings to be met. 5.23 Following the conference, social work responsibility for Child M and her sibling was transferred from the referral and assessment team to a social worker in the child in need team. This new social worker had responsibility for working with the multi-agency group to develop and implement the child protection plan. 5.24 The child protection plan is set out in detail below as an illustration of the wide range of services that were involved with the family. The plan included: contact with the mental health social worker, a psychiatric assessment, 11 It is not clear whether this was the student or the allocated qualified worker FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 12 of 37 attendance at the emotional coping skills programme, referral to Home-Start (although this was already in place), referral to Art Therapy for Child M, a referral to Child and Adolescent Mental Health Services for family therapy, ELSA support for Child M to continue, Child M’s sibling to attend toddler group, nursery nurse involvement to support Mother with learning how to play appropriately and social work visits to focus on stopping the ‘neighbour’s involvement’. 5.25 The multi-agency child protection plan did recognise that there should be no contact with the family member who Mother had alleged had previously abused her but no practitioner raised any queries about risks this person may pose to other children. Another problem with the plan is that the emotional coping skills six week programme provided by mental health services was linked with a planned outcome of “children being provided with long term stability”. This was potentially a rather ambitious undertaking for a six week teaching based skills programme when Mother’s problems were deep and long-standing. The aspect of the plan linked to accessing counselling/therapy to address her past issues was linked with engaging with a psychiatric assessment, but this assessment was a one-off consultation that did not provide the therapeutic input needed to achieve this outcome. 5.26 Following the conference in July 2013 Public Law Outline12 letter was issued to Mother. Due to an error the letter was not sent to Father who also had parental responsibility. There is no evidence of any structured plan linked to the PLO process and the next legal strategy meeting was not held until November 2013. The lack of focused work linked to the PLO is noted as being due to Mother failing to instruct a solicitor; this is not an acceptable reason and contributed to drift in the management of the case. 5.27 As a result of the child protection intervention during the summer of 2013, the intensive support from the church stopped, including the daily rotas to allow Mother to show her ability to parent independently. This was perceived by the church to be because the social worker wished them to reduce their involvement although there was less clarity from the church’s point of view that this was part of a positive plan. 5.28 On 5th August 2013, Mother was seen for an assessment by the consultant psychiatrist. The plan from this consultation was continue with medication, attend the emotional coping skills group and consider the possibility of continuing long term 12 The first stage of legal proceedings FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 13 of 37 therapy from a local counselling service if Mother could pay for it. Mother was to continue seeing the social worker from CMHT. 5.29 During August a range of services continued to be involved with the family. Mother attended a “Stay and Play” session at the children’s centre, and the community nursery nurse visited at home. At a core group meeting in August Mother referred to contact with a private psychiatrist. Regular visits from the social worker from CMHT and Home-Start continued. 5.30 The emotional coping skills group started in September. Mother attended the first three sessions, missed the fourth session due to a child protection conference, missed the fifth session and only attended 20 minutes of the sixth session. 5.31 In September 2013 the vicar from the church spoke to the head teacher of the local village school about concerns at a residential weekend which indicated that Child M was adopting the role of young carer for her sibling. When Mother became aware of this discussion Mother stopped attending church and the vicar spoke to the Diocesan Safeguarding Officer whose advice was that the church should report the situation to children's social care if there was “immediate danger” to the children. The minister didn’t feel that there was immediate danger, and believed that the neglect was being dealt with by children's social care. Following this, Mother began attending a group run by a free church nearby. 5.32 The role of churches in the safeguarding system is explored further in paragraph 6.11. At this point the issue related to the interpretation of “immediate danger”. It would have been good practice for the concerns of the church to be shared with children's social care and the failure to do so indicates a lack of clarity within the church community regarding their role in relation to families where there are concerns about ongoing neglect. 5.33 At the beginning of September, Child M’s sibling started at a private nursery. Mother had told the initial conference that she hoped to send Child M’s sibling to nursery but at that stage this was no longer certain and the nursery were not aware of the existence of the child protection plan. Staff at the nursery immediately began to record concerns about Mother’s physical care of Child M’s sibling and apparent disinterest when issues were raised with her. Concerns were discussed in supervision including the possibility that Mother’s disinterest was shyness and/or influenced by her cultural background. At this stage it was the view of the nursery manager that records should be kept and reviewed but the threshold had not been reached for a discussion with children’s services. This was a reasonable decision at that time. 5.34 Home-Start visits continued during September 2013 and notes for one visit on 27th September identified concerns regarding Child M’s sibling playing at the cooker, Mother opening the front door so he could play outside, dirty pots and pans, a sieve with mouldy kidney beans. The Home-Start coordinator followed these concerns up FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 14 of 37 with a report to a forthcoming core group meeting and review child protection conference. 5.35 During September there were further concerns regarding rent arrears which were only known to the income team in the Housing Association. At this stage the housing officer who had responsibility for tenancy management was unaware of the arrears and the Housing Association have identified during discussions for this review that internal communication systems need to be reviewed. Even if the housing officer had been aware of the arrears it is unlikely that direct contact would have been made with children's social care unless Mother had informed the housing officer of their involvement. At that stage plans were being made to manage the debt and there were no other causes for concern. 5.36 On 20th October 2013 a review child protection conference took place and the decision was that the children should remain on the child protection plan. The chronology indicates that the minutes of the meeting were not received by attendees until 27th November. The private nursery is noted to be part of the core group but they were not contacted and continued to be unaware of the existence of the plan. 5.37 During October, Mother and Child M’s sibling twice attended a speech and language group at the children’s centre. Health visitor contact continued as did regular visits from the community CMHT social worker and the children’s social worker. There is a note on the children’s social care file that the “PLO/CPP continues to be tracked. Core and parenting assessments are underway and other written evidence being collated.” 5.38 The outcome of a second legal strategy meeting was that a parenting assessment should be completed by a family support worker as well as a psychological assessment by mental health services. The parenting assessment began but no psychological assessment took place which could have assisted practitioners in assessing Mother’s psychological capacity to parent. This omission might have been less likely had the approach been formalised through a commissioned psychological assessment from a court recognised expert working to a clear letter of instruction. Practice in relation to expert reports was reviewed by Hampshire in 2014/15 and resulted in guidance being issued to clarify expected practice. The review has had sight of evidence which shows that current practice would include an expert report in similar cases. 5.39 On 12th November, notes of the core group comment that the PLO outline was proceeding alongside the child protection plan and work with the community nursery nurse had been completed. The ELSA expressed concerns about Mother’s emotional availability for Child M and that she was often the last to be picked up after school. 5.40 On 13th November Child M presented at school with a wobbly tooth and stated that she had done it herself because she had taken her uncle’s laptop without permission and thought he was going to hit her, so she moved away and banged her tooth FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 15 of 37 herself. The school passed this information to the social worker. A telephone strategy discussion took place between the social worker and the police child protection team and it was agreed that the allegation would be managed as a single agency s47 enquiry. Whilst usual expected practice as set out in procedures was for a strategy discussion “ordinarily be coordinated and chaired by the team manager/first line manager”13 the review was informed that since within procedures allowance was made for the discussion to be led by others. At that time, a discussion led by a social worker would not have been uncommon. This is why there is no evidence on file of management oversight of the decision, or the involvement of health professionals, as would be practice today within the Multi Agency Safeguarding Hub.14 5.41 The social worker visited Child M at school and Child M spoke about her uncle hitting her and taking pictures of her that made her cry. Talking to the child is a crucial element of social work assessments and it is to the social worker’s credit that this was a central aspect of the child protection enquiries. The possibility of consulting a paediatrician as a result of the wobbly tooth and allegation about being hit was not considered at this stage and further more detailed examination of the circumstances surrounding these events may have provided additional opportunity for Child M’s voice to be heard. 5.42 The social worker visited the family home and challenged Uncle with this information and recorded that he seemed genuinely shocked, did not realise the impact of his actions on Child M and apologised to her. The social worker also challenged Mother who seemed unaware of the incident. After this the social worker discussed the home visit with the team manager and it was agreed that there would be no further child protection action but the family were aware that there would be consequences if anything like this should occur again. Although there was appropriate management oversight at this stage, there is no recorded discussion with the team manager prompted any further consideration of whether relying on Uncle as the main source of support to the family was in the children’s best interests. 5.43 This incident is illustrative of an approach to work with the family which at times was insufficiently rigorous in using procedures which are designed to support a coordinated multi-agency approach including a systematic gathering and analysis of all available information. Although there had been a core group meeting the previous day, section 47 enquires should still have included contact with other professionals who knew the family15. This was particularly important where a child was subject of a child protection plan and would have informed them of the allegation as well as 13 4 LSCB procedures 14 Current practice is that strategy discussions would be managed within MASH and all decisions would include management sign off. 15 4LSCB procedures state that “The social worker must contact the other agencies involved with the child to inform them that a Section 47 Enquiry has been initiated and to seek their views. The checks should be undertaken directly with involved professionals and not through messages with intermediaries”. FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 16 of 37 gathering any further relevant information. There is no record in the chronology that any contact was made with other agencies or that anyone other than the school was aware of the allegation. More extensive enquiries may have gathered information regarding rent arrears and the concerns recorded by the private nursery about Mother’s care of Child M’s sibling which at that stage in isolation had not reached the threshold for a referral to children’s services. The day nursery remained unaware of the child protection plan or the recent s47 enquiries. 5.44 During November three of the support services working with the family ceased their involvement for various reasons: the case was closed to the local family centre because at that time the process was that once the family had been escalated to children’s services the case was closed to the centre. Mother and Child M’s sibling attended their last session of the Speech and Language Group as there was a new group leader who did not run the group in the same way as the previous leader and the group no longer met their needs. The Children’s Centre (where the group took place) did not know that the children were on a child protection plan, Home-Start finished their involvement as Mother cancelled the volunteer visits as she had obtained a part time job. 5.45 In December 2013, because of continued non-payment a Notice of Seeking Possession was sought by the housing association. There was an internal communication issue at this point, as the housing officer responsible for tenancy management was unaware of the arrears which meant that even if the social worker had made contact as part of the s47 enquiries the information about the arrears may not have informed social work decision making. The Notice of Seeking Possession was hand delivered, but Mother was not at home. The officer delivering the letter was quite surprised at how “scruffy” the property was but it was not bad enough to raise concerns with the housing officer. 5.46 Through December to March the child protection plan continued although the chronology suggests that contact with professionals was less frequent. 5.47 In January 2014 Mother started weekly counselling at a Rape and Sexual Abuse Counselling Service. 5.48 During January and February records suggest that Mother was struggling financially had significant debts and asked for support from the housing association financial inclusion officer. An indicator was added to the housing association debt advice section that Mother was vulnerable due to being a parent alone with mental health issues. The extent of these debts would not have been known to the social worker and at this point a referral should have been made to children’s social care by the Housing Association. The role of housing in the child protection system is discussed further in paragraphs 6.9 -10. FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 17 of 37 5.49 A third legal strategy meeting was held in January 2014. It was noted that the parenting assessment had been completed but no conclusion could be reached as it had not been shared with Mother. There is no review of the absence of a psychological assessment. 5.50 The review team sought to understand the reason why the assessment could not reach a conclusion at this stage but was not able to do so as the final assessment document could not be found within children's social care records. This raises an additional issue regarding efficient storage of records that may be important in informing future work with the family. 5.51 A further legal strategy meeting on 6th February 2014 heard that adult mental health services were reporting good progress (she was soon to be discharged) and there was an all-round improvement in Mother’s capacity to cope. It was agreed that the threshold for legal action was no longer met. 5.52 On 14th February 2014 the private nursery school received an invitation to a review child protection conference. They had not known that Child M’s sibling was subject to a child protection plan and they therefore contacted the social worker for more information. Concerns in the nursery had started to increase at this point with nursery records in February noting concern about Mother’s care of Child M’s sibling including Mother being distant and unaffectionate, being late arriving and Child M’s sibling often smelling of stale urine. These concerns were conveyed to the social worker. 5.53 On 6th March 2014, there was a review child protection conference and both children were removed from the child protection plan and this was stepped down to a child in need plan. This was the first child protection conference that the nursery manager had attended. They had not been part of the core group and when conference members were describing considerable improvements in the home they did not feel able to challenge the prevailing view that both children should be removed from a plan, even though they had concerns about Mother’s care of Child M’s sibling. Although the nursery manager had received training relating to the child protection conference process, this serves as a reminder that colleagues who are not frequent attenders may find the process daunting. Summary: Child protection conference and plans July 2013 – March 2014 This period started with significant concerns about Mother’s ability to care for her children, mainly linked to her own mental health issues and emotional vulnerability. By the end of the period there was a unanimous view expressed by the professional community who were part of the child protection conference process that progress had been made and the children no longer needed to be subject to child protection plans. It is significant that the nursery manager still had concerns during the conference but did not feel able to challenge the prevailing view that there had been considerable improvements. This stemmed from lack of confidence within the meeting but they also found it hard to measure their current concerns against the knowledge of others who were describing FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 18 of 37 considerable progress. The positive changes in the family were clearly identified by the professionals involved but there was also information that was not available to the conference. The practice issues that may have affected the decision making at this point were: the lack of involvement of the housing association in the conference and core group process, due in part to the fact that they had not referred to children's social care. Information from the housing association would have confirmed the potential for stress associated with a high level of debt, aspects of the child protection plan being overly optimistic about outcomes from specific actions ( e.g. the emotional coping skills group) and lack of clarity about how Mother’s capacity to sustain change over time would be assessed, a misunderstanding by some professionals about the therapeutic input from the CMHT (the health visitor referred to her having “intensive therapy with the CMHT”) insufficient liaison and supervision of the safeguarding work of the CMHT by their specialist safeguarding professionals, a lack of understanding within statutory agencies of the importance of working positively with the church community, a fragmented approach to the delivery of support services with key agencies being either unaware of the child protection plan (the children’s centre and private nursery) or having a remit that ended at the point that a case reached the child protection threshold (the family centre). During this period, concerns were sufficient to consider legal proceedings and these were spelt out clearly to Mother in writing. The review team had heard that it is possible that Mother did not fully understood the level of concern, the actions that needed to be taken to improve the wellbeing of both children as well as the consequences of changes not taking place. Although the decision to stop the PLO process was understandable given the reported progress, the absence of a psychological assessment meant that there was only a partial understanding of Mother’s capacity to sustain change. March 2014 – fatal accident on 9th December 2014 5.54 From March through to October 2014 a child in need plan was in place although records suggest that although there continued to be concerns, particularly following visits by the health visitor and housing officials these were not shared in a timely and systematic way with children's social care . 5.55 At the start of June the notes from the community nursery nurse and health visitor indicate deterioration in home conditions, with safety hazards and limited space for the children to play. There is no evidence that these concerns were shared with the social worker and the health visitor could not attend the child in need meetings in either June or July. There appear to be two factors affecting health visiting practice at that time, firstly, a lack of named supervisor who was familiar with the health visitors caseload, who could be contacted for a discussion where concerns were increasing, FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 19 of 37 and secondly, no mechanism within Southern Health to alert managers when practitioners could not attend key meetings. 5.56 There were further concerns about rent arrears and in June 2014 Mother was informed that court was pending. This was averted by a weekly payment plan being agreed with the housing association. On 16th July the housing association income officer referred Mother to the financial tenancy sustainment officer noting concerns about the condition of the property, Mother’s mental health and lack of local family support. The income officer asked the tenancy sustainment officer to contact relevant agencies as Mother had said she was under the child in need team. 5.57 There was an unacceptable delay in the tenancy sustainment officer making contact with children's social care. It was not until 2nd September 2014 a safeguarding enquiry was made to the social work team by the housing association tenancy support officer. The children's social care file noted that a notice seeking possession was likely. This is the first significant contact between housing and children's social care that indicated the severity of Mother’s financial situation. 5.58 On 26th September 2014, S47 (child protection) enquiries commenced as a result of concerns raised by the school. Child M had disclosed caring for her sibling, and that Mother had threatened to kill herself. A home visit by the social worker three days later noted that the home conditions had deteriorated to a point where they were hazardous. 5.59 An initial child protection conference was held on 17th October 2014. No one from the housing association was invited. The nursery did receive an invitation but the manager was on holiday and there was no other member of staff trained to a sufficient level who could prepare a report and attend. Nursery information was therefore conveyed verbally via the preschool inclusion officer. It was noted that Mother had been unable to maintain the home in a state of cleanliness and safety, she continued to fail to prioritise her children’s needs, and there were concerns about her mental health. It was agreed that both children should be placed on a child protection plan under the category of neglect and a core group of professionals were to work with Mother consisting of the social worker, health visitor, head teacher of Child M’s school and the nursery manager. 5.60 On 21st October a legal strategy meeting took place. At this stage it was decided that the threshold for legal proceedings had not been met as Mother was reporting to be doing more for Child M who was noted to be doing well at school. The chair was concerned about Mother’s psychological wellbeing and suggested that a report should be obtained from Mother’s private counsellor in London. 5.61 Around this time the partner of the vicar at the local church started to get more frequent texts from Mother saying that things were getting difficult, she wanted a divorce and she had money issues. The vicar’s partner had heard via other members of the church that the children were back on a child protection plan. FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 20 of 37 Mother asked the vicar and his partner to have Child M to stay for two nights while she went to London to sort out selling her house there prior to the divorce. 5.62 During early December, records relating to Child’s M’s sibling refer to him being quiet, poor language, poor attendance at nursery and withdrawn. 5.63 The vicar’s partner has told this review that the week before Child M’s death was “very intense” and there were lots of texts. Mother was having regular contact with her husband, which she found very difficult. Mother also said that the social workers were visiting on 4th or 5th December and she needed to sort the house out. She later said that this visit didn’t happen as “someone was away”. 5.64 The vicar’s partner told this review that the weekend was particularly stressful and when Child M was collected from home to be taken to church she (unusually) described problems at home and said that her father had been on the phone to her mother all day. Mother went to bed with a headache and Child M looked after her sibling. After church that day, the vicar’s partner offered to have Child M for the day and she was returned home at 8.30 p.m. 5.65 On 8th December records show that “a neighbour” contacted children's social care concerned about Mother’s high level of stress following a phone call from Father. This call had been made by the vicar’s partner who gave her name and left a message. 5.66 It was on the evening of 8th December that the fatal car accident took place. Information at the inquest confirmed that there were no other vehicles involved and Mother and Child M were not wearing seatbelts. Mother told the inquest that she cannot recall anything from the two months prior to the accident and the coroner recorded cause of death as a road traffic accident. Summary: March 2014 – fatal accident on 9th December 2014 From March to October 2014 Child M and her sibling were subject of a child in need plan. Given the lack of clarity about Mother’s capacity to sustain change at the point that their names were removed from a child protection plan, it was important that this was tested via a child in need plan. There is little evidence that this happened and that concerns noted by the health visitor appear not to have been relayed to the child in need meetings. The lack of timely referral from housing continued to be particularly significant as it is now clear that there were ongoing stresses associated with financial difficulties. Swift action was taken when other concerns came to light resulting in a further child protection conference and a child protection plan that recognised that legal action would be considered if changes were not sustained. A legal strategy meeting also took place. However, given the previous steps towards legal action were not all followed through completely and within timescales, it is unclear whether this aspect of the plan would have seemed significant to Mother. FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 21 of 37 The church continued to be very significant in the lives of Mother and the children but again did not feature within the plan. As the church became aware of increasing stress within the family, a stronger relationship with children's social care would have been beneficial in discussing their concerns. Another service which had been very significant to Mother was rape crisis. This had ended on 6th October 2014 yet the child protection plan developed at the conference on 17the October continued to refer to “Mother is accessing counselling/therapy to address her past issues and counselling is listed as a protective factor”. It is not apparent from the plan who would be delivering this. FINDINGS AND RECOMMENDATIONS 6.6.1 The inquest into the death of Child M concluded that the cause of death was a road traffic accident and it was noted that Child M and Mother were not wearing seatbelts at the time of the accident. It is the conclusion of this serious case review, that although Child M was subject of a child protection plan at the time of death, it could not have been predicted by professionals that a fatal accident would occur. 6.2 Many people worked hard to help Child M’s family over a number of years and as in most reviews, there are lessons to learn about how practice could be improved. In this case help to the family could have been more focused, better coordinated and the impact of plans scrutinised and reviewed more thoroughly; particularly in relation to the link between Mother’s emotional well-being and parenting capacity. There is also evidence of over optimism regarding Mother’s capacity to sustain the changes required to provide safe consistent care for both children. 6.3 The main factors driving an over optimistic approaches during the period under review were: The complexity of the support network surrounding Mother which resulted in significant information not being known by all the relevant people at the right time. The challenges of working with neglect where significant improvements in practical parenting can mask a longer term ability to sustain change. A lack of management oversight and opportunities for supervision which kept plans on track and challenged biases, beliefs and “groupthink” in a number of agencies. A lack of systematic use of multi-professional whole family assessments in order to gain a full understanding of the interaction between parental psychological wellbeing and child development and safety. FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 22 of 37 6.4 Several of the findings of this review echo those of other recent reviews covering a similarly historic timeframe. This suggests that the issues were not specific to this case and that there is an opportunity, through this review and the Hampshire Safeguarding Children Board response, to understand more fully the underlying factors that were affecting practice at that time and the impact of current practice improvements since the period under review. Specifically: working effectively with neglect and in particular assessing parental capacity to sustain change, ensuring that the voice of the child is heard and there is careful consideration of the lived experience of children within the family, recognition for the potential for children to become young carers where neglect is an issue within the family, ensuring the vital role of early years settings in the safeguarding system is understood by all involved, ensuring that housing providers discharge their safeguarding responsibilities effectively and their role in the safeguarding system is clear and unambiguous, providing effective supervision opportunities to all practitioners and volunteers who come in regular contact with children and families. Finding 1 Child protection assessments conferences and plans did not include all relevant organisations and engage positively with community support systems. 6.5 There was a complicated network of people /agencies working with Child M and the family. This complex network was in part the result of Mother’s own quest for support from a wide range of sources and as a result, social workers needed to engage with a significant number of people in order to make sure that all relevant information was understood and plans to help the family were effectively coordinated. Although there was involvement from core organisations such as schools and health professionals, other community based services including Home-Start, the private day nursery, housing and the church community were not always invited to child protection conferences or other forums such as core groups or child in need meetings. 6.6 Home-Start had significant information that they recorded within their own records as concerns and discussed with social workers, but they were not invited to the child protection conference. This is not usual practice and appears to have been a misunderstanding by an individual social worker regarding the correct criteria that should be used when issuing invitations. Home-Start was invited to subsequent conferences. 6.7 Child M’s sibling was known by the time of the second review conference in October 2013 to be attending the private day nursery and they were named as part of the core group. However, they were not informed of the child protection plan until they received an invitation to the review conference in March 2013. The concerns that FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 23 of 37 were being recorded by the nursery did not influence the generally positive view that developed by March 2014 and it is significant that the manager of the nursery did not feel able to challenge this within the conference. Even where training on child protection conferences has been received, attending an actual child protection conferences for the first time can be intimidating and in this case, lack of familiarity with the process alongside a strong view by those who had been involved with the core group, that substantial progress had been made, inhibited the nursery manager from disagreeing with the decision to discontinue the child protection plan. 6.8 With the benefit of hindsight, the decision to discontinue the plan at the first may have been based on an overly optimistic understanding of Mother’s capacity to sustain change. An element of “groupthink”16 may have been present and contributed to the consensus within the conference but at the time, with the information available, it is understandable why this decision was made. 6.9 Full participation by the day nursery in the second initial child protection conference was inhibited by the fact that only one member of staff was trained to prepare child protection conference reports or attend conferences and they were on holiday. This situation has now been remedied with additional staff members trained to take this role, but it is an issue that may need to be considered by other providers. 6.10 The housing association was notably absent from mainstream planning and they did not refer important information about Mother’s financial situation and potential stress as a result of arrears. Another recent serious case review within Hampshire17 found that the role that housing plays in safeguarding children may be underestimated. Although the circumstances of that review were different (the housing issues related to bed and breakfast accommodation) the underlying issue of housing providers being a key partner in the safeguarding system is relevant and their role in this regard should be fully understood by them. 6.11 An added complicating factor affecting full involvement of housing issues was fragmentation within the housing association itself as the housing officer with responsibility for tenancy and community management (who would often be the liaison point for children's social care) was unaware of the work being undertaken by colleagues managing arrears. 6.12 Of particular significance was the role of the church community in providing support and a lack of clarity about their role. Statutory agencies were concerned that the high level of help provided by church members masked any concerns and did not allow for a proper assessment of Mother’s capacity to parent the children. However, rather than looking at how to work positively with the church community and harness their resources in a planned way, the approach set out in the child protection plan was to stop their involvement. This was not only a waste of valuable resources but also left 16 Groupthink (Janis 1982) is a group process whereby there is a reluctance by group members to challenge the group consensus and has been found to occur within the child protection system. 17 Child L Published January 2016 FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 24 of 37 the church community unsure about what to do when faced with worries about the children. This was exacerbated by the diocesan safeguarding team being perceived by the local church community as being focused primarily on abuse within the church, rather than providing support where there were families causing general concern. 6.13 Other issues include: the children’s centre involved in delivering parenting support services not being aware of the child protection plan (this was reported to be usual practice at that time but different under current structures and arrangements) the practice in that area at that time which involved the family centre closing a case once it became allocated with the social work team. 6.14 One consequence of a lack of full coordination of professional input to the family was that it was much harder to assess any issues relating to Mother’s engagement with services. For the majority of the time, no one was aware of the full range of people that Mother and the children were in contact with and therefore did not have the full picture of what seemed to work best in providing help. It was also not possible to consider the impact of any non-engagement with services over time. The one consistent pattern of attendance was Mother’s contact with the rape and sexual abuse counselling service and it is not clear what sense was made of this in relation to Mother’s own needs. 6.15 One final issue raised by this review is the role of multi-agency information checks during section 47 enquiries. Following the strategy discussion regarding alleged abuse by Child M’s uncle the social worker was proactive in following up the allegations with Child M, Mother and Uncle but other organisations were not advised of the allegation or that section 47 enquiries were taking place. This is not in line with current procedures which are clear that other agencies should be informed and asked for their assessment in the light of the information presented. Recommendation 1a Hampshire Safeguarding Children Board should work with local faith and community groups and children's social care to agree and promote a positive role for community faith groups where a child is subject of a child in need or child protection plan and ensure there is an understanding of Hampshire Safeguarding Children Board’s information sharing protocol. Recommendation 1b The diocesan safeguarding team should work with local church communities to promote and clarify their role in providing support and assistance in situations where there are concerns about abuse and neglect within the family. Recommendation 1c FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 25 of 37 Hampshire Safeguarding Children Board should work with partner agencies to ensure that all relevant professionals (including those working in private and voluntary organisations) are included in child protection conferences and that the conference process encourages full participation by those unfamiliar with the process. Recommendation 1d Hampshire County Council Early Years Team should seek assurance from all early years providers that they have a full understanding of the child protection conference process and have their own safeguarding procedures in place. Recommendation 1e Hampshire Safeguarding Children Board should ask the housing association to: review internal communication pathways where a family is in arrears, ensuring that all staff with responsibility for tenant welfare are informed, ensure that all staff are aware of their safeguarding responsibilities and that referral processes into children's social care are fit for purpose. Recommendation 1f Hampshire Safeguarding Children Board should ask children's social care to remind staff that where section 47 enquires take place on open cases the same procedures should be followed as for new referrals and it is particularly important to notify colleagues across the professional network. Finding 2 Although Mother was in receipt of a wide range of services, there was insufficient understanding of her capacity to sustain change through a shared understanding of what constituted neglectful parenting, focused assessments and use of the Public Law Outline process. 6.16 The complexity of the network providing help to Mother has been commented on in Finding One and the first child protection plan was based on an assessment that too much help might mask an assessment of whether Mother was able to provide care on her own; hence the focus on asking the support from the church community to cease. The approach would have benefited from a clearer understanding of the underlying causes of Mother’s emotionally and physically neglectful parenting style, what help was needed to improve outcomes for the children and whether change could be sustained without a continuing planned package of support. 6.17 Across the partnership at that time there was a lack of shared understanding of what constitutes neglect and/or risky parenting which had the potential to affect positive working relationships. For example, following the first referral the student social worker believed that some people felt that the approach of children's social care was punitive and at the third child protection conference the nursery manager was reluctant to challenge a multi-agency decision to discontinue the plan even though they did not agree. The school and the day nursery have also raised the issue as to FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 26 of 37 whether there were added challenges because of the family’s culture leading to Child M being seen to be “different” rather than “vulnerable” in a predominantly white middle class area. This is likely to have added to the complexity of developing a shared understanding of the children’s situation. It is noticeable that the perception of Child M’s vulnerability increased with a change of head teacher who had considerable safeguarding experience, highlighting the very individual responses of professionals when faced with the less tangible forms of safeguarding concerns. 6.18 There was an opportunity to have a clearer understanding of Mother’s psychological vulnerability at the point that the legal strategy meeting recommended a psychological assessment. Within the PLO framework this could have been commissioned from a recognised expert and provided a basis for understanding her needs and capacity for change. Instead there was an overreliance on a parenting assessment completed by a family support worker and no follow up as to why the psychological assessment had not been completed. 6.19 Overall, the approach to the PLO process at that time lacked sufficient rigour. As a result of a more general recognition that more structure was needed, children's social care developed new frameworks for tracking the process and the Safeguarding Children Board will need to be assured that these are making a difference in practice. 6.20 An additional issue is the storage of assessments. It is of concern that the parenting assessment cannot be found on the electronic system and a paper copy cannot be located. This not only raises issues regarding safe storage of records but also means that if assessments are not readily available they cannot be used effectively to inform future work and measure change. Children's social care have commissioned a new IT system which will improve the storage and retrieval of records and there is therefore no recommendation in relation to this issue. Recommendation 2a The response of the recommendation in the serious case review relating to child E (developing a shared evidence based strategy for working with neglect) should be informed by the findings of this review. This work should include community and faith groups. Recommendation 2b Hampshire Safeguarding Children Board should ask children's social care for evidence that the current process for tracking progress within the Public Law Outline process is having a positive impact on outcomes. Finding 3 Practitioners working with complex families, professional networks and relationships, both within statutory and community organisations, need management and/or supervision arrangements that promote critical reflection and FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 27 of 37 analysis, clarify roles and responsibilities and keep plans on track. This was not consistently provided. 6.21 Although a large number of people worked hard to provide support to the family, the case history highlights the potential for practitioners to be “drawn into Mother’s world”18 and lose their capacity to stand back and see the whole picture. Additionally, as highlighted above, a dominant group view can inhibit individual challenge. In such situations time to stop, think and reflect on how assumptions and biases may be affecting thinking is of the utmost importance. Supervision is one place where this can happen and there were gaps in the supervision and management systems across the partnership which at times contributed to drift, loss of focus on assessing Mother’s capacity to change and the lack of coordination across the system discussed above. The main supervision gaps were: Case management supervision for the social work student. Management and supervision of social work practice in a long term case The effectiveness of group supervision within health visiting Safeguarding supervision within mental health services. 6.22 The management of the original referral as a child in need resulted in allocation to a student. Asking a student to carry out a child in need assessment is not unreasonable but ultimate case management responsibility should have sat with a qualified worker. The problem at this stage was that allocation seems to have been wrongly assigned to the student and additionally there was insufficient specialist case management supervision available. Students’ overall development is managed and assessed by a practice educator, but day to day case management responsibility lies with a practice supervisor in the team and in this case the practice supervisor was on sick leave. The team manager took over case supervision but the student concerned does not recall detailed management oversight and at times lacked confidence in dealing with other experienced professionals. At this stage best practice would have been for the case to be formally allocated to another qualified worker in the team as it was for child protection purposes. 6.23 The student’s practice educator did not have a child care background but, as a result of the lack of clarity over case allocation, was the only qualified social work professional at a complex multi-agency meeting in Mother’s home. This situation is not dissimilar to another recently published serious case review elsewhere19 and highlights the need to make sure that where a practice educator is observing practice assumptions must not be made about their role in identifying risks linked to case management. 6.24 The chronology suggests that once this case became “long term” and on the caseload of an experienced social worker there was an assumption that the issues in 18 Quote from a practitioner involved in the case. 19 Hertfordshire Safeguarding Children Board Serious Care Review “Sophie” (published May 2016) FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 28 of 37 the case were “known” and risks were managed. It is likely that this contributed to the minimal evidence within the records of scrutiny, challenge and oversight within supervision. For example, Mother was allowed to delay the Public Law Outline process citing a lack of solicitor and the process drifted for three months. This should have been challenged as the message could have been conveyed to Mother that the legal process was not being taken seriously within children's social care. As explored in paragraphs 5.48-49 above, the request from a later legal strategy meeting for a psychological assessment was also not actioned and there is no evidence that the decision not to go ahead with the assessment was a fully thought through decision agreed by the manager. 6.25 Similarly more active management involvement in decision making should have been evident at the strategy discussion between the social worker and Hampshire police in November 2013. Scrutiny of the subsequent section 47 process would have highlighted that the outcome of “no further action” had not been informed by full agency checks. This point in the case history could also have provided an opportunity to reflect on whether assumptions were being made about Uncle’s capacity to cope with the responsibilities being placed on him and and whether sufficient checks had been carried out in relation to his background. 6.26 It has not been possible to fully discuss the reason for apparent gaps in the role that supervision could have played within children's social care as key personnel have been on sick leave. However the review has been informed by senior managers that, based on the finding from audits, it is likely that the issues identified by the review are local rather than systemic. The Safeguarding Children Board will need to be assured that this is the case. 6.27 In relation to the health visiting and nursery nurse service, the review was told that although the health visitor and nursery nurse were both aware that this was a complicated case, supervision did not provide the opportunity to consider the role of the health visitor and nursery nurse in any depth. Safeguarding supervision was (and is) provided in groups and at the time it was usual for a different supervisor to lead each session. It was possible to ask for an individual session from the safeguarding team but this was not accessed in this case; the most likely reason was that at no one point was it deemed urgent but was rather continuing concerns of a similar nature over a long time period. 6.28 Within the CMHT arrangements for specialist safeguarding supervision are not well established. Discussion of safeguarding issues is integrated into the generic supervision provided by team leaders, the quality of which depends on the level of safeguarding expertise within the team. No practitioner was aware of any role for named doctors for safeguarding in supporting psychiatrists within adult mental health although there was an awareness that the safeguarding team can be contacted on an ad hoc basis as the need arises. In this case, although there was involvement from a number of team members and extensive involvement from the team social FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 29 of 37 worker, the opportunity for any practitioner to reflect on their role within the children’s safeguarding system was limited. 6.29 The head teacher at Child M’s school has reflected on the important role that the ELSA had in relation to providing continuity and emotional support to Child M. With hindsight the ELSA had a great deal of responsibility and did not always receive the support that was needed. ELSAs do receive group supervision outside the school but this would not have provided the individual input that would have been needed in this case. In addition, within the school the ELSA held their own confidential records and as a result the head teacher could not have the oversight that was needed to make connections between the various aspects of work with Child M within the school. 6.30 The church community worked hard to provide support but at times felt unsure about the boundaries of their roles and responsibilities. The diocesan safeguarding team was not perceived as the place to go for advice and support with non-urgent issues relating to families in the parish and as a consequence the local church community were not supported in managing their concerns. Recommendation 3 In the light of the lack of child focus in this case and a potential for over optimism in parental capacity sustain long term change, Hampshire Safeguarding Children Board should develop with partners and the Adult Safeguarding Board a statement of expectation regarding safeguarding supervision and undertake a multi-agency audit of the quality of supervision practice. In addition, specific actions required by individual organisations are as follows. Recommendation 3a Hampshire children's social care should ensure that its policy of not allocating responsibility for casework to student social workers and the respective roles and responsibilities of practice educators, practice supervisors and team managers is better understood throughout the workforce. Recommendation 3b Southern Health should be asked to review arrangements for safeguarding supervision for health visitors and nursery nurses in order to ensure that each practitioner has sufficient access to the individual support and critical reflection that is necessary for effective safeguarding practice. Recommendation 3c Safeguarding supervision systems within the community mental health team should be developed in order to ensure that all practitioners are receiving supervision from supervisors with sufficient specialist knowledge and skill. Recommendation 3d Schools should be asked to review their supervision and management arrangements for FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 30 of 37 ELSAs in order to ensure that there is management oversight of their work that ensures links with other aspects of school life and that they all have sufficient individual emotional support as required. Recommendation 3e The Diocesan Safeguarding Team should develop and communicate with churches the process for obtaining advice and consultation where there are safeguarding concerns relating to members of the local church community. Finding 4: Although the psychological vulnerability of Mother was recognised, plans to address this were not always located within a whole family approach which understood and addressed the interface between parental wellbeing, parent/child relationships and the lived experience of children within the family. 6.31 One of the challenges of this case was achieving a balance between the needs of the adult and focusing on the impact of their behaviour on the children. It has been noticeable that during this review it has been hard to gain a picture of Child M, mainly because responding to Mother’s needs was the focus of the work of many of the practitioners in the child protection system. Practitioners were aware of the danger of becoming adult focused and sustained efforts were made to provide emotional support to Child M at school, although there is less clarity about how far the impact of family life on Child M’s sibling was understood. It was positive that Child M’s allegations about Uncle were followed up directly with her by the social worker but there could have been further exploration regarding her injuries through discussion with others in the network including a paediatrician. This would have given a clear message to Child M that her voice had been heard. 6.32 Mother’s long standing, deep seated psychological issues were recognised and the child protection plan did provide a focus on Mother’s mental health but there was a lack of precision in the overall approach in relation to understanding the exact nature of her psychological difficulties and their impact on her capacity to provide safe consistent parenting. 6.33 The psychological assessment requested at the third legal planning meeting did not take place. The review has been assured that the revised arrangement for the public law outline mean that current practice includes commissioning assessments as required. 6.34 A consequence of no psychological assessment was that plans made assumptions about the impact of services, whereas it is questionable whether services that were provided as part of the child protection plan could produce the depth of change that was assumed. For example, a short term input such as the emotional coping skills group was unlikely to address long term problems. The impact of the private counselling services accessed by Mother was unknown and the local service that FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 31 of 37 Mother did engage with (rape counselling service) sits outside the child protection system and due to the confidential nature of the service there was no feedback regarding the depth of progress being made. The challenge is therefore to make sure that child protection plans adequately address the depth and complexity of parent’s psychological needs and assess change beyond surface presentation. 6.35 A potential feature of families where parental mental ill health and/or psychological vulnerability is present is for children to take on the role of carer for others in the family. Information suggests that Child M took on this role in relation to her sibling but it was not addressed explicitly in assessments or plans. This has been a feature of a recent review in Hampshire20, suggesting that this in an area that needs further practice development. Practice guidance in relation to young carers was issued in July 2011 and is now due for review21. This will provide an opportunity to work across the partnership to promote work with young carers as an important aspect of safeguarding practice. 6.36 There is no evidence within the documentation that practitioners during the period under review worked across adult mental health and children’s services using an established whole family assessment framework22 to help them understand the impact of Mother’s wellbeing on her relationship with her children. Hampshire children's social care are now piloting a whole family approach via the establishment of a family intervention team and the findings from this pilot and plans to embed whole family approaches in practice will form part of the response to this review. 6.37 Part of a whole family approach includes understanding stressors and support systems within the family network. In this case an assumption was made about the positive role of Uncle but there is little evidence that full background checks were carried out and time was taken to consider his relationship with the family. This was particularly significant at the time that Child M made allegations against him and a DBS check should have been carried out at this point. Recommendation 4a Hampshire Safeguarding Children Board should work with partner agencies and the Adult Safeguarding Children Board to progress an agreed approach to whole family approaches to work with children and their families with a particular focus on: The effectiveness of recognition and coordinated responses where neglect is leading to a young person taking on a caring role. The impact of the 4lscb joint working protocol on practice 20 For example SCR Child E 21 HCC (2011) Hampshire Practice Guidance for Adult and Children’s Services in supporting Young Carers within a Whole Family working model. ( was due for review March 2012) 22 For example: Falcov, A (2012) The Family Model Handbook. An integrated approach to supporting mentally ill parents and their children. Brighton: Pavilion. Mainstone F (2014) Mastering whole family assessment in social work. London: JKP FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 32 of 37 Recommendation 4b Hampshire Safeguarding Children Board should consider whether the voice of the child is adequately heard within assessments, particularly where these relate to safeguarding concerns. Finding 5 There was a lack of consistency and clarity regarding how to respond to Mother’s allegation regarding sexual abuse by another family member. 6.38 Mother’s allegation of previous sexual abuse by a close family member currently living in the UK was common knowledge within the professional and community network although not all were aware to what extent others knew. The church community were unsure how to respond, confidentiality prevented the rape counselling service from disclosing this without Mother’s permission and the implications were not fully explored within the child protection arena. It was good practice that steps were taken to advise Mother against Child M and her sibling having contact with the family member concerned but there was no consideration as to whether checks should be undertaken with the relevant police force regarding the alleged perpetrators potential access to children or whether there had been other allegations. 6.39 The challenge professionals’ face in responding to allegations of child sexual abuse within the family has been confirmed by a recent report by the children’s commissioner.23 There are very specific challenges about how to respond when a parent discloses sexual abuse by a family member as a child and it is important that members of professional and community networks within Hampshire have clear, well publicised messages as to how best to respond. Recommendation 5 Hampshire Safeguarding Children Board should ensure that professional and community networks have access to clear well publicised guidance as to how to respond when a parent discloses abuse as a child within their family. 23 Children’s Commissioner (2015) Protecting Children from Harm: a critical assessment of child sexual abuse in the family network in England and priorities for action. FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 33 of 37 APPENDIX ONE: THE REVIEW PROCESS 7.7.1 Following the death of Child M on 8th December 2014, the serious case review subcommittee of Hampshire Safeguarding Children Board agreed on 19th January 2015 that the case met the criteria for a serious case review. This decision was confirmed by the Chair of the Safeguarding Children Board on 3rd February 2015. 7.2 The review was led by the independent reviewer and the review group. The review group were supported by the Hampshire Safeguarding Children Board’s administrator who attended meetings and took notes. 7.3 The independent lead reviewer was Jane Wonnacott. Jane qualified as a social worker in 1979. She has an MSc in social work practice, the Advanced Award in Social Work and an MPhil as a result of researching the impact of supervision on supervision practice. She has published two books on supervision and co-wrote with Tony Morrison the national training programme for social work supervisors. Since 1994 she has been the author or chair of many serious case reviews and in 2010 completed the Tavistock Clinic and Government Office London nine day training programme for panel chairs and authors. She has also attended the 2012 Department for Education serious case review training programme. 7.4 The review group consisted of: Jane Wonnacott: Lead Reviewer Learning Reviews and Stakeholder Engagement Coordinator Area Manager, Children’s Services Team Manager, Children’s Services Designated Nurse Designated Doctor, Reviewer, Hampshire Constabulary serious case review team Inclusion Service Manager, Children’s Services Safeguarding Lead, Portsmouth Anglican Diocese 7.5 In considering the process for this review, account was taken of the principles set out within Working Together to Safeguard Children (2015) which specifies that: There should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works to promote good practice. The approach taken to reviews should be proportionate to the scale and complexity of the issues being examined. Reviews should be led by individuals who are independent of the case under review and of the organisations whose actions are being FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 34 of 37 reviewed. Professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith. Families including surviving children should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring the child is at the centre of the process. The final report must be published, including the LSCBs response to the review findings. Improvement must be sustained through regular monitoring and follow up. 7.6 Agencies who had been involved with Child M’s family were asked to provide a chronology as well as a narrative report of their involvement including any significant information outside the timescales. These reports also highlighted any emerging practice issues. 7.7 No specific terms of reference were set for the review beyond establishing the scope of the review as it was recognised that this was a complex network with many “unknowns” and the questions that needed to be considered would become apparent as the review progressed. 7.8 The agency reports were considered by the review group and practitioners were identified who would be most able to help the review group understand the detail of what happened and the influences on practice at that time. 7.9 The independent reviewer met practitioners either individually or in small groups with the member of the review panel who had professional expertise in their area of practice. This approach allowed the lead reviewer to gain an overview of practice and cross reference information whilst ensuring that practice issues specific to one staff group were fully explored. A full list of practitioners is set out in Appendix Two. 7.10 All practitioners were invited to a meeting with the review group to discuss the emerging themes from the review. This provided an opportunity to check the review group’s initial analysis with practitioners who had been directly involved and share ideas about potential practice improvements. 7.11 Mother and Father were offered an opportunity to contribute to the review. Neither responded to correspondence relating to the review. Both were again invited to participate after the inquest had concluded but at time of writing no response has been received. FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 35 of 37 7.12 The lead reviewer met on six occasions with the review team to discuss the emerging information and the draft report. The report was received by serious case review subcommittee and amendments made prior to presentation to the Hampshire Safeguarding Children Board on 28th September 2016. 7.13 A response to this review has been prepared by Hampshire Safeguarding Children Board. FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 36 of 37 APPRENDIX TWO: PRCTITIONER DISCUSSIONS 8.Childrens Social Care Student Social Worker referral and assessment team Social worker children in need team District manager children in need team Child Protection Conference Chair Early Years services Children’s centre leader Senior family support worker Manager private day nursery School Class teachers Student teacher Learning Support Assistant Special Educational Needs Coordinator Head teacher. Home Start Coordinator Volunteer Community Mental Health Consultant Psychiatrist Team Leader community treatment team Mental health practitioner Community Health Health visitor Student health visitor FINAL FOR LSCB Serious Case Review Draft 8 15.7.16 Page 37 of 37 Community nursery nurse GPs Specialist safeguarding nurse Housing Association Housing Officer Resident services manager Lead financial inclusion advisor Income officers Income team leader Church Vicar Vicar’s partner Telephone conversations were held with: Rape Crisis service Assistant head of workforce development children’s services Workforce development manager |
NC047736 | Serious, non-accidental injuries to "Philip", aged three. Mother's partner pleaded guilty to grievous bodily harm and was sentenced to three years imprisonment. Mother pleaded guilty and received a sentence of 12 months, suspended for 12 months. Philip and his brothers, aged 10 and five, were placed with a relative. In nine months, the police, GP and nursery staff made six referrals about the family to children's social care. Concerns included: poor home environment, mother's parenting difficulties and extensive bruising on Philip's body. After the fifth referral, Child in Need (CIN) processes were initiated. Family received support from the children's centre, health visitor, community nursery nurse and family support worker. Family history included: mother and father's substance misuse; father's threatening behaviour; mother and her new partner's offending behaviour. Findings include: the importance of formal early help in keeping children safe; the need for more child-focussed practice, less reliance on parental self-report and greater recognition of the role of fathers / father figures; the importance of effective decision-making and assessment in the management of physical abuse. Recommendations include: Gloucestershire Safeguarding Children Board should review the guidance for all professionals on the assessment of potential non-accidental injury and ensure it is compliant with NICE Guidelines, including information provided to paediatricians prior to child protection medical.
| Title: Serious case review: “Philip, (and his siblings, John and Darren)”. LSCB: Gloucestershire Local Safeguarding Children Board Author: Jane Wiffin Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Gloucestershire Local Safeguarding Children Board Serious Case Review “Philip, (and his siblings, John and Darren)” Version 1.0 (30.11.16) Lead Reviewer: Jane Wiffin 2 Section Page 1. Introduction 1.1 – Reason for the Review 1.2 – Methodology 1.3 – Family Involvement 1.4 – The Author 3 2. The Family 2.1 – Family background known to Professionals 3 3. Narrative Chronology of Professional Involvement with the Children 4 4. Findings 27 Appendix 1 - Methodology 43 Appendix 2 – Terms of Reference 45 Appendix 3 – Single Agency Recommendations 46 References 50 3 1 INTRODUCTION 1.1 Reason for the review (All names used are pseudonyms) This is the serious case review report in respect of Philip, who was aged 3 at the time of the critical incident described and two other siblings Darren aged 10 and John, aged 5. The review was instigated as a result of Philip being taken to hospital by his Mother after four days of abdominal pain and vomiting. At hospital Philip was found to be very seriously unwell, with multiple, significant bruising, several fractured ribs and a perforated intestine. All these injuries were assessed as non-accidental. Mother and her partner (Ian) were arrested on suspicion of GBH S.18. Ian was charged and pleaded guilty to S20 GBH and Mother was charged and pleaded guilty to S5 of the Domestic Abuse, Crime and Victims Act 2004. Ian has since been sentenced to 3 years imprisonment. Mother received a 12 month sentence, which was suspended for a 12 month period. 1.2 Methodology This review was undertaken using a new methodology developed by GCSB. Full details of the process are contained in Appendix 1 alongside the general and specific terms of reference in Appendix 2. Each agency involved with Philip, John and Darren produced a chronology of involvement, an analysis of practice and recommendations. The analysis contained in these documents is used as the basis for the analysis of practice contained in section 4 of this report and the single agency recommendations are included in Appendix 3. 1.3 Family Involvement Mother was invited to contribute to the review, but after talking it through with a Social Care Team Manager felt she was unable to do so and declined the offer of meeting with the Lead Reviewer. 1.4 The Author This report has been written by Jane Wiffin. She is a qualified Social Worker with extensive experience of safeguarding practice. She is an experienced Serious Case Review author, having completed over 30 reviews. She is completely independent of services in Gloucestershire. 2 The Family All names have been anonymised Relationship to subject (if applicable) Age at time of critical incident Philip Subject 3 John Brother 5 Darren Brother 10 Mother Mother 28 Father Father 30 Ian Mother’s Partner 22 Maternal Grandmother Maternal Grandmother All family members are White British 4 2.1 Family background known to professionals Mother and Father started their relationship when Mother was around the age of 17 and Father was aged around 19. They continued in an off/on relationship for many years. Mother told professionals that Father had long-term mental health difficulties, but he was not known to any services. Mother also reported that he was a drug user, taking heroin and cannabis, and he has a number of convictions for drug related offences. Nothing is known about Father’s extended family except that they had wanted to have contact with the children, but Mother had been reluctant because it might bring the children into contact with Father. 2.2 Mother and Father had their first child, Darren, when Mother was 19. Mother started using heroin when Darren was around 4 years of age, and she reported that she sought help from her GP after three months, was referred to a specialist substance misuse service and was prescribed buprenorphine, a replacement for heroin. She was still being prescribed a reduced dosage of this drug during the time under review, although there had been plans to help her detox and end her use. Darren went to stay with Maternal Grandmother (MGM) at some unspecified point because of Mother’s heroin use and has been intermittently in her care ever since. The precise nature of these arrangements remain unclear, and there were times when Darren was present in the family home and said to be due to return to live full time with his Mother. It is unclear if this actually happened. After the birth of Philip, Mother was noted to have suffered from post-natal depression. Little is known about Mother’s extended family, except that Mother said that MGM was very supportive, lived locally and Mother’s sisters also helped her. 3 NARRATIVE CHRONOLOGY OF PROFESSIONAL INVOLVEMENT WITH THE CHILDREN 3.1 This section provides a summary narrative of the professional involvement with the three children, and is drawn from the single agency reports produced as part of this review and the practitioner events held. It attempts to give a sense of what happened, what is the appraisal of the professional response at different points across the timeframe and to comment on why practice was as it was, where this is known. This forms a foundation for the Findings which analyse the practice response as a whole. Early Concerns: At the beginning of this period of time Philip was 18 months old, John was 3 yrs old and Darren 8 yrs old 3.2 No dates are included for reasons of anonymity At the start of the review the Health Visitor asked the Children’s Centre to provide Mother with support because she was struggling to manage the children’s behaviour and a Community Family Support Worker (CFSW) provided Mother with informal support over a number of years. There were concerns about John’s delayed speech, the poor home environment and Mother reporting that Father had mental health difficulties. The Children’s Centre suggested Mother attend a parenting course, which she declined, and John started to attend Nursery. Mother was also supported by the 5 Community Nursery Nurse (CNN)1 to manage the children’s behaviour. The Health Visitor had regular contact with Mother, but gradually Mother stopped being available for appointments, and although the Health Visitor found Mother easy to talk to, she felt that Mother did not follow or implement much of the advice given. 3.3 At the end of this year Father started to misuse drugs again, specifically heroin having stopped for a number of years (as reported by Mother). There was conflict in the home, and there was a protracted period where Mother asked Father to leave, which he eventually did 6 months later. Mother called the police to complain of Father’s disruptive behaviour; he was at the house trying to retrieve property and all three children were present. The Police notified Children’s Social Care (CSC) who assessed that no action was necessary. Three months later Mother discussed further concerns about Father’s drug taking and threatening behaviour with the CFSW and the Health Visitor. They were reassured when Mother told them that she had taken on the sole tenancy of the property and asked Father to leave. Nursery1 staff noted that John and Philip’s behaviour became more settled at this time. A month later Mother called the police again regarding Father’s disruptive behaviour and that the three children had been locked outside the house. The Police sent CSC a second child welfare notification and this was again assessed by CSC as requiring no action. Over this whole period Mother continued to seek advice about her concerns regarding managing John’s behaviour, but she never took part in any of the parenting support services offered. Commentary: During a 12 month period Mother and two of the children were provided with a range of informal support from the Children’s Centre, the Health Visitor and the CNN. It is hard to evaluate the effectiveness of this support, as Mother refused to take part in anything other than home visiting and nursery provision, despite asking for help to manage her reports of the poor behaviour of both children. Although professionals were reassured when Mother took steps to ask Father to leave and there was a period when the children seemed more settled, given Mother’s lack of engagement in services designed to meet the needs of her children, the Children’s Centre should have offered a more formal early help response under the auspices of CAF2. This would have enabled professionals to come together, share information and to set goals for the children’s well-being. This could have made it easier for professionals to understand the long term nature of Mother’s parenting difficulties during subsequent events. This is discussed in Finding 1 regarding the provision of formal early help response. 12 months later: Philip nearly 3, John 5 and Darren nearly 10yrs old 3.4 Third referral to CSC Over the New Year period Mother did not collect her prescribed medication and 1 Community nursery nurses provide services aimed at improving the health and well-being of families with children up to the age of eight. 2 The Common Assessment Framework (CAF) is a process for gathering and recording information about a child for whom a practitioner has concerns in a standard format, identifying the needs of the child and how the needs can be met. 6 through a routine test was found to have used cocaine, non-prescribed buprenorphine3 and diazepam4. A letter was sent by the drug agency to the GP in mid-January informing them of this. 3.5 Philip started to attend Nursery2 because Mother said she was unhappy with the number of hours provided by Nursery1. She was asked to provide information about Philip as part of the routine admissions processes and reported no health concerns, except delayed speech and dribbling. Nursery2 did not seek any transition information from Nursery1 at this time, but did make contact with Nursery1 six weeks later to express concerns regarding Philip’s poor speech and Nursery1confirmed that a referral had been made to the speech and language service. It was agreed that records would be shared between the two nurseries, but information was not shared until 6 months later. 3.6 At this time Mother contacted the police to report that Father had come to the family home, threatened her with a knife and taken John and Philip away. A family friend later returned the children. At this time Father was wanted by the police in regard to two outstanding court warrants. Mother made a statement to the police regarding a potential charge of theft; she subsequently withdrew this statement, saying she did not want to work with the police, and she was described as hostile. A referral was made to CSC, the third in a nine month period, and an Initial Assessment5 i was agreed. 3.7 A Social Worker visited the family at home and met with Mother, John, Philip and Maternal Grandmother (MGM). Mother explained that Darren “mostly stayed with his maternal grandma”6 because Mother had previously had a drug problem. Mother told the Social Worker that she had been drug free for six years and continued to be prescribed a heroin substitute. The quality of care provided by Mother on the day of the home visit was assessed as good and Mother was observed to have a warm and caring relationship with both children. The assessment reported that Mother was aware of the potential impact of Father’s behaviour and drug use on the children; Mother said she would take action to prevent him having contact if he used drugs again. She said that she was taking forward her complaint against Father with the police. This led to the conclusion that Mother was a protective factor for the children; the Social Worker did not know that Mother had withdrawn her statement to the police, and had refused to help them. The Social Worker engaged with the children and observed them playing, but did not see them on their own and reported that she had hoped to talk to Father, but had no contact details for him. 3 Buprenorphine is a prescription medication for people addicted to heroin or other opiates that acts by relieving the symptoms of opiate withdrawal 4 Diazepam is used for the treatment of disorders with anxiety and treatment of alcohol withdrawal. 5 An initial assessment was a short assessment of a child referred to Children’s Services focusing on establishing whether the child is in need or suffering/likely to suffer significant harm and to determine the services required and if a more detailed Core Assessment should be undertaken. This has been replaced by the Single Assessment process: http://www.proceduresonline.com/swcpp/gloucestershire/p_assessment.html?zoom_highlight=single+assessment+process 6 This quote is taken from the Initial Assessment completed by Children’s Social on 17 January 2014 7 3.8 Mother was asked for consent at the start of the assessment for information to be sought from other agencies. The assessment included contact with the drug agency, who were asked about Mother’s parenting and attendance at appointments and the drug worker reported no concerns and regular attendance. The drug agency does not appear to have been asked about any recent drug use and they did not mention that Mother had been misusing drugs over New Year. The Social Worker spoke to the GP who said there were no concerns, and it appears they were not asked about Mother’s drug use and did not share the recent information they had received from the drug agency regarding Mother using illegal substances over the New Year. Nursery1 was contacted and highlighted slight issues regarding John’s behaviour, but they did not say that they had had long term contact with Mother, had concerns about her management of the younger children, and that she had been offered support through parenting classes which she did not accept. They were unaware at this point that Philip had just started at Nursery2 as no contact had been made with them. Information was not shared with any agency about the reason for the Initial Assessment, and the worker at Nursery1 did not share the request with anyone else at the nursery or record that the request had been made. 3.9 The assessment concluded that Mother was providing good care to her children, had an extended support network and there was no need for any further action by CSC; but did not reflect on whether any early help response was necessary. Mother gave consent for the completed assessment to be shared with agencies and Nursery1 and the GP were provided with a copy, as well as Mother. The drug agency was informed there would be no further action by CSC, but did not receive the assessment. Nursery2 did not receive the assessment. There was no direct contact with the Health Visiting service, but a copy of the Initial Assessment was sent to them, but this did not prompt a visit to the family. Commentary It was appropriate that the police made a referral to CSC regarding concerns about the welfare of the children and this was responded to appropriately and in a timely way by CSC. Multi-agency information sharing: The drug agency was only asked about Mother’s parenting, a question they were not qualified to answer, but not asked about Mother’s recent drug use, and information held was not shared. The GP was asked a general question about concerns, but not told about the reason for the referral so could not fully evaluate what information was required. Nursery1 were also not aware of why the assessment was being completed so focussed on here and now information, rather than providing a clear outline of their historic involvement and concerns. The police were not asked for an update on the progress of the police investigation. It is clear that the Social Worker did not ask the right questions and other agencies were not sufficiently curious about the concerns, which meant they did not evaluate whether the information they were providing was appropriate. The issue of information sharing is a theme within the report and is discussed in Finding 2. Focus on the lived experience of the child: There is evidence that the Social Worker did engage with the two younger children, but did not speak with the children on their own or seek their perspectives more clearly. It is of concern that there was not more curiosity about 8 the circumstances of Darren. It was reported by Mother that he was “staying” with MGM because of her early drug use, but this was six years earlier. The Social Worker should have asked what the exact arrangements were, how often he was at home, when he saw siblings and Father and what the future plans were for the stability of his home circumstances. This issue was never addressed during the time under review and is addressed in Finding 3. Parental self–report: There was too much focus on Mother’s self-report of her circumstances, which would have been shown to be falsehoods if some aspects of the multi-agency knowledge had been sought and shared. The issue of parental self-report is discussed in Finding 4. Involvement of Fathers and Father figures: It was effective practice that the Social Worker considered the need to seek information from Father, but was hampered in doing so because of a lack of information about his whereabouts. She also sought police information about Father, but the risk that Father could pose was not clearly articulated, and the focus was only Mother’s ability to address Father’s risky behaviour, as opposed to holding Father responsible for his behaviour and its impact on the children and Mother. The issue of the involvement of Fathers and Father figures is a theme running through this report and is addressed in Finding 5. Overall, the conclusion that the threshold for CSC to provide services was not met was in line with existing thresholds given what was known at this time, this may have been different if CSC had sought or been provided with information about Mother’s illegal drug use, her history of difficulties with parenting and support services not being accessed or Mother withdrawing her complaint against the police - all of which would indicate that Mother was unlikely to accept advice about early help services and a different response was needed. The assessment does not provide a view regarding the need for an early help response and it may have been appropriate for the Children’s Centre to continue to offer early help support. This is addressed in Finding 1. 3.10 Fourth Referral to CSC Seven weeks later Mother informed Nursery1 that Father had been released from prison and that the nursery should not allow him to collect the children. A meeting was organised about this, which Mother did not attend. Philip told one of the Nursery1 staff that “My Daddy gone”7 and John said in a different room that “the police came for my Dad last night….Dad throwed make up at Mum, it’s OK now he’s in prison”8. Mother was asked about this and said this happened a long time ago and that she now had a new partner. 3.11 The next day a staff member at Nursery1 noticed extensive bruising to Philip. She appropriately recorded these on a body map9 and showed this to Mother. Mother said 7 And 8These quotes are taken from the Early Years Internal Management Review produced for the serious case review and taken from nursery records. 9 A body map is a recording format to note any marks or injuries on a child as part of concerns regarding physical abuse. They should record, date and sign and keep in the child's file. http://www.proceduresonline.com/swcpp/gloucestershire/p_ch_protection_enq.html?zoom_highlight=body+map 9 that the injuries had been caused by the children fighting and the facial bruises caused by a metal object being knocked onto his face in the shed by John. The nursery did not think that this was an adequate explanation for the number of injuries seen and appropriately decided to make a referral to CSC late in the afternoon. Mother said she did not agree to the referral and they made clear to her that they would be making the referral anyway because of their level of concern10. The referral was made by phone initially and they made clear the nature of their concerns. They were asked to submit a written referral form, which they did the next day. The information was passed via the help desk to the Deputy Team Manager (DTM) of the Referral and Assessment Team. The DTM telephoned the police and it was agreed that CSC would undertake an Initial Assessment. The records states that it was agreed that a further decision would be made as to whether or not there was a need for Child Protection enquires (Section 47)11 depending on the outcome of the visit. There was no acknowledgement that this was the fourth referral in the period of a year regarding these children. There is no evidence of a follow up discussion with the police following the home visit. The case was allocated to Social Worker2. Commentary This was an important opportunity to address concerns regarding an unexplained injury to a young child. Referral to CSC: Nursery1 made an appropriate referral to CSC – making clear the extent of the injuries, undertaking a body map and asking Mother for an explanation. This was effective practice, which would have been enhanced by the written referral being completed at the same time as the verbal referral, and the historic concerns about parenting being included. The nursery could also have considered making the referral when they discovered the bruises, rather than waiting for Mother to come to the nursery at the end of the session; the delay meant that Philip went home before he was assessed by a Social Worker. This is addressed in Finding 6 regarding early year’s settings and safeguarding. Strategy Meeting: The decision making process between the police and CSC remains unclear and unrecorded, but given the circumstances, it would have been expected that a strategy meeting/discussion would have been held given the extent of bruising and Mother’s reluctance to allow a referral to be made. This is addressed in Finding 7 regarding the lack of strategy meetings. 3.12 Social Worker2 undertook a home visit the next morning and Mother, Philip and John 10 Concerns which have been raised, should, where practicable, be discussed with the parent and agreement sought for a referral to LA children's social care unless seeking agreement is likely to place the child at risk of significant harm. http://www.proceduresonline.com/swcpp/gloucestershire/p_respond_abuse_neg.html#parental_consult 11 Children’s Services have a legal duty to look into a child's situation if they have information that a child may be at risk of harm. This is called a child protection enquiry or investigation as outlined in Children Act 1989. The purpose of the enquires is to gather information about the child and their family so that social workers can decide what action, if any, they need to take to keep a child safe and promote their welfare. 10 were seen. It is hard to know exactly what was discussed, because much of the information recorded in the Initial Assessment is copied12 from the previous assessment. Mother said that the bruises to Philip were caused by the children’s boisterousness/fighting and the facial injury by a fall on a metal object from the garden shed; it is recorded that Philip agreed with this. Mother told Social Worker2 that she had a new partner who did not live with her, but who was very good with the children. It was also reported that Darren remained living with his MGM. Social Worker2 recorded in the Initial Assessment that Mother was disappointed that the Nursery1 made a referral to CSC and as a consequence she would be removing Philip from Nursery1. 3.13 Nursery1 sent their written referral to CSC alongside a body map and the pupil information record which made clear that Philip now attended Nursery2 for some of the time; this information was seen after the home visit to the family. Nursery1 outlined that they had noted 27 small injuries, most of which were small bruises, some small scabs and scratches and four linear bruises that resembled a handprint13. They made clear that Mother had not given consent for the information to be shared with CSC because she said she believed she had already provided an adequate explanation to them. It is unclear whether this information was included in the verbal referral and the Initial Assessment does not acknowledge that consent was not provided or analyse the implications of this. 3.14 Social Worker2 recorded that contact was made with the GP surgery, but there is no evidence that this actually happened; the wording is taken from the previous assessment, and there is no evidence of this request in the GP records. Social Worker2 also reported telephoning the Community Paediatrician, and recorded that the advice given was that there was no need for Philip to be seen by a medical practitioner because the explanation provided by Mother was consistent with the injury. There is no record of this conversation taking place in the hospital records and this discussion/advice was not mentioned in the completed Initial Assessment. There was no contact with the Health Visiting service (they would hear about this referral and assessment 8 weeks later) and no contact with Nursery2 or the drug agency. The conclusion of the assessment was there were no child protection concerns and that the key issue was Mother’s management of the two boys and that she required support to improve her parenting. There was no recommendation regarding an early help response. 3.15 Mother went to see the Nursery1 the next day and told them she would ask Nursery2 to provide full time provision for Philip because she believed that the referral made by 12 Information from the previous assessment was automatically pulled through and required the Social Worker to change the text. 13 Injuries: Back of body: -Scuff/Graze marks to his lower back/- 4 x 1p size bruises to upper back/ - 4 x 1p size bruises on right hip/1 x 50p size bruise on left buttock/ 2 x 1p size bruise on left buttock/ 4 x Long bruises on right thigh. Described as being the width and length of a finger, and all fairly evenly/spaced./ 3 x 1p size bruise half way down left thigh. Front of body/ 1 x 50p size bruise on right hip/1 x 1p size bruise on right hip/ 2 x 1p size bruise on left hand side of chest, fairly low on the rib cage/ Scabs across his nose/- Smaller scabs around his eyes. 11 Nursery1 was unnecessary. Mother provided further information about her new partner, who she said she had known all her life. She said that he did not drink or take drugs and she trusted him around the children. The Nursery1 Senior Practitioner appropriately cautioned Mother to be careful regarding her new partner and his contact with the children. 3.16 Mother went to Nursery2 five days later and told them she was removing Philip from Nursery1 because they had reported bruising to CSC and she wanted him to attend Nursery2. Mother said that they should not have done this because she had explained to them that Philip bruised easily and that Philip and John were always fighting. This was not discussed or challenged and no contact made with either Nursery1 or CSC. She asked them to provide full-time provision for Philip. 3.17 Nursery1 phoned the Social Worker four days after making the original referral and they were told that the assessment had concluded that the bruises were consistent with the explanation provided by Mother and Philip. Nursery1 explained their concern that Mother had removed Philip and taken him to Nursery2 because they had made the referral; no action was taken regarding this. There is no evidence that any agency received a copy of the assessment, but Mother did. 3.18 At this time Mother also discussed her new partner with her recovery worker at the drug agency. Mother told the worker that he did not use drugs, “hardly drank” and was good with her three children (Darren was included in this). Mother said that the children were now more settled and that Darren’s behaviour had improved; she did not mention the assessment completed by CSC, who had made no contact with this agency. Mother was illegal drug free during this time, and appeared to be doing very well, with an improved mood and engagement in activities like attending the gym. Commentary This was a significant episode regarding an unexplained injury/possible physical abuse of a young child to which there was an ineffective response. The reasons for this appear to be issues regarding capacity for CSC and an inadequate assessment process. Assessment of physical abuse: The assessment suggests that the Community Paediatrician was consulted and said no examination was necessary. There is no record of the conversation within health records, and this discussion is not included in the assessment. It is impossible to know the truth of this - but either contact was not made with the Paediatrician, which is extremely poor practice, or it did happen and there should have been robust challenge. This highlights ineffective practice with regard to the assessment of likely physical abuse that is discussed in Finding 8. No medical examination: this is one of the most troubling aspects of this incident. Philip was never medically examined despite having over 25 small bruises. Given the number of bruises, regardless of the cause, this young child should have been medically examined. Mother was not asked by any agency involved to take him to the GP and she did not do so. The assessment: Overall the assessment of physical abuse did not comply with the 12 requirement of either Working Together 2013ii or the NICE Guidanceiii. It lacked a child focus and relied too heavily on Mother’s self-report. These are both issues that are addressed in the Findings. The assessment used the text from the previous assessment, only adding in a few comments regarding Mother’s explanation of the bruising. This meant that this was not an assessment of the current circumstances or the children’s needs. This is discussed in Finding 9. Challenge to parents: It is of concern that Mother’s comments about being disappointed that Nursery1 had made a referral to CSC were simply recorded, without comment or challenge in the assessment. When Mother repeated this to Nursery2 they did not recognise that this was important, should have been challenged, and contact made with the Social Worker2. This is addressed in Finding 4. The circumstances of Darren were not explored, and it appears to have been accepted that he did not live at home, and was therefore outside the remit of the assessment process. This is addressed in Finding 3. Mother’s new partner: At this point a number of agencies became aware that Mother had a new partner who had contact with the children. This was described in the assessment, without any analysis or any sense of a risk assessment. The nursery Senior Practitioner did caution Mother about contact with the children, but this was not discussed with any other agency. The drug agency also knew of this change, and the evidence presented to them was of a positive picture. There should have been more exploration of this new man in the family’s life. This is picked up in Finding 5. Multi-agency involvement: There was no contact with other agencies within the assessment process. Contact was not made with the Health Visiting service or the GP surgery and neither were informed that the assessment had taken place (the Health Visiting service was informed in August 2014 of this incident). Given that this was an issue regarding the physical well-being of a child under 5 contact would have been expected. It is of concern that the transfer of text from the previous assessment meant that it appeared that contact had been made with the GP. None of the agencies received a copy of the assessment as would be expected, and Nursery1 had to chase CSC for a response to the outcome of the referral. It is expected practice that any referrer is told the outcome of a referral to CSC. This meant that Mother was able to provide a skewed picture of the outcome. The drug agency were not asked for information or informed that the assessment had taken place. This meant that they had no other picture of Mother or the children’s circumstances other than Mother’s own self report and presentation; this enabled Mother to present an image of her own and the children’s lives as being more settled than was actually the case. Lack of inclusion of nursery: Nursery2 were not formally informed that a child protection referral had been made or that an assessment had been completed by CSC. They were, however informed by Mother that a referral had been made, but were unaware of the full details and they did not make contact with CSC or Nursery1 to get more information. It appears that a pattern developed where the nursery were not included as part of the professional network, and they did not see themselves in that role. This is explored further in 13 Finding 6. 3.19 Further Bruising: Eight weeks later Nursery2 noticed that Philip had a large bruise on his back; when asked about it he could not give any explanation. Mother was asked and said that Philip had fallen down the stairs. This explanation was accepted. Mother was advised to take Philip to the GP; this was not followed up, and this incident was not shared with the nursery designated safeguarding professional as would be expected. 3.20 Fifth referral to CSC Three days later Mother phoned the GP, reporting that Philip had been vomiting, was tired and had some unexplained bruises. Mother was offered an immediate appointment, but she said this was not convenient and because this was just before the weekend Philip was not seen for a further four days. The GP noted extensive bruising, with “finger tip” type bruises and a possible bite mark on his buttock, bruising covering quite a large area of the back and a carpet burn in the middle of the back. It is unclear if Philip was asked about the injuries as this is not recorded, but Mother said that she thought they were caused by a reported family history of easy bruising, some medical issues related to early reflux problems and Philip’s boisterous behaviour. The GP was concerned about the extent of the bruising and made an immediate referral to CSC and to a Paediatrician for a child protection medical examination. 3.21 The referral was viewed by the Deputy Team Manager and allocated for an Initial Assessment by Social Worker2. The GP surgery was informed of this. There was no strategy meeting held and no contact with the police. Social Worker2 telephoned the Paediatrician and explained that there had been a recent assessment because of bruising to Philip and that the conclusion of the assessment had been that Mother was struggling to manage her children’s behaviour, and that it was this that had caused the bruising. 3.22 The Paediatrician saw Philip with Mother who reported that Philip had fallen down the stairs, was boisterous and there was a family history of easy bruising. When Philip was asked how his injuries occurred his answer was “from outside”. The Paediatrician was concerned about the extent of Philip’s bruising, and judged Mother’s explanation to be inaccurate. The bruising was recorded on a body map and photographed and a Consultant Paediatrician reviewed these documents. Verbal feedback was provided immediately to the Social Worker and a written report was received a week later. The report outlines the injuries as: “Large 8cm x 6cm fading bruise in the centre of the back, with a /carpet burn area, which is beginning to heal and scar. 3cm x 2cm area of bruising over left buttock. 3cm x 2cm area of reddish bruising/scratch marks on right buttock, this area was circular in appearance and had five discreet reddish bruises on the left side, with three longer scratch marks on the right side. There was a bright red spot in the centre. Bruises noted to top of right thigh 3cm x 2cm and 2cm x 1cm faded brownish colour. Two discreet bruises noted to right flank, both 1cm diameter. Three bruises 14 noted to left flank, all 1cm diameter. Red mark below left nipple 1cm diameter. Bruise to top of left thigh 1cm diameter.” 3.23 The Paediatrician’s conclusion was that there were no medical causes and that some bruises could be consistent with the explanation provided by Mother, but it was unclear what had caused the injuries on the buttock, and there was concern that one was a bite mark. Blood tests were taken, and found some iron deficiency (all other test came back normal) and oral iron was prescribed. In the written report from the Paediatrician there are concerns that Mother had delayed seeking medical advice and that the injuries would “certainly reflect poor supervision of the child's behaviour”. Given that the Paediatrician had been asked to carry out a child protection medical, she believed that a child protection enquiry was underway. The medical report was sent to the GP, who received feedback regarding the outcome of the original referral a month later, confirming that the family were to be offered short term support; they did not receive a copy of the assessment at this time. 3.24 On the day of the child protection medical assessment, Mother told Nursery2 that she had been to see a Paediatrician because she was concerned that Philip bruised easily and blood test had been taken. She did not say that the medical was part of an assessment by CSC and they were not informed about this referral or assessment by any other agency. 3.25 An unsuccessful home visit was attempted by Social Worker2 a week after the referral was received, and a second unsuccessful home visit the week after. Social Worker2 had supervision and reported that the injuries to Philip were consistent with the explanation provided and there were no concerns; there was no current evidence that this was the case. It is unclear whether the fact that Philip had not been seen and his safety and wellbeing not assured were discussed. 3.26 Social Worker2 undertook a home visit almost a month after the original referral had been made; this was an unacceptable delay to address the cause of some unexplained injuries to a young child. Mother was seen with Philip and John. The subsequent Initial Assessment is very muddled. It once again uses information from the Initial Assessment undertaken in January, interspersed with more recent information. Darren is recorded to be still living with MGM at the beginning of the document, but in the analysis section he is described as having returned home and that his attendance at school was of concern. It is unclear where this information came from as there is no evidence that his school were ever contacted. There is no reflection on what this lack of stability might mean for a child of 10 and no attempt to ensure that clear future plans were made for him. He was not seen as part of the assessment, so we have no sense of Darren’s views about his circumstances. 3.27 Mother is reported to have provided two main explanations for the bruising – boisterousness and a family history of easy bruising and possible underlying medical issues. The assessment contains the paediatric report in full which contradicted Mother’s view making it clear that there was no current evidence that the bruising was medical in nature; further blood tests were planned. This contradiction was not 15 commented upon. The Social Worker did observe that both children were running around and that John “jabbed Philip in the side with a toy very hard”14 and this seemed to confirm Social Worker2’s existing hypothesis that the bruising was caused by rough play. There was no reflection on whether a child of five could inflict so many injuries. There is no sense that Mother was challenged about her strong assertion that there was a medical cause, there was no analysis of this and the final plan focussed almost entirely on medical issues. 3.28 The assessment does not make clear whether Mother’s partner Ian was seen but there is a comment that “Mother’s partner seemed to have a good interaction with the children and was supportive15. This implies he was in the family home. 3.29 It is unclear whether the Social Worker spoke to the children alone because the information in the assessment was taken from January’s assessment. 3.30 No other agencies were contacted during the assessment; however because information from the earlier assessment was included, it appears that they were. For example, the positive information provided by Nursery1 in the first assessment was included, providing a completely false picture of the family circumstances, and wrongly reported that Philip attended four days a week. In fact he had been taken out of the nursery 8 weeks earlier and was now attending Nursery2 with whom no contact was made. The Health Visiting service were also not contacted/mentioned, there was no contact with the drug agency and the concerns expressed by the Paediatrician regarding Mother delaying seeking medical attention were not included, and therefore not analysed. This assessment was not sent to the Paediatrician for another month. 3.31 The assessment was completed a week after the home visit and concluded that “further assessment of needs and support are required to reduce the risk of further excessive bruising or injury16”. A transfer email was sent to the social work long term team which provided a different plan: the case was open for short term monitoring there was no evidence to suggest Mother had caused the injuries she was struggling to manage the behaviour of the boys with some recent improvement Mother felt that there was some underlying medical cause for the bruising and so does not feel she needs parenting support. 3.32 During the time that the assessment was being undertaken, staff at Nursery2 noticed changes to Philip’s behaviour with reports of tantrums, throwing toys, pushing chairs, crying and banging his head on the floor. This was discussed with Mother who reported that she was going to take Philip for blood tests for possible anaemia. 14 This quote was taken from the Initial Assessment completed by the Social Worker 15 This quote was taken from the Initial Assessment completed by the Social Worker 16 This quote was taken from the Initial Assessment completed by the Social Worker 16 Nursery2 were unaware of the current referral or assessment and therefore this important information was not available. Commentary This was a second opportunity to make sense of extensive unexplained injuries/possible physical abuse of a young child to which there was again an ineffective response. The reasons for this appear again to be issues regarding capacity for CSC, very poor assessment practices by the individual Social Worker and some overall inexperience regarding the assessment of physical abuse. Clear referral made: An appropriate referral was made by the GP. The GP received acknowledgment of the referral, actions to be taken and the name of the Social Worker was provided in line with expected practice. No strategy meeting: As with the previous referral there was no strategy meeting or discussion with the police as would be expected. This is discussed in Finding 7. The assessment was poor. The assessment once again used existing material from the assessment in January, with some additional specific information about current concerns. It made it a very muddled document, when a clear outline of the issues for these children was required. The assessment indicated that information from other agencies had been sought about the children’s current circumstances, but information from the previous assessment was migrated into the document, and no contact was made with other agencies. This provided a false and misleading picture. There was a very unclear plan of action that emerged from the assessment, with the conclusion being the need for further assessment, implying that there was a need for a Core Assessment17. This would have been an appropriate course of action. Instead the focus was on the boy’s behaviour, potential medical issues and support to Mother. There should have been a clearer analysis of the issues and what would help to improve the lives of these children, as opposed to focusing on Mother and her concerns. This issue of poor assessment practices is discussed in Finding 9. Poor Assessment of Physical abuse: this was a very unclear assessment of physical abuse and there was inconsistency in professionals asking Philip directly about his injuries. The Paediatrician made it clear, that there had been many injuries, not all were consistent with the explanation provided, and were therefore unexplained. She also made it clear that there was no known medical cause for the bruises at this point, but that blood tests were underway; Mother’s view that there was a medical cause was recorded without comment or analysis. Mother’s assertion that there was a family history of easy bruising was never explored further, or information sought about it and from this point onwards all involved agencies believed that there was a potential medical cause to future injuries. If this were the case Nursery2 who were responsible for Philip’s care should have sought more information about the implications of this for their care of him. This is discussed in Finding 8. Early signs of neglect: Information emerged during this episode of early signs of the 17 potential neglect of these three children. Mother delayed seeking medical opinion regarding extensive injuries and it was clear that if the injuries were not evidence of physical abuse, they were indicative of very poor supervision of a three-year-old child. Inconsistent information was recorded about Darren, and it remained unclear where he was living, and what the arrangements were for his care. This was also indicative of issues regarding neglectful care. This is addressed in Finding 11. Overall there was a complete lack of a child focus and no reflection on what the impact of having so many injuries might be on a young child, regardless of the cause. In the section of the assessment on unmet needs it is recorded that “Philip has been hit by his brother and also has climbed on things placing himself at risk”. This implies that either he and/or his brother were responsible for the injuries. This was an inappropriate analysis. Darren was not provided with an opportunity to give a view about thoughts and feelings about living away from home. This is discussed in Finding 3. Poor multi-agency involvement: There was no multi-agency involvement throughout this episode, which was masked by the inclusion information from the previous assessment. This is discussed in Finding 2. The Paediatrician believed that child protection enquiries were underway and it would have been appropriate for there to be some follow up with CSC to establish what the conclusion was given that some injuries remained unexplained. This did not happen, and the completed assessment was not received by the paediatric service until a month later. There is no evidence that the assessment was reviewed and discrepancies noticed. This could have been an appropriate opportunity for challenge to this very poor assessment. This would have been the only opportunity as no other agency received a copy of the assessment. Reliance on parental self-report: There continued to be evidence across this episode that professionals relied too heavily on what Mother said, without there being a process for challenging or exploring whether it was true. The issue of easy bruising is a significant example of this. This is discussed in Finding 4. Lack of inclusion of Nursery2: This is an emerging theme. They were not told that the assessment was underway, or that there might be concerns about physical abuse, poor supervision or medical issues regarding early bruising, despite Philip being regularly in their care. This lack of inclusion meant that the valuable information about Philip’s behaviour that they held was not included. Overall the lack of inclusion of nursery is discussed in Finding 6. 3.33 CIN Process: Three weeks later Mother contacted the GP because Philip was unwell with a tummy ache, vomiting and was very tired. Philip was seen by the GP who found him to be well, but a little pale. Mother asked that Philip be tested for coeliac disease and it was agreed Mother would bring Philip in for some blood tests. Mother did not do this and had to be reminded in the next month and the month after that, and the test took place nearly six weeks after Mother made the request. 3.34 At this time the family were allocated a family support worker (FSW). The focus of this was said to be to help Mother to improve her parenting. However the goals outlined in 18 the Initial Assessment which formed the basis of the Child in Need plan were: Philip to have an appropriate diet; GP appointment to be made to test for Coeliac disease (acknowledged as a concern of Mother’s) ; The risk of Philip being bruised accidentally or deliberately to be reduced; Philip to not place himself at risk and his brother to stop hitting him. 3.35 The FSW visited the family twice over the next four weeks. It was noted that Darren was living with MGM but would be returning to live with Mother and siblings in September. Mother told the FSW that she was certain that there was something medically wrong with Philip who continued to be unwell. Mother also talked about her partner Ian who she said was supportive, did not take drugs, but did not know that she attended the drug agency or had problems with drugs in the past; she asked the FSW not to mention these issues. Phillip and John talked about playing with Ian. 3.36 The FSW had supervision and reported that she thought Mother’s parenting was good; this was the current focus of the work. It was agreed that there would be fortnightly visits and monthly Child in Need meetings (CIN18). The FSW was asked to obtain a full history of Mother’s drug misuse, to follow up the health testing and that CIN Plan would be developed at the CIN meeting. None of these tasks were completed, and there appears to have been no challenge regarding this. 3.37 The CFSW from Nursery1 rang the Health Visiting service to ask if the family had an allocated Health Visitor. John was still attending the nursery and the CFSW had also had a discussion with Mother at the nursery sports day regarding Philip being unwell and possibly coeliac. Mother told the CFSW that CSC had carried out an assessment because of concerns about bruising. 3.38 The Health Visiting service made contact with CSC and were given information (which was wrong in the detail) about an assessment being undertaken. This led to a Health Visitor being allocated with the aim of helping Mother improve her parenting. The newly allocated Health Visitor telephoned and emailed the FSW and was left a message saying that there was to be a CIN Meeting in three weeks’ time. Commentary Poor Planning regarding unexplained injuries: In July the family were allocated a FSW, rather than a Social Worker. This was because the focus was on parenting support and the FSW was very experienced at this. This focus was incorrect. The cause of some of the bruising on Philip, including a possible bite mark remained unexplained. Mother had made it clear that she did not accept that she needed parenting support because the cause of the injuries was medical. Although the paediatric assessment had made clear that there was no evidence that this was the case, the emergent plan from the Initial Assessment focussed almost entirely on medical issues. This is discussed in Finding 9. 18 A Child in Need Meeting is held so that children, young people, families and those professionals working with them are clear about their responsibilities within the Children in Need Plan, the role of the allocated social worker, timescales of the interventions and expected outcomes. 19 Holding children responsible for unexplained injuries: The plan also suggested that Philip had put himself at risk, which partially explained the injuries and that his brother John was also responsible because of rough play. There appears to have been no reflection on the appropriateness of holding children responsible for what were clearly adult parental issues. This is discussed in Finding 3. Lack of follow through of agreed tasks in supervision: A clear agenda was set for the work of the FSW which was not followed through. This does not appear to have been noted or addressed in a subsequent supervision session. This was important because, if for example the FSW had checked whether the medical tests had been undertaken as she had been asked, she would have found that Mother had failed to take Philip for these, despite reminders from the GP. This could have changed perceptions about Mother. Allocation of a Health Visitor: it is good practice that the CFSW contacted the Health Visiting service to see if there was an allocated Health Visitor. The family had some time before been assessed as requiring routine (universal) support and all the health milestones had been completed. Mother had stopped engaging, and did not seek advice. The Health Visiting service were not made aware that there were concerns, as would be expected, and therefore they could not revaluate the level of support needed. It is effective practice that as soon as they were made aware of concerns they allocated a Health Visitor. However there is no evidence that a Family Health Needs assessment was undertaken at this point as would be expected. 3.39 The First CIN Meeting The first CIN meeting took place at school. It was John’s first day at school and appropriately the school nurse and the school support worker were present. The meeting was chaired by the FSW and was also attended by the Health Visitor, drug agency worker, Mother and MGM. Nursery2 were not invited, but found out about the meeting by accident and attended. The report of the CIN meeting notes suggests that the children were consulted before the meeting, but there is no evidence to suggest this was the case, and their views were not included in the discussion. The meeting was dominated by Mother and her concerns regarding Philip being unwell. Mother said that the GP had not yet conducted blood tests, but did not say that they had tried to contact her to remind her to bring Philip in which she had not done. The Health Visitor said she would support Mother to contact the GP, but Mother said this was not necessary. A very worrying picture emerged regarding Philip’s wellbeing; Mother reported he was losing hair, was being sick 2/3 times a day and was sleeping in Mother’s room because she was concerned he would be sick in the night and choke. 3.40 There were concerns expressed about Darren who was described as exhibiting aggressive outbursts and behaviour. His school were unable to attend the meeting so there was no further detail and he was reported to be back living with Mother, but spending time with MGM after school. 3.41 The meeting was convened to develop a plan, but this did not happen. Mother said she did not have time for parenting classes as she wanted to get a job. The only 20 update to the CIN plan completed as part of the Initial Assessment was that the Health Visitor would support Mother to seek medical help regarding bruising; there was no acknowledgement that Mother had already declined this. Mother’s partner Ian was not discussed. 3.42 The Health Visitor had safeguarding supervision after the CIN meeting and the analysis of current concerns was that Mother was meeting the children’s needs but there needed to be an assessment of Philip’s development and to follow up on the health issues. The Health Visitor did ring the GP surgery to ask about progress of the blood tests, but was told these could not be discussed with her and she needed Mother to ring. It is unclear at this time whether the CIN meeting was discussed and that the information was required for that purpose. The GP practice were not asked to provide any information for the CIN process, despite the focus on health matters. 3.43 The GP surgery telephoned Mother the day after the CIN meeting and asked her to organise the blood test for Philip and the test was undertaken. Mother was told a week later that Philip was not coeliac. 3.44 Three days after the CIN meeting Nursery2 noted a large bruise on Philip’s right ear (top and back) and when he was asked about it he said he had bumped his head. He was collected by another parent and she was asked to mention the bruise to Mother. This adult said that it had been there for a number of days, but the nursery should not worry because Philip bruised easily. Mother was spoken to the next day and said Philip had bumped his head. This information was not shared with the FSW as would be expected and Mother was not advised to take Philip to the GP. Commentary: CIN meeting lacked a focus on the ends and circumstances of all three children: The CIN meeting was convened in a timely way (given the summer holidays). It brought together a number of agencies. Nursery2 inappropriately heard about the meeting by accident, they had not been invited. The GP was not asked to provide any information, despite the focus on Philip’s health needs. This process was ineffective in developing a child focussed plan. This is discussed in Finding 10. At this point there remained concerns about unexplained injuries to Philip which were unacknowledged and no professional present had seen a copy of the assessment, or knew in detail its conclusions. This made it difficult for professionals to judge whether there was an undiagnosed medical issue. This was based entirely on self –report from Mother. Mother’s views dominated without challenge. This was a further example of parental self-report which is addressed in Finding 4. The discrepancy between Mother’s stated concern regarding Philip’s health and her failure to bring him for medical tests was not known because the GP was not asked to provide any information to the CIN meeting. This issue is discussed in Finding 2. A worrying picture emerged during this meeting of a very unwell little boy. This should have prompted professionals to ask Mother to seek urgent medical attention for him and to ask 21 why this had not been done before. There was no reflection however, that the picture provided by Mother was not seen in nursery and if the bruising was caused by either an undiagnosed health issue or easy bruising it would be expected that Nursery2 would have seen more evidence of bruising in their setting. They only ever saw pre-existing bruising, and because they believed this was caused by a medical issue, did not report them. The reasons for this appear to have been poor knowledge and skills in the assessment of physical abuse, an over reliance on parental self-report without a full triangulation to other information and the lack of effective supervision for those centrally involved. Lack of inclusion of Nursery2: It was only by chance that nursery 2 attended the CIN meeting, yet they had most knowledge about Philip, who was the primary focus of this CIN process. This was a consistent pattern which is addressed in Finding 6. Children’s voice and child focussed practice: There remained contradictory information about where Darren was living. It was noted that he was struggling with angry outbursts, but there was no discussion about why this was or whether this behaviour might be connected to the instability in his living arrangements and possible confusion about who was his primary caregiver. The children were reported to have been consulted before the CIN meeting, but there was no evidence that this happened and the records indicate that their views and/or life experiences were not discussed. This is discussed in Finding 3. Mother’s partner Ian was barely discussed, and there was no evidence at this stage that any professional considered what his role was in the family unit. This is discussed in Finding 5. 3.45 Sixth Referral to CSC A week after the CIN meeting Mother and her partner Ian were arrested for handling stolen goods; two stolen laptops were found in the garden. During the search of the house, Police Officers found that the children’s bedroom and other rooms had high external locks on the outside of the doors; they were in a position that the children could not reach. The Police Officer challenged Mother about these locks and their location, expressing concern that the children were locked in their bedroom and only the adults would be able to let them out. Mother said the locks were there to stop the children going into other rooms. The Police Officer spoke to John who said that he was locked in his bedroom and the adult with him (no record of who this was although was thought to be MGM) said that “he shouldn’t say things like that”. The sheets on John’s bed were filthy and smelt unwashed; the room was described by the Police Officer as very sparse and they noted that there was no evidence in the kitchen that children lived there. The garden had personal belongings strewn across it. Mother said these belonged to Father and she had thrown them into the garden because they kept arguing. Photographs were taken, but not shared with any other agency. The police asked Mother to remove the locks and clean up the bedroom, which she did and the police made a referral to CSC. 3.46 The FSW went to the family home the next day. Mother denied locking the children in their rooms and said she would never do such a thing. She then said that sometimes the children took water from the bathroom and caused flooding, so there were locks on some rooms. The issue of Mother initially denying that the children were locked in, 22 and then admitting it happened on some occasions was not challenged or discussed further. It should have been made clear that the children should never be locked in their rooms. The FSW did not have a discussion with the police about the size and location of the locks and did not ask if photographs had been taken, this meant she did not have a clear picture of the seriousness of the concerns because the police had already asked Mother to remove the locks and clean the house. Philip had a bruise on his face and the FSW recorded that he had been heard to say he banged his cheek when he woke up. Mother said the disgusting sheets on John’s bed were temporary because he had wet the bed and his normal sheets were being washed. Philip was asleep in Mother’s room and Ian was also asleep in bed in the same room; this was not questioned. The FSW went to see John at nursery because she was aware that he had told the police about being locked in his room, but when asked again he said “no”. There was no reflection on the meaning of this retraction by John or whether he had been told to say this. The FSW did not seek any immediate managerial advice about the appropriate response to this referral and no other agency was informed that it had happened. 3.47 There is some confusion about the sequence of events regarding this whole incident, but it appears there was a teleconference call between the FSW’s manager and the Police four working days after the initial referral to CSC. Feedback was provided to the Police about the home visit and despite their original serious concerns, they were reassured that action was being taken and it was agreed that there was no role for the police, but that CSC would continue enquiries. The police understood interviews would be undertaken with the children at school, but this did not happen. No formal enquiries were undertaken. Overall it was inappropriate to ask the FSW to undertaken this work, which should have been completed under the auspices of child protection enquiries. 3.48 Seven working days after the referral from the police the FSW had supervision with her manager. They discussed the referral and that Philip had a bruise on his cheek at the home visit, which was said to have been caused by a Lego brick. This was a different explanation to the one previously recorded, but there was no further discussion of this. The contradiction between John’s disclosure and retraction was not discussed. The only agreed action was for the FSW to see Darren at school. The purpose of this is not made clear in the records and this never happened. The previously agreed tasks from the last supervision regarding these children were not reviewed and so the fact none of them had been completed was not acknowledged. 3.49 The next home visit did not take place for another three weeks and Mother discussed her concerns about Philip being unwell and tired. Mother said she had been to the GP who was to make referral to a Paediatrician. Philip had another bruise on his cheek and Mother said this had been caused by a child throwing an object at him. This should have been further explored. The house was seen to be clean and tidy. 3.50 The Health Visitor could not make contact with Mother for a few weeks and it was nearly two weeks before she could visit and undertake the developmental assessment where Philip was assessed as developing appropriately. 23 3.51 Mother saw her worker at the drug agency at this time. She had Philip with her who was described as happy and smiling, but who went to sleep during the appointment. Mother said that the police had raided her property because her partner Ian had hidden some laptops in the garden and they had been arrested. She also reported feeling stressed by CSC involvement. Mother’s care plan was reviewed and the planned reduction in her medication was put on hold. The drug agency worker did not contact the FSW to ensure that she knew about the police involvement. Commentary Incident led practice: This was the sixth referral in a nine month period about the wellbeing of these children and was an opportunity to step back and consider what was happening. Instead the focus was on the presenting problem, rather than professionals seeking to understand the cumulative nature of the concerns and consider what was the overall picture for these children. There was no formal assessment or enquiries: this was a serious incident which should have led to a strategy meeting, or at least a further assessment of this new information. The allocation of this case to an experienced FSW may have influenced this. This allocation was in line with existing custom and practice for cases where the main focus was parenting support. This was incorrectly the initial focus, but quickly it should have been clear there was something more serious happening here which required further investigation, and a qualified Social Worker was required. Capacity issues for CSC seemed to have played a part here. Multi-agency working: despite this being a CIN case, with a multiagency group supposedly overseeing the plan, no other agency in the network was informed of this incident. When Mother told the drug agency that the raid had happened because of her partner Ian’s actions, this should have been discussed with the FSW and the implications for the children considered. The FSW did not make contact with the police to establish clear information about the state of the house, and ask for more information about the locks. The pictures taken by the police were also not included in the referral or discussed in the teleconference. This meant that the implications of the size and location of the locks in the context of the young age of these two children was not explored or analysed. In effect this worrying information got lost. This was further evidence of inconsistency/uncertainty in multi-agency working across the period under review and is explored in Finding 2. Understanding of neglect: the information from the police suggested there were concerns about the physical care the children were bring provided with and their emotional wellbeing in the context of being locked in their rooms, yet this was never described as evidence of neglectful care. The implications of the criminal activity taking place in the home, and the presence of unknown adults was not addressed as a risk factor for the safety and wellbeing for the children. This is discussed in Finding 11. Parental Self-report: Mother dismissed the concerns of the police and the explanations she provided were given more credence than either the police or the disclosure from John. 24 This was completely inappropriate and further evidence of a reliance on self-report. This is discussed in Finding 4. Continued concerns regarding bruising unexplored: Philip was seen on two occasions during this time (a three week period) with bruising, which were not appropriately assessed or the causality explored. This appears to have been caused by a lack of clarity of what was the main focus of the work, alongside the continued influence of Mother’s insistence of a medical cause. Lack of child focussed practice: Mother and her partner Ian should have been challenged about their decision making, which brought police raids to the house, where there were two young children living. This would have been a frightening experience, and was evidence that both adults were prepared to put their own needs above the needs of the children. This required further exploration. This is discussed in Finding 3. Children’s voice: The FSW did go and see John as part of her exploration of this critical incident. There is little available information about what was covered with this five year old, or what developmentally appropriate methods were used to give him an opportunity to share his view and any worries. The fact that John withdrew his assertion that he was locked in his bedroom should have been subject to further analysis. The issue was not that he withdrew it, but why he did so and what the implications of this were. The FSW was asked to go and see Darren, but this never happened, and Philip was not seen alone at all. This is the continuation of a significant theme of this review about the importance of understanding the lived experiences of children and enabling them to have a voice. This is discussed in Finding 3. 3.52 A month after the first CIN meeting there was a second CIN meeting which all professionals and Mother attended, but the FSW did not. The professionals found out that the FSW was unwell and it was agreed that the meeting would be rescheduled. Mother told those present that Philip did not have coeliac disease. 3.53 The next day Mother took Philip to the GP with abdominal pain, vomiting and bruising to the cheek. Philip was pale, but there were no concerns when he was examined. 3.54 The rescheduled second CIN meeting took place a week later. It was chaired by the FSW and attended by the same group of professionals as at the first, alongside Mother and MGM. Mother had asked the FSW not to share the details of the police raid, but agreed that the issue regarding the locks and dirty bedding could be discussed. Nursery2 shared that Philip had a bruise a few weeks earlier, but they had not been concerned because they understood that this was a medical issue which was being addressed by the GP. The FSW said that any bruises must be shared with CSC. She also asked Mother if any other adults or her partner Ian looked after Philip, Mother said no and she could not see why the FSW had asked. 3.55 Mother said that the GP had now made an appointment for Philip to be seen by the Paediatrician for further tests and this was confirmed by the Health Visitor. Professionals agreed that John was making good progress and that there remained 25 concerns about Darren’s school attendance. MGM said that she found him difficult because of his angry outbursts, but at these times Mother would come and help. The children were reported to be too young to provide their views to the CIN review by the FSW. The existing minimal plan remained, and was updated with information about the potential appointment with the Paediatrician. 3.56 The FSW felt very concerned about the situation and planned to talk with her manager about this the next day. Before she had a chance to do this Philip was taken to hospital by his mother and found to have a number of non-accidental injuries. Commentary The effectiveness of CIN processes: The CIN meeting was dominated by Mother’s concerns regarding Philip’s wellbeing, without there being any agreed actions other than the future appointment with the Paediatrician This meeting was attended by all the appropriate professionals, but was once again ineffective in its task which should have been to review the circumstances of these three children, reflect on the CIN plan and discuss amendments or how to respond to a change of circumstances. This is discussed in Finding 10. Stability for Darren: Darren was said at this meeting to be living with MGM, whereas at the last meeting five weeks earlier he was said to be living with Mother. This continued confusion and uncertainty about his circumstances was not discussed, and the evidence that this was having an impact on his wellbeing in the form of angry outburst and poor school attendance was not acknowledged. This is discussed in Finding 3. Role of Mother’s partner: A more direct question was asked of Mother about her partner Ian and his care of Philip at this point, indicating that there was beginning to be a growing understanding that professionals needed to understand this more. This is discussed in Finding 5. Further bruising: It became clear during this meeting that Nursery2 had seen bruising some weeks before and had not reported it. This was because they believed that Philip suffered from some medical condition/easy bruising. This was clear in the meeting, but there was no discussion about this false perception despite the FSW’s concern about this, as evidence by the use of exclamation marks in the CIN records and the Health Visitor’s concerns. There should have been a more robust plan of action for the future. This is addressed in Finding 8. Parental challenge: The CIN minutes report that the Mother asked the FSW not to discuss why the police had visited the family home, and although the FSW told Mother she would need to share the concerns about the state of the house, she appears to have agreed not to share the issues about criminal activity. This was important information for the multi-agency group to know about, and analyse in the context of the children’s needs. The FSW should not have agreed to Mother’s request, and she should have sought her manager’s advice regarding this. This is addressed in Finding 4. 3.57 That evening Mother called an ambulance because Philip had been constantly vomiting for the last four days. The ambulance crew were immediately concerned 26 because Philip was extremely unwell, appeared to be small for his age and looked slightly malnourished and there had been a significant delay in Mother seeking medical help. This concern was replicated at hospital, and it was noted that Philip had lost 1.5kg in the last three months, a significant weight loss for a young child. There were additional concerns regarding Mother’s attitude to Philip; she was distant, did not comfort him and left him on his own for long periods whilst he was receiving medical care. There was a strong belief amongst hospital staff that the cause of Philip’s admission was child abuse, but the task of providing medical care dominated and safeguarding action was not taken that night. A strategy meeting was held the next day. Philip was treated medically overnight and transferred to Bristol Children’s Hospital as a severe emergency with life threatening injuries six hours later. The details of the admission and the initial body maps of the injuries did not transfer with him. Family history was sought the next day. The siblings were placed with a relative. Commentary Philip was taken to hospital with significant injuries for which he received prompt medical attention. Professionals at the hospital noticed Mother’s poor attitude and care of Philip but the task of providing medical care dominated, and these observations were not recorded, or any safeguarding action taken until the next day. This could have left other children vulnerable to harm. If the concerns were as serious as this the police and CSC should have been called. It is good practice that extensive records of the injuries were taken, but were not sent to Hospital 2 because they were left behind in the urgency of the transfer. 27 4 Findings 4.0 Introduction At the heart of this review are significant concerns about unexplained physical injuries to a young child. It is essential that professionals are able to effectively identify, assess and take positive action when children have injuries of concern. This is one of the Findings of this review alongside 10 others outlined below. 4.1 Finding 1: The role of a formal early help response in keeping children safe The case for preventative services is clear, both in the sense of offering help to children and families before any problems are apparent and in providing help when low level problems emerge. From the perspective of a child or young person, it is clearly best if they receive help before they have any, or have only minor, adverse experiences. Munro 2011iv 4.1.1 Research, policy and guidance has highlighted the importance of intervening early in the lives of vulnerable children and their families; as the quote from the Munro review indicates intervening early is more effective in improving children’s outcomes than later, reactive services, when problems have become entrenched and are more difficult to address. The focus here is on identifying the needs of children and young people before they have reached a point where their development and wellbeing is seriously compromised. This includes early assessment, in collaboration with family members, and the provision of services which meets children’s needs. Although the early help approach relies on good partnership working with families, it also emphasises the need for professionals to be clear with parents about the likely negative long term consequences for children if they feel unable to engage with services intended to improve the life circumstances of their children. This requires professionals to develop good engagement strategies, and to be able to challenge parents appropriately. 4.1.2 Philip and John were identified as needing help because of their parent’s difficulties. Mother had previously misused drugs, was struggling with Father’s aggressive behaviour, and reported finding it difficult to manage the children behaviour. Some of these difficulties had led to her asking for Darren to be cared for by Maternal Grandmother. Mother reported that Father had poor mental health, misused drugs and was aggressive. These parental concerns are exactly the kind of issues which can impact on children and for which an early help response was designed. Over a 12 month period a range of professionals offered support which Mother said she would consider, but ultimately did not accept. During this time there was no assessment using the CAF process and therefore no formal setting of goals or plans to address the children’s needs. The lack of a formal process meant that Mother’s lack of engagement with services aimed at addressing the needs of her children was not formally acknowledged and the information was not part of the analysis of the first Initial Assessment. 4.1.3 The police referral (which was referral number three to CSC ) which led to the first Initial Assessment made clear that there were concerns regarding Father’s aggression and drug use and that Mother continued to struggle with the children’s behaviour; there remained uncertainty about the wellbeing and living circumstances 28 of Darren. The conclusion of this assessment was that there was no need for further action. In reality this conclusion was really that the threshold for CSC had not been met, and given the available information this was correct. It did not mean that there was no need for services to be offered, and this could have happened using the early help process. In effect Nursery1– part of the Children’s Centre – continued to offer support informally, but the lack of progress and a deteriorating situation would have been more clearly identified through a formal plans which was reviewed and would have provided context for the next assessment. The need for enhanced Health Visiting support might also have been recognised. 4.1.4 The fourth referral to CSC also led to an Initial Assessment and this concluded that support could be given through School or the Children's Centre, without any sense of how this might happen. This recommendation was not made in the context of an early help response, despite there remaining concerns about Mother’s ability to cope with the children’s behaviour and ability to provide effective supervision. No other agency considered that an early help response was necessary. There is no recommendation regarding this Finding as Gloucestershire County Council is currently working with partners to develop the Early Help offer across Gloucestershire. Early Help Partnerships and Allocations Groups have been developed across the County to support families and practitioners working with them to access the additional support they need. The GSCB will need to be assured that this work is addressing the concerns raised in this SCR. This can be achieved by existing reporting processes. 4.2 Finding 2: Multi-agency Information sharing 4.3.2 Good quality multi-agency information sharing lies at the heart of effective safeguarding practice and there is clear guidancev about its importance and the principles which underpin effective practice. Poor information sharing is a key theme across many of the Serious Case Reviews published in the last fifty years, and these reviews highlight the consequences for children, young people and their families if professionals are unclear about their responsibilities in this area. More recent reviews have highlighted that information sharing is about more than just passing information from one agency to another. It is about each agency sharing its own analysis of the child and families circumstances, and ensuring that those who know the child best communicate their understanding of the child’s world. 4.3.3 Information sharing is a two way process; each agency needs to be clear what it needs from others when undertaking assessments or inquiries about children’s wellbeing and all agencies need to think about the information and knowledge they hold, and actively consider its relevance. In this case information was sought from agencies during the first Initial Assessment, but the reasons for the assessment do not appear to have been made clear. Information about Mother’s drug use does not appear either to have been sought or shared. It is unclear why, but this was relevant information and could have led to a clearer analysis of substance misuse, and issue which was never fully explored. 4.3.4 This first assessment was shared with the GP and Nursery1which was good practice, but both agencies filed the report, and the information was not used to make sense of 29 any of the children’s circumstances. There appeared to be a fundamental misunderstanding about why this information was being shared. The assessment was not shared with the drug agency, who worked closely with Mother, and they therefore had no knowledge of any wider concerns. Information was also not shared with the Health Visiting service, and they were therefore not able to evaluate whether there was a need for an enhanced response. 4.3.5 Nursery1 did provide good information about their concerns and gave a clear picture of the extent of bruising to Philip. They also provided some analysis of Mother and concern that her explanation was not consistent with the injuries seen. This was good practice, which was undermined by the assessing Social Worker taking a different view, but not discussing it with the Nursery1. Nursery1 did not have a full opportunity to challenge this because they did not receive a copy of the assessment and were given brief information about the outcome of the referral they had made. However, the information they were given contradicted their concerns and this should have been challenged. They did not feel able to do this because they considered the assessing Social Worker to be the safeguarding expert. This is discussed in Finding 6. 4.3.6 During the second assessment contact was not made with any other agency except Nursery1 who had made the referral; information was migrated from the previous assessment, which meant it was out of date and not relevant to the current concerns. No agency was sent a copy of the assessment. This was extremely poor multi-agency practice and meant that agencies were not aware there were concerns about bruising and inadequate supervision. It is of concern that the assessing Social Worker indicated that advice had been sought from a Paediatrician, when there is no evidence that this was the case. Nursery2 were not made aware of the concerns regarding Philip, despite this information about their involvement being known to Nursery1 and the assessing Social Worker. 4.3.7 A clear referral was made by the GP regarding injuries to Philip, and a medical organised. The GP was informed of the outcome of the assessment, but did not receive a copy and therefore was not able to evaluate the response to their referral. The Paediatrician who undertook the medical was given verbal information about the recent assessment, but was not provided with a copy, which would have highlighted recent significant concerns regarding extensive bruising. 4.3.8 There was also little multi-agency contact during the third Initial Assessment, where once again information was migrated across. This meant that there was no multi-agency analysis, and Nursery2 were not asked to provide information about how Philip was in nursery; something they were concerned about. Once again the assessments were not shared with most agencies, with the exception of the Paediatricians who undertook the Child protection medical; they received a copy a month after it was completed; they did not review this document or comment on the fact that its conclusion was at odds with their analysis. 4.3.8 The CIN process did bring most agencies together; although nurrsery2 were not invited and the GP not asked for information. This was an important opportunity for information to be shared, and a clear plan developed. This did not happen; the involved agencies were not provided with a copy of the assessment, which formed 30 the basis of the original plan. The first meeting was dominated by Mother, and at the second meeting Mother was able to ensure that the family support worker only shared partial information about concerns. 4.3.9 Information was never sought about Darren and therefore his school was never aware that there were any concerns about the family, and were not asked for information about him. 4.3.10 There were significant gaps in the sharing of information across the multi-agency network regarding Philip, Darren and John. This appears to have been caused in part by the poor assessment processes, but also some lack of confidence and ownership by other agencies regarding their responsibilities to ensure that all information is shared, information is sought from others and discrepancies in the analysis of concern challenged. Recommendation: the GSCB needs to understand what prevents professionals from working to the national information sharing guidance Recommendation: the GSCB needs to understand in what circumstances it is appropriate for CSC to share the assessments with other agencies regarding children those other agencies are working with and clarify this to partner agencies 4.3 Finding 3: The importance of Child Focussed Practice “everyone involved in safeguarding and support should pursue child-centred working and recognise children and young people as individuals with rights, including their right to participation in decisions about them” Munro 2011vi 4.3.1 The South West Child Protection proceduresvii, underpinned by Working Together 2015viii makes clear that one of the core principles of effective safeguarding practice is a child centred approach which is focused on the needs and views of children. This is reinforced by the United Nations Convention on the Rights of the Child (CRC)ix, which recognises a child’s right to expression and to receiving information. This right is also reinforced by Article 10 of the Human Rights Act 1998x and the Children Act 1989xi, which requires a local authority to ascertain the ‘wishes and feelings’ of children and to give consideration to these when determining what services to provide, or what action to take (taking into account the child’s age and understanding). The Assessment Framework (2000)xii also clearly states that direct work with children is an essential part of the assessment process because children are a key source of information about their lives and the impact any problems are having on themxiii. 4.3.2 Despite this mandate, evidencexiv shows that children are not being routinely fully included in safeguarding and support work. The consistent finding from serious case reviews is that professionals do not speak to the children enough; a report by Ofstedxv on the themes and lessons to be learned from Serious Case Reviews highlighted that children were not seen frequently enough by the professionals involved in their lives, professionals focused too much on the needs of the parents, 31 and overlooked the implications for the child. This appears to be caused in part by workload pressures, parental resistance, undeveloped skills and differing views about at what age a child is able to participate. 4.3.3 Overall, the views and experiences of these three children were rarely sought. There were some exceptions. Nursery1 always asked Philip about the cause of his bruises, and shared this with others. Nursery2 often spoke to Mother about Philip and their concerns regarding him. This nursery were not consulted as part of the two main assessments so this information was not shared with any other agency. The Social Worker in the first assessment did spend time with Philip and John, and this is clearly reflected in the assessment. There does not, however, appear to have been any attempt to see them on their own to ask them their views about what had happened and consider any concerns or worries they had. The assessment does not also reflect on what was likely to have been a very scary incident where their Mother was threatened with a knife and they were taken away by their Father. 4.3.4 On the two occasions where extensive bruising was found to Philip, he was asked by the Paediatrician about the cause of his bruising, but more could have been done to explore the contradictions with what Mother had said. Neither he nor his brothers were seen alone during the last two Initial Assessments to ask what had happened, to provide them an opportunity to discuss any concerns or views about their circumstances and there was no sense of Social Worker2 reflecting on what the impact on Philip might be of so many bruises, regardless of the cause. 4.3.5 When the police made a referral about criminal activity and neglect the children were again not seen alone to discuss their views and to ask about day to day life. John made an allegation that he was locked in his room but changed the story the next day. There was no reflection about this retraction or the possibility that a parent/carer had influenced this. Researchxvi highlights how difficult children find it to make disclosures of abuse by family members, the pressures they feel and their need for professionals to ask questions, notice what life is like for them and investigate fully. 4.3.6 It is of concern that the most invisible of the children was Darren. There was considerable uncertainty about where he was permanently living, and a different story was provided by Mother and MGM during each assessment. Mother said that Darren had moved to stay with MGM because of her drug use, but this arrangement was said to be still in place some six years later. There was no discussion of what the implications of this uncertainty might be for Darren, how it might be exacerbating his behavioural difficulties and what the actual arrangements were. He was aged 9/10 years old and should have been offered an opportunity to talk about his circumstances and have the potential instability addressed. Recommendation: The Gloucestershire Safeguarding Children Board should seek assurance from all partner agencies about the quality of child focussed practice and draw on any current work, such as audits, to consider whether there is any other evidence regarding poor child focussed processes which requires action. 32 4.4 Finding 4: An overreliance on parental self-report and a lack of challenge to parents 4.4.1 It is essential that all professionals working with children and their families do so in a respectful and open way. This is the cornerstone of partnership practice as embedded in the Children Act 1989xvii and subsequent guidance and legislation. However, research and Serious Case Reviews emphasise the importance of not taking at face value what parents or carers say when asked about the possible abuse of children. The Munro reviewxviii commented that adults in this situation have a number of motives for not always providing a full picture of their or their children’s circumstances. The task of professionals is to remain in a position of “respectful uncertainty” and display “healthy scepticism” which in practice means: checking the validity of information provided by parents/adults by cross referencing/triangulating with other sources testing out the level of parental care and concern for children and the extent to which parents feel a sense of responsibility for their children and their well-being 4.4.2 Neither happened in this case, with significant consequences for Philip particularly, but also John and Darren. Information provided by Mother was often taken at face value, and overall there was an over-reliance on her own self-report of her circumstances, which was often unreliable, but which was included in reports, assessments and the minutes of meetings as statements of fact. The issue of easy bruising was an example of this. Mother reported a family history of easy bruising, without there being any evidence that this was the case, and she suggested that this might be the cause of the bruising to Philip. Despite there being no evidence that this was the case, this continued to be discussed as an issue at the CIN meetings, and was the reason why Nursery2 were not concerned about bruising to Philip because they believed this was a medical issue. 4.4.3 During the first Initial Assessment Mother reported that she would be pursuing police action regarding Father taking the children out of the house and threatening her with a knife. This was accepted as true, and seen as a protective factor because Mother appeared to demonstrate an understanding of the likely impact of the children witnessing domestic abuse and putting their needs first. In fact, Mother did not pursue charges and was described as hostile to the police as she did not want to cooperate with them. This provided a completely different picture of Mother’s capacity to put her children’s needs first. 4.4.4 There was no challenge to Mother regarding actions she took which were not in the best interest of her children, and which indicated a lack of respect for professional concerns. For example when Nursery1 made a referral to CSC regarding extensive bruising to Philip, Mother informed them that she would be taking him out of nursery because of this. Philip had been going to the nursery for some time and had become settled. This decision was not in his best interest, both in terms of his safety and wellbeing, but was not fully challenged by Nursery1 or Nursery2 when they were told about Mother’s decision to move him. It was incorporated into the Initial Assessment 33 completed at this time without comment from either Social Worker2 or the manager who authorised the assessment. 4.4.5 The FSW agreed with Mother’s request before the Child in Need meeting not to share the police investigation of potential criminal activity from the home. This was inappropriate and meant that the opportunity to discuss the potential risks that this might bring to young children was not discussed or addressed. Recommendation: The Gloucestershire Safeguarding Children Board should seek assurance from partner agencies about: • The criteria they use to determine how reflection and critical thinking is embedded within their organisation in order to enable practitioners to consider the information they hold, what additional information they need, who would hold this information and how this process addresses the potential impact of parental self-report. • Why they are content that this is working well • Any steps that need to be taken to improve this aspect of safeguarding practice. 4.5 Finding 5: A lack of recognition of the role of fathers/father figures can leave children unprotected and at risk of harm 4.5.1 Fathers and father figures can play a very important role in family life and research suggests that they can have a great influence on the children’s lives both positively and negativelyxix. Despite this there is considerable evidence that they can be marginalised by professionals who sometimes focus almost exclusively on the quality of care children receive from their mothers and female carers. The implications of this are that the benefits for children are often overlooked, and the risks posed by fathers and men more broadly are not well understood leaving children at riskxx. 4.5.2 Father of the three children in this review was said to have significant mental health difficulties, he misused substances such as heroin, had a significant criminal history and was domestically abusive to Mother. The first Initial Assessment was completed as a result of concerns that he had threatened Mother with a knife and taken Philip, aged nearly 3 and John, aged 5 away in a car. The Social Worker completing the assessment recognised the need to make contact with him but had no address or contact details for him. The assessment described his difficulties, but there was no analysis of the significant risk he posed, and responsibility was placed solely on Mother to be a protective factor for the children. 4.5.3 The assessment should have made clear Father’s responsibility for placing the children at risk, and of potentially causing them harm. Father went to prison and on release there is some evidence that he was in contact with the children, and continued to be abusive to Mother. This was reported by Philip and John to Nursery1 and although Mother was spoken to regarding this, she was dismissive of the concerns, and no further action was taken. No further contact was had by any professional with Father and he was unaware of the growing concerns regarding 34 Philip or the subsequent assessments. There is no evidence that attempts were made to contact him when two assessments were carried out: information was migrated from the previous assessment about his circumstances, despite this being historic information. 4.5.4 Mother told all the professionals she had contact with, about her new relationship with her partner Ian, which appears to have started around March 2014. There is no evidence that more information was sought about him, and Mother’s assertion that he “got on well with the children” and “did not smoke or take drugs” was accepted at face value. He was mentioned briefly in the two assessments but no information was sought from him or Mother about his circumstances/background or family. The assessments were about physical abuse, and yet there were no questions asked about how much care he had of the children. 4.5.5 He was centrally involved in the concerns raised by the police about criminal activity and neglect, but the part he played was not analysed in the context of any further risks he might pose, and he was not interviewed alongside Mother about the incident. There was evidence that Philip was sleeping in the same room as Ian and Mother: indeed this is what the FSW found when she visited once the police had raised concerns. This should have been discussed further and its appropriateness and safety explored. 4.5.6 Professionals did not know that Mother’s partner Ian posed a significant risk to Philip and they had no evidence that this was so. However, there is clear evidence from research and national/local serious case reviews there should have been more exploration of who this new man was and what part he played in the children’s lives. 4.5.7 It is not clear exactly why professionals were not more curious or concerned. Research suggests that professionals are often reluctant to ask about new partners for fear of being considered intrusive, and a focus on Mother’s is culturally embedded into some safeguarding practice. These are likely to have been influences on practice in this case. Recommendation: Review practice in relation to the role of fathers, building on actions identified through Finding 2 of the Ben SCR (June 2016) and widening to include children of all ages. 4.6 Finding 6: The important role of the early years sector in safeguarding children 4.6.1 Working Together 2015xxi and the EYFS (2014)xxii make clear the central role that early year’s setting/professionals play in promoting the welfare of, and safeguarding young children. They are in a position to identify abuse and neglect, as well as recognising when children’s needs are not being met and parents/carers are struggling. It is important that these settings/professionals are aware of their dual responsibilities of sharing information with others and collecting information emerging from their contact with the child and family. Research and SCR’sxxiii xxivhighlight that early years setting often lack training and confidence in safeguarding practice and 35 are at times not incorporated into the safeguarding network. This latter point was central in this case. 4.6.2 The early years professionals in this case were critically important. They were the agency that knew the two younger children best; they saw Philip and John on a regular basis and recognised early on that Mother needed support to meet the children’s needs. Nursery1 appropriately suggested that Mother attend parenting classes to address her difficulties, but she declined. They liaised with the Health Visiting service and sought their involvement, and made a referral to speech and language. They did not, however, formalise these offers of help and support into a plan which would have enabled them to set goals, and monitor progress or the lack of it. This would have been useful information for the first and subsequent Initial Assessments. 4.6.3 Nursery1 were contacted by CSC during the Initial Assessment and the information sought was focussed on attendance and potential concerns, not what support had been provided. The nursery were not told why the assessment was being undertaken, and they did not ask; the telephone conversation was not recorded or shared with the Designated Safeguarding Lead (DSL), and therefore this information was not available on either Philip or John’s records – making it impossible to build up a picture of the children’s circumstances. Nursery1 did receive a copy of the first completed Initial Assessment, and this was filed in the records, but does not seem to have been read or used in anyway. It was also not shared with Nursery2 who were not aware that an assessment had been completed or that there were any concerns regarding Philip. 4.6.4 When Nursery1 noticed bruising to Philip they recognised that these were of concern. They delayed making a decision about what action to take in order to ask Mother for an explanation. This delay meant that the referral was not addressed until the next day, and given the extent of the bruising it would have been good practice to have asked Mother to come in earlier or tried to get an explanation by telephone. The referral was followed up with a written referral the next day, which arrived after the Social Worker had gone out to see Mother and the children. 4.6.5 This was a comprehensive referral, giving a clear outline of the injuries and the concerns regarding Mother’s explanation. They did not include the information provided by both children about their Father visiting, throwing things at Mother and being arrested by the police. It is not clear why, but this was important information. The nursery were not informed about the outcome of their referral, in line with expectations, but they did appropriately follow it up. They were told by Social Worker2 that the assessment was underway, that the issue was supervision of the boys, and that the explanation was consistent with the injury (they were not informed that Philip had not been seen by a Paediatrician). They did not challenge the outcome. This was because of issues of confidence and a belief that CSC are the safeguarding experts. 4.6.6 Nursery2 were not consulted in either the second or the third assessment. This meant that when they noticed bruising to Philip sometime later they were not able to consider the significance and when the third assessment was being undertaken the 36 only agency that was seeing Philip was not included. They were also not invited to the CIN meeting, and only got to attend by chance. 4.6.7 In both nursery settings there was an inconsistency in the provision of safeguarding supervision, variable recording practices and an overall lack of confidence in fulfilling their safeguarding roles and responsibilities. These are all essential ingredients of effective safeguarding practice. 4.6.8 The single agency report produced by the Early Years’ service highlighted staffing pressures and lack of clarity on roles and responsibilities as influencing factors, alongside a lack of management oversight and supervision in place. An extensive action plan has been developed by the Early Years’ service and the GSCB will need to be made aware of progress regarding this. Recommendation: The GSCB should reinforce the need for all professionals to recognise the important role played by Early Year’s settings in the support and safeguarding of vulnerable children and promote a multi-agency approach to all aspects of assessment and planning for vulnerable children. 4.7 Finding 7: Practice didn’t demonstrate the role of Strategy Meetings to ensure multi-agency information is shared. 4.7.1 When concerns are identified that suggests that a child/young person has suffered or is likely to suffer significant harm19 it is required that a strategy discussion/meeting is convened20. The purpose is to share information about the child and family and to form a view about whether there is a need for further enquiries under the auspices of child protection enquiries or in the form of further support. Strategy discussions/meetings are an important opportunity for key agencies to step back to consider a child and families circumstances and consider what “strategy” or approach to adopt. The absence of strategy discussions/processes has been linked with fixed thinking and silo practicexxv; the process whereby one agency follows its own agenda without collaboration with the professional network. 19 The Children Act 1989 introduced the phrase "significant harm" to describe the amount of harm that a child must be suffering before Children’s Services become involved in family life against the family's wishes. For example, Children’s Services must: carry out child protection enquiries if they suspect a child is suffering or is likely to suffer significant harm, and take steps to protect a child whom they have reasonable cause to believe is suffering, likely to suffer, or has suffered significant harm - either in agreement with the family or through the court. There is no definition of "significant" but the law requires local authorities and the courts to compare your child's health and development with a similar child to establish whether the harm is significant. 20 Children’s Services must hold a strategy discussion whenever there is reasonable cause to suspect that a child has suffered or is likely to suffer significant harm. The purpose of the strategy discussion is to enable the Children’s Services’ department and other relevant agencies (e.g. education department, health services) to share information, make decisions about initiating or continuing enquiries under Section 47 of the Children Act 1989, what inquiries will be made and by whom, whether there is a need for action to immediately safeguard the child. http://www.proceduresonline.com/swcpp/gloucestershire/p_ch_protection_enq.html?zoom_highlight=strategey+meeting#strategy_discuss 37 4.7.2 There were three significant referrals regarding Philip over a six month period, two of which related to extensive bruising, which at the point of referral were unexplained. Both these incidents clearly met the criteria of likely/actual significant harm, and should have led to a strategy discussion/meeting. This would have been an opportunity to think about and plan enquiries. Instead, on both occasions a Social Worker was asked to carry out an Initial Assessment to determine whether a strategy meeting was needed. In effect this meant a home visit to ask Mother her views about what had happened. Mother’s view on the first occasion was that the injuries were caused by the boy’s boisterous behaviour and fighting. This explanation was accepted without any further enquires being undertaken. This was not an appropriate response. 4.7.3 The second referral was made by the GP and a medical organised. This medical did not form part of any safeguarding enquiries, and despite the conclusion being that some of the injuries were unexplained no strategy meeting was held, and again a home visit was undertaken, with some considerable delay. Once again Mother was the key source of information about what had happened to Philip. The absence of any multi-agency discussion meant that her view that this was a medical issue dominated, despite evidence to the contrary. The strategy meeting/discussion would have been an opportunity to step back and consider the evidence. 4.7.4 The third referral was from the police and related to concerns about possible child cruelty (high locks on the outside of the doors of the children’s bedroom) and neglect. This incident was also not subject to a strategy meeting, and there were no formal planned enquiries, just another home another visit to talk to Mother and a discussion with John. Recommendation: The GSCB seeks assurance from Social Care that actions in the single agency response plan are being addressed. This finding also links with Finding 5 (Ben, 2016) and Finding 4 (Lucy, 2016) and also in the establishment of a culture of high challenge and high support and restorative ways of working together. 4.8 Finding 8: The importance of effective decision making, assessment and management of physical abuse 4.8.1 At the heart of this review are significant concerns about unexplained physical injuries to a young child of 3 years old. There is evidence across the whole review that some professionals did not feel skilled at working effectively with physical abuse, and found it difficult to distinguish between whether injuries were accidental, caused by deliberate child abuse, indications of an underlying medical condition or are indicative of broader concerns of neglect or violence. This was manifest in this case in a number of ways: 4.8.2 The lack of any strategy discussion/multi-agency meetings meant that very narrow assessment processes were undertaken. These assessments were flawed in a number of ways. They lacked focus on physical abuse; information was migrated from the previous assessment and there was a lack of multi-agency involvement. 4.8.3 Lack of focus on physical abuse: The NICE Guidelinesxxvi make it clear that in order to establish whether a child has been physically abused there are a number of issues 38 to be considered alongside the usual domains of the assessment frameworkxxvii. These are: the nature of the injury; the explanations provided for it by the child; the explanations provided by the parent and any other person involved; any contradictions or discrepancies in the story; Family history and known risk factors. 4.8.4 This information then forms the basis of an analysis and a clear conclusion drawn from the available evidence. This did not happen for Philip, despite much of this information being available. 4.8.5 The nature of the injury: An evaluation of the injuries to a child is a crucial part of decision making and planning. This requires good quality medical assessment that comes to a conclusion about whether the injuries are indicative of child abuse. The injuries in one of the referrals was extensive. The NICE Guidelines make it clear that professionals should be concerned where there are multiple bruises or bruises in clusters, bruises of a similar shape and size, bruises on any non-bony part of the body or face including the ears and buttocks and bite marks that are likely to have been caused by an adultxxviii. These were all present. There was no medical examination of Philip after the first referral regarding extensive bruising. The exact reasons for this remain in dispute, but whatever the cause, it was a completely inappropriate response to the potential physical abuse of a young child. 4.8.6 There was a medical examination conducted as a result of the referral from the GP. Very little background was provided to the Paediatrician, beyond a brief and subjective summary of Social Worker2’s conclusion of the previous assessment. A clearer outline of the history of concerns should have been provided, ideally in written form. 4.8.7 This paediatric assessment provided a full description of the injuries and an opinion regarding how consistent they were or were not with the explanation given. Some injuries were described as clearly unexplained. However, no clear view was given regarding whether overall this indicated that there should be concerns about child abuse or not. The Initial Assessment cut and pasted this report and made no comment on it. This assessment was sent to the paediatric department a month later. It was not reviewed, largely because it was not sent for action by Social Worker2 and it was not possible to hold it electronically. It was filed in the child’s paper file. 4.8.8 Discrepancies in explanations: It remains hard to evaluate the extent of the discrepancies in the explanations provided by Mother regarding the bruising to Philip because these were always recorded in quite general ways, with two or three explanations. For example in the second referral the injuries were caused by “Philip falling down the stairs, boisterousness and a family history of easy bruising” There is no sense that Mother was asked by each professional that she had contact with to provide a clear explanation for all the bruising seen, and that this was shared across the multi-agency group. This is what is required for an assessment of physical abuse. 39 4.8.9 Philip was not always asked what had caused his bruising making it difficult to evaluate whether his explanations were consistent with his Mother’s. When he was asked there were some discrepancies; for example when seen by the Paediatrician he said that the bruises were caused “by outside” and his Mother talked about falling down the stairs. This required further questioning and analysis. 4.8.10 Overall the response to unexplained injuries to a young child was inadequate. Recommendation: Paediatricians should receive a full history when a CP medical is requested, which is backed up in writing. Recommendation: The GSCB should review the guidance for all professionals regarding the assessment of potential non accidental injury and ensure it is compliant with the existing NICE Guidelines regarding child maltreatment, including information provided to paediatricians prior to CP medical. 4.9 Finding 9: Poor assessment practice leaves children’s needs unknown and unaddressed 4.9.1 Good assessment mattersxxix xxx; they are key to effective intervention and to improving outcomes for children. Conversely, research has shown that poor or inadequate assessments are associated with unclear plans to meet children’s needs, poor outcomes and drift. 4.9.2 The Assessment Framework (2000)xxxi was developed to provide a conceptual framework for the systematic and purposeful gathering of information. It was intended that this information would be analysed in a child focussed way using knowledge of child development, attachment relationship, alongside recognising parenting issues which impact on parents capacity to meet their children’s needs and with an acknowledgement of family history and the social context in which a family lives. Each child should be considered separately, and where appropriate given the opportunity to express their views about their circumstances and the end point should be a clear plan to address any identified needs. 4.9.3 During the time under review there were three Initial Assessments, but no early help assessment processes (this is addressed in Finding 1). 4.9.4 The first Initial Assessment was of a reasonable quality. The children were engaged with as part of the process, with the exception of Darren. Historic factors were considered, including the role of Father. Written consent was sought from Mother to seek information from other agencies. 4.9.5 Information was sought from other agencies, but it remains unclear whether the right questions were asked of them. For example the drug agency was asked to comment on Mother’s parenting capacity, about which they had little knowledge, and no concerns. It is not clear whether they were explicitly asked about Mother’s current prescribed or illegal drug use, and information about this was not shared. This was an important issue. 40 4.9.6 The assessment relied on Mother’s self-reporting of her circumstances. She told the Social Worker that Father had mental health problems, having been diagnosed with schizophrenia, but there is no evidence that this was so. Mother also told the Social Worker that she would be pursuing charges against Father, something that was seen as an important protective factor. This was not true. The Initial Assessment is brief, and where it has not been possible to establish whether information provided by adults is verified this should be made clear. 4.9.7 The subsequent two Initial Assessments were extremely poor. Home visits were undertaken as part of the process and children were seen, but as both assessments left information directly migrated from the first assessment it is not clear exactly what was discussed, what engagement there actually was with any of the children or which agencies were contacted. The needs of Darren were marginalised and the very real concerns regarding both Philip and John not addressed. The assessment did not make use of the available information. 4.9.8 In the second assessment Mother had refused consent for a referral to be made by Nursery1in the context of significant bruising to Philip, who was just three years old. This was not putting his interests first and she should have been asked about this and this information analysed more clearly. The same is true of Mother’s assertion that she was not happy that the nursery made the referral. This should have been challenged and analysed. Both assessments were not clear that their primary focus was unexplained injuries to a young child, and this is addressed in Finding 8. 4.9.9 Gloucestershire has now introduced the Single Assessment process, in line with the Munro recommendations. This means that the impact of the timescale pressures evident here are lessened. What remains are concerns about parental self-report, child centred practice and assessment of physical abuse – all of these are addressed in the other Findings in this report. Recommendation: GSCB to seek assurance from Social Care that this finding has been addressed through their Single Agency response. 4.10 Finding 10: The importance of clear and effective child in need processes 4.10.1 The Children Act 1989xxxii defines Children in Need (CIN) as those children whose vulnerability is such that they are unlikely to reach or maintain their health and development milestones without the provision of services to them and their families. This is a serious issue for all children, and particularly for those under 5 for whom development is rapid and critical for their future. The emphasis placed on good quality assessment to determine the level of need is reflective of the potential risks for a child’s future. Once an assessment is undertaken and needs identified it is expected that a child focused plan is formulated which addresses those needs, there is a clear outline of the outcomes expected, services to be provided and the reviewing mechanisms identified. This did not happen for Philip, John or Darren. 4.10.2 Philip and John were identified as Children in Need after the third Initial Assessment. The quality of the assessment was poor (addressed in Finding 9) and the resulting conclusion was muddled. There was no outline of the needs of Darren, and the goals in the assessment were focussed on the possible medical needs of Philip, the requirement for him to keep himself safe, aged 3 and that John needed to be aware 41 of the impact of his boisterousness; this was not child centred and bordered on holding the child responsible for the events that led to them being harmed. This is inappropriate. 4.10.3 No clear plan was put in place, and there was no management oversight of the lack of one. The brief CIN process in this case was not as effective as it could have been at beginning to make sense of and address these children’s needs. This is despite good multi-agency inclusion and engagement. The issue appears to be that because there was a poor assessment, there was a poor foundation on which to build a plan. Despite this, a plan should have been developed through the expertise held in the meetings; Mother distracted the meeting by focussing on “here and now” problems and no professional noticed this was happening. The meeting was also hampered by Mother’s request that some information was not shared – something that needed much greater analysis and reflection. Recommendation: GSCB to produce a multi-agency Child in Need Strategy Finding 11: Poor recognition of the early signs of neglect 4.11.1 Chronic long term child neglect has a profoundly negative impact on children’s lives, developmental outcomes and has far reaching effectsxxxiii. This is particularly true if neglect occurs in the first five years of life and is not addressed quicklyxxxiv xxxv. Researchxxxvi suggests that good quality assessment, which is clear about the particular parenting concerns, causal factors and precise impact on the children is critical, alongside a clear plan of action, with agreed goals, timeframes and a process for recognising where there is a lack of change, or parental false compliance is essentialxxxvii. 4.11.2 There were many concerns regarding the quality of care received by Philip. John and Darren, but no agency considered these as the early signs of neglect that needed to be proactively addressed. Concerns regarding bruising to Philip were attributed to a number of accidents or fighting amongst the boys which indicated at the very least an acute lack of supervision. Mother was never held responsible for this, and the third assessment suggested that it was the fault of Philip for not keeping himself safe, and John for fighting with him. Mother never took responsibility for these issues, and declined parenting classes which might have helped. Neglect of children is underpinned by the lack of recognition by their parents/carers of their responsibilities to them, particularly keeping them safe. Mother’s attitude should have been challenged, and seen as neglectful care which needed addressing. 4.11.3 Significant concerns about the physical care/physical environment for Philip and John were raised by the police when they visited the family home. Photographs were taken, but not shared with CSC and Mother was able to dismiss the concerns without challenge. These issues should have been explored, and the issue of allowing criminal activity to take place in the family home addressed as significant indicators 42 of neglect. In fact, Mother was able to persuade the family support worker not to share this last piece of information with the rest of the involved professionals. 4.11.4 It is not clear why professionals were reluctant to name concerns as the neglect of these children. In part this appears to have been influenced by the poor assessments that took place, the lack of a clear early help plan which named concerns and attempted to address them, which would have revealed some lack of compliance on Mother’s part. More latterly professionals sought to engage Mother in the CIN process; there was continuing evidence that Mother was unable to respond to professional concerns, but the need to keep her engaged appears to have had an influence on naming neglect at this early stage. No recommendation is made here as Gloucestershire Local Safeguarding Board are currently in the process of ratifying a neglect strategy which will aim to equip professionals with the skills and knowledge to address the early signs of neglect effectively. The GSCB will need to be reassured that this planned work addresses the issues raised in this SCR. 43 Appendix 1 Review Methodology - Gloucestershire’s Multi Agency Appraisal of Practice (MAAP©) Model 1. 1. PLANNING PHASE Terms of Reference / Scope of review / IMR authors identified in relevant agencies and training in systems thinking undertaken. Multi agency chronology commissioned 2. GATHERING INFORMATION AND FIRST ANALYSIS PHASE (Single Agency) Interviews with case holders and first line managers / Agency context / Multi agency context from single agency perspective / peer reviewer from separate agency Peer Review / challenge Individual Management Reports Individual Management Reports Individual Management Reports Family member’s interviews 4. LEARNING EVENT (Discussion, debate and reflection – independent facilitation) The findings from the IMR’s are presented and key practice points identified. The learning event will include; SCR sub group members, senior managers, first line managers and practitioners across agencies to establish learning from the particular case PEER CHALLENGE SYSTEMS PERSPECTIVE MULTI AGENCY MESSAGES AND FINDINGS SENIOR MANAGER CHECK AND CHALLENGE 5. REPORT PHASE (INDEPENDENT AUTHOR) Overview report, findings, recommendations INDEPENDENT PERSPECTIVE AND CHALLENGE 3. QUALITY ASSURANCE / INITIAL SCRUTINY PHASE Surgery Sessions for IMR authors with independent Author IMR Authors meet with SCR sub group Week 1-8 Week 9-17 Week 18-21 Week 17-20 Week 20-24 Completion of IMR and Sign-Off Surgery Sessions for IMR authors with independent Author Week 22-24 44 1. Planning Phase Terms of reference will be established and for a SCR will be agreed by the GSCB Independent Chair and the SCR sub group. Relevant agencies and practitioners will need to be identified and IMR authors agreed. Chronologies completed by single agencies (time period and depth to be stipulated). IMR authors will receive a training session looking at systems methodology, report standards and this should ensure a shared understanding of the agreed approach. Timescales will be agreed and dates set for completed reports and learning event established. If SCR, dates set with GSCB SCR sub group and GSCB Exec. An Independent reviewer with relevant experience will be identified. Their oversight and approval of the Terms of Reference is required. Parent(s) need to be notified of the review by the GSCB and invited to speak with the independent reviewer. Key family members (including children and young people) where considered appropriate need to be invited to share their experiences. 2. Gathering information and first analysis phase A multi-agency chronology is developed and shared with IMR authors. Each IMR author is required to review the case records of the subject child and the family members and provide an appraisal of practice against current agreed standards. Key practitioners need to be identified and an (sensitive/facilitative/collaborative) agreed interview approach taken. For example individual conversations followed by a group discussion. Peer reviewers will be identified from another agency to provide challenge and opportunity for reflection. Individual management reports An Individual management report will need to be produced. The practitioners need to have the opportunity to comment on the final IMR which will provide a check in the system to ensure the IMR author has understood the context of the work as well as the practitioner’s experience and barriers faced. There is a standard format for the report which focuses on the narrative behind the chronology, analysis and appraisal of events and practice, good practice highlighted and single agency learning and systemic findings to be discussed at the learning event. Once signed off, IMR’s to be shared with agency staff involved. 3. Quality Assurance and initial scrutiny phase Surgery sessions for the IMR authors will be provided and the independent author will offer advice and guidance to IMR authors to ensure quality and depth of report including analysis and appraisal of the issues. IMR’s will be reviewed based on the feedback received. Once completed the IMR’s will be shared with IMR authors and the SCR sub group and a meeting will be held to begin the cross referencing of conclusions and findings. 4. Learning event Findings from IMR’s are shared with all those attending the learning event. The purpose of which is to create ownership within single agencies in the learning process and receive peer challenge and feedback. A multi agency systems approach is required. This discussion and learning event will be facilitated by the independent reviewer. The specific methodology will be planned depending on the needs of the review. Multi agency perspective on the wider findings will be agreed and learning across agencies will be identified. 5. Report phase The final report will pull together the key issues from the reports and learning event across the agencies. The report will highlight findings and challenges in the system and make recommendations to the GSCB via the SCR sub group. 45 Appendix 2 Terms of reference General To establish whether there are lessons to be learnt from the circumstances of the case about the way in which local professionals and agencies work together to safeguard children and young people and promote their welfare To review the effectiveness of procedures (both multi-agency and those of individual organisations) and understand what is present in our safeguarding system to enhance or hinder good practice. To inform and improve local inter-agency practice To improve practice by acting on learning (developing best practice) To prepare or commission a summary report which brings together and analyses the findings of the various reports from agencies in order to make recommendations for future action Specific: To examine the quality of risk assessment and understanding of the Levels of Intervention guidance To consider how and when the child’s views and experiences were considered and taken into account in the decision making process To examine the level and quality of partnership working To consider whether professional differences occurred, and if so, how they were responded to To consider all agencies understanding of when information can and should be shared To consider all forms of abuse, not just physical abuse 46 Appendix 3 - Single Agency Recommendations Gloucestershire Hospitals NHS Foundation Trust Child Protection (GHNHSFT) Medical Reports, to include a section on information shared from primary health care professionals involved with the child GHNHSFT Child Protection Clinical Paperwork to be revised and updated to:- Separate information to be taken in the acute situation from information to be taken in next 24 hours Separate body map diagrams GHNHSFT Clinical (Interhospital) Transfer Paperwork to be revised and updated to ensure information related to safeguarding the child, travels with the child Hospital staff to actively engage in Supervision for Child Protection Work Early Years Both Early Years settings and providers concerned in the case should improve record keeping providing greater clarity and clearer detailed information on their record forms in relation to all types of possible signs and symptoms of abuse. This recommendation could have wider implications for the Early Years Sector to generally improve practice. Both Early Years settings/providers concerned should log all concerns both verbal and written in a chronology Both Early Years settings must ensure chronologies are completed at the time of each event occurring, and review these records to identify any patterns/concerns Children’s Centre family support provision should have clearer planning of expected and measureable outcomes from Early Help offers The Children Centre needs to have a clear action plan that provides details of support to be offered to children and families and clear information on what further action will be taken if support is not accessed and or outcomes are not successful. At Nursery2, training on recognising possible signs and symptoms of abuse and neglect should be attended and disseminated to all staff, and be on-going and regular At Nursery2 staff should receive regular supervision by the school Head Teacher who is the DSL which will give opportunities to share safeguarding concerns and this should be documented. This recommendation could have wider implications for the Early Years Sector to generally improve practice. Both Early Years settings should establish and maintain an environment where children feel 47 secure, are encouraged to talk, and are listened to and their non verbal communication is carefully considered and recorded. This must be documented and recorded, particularly when injuries or changes in behaviour are noted. Both settings must have clear guidance available on information sharing. Both setting should be clear on when and with whom to share child protections concerns in a timely manner and how to follow those up with other professionals. Clearer guidance on sharing child protection concerns where settings are providing dual care must be in place. This recommendation could have wider implications for the Early Years Sector to generally improve practice Both settings should develop systems/processes for checking when children are absent from provision to ascertain the reason for this. This recommendation could have wider implications for the Early Years Sector to generally improve practice. Both settings should be familiar with and confident to use the Escalation Procedures should they disagree with a decision made by another agency. This recommendation could have wider implications for the Early Years Sector to generally improve practice. Both setting and Early Years Practitioners need to develop awareness and confidence in the need to involve parents and carers when concerns arise but be mindful to question and challenge information given by parents and carers with appropriate line managers, particularly where inconsistencies’ occur. This recommendation could have wider implications for the Early Years Sector to generally improve practice. At Nursery 2 family support should be deployed to work across the whole provision on site to support vulnerable families. Gloucestershire Care Services Although the situation may not have met the threshold that would result in services being offered from Children’s Social Care it does not necessarily follow that support or work could not be carried out by other services as part of an early help intervention Primary Health Care Team meetings are set up in a way to better improve communications between GP’s, Health Visitors and Midwives with consideration to this being expanded to inviting children’s social care to Primary Health Care team meetings Preceptorship programme can be extended dependent on circumstances, particularly for staff returning to work following extended periods of leave. 48 GP The practice should produce a protocol defining a specific process for managing the recording of all social service assessment reports. As well as being scanned onto the medical record in full a clinical entry should be made, highlighting the salient features and conclusions for all reports. The practice should use a protected learning session to remind clinical staff of best practice in Child safeguarding. In particular this should remind professionals that they should always ask a child directly about what has happened to them, even if the child is very young. Also when social workers request information about concerns prior to undertaking an assessment doctors should always ask for, and document, the reason for the assessment, and what information is shared. The PLT session should also include informing staff of amendments to the practice safeguarding protocol (as mentioned above). The practice should undertake a search of all medical records to identify patients with a documented history of substance misuse. The notes of all children living with the index patient should be flagged to indicate this risk. Medical professionals need to understand the meaning behind a conclusion of “no further action necessary” following a social service assessment. I think this is generally misunderstood to mean that there are no grounds for concern, rather than that the concerns have failed to reach a predefined threshold. I would suggest that this is discussed at a Countywide GP Liaison Child Safeguarding meeting to ensure this misunderstanding is corrected and explained. Police Deliver a new IT system which is fit for purpose to enable photographs to be stored as well as viewing all relevant information through one IT system. Increase the staffing levels within the CRU and encourage greater levels of consultation with the CRU DS. Ensure Public Protection maintains a level of detective capacity at both DC and DS rank to meet demand and deliver thorough investigations within the Criminal Justice timescales. Children’s Social Care Pupil Referral Records should be scrutinized by all staff receiving child welfare concerns to ensure that all education/nursery providers are identified, and that in cases of unexplained/suspected non accidental injuries all relevant professionals are contacted. The outcomes of each of these discussions should be clearly recorded as individual case notes. Decisions in relation to investigation of unexplained injuries should where possible be taken following receipt of the written MASRF. If this is not possible, the MASRF information should be used to re-evaluate any conclusions already reached, once received. The local authority should agree further arrangements and key standards for the holding of strategy discussions in partnership with the police. 49 Undertake further workforce development activity to address the key areas of concern: Response to unexplained injuries and physical abuse Critical thinking and analysis including use of supervision to facilitate this approach Ensuring that front line workers are equipped with the right skills to ask the right questions when investigating suspicious or unexplained injuries Managers challenge about the inclusion (or lack of) male partners in assessments A mechanism to ensure challenge of an initial perspective in light of new information is embedded in practice Establish clarity regarding the expectations and managerial / social work oversight of cases held by family support workers whilst the work to cease this practice continues. The decision that this is not good practice has been made. Ensure that arrangements are in place to provide robust management oversight of work being undertaken by FSW’s Continue the current work aimed at reducing social work case loads across all teams Review guidance and policy in relation to Children in Need cases so that there are robust arrangements in place to: Ensure a full assessment is undertaken in all cases where there are unexplained injuries Ensure that assessments fully take into account all household members and evaluate the impact of any new household members Ensure that CiN plans are reviewed and developed following the first CiN meeting, and in light of any new events or information Ensure the practice of developing chronologies and utilising them in practice is embedded in the workforce. Turning Point We will ensure that our staff teams continue to access the GSCB Parental Substance Misuse training in order to support them in building their understanding of and skills in identifying hidden harm We will consider our approach to lines of enquiry when service users report new partners We will continue to emphasise the importance of accuracy and quality in record keeping We receive ongoing support from the specialist substance misuse health visitor and midwife. A workshop to staff is due to be delivered at the end of June 2015. 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(2010) Safeguarding in the 21st Century -Where to Now. Dartington: Research in Practice. xxx Turney, D et al (2011) Social work assessment of children in need: what do we know? Messages from research; DfE https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/182302/DFE-RBX-10-08.pdf xxxi DoH (2000) Framework for the Assessment of Children in Need and their Families: TSO http://webarchive.nationalarchives.gov.uk/20130401151715/https:/www.education.gov.uk/publications/eOrderingDownload/Framework%20for%20the%20assessment%20of%20children%20in%20need%20and%20their%20families.pdfDoH (2000) Framework for the Assessment of Children in Need and their Families: http://webarchive.nationalarchives.gov.uk/20130401151715/https:/www.education.gov.uk/publications/eOrderingDownload/Framework%20for%20the%20assessment%20of%20children%20in%20need%20and%20their%20families.pdf xxxii http://www.legislation.gov.uk/ukpga/1989/41/contents xxxiii Horwath, J. (2013) ‘Child neglect: Planning and intervention’, Basingstoke: Palgrave Macmillan xxxiv Cuthbert, C., Rayns, G. and Stanley, K. (2011) ‘All babies count: prevention and protection for vulnerable babies’, London: NSPCC 53 xxxv Ward, H., Brown, R. and Westlake, D. (2012) ‘Safeguarding babies and very young children from abuse and neglect’, London: Jessica Kingsley Publishers xxxvi Gardner, R. (2008) Developing an effective response to neglect and emotional harm to children, Norwich: University of East Anglia/NSPCC. xxxvii Daniel, B., Taylor, J. and Scott, J. (2011) ‘Recognising and Helping the Neglected Child’, London: Jessica Kingsley Publishers v Daniel, B., Taylor, J. and Scott, J. (2011) ‘Recognising and Helping the Neglected Child’, London: Jessica Kingsley Publishers |
NC52199 | Death of a 15-year-old boy in the summer of 2018. Frankie was fatally stabbed when attacked by a group of adolescent males in London. One young person was convicted of murder and four were convicted of conspiracy to cause grievous bodily harm. Frankie lived with his mother and two siblings; his father was in prison from 2016. Family was supported by a Child in Need Plan, following a social work assessment that identified concerns around involvement in crime. Frankie had a Referral Order for theft and knife possession and was permanently excluded from school in 2018. Frankie's social worker had concerns about his associations with gang culture. No evidence to indicate that Frankie's murder was gang related. Ethnicity or nationality are not stated. Learning and recommendations are integrated and include: ensure timely notifications to relevant persons when a child dies outside of the area in which they reside; improve notification processes for agencies when a child becomes the subject of a Child in Need Plan; review permanent exclusion processes within schools to reduce the potential for safeguarding risks to children at risk of exclusion; understand how to incorporate the concept of contextual safeguarding in the assessment of risk to children in the future; evaluate how partner agencies support families affected by gang association; assess how partner agencies share intelligence related to gang affiliations. Recommendation made to the National Child Safeguarding Practice Review Panel to consider a national thematic review because of the prevalence of similar incidents across the country.
| Title: Frankie: serious case review: overview report. LSCB: Thurrock Local Safeguarding Children Board and Thurrock Local Safeguarding Children Partnership Author: Tom Savory Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 FRANKIE SERIOUS CASE REVIEW Overview Report Independent Author – Tom Savory THURROCK LOCAL SAFEGUARDING CHILDREN BOARD COMMISSION 2 Contents Chapter 1 ............................................................................................................................................. 3 Introduction ..................................................................................................................................... 3 Chapter 2 ............................................................................................................................................. 4 Initiation of the Serious Case Review ...................................................................................... 4 Terms of Reference ...................................................................................................................... 5 Scoping............................................................................................................................................. 6 Key Issues to Consider ................................................................................................................ 6 Agencies Participation ................................................................................................................ 7 SCR Frankie Panel and Meetings .............................................................................................. 7 Frankie’s Murder ............................................................................................................................... 7 A brief overview of relevant background in relation to Frankie’s contact with Thurrock agencies ............................................................................................................................ 9 2016 ................................................................................................................................................... 9 2017 ................................................................................................................................................. 10 Period of Serious Case Review: October 2017 – August 2018 .......................................... 11 From October 2017 ..................................................................................................................... 11 2018 ................................................................................................................................................. 12 Thurrock response to gangs and violence .............................................................................. 14 What needs to happen to ensure that agencies learn from this case .............................. 15 Local Learning Points – Areas for consideration by the Thurrock LSCP ....................... 15 Learning Point One ..................................................................................................................... 15 Learning Point Two ..................................................................................................................... 15 Learning Point Three .................................................................................................................. 15 Learning Point Four .................................................................................................................... 15 Learning Point Five ..................................................................................................................... 16 Learning Point Six ....................................................................................................................... 16 Learning Point Seven ................................................................................................................. 16 Learning Point Eight ................................................................................................................... 16 Learning Point Nine .................................................................................................................... 16 Learning Point Ten ...................................................................................................................... 16 Summary ............................................................................................................................................ 17 Glossary ............................................................................................................................................. 18 3 Chapter 1 Introduction Having celebrated his birthday just weeks before, Frankie was only 15 years old when he became a victim of murder in 2018. At the time of his death he was the youngest victim of a fatal stabbing in London. Following his murder, a Facebook page included the following tribute, “He was very talented and loved rapping, everyone that loved him knew this. He only brought joy into people’s lives, he was always laughing and joking”. Frankie was known to various agencies at the time of his death, and he is described by the professionals who worked closely with him as being charismatic, polite, popular, very likeable, always laughing and joking. Thurrock Local Safeguarding Children Board (LSCB) initiated a Serious Case Review (SCR) following the murder of Frankie. The review covered the period from October 2017 to August 2018. An Independent SCR Panel Chair was appointed, and an Independent Author commissioned to undertake the review and identify any learning in this case. The Police investigation into Frankie’s murder identified that a number of young people had been involved. At the first criminal proceedings one young person was convicted of his murder, two young people were convicted of conspiracy to cause Grievously Bodily Harm (GBH), and one young person was convicted of perverting the course of justice. Subsequently two further young people were convicted of conspiracy to cause GBH. Based on all the evidence and information gathered throughout the Police investigation and criminal proceedings there is no evidence or intelligence to indicate that Frankie’s murder was gang related, or that the males who have subsequently been convicted had any affiliation with relevant gangs. 4 Whilst Frankie was known to have some association with gang culture within Thurrock, his murder was not predictable or gang related, it was a spontaneous act of violence resulting in the tragic loss of life. Frankie at the time of the incident was not found to be carrying a weapon. Frankie was a 15 year old who went out with some friends to a birthday party early on a Summer Sunday evening. Chapter 2 Initiation of the Serious Case Review At the time of this incident Local Safeguarding Children Boards were in a transition period, following changes in Legislation to multi-agency safeguarding arrangements. A Rapid Review Meeting was held in July 2018, to review the information available. The Review Meeting members and Legal Adviser determined that the criteria for a SCR was not met. However, the prevalence of knife crime has become such a national issue, that Thurrock LSCB referred the case to the National Child Safeguarding Practice Review Panel (CSPRP) recommending a national thematic review be considered because of the prevalence of similar incidents across the country. The information from the Rapid Review Meeting was considered by the CSPRP. At the time of this incident, the CSPRP was in the early stages of being established, and there were no plans for a national thematic review at that time. The CSPRP responded with a recommendation to consider a SCR. The case was carefully considered by the Independent Chair of Thurrock LSCB, who determined that although the statutory criteria for a SCR was not met, there was learning to be obtained from conducting a SCR and the decision was made that a SCR should be conducted under the transitional arrangements from Working Together 2015. A Multi-Agency SCR Panel was established to oversee the management of the review. During the course of this review the Independent Chair of the Thurrock LSCB received correspondence from Edward Timpson (Chair of the CSPRP) early February 2019 advising that there was to be a national thematic review of adolescents and criminal 5 exploitation. It stated “We have received notification of a significant number of serious child safeguarding cases which raise issues which are complex and of national importance in relation to adolescents in need of State protection from criminal exploitation”. This also included an invitation for Thurrock LSCB to support this national review with the case of Frankie alongside other cases identified. The arrangements and scope for the national thematic review were confirmed with the Independent Chair of the Thurrock LSCB mid-April 2019 and the decision was taken by the SCR Panel early May 2019 to co-operate with the national thematic. In May 2019 the National Panel Review Team attended Thurrock and met with practitioners involved in the case and updated on the details of SCR Frankie. As a result, the methodology used in undertaking this review did not include submission of Individual Management Reports or convening a Practitioner event and relied on the information included in the Summary Reports and Chronologies submitted by agencies soon after Frankie’s murder (as set out below) and four meetings of the SCR Group (as set out below). The family were invited to meet with the independent author however they did not respond to the offer to take part within this review. Terms of Reference 1. This Serious Case Review will be undertaken by the Thurrock Local Safeguarding Children Board, being the Board area in which this young person/s normally resided (Working Together 2015). 2. An Independent Author has been appointed to undertake the Overview Report and make any necessary enquiries to establish the circumstances and any subsequent learning. 3. An Independent Chair has been appointed to oversee the Serious Case Review Panel and process who has not had direct involvement in the case. 4. The publication date of the final overview report will take into account the statutory responsibilities of any other statutory body or criminal proceedings. 6 Scoping The scoping within this review was:- 1. The time period of the review will cover from October 2017 to August 2018. 2. There is a requirement to provide a detailed chronology and brief summary to show key episodes or events that each organisation was involved in with this family. 3. The scope of the Review, in respect of family information, to be limited to Frankie, any siblings and parents only. 4. The SCR Panel will examine all relevant information provided by individual agencies and professional’s reports. 5. The family to be informed that a Serious Case Review is to be undertaken. 6. As well as receiving reports from the statutory LSCB member agencies, the SCR Panel will request reports or disclosure of information from any bodies believed to have engaged or had involvement with the family as required. 7. Given the press interest of this Review, the Board have agreed a media strategy involving the media lead from the three Strategic LSCB Partner agencies (Police, Local Authority & Clinical Commissioning Group (CCG)). This is being led by the Local Authority Media Team. A proactive press release has been prepared. 8. The Panel will utilise the LSCB Legal Adviser to the Board and call upon any expert witness or adviser as required. Key Issues to Consider The key issues to consider were:- 1. Did all agencies work together effectively to safeguard these children? 2. Was the outcome preventable? 3. Were the safeguarding procedures followed appropriately? 4. Was the young person’s voices heard throughout agencies involvement? 7 Agencies Participation The following Agencies were asked to provide a brief summary and chronology report. Essex Police - Brief Summary and Chronology NELFT - Brief Summary and Chronology CCG – on behalf of NHS England Primary Care – Brief Summary Youth Offending Service - Chronology Metropolitan Police - Brief Summary and Chronology Children Social Care - Brief Summary and Chronology Secondary School - Brief Summary and Chronology SCR Frankie Panel and Meetings The SCR Panel met on four occasions and comprised of the Independent Chair, Independent Author and the following Senior Representatives from agencies: LSCB Business Manager LSCB Learning & Practice Review Co-ordinator LSCB Legal Adviser Children Social Care NELFT Youth Offending Service Metropolitan Police Essex Police Hospital Clinical Commissioning Group – on behalf of NHS England Primary Care Frankie’s Murder On the evening of his murder Frankie was attending a 16th birthday party in London. There had been an open invitation to the birthday party advertised on social media. As a result upwards of 300 young people had turned up at the venue. 8 Frankie was dropped off by car at the party at around 20:30 with a number of friends. When they arrived at the party, they could see that there was a long queue and they walked to a nearby street and then after a short time walked towards the party. They queued for a few minutes. Initially they were told they could not enter but then were allowed access. By the time they entered the venue it was already overcrowded as it could only accommodate a maximum of 150 guests, and the host was asked to remove guests. Following unsuccessful attempts by the host and family to remove guests, the decision was taken to end the party. After leaving the party, Frankie and his friends stayed in the area. As people were leaving the party into the surrounding streets there were reports of fights breaking out. It is reported that numerous calls were made to Police by members of the public, the first call being made at 21:05. At some point around this time, there was an exchange involving Frankie and a small group of adolescent males, the circumstances surrounding this incident are not clear. However the situation was quick moving and the outcome was that upwards of 100, mainly male youths, started running up the road, with Frankie being chased by a group of male youths within the large running group. Eventually the small group caught up with Frankie, surrounded him, and he tumbled onto the pavement, whereupon the small group set upon him. The phone calls to Police stated that there was a large group of youths at the location and that it was ‘kicking off’, ‘youths fighting’ and ‘someone had been attacked’. Frankie’s friends followed on and found him fatally stabbed. In the attack Frankie had received two stab wounds, either of which would have been fatal. Despite the best efforts of paramedics and doctors, Frankie was pronounced dead at 22:21 hours, less than two hours after arriving for the birthday party. 9 The news of Frankie’s murder became widely reported through both social media and on the internet rolling news. However, interagency communication was limited. The Metropolitan Police contacted the Thurrock Emergency Duty Team (EDT) that evening informing them of the death of Frankie. However, it was not until the following morning, when Frankie’s Mother telephoned staff at his school to inform them of his murder and to cancel transport, that they became aware of his death. This was the first notification the school (Pupil Referral Unit (PRU)) received from any party – Please refer to Learning Point One. Frankie’s funeral took place over two days, starting with a celebration of his life which was well attended with many family and friends. The Pastor talked about gangs and knife crime and of working with other families who have lost children through knife crime. He shared photographs of Frankie and led a walk of remembrance. A brief overview of relevant background in relation to Frankie’s contact with Thurrock agencies Frankie was one of three siblings having one older and one younger brother. They all resided in the same family home with their mother and father, and the family had been known to Childrens Services since 2007. 2016 Frankie was involved in a robbery of a bike and received a Community Resolution (CR). According to the relevant charging standards guidance, robbery is too serious an offence for a CR without Youth Offending Service (YOS) intervention. As the CR had been issued by the investigating officer, this offence was not referred to YOS. Had there been a referral to the YOS, there would have been a TRIAGE (now called Community Resolution Plus) process, which would have resulted in a diversion/prevention intervention from YOS with Frankie – please refer to Learning Point Two. 10 During this period Frankie’s father was convicted for offences of fraud and received a custodial sentence of over six years. This left the parental responsibilities for him and his siblings to his mother – please refer to Learning Point Three. 2017 The Police had initial contact with Frankie’s older brother when he was a witness to a stabbing. Frankie was arrested for possession of a knife and theft from person, where he placed a victim in a headlock and demanded that the victim give him his bag. Subsequently Frankie appeared in Youth Court and pleaded guilty to theft from person and possession of a bladed article. Although in fact this offence was a second robbery, he had not previously been referred to YOS for intervention as the first robbery had been dealt with by way of CR. As a result, there had been no opportunity for YOS to do the work with Frankie that might have diverted him from committing the second offence in 2017. In the Youth Court proceedings in 2017, Frankie was assessed as low risk of further offending but a medium risk of serious harm (due to the nature of the offence) and a medium risk of vulnerability, due to his emerging association with gangs. He was made subject to a 10-month Referral Order. Following sentencing, Frankie and his Mother attended the initial Youth Offender & Compliance Panel. Both agreed to comply with the conditions of the Referral Order and a contract was agreed consisting of the following:- Streetwise The weapons awareness programme Offending behaviour sessions to address street crime, peer pressure, consequential thinking and joint enterprise. In addition, Frankie would attend victim awareness sessions and undertake 12 hours of indirect reparation to the community. 11 Period of Serious Case Review: October 2017 – August 2018 From October 2017 Frankie’s mother and older brother were arrested for alleged money laundering. During the Police search of the family home a large hunting knife with a black coloured balaclava was found in Frankie’s older brother’s bedroom. There was also a knife and a baton under Frankie's bed. This resulted in a referral to Children Social Care (CSC) which led to a social work assessment in October 2017. The social work assessment concluded that the children's care needs were being met, there were no concerns in relation to neglect. However it identified significant concerns around the family involvement in crime which included Frankie and his older brother, including the possession of weapons, possible drug and gang affiliation, all of which made them and their younger sibling and mother vulnerable. The recommendation of the assessment was for the family to be supported under a Child in Need (CIN) Plan. Health records indicate that the GP was requested to provide a report for the assessment but along with other health services was not formally notified that Frankie became subject of a CIN plan – please refer to Learning Point Four. The subsequent CIN Plan was implemented in December 2017 which included regular (four-weekly) visits to be undertaken by the allocated Social Worker (SW), ensuring that the children were seen, and their wishes and feelings considered. The purpose of these visits was also to ascertain whether the children were being appropriately safeguarded by their Mother. In line with the plan, CSC made a referral for Frankie’s mother to attend parenting classes to learn different ways of parenting. In addition, she was offered church group support, and a Family Group Conference. 12 2018 Children’s Social Care was supporting the family under a CIN Plan up to the time of Frankie’s death. However, the support services offered to his mother, in relation to parenting, were not what she said she wanted. She consistently maintained that things would improve when her husband returned home from prison. The support being offered to the mother related to her parenting, however the social work assessment had concluded that parenting was ‘good enough’ and there were no concerns in relation to parental neglect. The risks being identified were risks from outside the home – please refer to Learning Point Five. In the face of offers of support in relation to her parenting, Frankie’s mother moved from feeling she needed support to feeling professionals were judging her and her parenting skills. She subsequently declined all these offers of support. Frankie’s school reported that he had large amounts of cash and expensive clothes. When asked about this he consistently claimed that the money was from his uncles and his mother always supported this explanation. His social worker was told that a maternal aunt, who lived locally, supported the family financially. At the end of 2018 Frankie was accused of bringing cannabis onto school premises. Despite no evidence to support this allegation and Frankie’s consistent denial, he was permanently excluded by the school. Having been permanently excluded by his secondary school, Frankie began attending the Pupil Referral Unit (PRU). His SW reports that Frankie wanted desperately to go back to mainstream education and he believed that if he stayed at the PRU too long, he would not be able to get the grades he needed to go to college to study Business. Frankie’s SW went to see him at home, soon after he had started attending the PRU and she reports that he told her, "I do not think I belong there". Frankie said he wanted to go to University and become a businessman, and the PRU has confirmed he was capable of achieving the grades needed at GCSE to go to college – please refer to Learning Point Six. 13 Frankie’s SW spoke to him about his involvement in drill music1 and concerns about association with gang culture and he would always laugh and say it was about the music. He maintained that he did not carry knives and that he did not want to “go down that road, I do not want to go to prison”. He said that he never covered his face in the videos he appeared in, which he believed indicated his interest was solely in the music, and that he was serious about his music. Frankie’s mother said that she had family in the area that were supportive and helped her when she was feeling low. She went on to say that when the boys were at home, she knew what they were doing but she felt helpless when they were outside. She said she did not know much about their friendship groups – please refer to Learning Point Seven. Prior to Frankie’s death, his school attendance had improved to 96%, he engaged well with his social worker and after a few missed early sessions he had engaged well with the Youth Offending Service. Professionals were talking to Frankie, finding ways to engage with him and talking to each other about Frankie’s needs, in particular YOS, CSC and the PRU worked well together to support Frankie. The last time Frankie was seen by his SW he said that he felt that he was achieving well at school and was still looking towards returning to mainstream. He has been attending his YOS appointments and felt that he was getting a lot out of it. He told his SW that he was able to talk to his YOS worker and was trying to put into practice what she suggested. This was confirmed by his YOS worker who says that Frankie was “amazing” in sessions, that he engaged well, would go home and think things through, and when they did victim work, he felt “ashamed”. He attended his final Victim Awareness session at YOS in June 2018. He had completed his final reparation hours and was commended by the Reparation worker for his hard work. This was the last time Frankie was seen by his YOS keyworker and the draft letter of apology to the victim of his crime was discussed, and he was given the letter to take home to reflect on. 1 Drill music is a style of trap music that originated in the South Side of Chicago in the early 2010’s. It is defined by its dark, violent, nihilistic lyrical content and ominous trap-influenced beats. 14 Thurrock response to gangs and violence This review has identified how the Thurrock community is changing as families are relocated into Thurrock from London Boroughs because of the relatively low cost accommodation compared to London rental costs. Some local landlords with big property portfolios only work with London Boroughs. Local agencies are not always informed by the placing authorities and the issue of gang related rivalries is growing, as members of rival gangs are placed in the same areas – please refer to Learning Point Eight. Thurrock partners are responding to these changes, and some of the gang related disruption activities have received coverage in the local media – please refer to Learning Point Nine. Gang culture creates a web of affiliations between some gangs and violent rivalries between others. Anyone aligned with a certain gang, is a rival to anyone who is considered a rival to that gang. Gangs can be aligned or affiliated all over UK. Operating like a cartel, these gang affiliations create the conditions to control drugs supplies that will allow the gangs to move drugs in what have become known as “County Lines” – please refer to Learning Point Ten. YOS has employed a Serious Youth Violence lead to upskill social workers in how to work with young people. Funds have been secured to fund mentoring for young people in the short stay school academy. Since Frankie’s murder, the relationship between the YOS and the PRU has been strengthened. The Streetwise knife prevention programme has had a significant impact on reducing the reoffending rate for those young people undertaking the programme. YOS are undertaking a lot of training with schools, health agencies and other partners. The Safeguarding Children Board has run the “Walk Online” roadshow educating children about the risks of gang affiliation which has reached over 3,000 primary school pupils. 15 What needs to happen to ensure that agencies learn from this case Representatives of the Thurrock Local Safeguarding Children Partnership (LSCP) attended an event arranged by the National CSPRP in July 2019 when the emerging findings from the national review were shared. The Child Safeguarding Practice Review Panel published its first national review in March 2020. This national review focused on safeguarding children at risk from criminal exploitation. Thurrock LSCP will be arranging a Learning Event following the publication of this SCR and the national review report to consider the findings and agree how they can support improving practice with vulnerable adolescents in Thurrock. In particular the Learning Event will focus on those young people who are vulnerable to being drawn into gang related criminal exploitation. Local Learning Points – Areas for consideration by the Thurrock LSCP Learning Point One The current notification process under the SET Child Death Review arrangements (Section 9.7.17) should be reviewed to ensure timely notification of child deaths are received by the relevant persons when a Thurrock child dies outside of the area. Learning Point Two Essex Police should remind staff decision makers regarding the correct threshold for disposal in juvenile cases and the YOS referral process. Learning Point Three The Thurrock LSCP to lead a review of how all agencies respond to the impact on children when a parent is given a custodial sentence. Learning Point Four Thurrock CSC to ensure that Child in Need procedures includes a notification process to other relevant agencies when a child become the subject of a CIN Plan. 16 Learning Point Five The Thurrock LSCP to lead the opportunity for local agencies to consider and find ways to understand how to incorporate the concept of contextual safeguarding in the assessment of risk to children in the future. Learning Point Six The Thurrock LSCP to engage with the education system to review the current process when permanent exclusion is being considered, to ensure that consideration is given to reducing the potential for creating additional vulnerability and safeguarding risks to children at risk of exclusion. Learning Point Seven The Thurrock LSCP to co-ordinate a review of local interventions currently available to support parents when identified safeguarding risks are outside the home. What do young people and their parents tell us about this? Learning Point Eight Thurrock LSCP to review data about families being moved into the area by other local authorities as part of their own gang disruption activities, and consider the role of the LSCP in liaising with the relevant LSCPs about how agencies can work better together to meet the needs of these families and manage risk. Learning Point Nine Thurrock LSCP to review how partner agencies respond to and provide support to those families and children affected by gang association. Could Thurrock LSCP, Adult Safeguarding Board and Community Safety Partnership build on the current work to develop a violence and vulnerability framework? Learning Point Ten Thurrock LSCP to review how well Partner agencies currently share intelligence related to gang association and affiliation. 17 Summary Frankie’s murder was not predictable, and he was not murdered in Thurrock. Frankie was murdered by a stranger in London. However, the prevalence of knife crime inflicted on young people by young people has become an issue of national importance. The findings of the national thematic review, with which Thurrock has engaged, will be used to inform how Thurrock agencies review the local approach to tackling serious youth violence and contextual safeguarding risks. 18 Glossary Clinical Commissioning Group CCG Child in Need CIN Community Resolution CR Children Social Care CSC Child Safeguarding Practice Review Panel CSPRP Emergency Duty Team EDT Grievously Bodily Harm GBH Local Safeguarding Children Board LSCB Local Safeguarding Children Partnership LSCP Pupil Referral Unit PRU Serious Case Review SCR Social Worker SW Youth Offending Service YOS |
NC52179 | Delay in responding to potential trafficking of a female child in May-June 2019. Aaron and Helen, both African, presented as homeless; Aaron applied for accommodation. Housing raised concerns with children's social care and police that Helen, 24-years-old according to Aaron, was a child. Helen was removed under Police Protection Powers and placed in foster care in June 2019. An age assessment of Helen resulted in an age of 12-years-old assigned to her. Aaron was arrested for trafficking offences. Learning includes: immigration identification documents are not evidence-based; need for professional curiosity; need for professional advice in a timely manner and to escalate concerns to enable a multi-agency approach; need for a multi-agency approach to age assessment and to have a pathway to resolve disputes on the presenting age of an individual; consider the child's views at all times. Recommendations include: Local Safeguarding Partnership to develop effective multi-agency pathway and deal with risk of child trafficking; UK Visas and Immigration to ensure robust identification procedures and have a consistent approach to directing practitioners with concerns if someone with an adult ID is thought to be a child.
| Title: Child safeguarding practice review Helen. LSCB: Salford Safeguarding Children Partnership Author: Nicola Dugdale and Emma Ford Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Child Safeguarding Practice Review Helen Reviewers: Nicola Dugdale Deputy Designated Nurse: Safeguarding Children and Looked After Children NHS Salford CCG Emma Ford Head of Safeguarding Salford City Council Final CSPR Report Helen Page 2 of 25 1. Contents 1. The reason for the Child Safeguarding Practice Review .................................................... 4 2. The decision to complete a Child Safeguarding Practice Review ...................................... 5 3. Rapid Review Panel Membership ...................................................................................... 5 4. Governance Arrangements ................................................................................................ 6 5. Family Participation and Equality and Diversity Considerations ....................................... 6 6. The methodology ............................................................................................................... 7 7. Key Lines of Enquiry ........................................................................................................... 7 8. Practitioner Participation ................................................................................................... 8 9. The reviewers ..................................................................................................................... 9 10. The story of Helen ............................................................................................................. 9 11. Background to the entry of Helen into the UK ................................................................ 10 12. Practice Review Chronology ............................................................................................ 12 13. GMP investigation update: .............................................................................................. 16 14. Key Lines Of Enquiry ......................................................................................................... 16 15. Conclusion…………………………………………………………………………………………………………………..22 16. Recommendations ........................................................................................................... 23 17. Reference List ................................................................................................................... 24 Final CSPR Report Helen Page 3 of 25 Relevant Abbreviations ABEN A ‘Bed Every Night’ Scheme BRP Biometric Residence Permit CAFA Child and Family Assessment CCG Clinical Commissioning Group CSC Children’s Social Care CSPR Child Safeguarding Practice Review DfE Department for Education GMP Greater Manchester Police PPP Police Powers of Protection PRSG Practice Review Subgroup RPE Reflective Practitioner Event SMART Specific, Measurable, Agreed, Realistic and Time-Based SSAB Salford Safeguarding Adult Board SSCB Salford Safeguarding Children Board SSCP Salford Safeguarding Children Partnership SSP Salford Safeguarding Partnership UFF Uniform Format Form UK United Kingdom UKVI UK Visas and Immigration VAC Visa Application Centre Final CSPR Report Helen Page 4 of 25 1. The reason for the Child Safeguarding Practice Review: 1.1. Delay in potential trafficking of a child being effectively addressed. For the purpose of this review the child will be referred to as Helen. 1.2. A referral to Salford’s Safeguarding Children Partnership was made by the safeguarding lead for housing. Concern was raised through the Housing Options team regarding a delayed response to a potential concern of trafficking. Housing Options are the team within the City Council who carry out homeless assessments and manage temporary accommodation. 1.3. An adult male, Aaron presented at Housing Options on the 29th May 2019, requesting to make a homeless application for himself and Helen (who was presented as Aaron’s wife) whom had recently joined him in the UK from Africa. This was the third time that they had presented requesting accommodation, having been initially referred to the night shelter a week prior to this but had chosen not to utilise the service. On this occasion the staff member of the Housing Options team who was completing the homelessness assessment immediately had concerns regarding the age of Helen and the validity of the identification documents being presented, which claimed that she was 24 years old. Based on the appearance, stature and behaviour of Helen, the professional believed a more realistic estimate of age was that she was a 12 year old child. 1.4. The concerns were immediately raised internally within Housing Options organisation and then with Children’s Social Care (CSC), Greater Manchester Police (GMP), Immigration and with a Modern Day Slavery helpline. GMP visited Helen however no further action was taken as Helen had identification documentation supporting the fact that she was 24 years old. This resulted in the Housing Options team referring the couple to the ‘A Bed Every Night Scheme’ (ABEN) under Supported Tenancies who placed the couple in the night shelter (which is an adult only provision). This was deemed to be the most appropriate accommodation, in the context of professional concerns, due to the fact that staff were in place 24 hours a day and the regulations, layout and sleeping arrangements within the shelter (dormitory style), meant they had separate beds and sharing a bed was prohibited. 1.5. Helen was removed under Police Powers of Protection (PPP) on 21st June 2019 and placed into foster care. Aaron was arrested for trafficking offences. An age assessment commenced and completed on 5th July 2019 resulting in an approximate age being assigned to Helen of between 12 and 15 years. 1.6. X-ray tests were undertaken on the 6th August 2019 using the Greulich and Pyle method of assessing bone age, indicating that Helen was chronologically aged 12 years and 6 months. Final CSPR Report Helen Page 5 of 25 2. The decision to complete a Child Safeguarding Practice Review 2.1. The case was referred to the SSCP Practice Review Subgroup on the 17th July 2019 by the safeguarding lead in housing due to concerns about the way agencies had worked together to address the concern that Helen was a child and a concern that Helen had potentially been harmed. The criteria and threshold had been met to hold a Rapid Review. 2.2. Salford Children’s Social Care Services notified the National Panel in line with expected practice on 23rd July 2019. 2.3. The Rapid Review took place on 12th August 2019, within the expected timescales of 15 working days. The outcome was that the criteria for a Local Child Safeguarding Practice Review had been met proportionate to the scale and issues of concern being raised locally and for national consideration. 3. Rapid Review Panel Membership: Safeguarding Team Manchester Foundation Trust Detective Sergeant GMP Serious Case Review Team Service Manager Housing Options Director Manchester City Mission Designated Nurse Safeguarding Children and Looked after Children (Chair) NHS Salford Clinical Commissioning Group Legal Adviser Salford & Manchester Legal Service Head of Safeguarding (Co-chair) Salford City Council: People Head of Integrated Social Work Salford City Council: People Head of Social Work Improvement Salford City Council: People Social Worker Salford City Council: People Practice Manager: Looked After Children Team Salford City Council: People Head of Regulatory Services Salford City Council: Place Final CSPR Report Helen Page 6 of 25 Supporting People Safeguarding Lead Salford Community, Health and Social Care Named Nurse: Safeguarding & Looked After Children Salford Royal Foundation Trust (SRFT) Business Manager SSCP Senior Business Support Officer (Minutes) SSCP Principal Officer Supported Tenancies Visas & Citizenship Director's Office UK Visas & Immigration 3.1. The National Panel advised that this be a Child Safeguarding Practice Review (CSPR), agreeing with the proposed methodology of a Reflective Practitioner Event (RPE) to finalise the learning. 4. Governance Arrangements 4.1. The conduct of the CSPR was overseen by the rapid review panel and the SSCP practice review sub-group. The final draft was shared with practitioners who attended the RPE for a factual accuracy check. 4.2. The final report was signed off by the SSCP on 23rd March 2020. 5. Family Participation and Equality and Diversity Considerations 5.1. We now know that Aaron is a direct relative to Helen and that he had initially planned to bring his wife over to the UK and then changed the plan to bring Helen, his family member to the UK. He used some of the documentation from his wife’s identification to support the family reunion application. 5.2. Helen has shared some of her experience regarding the time period of this review. Helen says that she was woken up by the police (on the 21st June) and Aaron was not present at the accommodation. He had at this point been arrested and removed by the police. He was the only individual she had known in the UK and when he had disappeared, she was upset. Helen shared that she did not understand why she had been taken to the police station. Helen remembered that she was provided with an interpreter; however she was unable to recall if she understood what was being said to her, this possibly related to the emotions she was feeling at the time. When asked, Helen said that she felt no-one listened to her throughout the process of the police protection powers being exercised. Final CSPR Report Helen Page 7 of 25 6. The methodology 6.1. Due to the length of time Helen had been in the UK, only housing agencies and GMP had direct contact with her before being placed in emergency foster care, so the timeline for the review was from 29th May 2019 until the 21st June 2019. 6.2. SMART actions to address the immediate learning had been developed by the Rapid Review panel but to support the review and understand the decision making around the needs of the child, the Rapid Review panel ascertained that the RPE would be integral to the learning. The purpose of the RPE was to gather the views and experiences of the practitioners directly involved with family during the time period under review. It provided an opportunity for frontline practitioners to:- Contribute their perspectives without fear of being blamed for actions they took in good faith Understand precisely who did what and the underlying reasons Understand practice from the viewpoint of the individuals and organisations involved at the time 6.3. Salford Safeguarding Children Partnership’s Case Discussion Tool was utilised to facilitate the RPE as a holistic and collaborative approach of reviewing cases. The scope of which looks beyond the specific detail of any case but attempts to identify and understand underlying issues that influence front line practitioners. It is an asset based model with a focus on systemic strengths and weaknesses. Understanding these is at the heart of driving change, culture and wider practice to improve outcomes for children, young people and their families. It helped identify key periods of time within this review that were significant and allowed the story of Helen to unfold and helped the reviewers to explore the key lines of enquiry. 7. Key Lines of Enquiry 7.1. The Rapid Review panel identified key issues that needed to be explored within the RPE which generated some key lines of enquiry Key lines of enquiry KLOE 1 Explore the lived experience of Helen to consider if significant harm has been caused. KLOE 2 Explore the family context of Helen, her previous familial life and her journey from Africa into the UK. KLOE 3 What impacted the delay in Helen being formally assessed to be a child? Final CSPR Report Helen Page 8 of 25 KLOE 4 Did agencies recognise that this was a child whom had potentially been trafficked into the UK? KLOE 5 Are the pathways for managing cases of children and adults who have been potentially trafficked in place, transparent and embedded into local practice? KLOE 6 Understand why professional escalation was not fully utilised. KLOE 7 To ascertain whether the local actions arising from the joint case review (Child/Adult 15) were implemented and embedded across agencies. 7.2. A previous case review jointly commissioned by Salford Safeguarding Children Board (SSCB) and Salford Adult Safeguarding Board (SASB)1 in 2015 “Trafficking of Child/Adult 15 for Domestic Servitude and Sexual Exploitation” identified similar issues in relation to Helen. This included challenges with biometrics, lack of access to appropriate interpreters and relying on valid documentation which was not issued based on evidence of the persons date of birth. Therefore, as part of this review the learning from Child/Adult 15 was revisited to understand how that learning impacted practice for Helen. 8. Practitioner Participation 8.1. The following practitioners and managers attended the RPE: Organisation Role Greater Manchester Police Police Sergeant Greater Manchester Police Police Constable Housing Principal Officer Housing Team Leader Housing (Supported Tenancies) Principal Officer Housing (Supported Tenancies) Supported Tenancies Officer Night shelter Shelter Chaplain Salford City Council: People (Children’s Services) Independent Review Officer 1 https://safeguardingadults.salford.gov.uk/media/1120/child-adult-15.pdf Final CSPR Report Helen Page 9 of 25 Salford City Council: People (Children’s Services) Advanced Social Worker Salford City Council: People (Children’s Services) Practice Manager UK Visas & Immigration Visa & Citizenship Director’s Office 9. The reviewers 9.1. Emma Ford: Emma is the Head of Safeguarding and Quality Assurance within Salford Council. Emma is a qualified social worker and holds a Masters of Science in Advanced Practice in Forensic Mental Health. Emma has over 22 years of experience working with children, young people and families, with 13 years experience within the Child Protection area of practice. Emma’s roles have included managing youth services, social workers and managers. Her most current role is focused on practice improvement, and she chairs the multi agency partnership practice review sub group for Salford’s Safeguarding Children Partnership. 9.2. Nicola Dugdale: Nicola is the Deputy Designated Nurse Safeguarding Children and Looked After Children within NHS Salford CCG. Nicola is a qualified Registered Mental Health Nurse and is currently undertaking a Masters of Science in Safeguarding in an International Context. Nicola has worked in the field of adult mental health from 2004 and in the arena of safeguarding children since 2014. Her most current role is focussed on supporting the Designated Nurse for Safeguarding Children and Looked After Children in the provision of clinical leadership and expertise in safeguarding to drive quality across the commissioning environment and within provider health services. 10. The story of Helen 10.1. Helen initially arrived in the UK and stated that her maternal family lived in Africa. There have been several disclosures of new information regarding Helen’s family composition since the review has commenced. 10.2. In October 2019 Helen informed her social worker that Aaron is a family member and not her husband. Aaron has since shared that he had previously been married and his wife was due to travel to the UK, however they had an argument which resulted in them separating. Helen did not wish to remain in Africa and therefore Aaron used his wife’s visa and documents to transport Helen to the UK. 10.3. The police investigation in relation to the trafficking offences concluded on result of the evidence that Aaron is a family member and no evidence of exploitation is evidenced. The Home Office have been updated with regards to whether there will be a criminal investigation into Aaron assisting illegal entry into the UK. The Home Office (Immigration and Enforcement unit) have confirmed they will not be pursuing a Final CSPR Report Helen Page 10 of 25 criminal investigation or prosecution into any immigration related offences and will be dealing with it on an administrative level. 11. Background to the entry of Helen into the UK 11.1. Aaron claimed asylum in the UK in 2015. An asylum application would have been made which included the rationale for seeking asylum and relevant family history including his spouse. UK Visas and Immigration (UKVI) would be responsible for reviewing the request and making a decision as to whether the criteria had been met. 11.2. Under the Family Reunion process a spouse, partner or child under the age of 18 of those granted humanitarian protection in the UK, can reunite with family members in the UK. This is providing they formed part of the family unit before their sponsor fled the country of origin (in this case Aaron). Anyone who has claimed asylum successfully can apply for family members to join them as long as they can adequately prove that they are related as claimed2. 11.3. In order to join family members under this process, in these circumstances individuals do not always have to have a passport. By the very nature of their lived experience, refugees often have left their country of origin or habitual residence with no identification. An informed decision is therefore made on whether they should be allowed to travel based on the information available. A visa or entry clearance would allow the travel to take place and a Uniform Format Form (UFF) would also be issued. Guidance from UK Visas and Immigration3 indicates that the UFF has replaced the previous Declaration of Identity form and unlike this previous form, the UFF “does not confer nationality and neither does it confirm identity”. 11.4. Therefore the identification is not based on evidence of the person’s actual identity. It is formed and issued based on the information provided by the applicant and their sponsor. LEARNING POINT: Home Office ID for refugees and their family members is not always evidence based. Practitioners to be aware of this and to exercise appropriate professional curiosity into the age and developmental stage of a presenting person. 2https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/856915/family-reunion-guidance-v4.0-ext.pdf 3 https://www.gov.uk/government/publications/what-are-acceptable-travel-documents-for-entry-clearance-ecb08/ecb08-what-are-acceptable-travel-documents-for-entry-clearance Final CSPR Report Helen Page 11 of 25 February 2019 11.5. Helen or a third party will have made an online application and provided all relevant personal and familial details. Helen attended a Visa Application Centre (VAC) situated in Africa where she was residing as a refugee, to provide biometrics which included fingerprints and facial images. The information provided as part of the application indicated that Helen and Aaron met in 2013 and last saw each other in 2014. Aaron had entered the UK in 2015. It is not known who completed this application, whether it was Helen or a person on her behalf. 11.6. The VAC is operated by a commercial partner trained to undertake administrative functions of processing visa applications. All documentation is forwarded to the decision-making centre. In this case it would have been sent to UKVI Pretoria, South Africa. They consider all information and supporting documents and ensure it aligns with the statement of evidence provided by the sponsor at the point they claimed asylum. In this case, Aaron had provided details of his spouse in 2015 when he originally claimed asylum. Helen as part of her supporting evidence under the Family Reunion Process had provided evidence including wedding photographs, a marriage certificate, and evidence of a pre-flight relationship before Aaron entered the UK and evidence of ongoing communication and money transfers since then. 11.7. Once the successful application was made a short validity vignette would have been issued to Helen which allows entry into the UK and is valid for 30 days from issue. This vignette allows collection of a biometric residence permit (BRP) within 10 working days of entry into the UK which includes biographic details and biometric information such as facial image and fingerprints4. 20th May 2019 11.8. Housing Options received notification from Aaron that Helen would be joining him from Africa. It was understood this would be under the Family Reunion process. 11.9. Helen would have had no contact with any civil servant or any government official until she boarded a flight in May 2019, after leaving the refugee camp, when she would have passed through border control and come into contact with airline staff. During transit in Brussels Helen would mainly have been in contact with airline staff. Her first contact with any official government staff from within the UK would have been on arriving on her flight and reaching Birmingham. 4https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/533854/BRP_OA_information_leaflet_-_July_2016.pdf Final CSPR Report Helen Page 12 of 25 11.10. Considering the chronological age of Helen, it is suspected strongly that she would have travelled with someone during this journey. This is evidenced by the fact that two airline tickets were purchased at the same time and sent to a ‘WhatsApp’ account of Helen. Helen has denied travelling with anyone. If Helen had not been alone this may have reduced the professional curiosity of airline staff than if a young girl who appeared to be aged 12 was travelling alone. 23rd May 2019 11.11. Aaron and Helen presented as homeless and they were referred to the night shelter under the ABEN scheme under Supported Tenancies. The couple did not stay at the shelter. 24th May 2019 11.12. Aaron and Helen presented again as homeless stating they couldn’t stay at the night shelter due to men being there. Advised this was the only accommodation available under the ABEN scheme. The couple did not remain. 12. Practice Review Chronology 29th May 2019 12.1. Aaron and Helen presented at housing options as homeless and asked for accommodation. Safeguarding concerns were raised by the professional undertaking their homeless assessment. This practitioner was of the view that Helen was a child. 12.2. The housing practitioner raised the concerns internally to her safeguarding lead. A telephone call to The Bridge (Salford’s front door service if worried about a child), was made to seek advice. The advice provided was to speak to Helen alone to ascertain her views, wishes and feelings and to contact the police for advice and to feedback the outcome back to the Bridge. A formal written/online referral was not made under the auspice of ‘Worried about a Child’ at this point as it was an advice call only. 12.3. The housing practitioner made attempts to contact the police via 101 but the practitioner was unable to speak to anyone as no one answered the phone. This resulted in the practitioner subsequently attending the local police station requesting support. It was noted within the reflective practitioner’s event that the housing officer was tenacious in her action to ensure the police were aware of her concerns that Helen was a child. 12.4. Parallel to the housing practitioner making contact with The Bridge and police, a referral was made for Aaron and Helen under the ABEN scheme under Supported Tenancies. The safeguarding concerns were discussed and shared openly so the viewpoints and concerns of the agencies were known and understood and further Final CSPR Report Helen Page 13 of 25 monitoring and observations of Aaron and Helen’s relationship and interactions could take place. A decision was made to place Aaron and Helen in the night shelter. 12.5. Practitioners from Supported Tenancies on meeting Helen had the same concerns regarding her age and raised the concerns internally within their organisation, as they believed her to be a child. As Housing Options were linking in with the Bridge and GMP, supported tenancies contacted a Modern Slavery helpline following recent training they had attended. They were advised that this was a matter for Police and Immigration services. Contact with Immigration services was attempted but unsuccessful as the call was unanswered. Senior staff within Supported Tenancies attempted to liaise with individual officers in GMP as they had contacts within this part of the organisation. Although direct contact with specific individuals was not successful, contact with GMP did take place and an incident log was created. The concerns were recognised and officers were dispatched. Attempts were also made to discuss the safeguarding concerns internally with the housing services organisational Safeguarding Lead but she was not available. 12.6. Officers from GMP attended Housing Options the afternoon of 29th May 2019 and spoke to Aaron and Helen separately. Initially concerns had been raised that an interpreter had not been used to speak with Helen. It was clarified within the RPE that attempts were made to speak to Helen via the use of telephone interpreter services however at the time of the call; an exact dialect could not be matched. Therefore an interpreter was provided but did not fully meet the language and communication needs of Helen. GMP officers liaised with Immigration services that confirmed the details of Helen and sent photographic evidence from biometrics provided at the VAC. There were distinctive marks within the photograph that matched the facial marks of Helen. The Bridge were updated by Supported Tenancies and no further action taken as they had been reassured that GMP had followed up the matter and confirmed that Helen’s identification confirmed that she was the person on the identification card, and therefore an adult. 30th May 2019 12.7. A practitioner from the night shelter contacted Supported Tenancies expressing the same concern regarding the age of Helen as they believed her to be a child. Their concerns were acknowledged and advised that safeguarding issues were being raised with the police and children’s social care but the rationale for placing there was for ongoing monitoring of the situation in the interim period. 2nd and 3rd June 2019 12.8. Concerns were raised internally within the night shelter about the age of Helen to both senior staff and then to their Safeguarding Lead. Liaison was then made with the Principle Officer at Supported Tenancies. It was confirmed that the concerns were shared and they had already contacted their Safeguarding leads, Children’s Social Care Final CSPR Report Helen Page 14 of 25 and the Police. This issue had been investigated and no evidence could be found to prove the identification was not genuine. 3rd June 2019 12.9. Staff at the night shelter were concerned that there was tension between other residents regarding the age of Helen. Further concerns related to Aaron not allowing Helen to shower. It is also noted that Helen was going out throughout the day with 4 or 5 other people, not known to the housing service or provider. 5th June 2019 12.10. Practitioners from the night shelter informed Supported Tenancies that they had other concerns that Helen was being taken out by Aaron and 3 other men in a car and when asked on where they were going the reply was to "the shipping place". An update of the actions being taken by Supported Tenancies was provided with advice that the police should be contacted if there was a suspicion that Helen was in potential danger. 12.11. Supported Tenancies raised their concerns with their Safeguarding Lead in Housing on the 5th June 2019. The Safeguarding Lead subsequently made attempts to contact practitioners within the Complex Safeguarding Hub; however they could not get hold of the person they were attempting to contact. They therefore made further contact by Supported Tenancies, on 5th June via email, to the Trafficking and Slavery GM Co-ordination Unit to share their concerns. 6th June 2019 12.12. On receipt of the email an officer within the Unit reviewed the case. The officer was aware that response officers from GMP had previously attended and spoken to Helen on the 29th May 2019. Due to this there were no immediate safeguarding concerns highlighted and it was agreed he would recheck with Immigration services the validity of the immigration card for Helen. 12.13. On the 6th June 2019 another practitioner from the night shelter raised concerns with the charity Hope for Justice and again with Supported Tenancies. He was advised that the case continued to be reviewed and Helen was deemed to be in the safest place as she could be monitored. This notion was contended by the practitioner based on the information that Helen was being taken out daily with unknown males. The practitioner was advised that if they had concerns they should contact GMP, which they subsequently did. 12.14. Two officers from GMP attended the night shelter on 6th June 2019 in response to the concerns raised. Helen was spoken to alone via an interpreter service. She confirmed her name and date of birth and provided a UK visa issued in the UK. She stated that she married Aaron in Africa and had relocated to the UK to be with him. She reported Final CSPR Report Helen Page 15 of 25 to be acting freely, was happy in the relationship and had no concerns she wished to report to GMP. Immigration services were contacted, and the identification was confirmed, including that both Aaron and Helen were in the UK legally and as biometrics had been undertaken including photo identification there was confidence that the age was correct. As this was the second query being raised by GMP, Immigration services agreed to forward the case to their local Immigration Safeguarding team to make further inquiries into the case. At the RPE it was reported that on this occasion, GMP agreed that Helen looked like a child but were assured that the identification was genuine. 11th June 2019 12.15. A copy of the Immigration card for Helen was forwarded to the officer in GMP Modern Day Slavery Co-ordination Unit and 2 days later Immigration services confirmed that there was no passport on Immigration systems and Helen was a refugee. 18th June 2019 12.16. The Safeguarding Lead for Housing attended a local multi agency subgroup which is responsible for developing responsiveness and outcomes in relation to complex safeguarding issues. The senior GMP officer present at this meeting was updated, opportunistically, regarding the concerns from Housing agencies that Helen was not an adult. The senior GMP officer requested that the information about the concerns be sent over and upon doing so, confirmed that it would be picked up and investigated by the Complex Safeguarding Hub. It was allocated the same day and the complex safeguarding hub undertook further investigations into the validity of Helen’s ID. 21st June 2019 12.17. A referral was made by GMP to The Bridge who requested an age assessment of Helen. A referral was subsequently made to Salford Complex Safeguarding Hub and a Section 47 strategy meeting was convened. Helen was made subject to Police Powers of Protection (PPP) and placed into emergency foster care on 21st June 2019. At the RPE reflection took place to consider why the age assessment progressed at this stage, following the referral to the bridge from GMP. It was agreed that as the PPP had been taken, this triggers an automatic response for a section 47 to take place. It was also evident at this point that the ID for Helen was not informed by genuine documents relating to her age. 12.18. The age assessment was conducted and concluded that Helen was approximately 12 years and 6 months of age. Final CSPR Report Helen Page 16 of 25 13. GMP investigation update: 13.1. GMP commenced an investigation as a result of Helen being taken into police protection when they attended a homeless shelter due to concerns of human trafficking. 13.2. The concerns related to a female who presented as a child, however reported to be in her early twenties and married to the male adult that accompanied her in the shelter. She was placed in foster care where she has remained since. Aaron was arrested and bailed for human trafficking offences. 13.3. Since this time, GMP have liaised with a number of agencies. Helen has recently stated that she is a family member of Aaron, she came to the UK as his wife so that this would fit the criteria of a 'family reunion' for immigration purposes. DNA analysis has confirmed the biological relationship. Considering this, immigration have been updated. There will be no further police action in relation to the trafficking offence. 14. Key Lines Of Enquiry KLO 1 Explore the lived experience of Helen to consider if significant harm has been caused. 14.1. It is now known that Aaron is related to Helen by blood. There is no evidence that Helen has experienced significant harm as a result of the direct care given from Aaron or during the time period that professionals raised concern that she was potentially a child. The lived experience of Helen from birth is not fully known, it is likely she has experienced a number of life events and transitions that would not be experienced by the average child within the UK. The extent of the impact of these events are not yet fully known and Helen is being appropriately supported. KLO 2 Explore the family context of Helen, her previous familial life and her journey from Africa into the UK. 14.2. Children and young people who have endured the experience of leaving their home, community and family via the process of asylum will experience challenge as they journey and transition into a new country to seek safety and protection. These journeys can be difficult and can last days or up to years. Often, they will have little or no familial or social contacts or support. There is a myriad of sociocultural reasons for leaving their country of origin but have been associated with conflict, war and human rights abuses and they are seeking safety and protection in the UK via asylum. Some children and young people will have experienced bereavements or may be separated from family members such as their parents. They may be affected by significant trauma, by their experiences in refugee camps or through the journey to the UK Final CSPR Report Helen Page 17 of 25 where they are furthermore at significant risk of being trafficked or exploited due to their vulnerability and isolation. These circumstances can be exacerbated on reaching the UK through issues relating to for example, asylum, poverty, housing, cultural and language barriers and even racism. All of which can impact on integration5. 14.3. It was therefore important to try and understand how these risk factors have impacted Helen to understand how to help best support her. Ongoing therapeutic support is in place for Helen. 14.4. The presenting needs of Helen and understanding around any serious harm she has suffered is limited and current multi-agency intervention is focused on reducing her distress and ensuring the relevant supports are in place, in a culturally sensitive manner that understands the complexity of her current perception and experiences of relationships KLOE 3 What impacted the delay in Helen being formally assessed to be a child? 14.5. This review has considered that professionals and agencies did exhibit concern over the validity of the personal identification being presented in comparison to the appearance, behaviour and stature of Helen. Professional concerns regarding this issue were legitimately raised internally and safeguarding advice was sought. Many of the professionals who met Helen believed that she was a child. 14.6. What was evident within the Rapid Review meeting and RPE was that despite having these ongoing concerns between the period of Helen being seen at housing options and the PPP being obtained, further investigation into her age (other than reviewing the ID) did not progress. There was an over reliance upon the assurance that Helens ID stated she was an adult. The review has identified that professional curiosity was present but not effectively followed through, utilising the professional challenge and escalation policy. Although concerns continued to be raised, they were not escalated within any organisation. This was impacted by the assurance given from immigration services that the personal identification that Helen held was genuine and practitioners being unsure of where else they could have their concerns heard. 5https://www.unicef.org/publications/files/Harrowing_Journeys_Children_and_youth_on_the_move_across_the_Mediterranean.pdf LEARNING POINT: Professional challenge and escalation of concerns in safeguarding should be adopted once local resolution has been unachievable between agencies. Final CSPR Report Helen Page 18 of 25 KLOE 4 Did agencies recognise that this was a child whom had potentially been trafficked into the UK? 14.7. Housing agencies did recognise that Helen was potentially a child trafficking victim, and this was evidenced by their attempt to contact the Modern Day Slavery helpline. However, there was an uncoordinated approach at the point of the concerns being raised with other agencies and the challenge of her presenting age was not adequately followed through in a timely manner through professional escalation processes. 14.8. It is also noted that although trafficking was considered for Helen at the initial point concerns were raised, when concerns were raised on 6th June 2019 that she was being taken to the ‘shipping area’ with men, although the safeguarding response of contacting GMP was appropriate, there is no evidence that Helen was considered to be a potential victim of adult trafficking. This is likely due to the fact that professionals were of the view she was a child, thus not leading them to consider the possibility of being a vulnerable adult. KLOE 5 Are the pathways for managing cases of children and adults who have been potentially trafficked in place, transparent and embedded into local practice? 14.9. The Home Office6 provide guidance on the process to follow when a child claims asylum in the UK. Bolt (2018) reviewed Home Office data of asylum claims and noted that between July 2016 and June 2017 in approximately 1 in every 4 cases of children seeking asylum there was an age dispute. And of these cases, 65% were deemed to be adults posing as children. It is therefore well evidenced that adults seeking asylum will often seek asylum posing as unaccompanied asylum seeking children. There are systems and processes in place to manage this with the person treated as a child in the first instance until evidence or an age assessment concludes that they are not a child. In the case of Helen the processes around how to address a child presenting as an adult was missing and there was no clear protocol or pathway to follow. 6https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/825735/children_s-asylum-claims-v3.0ext.pdf LEARNING POINT: A clear multi agency pathway to respond to concerns regarding trafficking and/or disputes on the presenting age of an adult/child were not in place Final CSPR Report Helen Page 19 of 25 14.10. Since the review has taken place, an interim pathway has been developed and used in practice, resulting in a timely and appropriate response to age assessments progressing in similar circumstances. In all cases where there is professional concern that someone presenting as an adult is a child, the person will be seen by an age assessment trained social worker on the same day (EDT social worker if out of hours) and if required, consultation held with the police following this visit to plan a course of action. KLOE 6 Understand why professional escalation was not fully utilised. 14.11. Professional challenge and escalation has an integral role to play in multi-agency safeguarding. Disagreement between agencies is inevitable and acceptable. The management of this, in order to provide resolution, has to be undertaken in a timely and prescribed manner. Housing agencies did try to raise their concerns by contacting external agencies and discussing their concerns internally with their safeguarding lead. Despite continued concerns, professional challenge and escalation processes were not implemented formally. For example, The Bridge were assured after the GMP investigation that Helen was an adult, no further contact with them occurred until the PPP and GMP referral on 21st June 2019. It was identified at RPE that this was impacted by the following factors: - The professional challenge and escalation process was not embedded within the organisation/s raising concern that Helen was a child. - Housing were not sure who to escalate the matter to as they received advice from a range of agencies and through their own safeguarding lead. - No coordinated multi agency pathway was in place in order to respond to concerns where someone with an adult ID is presenting as a child. KLOE 7 To ascertain whether the local actions arising from the joint case review (Child/Adult 15) were implemented and embedded across agencies. 14.12. Child/Adult 15 was a joint review undertaken on behalf of both Salford Safeguarding Children and Adults Boards in 2015. The case related to a victim of child trafficking from Pakistan into the UK for the purpose of domestic servitude and sexual exploitation. Final CSPR Report Helen Page 20 of 25 14.13. She was trafficked into the UK in 2000 and although her passport had been legitimately issued, the year of birth specified was inaccurate and recorded as 1980. The reality is that she was probably born in or around 1990. She applied for and was accepted for a visa application as a domestic worker to work in a private household. She was residing as a child with personal identification presented to agencies as an adult, and this continued over a period of 9 years. 14.14. One of the key lines of enquiry that stemmed from the Rapid Review for Helen was to establish if the learning from Child/Adult 15 had been embedded. Key similarities in the cases have been noted and have been considered as part of this review. 14.15. In the case of Child/Adult 15 her abusers were used to speak for her including for the purpose of interpreting. She was rarely given the chance to speak to agencies alone and therefore her communication difficulties or her inability to speak English was unknown. Her voice was never heard. 14.16. In the case of Helen, at the point that the police attended in response to the concerns raised by Housing Options on the 29th May 2019, an interpreter was accessed at the first point of contact and she was spoken to alone in order to try and obtain her voice and to ensure she was heard. It has been acknowledged that the interpreter service could not provide someone with the exact dialect so there is the potential that some words did not translate exactly. However, use of an interpreter provided opportunity for any concerns of Helen to be raised. At this point and during subsequent discussions with the police and even after the point she was removed into the care of the Local Authority, Helen herself was given opportunities to ensure her voice was heard, utilising the interpreter service. She was complicit and maintained she was the age that her personal identification stated and that she was legitimately in the UK with her husband. 14.17. It was identified that when Helen was at the night shelter, interpreters were not accessed by the night shelter staff to speak with Helen. It was the “persuasiveness” of the personal identification issued legitimately in the case of Child/Adult 15 that was an integral factor in the ability of her abusers to maintain the deception for 9 years. The fact that Child/Adult 15 had a genuine passport appeared to lead every agency and professional in contact with her to act without exhibiting any professional curiosity. 14.18. In the case of Helen it was evident after her entry into the UK and during the third point of contact with the Housing Options team that there were doubts over the validity of the recorded date of birth within her identification, as the housing officer viewed her to be a child. This led agencies and professionals to raise concerns with a range of statutory agencies including Children’s Social Care, Greater Manchester Police and Immigration services. Housing Options contacted a Modern-Day Slavery hotline for advice following their attendance at a recent training session. It appears Final CSPR Report Helen Page 21 of 25 that professional curiosity was exhibited on a number of occasions with tenacity. The difficulty in this case was the fact that at every stage, agencies that were able to take further action, were ‘assured’ that the personal identification was valid. There was an integral gap in understanding that identification is not evidence based and is issued based on the information, in this case under the Family Reunion process, provided by Helen and her sponsor, Aaron. This essentially rendered any attempt to safeguard Helen via the ‘usual’ channels ineffective. 14.19. Professional curiosity was present and a number of professionals, at different times (housing association, housing provider and GMP officers) were in agreement that Helen was likely to be a child. Professional feedback at the RPE indicated that it felt that there was little more professionals could do to explore and/or act on this concern as the official advice from immigration was that the identification card was valid. 14.20. In the case of Child/Adult 15, the case review indicated that there had been a significant delay in identifying safeguarding concerns pertaining to trafficking. Trafficking was identified as a potential risk factor in this case providing assurance that lessons from Child/Adult 15 have been embedded across the locality. 14.21. In the case of Child/Adult 15 as she entered the UK in 2000, by the time the case review took place, a lot of changes to immigration processes had already taken place. That review predominantly relates to immigration rules surrounding the application for domestic visas however immigration changes were recognised within the case review as having the potential to hinder safeguarding processes. Specifically section 5.9 states that:- 14.22. The predictions within the case of Child/Adult 15 have been evidenced within the case of Helen. The integral difference in the case of Helen however, is that agencies quickly recognised that she was potentially a child. It was the legitimately issued documentation that impacted the ability of agencies to move forward in their ability to safeguard Helen. 14.23. The case of Child/ Adult 15 spoke in detail about safeguarding responsibilities and obligations of the Home Office, including Border Force under Section 55 of the Borders, Citizenship and Immigration Act 2009. Within the RPE it was clarified that safeguarding training is undertaken with all of its member organisations including “The “fingerprint enrolment process” is now a central part of the visa application process. The applicant provides biometric data (fingerprints and photograph) which are linked to the corresponding passport information. This is a process which is likely to make fraud more difficult, but in a case like Child/Adult 15 there is a danger that once her identity – including her false date of birth - was ‘locked in’, the fingerprint verification process used by all other ECOs, Border Force and Premium Services Officers would simply confirm the details were correct, potentially reinforcing the deception” Final CSPR Report Helen Page 22 of 25 ECO’s and Visa Application Centres. Staff are not trained to a level of being able to undertake age assessments however any concerns would have been raised at the time if, during either of these processes, the validity of the age of Helen or the validity of the documentation came into question. 14.24. The integral personal and face to face contact with Helen that would have taken place with any specific degree of detail would have taken place at the VAC in the country of origin where Helen had been residing as a refugee. However, the final responsibility for identifying age related concerns rests with the decision maker, in this case UKVI Pretoria. It has been acknowledged that as Helen appears to be wearing a wig and make up in her photographic identification, this could have contributed to the deception when biometric data was being collated. 14.25. Since the rapid review took place, UK Visas & Immigration have taken a number of steps to address the learning, including updated training for immigration call centre staff regarding the evidence base of ID documentation, appointing a safeguarding lead within the organisation and looking at the possibility of introducing video interviews for family reunion applications, especially when there are anomalies and evidence does not corroborate 15. Conclusion 15.1. The review concludes that the concerns regarding Helens presenting age were consistently raised, and with various agencies and specialist call centres. The concerns were not effectively escalated via the professional challenge and escalation policy, impacting on delay of further age assessment progressing for Helen. There was an over reliance on the presenting ID of Helen, which was compounded by reassurance from immigration services that the identification of Helen was genuine. Findings: Evidence of good practice 15.2. There is evidence of good practice throughout the review period for Helen. Professional concern and curiosity was evidenced and appropriate contact made with the Bridge, GMP, the Modern Slavery Unit and Immigration. 15.3. Housing placed Helen in a provision with high monitoring as they continued to have concerns that she was a child and not an adult. Therefore they approached their decision making to consider the level of support and staff available to observe Helen and her relationship with Aaron. 15.4. Information sharing between housing and the housing provider is evidenced, which supported the ongoing understanding of the relationship between Aaron and Helen. Final CSPR Report Helen Page 23 of 25 Learning Lessons: 15.5. The immigration processes for family reunions does not always produce evidenced based IDs. Therefore the true age, status and name of the person may not be accurate. Practitioners in the case of Helen were not aware that the presenting ID was not evidenced based. 15.6. There was a reliance on the presenting ID to validate Helen’s age. Professional curiosity and/or escalation of concerns that she was a child were not swiftly followed through to further assessment or investigation. 15.7. It is important that professionals have access to the relevant professional advice in a timely manner, exhibit awareness by effective use of the escalation policy to enable a coordinated multi agency approach if someone is worried about a child. 15.8. A clear multi agency pathway to respond to concerns regarding trafficking and/or disputes on the presenting age of an adult/child were not in place. Specifically, the approach to age assessment when a professional has a concern that someone presenting as an adult may be a child. 15.9. Helens experience when Aaron was separated from her should be taken into consideration for future approaches to such circumstances, considering how the adult/child’s views can be obtained and understood at all times. Allowing multi agency planning to be sensitive and responsive to their experience. Recommendations: Salford Safeguarding Partnership to be assured that a local, multi agency, effective pathway is developed and embedded to address concerns that a presenting adult maybe a child and that the risk of trafficking may be present. Salford Safeguarding Partnership to be assured that all partners and practitioners are aware of the professional challenge and escalation process, when and how it should be used and to support the follow through of professional curiosity to an evidenced based outcome. Salford Safeguarding Partnership to be assured that all people within the city, working with adults and children are aware of the limitations of immigration ID and the pathway for raising concerns regarding age disputes and trafficking. UK Visas & Immigration to consider how they will review the newly implemented changes in light of the learning from this case to ensure safeguarding processes pertaining to the issue of identification are robust and embedded. UK Visas & Immigration to ensure advice is given to professionals and the public in respect of the evidence base of ID and what to do if someone with an Adult ID is Final CSPR Report Helen Page 24 of 25 thought to be a child, therefore having a consistent approach nationally to directing the assessment of a child. Reference List Bolt, D. (2018). An inspection of how the Home Office considers the ‘best interests’ of unaccompanied asylum seeking children, August – December 2017. London: Independent Chief Inspector of Borders and Immigration. Carole Brooks Associates and Salford Safeguarding Children Partnership. (2019). Practice Review Policy and Toolkit: Case Discussion Tool. Retrieved from https://safeguardingchildren.salford.gov.uk/professionals/practice-reviews/ Department for Education. (2018). Working together to safeguard children: Statutory guidance on inter-agency working to safeguard and promote the welfare of children. London: Department for Education. Home Office. (2019). Children’s Asylum Claims – Version 3.0. London: Home Office. Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/825735/children_s-asylum-claims-v3.0ext.pdf Home Office. (2020). Family reunion: for refugees and those with humanitarian protection. Version 4.0. London: Home Office. Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/856915/family-reunion-guidance-v4.0-ext.pdf7 Mellor, D. (2015) Case Review: The Trafficking of Child/Adult 15 for Domestic Servitude and Sexual Exploitation. Salford: Salford Safeguarding Children & Adult Boards. Retrieved from https://safeguardingadults.salford.gov.uk/media/1120/child-adult-15.pdf UK Visas and Immigration. (2013). Guidance – ECB08: what are acceptable travel documents for entry clearance? London: Home Office. Retrieved from Final CSPR Report Helen Page 25 of 25 https://www.gov.uk/government/publications/what-are-acceptable-travel-documents-for-entry-clearance-ecb08/ecb08-what-are-acceptable-travel-documents-for-entry-clearance UK Visas and Immigration. (2016). Guidance Notes: Biometric residence permits (BRPs): General information for overseas applicants, their employers and sponsors. London: Home Office. Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/533854/BRP_OA_information_leaflet_-_July_2016.pdf Unicef. (2017.) Harrowing journeys. Children and youth on the move across the Mediterranean Sea, at risk of trafficking and exploitation. Unicef. Retrieved from https://www.unicef.org/publications/files/Harrowing_Journeys_Children_and_youth_on_the_move_across_the_Mediterranean.pdf |
NC52360 | Death of a 2-year-1-month-old boy in in October 2019. Ben died from significant non-accidental injuries; his mother and her partner were charged with murder and causing or allowing the death of a child. Learning includes: the need to consider a multi-disciplinary response when assessing head injuries, especially in young children; the importance of informing referring agencies when a referral is not accepted, and why; the need to understand how parenting education is provided for new and inexperienced parents; considering 'was not brought' (to medical appointments) as a possible indicator of neglect of young children; keeping the child in mind and the child's experience central; the challenges of seeking to engage vulnerable parents who choose not to engage; assessing the risk of domestic abuse and supporting women who have experienced domestic abuse; tracking known violent adults and identifying them when there are concerns about children with whom they are in contact. Recommendations include: consider routine progression to a child and family assessment for any child with an injury when requested by health professionals; inter-agency dialogue about next steps when a child requires in-patient observation or a skeletal survey following a serious unexplained injury; review the guidance to GP practices on linking parent and child records and childcare alerts to ensure that the child's vulnerability is noted on the parent's record; review the routine enquiry policy for midwives and health visitors.
| Title: Child safeguarding practice review: Ben. LSCB: Croydon Safeguarding Children Partnership Author: Malcolm Ward Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Croydon Safeguarding Children Partnership 1 Child Safeguarding Practice Review Ben Croydon Safeguarding Children Partnership 2 Contents Page 1. Executive Summary 3 2. Reason for review and methodology 5 3. Background information 6 4. Summary account of events and agencies’ involvement with Ben’s family 7 5. Family involvement and views 16 6. Analysis and lessons 18 7. Recommendations 33 Croydon Safeguarding Children Partnership 3 1. Executive Summary 1.1 The review has identified lessons about working with vulnerable young and first-time mothers (and separated fathers) and the challenges of engaging them in Universal and Early Help Services. It shows that the needs of infants and toddlers can be missed when there is no engagement. It raises practice questions about how to engage parents where there are concerns about alleged domestic abuse and the need for assertive enquiry and analysis about men who are known to have a violent history and who form new relationships. 1.2 Ms A, Ben’s Mother, reported adverse childhood experiences, mixed feelings about her pregnancy and low-level depressive symptoms in pregnancy and later. She was offered a range of services because of her vulnerability but did not engage well. 1.3 On the occasions that she reported domestic abuse it was taken seriously but she did not then follow through with support, advice or possible actions. 1.4 Her vulnerability as a young and new mother was recognised after Ben’s birth, it was assessed that they would benefit from the Universal Plus Partnership Health Visiting Pathway1. Initially there was good and persistent work to engage with her. This was then impacted by a move and the Universal Plus Pathway approach was disrupted and not re-assessed or re-established. 1.5 Following an allegation of domestic abuse several months later, a Child and Family Assessment was undertaken and it was decided that a child in need service was not required. It may have been useful to signpost the family back to Early Help Services. Ben and Ms A were again no longer being seen by services. 1.6 When Ben was one year and eight months, he had a significant injury to his head. The hospital’s clinical assessments were rigorous and resulted in a judgement that the injury was most likely accidental; but concerns remained about the cause and further medical investigations were in place. The review has raised the question about the point at which a multi-agency child protection approach to such assessments should be considered when there is doubt about the cause of a significant injury. Although a referral was made to Children’s Social Care this was not followed through as it was not seen in a child protection context, given the view that the injury was probably accidental. The decision not to proceed with a multi-agency Child and Family Assessment was influenced by the systems context of large numbers of ineffective referrals. 1.7 Opportunities were missed to identify a new male partner who was known to be a potential risk. 1.8 Ben died from significant injuries, aged two years and one month. His Mother and her new Partner have been charged with Ben’s murder. 1 Universal Partnership Plus - Health Visiting Service Best Practice Pathways - NHS Healthy Child Programme Croydon Safeguarding Children Partnership 4 1.9 Lessons learned include: o The need to consider a multi-disciplinary response when assessing head injuries, especially in young children o The importance of informing referring agencies when a referral is not accepted, and why o The need for a better local understanding of how the National Healthy Child Programme, Early Help Services and the multi-agency Threshold for Intervention are operating at Levels 1 and 2, to ensure that young children are not lost to the system o The need for an understanding of how parenting education is provided for new and inexperienced parents o Holding ‘Was Not Brought’ (to medical appointments or checks) in mind as a possible indicator of neglect of young children o Keeping the child in mind and the child’s experience central o Assessments, Engagement and non-Engagement, where parental consent is required – the challenges of seeking to engage vulnerable parents who choose not to engage o Assessing the risk of domestic abuse and supporting women who have experienced domestic abuse o Including the importance of tracking known violent adults and identifying them when there are concerns about children with whom they are in contact. 1.10 A number of recommendations have been made in the light of these findings. They are summarised in section 7. The Croydon Safeguarding Children Partnership endorsed this Review and agreed the recommendations in Section 7 in June 2021 and will put them in to place through a multi-agency Action Plan. Croydon Safeguarding Children Partnership June 2021 Croydon Safeguarding Children Partnership 5 2. Reason for review and methodology 2.1 Ben died from significant non-accidental injuries, in October 2019, aged two years and one month. The Croydon Safeguarding Children Partnership commissioned a Rapid Response2 and agreed that a Safeguarding Practice Review (SPR) should be undertaken. Ben’s mother and her new partner were arrested, and a murder investigation was initiated. 2.2 The purpose of a SPR is to learn lessons through a systems analysis of the family dynamics and of the single and multi-agency work undertaken to assess and support the family. Such a review should make recommendations where any changes may be required to improve the way that local services for children and families are provided. The process seeks to involve family members and practitioners as much as possible, to learn from their perspective. 2.3 An Independent Panel drawn from key agencies was appointed with an Independent Chair and an Independent Reviewer. The Panel analysed a detailed chronology of all the agency contacts with Ben, his mother and other key adults from when his mother’s pregnancy became known (2017) until his tragic death. Agencies were asked to provide an internal independent evaluation of the work undertaken in the context of local procedures and resources and any significant systems issues which may have influenced the work; and to identify any lessons. 2.4 Ben’s parents and Ben’s Mother’s partner were advised of the review and invited to contribute their views. Ben’s Mother and Partner did not respond to the initial invitation. Ben’s Father and Paternal Grandmother met with the Lead Reviewer at the end of the review Process to share their views on services received. 2.5 The Review Terms of Reference set the following Learning Outcomes • To gain an understanding of the systemic factors that led to this child’s death • To identify learning from all aspects of the history and engagement with the family • To promote any learning from this SPR across the safeguarding partnership Specific Questions (areas for exploration) • Expectations from professional referrals which result in no further action e.g., Hospital to Children’s Services, Hospital to Mental Health • Procedures and expectations in relation to serious child injury • Information sharing - VISOR offenders, moves across boroughs, Domestic Abuse, MARAC expectations • Risk assessments – including the child’s experience, parenting capacity, culture, and any possible substance use. 2 A Rapid Response is required by statutory guidance Working Together to Safeguard Children 2018. One of the outcomes may be a Child Safeguarding Practice review as set out in Chapter 4. https://www.gov.uk/government/publications/working-together-to-safeguard-children--2 Croydon Safeguarding Children Partnership 6 2.6 Panel Membership Independent Chair Lead Reviewer Bridget Griffin Independent Author Lead Reviewer Malcolm Ward They are both experienced in leading child safeguarding reviews using a systems approach. Representatives from the following agencies: Croydon Children’s Social Care, Croydon Community Development Service, Croydon University Hospital NHS Trust, Lambeth Children’s Social Care, London Ambulance Service, Metropolitan Police Service, National Probation Service, South London and Maudsley NHS Trust, and the Croydon Safeguarding Children Partnership and the Lambeth Safeguarding Children Partnership. The review was supported by the Croydon Safeguarding Children Partnership The Panel Representatives were senior managers who had no direct involvement in the case. 2.7 During the main period of the review, the Covid-19 pandemic prevented face to face meetings. It was not possible to hold an online Practitioners’ Focus Group until November 2020. 2.8 The criminal investigation into Ben’s death was impacted by a long period awaiting the results of the post-mortem and biopsies; this is a known national shortage and systems issue for such investigations which impacts on learning reviews as well as on criminal justice processes. In December 2020, Ms A and Mr D were charged with murder and causing or allowing the death of a child. Their trial is awaited 3. Background information 3.1 Ben was born in autumn 2017. He was Black British. He was the first child to his mother, who was nearly 20, when he was born. Ms A initially described the pregnancy as “unplanned but welcome” but later she said that she was unhappy about the pregnancy. 3.2 Ben’s Mother and Father ended their relationship before Ben was born but Ben’s Father continued to have contact for a substantial part of the period under review. 3.3 Ben’s maternal grandparents had settled in the UK. They were said to have had a difficult relationship during Ms A’s childhood and divorced when Ms A was 17. 3.4 When Ms A was 18 Police were called to an incident between Ms A and her mother when Ms A alleged that she was assaulted. However, she continued to live in the household after this. 3.5 After Ben’s death it was learned that Ms A had been in a relationship with Mr D, probably from November 2018. He was previously known to the police, youth offending services and to children’s services in a neighbouring local authority where there was concern about his previous involvement in criminal activity and domestic abuse. Croydon Safeguarding Children Partnership 7 4 Summary account of events and agencies’ involvement with Ben’s family February 2017 to September 2019 The summary is drawn from agency records3 of many contacts with Ms A and Ben and their family and parallel and then later contacts with Mr D. It covers the period from when Ms A was confirmed as pregnant with Ben. February to October 2017 (Pregnancy with Ben) 4.1 Early in the pregnancy there was an allegation that Ms A had been assaulted by her mother. Ms A’s mother counter-alleged that Ms A was drinking and using drugs. Police informed Children’s Social Care (CSC) because of the vulnerability of Ms A’s younger brother and the pregnancy. 4.2 Ms A was supported by the Croydon Family Justice Centre and Housing to move to temporary emergency accommodation. Her situation was discussed at the Multi-Agency Risk Assessment Conference - MARAC4 on two occasions during the pregnancy but Ms A withdrew from support of the Independent Domestic Violence Advisor. 4.3 Midwifery saw Ms A for the first time in late March. She reported little family support and a history of depression and was referred to the Perinatal Mental Health Team but did not meet their criteria. 4.4 The Children with Disabilities Team assessed that there was no risk to Ms A’s younger brother. The case was closed with no contact with Ms A or consideration of her as the potential victim of domestic abuse. This was a missed opportunity to consider unborn Ben’s needs, including the allegation of Ms A’s use of alcohol and drugs. 4.5 A Midwife saw Ms A at 16 weeks’ pregnant. She was still only 19 and was in “homeless persons accommodation” and isolated. She did not attend any antenatal classes during her pregnancy. In mid-May she moved to temporary self-contained accommodation, within a hostel. 4.6 In June, the Health Visitor sought information from the GP, and the Best Start Social Worker to initiate a pre-birth health visiting assessment. 3 Services involved were GP, Midwifery, Police, Domestic Abuse Services, Early Help Services/Best Start, Health Visiting, Ambulance Service, Mental Health Services, Children’s Social Care (in two Local Authorities) and Probation 4 MARAC Multi-agency Risk Assessment Conference. These are local multi-agency meetings where service representatives share and review information about cases of domestic abuse to plan and co-ordinate responses. Croydon Safeguarding Children Partnership 8 4.7 At the end of July, Ms A told a Midwife that she was still feeling low, had financial worries, and had fallen out with her mother. The Midwife re-referred her to the Perinatal Mental Health Service, but again the referral did not meet the criteria. It was wrongly assumed that Ms A had been referred to the Family Nurse Partnership5. The Perinatal Service advised the GP that Talking Therapies could be considered. 4.8 The Health Visitor met Ms A for the first time in early August. Ms A had not kept a prior appointment. Ms A was unhappy about the pregnancy. She agreed to an Early Help6 referral and for the GP to be informed. 4.9 Ms A saw a GP in mid-August. She was tearful and reported financial difficulties and no support. At the follow up review with the GP, Ms A said she was feeling better. She had seen her mother and was again in contact with Ben’s Father who she now described as “supportive”. When seen by the Health Visitor Ms A reported feeling better. The Early Help/Best Start Social Worker was due to visit. 4.10 In the third week of September, Ben was born prematurely. Ben’s Father was present at the birth. Ben was in the Special Care Baby Unit for eleven days. There were mixed observations about Ms A’s care of Ben and although this concern was to be passed on to community health staff there is no evidence that it was. October 2017 to December 2017 (Ben birth to 3 months) 4.11 A different Health Visitor made the New Birth Visit and observed good mother-baby interaction. Ms A reported no low mood and expressed trust in her GP and knew how to seek help. When asked, through Routine Enquiry7, about domestic abuse Ms A said there had been none. An enhanced Universal Plus Health Visiting service8 was agreed due to “prematurity and Mother’s history”. Ben was seen at home a week later and was progressing well. 4.12 In mid-October, the Early Help Teenage Pregnancy Support Worker (from Best Start) met Ms A for the first time as Ms A had not accepted previous appointments, during the pregnancy. Ms A was assessed to be coping and to have made connections to services. They agreed a plan to work together but Ms A did not respond to further contacts. 5 Family Nurse Partnership The Family Nurse Partnership is a voluntary home visiting programme for first time parents aged 19 or under, it should be started before the 28th week of the pregnancy. A specially trained family nurse supports the mother from early in pregnancy until the child is two. 6 Early Help is the additional voluntary available for children, and their families where they have additional needs that are not being met by universal services. At the time this was provided by the Best Start Service. 7 Routine Enquiry Involves the safe screening of all service users within a service by asking sensitive questions about their experiences of specific issues – in this case of domestic abuse. It is expected practice for Midwifery and Health Visiting Services. Domestic abuse: a resource for health professionals - GOV.UK (www.gov.uk) 8 Universal Partnership Plus - Health Visiting Service Best Practice Pathways - NHS Healthy Child Programme Croydon Safeguarding Children Partnership 9 4.13 The original Health Visitor took lead responsibility from this point. Ms A reported regular visits and support from her mother, Ben’s Father and other friends and family. However, a member of the community reported to the GP and to the Health Visitor that Ms A had low mood, was tearful and was feeling unsupported. Ms A was seen separately by the GP and by the Health Visitor. She had low mood and was concerned about not bonding with Ben as he had been in SCBU. She felt unsupported. She declined medication and was advised to refer herself to the Improving Access to Psychological Therapies Programme (IAPT)9. The GP and Health Visitor planned to monitor her. The Health Visitor updated the Teenage Pregnancy Worker. 4.14 Ms A referred herself to IAPT, which accepted her referral, noting it as ‘low risk’. They offered her a telephone assessment. 4.15 Ms A did not respond to the Health Visitor’s further contacts until mid-November. She felt more positive, but she had argued with Ben’s Father. She felt a strong bond with Ben. Ms A said that she had not received an appointment from the IAPT. The IAPT had closed the referral as they had not heard back from her. She had not followed up with the Teenage Pregnancy Worker as part of the agreed support plan. 4.16 Ms A saw the GP, Ben (now eight weeks old) was not present. Her mood was better she said that was awaiting a response from IAPT. The next week the Health Visitor saw Ms A and Ben. Ms A was feeling positive and continued to see her family and Ben’s Father. The Health Visitor observed “Sensitive and responsive parenting”. Ms A intended to transfer to a more local GP and to attend the baby clinic nearer to her temporary home. 4.17 The Health Visitor saw Ms A and Ben for the last time in mid-December, as Ms A was transferring to a different geographical team. Ben’s Father and Ms A’s mother were said to be visiting regularly. Ms A was still awaiting her appointment from the IAPT, which had been closed. In late December Ms A transferred to a more local GP and more local Health Visiting Team. January to October 2018 (Ben aged 3 months to 13 months) 4.18 Ben was seen by an Out of Hours GP in mid-January for a minor issue. (This was the first time Ben was seen by a GP, aged 4 months.) He was seen in the surgery three days later and had his first and overdue immunisation. 4.19 In early February Ms A contacted NHS 111 for herself. She was advised to contact her own GP within two hours – but did not. 4.20 In late February, Police received information that a package sent to Ms A’s address, containing cannabis, had been intercepted; it was not specifically addressed to Ms A. The investigation was inconclusive. 4.21 Ben was not brought for his next immunisation. The Surgery wrote to Ms A about this in April. 9 IAPT Welcome | SLaM: Improving Access to Psychological Therapies (slam-iapt.nhs.uk) Croydon Safeguarding Children Partnership 10 4.22 Ms A called the Police in April because of a dispute with her mother and sister. They claimed that Ms A had mental health problems and that they were worried about Ben’s welfare. Police noted Ben to be well; there were no concerns about the home. Ms A made a historic allegation about a significant traumatic event in her childhood; Police tried to follow up this historic allegation but Ms A did not take it further. Croydon Children’s Social Care was informed of this call out. 4.23 In May, Ms A alleged to the Police that Ben’s Father had seriously physically assaulted her in April. She had not reported it at the time as she had thought that it would make matters worse but had been advised to do so by the Family Justice Centre worker. The Police had no concerns about Ben. They advised Children’s Services of the new allegation. Police later arrested Ben’s Father for this alleged domestic violence but could not investigate further as Ms A declined to assist. 4.24 Ms A requested a consultation with her GP but did not then respond to calls from the surgery. 4.25 Ms A told the Family Justice Centre worker that Ben’s Father had punched her in the face. (This was different to the account given to the police) The FJC arranged for Ms A’s locks to be changed and made referrals to Housing, Children’s Social Care and to the MARAC. 4.26 Children’s Social Care agreed to undertake a Child and Family Assessment10. In late June, the case was discussed at MARAC. Ms A had alleged that Ben’s Father was coercive and controlling and that he had physically assaulted her in front of Ben. She did not wish to press charges or seek a non-molestation order against him because she was too fearful of him. It was understood that Ms A’s younger, disabled brother was resident with her and Ben. The Independent Domestic Violence Advisor (IDVA) agreed to liaise with Children’s Services about both children. The new Health Visiting Team for Ben and the School Nurse for Ms A’s disabled brother were advised of this MARAC discussion. 4.27 The IDVA later alerted CSC that Ms A was not responding to attempts to work with her. The Social Worker visited Ms A at the end of June. There were no immediate safeguarding concerns. Ben was seen to be physically healthy. Ms A reported that she had taken protective measures to cease contact with Ben’s Father. This was assessed as her ability to prioritise Ben’s safety. Ms A was advised to speak to the Family Justice Centre about safe contact arrangements between Ben and his father. It is not clear that the safety of Ms A’s brother was considered, nor for Ben regarding the parallel allegations about the maternal family. 4.28 In late September, the GP surgery wrote again to Ms A about Ben’s outstanding immunisations. She contacted the surgery seeking a consultation for herself but did not respond to several return calls to follow this up until October when she spoke with a GP by phone. She had been feeling tired for a few months. Ben was said to have been unwell with a fever and vomiting for two weeks. This was a possible opportunity to discuss Ben’s outstanding immunisations. An appointment was given for Ben, but he was not brought to it. 10 A multi-agency assessment under the Children Act 1989, led by a social worker, to ascertain if a child needs additional services. Croydon Safeguarding Children Partnership 11 4.29 At the start of October, the CSC Children with Disabilities Team responded to the Family Justice Worker, following the MARAC meeting in June, to say that Ms A was not known to them but that they were working with her younger brother. There appears to have been no assessment of the concerns raised about possible risk to the younger brother. 4.30 In late October, the GP Surgery wrote again to Ms A about Ben’s outstanding immunisations. 4.31 At the end of October Children’s Services completed the Child and Family Assessment. This was completed outside the recommended time scale. It noted that contact with Ben’s Father was an important but unresolved issue and that both Ben’s parents had been given advice about this. There were said to be no other concerns, despite the alleged domestic abuse and the GP being worried that immunisations were overdue. The case was closed to CSC with no further action. It is not clear that there was an attempt to speak with Health Visitor or refer for Early Help such as a Children’s Centre. November 2018 to April 2019 (Ben aged 14 months to 19 months) Hindsight information suggests that Ms A met and started a relationship with Mr D in November 2018, but this was not known to agencies at the time. 4.32 At the end of November, the GP surgery sent another letter to Ms A about Ben’s overdue immunisations. 4.33 There appears to have been no involvement with Ben or Ms A by any agency until April 2019. 4.34 In April 2019 Ms A consulted the GP Surgery about Ben by telephone. He was assessed to have a viral infection. The Surgery later followed up this phone consultation with a text alert asking Ms A to bring Ben for his overdue immunisations. May 2019 Critical incident - Ben’s Head Injury, Inpatient Stay and Referral to Children’s Social Care (Ben aged 1 year 8 months) 4.35 In early May, Ben was brought by ambulance to hospital with a head injury and extensive bruising to the side of his head and face. Ms A stated that Ben had jumped one metre from the sofa on to the metal edge of a highchair. There were two different accounts given – one referring to the base of the highchair and one to the leg, but they were similar. Ben was admitted to the children’s ward. 4.36 Further tests were done and second and third opinions were obtained. It was suggested that there may have been multiple impacts. Safeguarding was to be considered. Background checks were made to Children’s Social Care which shared the limited previous involvement and that Ms A had been responsible for the domestic abuse of Ben’s Father, which was not the case. Croydon Safeguarding Children Partnership 12 4.37 The view was being formed that the injury was, on balance, more likely accidental and consistent with Ms A’s account that Ben had jumped from a sofa and hit his head on the base of the highchair. She said that she had witnessed this and that her partner was in the kitchen. This is the first information received by any agency that Ms A may have been in a new relationship. It is possible that this was Mr D, but his identity was not checked at the time. 4.38 Ben was observed regularly; there were no concerns about the mother and child relationship. Family members reported that Ben was boisterous and often flung himself from furniture. Hospital staff also noted such risky behaviour. 4.39 Lead Safeguarding Advisors within the hospital recommended that a body map of injuries should be completed and that a referral should be made to Children’s Social Care, given the uncertainty. The written referral to CSC did not reflect the uncertainty or the seriousness of the current concerns held by medical staff about Ben’s injuries. 4.40 In the absence of clear contrary evidence, a medical view was formed that the injuries were likely to be consistent with Ms A’s account. The Named Nurse observed that the injuries were extensive for a fall, that Mother was in a new relationship with an unknown male and that even if accidental, the injury should raise concerns regarding lack of supervision as Ben was described as highly active. 4.41 The Named Nurse, the Consultant and a Doctor met to review the case. The CT scan was inconclusive. The next day a skeletal survey was done as the injuries were out of proportion to the stated mechanism. No fractures or other bony injuries were seen in that survey. 4.42 The Named Nurse made a special effort to speak face to face with the Manager of the Single Point of Contact / MASH, because of her concerns. Children’s Social Care noted that the injury to Ben’s face was considerable. The hospital Multi-Disciplinary Team were not calling the case Non-Accidental Injury but felt that the injury was big given the explanation. Further results were awaited. The CSC Manager agreed for CSC to undertake a home visit and to share the family background information with the hospital. The Named Nurse understood that a Child and Family Assessment would be undertaken and that an Early Help referral would be made if social work was not required. 4.43 Ben was discharged home. An ophthalmology review later showed no damage but was to be repeated in four weeks. The GP was informed. 4.44 A Senior Manager in Children’s Social Care reviewed and overturned the decision to undertake a home visit on the basis that the threshold for a referral and had not been met. Social Care understood from the written referral that Ben had not suffered Non-Accidental Injury. The Child and Family Assessment was cancelled as an opinion was formed that it was not proportionate to complete an assessment of need based on mother’s personal history and on the hospital staff’s “professional anxiety”. There was no dialogue with the hospital Safeguarding Team about overturning this decision; nor was the decision to close the referral conveyed back to them. 4.45 Ben had a follow up chest X-ray two weeks later which showed that there was no evidence of any fractures. Croydon Safeguarding Children Partnership 13 Mid-May 2019 to October 2019 & Ben’s death (Ben aged 1 year 8 months to 2 years) 4.46 A new Health Visitor (alerted by the hospital) tried unsuccessfully to contact Ms A both by phone and by unannounced visit. No Health Visitor had seen him since December 2017. 4.47 In late May, Ms A contacted the GP surgery by phone worried about a swelling in Ben’s scrotum. She was offered an appointment for that afternoon - but did not bring him. 4.48 In late June, the new Health Visitor saw Ben and completed his two-year developmental check. He was one year and nine months. Ms A reported that Ben jumped from the sofa and hit his head on the wall; a different account to the one given to the hospital. The home was clean and tidy with plenty of age-appropriate toys. Ben’s assessment suggested that he had significant speech delay for his age. Ms A was advised to take him to a service which could then link him on to the speech and language service. The Health Visitor planned to liaise with Children’s Social Care but noted, a week later, that CSC had closed the case. 4.49 In late July, Police were called to the family home because of a domestic dispute between Ms A and Mr D. Ms A had been heard to shout “Stop hitting my face”. She told the Police that she and Mr D had been together for nine months (from November 2018). They had been arguing but Ms A denied that there had been a physical assault. She declined to answer the SafeLives domestic abuse assessment / DASH questionnaire.11 Police checks showed that there had been no previous incidents between this couple. Ben and Mr D’s own child were present at the time. Both children appeared happy and well fed. This appears to be the last time Ben was seen by any professional. 4.50 The Police did not complete a routine notification to Children’s Services which would have been expected operational procedure after such a domestic incident. This was the first time that there was clear evidence that Ms A had a new partner. Mr D’s violent background and convictions would have been known in Police records. This was a missed opportunity. Historic information about Mr D which was available in July 2019 Mr D was well known to the Police from 2006 for offences of robbery, assault, burglary, affray, possessing weapons, possessing cannabis, breaching bail conditions and domestic abuse. He had been assessed by the Probation Service as a high risk of harm to the public, to rival gang members and to previous or future partners. From November 2018, Mr D missed occasional meetings with his Probation Officer and admitted to daily use of cannabis. He also reported regular contact with his own child. Lambeth Children’s Services were not advised about this, at the time. In February 2019 he told his Probation Officer that he was not in a personal relationship. In April, the Probation Officer was concerned that Mr D was not staying at his approved address. 11 DASH Domestic Abuse, Stalking and Honour Based Violence https://safelives.org.uk/node/516 https://safelives.org.uk/ Croydon Safeguarding Children Partnership 14 In July Mr D informed his Probation Officer that the Hostel was helping him look for work, giving the impression that he was still resident in, and co-operating with, the Hostel. 4.51 The day after this domestic abuse incident Ben was not brought to a follow up appointment at the hospital in relation to his head injury. 4.52 In the last week of July, Ms A saw her GP. She described depression and low mood for a year with poor sleep and being tearful and that she had been emotional since Ben’s birth. She was advised to self-refer to the IAPT Service, which she did the same day. 4.53 Mr D was warned by his Probation Officer about non-co-operation. In subsequent meetings he said that he smoked cannabis twice per day and that he did not see cannabis misuse as either a problem or illegal. 4.54 The GP Surgery sent a message to Ms A about Ben not having been taken to his follow up hospital appointment. She was seen in the surgery a few days later for herself by a different practitioner. No link was made to the request for her to contact the surgery to discuss Ben not being taken for the hospital follow up. 4.55 In late July, Police received intelligence about Mr D’s probable association with gang activity. 4.56 In early August, the Probation Service wrote to both the Croydon CSC and the Lambeth CSC giving information about a possible move by Mr D to an address in Croydon, not Ms A’s address. Croydon CSC replied that they were not aware of any children at the address given and had no awareness of Mr D’s child in Lambeth. Lambeth Children’s Services have not been able to confirm that they received this request for assistance from Probation. 4.57 In the second week of August the IAPT assessed Ms A. She had severe symptoms of depression and anxiety arising from social anxiety and low mood with a history of suicidal thoughts resulting from trauma. She denied current thoughts to harm herself or others and reported no substance misuse. Ben was seen as a protective factor, which was noted to be unrealistic, given his young age. It was agreed that she should be allocated a higher level of intervention and an appointment was given. 4.58 The same day Ms A contacted the Health Visitor by phone to seek advice about funding for a nursery for Ben. Ms A told the Health Visitor that she was accessing support through IAPT for depression and was feeling better. 4.59 In mid-August Ms A attended an appointment in her own right at the Surgery. Ben was not discussed. Two days later the Surgery Administration texted her asking her to contact them about Ben’s missed immunisations. 4.60 The Health Visitor contacted Ms A to be told that Ms A was out of London. 4.61 In the third week of August Ms A called IAPT to cancel her appointment saying that Ben had chickenpox. That same day Ms A did not keep a GP appointment for herself. Croydon Safeguarding Children Partnership 15 4.62 Mr D met with his Probation Officer and for the first time shared that he was in a new relationship. This should have been explored more fully so that relevant checks could be undertaken, given his history, and known risk to prospective partners. This was a missed opportunity to assess risk to Ms A from Mr D. 4.63 In early September Ms A did not attend the replacement appointment with the IAPT therapist. She was asked to make a further appointment, or the request would be closed. Three weeks later the service closed the contact as there had been no response. 4.64 In the last week of September, Ms A was seen at the GP Surgery for herself. Later in the week she sought further medical advice by phone and after not responding to return calls from the GP she was finally spoken with and given advice over the phone. 4.65 In contacts with his Probation Officer in late September and early October Mr D was noted to be looking for employment and continuing to smoke cannabis. He reported that he was still seeing his child but there was no mention of his probable regular contact with Ms A and Ben. There was no follow up to the information request to Lambeth Children’s Services about his own child. 4.66 Ms A contacted the GP Surgery concerned (again) that Ben’s scrotum was swollen from time to time. She was advised to ring back when the swelling was evident so that he could be examined. 4.67 Four days later Ms A attended the surgery for herself. 4.68 In mid-October Mr D completed his one-year Probation follow up to his discharge from prison. Regarding accommodation, he said that if he could not afford the rent he would live with his partner. There was no exploration as to who his partner was. 4.69 Two days later an ambulance was called to the house as Ben had ‘collapsed’. He was taken to hospital where he died, despite attempts to save him. Initial examination of the home noted a distinct smell of cannabis and a cannabis grinder was found. 4.70 A murder investigation was started. 4.71 The post-mortems showed many non-accidental fractures and re-fractures which were assessed to have occurred over the preceding four weeks. Ben’s death was caused by blunt force trauma. He had injuries to his liver and other bruising, including to his penis. Croydon Safeguarding Children Partnership 16 5. Family involvement in the review and their views 5.1 At the start of the review Ms A and Ben’s Father, Mr B, were contacted and invited to contribute their views about the services that they had received to inform the learning for this review. Mr D was also informed of the review. None of them responded. 5.2 At the end of the review process, they were contacted again. Ms A and Mr D did not respond (they had been charged by this time). Mr B and his Mother agreed to meet with the Lead Reviewer. This took place in May 2021. 5.3 Mr B and his Mother were very upset by Ben’s death. A different picture emerged from their account as they had been much more involved in Ben’s life than agencies working with Ms A had known at the time. 5.4 Mr B and Ms A were not a couple and had no intention of being together. However, Mr B and his Mother reported frequent regular contact with Ben and that Ben came often, when Ms A permitted this, to his grandmother’s home. 5.5 Mr B was present at Ben’s birth. He had Parental Responsibility. Despite this he believed that the system was weighted towards mothers when parents were not together. He was not invited to any antenatal appointments or classes and wondered whether services should write to fathers who are interested in being part of their children’s lives. He was not clear about which services were available for fathers to get information. He believed that the power was with the mothers. 5.6 He tried to see Ben as often as he could but was dependent on Ms A agreeing to this, and at times, she would refuse it. His contact with Ben was not as regular as he would have liked as a result, especially when Ms A was working and Ben was, at times cared for by a relative of Ms A’s, sometimes for a week at a time. 5.7 Mr B was shocked about being arrested and detained by the Police in May 2018 when Ms A alleged Actual Bodily Harm. He said that he had not hit her. 5.8 His contact with the Social Worker undertaking the Child and Family Assessment was by telephone and he was able to express his wish to have ongoing contact with Ben. He was able to have occasional contact with Ben after that. 5.9 Mr B believed that from April 2019 things changed. He was most concerned about the head injury to Ben in early May 2019. Ben had been with him that weekend at his Mother’s house. The next day Ms A informed him that Ben was in hospital. Mr B was angry and very worried about when he saw the injury to Ben’s head and face. He felt that despite being the father he was not being given information. This outburst led to Ms A seeking to have Mr B removed from the hospital. A doctor then spoke with him and was reported to have said “these things can happen”. Mr B felt that the injury was not being taken seriously. He believed that Social Care should have been involved and was not aware that the hospital had, in fact, referred their concern about the injury to Social Care. No professional contacted him after that. Croydon Safeguarding Children Partnership 17 5.10 He was able to see Ben for a few weekends after that but then things broke down between Mr B and Ms A in July and there was no more contact. Mr B did not feel that he could take the matter to court to have greater or more consistent access or even care of Ben as he believed that the courts place greater weight on children being with their mothers. 5.11 This conversation with Mr B and his Mother shows a different picture to that given by Ms A. It was clear from evidence provided to the reviewer that Mr B and his Mother were frequently in contact with or had care of Ben. It raises questions about how services work with separated parents and with absent fathers; and how services form a view of fathers when the only informant is the mother. 5.12 Ben’s Father and Grandmother agreed to use of the pseudonym “Ben”. Croydon Safeguarding Children Partnership 18 6. Analysis and lessons 6.1 A Reflective Workshop for as many practitioners and managers as possible who had been involved in the case was held online because of the Covid 19 Pandemic. The purpose was to capture the experience and reflections at the time of the work from a systemic perspective and to seek to avoid hindsight bias. The practitioners were asked to comment on the emerging lessons from the review identified by the Panel. Their responses are incorporated into the analysis and lessons below. 6.2 It is not the purpose of a Child Safeguarding Practice Review to assess whether the death of a child or significant harm was preventable. The Review’s purpose is to use the case as an example of how well the local child welfare systems were or are working singly and together and whether there are any actions which should be taken to improve services and their delivery. 6.3 From mid-July to his death three months later it seems that no practitioner saw Ben. Questions are: whether he was being kept from view and/or whether Ms A may have been subject to coercive control? At this point we do not have evidence to answer these questions. They underline the potential vulnerability of young children who may be being harmed but who are not involved in pre-school activities and thus hidden from view unless drawn to attention by family or the community. 6.4 The review highlights lessons for local agencies, some of which are familiar and some not. It is easier to see these with hindsight and it would be unfair to judge practitioners and services by what was not apparent at the time, or which could not have reasonably been obtained. There were, however, missed opportunities to identify risks to Ben. This section highlights the most important lessons from the review. 6.5 Assessing head injuries in young children – the need for a multi-disciplinary response 6.5.1 Ben’s time in hospital in May 2019 is significant. Head injuries in children are potentially profoundly serious. The fact that there was no fracture or damage to his brain and that he made a quick and apparently good recovery may have lessened the concern about him. Thorough assessments were done as part of the medical diagnosis and appropriate advice was sought from specialists and from the hospital’s lead professional advisors on child protection. After several assessments and observation over a few days a view was formed by the treating clinicians that the injury may have been accidental. However, there was still doubt about the cause of the injuries and the explanation given by his mother, which was plausible, but which had changed slightly over time. (A third, different account was later given after Ben had been discharged from hospital.) Given that it could not be established that the harm to Ben had been caused by an adult, on balance it was seen that the account that Ben had caused the injury himself by jumping could be possible, but there was still doubt. There also remained, however, the question of the possible lack of parental supervision and Ben’s overactive behaviour, which was observed by hospital staff and also reported by family members. Croydon Safeguarding Children Partnership 19 Therefore, even if the injury had not been deliberate, the possibility of elements of neglect or behavioural and developmental issues being involved was still present. 6.5.2 A lesson which must be repeated is that diagnosis of non-accidental injury is complicated and needs to consider not only the medical aspects but also the wider circumstances; including the possibility of checking the environment of the alleged accident to confirm its mechanism.12 It has been noted in previous enquiries that child protection investigating agencies often want the confirmation of a clear diagnosis of deliberate harm but that this is not always possible, and that the system must, therefore, work with uncertainty. 6.5.3 The lack of an immediate ‘child protection’ label about the cause of the injury meant that a Strategy Meeting was not considered as the threshold was not seen to be definitively met. Nor was a Discharge Planning Meeting convened. However, hospital staff still had serious concerns and further tests were to be undertaken by further monitoring and follow up x-rays and a skeletal survey, which is used rarely and usually only in serious cases. A Strategy Meeting or Discharge Planning Meeting would have enabled a greater sharing about what was known and the degree of uncertainty and concern that remained. A Strategy Meeting would also have led to Police involvement and screening and to more curiosity about the male who had been present in the home – probably Mr D. 6.5.4 It was noted as a systems dynamic that paediatricians are more likely to focus on the clinical issues of the injury and are less familiar with child protection procedures, such as Strategy Discussions, and that Strategy Discussions may not be happening locally as often as they should. 6.5.5 All extensive injuries to young children are worrying, and some will, of course, be accidents. However, head injuries may be particularly significant in younger children especially where there is doubt about their cause. It was appropriate for the hospital to refer Ben to Children’s Social Care for a fuller assessment. However, the referral only raised questions about parenting and history rather than about unanswered questions about the injury, possible inconsistences in the account and possible other injuries to Ben. Further medical investigations were still to be undertaken to seek to explain the injury. This raises questions about how such referrals are quality assured and updated when further diagnostic work (for example additional tests) is planned after the referral to social care has already been sent in. Also, what is reasonable to expect in a busy Emergency Department or Children’s Ward? 6.5.6 The Named Nurse continued to be seriously concerned about Ben and took the extra steps as outlined in 4.44. 12 See Abusive head trauma in infants, BMJ, April 2018 & December 2020 Abusive head trauma in infants - Symptoms, diagnosis and treatment | BMJ Best Practice; and Child Abuse Review: Special Issue: Abusive Head Trauma: Recognition, Response and Prevention, May – June 2020 https://onlinelibrary.wiley.com/doi/epdf/10.1002/car.2578; and A National Child Safeguarding Practice Review Panel Thematic review into non-accidental injury in children under one is expected to be published in 2021. Croydon Safeguarding Children Partnership 20 6.5.7 Children’s Social Care later overturned the decision to undertake a Child and Family Assessment seeing the hospital’s concern as ‘professional anxiety’, rather than seeing it as a legitimate statement of professional concern about a child without being able to ascertain as fully as possible the cause of that concern, without the fuller assessment of the child’s circumstances. The decision to close the referral did not take into account wider issues of the context of the injuries, even if they were being seen as consistent with an accident. The wider context included the nature of Ben’s possible overactive behaviour, a new and unknown male partner in the household, and that Ben was not being seen by universal and pre-school services. Ben’s behaviour seems to have been accepted rather than reflected upon. It raised questions about both his development and about parenting. 6.5.8 This review made an interim recommendation about the multi-agency assessment of head injuries to the Croydon Safeguarding Children Partnership and Croydon Children’s Social Care: Recommendation 1a: Serious Injuries to Children There should be serious consideration of routine progression to a Child and Family Assessment for any child with an injury where this is requested by Health professionals. Recommendation 1b: When, after a serious unexplained injury, a child requires in-patient observation and/or a skeletal survey there should always be inter-agency dialogue about next steps. This would best be achieved through a multi-disciplinary Strategy Discussion. It is important that there is dialogue between the key services (Health, Social Care and the Police) about whether a wider assessment is required and how that can best be undertaken. This is best done through a Strategy Discussion or other conversation rather than by solely written referrals. Then the medical assessments, further planned assessments and background enquiries can be fully considered and non-medical professionals can ask relevant questions of the medical assessors to support the multi-agency decision about the need for a child and family assessment. 6.6 A single agency overturning agreed multi-agency decisions; communicating decisions to referring agencies and ensuring representation and escalation where there is (possibility of) disagreement about whether to undertake a multi-agency assessment 6.6.1 Despite the initial agreement by the MASH to undertake an assessment this was later overturned, and the case was closed. This Review has been informed that the decision not to proceed was taken in a wider context of a bigger system view which had been formed within Social Care that too many referrals were being made by partner agencies which did not meet the threshold for assessments. Such referrals were often found to be unsuccessful as they did not have the consent or cooperation of the parents, who often declined assessment. This must also be seen in the context of Croydon Social Care improving following an Inspection in 2017 which had judged the authority as inadequate. In February 2019, just before this incident, improvements were being noted for most cases but there was still variability 13. 13 https://files.ofsted.gov.uk/v1/file/50062794 Children’s services OFSTED Monitoring Letter Croydon Safeguarding Children Partnership 21 6.6.2 The decision to close the referral in May 2019 was taken unilaterally without reference back to the referrer or to the Named Nurse who had advocated specially for the case. She is clear that had she known that the agreement had been overturned she would have made further representation and escalated her concerns about Ben. No other agency, such as Health Visiting or the GP was consulted about whether an assessment was required. Consulting the GP would have shown a pattern of non-engagement in universal health services. 6.6.3 To not inform the referrer of the change of decision and the case closure was not agreed practice. It was noted that this was a practice issue which had been highlighted previously in other local reviews. The Review Panel was advised that a recent changes introduced in Children’s Social Care include work to ensure feedback to referrers. 6.6.4 Recommendation 2: The Croydon Safeguarding Children Partnership should seek assurance from Services and through regular case audits that decisions not to proceed to a referral (for any issue) are communicated back to the referrer / referral agency in a timely way, with an explanation and an opportunity to question the decision not to accept the referral. 6.7 The local operation of the National Healthy Child Programme, Universal Services monitoring of young children like Ben, ensuring that they do not get lost, the Threshold between universal services and the need for additional support and or Early Help; Use of the Croydon Thresholds Guidance 6.7.1 This review of Ben’s life and wellbeing should be seen in the context of both his family-based care and the wider safety net of the universal services around him. Ben was a child for whom the National Healthy Child Programme14 should have been both a support and a safety net. During the time of this review period, the Director of Public Health in Croydon published The first 1000 days from conception to the age of 2 15, this sets out the context and expectations for support of families with young babies and infants in Croydon. Ben also met the local threshold16 for Early Help Services. All of these are services offered to families on a voluntary basis subject to family agreement and take up. 6.7.2 Ms A was a young and new single mother, separated from the child’s father. She reported that she had allegedly experienced traumatic abuse as a young person, including historic domestic abuse in the family home; she also alleged serious sexual assault as a child. She was in temporary accommodation and was potentially isolated. She described low moods and a history of depression. Ms A became pregnant with Ben, unplanned – although he was said initially to be wanted, Ms A later said that she was unhappy about the pregnancy. As a result of the pregnancy, she felt that she had to step down from further education. No one appears to have talked with her about her feelings about giving up her course and what the potential loss of her ambitions meant. 14 NHS, Healthy Child Programme, http://www.healthychildprogramme.com/ date? 2014/15? 15 We are Croydon, Early Experiences Last a Life time, The first 1000 days from conception to the age of 2 http://croydonlcsb.org.uk/wp-content/uploads/2018/12/Director-of-Public-Health-report-2018-first-1000-days.pdf 16 Croydon Safeguarding Children Board Thresholds Guidance. 2013 & 2017 http://croydonlcsb.org.uk/wp-content/uploads/2013/08/CSCB-Thresholds-Guidance-.pdf Croydon Safeguarding Children Partnership 22 6.7.3 The local delivery of the National Healthy Child Programme and the Croydon Early Help services were there to support her in becoming a (first-time) parent, as a vulnerable person. The systems were also there to monitor Ben’s growth and development through routine screening services. This review suggests that these did not work as well as they might have done. It should be noted, however, that such services are voluntary and rely on parental cooperation and engagement. Questions arise, however, about how well the systems work when a family has been identified as vulnerable and in need of additional support but when parents do not engage – what should agency responses be? 6.7.4 It has been agreed that Ms A would have benefitted from a referral to the Family Nurse Partnership17 which offers targeted support to young and vulnerable parents. This does not appear to have been considered by Midwifery and when the Health Visitor first became involved it was too late to refer Ms A. 6.7.5 Midwifery, Health Visiting and other services supporting vulnerable pregnant women (especially those under) 19 may wish to consider reviewing how well practitioners are informed about The Family Nurse Partnership Service and how well it is used. 6.8 Parenting education for new and inexperienced parents 6.8.1 A systems question arises: How are new and possibly young parents supported by parenting education as they become first-time parents? It seems that Ms A did not attend any antenatal classes – although it was usual practice to inform and invite prospective parents, including fathers. Records do not indicate if Ms A was invited to such parenting classes. Mr B said that he was not invited. Parenting education would, therefore, have been advice from Midwifery during limited antenatal contacts – where sessions often concentrate on the mother and developing baby’s well-being and preparation for the birth rather than future parenting. Beyond this a soon-to-be parent is offered leaflets which are not a reliable education medium. Or the parent is left to their own devices, and the experiences, advice and teaching from family and friends or social media. Where does such a parent learn to parent, apart from her own experiences and in Ms A’s case occasional care of her disabled younger brother? 6.8.2 Recommendation 2: Public Health, with Midwifery, Health Visiting and other relevant services are recommended to undertake a review of the current strategy and practice response to parenting education for first time and young parents. This should include the use and efficacy of alternative approaches and best practice such as leaflets and online media, especially when a parent does not accept the offer of parenting classes. The review should include how fathers are included in parenting education. 17 Family Nurse Partnership Search | Croydon Health Services NHS Trust Croydon Safeguarding Children Partnership 23 6.8.3 Early Help Throughout the pregnancy and early in the postnatal period there were several occasions when practitioners noted concern for Ms A, and thus for unborn Ben and Ben after birth. The Midwifery Services, the Domestic Abuse Services of the Family Justice Centre and the Health Visiting Service all noted her vulnerability and that she may need additional support. At times she seemed to be coping or accepting of advice but she also expressed concern about her own low mood and depression (and history of depression and alleged adverse experiences when younger.) As such Ben and his mother met the criteria for Level 2 Early Help support under the agreed multi-agency Croydon Thresholds Guidance.18 6.8.4 Different practitioners offered help and advice directly or made referrals to other services (such as Housing, Perinatal Mental Health Services or Best Start Services19) but such multi-agency work appears to have been linear rather than a joined-up team approach making use of a Team around the Child and a Lead Professional 20. This raises questions about how well the Team Around the Child approach worked in Croydon’s Early Help system. 6.8.5 Recommendation 3 The Croydon Safeguarding Children Partnership should review the wider operation of the arrangements for Early Help provision at Tier 2 of the agreed Threshold Guidance and test how well a Team Around the Child System is understood and is working in practice for vulnerable families. It may be useful to commission some case audits as part of this as well as undertaking a review of agencies’ understanding and evaluation of the TAC system. 6.8.6 The Midwifery Services were concerned about Ms A’s emotional state on two separate occasions during pregnancy and referred her to the Perinatal Mental Health Services. This review has learned, however, that the Midwifery Service agrees that on neither occasion did Ms A actually meet the criteria for referral. However, a discussion about her in the in-house Midwifery Service Vulnerable Women’s Meeting21 may have been beneficial; for professionals to consider possible additional types of support. This was not considered at the time and would have required Ms A’s consent. 18 Croydon Safeguarding Children Board Thresholds Guidance. 2013 & 2017 http://croydonlcsb.org.uk/wp-content/uploads/2013/08/CSCB-Thresholds-Guidance-.pdf 19 The Best Start Social Work Team was an integrated team within the Best Start Partnership which provided social work interventions and support to children, young people and their families. The key objective of the service was to offer practical advice, support and direct case work to prevent issues escalating and requiring statutory intervention. 20 Tier 2: Early help These are children with additional needs, who may be vulnerable and showing early signs of abuse and/or neglect; their needs are not clear, not known or not being met. These children may be subject to adult focused care giving. This is the threshold for a multi-agency early help assessment to begin. These are children who require a lead professional for a co-ordinated approach to the provision of additional services such as family support services, parenting programmes and children’s centres. These will be provided within universal or targeted services provision and do not include services from children’s social care. 21 The Vulnerable Women’s Meeting is a monthly multi-agency professionals’ meeting for case discussion about pregnant women where there is a likelihood of a safeguarding concern or need for early supportive intervention (Early Help). It is not a direct service for women but an advisory service for professionals. Croydon Safeguarding Children Partnership 24 6.8.7 After Ben’s birth, a Health Visitor assessed the need for additional help and agreed a higher level of support through the Universal Partnership Plus approach. There was good and persistent work by the Health Visitor to establish rapport and engage Ms A, but there was no agreed Lead Professional and no team around the child (TAC) approach. There was some communication between the Independent Domestic Abuse Advisor, the Best Start Teenage Pregnancy Worker and the Health Visitor but this was not a team approach and it is significant that the GP and Clinics were not included. When Ms A’s first self-referral to the IAPT stalled there was no attempt by professionals to help her follow it up. Some of this appears to be because of Ms A’s non-engagement and giving varying accounts about how she was feeling to different people. This will be discussed below. Some may also have been caused by organisational systemic factors, such as staffing and workloads. 6.8.8 The first Health Visitor worked hard to keep in contact with Ms A and establish a supportive relationship. However, circumstances intervened when Ms A and Ben were appropriately offered new temporary accommodation in a different area and had to transfer to a new GP Practice and to a new Health Visiting Team. This break in continuity is a well-known systemic problem and it can lead to disruption of good support and relationships with vulnerable parents and understanding of their history. Delay of transfer of GP records may have been an issue in this case, and this review has been told that this is a common systems issue. 6.8.9 The new Health Visiting Team did not work with Ms A in a similar enhanced way, although there is no evidence that the status of Universal Partnership Plus had been re-assessed or stepped down. There was no Health Visitor contact from December 2017 until after Ben’s head injury in May 2019. This raises the question of how the Health Visiting Service monitors the delivery of the Universal Partnership Plus Programme locally and how families move into and formally out of it. 6.8.10 As the timeline has shown, Ben missed key immunisations and developmental checks to monitor his development. These were not monitored or followed up at the time. By the time that he came to attention with a head injury in May 2019, aged 20 months, there were questions about his behaviour and possible speech delay. Ms A appears to have withdrawn from active contact with services except when she perceived a need and so encouragement to support Ben through linking with a children’s centre or other pre-school activity as part of supporting her as a parent and assisting Ben’s development had not happened. 6.8.11 Recommendation 4 : Croydon Public Health Services, with the Health Visiting Providers and Clinical Commissioning Group, acting for the Croydon Safeguarding Children Partnership, should consider the local specification and operation of the Universal Plus Health Visiting Offer under the commissioning contract to ensure that there is clarity about how vulnerable parents and children are monitored to prevent them dropping out of the Universal Plus System and ensuring that they are reviewed to assess if they should be considered for other services, including Early Help, or stepped up to children in need or child protection services if there is evidence of neglect. 6.9 Holding ‘Was Not Brought’ in mind as a possible indicator of neglect of children Croydon Safeguarding Children Partnership 25 6.9.1 Over time a pattern of Ben not being seen or brought for appointments, checks or immunisations came to be noted. It is interesting to note that in Croydon these were often referred to as ‘Did not Attend’ rather than the newer agreed term of ‘Was not Brought’ to ensure that there is a focus on the adult responsibility to bring the vulnerable child and consider if there is a safeguarding need. The Croydon Health Services Trust advised this review that they now have in place a “Was Not Brought Policy” for children. This does not include GPs, however. 6.9.2 In mid-2019, after the head injury, the GP Surgery became increasingly concerned about Ben’s missed immunisations and through an administrative process sought to follow these up by text, but to no effect. Ms A had contact by phone or in person in her own right several times in this period but there was no joined up Think Family22 approach on those occasions to speak with her about Ben and his missed checks and immunisations. On one occasion she sought an appointment for him as his scrotum was swollen. She did not follow through with this but there was no follow up with her as to why. 6.9.3 Practitioners told this review that young parents often act in the “here and now” if they feel low. If they feel they have a problem they want help immediately and so may not respond to delayed appointments, and if they then feel better or do not still perceive the problem in the same way and they do not follow up. 6.9.4 Texts are convenient for services to send and they can perhaps be set up automatically, but they can easily be ignored by recipients. Has this become a system of convenience for agencies? What research has there been about their efficacy in health care provision to support patient engagement, especially when there is evidence of non-engagement? 6.9.5 Declining immunisations. A social care practitioner told this review that Ms A was reluctant to have Ben vaccinated because of what she had read on websites. She was advised to discuss this with her health visitor, but at that time she was no longer seeing a health visitor. She had, however, previously agreed to Ben being immunised and he had some of his early vaccinations. It does not appear to have been raised as a worry by Ms A with the first Health Visitor, with whom Ms A had a good relationship. 6.9.6 What is not clear in this case is why the issue of Ben not being brought for immunisations was not raised by the GP with the Health Visiting Service when Ms A continued to not respond to texts, and she did not take Ben back to the hospital after his head injury for a planned check. 6.9.7 This issue raises questions for strategy and practice. What advice is given to parents about this, and how is parental refusal recorded? Is there a point at which declining immunisations for children should be seen as possible neglect especially if accompanied by other examples of not bringing children for developmental or other forms of health care? How is refusal to vaccinate assessed by non-medical practitioners? 22 Think Family – https://www.scie.org.uk/publications/guides/guide30/introduction/thinkchild.asp Croydon Safeguarding Children Partnership 26 6.9.8 The Croydon Public Health Service reported in 2019 to the Health and Social Care Subcommittee on the low take up of MMR immunisations in Croydon (contemporaneous to this case review) and the strategy being adopted to tackle this and to seek to achieve 95% take up23. 6.9.9 Recommendation 5a: The Croydon Safeguarding Children Partnership, with Public Health, should consider adopting the approach being taken in many other areas following the leadership of Nottingham Safeguarding Children Board’s “Was Not Brought” Campaign and Video, which heightens the vulnerability of children and that not being brought to appointments is potentially a sign of neglect.24 Recommendation 5b: The Clinical Commissioning Group should undertake a Review of current Did Not Attend / Was Not Brought policies for children to ensure that they recognise the vulnerability of young children and when to recognise and escalate concerns as possible symptoms of neglect. Recommendation 5c: The Clinical Commissioning Group should review the guidance to GP Practices on linking Parent and Child records and childcare alerts – such as Was not Brought, child protection enquiries or concerns about possible domestic abuse to ensure that they are cross referenced in the records and the child’s vulnerability is noted on the parent’s record too. 6.10 Keeping the child central The child’s experience 6.10.1 It has been hard to get a pen picture of Ben and his daily lived experience. This can be the case when young children are only minimally engaged in universal services. When he was seen as an infant by the first Health Visitor there was no concern about him physically or about his care or the relationship with his mother. From December 2017 to June 2018, he seems to have disappeared from view, no services saw him. The social work assessment from May to October 2018 following the concerns about domestic abuse noted Ben to be healthy but he seems to have been seen only once in that period and there is no picture of what his daily life was like. The main concern was possible exposure to domestic abuse and he was assessed as being protected from that by his mother’s actions. 6.10.2 This review has noted from the feedback from practitioners that it is not expected practice to include pen pictures of children in agency records or build a picture of their daily life. 23 Immunisation Priorities in Croydon.pdf November 2019 24 Nottingham Safeguarding Children Partnership Was not Brought https://www.nottinghamshire.gov.uk/nscp/resources/for-professionals-and-volunteers https://youtu.be/DPgw28DSgNA Croydon Safeguarding Children Partnership 27 6.10.3 When seen in May 2019, in response to the head injury, Ben was described as a very active child and there were concerns about his boisterousness, from wider family; also noted by hospital staff. His early two-year developmental check at one year and nine months suggested significant speech delay for his age. Although Ms A was given advice about this and how to link him to support there was no further assessment. The Health Visitor believed at the time that Social Care was undertaking an assessment (where any underlying concerns about causes for his behaviour and speech delay could have been explored further) but that assessment had been stopped. Ms A did not respond to the Health Visitor’s further contacts. 6.10.4 This highlights the challenges in universal welfare and safeguarding systems that young children can go unnoticed unless there are specific worrying concerns which bring them to attention. They are sometimes seen briefly for occasional one-off contacts but, if parents do not engage in services or early years’ provision, children with developmental needs may not come to attention until they start to attend nursery or school. On the few occasions when Ben was seen at home there were no grounds to think that he was being harmed or neglected. He was well provided for, appeared healthy and had toys, and Ms A appeared able to meet his needs. 6.10.5 In the few professional contacts that there were with Ben his ethnic identity was noted. Ms A was clear that she wished to have no contact with Ben’s Father, but thought was being given to Ben’s future need to possibly have contact with his father. 6.11 Assessments, Engagement and non-Engagement, where parental consent is required 6.11.1 Ms A was seen as an intelligent and able person. She was screened routinely antenatally and postnatally and was rightly identified as vulnerable. She was offered services to support her at the Early Help level with regard to domestic abuse and parenting support. However, she did not engage with the Best Start Early Help Services although she had agreed to do so. She also dropped out of domestic abuse support. 6.11.2 The first Health Visitor responded to Ms A’s vulnerability with persistence and assertiveness to maintain contact and perhaps had the longest-term professional relationship with her. The contact was then broken by the move of locality (a systems issue). This demonstrates the value of relationship-based work but is not always possible for practitioners with large caseloads. Croydon Safeguarding Children Partnership 28 6.11.3 Ms A reported a traumatic history. In pregnancy and later she also reported low mood and that she was not coping, at times. At other times she reported that she was coping with support from family, friends and Ben’s Father (although he was also alleged to have been abusive to her). Given the adverse childhood experiences that Ms A reported, research25 suggests that there would possibly have been longer term impacts on her ability to cope as a parent. She was referred for talking therapy support twice in pregnancy but did not meet the threshold and no alternative provision was offered for her. Later she was again referred for talking therapy and was offered an assessment but did not follow this through. 6.11.4 At times Ms A appeared to be able to parent Ben well and initially he was developing well. Her vulnerability was noted, and she was offered services, but she did not engage. There were no grounds to require her to use services. At times she expressed a need for advice or a service and then did not follow up when appointments were offered. Her ability to cope was fragile. Adults who have been traumatised may require longer term services and relationship-based support to develop trust and to engage. The persistent approach of the first Health Visitor did appear to engage her. Practitioners may have to work hard to maintain links and engage with some parents but busy services with high caseloads are not set up for this and “Did not attend” or “Did not respond” policies and services which rely on self-referrals and commitment as evidence of motivation may lose touch with service users who are not emotionally well-integrated because of previous trauma and who may require more proactive encouragement and trust building. 6.11.5 A question in non-engagement which perhaps needs greater consideration is the possible impact of coercive control. Women who are subject to coercive control may want assistance but may be fearful of reactions from an abusive partner if they take up a service or may be fearful of threats that a child will be removed or may be prevented from accessing services. Ms A was advised as part of the Child and family Assessment in 2018 that if there were further examples of domestic abuse child safeguarding measures would be considered. The fear of such safeguarding procedures may be a disincentive to parents to come forward when they need help or protection as they believe children will be removed. Telling the police in July 2019 that Mr D had in fact assaulted her, as had been alleged, may have been more worrying for her than his abuse. 6.11.6 A health practitioner noted that it is not uncommon for mothers to withhold the identity of fathers or partners from professional agencies. Unless there are grounds for child protection or criminal investigation this has to be accepted or negotiated with. 6.12 Assessing the risk of domestic abuse and supporting women who have experienced domestic abuse 25 Adverse Childhood Experiences For a helpful introduction and signpost to current research about the possible impact of adverse childhood experiences and the pros and cons of ACEs as a tool in assessments and intervention in work to support those affected see Children and Young People Now Special Report September 2020 Adverse Childhood Experiences: Special Report | CYP Now Croydon Safeguarding Children Partnership 29 6.12.1 Ms A made several allegations of abusive experiences from her family and from Ben’s Father. These were taken seriously, and she was offered support by the Croydon Family Justice Service and referred to MARAC on two occasions. She later withdrew from domestic abuse support services. She denied to the Police that Mr D had been physically abusive. 6.12.2 It would have been expected that she would have been asked about possible domestic abuse at her Midwifery Booking appointment – this is known as Routine Enquiry. There is no record of this having been asked. Practitioners told this review that there was no system for recording why a woman has not been asked and that a note may have been made in the hand-held records. This would be surprising as making such a note in hand-held records may place a woman at greater risk if an abusive partner were to access the patient-held notes. Policy expects that if a woman is not asked at the first appointment, then this should be followed up in a later appointment, but no evidence has been found that this was done. The Health Visitor did ask at the New Birth Visit and was told by Ms A that there had been no domestic abuse; this was not the case. A recent (2020) review of this Routine Enquiry policy in the Trust suggests that compliance may be as low as 5%. 6.12.3 Recommendation 6: The Croydon Health Services NHS Trust and its commissioners and the Clinical Commissioning Group should review the Routine Enquiry Policy, and how the Trust supports and monitors the competence and confidence of Midwives and Health Visitors in managing this; and provide evidence to the Croydon Safeguarding Children Partnership that the system is working effectively. 6.12.4 Following a witnessed assault by Ben’s Father in April 2018 Ms A alleged that she was subject to verbal abuse and to his coercive and controlling behaviour. Ms A did not wish to press charges or seek a non-molestation order because she was, she said, too fearful of him. Police reported that Ms A, did not wish to complete a risk assessment26 and withdrew her statement. Later she did not continue with support offered by the Family Justice Service. The case was discussed, appropriately, at MARAC and relevant professionals were advised of the incident. Children’s Social Care undertook a Child and Family Assessment following this incident and found a more confusing picture of the incident. Ben was found not to have been harmed and to be developing well. Both parents were advised of the risk to children from domestic abuse and that if this were to be repeated safeguarding procedures may be used. Ms A reported being torn between allowing Ben to have contact with his father and risking domestic abuse. No further incidents between them were reported. 6.12.5 A question for practice raised by this case is how to work with women who are subject to abuse and particularly if the abuse includes coercive control. They may be fearful for themselves and therefore reluctant to engage with services for fear of further abuse from their partner or ex-partner. Related to this question is how to work with the male partners. Contact was made with Ben’s Father and he was given advice. As this was an assessment and no service was working with Ms A in the longer term at that time there was not an opportunity to work with Ms A in more depth about dynamics of domestic abuse and implications for future relationships. She disengaged from the Family Justice Service. 26 SafeLives DASH Risk Assessment Dash without guidance.pdf (safelives.org.uk) Croydon Safeguarding Children Partnership 30 6.12.6 Mr D was under the supervision of the Probation Service which enquired of Croydon Children’s Social Care and Lambeth Children’s Social Care about any possible connection he may have to children in their areas. This information sharing and assessment system worked effectively in Croydon, in that Croydon Social Care checked their records for the address given (not Ms A’s) and found no record of any children who could be at risk at that address. The parallel request to Lambeth received no response. Lambeth Social Care has advised this review that they can find no trace of the request. (This does not mean that it was not sent but may raise system issues about risk of requests for information not getting to the right service or not being picked up by partner agencies). It is unfortunate that the Probation Service did not follow up the lack of response to their information request to Lambeth Social Care, as he was still seeing his own child who was resident there. 6.12.7 In May 2019, when Ben sustained his head injury it was noted, by the Ambulance Service, that a male was in the household. We cannot be sure that this was Mr D as his identity was not established at the time. Ms A’s statement that this man was “in the kitchen” at the time when Ben was said to have jumped from the sofa was accepted. As there was no immediate and conclusive evidence that Ben’s head injury was non-accidental at the time there was no follow up to ascertain who this man was. If it was Mr D his presence was worrying. As noted above, had there been a Strategy Discussion his identity would probably have been ascertained and given his history was likely to have led to a new Child and Family Assessment. Given his assessed level of potential violence a question which should have been asked, easier now with hindsight than for practitioners at the time, was: “Is Mr D exerting control over Ms A?”. This raises a question about how practitioners keep this in mind as a possibility even if there is no immediate report of domestic abuse. A woman who does not feel safe is unlikely to report this for fear of the consequences. 6.12.8 In July 2019, Police were called to the home by a community member alleging domestic abuse by Mr D against Ms A. This is the first time that Mr D was confirmed to be in a relationship with Ms A. His child from another relationship and Ben were both present. The Police Officers attending had no concerns about the children. Ms A denied that there had been any domestic abuse. Although a check was undertaken by the Police it was noted that there had been no previous record of concern about Mr D and Ms A as a couple. A routine notification was not therefore sent to the relevant Children’s Services for either child, as it should have been. This was a procedural error and a missed opportunity and has been assessed to have been related to a single officer’s understanding rather than a whole systems issue, as appropriate systems were in place but not followed. 6.12.9 In late August 2019, Mr D told his Probation Officer that he was in a new relationship, given his history there should have been a more rigorous safeguarding enquiry about this to establish who the partner was and if there were children present. Croydon Safeguarding Children Partnership 31 6.13 Conclusions 6.13.1 Ms A’s vulnerability from both her personal history and to alleged domestic abuse was recognised and she was offered services to support her in the early period. However, for reasons which are not fully clear she did not engage with services or dropped out, which was her right. There were no grounds for mandatory intervention. 6.13.2 When alleged domestic abuse came to light this led to appropriate responses from the Family Justice Centre, Ms A was given good advice and offered support, but she did not continue with this. 6.13.3 The recognition by the first Health Visitor that Ms A was vulnerable and required a Universal Plus pathway was good and there was good and persistent work to engage with Ms A as a young mother. A systems dynamic of a move of temporary housing, which was an improvement for Ms A and Ben, meant that the continuity of health visiting was broken. Although assessed as needing an enhanced service this was not followed up by the second health visiting team, which it is understood had staffing difficulties and pressures at the time. 6.13.4 The Child and Family Assessment in 2018, following alleged domestic abuse concluded that a child in need service was not required. It is not clear if consideration was given to steering Ms A to Early Help services again and, given Ben’s age at the time, signposting him to Early Years provision which would have supported his development. When an assessment decides that a child in need service is not required it is important that consideration is given to considering if an Early Help Service may be useful. 6.13.5 The clinical assessments into Ben’s head injury in May 2019 were rigorous and considered the possibility of non-accidental injury but on balance made a judgement that the injuries were probably accidental; but concerns remained. This raises a question about the point at which a child protection strategy discussion with other key agencies should be considered and whether this should be during the clinical assessment or at the end of the clinical assessment. The referral from the hospital requesting a social care assessment was lacking in depth about the uncertainty that still remained about the cause of Ben’s injuries. The identity of the male in the household was not established and without being in a formal multi-agency safeguarding framework there was no possibility to complete checks on him that would have revealed a worrying background. These are difficult practice judgement calls which clinicians make all the time and it is clear from this review that the clinicians explored the injuries carefully and also sought specialist advice. It is not practical to say that every consideration of a head injury in a child must result in a Strategy Discussion as many will be accidents but where there are doubts about cause the value of a multi-disciplinary discussion should be considered. 6.13.6 The decision by Children’s Social Care to overturn the previous decision to undertake an Assessment was made in a bigger systems context of the high incidence of referrals being made to social care which were unsuccessful because parents were not fully engaged, had not given consent and there was not a clear threshold for child protection. The safeguarding system was slowly emerging from being “inadequate” and was more crisis-led and thus seeking to accept only the highest priority referrals. To close the case without informing the hospital was a mistake as this would have led to further dialogue about the hospital’s concerns. Croydon Safeguarding Children Partnership 32 6.13.7 The police call out in July 2019 when Mr D was identified was not shared with Children’s Services, as it should have been, and given information about Mr D would probably have led to a Child and Family Assessment. This would have identified potential risk to Ben. Croydon Safeguarding Children Partnership 33 7. Recommendations Recommendation 1a: Serious Injuries to Children There should be serious consideration of routine progression to a Child and Family Assessment for any child with an injury where this is requested by Health professionals. Recommendation 1b: When, after a serious unexplained injury, a child requires in-patient observation and/or a skeletal survey there should always be inter-agency dialogue about next steps. This would best be achieved through a multi-disciplinary Strategy Discussion. Recommendation 2 The Croydon Safeguarding Children Partnership should seek assurance from Services and through regular case audits that decisions not to proceed to a referral (for any issue) are communicated back to the referrer / referral agency in a timely way, with an explanation and an opportunity to question the decision not to accept the referral. Recommendation 3 The Croydon Safeguarding Children Partnership should review the wider operation of the arrangements for Early Help provision at Tier 2 of the agreed Threshold Guidance and test how well a Team Around the Child System is understood and is working in practice for vulnerable families. It may be useful to commission some case audits as part of this as well as undertaking a review of agencies understanding and evaluation of the TAC system. Recommendation 4 Croydon Public Health Services, with the Health Visiting Providers and Clinical Commissioning Group, acting for the Croydon Safeguarding Children Partnership, should consider the local specification and operation of the Universal Plus Health Visiting Offer under the commissioning contract to ensure that there is clarity about how vulnerable parents and children are monitored to prevent them dropping out of the Universal Plus System and ensuring that they are reviewed to assess if they should be considered for other services, including Early Help, or stepped up to children in need or child protection services if there is evidence of neglect. Recommendation 5a The Croydon Safeguarding Children Partnership, with Public Health, should consider adopting the approach being taken in many other areas following the leadership of Nottingham Safeguarding Children Board’s “Was Not Brought” Campaign and Video, which heightens the vulnerability of children and that not being brought to appointments is potentially a sign of neglect.27 Recommendation 5b The Clinical Commissioning Group should undertake a Review of current Did Not Attend / Was Not Brought policies for children to ensure that they recognise the vulnerability of young children and when to recognise and escalate concerns as possible symptoms of neglect. Recommendation 5c The Clinical Commissioning Group should review the guidance to GP Practices on linking Parent and Child records and childcare alerts – such as Was not Brought, child protection enquiries or concerns about possible domestic abuse to ensure that they are cross referenced in the records and the child’s vulnerability is noted on the parent’s record too. 27 Nottingham Safeguarding Children Partnership Was not Brought https://www.nottinghamshire.gov.uk/nscp/resources/for-professionals-and-volunteers https://youtu.be/DPgw28DSgNA Croydon Safeguarding Children Partnership 34 Recommendation 6 The Croydon Health Services NHS Trust and its commissioners and Clinical Commissioning Group should review the Routine Enquiry Policy, and how the Trust supports and monitors the competence and confidence of Midwives and Health Visitors in managing this; and provide evidence to the Croydon Safeguarding Children Partnership that the system is working effectively. Malcolm Ward B.Soc.Sc, Master of Social Work Independent Lead Reviewer June 2021 |
NC50689 | Death of 17-year-old male child from Vietnam in December 2016 by drug misuse. Child C presented to services as an unaccompanied asylum-seeking child in April 2016 after being discovered in a lorry in Shropshire. Child C was suspected to have been trafficked into the UK. During the review process it was established that Child C was in fact an adult being 21 years of age. Child C went missing from his foster care placement within days of being placed. He remained as a missing person, until he was found deceased in Derbyshire. Child C was known to police, social services and health services. Learning includes: a number of issues concerning agencies' awareness of the indicators of trafficking and associated risks, their assessment of young people who present as unaccompanied asylum seekers, the management of risk in cases where children remain missing for a long time and the impact of a child's status on how they are managed and reviewed. Recommendations include: interagency guidance on children who present as unaccompanied asylum seekers and trafficked children should have a dedicated referral pathway that outlines the role of each agency; national guidance should be issued to clarify how Police and Local Authorities work together and agree on who takes primacy in the identification and confirmation of age of a person who presents as an unaccompanied asylum-seeking child.
| Title: Serious case review: Child C. LSCB: Shropshire Safeguarding Children Board Author: Geoff Corre Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Foreword to the Serious Case Review (SCR) - Child C Published 7th November 2018 This SCR was commissioned by the Independent Chair of Shropshire’s Safeguarding Children Board (SSCB) following the death of Child C who presented to services as an unaccompanied asylum-seeking child (UASC), and was suspected to have been trafficked into the UK. Child C went missing from his foster care placement within days of being placed. He remained as a missing person, believed to have been within the West Midlands area until he was found deceased in Derbyshire. This serious case review was commissioned to identify any lessons that the agencies involved could learn in order to improve practice and better improve their services to unaccompanied asylum-seeking children in the future. During the review process it was established that Child C was in fact an adult being 21 years of age. It is important to note that prior to this case Shropshire had no or very little previous experience for a case such as this. Since that time significant improvements have been made across agencies which have been evidenced most recently through an SSCB multi-agency audit of safeguarding practice in respect of a number of UASC’s who subsequently presented in Shropshire. 6 cases were audited with 5 being graded as ‘Good’ and 1 graded as ‘Outstanding’. The SCR overview report makes a number of recommendations for the agencies involved in Child C’s care - for Shropshire’s Safeguarding Children Board, and for the government – and does report on some of the improvements which have already been made to practice. Whilst acknowledging the work of the Independent Reviewer in respect of this review, as has been indicated, SSCB is of the opinion that because the case dates back to 2016 not all of the improvements in practice have been included. In addition SSCB has identified a number of additional specific learning points for action over and above those recommended in the report. 2 This covering report outlines the progress made specifically in relation to the improvements in service that have been made by Children’s Social Care: • Policies and Procedures have been updated to reflect the learning from this case. • Significant improvements in the timeliness of assessments with assurance being provided to SSCB. • The introduction of a UASC Team/Worker who has become a subject matter expert and has built good relationships with these young people contributing to good outcomes for them. • All trafficked children are now referred to the National Referral Mechanism (NRM). • Commissioned Service with Refugee Action to provide additional support to UASC’s and trafficked young people. Additional National Recommendation: On considering the final report SSCB identified that an additional national recommendation was required in order to keep UASC’s safer at the earliest opportunity. The recommendation is as follows: • National guidance should be issued to clarify how Police and Local Authorities work together and agree on who takes primacy in the identification and confirmation of age of a person who presents as a UASC. SSCB are actively exploring this with the National Panel, the Home Office and the National Crime Agency to establish clarity on what processes currently exist and how gaps in that process should be closed. The learning from this SCR will continue to inform the on-going development of safeguarding systems and practice in Shropshire. A multi-agency action plan has been developed which covers actions against all of the recommendations in the final report. The SSCB Learning and Improvement sub-group will continue to monitor the multi-agency action plan and seek assurance from individual agencies that improvements have been made to safeguard this vulnerable group of young people. INDEPENDENT AUTHOR;GEOFF CORRE SERIOUS CASE REVIEW; CHILD C SHROPSHIRE SAFEGUARDING CHILDREN BOARD 1 Table of Contents 1. Introduction 2. Process of the Review 3. Family engagement 4. The facts 5. Key Practice Episodes 6. Context 7. Analysis of Terms of Reference 8. Informing local and national policy and procedure 9. Conclusion and themes 10. Good practice 11. Lessons learned 12. Recommendations Appendices 2 1 Introduction 1.1 At the time of his presentation to agencies in Shropshire, Child C gave his date of birth as 4 May 1999 in Vietnam, his country of origin. During the course of this review, it was discovered that his actual date of birth was 5 April 1995.His body was found on 25 December 2016 in Derbyshire. He had presented as an unaccompanied asylum seeker in Shropshire on 16 April 2016 when he was discovered, with a group of other men, to have jumped out of a lorry that had been parked on the A41 in Shropshire. 1.2 Child C informed the Police and the local authority that his parents were dead and that he had been brought up in Vietnam by two uncles. 1.3 He stated that he had come to the United Kingdom via Moscow, where he alleged that he had been kidnapped and brought to the United Kingdom. 1.4 Child C claimed that he was 17 years old and there was no evidence to disprove this. An age determination concurred with this and he was received into the care of the local authority under Section 20, the Children Act (1989) and placed with foster carers in Shropshire on 17 April 2016. He absconded from the foster home on 23 April 2016 and was found dead in Derbyshire on 25 December 2016. 1.5 Child C was reported as missing to West Mercia Police on 23 April 2016. During the time that he was reported as missing, there were reported sightings in Birmingham where he was known to have links with a nail bar and a lap dancing club. Multi-agency strategy meetings were held in April, May, June and November 2016.The missing person´s enquiry was transferred to West Midlands Police on 19 May 2016.The police missing person´s enquiry status was altered to inactive on 6 July 2016, the police risk assessment level was altered from medium risk to low risk on 26 July 2016 and the social care status was changed from being a looked after child to being a child in need on 28 November 2016. 1.6 A serious case review should be instigated when (a) Abuse or neglect of a child is known or suspected; and (b) Either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child1 1.7 On 4 January 2017 and 3 February 2017, the Learning and Improvement sub group of the Shropshire Safeguarding Children Board received requests to consider a Serious Case Review or Learning Review from the Head of Children’s Services at Shropshire Council. 1 Working Together to Safeguard Children HMG (2015) P75 3 Immediately following his death, it had been uncertain as to whether Child C was a child so Shropshire Safeguarding Children Board sought advice from the National Panel on Serious Case Reviews. They advised that a Serious Case Review should be commissioned on two grounds; agencies had understood that he was a child, and there were lessons to be learned as a result of the manner in which his case had been managed. On 11 February 2017, the Independent Chair of the Shropshire Safeguarding Children Board agreed to commission a Serious Case Review on the grounds that Child C was believed to be a child who had died and abuse or neglect was suspected. 1.8 Working Together to Safeguard Children (2015) states that serious case reviews and other case reviews should be conducted in a way which: • recognises the complex circumstances in which professionals work together to safeguard children • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight • is transparent about the way data is collected and analysed and makes use of relevant research and case evidence to inform the findings. 1.9 This review has been undertaken in a way that ensures these principles have been followed. 2 Process of the Review 2.1 This review was conducted by Geoff Corre, a Safeguarding Consultant with over 40 years’ experience in child protection, who is independent of the Shropshire Safeguarding Children Board and of the agencies involved. He has inspected child protection services with Ofsted and her Majesty’s Inspectorate of Constabulary. He is currently a trainer and consultant on Human Trafficking and Modern Slavery and is the former Chair of the Board of Trustees of the National Working Group on Child Sexual Exploitation and Trafficking. 2.2 The scope of the review covers the period from 16 April 2016 when Child C first came to the attention of agencies having jumped out of a lorry, along with other young men, which had been parked on the A41 in Shropshire to 25 December 2016 when his body was found in Derbyshire following an anonymous phone call to the police. The primary focus of the review is on Child C but it has also considered whether there is wider learning to be obtained regarding the arrangements for young unaccompanied asylum seekers and children who have or may have been trafficked. 4 2.3 The following terms of reference were agreed by the Learning and Improvement sub group of Shropshire Safeguarding Children Board on 27 March 2017. • Were the care planning arrangements for Child C appropriate and timely? • Were agencies aware of the issues and risks associated with unaccompanied asylum seekers? • Was consideration given within this assessment to the possibility that Child C may have been trafficked? • Were appropriate measures put in place to mitigate any risks? • Were suitable measures taken to locate Child C after he had been reported as missing? Was information effectively shared between agencies? Did strategy meetings and reviews effectively assess the risks? Did his status have any impact on efforts to locate him? • Was sufficient consideration given to Child C’s status, cultural and linguistic needs? • How appropriate did agencies use terminology and to what extent did this impact on their decision making? • Was practice in line with current policies and procedures? Were they effective in addressing the issues? • Does any learning from this case need to inform local policy and procedure and need to be communicated nationally? 2.4 The following agencies were involved in the review; • Shropshire Council Children’s Services • West Mercia Police • West Midlands Police • Derbyshire Police • Shropshire Community Health NHS Trust 2.5 A learning event was held on 13 April 2017 and this included representatives from West Mercia Police, West Midlands Police, Derbyshire Police, Shropshire Council and Shropshire Community Health NHS Trust. 5 Pen Picture; Child C2 Child C came to Shropshire from the Socialist Republic of Vietnam. He was approximately 5’ 8”-5’ 9, slim in stature and when he arrived had a shaven head. Child C said he was from Quang Binh, but also stated that he attended Tran Phu High School which is in Ho Chi Minh City, and some distance away. Over 80% of the population live on agricultural production in Quang Binh, where education is valued as a means to escape poverty. Child C described family members working as market traders and an uncle who worked as a taxi driver. Child C reported that he had left school early due to his low attainment in Maths and Science, but that he did well in all his other subjects including History and Geography. He reported that he had not worked in Vietnam but had assisted around the house after leaving school. Child C was described by the foster carers as a confident young man, and although quietly spoken he was able to articulate his views to them and to others. He ate and slept well. He did not appear to have any health problems, although he did say that he had asthma which had been controlled by medication whilst living in Vietnam. Child C’s health and well-being was not assessed by a health professional because he went missing prior to his statutory Initial Health Assessment appointment with a paediatrician. 3 Family engagement 3.1 After his death, contact was made with a man in Vietnam who alleged that he was the father of Child C. This man e-mailed a photograph which, along with fingerprints, confirmed the identity of the deceased. 3.2 Attempts have been made via Derbyshire Police for the independent author to speak to Child C’s father but he has not responded to any requests to do so. 3.3 Child C’s father stated to police that his only concern was to have the body of his son repatriated to Vietnam. It has therefore not been possible to include the family’s perspective in this review. 3.4 It is not possible to ascertain why he did not wish to engage with the review. 2 This information was obtained by Shropshire Council Children´s Services during the short period of their engagement with Child C 6 4 The facts; Summary of agency involvement 4.1 On 16 April 2016, West Mercia Police received three telephone calls relating to a lorry that was parked in a lay by on the A41 in Tong, Shropshire. A number of men were seen to emerge from the rear of the lorry, three of whom, including Child C, were detained and taken to Malinsgate Police Station, Telford, where he was arrested on suspicion of entering the United Kingdom without leave to remain. 4.2 He remained in custody overnight, and on 17 April 2016 an age determination concluded that he was 17 years old. On 18 April 2016 he was accommodated by Shropshire Council under S20 of the Children Act (1989) and placed with foster carers. 4.3 On 19 April 2016, Child C was visited by the allocated social worker and it was noted that he had been skyping unknown persons via a tablet that the foster carer had given him access to, and that he had 260 Euros in his possession which he was eager to be changed into British pounds. 4.4 On 22 April 2016, the allocated social worker and fostering social worker visited Child C in the placement and noted a photograph of him on his Facebook page that had been taken in Moscow four weeks earlier. When he was challenged that he had previously stated that he had only been in Russia for five days before being allegedly kidnapped, it was reported that his demeanour changed and that he had tried to retract his earlier statement. 4.5 On the following day, 23 April 2016, there were two episodes of his going missing. The first had occurred at 09:30 hours, prior to which Child C had obtained the foster carer’s iPad and was searching for the port of Calais. He was returned and was noted to have written on the reverse of a magazine that he wanted to go to Birmingham. He also had the address of a lap dancing club in the city. Later, he asked the foster carer to either take him to Birmingham or to arrange a taxi to take him there. When she refused, he left the foster home one hour after the first incidence of going missing. 4.6 Child C was reported as missing with West Mercia and Warwickshire Police and assessed as being at medium risk. Enquiries ascertained that he was active on Facebook and associated with a night club in Birmingham. 4.7 A telephone discussion between the Social Worker and Police Officer noted that officers had visited the club in Birmingham but that no-one had seen or heard of Child C. A decision was made for him to remain as a missing person and for this to be reviewed on a daily basis. 4.8 An initial strategy meeting was held on 29 April 2016 during which officers from West Midlands Police informed colleagues that they had visited the night club in Birmingham, where staff had denied knowledge of him. The meeting concluded that the police missing 7 person investigation would continue, attempts would be made to access a laptop computer that had been used by Child C and his mobile phone, and the enquiry would be reviewed on a daily basis. 4.9 On 30 April 2016 digital enquiries provided further evidence that Child C was associating with the night club, and on 3 May 2016 this information was conveyed to the Multi-Agency Safeguarding Hub (MASH) in Birmingham. 4.10 A Review Strategy Meeting was held on 16 May 2016 and, as a result, a photograph of Child C was sent to the Birmingham MASH in support of the information that had previously been sent. 4.11 On 16 May 2016 Child C was identified via Facebook as attending the night club in Birmingham. At the behest of the police, the manager of the club agreed to contact them if Child C were to appear there again. 4.12 Due to his known associations in the Birmingham area, responsibility for the missing person enquiry was transferred from West Mercia Police to West Midlands Police on 19 May 2016. 4.13 On 27 May 2016, the social worker contacted West Midlands Police who agreed to contact the Department for Work and Pensions to ascertain if Child C had made a claim. There was no information regarding his attendance at either night club or the nail bar. 4.14 A Review Strategy Meeting was held on 8 June 2016, in which the West Mercia Police representative reported that he had requested to colleagues at West Midlands Police that Child C’s risk assessment be reviewed. It was assessed as medium risk at the time but more in depth enquiries would be possible if it were assessed as high. It was also reported that all actions from the previous meeting had been completed and that all avenues of the missing person enquiry had been exhausted. 4.15 On 1 July 2016 enquiries were obtained from his Facebook account which provided information that Child C had been active from 8 - 10 May 2016 in the Brownhills area of the West Midlands, but it was not possible to determine the specific location. From 13 - 18 May 2016, digital enquiries indicated activity in Vietnam, which suggested that either Child C had returned there, or had allowed someone in Vietnam to access his Facebook account. The last access to the Facebook account was recorded as 18 May 2016. 4.16 On 6 July 2016, a telephone conversation took place between a social worker from Shropshire Council and a Sergeant from West Midlands Police. The social worker was informed that all existing lines of enquiry had been completed and that the missing person enquiry was to be designated as inactive on the police missing persons’ case management system. 8 4.17 On 26 July 2016 West Midlands Police altered the risk assessment from medium to low on the grounds that Child C was considered to be an adult 4.18 On 2 August 2016, the social work assessment was completed. It concluded that consideration should be given to convening a further strategy meeting with a view to altering Child C’s looked after status. 4.19 On 17 November 2016, a Review Strategy Meeting was held. Due to the fact that West Midlands Police were not in attendance, a decision was made to arrange a further meeting to confirm the actions taken since the previous meeting on 8 June 2016. 4.20 On 28 November 2016 a further review strategy meeting was held at which it was decided to alter Child C’s status from being a Looked After Child to being a Child in Need. The rationale for this decision was based on the decision of West Midlands Police to alter the status of the missing persons’ enquiry to inactive. It was agreed that should Child C be found he would immediately become subject to Looked After Child status again. 4.21 On 22 December 2016, Child C was identified by digital enquiries on Facebook to have attended a residential address in Birmingham. 4.22 On the night of 24-25 December 2016, Child C was reported to have attended a night club in Birmingham where witnesses described a male fitting his description as leaving the club in an intoxicated state and as requiring assistance to get into a taxi. Information from the police suggests that he was supplied with controlled drugs in the nightclub and that individuals who were with him refused to call an ambulance and carried him into a taxi. 4.23 Later on 25 December 2016, Child C went to an address in Derbyshire where it is suspected that he died. On the same day, his body was located behind a wall in Derbyshire. Derbyshire Police commenced an investigation regarding the circumstances surrounding his death. 4.24 The police had been alerted by a representative from the Buddhist temple in Birmingham which had received an anonymous phone call informing them of the whereabouts of the body. 5. Key Practice Episodes Key Practice Episodes are defined as the most significant episodes in the case that require further analysis. They are set out in chronological order and are to be analysed in order to gain a clear oversight as to agencies’ engagement with Child C. They are as follows; Key Practice Episode One; Arrival in Shropshire, 16 April 2016 9 Key Practice Episode Two; Initial Care Planning Arrangements, 17 April 2016 Key Practice Episode Three; First period of going missing, 23 April 2016 Key Practice Episode Four; Second period of going missing, 23 April 2016 and Initial Strategy Meeting, 29 April 2016 Key Practice Episode Five; Review Strategy Meeting, 8 June 2016 Key Practice Episode Six; Decision to alter Child C’s risk level and status of missing person´s enquiry, 26 June to 26 July 2016 Key Practice Episode Seven; Review Strategy Meetings, November 2016 The following paragraphs outline the factual details of each key episode which are then the subject of analysis in the following sections. 5.1 Key Practice Episode One; Arrival in Shropshire, 16 April 2016 5.1.1 On 16 April 2016, Child C, along with six to eight other young men was seen to jump off a lorry that was parked on the A41 at Tong, Shropshire near Telford. Following several telephone calls from members of the public to the Police, he was arrested but not charged with any offence and taken to Malinsgate Police Station, Telford. 5.1.2 Police enquiries revealed that a Hungarian lorry driver had entered the UK at Dover from Calais bound for Market Drayton, Shropshire. He had stopped on the M1 en-route before continuing his journey. He then had a second break on the A41 at Tong, near Shifnal where he heard banging noises from the rear. On inspection he noticed that the clamp fastening on the rear doors had been damaged and on opening the doors, eight to fifteen young men jumped out of the lorry and into the surrounding fields. 5.1.3 Child C was found to be in possession of 260 Euros, a five Euro mobile phone top up card, miscellaneous papers with a route, a wallet containing pictures and a mobile phone all of which were seized for safe keeping, and then returned to him after he was released from custody. In addition, his fingerprints were taken. 5.1.4 A telephone call was made by the police to the Telford and Wrekin Emergency Duty Team (EDT) as they had thought that Child C had arrived in that local authority area. However, 10 the police received a message from the Telford and Wrekin EDT informing that it would take at least five hours for them to arrive and that the case may therefore be passed on to the day time team. 5.1.5 On 17 April 2016, Telford and Wrekin EDT telephoned West Mercia Police to state that Child C had been located within the local authority boundary of Shropshire Council, and subsequently, a social worker from Shropshire Council determined the age of Child C via an interpreter as being 17 years old. 5.2 Analysis of Key Practice Episode One 5.2.1 On his arrival in Shropshire, agencies were presented with several indicators that suggested that Child C was likely to have been a victim of trafficking; the manner of his arrival in a lorry with other young men, the fact that he was in possession of a fairly large amount of cash and a payment card in Euros, and papers which contained a route. Despite these indicators, agencies did not operate with sufficient awareness and nor did they follow up on some critical issues, such as interviews with Child C himself or with the other young men with whom he had been transported, or the sharing of information about Child C’s allegation that he had been kidnapped in Russia. 5.2.2 Child C was detained in police custody on suspicion of committing immigration offences, and was not taken into Police protection. His detention was authorised by the custody officer who considered that there were reasonable grounds to believe that it was necessary to prevent the prosecution of immigration offences being hindered by the departure of Child C, and to allow a prompt and effective investigation. His detention was in accordance with S34 (2) of the Police and Criminal Evidence Act (1984). 5.2.3 The West Mercia Police custody unit had initially contacted Telford and Wrekin Emergency Duty Team who responded over ten hours later to inform them that the responsible authority was Shropshire Council. It then took a further four hours for a member of that team to undertake the assessment. 5.2.4 The Police power to examine information concerning his mobile phone was not exercised because he had been age determined as a juvenile and the immigration enquiry had ceased. His status, therefore, did not comply with the statutory purposes in operation at the time under which communications data may have been accessed.3 Similarly, his fingerprints were not submitted to the authorities in Vietnam due to the fact that he was believed to have been under 18 and he was not under investigation for an alleged offence. However, they were checked against the UK database and no record was found. 3 The Data Retention and Investigatory Powers Act(2014) 11 Items such as 260 Euros in cash, a map and a mobile phone were kept for safekeeping, and then returned to him, but the fact that he was in possession of such items was not analysed within the context of the an hypothesis that he may have been subject to continuing risk as the victim of trafficking. 5.2.5 Child C was not interviewed by West Mercia Police concerning an allegation of kidnapping in Russia due to the fact that they were not aware of this allegation until they were informed of it by Shropshire Council Children’s Services on 29 April 2016.By this time Child C had gone missing and it was not possible to pursue any enquiry. 5.2.6 A local authority age assessment is be required when there is significant reason to doubt an individual’s claimed age in order to be sure they are treated appropriately and that they receive the necessary services and support. Although there is no prescribed way in which local authorities are obliged to carry out such assessments, general guidance has been provided by the courts4. This states, among other issues, that an assessment should not be based solely on observation except in exceptional circumstances. The Department of Education provides statutory guidance for local authorities on the care of unaccompanied and trafficked children. It states under Age Determination that “Many unaccompanied and trafficked children arrive in the UK without documentation or with fake documents. Where the age of a person is uncertain and there are reasons to believe that the person is a child, that person is presumed to be a child in order to receive immediate access to assistance, support and protection in accordance with Article 10(3) of the European Convention on Action against Trafficking in Human Beings. Where an age assessment is required, local authorities must adhere to standards established within case law. Age assessments should only be carried out where there is significant reason to doubt that the claimant is a child. Age assessments should not be a routine part of a local authority’s assessment of unaccompanied or trafficked children.”5 5.2.7 Child C was not initially subject to an age assessment6, as an age assessment is a longer piece of work and this would not be carried out by the Emergency Duty Social Worker. Instead, she undertook an age determination by meeting with him briefly and interviewing him via an interpreter. This age determination accepted Child C’s statement that he was 17 years old, and was based on the stated assumption that there was no evidence with which to disbelieve Child C’s account that he was 17 years old or that he had come to the UK because his parents were dead. 4B v London Borough of Merton [2003] EWHC 1689 (Admin) 5 Care of Unaccompanied and Trafficked Children, (DfE, 17 July 2014) 6 The process for undertaking such assessments is set out in Assessing Age for Asylum Applicants (UK Visas and Immigration,15 June 2015) and in Age Assessment Guidance (Association of Directors of Children’s’ Services October 2015) 12 5.2.8 Had the police and local authority demonstrated greater awareness of how to respond to the indicators of trafficking at the outset, it is possible that their subsequent risk management may have been more informed and therefore more robust. The first 24-48 hours are an essential period for gathering information from young people who have potentially been trafficked to safeguard their welfare should they go missing or be abducted. 5.3 Key Practice Episode Two; Initial Care Planning Arrangements; 17 April 2016 5.3.1 Following the assessment, Child C was accommodated by Shropshire Council under S20 Children Act (1989). This requires local authorities to accommodate children for any child in need within their area who appears to them to require accommodation as a result of- (a) There being no person who has parental responsibility for him; (b) His being lost or having been abandoned; or (c) The person who has been caring for him being prevented (whether or not permanently, and for whatever reason) from providing him with suitable accommodation or care. 5.3.2 Child C was placed with registered foster carers in Shropshire. 5.4 Analysis of Key Practice Episode Two; Initial Care Planning Arrangements, 17 April 2016 5.4.1 Safeguarding Children Who May Have Been Be Trafficked (para 5.74) states that “ It is … essential that, where a trafficked child is identified and placed in local authority care, specific arrangements are put in place to safeguard the child from the risks of going missing or being re-trafficked. Where a child goes missing, these cases should be urgently reported to the police…Local authorities should consider seriously the risk that a trafficked child is likely to go missing and take this into account in planning that child’s care. A contingency plan could include contact details of agencies that should be notified if a potentially trafficked young person goes missing, including the police and the UK Border Agency”7 In view of the fact that agencies were insufficiently aware of the issues and risks associated with children who may have been trafficked, no contingency plan was in place for Child C in the event of his going missing. 5.4.2 On 17 April 2016, the local authority social worker explained, by means of the police telephone interpreting service, to Child C that he would be placed in foster care. At a 7 Safeguarding Children Who May Have Been Trafficked, Department for Education and the Home Office (18 October 2011) 13 meeting on 19 April at the foster home, he is reported to have confirmed his understanding. 5.4.3 The social worker provided some information about Child C to the foster carers by telephone but he was taken to the foster home by police officers without being accompanied by a social worker. Shropshire Council Children’s Services acknowledge that he should have been transported by a social worker. Such a course of action would have represented a minimal level of expected practice, but it may also have been reassuring to a young man from a country in which expectations of the police may have been more fearful than in the United Kingdom. 5.4.4 The foster carers had received equal opportunities training in 2010 - some six years previously - but did not have any knowledge of the Vietnamese language and therefore had to communicate by means of an application on their mobile telephones and tablets. The foster carers had a limited appreciation of Vietnamese culture as they had recently had a holiday there, but communication via a digital application cannot be a substitute for clear communication on a daily basis and will inevitably have made it difficult for Child C and his foster carers to have formed a relationship. In addition, the foster carers had not received any training on human trafficking and would not have been aware of the specific risks and vulnerabilities of young people such as Child C. 5.4.5 Several internal systems issues impacted negatively on information sharing within Shropshire Council Children’s Services, as follows; The EDT were able to place initial records but were not able to add new records to the Shropshire Children’s Services Integrated Children’s System. As a result, new information was not recorded on the system but on an excel spreadsheet instead. Following the interview with Child C, the EDT Social Worker was not able to follow up on the work with Child C due to other commitments and therefore handed over responsibility for the care admission forms to a colleague verbally. Some information was therefore not passed on and this was compounded by the fact that the EDT Social Worker who had undertaken the initial assessment then lost some notes. The subsequent referral from the EDT for an assessment therefore contained limited information about the circumstances of Child C’s arrival and family details. 5.4.6 Child C was visited in the foster home by the social worker, the foster carers’ supervising social worker and an interpreter on 19 April 2016, within statutory time scales, with a view to completing the assessment. 5.4.7 Information received on a visit the following day regarding inconsistencies in Child C’s account as to how long he had allegedly been in Russia was interpreted as an indicator that he may have been trafficked . However, neither this information nor the evidence about his being in possession of a large amount of cash was used to inform an analysis of an 14 increased risk of Child C going missing from the foster home within a short time of his placement there. As a result, no additional safeguards or contingency plan were put in place. 5.4.8 An initial Looked After Child Review took place on 20 April 2016, but this was the only such review to be held, despite the fact that Child C had remained accommodated by the local authority until November 2016.The strategy meetings that were held after he had gone missing were regarded as a substitute for reviews, but both should have been conducted in parallel during the time that Child C remained a Looked After Child. 5.4.9 This review has concluded that a combination of factors prevented appropriate and effective initial care planning arrangements for Child C; a failure to appreciate the likelihood of his going missing soon after placement, the absence of a contingency plan, the fact that he was not accompanied to the foster carers by a social worker and the lack of specific training for the foster carers on caring for children who may have been trafficked. These issues, together with inadequate systems of communication both within the EDT and from the EDT to colleagues in Children’s Services resulted in initial care planning arrangements which were insufficiently robust and lacked sufficient information with which to make an effective care plan for a young person in Child C’s circumstances. 5.5 Key Practice Episode Three; First period of going missing, 23 April 2016 5.5.1 Child C went missing on 23 April 2016 three days after an interview with the social worker which revealed some discrepancies in his original story. He was located within one hour and returned to the foster home twenty minutes after being located. 5.6 Analysis of Key Practice Episode Three; First period of going missing, 23 April 2016 5.6.1. Although discrepancies in Child C’s story had been identified prior to the first missing episode, they did not result in any contingency planning in the event of his going missing. 5.6.2 On his return, Child C had informed the foster carers that he had gone missing because he had wanted to go to a particular night club in Birmingham. This information was conveyed to the Social Worker. 5.6.3 Child C’s absence was not reported to the police as the West Mercia Joint Runaway and Missing from Care Protocol in operation at the time did not include a requirement to report absences to the police if they are defined as absent (i.e. missing) for a period of up to six hours. 5.6.4 However, it was not possible to conduct a return interview, as set out in that protocol, because Child C went missing within an hour of his return. 15 5.6.5 The protocol also requires a risk assessment but this was not implemented. A risk assessment may have identified the heightened risk of Child C going missing soon after placement and the need for a suitable contingency plan. 5.6.6 A toothbrush belonging to Child C was seized by officers from West Mercia Police on 29 April 2016 but was not subject to DNA analysis. Such analysis would only be instigated in the event of concern that a missing person was deceased. At this time, there were no such concerns and the item was therefore not submitted for such testing. 5.7 Key Practice Episode Four; Second period of going missing, 23 April 2016, Initial Strategy Meeting, 29 April 2016,Looked After Review,12 May 2016 and Review Strategy Meeting, 16 May 2016 5.7.1 Within one hour of his return, Child C went missing again and his precise whereabouts remained unknown although there were reports of his being in the West Midlands area. 5.7.2 As a result of Child C being known to be active in the West Midlands area, the missing person enquiry was transferred to West Midlands Police and the missing person report conducted by West Mercia Police was concluded on the 19 May 2016. 5.7.3 Officers from West Midlands Police visited a nail bar on 19 May 2016 to which Child C had been located via Facebook postings and showed staff a photograph of Child C and asked if they knew of him or his whereabouts. They all denied any knowledge of him despite the fact that the police had evidence that he had accessed an encrypted password belonging to the Wi-Fi service there over fifty times. The officer also checked that there were no accommodation premises belonging to the building and also some adjacent flats to determine if Child C was living in the vicinity. 5.7.4 On 21 May 2016 further enquiries were made at a night club in Birmingham known to have been frequented by Child C. A press release and the issuing of photographs to the local Neighbourhood Police teams and British Transport Police were both actioned on the same day. 5.7.5 In view of the fact that Child C’s Facebook account was linked with that of another person with a Vietnamese name, enquiries were made at the address to which the account was linked and to the letting agency for the premises, but did not produce any information that would assist with the enquiry. 5.8 Analysis of Key Practice Episode Four; Second period of going missing, 23 April 2016, Initial Strategy Meeting,29 April 2016, Looked After Review,12 May 2016 and Review Strategy Meeting, 16 May 2016 16 5.8.1 The West Mercia Police missing person record includes an entry dated 23 April 2016 which states that Child C had expressed to the foster carer that he wanted to go to Birmingham and had repeatedly asked for directions to a particular night club there. This entry concludes “He (Child C) said [to the foster carers] he did not want the Police involved”. However, this was not reported to the social worker and was therefore not subject to any further scrutiny. Had the foster carer informed the social worker of Child C’s intentions it may have afforded additional evidence of the possibility of the continuing influence of traffickers on Child C. 5.8.2 A Strategy Meeting was held on 29 April 2016. The primary area of risk was defined as emotional, but the rationale for this was not specified and nor was the evidence that he was at risk of emotional abuse as opposed to other categories of abuse. The meeting concluded that the threshold for enquiries under S47 of the Children Act (1989) had been met. Reference was made to Child C’s assertion that he had gone on holiday to Moscow and was kidnapped, his possession of large amounts of cash and, his links with night clubs in Birmingham. However, these factors were not aggregated to provide an assessment of increased risk to Child C. The strategy meeting noted appropriate efforts to locate Child C as a missing person, and that he may have been at risk of trafficking, but it did not recommend a referral to the National Referral Mechanism 8 .However, the meeting appropriately recommended that the Police inform the United Kingdom Trafficking Centre (UKTC) and UK Visas and Immigration 5.8.3 On 12 May 2016, Child C’s only Looked after Children Review was held. Strategy Meetings and Review Strategy Meetings were regarded as a substitute for future reviews. The absence of any national guidance as to whether children should retain their status as looked after in this circumstances contributed to the local authority’s uncertainty as to how to proceed. Whilst Child C remained accommodated by the local authority, he should have remained subject to statutory reviews. The fact that he had remained missing should have prompted the local authority to act as his advocate and his voice rather than be seen as a reason not to hold reviews. 8 The National Referral Mechanism (NRM) is a framework for identifying victims of human trafficking or modern slavery and ensuring they receive the appropriate support. The NRM is also the mechanism through which the Modern Slavery Human Trafficking Unit (MSHTU) collect data about victims. This information contributes to building a clearer picture about the scope of human trafficking and modern slavery in the UK. The NRM was introduced in 2009 to meet the UK’s obligations under the Council of European Convention on Action against Trafficking in Human Beings. At the core of every country’s NRM is the process of locating and identifying “potential victims of trafficking”. From 31 July 2015 the NRM was extended to all victims of modern slavery in England and Wales following the implementation of the Modern Slavery Act 2015 17 5.8.4 A Review Strategy Meeting held on 16 May 2016 also agreed on a number of appropriate measures to locate Child C such as a press release, and the production of photographs on billboards, both of which were actioned on 21 May 2016. In view of the fact that Child C had been seen at a night club in Birmingham, officers contacted the owners of the night club and made an agreement with them that they would contact the Police if Child C were to appear there. 5.8.5 The minutes of this meeting held on 16 May 2016 are incomplete. The section that sets out attendees lists the participants who were invited to the meeting but is not clear as to which professionals actually attended and from whom apologies were received. Other key sections that were incomplete are those relating to Child C’s status as a Looked after Child, whether a social work report was to be required and whether S47 enquiries should be instigated. Although these sections are recorded in the initial strategy meeting held on 29 April 2016, their absence in this review meeting results in an incomplete record. For Strategy Meetings to be effective, it is essential that they consider all key issues and that the minutes provide a complete and comprehensive record of attendees, discussions, decisions and actions. 5.9 Key Episode Five; Review Strategy Meeting, 8 June 2016 5.9.1 A further Review Strategy Meeting was held on 8 June 2016. At this meeting, West Midlands Police requested information about the two other young men with whom Child C had arrived in Shropshire and it was reported that enquiries had been made at a hostel and hotel at which the men had been staying. However, by the time of the enquiries, they had left and one of them had failed to appear, as required, at a meeting with UK Immigration and Visas. 5.9.2 The strategy meeting concluded that the threshold for a S47 enquiries had been met and that Child C remained at risk of harm as a trafficked young person. 5.10 Analysis of Key Practice Episode Five; Review Strategy Meeting, 8 June 2016 5.10.1 The Review Strategy Meeting held on 8 June 2016 was highly significant. Although the missing person enquiry had been transferred to West Midlands Police on 19 May 2016, there were no officers from that force present. Representatives from the force were invited but did not attend, and, at their request, they were informed of the outcomes via the police missing persons’ system rather than via the minutes of the meeting. It is reported that it is difficult to send such minutes directly other than to a named Police Officer 5.10.2 At this meeting, the West Mercia Police Harm Assessment Unit Manager requested to colleagues at West Midlands Police that Child C’s risk assessment be reviewed with a view to his being considered as high risk on account of the fact that he had been age determined 18 as a child. The manager reported to the meeting that he was awaiting a response to his request for a review from colleagues at West Midlands Police, or for clear reasons as why this was not to be undertaken. This would have enabled more in depth enquiries as Child C was considered to be a child. However, in view of the fact that responsibility for the management of the enquiry had been transferred, he did not have the authority to insist on this. 5.10.3 This review has concluded that Child C remained a vulnerable young man who had appeared to have been trafficked and that he remained at risk of harm. In spite of this assessment and the request from West Mercia Police, decisions were taken only three weeks later which ran contrary to this assessment. Despite the fact that the management of the missing persons enquiry had transferred to West Midlands Police, it would have been good practice to have consulted with colleagues in West Mercia police and to have taken account of the transferring force’s recommendations in undertaking their own risk assessment. 5.10.4 It is important to ensure that information from strategy meetings is effectively shared via official minutes. At the request of West Midlands Police, information regarding the meeting held on 8 June 2016 was instead conveyed via the police missing persons’ case management system by colleagues in West Mercia Police. West Midlands Police should seek to resolve the systemic issue regarding the difficulty of sending minutes in the absence of a named officer. 5.11. Key Practice Episode Six; Decisions to alter Child C’s risk level and status of the missing person’s enquiry, 26 June to 26 July 2016 5.11.1 The missing persons case management system used by over twenty-two police forces, including West Mercia Police and West Midlands Police includes three risk assessment categories; high, medium and low. In addition, enquiries are designated as active or inactive.9 9 The College of Policing provides guidance as to how officers should determine the level of risk as follows; Low risk The risk of harm to the subject or the public is assessed as possible but minimal. Proportionate enquiries should be carried out to ensure that the individual has not come to harm. Medium risk 19 However, this does not include any specific reference to high risk groups such as children who are considered to be at risk of trafficking or who are unaccompanied asylum seekers, These groups are included in other statutory guidance such as Statutory Guidance on Children who Run Away or Who are Missing 10 and Care of Unaccompanied Migrant Children and Child Victims of Modern Slavery11. In order to facilitate closer links between risk assessments and these vulnerable groups, joint guidance for Local Authorities and Police Forces would enable professionals to work more effectively in identifying and protecting such groups of young people. 5.11.2 On 6 July 2016, there was a telephone call between a social worker from Shropshire Council and a Sergeant from West Midlands Police in which the social worker was informed that the status of the missing enquiry was about to be altered from active to inactive on the police system. (Such a change would indicate that all existing lines of enquiry had been exhausted and would not be revisited, but any new lines of the missing person’s enquiry would be followed up).This alteration from active to inactive was subsequently authorised by a Superintendent. 5.11.3 Child C’s risk category was changed on the police missing person system from medium risk to low risk on 23 July 2016 by West Midlands Police on the grounds that agencies considered that it was likely that he was an adult based on photographic evidence of his The risk of harm to the subject or the public is assessed as likely but not serious. This category requires an active and measured response by the police and other agencies in order to trace the missing person and support the person reporting. High Risk The risk of serious harm to the subject or the public is assessed as very likely. This category almost always requires the immediate deployment of police resources – action may be delayed in exceptional circumstances, such as searching water or forested areas during hours of darkness. A member of the senior management team must be involved in the examination of initial lines of enquiry and approval of appropriate staffing levels. Such cases should lead to the appointment of an investigating officer (IO) and possibly an SIO, and a police search adviser (PolSA). There should be a press/media strategy and/or close contact with outside agencies. Family support should be put in place where appropriate. The MPB should be notified of the case without undue delay. Children’s services must also be notified immediately if the person is under 18. Risk of serious harm has been defined as (Home Office 2002 and Offender Assessment System 2006): ‘A risk which is life threatening and/or traumatic, and from which recovery, whether physical or psychological, can be expected to be difficult or impossible.’ Where the risk cannot be accurately assessed without active investigation, appropriate lines of enquiry should be set to gather the required information to inform the risk assessment. 10 Department of Education (last updated April 2017) 11 Department of Education (,last updated November 2017) 20 physical appearance. The decision to regrade the missing person’s enquiry to inactive was made by a neighbourhood inspector and a sergeant and was authorised by an inspector after a review on 26 July 2016 in accordance with force policy. The overriding rationale for the decision was that Child C was considered to be an adult based on a consideration of his age from photographs, although evidence from the missing person’s enquiry concerning his life-style, his actions and expressed desires and an assessment that he did not appear to represent a risk to himself or the public, was also taken into account. West Midlands Police do not have a policy of determining age from photographic evidence alone, or of determining age in the absence of the individual concerned, or of any anthropometric measurements. The age determination by the local authority was not taken into account in reaching this conclusion, as there is no specific requirement for the police to consult with partner agencies before altering a missing person’s risk category. 5.12 Analysis of Key Practice Episode Six; Decision to alter Child C’s risk level and status, 26 June 2016 to 26 July 2016 5.12.1 The decision by West Midlands Police to alter the status of the missing person´s enquiry played a part-along with other considerations - in Children’s Services’ own subsequent decision about Child C’s status as a Looked after Child. 5.12.2 The decision to alter the risk level of the missing person enquiry made on 26 July 2016 was made in accordance with force policy by an Inspector and reviewed by another Inspector. The decision was taken on a single agency basis. 5.12.3 Whilst there is no requirement for agencies to consult with their partners about internal decisions, there is a requirement on all agencies to work together to safeguard children.12 The decisions to alter Child C’s risk level and status of the missing person’s enquiry by West Midlands Police should therefore have been discussed at a Review Strategy Meeting in which all agencies would have had an opportunity to share information, to provide a forum for a consideration of Child C’s age assessment and risk level and to enable a more integrated approach to important decisions. West Midlands Police should have attended all of the strategy meetings to have enabled such opportunities. The issues identified in this review concerning age determination and assessment and changes to Child C’s missing person’s status indicate the need for new joint guidance. This should include the requirement for police services to take account of local authorities’ age determinations and assessments in assessing risks to missing persons. 5.13 Key Practice Episode Seven; Review Strategy Meetings, November 2016 12 Working Together to Safeguard Children(HMG 2015) 21 5.13.1 The next Review Strategy Meeting was not held until 17 November 2016. This stated that its purpose was to review Child C’s missing status, review actions taken and to review his looked after child status. It also noted that the case had been designated as an inactive missing person case by the police on 26 July 2016. It recommended that a full multi-agency case discussion be convened, that the police were to confirm actions taken in view of the inactive status and that Child C should no longer be designated as a looked after child. 5.13.2 Although the minutes of the Review Strategy Meeting held on 17 November 2016 refer to the need to convene a full case discussion, the next meeting held on 28 November 2016 was designated as a further review strategy meeting. This unanimously concluded that Child C’s Looked After Child status should be ended and that he should be categorised as a Child In Need. In addition, it reversed the decision of the previous meeting by concluding that the threshold for S47 enquiries had not been met. 5.14 Analysis of Key Practice Episode Seven; Review Strategy Meetings, November 2016 5.14.1 No Review Strategy Meetings took place between June 2016 and November 2016, which was too long a period for the case not to have been reviewed and monitored. Despite the fact that no new lines of enquiry had been identified, Review Strategy Meetings should have been held on a regular basis at defined intervals. 5.14.2 Two critical Review Strategy Meetings were held during November 2016, following a recommendation in the social work assessment for a meeting to reconsider Child C’s looked after status. 5.14.3 The first meeting took place on 17 November 2016 and no representative from either West Midlands or West Mercia Police was present; it is not possible to determine from the minutes as to whether they were invited as they do not specify those agencies that gave apologies for non-attendance. West Midlands Police have no record of their having received an invitation. Although reference is made to attempts to locate Child C, it concludes by recommending a review to consider Child C’s status as a looked after child. 5.14.4 The second meeting took place on 28 November 2016 and included representation from the West Mercia Police Harm Assessment Unit Manager. The minutes inaccurately refer to Child C’s status as being on the missing persons system to West Mercia Police when in fact the enquiry had been transferred to West Midlands Police in May 2016. The representative from West Mercia Police was unable to correct this as he did not receive a copy of the minutes. 22 Contrary to the conclusion made at the meeting that had been held two weeks earlier, this meeting decided that the threshold for S47 enquiries had not been met. The rationale for this decision was that all attempts to locate Child C had been futile and that agencies were to contact Shropshire Council in the event of Child C being located. This meeting is identified as a strategy meeting. It concluded that all agencies agreed that his status should be altered to that of a Child in Need, but there is no reference to the threshold criteria for determining a child in need as set out in the local threshold document that was in operation at the time. The use of a strategy meeting instead of a looked after review to consider such issues did not comply with Working Together To Safeguard Children (2015) which states that “Local authority children’s social care should convene a strategy discussion to determine the child’s welfare and plan rapid future action if there is reasonable cause to suspect the child is suffering, or is likely to suffer, significant harm”13. This review has concluded that any decision regarding Child C’s Looked After Child status should have been made at a statutory review which would have more effectively enabled a fuller analysis of his needs and enabled the child to be the focus of the meeting. Critically, a review would have included an Independent Reviewing Officer (IRO) whose role is to represent the child’s voice, to challenge the local authority and to prevent drift in planning. There is no evidence that, in coming to the decision to alter Child C’s status to that of a Child in Need, agencies took account of the threshold criteria that were in place at the time. An examination of the criteria indicates that he probably did meet the criteria, namely a) he is unlikely to achieve or maintain, or to have the opportunity of achieving or maintaining, a reasonable standard of health or development without the provision for him of services by a local authority under this part; (b) his health or development is likely to be significantly impaired, or further impaired, without the provision for him of such services; or (c) he is disabled.14 It is the conclusion of this review that Child C should have remained subject to statutory reviews until he had reached the assumed age of 18 as a means of quality assuring care planning, scrutinising decision making and tracking progress. It is important that the status and precise nature of meetings should be specified and documented so that all agencies are clear as to their purpose and function. 13 Working Together to Safeguard Children (HMG 2015) p36 14 Accessing The Right Service at the Right Time ; Multi-agency Guidance on Threshold Criteria to help support Children, Young People and their Families in Shropshire. 23 Multi-agency meetings have a vitally important role in ensuring robust and positive outcomes for children. As such, they need to be attended by all key agencies, enable appropriate professional challenge and provide clear rationale for decisions. This did not happen in all of the meetings held about Child C. 5.14.5 Despite the fact that there had been too long a gap between the Review Strategy meeting that was held on 8 June 2016 and the Review Strategy meetings held in November 2016, agencies did not consider the likelihood of increased risk to Child C as a result of his remaining missing for a longer time, nor is there any reference in the minutes to a consideration of the possibility that he may have been controlled or influenced. Whilst there is no definitive evidence that this was the case, agencies should have considered the hypothesis that a range of factors may have been indicators of increased risk. Instead, the minutes indicate too strong an emphasis on his status and do not focus on what may have been going on in his life whilst remaining missing for such a long time. 6. Context The following information is provided due to the fact that this review has concluded that there are a number of indicators in Child C’s life which lead to the hypothesis that he may have been trafficked into the United Kingdom. At the same time, it is recognised that some people may choose to enter the country in a clandestine manner. The National Context 6.1 The United Nations estimates that human trafficking is one of the most profitable forms of criminal activity globally (UN International Labour Organisation Report 2014). In the UK, the National Crime Agency (NCA) includes human trafficking as one of the major strategic threats from serious and organised crime 15.It is estimated that, globally, it is worth $32 billion a year and that around 2.45 million people are trafficked. 6.2 In 2011, the Child Exploitation and Online Protection Centre (CEOP) in conjunction with the British Embassy in Hanoi produced a report entitled The Trafficking of Women and Children from Vietnam16. This noted that CEOP’s Strategic Threat Analysis (STA) in 2010 concluded that the largest identified trend was of Vietnamese women and children trafficked into the UK. The report identified 58 children potentially trafficked from Vietnam to the UK over the 12 month period of the study, 37 of whom were exploited in cannabis farms, with a number being exploited in brothels, nail bars and for street crimes. 6.3 The most recent Strategic Threat Assessment produced by the National Crime Agency (NCA) published in December 2015 reported on activity for the calendar year 2014. It noted the following significant issues; 15National Crime Agency Strategic Threat Analysis (2016) 16The Trafficking of Women and Children from Vietnam (CEOP 2011) 24 6.4 Vietnam was the eighth most prevalent country of origin for all victims of trafficking (adults and children) with an increase of 18% from the 2013. Vietnamese children represented the second most prevalent group (13%) after UK children (16%). The most common type of exploitation for girls was sexual exploitation (49%) where boys were mainly exploited for criminal exploitation (35%). 21 % of potential child victims of criminal exploitation were trafficked for cannabis cultivation, of whom 86% were Vietnamese. 6.5 The most recent analysis of referrals of potential victims of human trafficking made via the National Referral Mechanism for the calendar year of 2016 identified Vietnam as the second most prevalent country of origin after Albania for all referrals, an increase of 8.6% from the previous year. Referrals of children were reduced from the previous year, 2013, by 8.5% but Vietnamese children represented the second most prevalent group along with children from Albania.17 6.6 The 2010 Child Exploitation and Online Protection Centre (CEOP) Strategic Threat Analysis highlighted the fact that the first leg of the trafficking route for many children trafficked into the UK was to fly from Vietnam into Russia. According to information supplied by the Russian Embassy, Russia issues approximately 50,000 visas to Vietnamese citizens every year. There are no Russian immigration staff based in Vietnam, and officers issue visas, for the most part without referral and with few, if any, checks. The report noted that there appear to be few barriers to trafficking networks moving victims into and through Russia.18The report noted that “The trafficking of Vietnamese children into and within the UK is the largest and most significant trend ... Most victims are trafficked overland from Vietnam by lorry and enter the UK by clandestine methods via seaport. The criminal networks involved in the recruitment, transportation and exploitation of children are well organised, flexible and generate large finances, mainly from the cultivation and wholesale distribution of cannabis.”19 The Local Context 6.7 Within the West Midlands region in 2016, Vietnam was the sixth most prevalent country of origin of trafficked children20 6.8 For the period 2015-16, the West Midlands region had 370 unaccompanied asylum seekers, which represented the fourth highest region in England 21 17Modern Slavery Human Trafficking Statistics(National Referral Mechanism), August 2017,National Crime Agency 18 Child Exploitation and Online Protection Centre, Strategic Threat Analysis ;Child Trafficking in the UK(2010) 19 Child Exploitation and Online Protection Centre, Strategic Threat Analysis ;Child Trafficking in the UK(2010)P23 20 National Crime Agency Strategic Threat Analysis (2016) 21 Unaccompanied Asylum Seekers and Refugee Children ;Safeguarding Pressures(Association of Directors of Children’s Services November 2016) 25 6.9 At the time of Child C being received into the care of Shropshire Children’s Services, they were inexperienced in the care of young people who presented as unaccompanied asylum seeking children. Child C was their fourth such young person in two years and the second young person from Vietnam who had been in their care. Since 2016 the numbers have significantly increased, along with their experience in caring for young people from Vietnam. It is reported that their awareness of specific vulnerabilities and risks for young people who arrive unaccompanied in the UK from Vietnam has increased and that they have now implemented a range of strategies and services in place to keep this particular group of young people safe, as well as regularly liaising with other Local Authorities who have high numbers of trafficked young people to share best practice. 7. Analysis of Terms of Reference In addition to the Key Practice Episodes, a number of specific questions have been formulated in order to identify the learning from this review. 7.1 Were the Care Planning Arrangements for Child C appropriate? 7.1.1 The Children Act (1989) Guidance Volume 2 states that “Robust assessment underpins the effectiveness of all subsequent actions and interventions and is essential to ensure improved outcomes for children.” 7.1.2 In view of the fact that Child C went missing from his placement five days after being placed in foster care, there was insufficient time for a comprehensive assessment to be undertaken. 7.1.3 Although several risk factors were identified, these factors are not linked to provide an evaluation of the likelihood that together, they constitute a risk that Child C was trafficked into the country, nor is there any evaluation of the likelihood of his going missing or continuing to be under the influence of traffickers once he had been accommodated 7.1.4 The assessment was not completed until 2 August 2016 and was therefore well outside the required timescale of 45 days. It was not signed off by the manager until 29 September 2016, almost two months after its completion. There is insufficient evidence of management oversight and challenge to the recommendation regarding the change in looked after child status. There is no evidence of any management analysis of the assessment or interpretation of Child C’s statements or behaviours as described in the assessment report. 26 Neither the social worker nor the manager made reference to the Modern Slavery Act (2014) nor to the possible need to make a referral to the National Referral Mechanism (NRM) in the event of Child C being found. 7.1.5 The assessment of Child C was insufficiently robust with regard to the risk factors associated with trafficking and absconding, was not timely and was not subject to adequate management scrutiny. 7.2 Was consideration given within the assessment to the possibility that Child C may have been trafficked? Were agencies aware of the issues and risks associated with unaccompanied asylum seekers? 7.2.1 These terms of reference are linked and will be considered together. 7.2.2 At the time of Child C’s arrival in Shropshire, consideration was given to the possibility that he may have been trafficked and it was concluded that this may have been the case. However, a lack of experience and training in the needs of trafficked young people meant that his social media contacts were not subject to evaluation by the Local Authority, there was no contingency plan in place in the event of his going missing soon after placement and the social worker from the EDT did not accompany the police officer and Child C to the foster carer placement. Although the foster carers checked his social media, information gleaned from his digital activity was not used by Children’s Services to inform their risk assessment. 7.2.3 Child C arrived in Shropshire via what has become known as a ‘lorry drop’, an illegal means of transporting immigrants into the UK via goods vehicles. At the time of his arrival, West Mercia and Warwickshire Police had not implemented its current Clandestine Entry Procedure which includes guidance to the effect that a) Every clandestine entrant has the potential to be a victim of modern slavery or human trafficking; b) Every driver has the potential to be in involved in human trafficking or modern slavery; c) Every ‘lorry drop’ should be treated as a potential crime and a proportionate level of investigation completed. 7.2.4 At the time of Child C’s arrival, officers from West Mercia Police responded to calls from members of the public and regarded their primary role as to locate and detain anyone who was considered to have entered the country illegally and to take them to the nearest custody unit where their identity and status could be verified by UK Immigration and Visas As a result, no immediate enquiries were made in respect of Child C’s mobile phone, or the photographs or route that were in his possession on being admitted to custody. 7.2.5 Although reference is made to the risk of emotional abuse, other potential risk factors such as physical abuse, sexual abuse, labour exploitation and criminal exploitation are not identified. 27 7.2.6 The assessment of risk was too narrowly focused on the categories of abuse as defined for purposes of instigating S47 enquiries and child protection plans and did not take account of the wider risk factors to which a young man who may have been trafficked such as; • The inconsistencies in his story as to how he arrived in the UK • The manner of his arrival in Shropshire • His reference to being allegedly kidnapped in Moscow • His use of social media • His apparent links to Calais • The fact that he went missing soon after being placed in foster care • The length of his remaining a missing person 7.2.7 This review has concluded that conventional strategy meeting agendas and categories, whilst consistent with Working Together to Safeguard Children (2015) are not appropriate in the case of children who remain missing for a long period who may have trafficked and who are at risk of remaining under the influence of traffickers. 7.2.8 The categories of risk and abuse used in child protection strategy meetings and the thresholds with regard to the instigation of S47 enquiries are applicable to children at risk who are living in their own homes or in establishments but do not always apply to the combination of risks for trafficked children or for those who may have been trafficked. This review includes a recommendation to HM Government that a dedicated risk assessment and strategy system be devised for such children. 7.3 Were appropriate measures put in place to mitigate any risks? 7.3.1 Safeguarding Children Who May Have Been Trafficked requires the local authority to assess the child’s needs in accordance with the same domains as any other looked after child but also requires them to establish relevant information about the child’s background, including understanding the reasons the child has come to the UK, to assess the child’s vulnerability to the continuing influence or control of his or her traffickers and the risks that they will go missing. It goes on to state that responding to this information ensures that the care plan includes a risk assessment setting out how the local authority intends to safeguard the young person so that, as far as possible, they can be protected from any trafficker to minimise any risk of traffickers being able to re-involve a child in exploitative activities. This plan should include contingency plans to be followed if the young person goes missing.22 7.3.2 This was not carried out in the Case of Child C due to the emergency nature of his admission to care and the short period that he was in placement before he went missing. 22 Safeguarding Children Who May Have Been Trafficked(DfE and Home Office ,2011) p30 28 Nevertheless, the risk of his being under the influence of traffickers was not cited and no contingency plan was put in place. 7.4 Were suitable measures taken to locate Child C after he had been reported as missing? 7.4.1 A series of measures were taken to locate Child C, such as enquiries at locations which he had been known to have frequented, a press release, checks with hospitals and the release of photographs 7.4.2 The missing person enquiry was conducted in accordance with force and national policy. Lines of enquiry were pursued and officers from West Mercia joined colleagues from the West Midlands in visiting locations that Child C was known to be frequenting. However, no attempts were made by any agency to contact the authorities in Vietnam to ascertain information or to seek to verify Child C’s account of his family history or how he had arrived in the UK. Agencies did not demonstrate sufficient professional scepticism regarding these matters. 7.5 Was information effectively shared between agencies? 7.5.1 Interagency coordination and communication have been well-documented as having the potential to enhance or undermine child protection case management, and the decisions professionals make.23 Collaboration between agencies, however, is highly complex and involves interpersonal, inter-professional and inter-organisational dimensions, such as different levels of accountability and decision making. 7.5.2 Strategy meeting minutes indicate a reasonable level of information sharing between the local authority and the police, but no representatives from the health service were invited as they should have been, in accordance with Working Together (2015). This review has also concluded that a key issue-the allegation made by Child C to the social worker that he had been kidnapped in Russia – was not shared with the police in a timely manner and nor was it followed up with regard to enquiries with the authorities in Russia. 7.5.3 The police were not informed of Child C’s disclosure to the local authority that he had allegedly been kidnapped via Russia until the second strategy meeting and this meeting did not consider whether a referral should have been made via the National Referral Mechanism to the UK Human Trafficking Centre. In addition, no arrangements were made between the local authority and the police to secure a copy of Child C’s statement to the social worker for police records. 23 Morrison, T. (1998). Inter-agency collaboration and change: Effects of inter-agency behaviour on management of risk and prognosis for change in dangerous family situations. Paper presented at the Twelfth International ISPCAN Congress on Child Abuse and Neglect, ‘Protecting Children: Innovation and Inspiration’, Auckland, New Zealand, September 6-9, 1998. 29 7.5.4 The minutes of the second strategy meeting held on 8 June 2016 were not attached to the police record and the information it contained was not disseminated on Child C’s police missing person’s case management record. 7.5.5 This review has concluded that communication and information sharing between agencies was insufficiently effective with regard to the conduct, composition and recording of strategy meetings and the sharing of information between Children’s Services and the police. 7.6 Did strategy meetings and reviews effectively assess the risks? 7.6.1 When he had been reported as missing, Child C was assessed as medium risk in accordance with the Police National Compact System which defines a person as being at medium risk if the risk posed is likely to place themselves in danger or they are a threat to themselves or other people. This review has concluded that this assessment of risk was accurate given the information available at the time. 7.6.2 Agencies also assessed risk in accordance with the categories in Working Together (2015), and the primary risk to Child C was identified as emotional, but the evidence indicated a broader category of risk in view of his presentation as an unaccompanied asylum seeker and the possibility of his being trafficked. These broader risk categories were not considered at any of the strategy meetings and this indicates that the classifications in current statutory guidance do not always lend themselves to enabling agencies to consider the risks associated with young people who may have been trafficked. 7.6.3 The fact that Child C had remained missing for a long period of time should have resulted in a heightened level of risk analysis rather than a reduction and the subsequent alterations in his status. 7.6.4 This review has concluded that any alteration in internal agencies’ risk categories should be subject to inter-agency discussion and scrutiny and that agencies should consider the implications of any such decisions for multi-agency working. 7.7 Did Child C’s status have an impact on efforts to locate him? 7.7.1 Child C’s status was altered from that of a Looked After Child to that of a Child in Need by Children’s Services and from active to inactive and from medium risk to low risk by West Midlands Police 30 7.7.2 The police decision concerning Child C´s missing status was one of several factors that contributed to the decision of Children´s Services to alter his status to that of a Child in Need 7.7.3 Whilst it is not possible to determine whether these decisions impacted on efforts to locate him, they indicate a lack of priority accorded to him by the respective agencies. 7.8 Was sufficient consideration given to Child C‘s status, cultural and linguistic needs? 7.8.1 Child C came from the Socialist Republic of Vietnam and claimed that he had travelled from Vietnam to Moscow and from Moscow to Shropshire. 7.8.2 Appropriate measures were taken to obtain interpreters to enable police interviews and the social work assessment 7.8.3 Child C was placed with white British foster carers who had received some training in equal opportunities some six years previously, but they had not received training in caring for children from specific backgrounds and there was insufficient time for them or the social worker to explore with Child C his specific cultural, linguistic, dietary or religious needs prior to his going missing. 7.8.4 This review has concluded that some consideration was given to Child C’s needs in the limited time that was available to agencies, but that the foster carers had not received appropriate, specific and up to date training to enable them to care for a child from Child C’s background. 7.9 How appropriate did agencies use terminology and to what extent did this impact on their decision making? 7.9.1 Terminology is defined in the Oxford English Dictionary as the set of technical words or expressions used in a particular subject. 7.9.2 Child C was variously described as an illegal immigrant, an unaccompanied asylum seeking child and a child who may have been the victim of trafficking. 7.9.3 Illegal immigration is the migration of people across national borders in a way that violates the immigration laws of the destination country. Immigration, including illegal immigration, is usually from a poorer to a richer country. 7.9.4 Child trafficking is defined as the “recruitment, transportation, transfer, harbouring or receipt” of a child for the purpose of exploitation. The internationally accepted definition of human trafficking comes from the Protocol to Prevent, Suppress and Punish Trafficking 31 in Persons, Especially Women and Children, supplementing the United Nations Convention against Transnational Organized Crime (2000, ‘Palermo Protocol’), which the UK ratified in February 2006. 7.9.5 The United Nations Convention on the Rights of the Child defines an unaccompanied child as a “child who has been separated from both parents and other relatives and are not being cared for by an adult who, by law or custom, is responsible for doing so”.24 7.9.6 Each of these terms was used in regard to Child C and there is often an overlap between them. However, the links are complex and it is important not to conflate them. For example, trafficked children are not always unaccompanied and they may not always claim asylum; they may be European Union or British nationals and, therefore, not be subject to immigration control. Conversely, not all unaccompanied children are victims of trafficking, although being unaccompanied significantly increases their vulnerability to exploitation. At times, Child C was referred to as an unaccompanied asylum seeker rather than as a young person who had presented as such. 7.9.7 This review has concluded that agencies did not always use terminology appropriately and lacked sufficient awareness to identify the complex inter-relationships between the terms. There is no evidence to indicate that the use of terminology per se had an impact on decision making but staff at all levels would benefit from increased awareness as to how to use the terms with precision and with appropriate linkages so as to ensure early identification of risk. 7.10 Was practice in line with current policies and procedures? Were they effective in addressing the issues? 7.10.1 During the period of the review, the key local policies in place were local adaptations of national guidance, namely Safeguarding Children Who May Be Trafficked and Safeguarding Children from Abroad.25 7.10.2 Safeguarding Children Who May Be Trafficked sets out additional child protection measures that may be required in the case of actual or potentially trafficked children, and stresses the need for robust assessment and strategy meetings to decide whether to instigate S47 enquiries. Strategy meetings were held in respect of Child C after he had gone missing and their focus was on enquiries as to his whereabouts. 24 UNICEF (1989) 25 Safeguarding Children who May Have Been be Trafficked (DfE and Home Office) ) 2011 and Safeguarding Children from Abroad(DfE) 32 7.10.3 Safeguarding Children Who May Be Trafficked also includes guidance on the management of missing children and, in the case of Looked after Children who go missing, it directs the reader to the West Mercia Joint Protocol for Missing Children and Young People. 7.10.4 Safeguarding Children from Abroad also refers to the need to seek information from other countries, but no enquiries were made with the authorities in Russia or in Vietnam at the time of Child C’s arrival. 7.10.5 The West Mercia Joint Protocol for Missing Children and Young People was in operation. This specifies that a Risk Assessment must be completed prior to placement, but this was not possible in the case of Child C because he had been admitted on an unplanned basis due to the circumstances of his arrival in Shropshire. 7.10.6 The two guidance documents that were in place set out the policies and procedures to be adopted in respect of safeguarding children who may be trafficked and safeguarding children from outside the UK ,and include procedural guidance. This guidance was incorporated into local policies and procedures with cross referencing to other local procedures, but it would have been clearer if they had been more specifically customised as local documents that set out the steps to be taken by practitioners in Shropshire. For example, the guidance concerning enquiries from abroad would have benefitted from a procedure outlining timescales and agency responsibility for this action. 7.10.7 Statutory Guidance on Children Who Run Away or Go Missing 26 includes a section on children who may have been trafficked from abroad. This states that “Some looked after children are unaccompanied asylum seeking children or other migrant children. Some of this group may have been trafficked into the UK and may remain under the influence of their traffickers even while they are looked after. Trafficked children are at high risk of going missing, with most going missing within one week of becoming looked after and many within 48 hours. Unaccompanied migrant or asylum seeking children who go missing immediately after becoming looked after should be treated as potential victims of trafficking”. It goes on to stress the need for an immediate assessment and for the local authority to work in close conjunction with the UK Human Trafficking Centre and immigration staff. This review has concluded that this guidance was insufficiently adhered to in the case of Child C. Local agencies did not liaise with central government agencies appropriately and did not recognise the possibility of Child C being under the continued influence of traffickers. 8. Informing local and national policy and procedure Does any learning from this case need to inform local policy and procedure and need to be communicated nationally? 26 Statutory guidance on Children who Run Away or Go Missing(DfE 2014) 33 8.1 It is apparent that local policies and procedures on trafficking and missing children in place during the period of this review were based on national guidance. However, local safeguarding boards should customise such national guidance to local need and clearly distinguish between policy and specific procedural steps for agencies to follow. 8.2 In addition, this review has concluded that the use of strategy meetings and S47 enquiries in accordance with Working Together (2015) has limitations and is not appropriate when applied to children who may be trafficked and children who remain missing for a long period of time. Although they may be subject to emotional, physical or sexual abuse and neglect, it is also necessary for agencies to consider the additional categories of labour exploitation, criminal exploitation, sexual exploitation, organ harvesting, domestic servitude and benefit fraud in strategy meetings and risk assessments. 8.3 The Police Missing Person investigation was conducted in accordance with national and force policy using standard risk management categories. 8.4 This review has concluded that consideration should be given to the inclusion of indicators of trafficking to enhance risk assessments in cases in which it is suspected that a young person may have been trafficked. In addition, it recommends that there should be joint guidance for Local Authorities and police services that incorporates guidance on age assessment, risk assessments of missing people and children at risk of trafficking. 9 Conclusions and themes 9.1 This review has concluded that it is highly unlikely that the tragic and untimely death of Child C could have been foreseen by the agencies with whom he had contact. It has demonstrated that the way in which agencies managed the case has provided an opportunity to learn a number of significant lessons as to how they may improve practice and better improve their services to young people such as Child C in the future. 9.2 The following key themes have emerged from the review; • The level of awareness of agencies about the implications of indicators of child trafficking and the associated risks • The process of initial assessment of young people who present as unaccompanied asylum seekers. • The assessment of risk in cases in which children remain missing for a long time • The use of terminology 34 • The appropriateness of current risk categories in statutory guidance to young people who may have been trafficked • Inter-agency communication 9.3 It is apparent that, at the time of their contact with Child C, agencies did not have sufficient awareness or experience of child trafficking to fully evaluate the various indicators or to fully evaluate the risks at the outset. The fact that he had arrived on a ‘lorry drop’, that he maintained that he had arrived via Moscow after an alleged kidnapping and was claiming to be a juvenile did not alert professionals to the prospect that he may have been trafficked or that he may have been coached to provide information that would result in his being admitted to care. The Children’s Services assessment was not completed in a timely manner and nor was it subject to sufficient scrutiny and management oversight. Staff were not trained in age determination and therefore relied too heavily on Child C’s physical appearance. Child C’s admission to care should have been undertaken by a social worker rather than a police officer. It is clearly the responsibility of the local authority to receive children into care and also to provide assurance and information to the young person during the process. 9.4 The guidance in use at the time, Assessing Age 27 has since been updated to take account of case law and the following is now required in undertaking age assessments; • The assessment must be carried out by two trained social workers in cases where whether the claimant is an adult or a child is objectively borderline and therefore a more in-depth assessment of their age is necessary • An interpreter must be provided if this is necessary • The individual must be offered the opportunity to have an independent appropriate adult present • Local authorities must comply with their own guidance when carrying out the assessment • If the circumstances of the case are such that the individual is being reassessed (for example, they are undergoing a second age assessment), it is preferable for those who undertook the first assessment not to take part in the second 27 Assessing Age, Home Office(June 2011), updated in February 2017 35 • Except in clear cases (where it is obvious that a person is under or over 18 and there is normally no need for prolonged inquiry), those who are assessing age cannot determine age solely on the basis of the appearance of the claimant 9.5 As the length of time in which he had been missing increased, agencies reduced the risk level. They did not consider the possibility that the long period in which he had remained as missing may have represented an increased risk due to the possibility of his remaining under the influence of traffickers. This possibility –along with a consideration of other reasons for his long period of remaining missing-should have been subject to inter-agency consideration 9.6 Child C was referred to, inter alia, as an unaccompanied asylum seeker and a potentially trafficked child without a clear appreciation of these terms, or of the possible links between a young people who claimed to be an asylum seeker but who may have been doing so at the behest of traffickers. 9.7 Written communication such as strategy meeting minutes were insufficiently accurate and were not subject to quality assurance. 9.8 This review has also concluded that agencies were constrained by the statutory guidance contained in Working Together to Safeguard Children (2015) which is not designed to assess the risk and take measures for children who present as unaccompanied asylum seekers and who may have been trafficked 9.9 During the period covered by the review, agencies lacked sufficient experience in the issues associated with trafficking. As a result, professionals did not recognise three linked risks; the likelihood that a young person presenting as an unaccompanied asylum seeker may have been trafficked and the subsequent probability of their remaining under the influence of traffickers, resulting in a strong risk of absconding soon after placement in care 10. Good practice 10.1 Whist it has not been possible to identify any elements of practice above expected standards during the period covered by this review, it is apparent that all agencies have been open to learning lessons , have engaged fully in the process of the review and have implemented some changes to policy and practice since the events covered by this review. 11. Lessons learned 11.1 This review has identified a number of issues concerning agencies’ awareness of the indicators of trafficking and associated risks, their assessment of young people who present as unaccompanied asylum seekers, the management of risk in cases where 36 children remain missing for a long time and the impact of a child’s status on how they are managed and reviewed. 11.2 Examples of improved practice include the following; photographs are now taken of all young people on admission to care, an emergency response plan is now in place to be implemented in the event of a large number of unaccompanied young asylum seekers arriving at the same time, biometric and DNA tests have been undertaken in liaison with Immigration Compliance and Enforcement, weekly intelligence sharing meetings are being held with partners from West Mercia Police on children missing from care and contact has been made with relevant embassies to locate the families of these children. 11.3 Similarly, since the period of the review, West Mercia Police have implemented a new set of policies and procedures on Clandestine Entry into the UK and have trained staff in their application. 11.4 West Midlands Police have implemented a new policy and procedure for managing the transfer of missing person’s investigations. This includes an agreement between Duty Inspectors and an escalation procedure in the event of disagreement. Where it is proposed to transfer responsibility for managing an investigation between police areas, the matter should be agreed between Duty Inspectors. Where an agreement cannot be reached, a Chief Inspector or Superintendent will speak to their counterpart and agree the transfer. 11.5 Shropshire Council Children´s Services have altered their systems to enable the Emergency Duty Team to add records and have improved the communication systems between the local teams and the Emergency duty Team to enable more effective care planning 11.6 Shropshire Council Children´s Services now maintain the looked after status of missing children who are unaccompanied asylum seekers and hold statutory reviews in accordance with national guidance 11.7 Shropshire Council Children´s Services now hold review strategy meetings at agreed intervals 12. Recommendations Agency report writers have made a number of single agency recommendations which are listed in Appendix 1. In addition, the Lead Reviewer has identified some further recommendations for HM Government, West Midlands Police and the Shropshire Safeguarding Children Board. 37 Recommendations for central government 1. Consideration should be given to reviewing the guidance in Working Together to Safeguard Children(2018) and Safeguarding Children who May be Trafficked (2011) to determine the suitability of the system of risk assessment, S47 enquiries and Child Protection Plans to children who are at risk of trafficking or who may have been trafficked. 2. Children who go missing from care should retain their status as looked after children, should remain subject to the scrutiny of looked after children reviews and remain the responsibility of the Council as Corporate Parent until the child reaches the age of 18. 3. The Home Office, College of Policing and Association of Directors of Children’s Services should give consideration to the development of a national multi-agency procedure on age determination and age assessment, to include: • How common agreement with supporting rationale should be reached between a local authority and partner agencies where contrary evidence is gained through missing persons investigations, and • There is no documentary or factual evidence to determine age and • The Local Authority is unable to conduct a review of age assessment or determination because the subject is not available for such an assessment to take place. Recommendations for West Midlands Police 1. West Midlands Police should ensure that accurate records are maintained in relation to strategy meetings and that the detail of the meetings and any decisions is made available to the investigating officers and their supervisors / managers. 2. West Midlands Police should inform partner agencies of any change to the risk levels, status or categorisations of missing children and should consider any information that partner agencies hold in making such a decision. Recommendations for the Shropshire Safeguarding Children Board 1. Inter-agency guidance on children who present as unaccompanied asylum seekers and trafficked children should be more clearly customised for the region. It should include dedicated referral pathway and a set of procedures that establish a plan of action indicating the role of each agency. 38 2. A dedicated strategy meeting agenda and risk assessment tool in respect of children who remain missing for long periods should be devised, along with a policy as to the minimum frequency for such meetings. 3. Dedicated inter-agency training on the trafficking of children and adults should be commissioned so as to raise awareness of indicators of trafficking and how to take all necessary steps to safeguard children who are victims or potential victims. As a minimum, this should include general awareness training, risk assessments and case studies. 4. Agencies designated as first responders in accordance with the Modern Slavery Act(2015) should develop a protocol to agree on the process and responsibility for referrals of victims and potential victims of trafficking in accordance with the National Referral Mechanism (NRM)28 5. The Board should assure itself that child protection strategy meeting minutes specify the rationale for the specific harm test and dates for the implementation of actions. 28 See National Referral Mechanism :Guidance for Child First Responders; Home Office 2016 39 Appendix 1; Recommendations from West Mercia Police 1. The alleged kidnapping and trafficking offences reported by Child C should be recorded on the Force Crime recording system and a referral made to the United Kingdom Human Trafficking Centre(now the Modern Day Slavery Trafficking Unit) 2. All the strategy meeting minutes relating to Child C should be attached to the Risk Management Plan 3. The Home Office Counting Rules for recorded crime and the associated Force Policy adequately caters for the recording of crime within West Mercia. In addition, Officers and Police Staff to be reminded in relation to the processes in place regarding the identification and recording of Human Trafficking and Modern Slavery investigations Appendix 2 Recommendations from Shropshire Council; Children’s Services 1. The Emergency Duty Team should be able to add new records to the client information system, CareFirst 2. Children’s Services to undertake an audit of strategy meetings and their timeliness is to be tracked. 3. New agendas for strategy meetings are to be embedded 4. Refresh of policy and procedures for unaccompanied asylum seekers and young people from abroad 5. Continued roll out of the training for foster carers and workers on working with Unaccompanied Asylum Seeking Children 6. Children’s Services to commission training on Child Trafficking 7. Continue with planned development and support of the Unaccompanied Asylum Seekers Team 8. Emergency Duty Team workers to undertake age assessment training 9. Develop a template for initial visits with unaccompanied asylum seekers 10. All children and young people to be escorted to any new placement by a social worker 40 Additional Recommendations for Shropshire Council Children’s Services In addition to the recommendations above, the Serious Case Review author has added the following; 1. Foster carers should receive cultural awareness training that is regularly updated so that they are familiar with the diverse needs of children in care 2. Foster carers should receive training in human trafficking and modern slavery with a specific emphasis on the risks of young people going missing from care Appendix 3; Additional Information On 6 March 2017, Derbyshire Police informed the Shropshire Safeguarding Children Board that Child C was, in fact, an adult and that information received from the authorities in Vietnam indicate that his date of birth was 5 April 1995 which would make him 21 years old at the time of his death. In retrospect, there are reasons to doubt the statements that Child C made about his early life. He claimed that he was born on 4 May 1999, that his parents had died in a road traffic accident when he was a small child, that he had been brought up by two uncles and his paternal grandmother, and left Quang Binh in April 2016 to go to Moscow on holiday, where he was kidnapped and taken to the UK on a lorry. Following his death, the police made contact with a person in Vietnam who is alleged to be his father. This man e-mailed a photograph which, along with fingerprints, confirmed the identity of the deceased. Derbyshire Constabulary undertook an investigation into the circumstances leading to Child C´s death, concluding that there was no sign of third party involvement. Wider coronial offences continue to be investigated. 41 Appendix 4; Definitions Migrant The International Organisation for Migration defines a migrant as any person who is moving or has moved across an international border or within a State away from his/her habitual place of residence, regardless of (1) the person’s legal status; (2) whether the movement is voluntary or involuntary; (3) what the causes for the movement are; or (4) what the length of the stay is.29 Asylum seeker An asylum seeker is a person who has claimed asylum under the United Nations 1951 Convention on the Status of Refugees on the grounds that if they are returned to their country of origin , they have a well-founded fear of persecution on account of race, religion, nationality, political belief or membership of a particular social group.30 Refugee A refugee defined as “ a person who owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it." 31 Absent The National Police Chiefs’ Council (NPCC) definition of ‘absent’ is: “A person not at a place where they are expected or required to be and there is no apparent risk.” Absent cases are required to be monitored over certain periods of time with consideration given to escalating to an at-risk category if the level of risk increases. The interpretation of the definition differs across police forces, making it difficult to directly compare data. From March 2015, the ‘absent’ category was developed to include the term ‘no apparent risk’. Child The United Nations Convention on the Rights of the Child (Article 1) defines a ‘child’ as a person below the age of 18. ‘Children’ therefore means ‘children and young people under the age of 18’ .Note that, where the person’s age is in doubt, they must be treated as a child unless, and until, a lawful age assessment shows the person to be an adult. Child Trafficking Child trafficking is defined as the “recruitment, transportation, transfer, harbouring or receipt” of a child for the purpose of exploitation. The internationally accepted definition of human trafficking comes from the Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women 29 https://www.iom.int/who-is-a-migrant 30 UNHCR Convention and Protocol Relating to the Status of refugees(1951) 31 Ibid ; Section 1(A) 42 and Children, supplementing the United Nations Convention against Transnational Organized Crime (2000, ‘Palermo Protocol’), which the UK ratified in February 2006. Article 3 states: “(a) ‘Trafficking in persons’ shall mean the recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation shall include, at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labour or services, slavery or practices similar to slavery, servitude or the removal of organs “(b) The consent of a victim of trafficking in persons to the intended exploitation set forth in subparagraph (a) of this article shall be irrelevant where any of the means set forth in subparagraph (a) have been used “(c) The recruitment, transportation, transfer, harbouring or receipt of a child for the purpose of exploitation shall be considered ‘trafficking in persons’ even if this does not involve any of the means set forth in subparagraph (a) of this article “(d) ‘Child’ shall mean any person under 18 years of age.” Missing The National Police Chiefs’ Council (NPCC) definition of missing is: “Anyone whose whereabouts cannot be established and where the circumstances are out of character to the context suggests the person may be subject of crime or at risk of harm to themselves or another.” Missing from care Missing from care refers to a looked-after child who is not at their placement or the place they are expected to be (e.g. school) and their whereabouts is not known.32 Unaccompanied asylum-seeking child (UASC) The Department for Education’s Statutory guidance for local authorities on the care of unaccompanied migrant children and child victims of modern slavery defines an unaccompanied asylum-seeking child as a “child who is applying for asylum in their own right and is separated from both parents and is not being cared for by an adult who in law or by custom has responsibility to do so”33 Unaccompanied child The United Nations Convention on the Rights of the Child defines an unaccompanied child as a “child who has been separated from both parents and other relatives and are not being cared for by an adult who, by law or custom, is responsible for doing so”.34 32 Statutory Guidance on children who run away or go missing from home or care( DfE January 2014) 33 Statutory guidance on the care of unaccompanied migrant children and child victims of modern slavery (DfE November 2017) 34 UNICEF (1989) |
NC52754 | Life-threatening injuries to a 4-year-old girl who was struck by a road vehicle in June 2021. Police commenced an investigation into possible neglect following reports of mother being intoxicated at the time. Learning includes: disproportionate/issues of professional optimism in the context of substance abuse addiction and domestic abuse; the voice of the child and the child's journey was not understood by all professionals; engagement and communication with the family was not always/could have been more robust and concerns raised by relatives were not given/could have been given adequate weight; the family's history, including an older sibling being subject to a Special Guardianship Order, should have been considered more when assessing parenting capacity; engagement and service delivery were impacted by Covid-19. Recommendations include: ensure families are systematically used to inform decision-making, information sharing and managing risk, with extended families able to contribute to the plan for a child; ensure a full understanding of a family's history is collated and this is considered in all assessments; children placed on Special Guardianship Orders with family members must be comprehensively included in assessments and planning; police should ensure that incidents of domestic abuse are linked to the same family network so that the cumulative impact is understood and risks can be assessed; partner agencies working with adults must share information with relevant children's professionals where there are concerns which could impact on parenting capacity.
| Serious Case Review No: 2022/C9525 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. 1 Local Child Safeguarding Practice Review Subject: Daisy 2 Daisy – Local Child Safeguarding Practice Review 1 Introduction This Review was commissioned in July 2021 to examine the circumstances of the incident and consider lessons to be learnt across the partnership. Daisy Subject of the Review M1 Mother F1 Father OS1 Older sibling OS2 Eldest sibling MGM Maternal Grandmother F1P Father’s partner MA Maternal Aunt Daisy is a 4-year-old, white British girl and at the time she and her sister lived with their mother (M1). M1 was in a relationship with the girls’ father (F1) until sometime in 2020. Both M1 and F1 have children from previous relationships, but of note in this review is M1’s 12-year-old daughter (OS2) who resides with her maternal grandmother (MGM) under a Special Guardianship Order (SGO). On an evening in June 2021 M1 travelled to F1’s home with Daisy and OS1 and there was a domestic disturbance and conflict between M1, F1 and F1’s new partner. M1 was described by witnesses as being heavily intoxicated at that time. M1 called a taxi around 10.00pm to take herself, OS1 and Daisy home a couple of miles away. On getting back home, M1 was in dispute with the taxi driver as she did not appear to have means to pay the fare and in this time Daisy and OS1 exited the car. Very shortly after this Daisy wandered into the road and was struck by a passing vehicle. Daisy sustained life-threatening injuries including several fractures to her legs, ribs and arms, alongside internal injuries, and a head injury. She was placed under sedation at a Children’s Hospital and underwent various surgeries. The sedation was lifted over the weeks following the incident. Daisy remained in hospital for a significant period, and although she is making a recovery in respect of most of the injuries there are fears that she may have acquired brain injuries which will result in lifelong disabilities. Due to the reports of M1 being intoxicated at the time of the incident and queries around her lack of supervision of Daisy at the time, Police commenced an investigation into a possible crime of neglect. 2 Terms of Reference The Panel of professionals, including practitioners agreed the following terms of reference: a. Was professional engagement, communication, and involvement with the family (including extended family) robust prior to this incident? b. Was there a full understanding of the family history in the context of capacity to parent to support decision making? During the course of the rapid review and the first panel meeting, it was agreed that there were some key lines of enquiry already in scope from historical reviews and those recommendations had already formed actions for agencies. These were posed as questions to the review: 3 • Was there disproportionate professional optimism about the safety of the children and progress sustained by M1? • Did poor quoracy, attendance or delay in execution of strategy and core group meetings impact on information sharing and planning? Would this have impacted on the ability to exchange information, assess risk, and ensure effective planning? • Was the voice of the child and child’s journey really understood by all professionals? • Was there consistent application of safeguarding thresholds throughout the child’s journey? • Did drift and delay in professional response impact on the outcomes for Daisy? The above elements were explored while undertaking this Review, but the Authors are aware that any recommendations that would follow this are in scope within other reviews. In order to avoid duplication of learning these areas were explored but not included in recommendations The partnership is tracking learning through system change to address: • Professional optimism • Poor quoracy and attendance (including delays) in key meetings • The voice of the child and the child’s journey • Consistent application of thresholds Although these recommendations are not being reiterated in detail here they will be raised as areas of ongoing challenge to inform practice implications across the partnership. 3 Review Process In June 2021 a Rapid Review was held to consider the facts of the case and consider the potential for identifying improvements to safeguarding. The Rapid Review agreed that a concise Local Safeguarding Children Practice Review (LCSPR) was needed to highlight improvements, reoccurring themes and where agencies could work together more effectively to safeguard children. Agencies submitted their involvement with the family including an analysis of practice identifying any potential learning. A Panel was formed of key professionals, including the practitioners involved in the case. A root cause analysis exercise was used to extract the learning as a Panel, focusing on the pathways to decision making (see appendix 1) The report is based on agency submissions and the Panel meetings held with key agencies and practitioners. We also had participation from Maternal Aunt, although other family members were asked to participate. 4 Agencies involved in the review Business Manager Safeguarding Children Partnership Detective Sergeant SCR Unit, Police Interim Virtual School Head Children’s Services Safeguarding Lead National Probation Service Head of Service Innovate CYPS – Children’s Social Care (CSC) Community Domestic Abuse Worker DIAS Director Innovate CYPS - CSC Senior Lettings Officer ASC and Health Homes Named Nurse Safeguarding Children Manchester NHSFT Specialist Nurse Safeguarding Children WWL NHSFT Named Nurse Safeguarding Children MH NHST (Mental Health) Manager Nursery Quality Assurance Manager Children’s Social Care Practice Manager Start Well Service Operations Manager We Are With You Safeguarding Lead Early Years Service Manager Inclusion Service Service Lead Children’s Safeguarding 4 Findings The following section seeks to explore the questions identified in the Terms of Reference. This analysis is drawn from the written submissions from individual agency discussions with the panel and practitioners who took part in the review process. 5 Information from the Review 5.1 F1 and M1’s relationship has a substantial history of domestic abuse, with the majority being F1 as the perpetrator of violence on M1 and on maternal aunt, MA at other times. This review looked at the 2 years prior to the incident, however it is notable that M1 has been in at least one previous relationship with a violently abusive partner in 2009. This had impacted at that time on M1’s older daughter, OS2. As a result of Children’s Social Care intervention OS2 was placed, eventually on a Special Guardianship Order, with her MGM. F1 has a history of offending behaviour and in early 2020 he was charged and remanded to custody. After a long period on remand of around a year, he was released on conditional bail in early 2021. Almost immediately upon his release from custody in March 2021 incidents began to recur between F1 and M1, albeit both state that they were not in a relationship. As mentioned above in this report, F1 then formed a new relationship with another female who he was with on the evening of Daisy’s accident. Alongside her experiences as a victim of domestic abuse, M1’s use of alcohol, and her mental health issues have been problematic for her since at least 2009, and she has had contact with services around these issues intermittently since 2012. Family members including MA made referrals to services for help and support for F1 and the children. There is a repetitious pattern of her not sustaining contact with services and poor engagement around her alcohol use. This was a woman who was being subjected to domestic abuse, had poor self-esteem and addiction to substance misuse in the form of alcohol misuse. Latterly, in May 2021 around 3 weeks prior to the accident involving Daisy, M1 had said that she had gone 30 days without drinking. This view was challenged by her sister, MA who felt that there was no way M1 could have done that but reflects what M1 had also told her substance misuse worker at We are With You. 5 Commentary All the above sets a robust picture that there is long term, chronic indicators of vulnerability and static risk factors – the nature of which should have underpinned all assessments of the children or adults in the family. Were extended family views listened to and did they form enough ‘weight’ in the assessments? Arguably there was professional optimism about M1’s ability to sustain abstinence and keep the children safe from harm. 5.2 Focusing on the period June 2019 – June 2021 it is evident that M1’s alcohol use, the impact of this on the children and the unhealthy relationship with F1 had not meaningfully changed. On 16th August 2019, MA (MA to Daisy and OS1) contacted Children’s Services in respect of M1’s drinking following an incident attended by police on 26th July where both M1 and F1 had been drinking and the children were resultantly taken care of by neighbours. There was a decision taken to commence a Child and Family Assessment, but this did not occur, and a further contact was made to Children’s Services by MA on 10th September. It is unclear from the review why the initial assessment did not occur. Resultantly, a S47 investigation was conducted, with the eventual outcome being that OS1 and Daisy were placed on Child Protection Plans on 2.10.19 under the category of emotional abuse. Further information shared at the panel meeting indicated that it was MA who reported to the police in relation to live domestic incidents. Although minimised by the mother, the third-party report was acknowledged and acted upon as a domestic incident by Police. No further action taken, or referral made to CSC. Commentary It was the view of the Rapid Review Panel that placing the children on Child Protection Plan was the correct decision for the children, based on the frequency and impact of M1 and F1’s behaviour. However, delays in statutory intervention in July meant that by September 2019 intervention was required in the form of assessing risk of harm. The needs and risk to Daisy had accelerated due to drift and delay. This was identified as due to missed opportunity to plan and individual agencies focusing on specific pieces of work rather than considering the holistic needs of the family. 5.3 The following period of Child Protection Planning showed two Core Groups taking place, at which there was insufficient representation from some agencies. In mid-January 2020, the second Review Protection Conference was held and the position on the Child Protection plan continued. Later, on 24th January there was another police attendance to the property where both F1 and M1 were intoxicated and deemed unable to care for OS1 and Daisy. The police then used Powers of Protection to place with their MA. A strategy meeting was held, albeit delayed by 7 days on the 31.1.20 where there was no further action taken and the Child Protection plan continued. This coincidentally was also the day that F1 was arrested and subsequently remanded to custody. Commentary The delay in the strategy meeting meant information couldn’t be shared swiftly and decisive action wasn’t taken to secure the welfare of the children and plan effectively. At the time the delayed strategy meeting was not deemed significant due to the perceived reduction in risk due to F1 being placed in custody. However, this meeting could have been utilized to plan for F1 eventual release and escalation of risk due to domestic abuse. The risk was temporarily removed due to F1 absence, but this did not reduce risk only delayed it. Whilst timescale is determined by need and level of risk good practice states strategy meetings should be held within 24 hours as per CSC practice standards. 5.4 There was then a period of almost 6 months where the only reported incident was attendance by the police to M1’s address in April where she had been reported to be passed out in front of the children through intoxication, but this was not substantiated by the police, and nothing further happened. 6 Commentary It is notable in review that F1 was in prison in this period, perhaps suggesting that the risks both to M1 of domestic abuse, and those of her drinking impacting on the children reduced simply due to his absence. This physical removal of a risk however and period of desistence of incidents, appear to have been taken as a positive indicator in M1’s ability to protect the children both from the external risks of the abusive relationship but also as a mitigative factor around her alcohol use. There is little evidence to support that decisions were made pursuant to robust risk assessment, and this is further evident in the following section. Information shared at the panel meeting included further clarity on this point. At the time of F1 being taken into custody it was predicted he would receive a significant sentence due to the nature of the crime. COVID 19 impacted this due to the high number of cases in the remand centre/prison which resulted in his early release on bail pending court hearing and sentence. Children’s social care state this could not have been foreseen due to the unique impact of COVID 19. 5.5 In June 2020, a Review Child Protection Conference was held, without M1 (or F1 due to his continued period in custody) and the recommendation was made to move the case to Child in Need Planning. There follows a long period through to November 2020 where a CIN plan was in place, but reviewing information shows there was little evidence of work being completed with M1. The case was closed to Children’s Social Care on 23.11.20 with further support through Start Well (early intervention and prevention) recommended predominantly in relation to supporting M1 seek new housing as part of an Early Help Plan. Start Well’s records show some engagement regarding the housing progress and with her GP but also, pertinently, say that M1’s mother phoned Children’s services on 5.2.21 after finding M1 drunk in the house with OS1 and Daisy, a half bottle of vodka and the gas hob on. There is no record of this contact within Children’s Service’s records. However, Start Well records show that they had acknowledgement of this referral to CSC. M1 engaged with support from Start Well services during this period to address her housing needs. This was an opportunity to support via wider engagement of services to address her parenting needs and the safe care of her children. The escalation to CSC meant Start Well closed the case on 10th March 2021. Start Well closing the case was more understandable than the earlier CP – CIN ‘step down’ move, and subsequent closure to children’s social care, as it was only an Early Help plan and was therefore wholly voluntary, but it is repetitious of decision making without full view of the history of agency involvement or testing the hypothesis of how long M1 would sustain that engagement for. On 15th March 2021, Children’s Services were contacted again by MA with concerns that her sister M1 had been drinking again and had re-kindled her relationship with F1 who had been bailed from custody. There was no immediate action in response to this. However, on 29th March 2021 there was an incident where a member of the public contacted the police having witnessed M1 so intoxicated that she tipped the pushchair she was steering causing the young child (assumed to be Daisy) out. The police attended and found an empty vodka bottle under the pram. M1 became volatile and both Daisy and OS1 were taken to their MGM by police. Commentary This delay to the strategy processes, and the eventual decision of it not crossing the threshold for further Child Protection Planning are both concerning. This should have warranted legal advice with a view to initiating proceedings. The social workers view that the family were ‘working well together’ was optimistic. 5.6 Subsequently there were other incidents in April 2021 where M1 reported being assaulted by a male in the community (17th) and being sat on a bridge threatening suicide reporting alcohol problem and suicidal thoughts (20th). On 27th April almost a month from the incident of 29th March a strategy meeting took place to consider all three recent incidents. A further S47 investigation commenced, and the outcome was that the CIN plan should continue. 7 Commentary This delay to the strategy processes, and the eventual decision of it not crossing the threshold for further Child Protection Planning are both concerning. This should have warranted legal advice with a view to initiating proceedings. The social workers view that the family were ‘working well together’ was optimistic. 5.7 The early years setting which Daisy attended described Daisy as a lovely, friendly, happy girl who socialises well with her friends and had settled into the nursery well when she started attending there in March 2021. There had been disclosures to the nursery by Daisy’s MA about M1 not being able to control her alcohol use and explanations that she, and MGM would sometimes cover the care of OS1 and Daisy. There is reference of a Strategy Meeting on 24.5.21 which the nursery attended where positive progress was being made that reflects the reports earlier of M1 being abstinent of alcohol over that month prior possibly since the incident of 20th April. Nursery staff would have regular contact with M1 but within a specific context of bringing Daisy to nursery and potential brief observation of interaction with other families and children. Using a signs of safety practice framework approach to measure the situation on a scale of 1-10 (1 extremely unsafe – 10 being extremely safe) the meeting gave a 7 based on observed progress and communication with M1. This is the last substantive meeting prior to Daisy’s accident on 10th June and potentially points to over optimism on the part of professionals Commentary It is notable that the nursery modelled good practice in this case albeit for only a couple of months with Daisy. The nursery attempted to gather transfer information from Daisy’s previous nursery, offered free additional sessions to support the family and clearly fostered a good relationship with both M1 and MA. There was less known about F1 by the nursery that would have been helpful to them, but when they asked M1 whether there were any other agencies involved they were told no. This point, minor in context, was discussed at the Rapid review. The Panel felt this was perhaps the use of professional ‘jargon’ in saying ‘agencies’ – to that end the Early Years team and the Nursery have adapted the proforma used to capture initial information to make it more informal / accessible. Notably, the nursery felt that the fact that all contacts with M1 and F1 were subject to both the family and staff wearing face coverings due to Covid and may have impacted on communication as some of the ‘enablers’ for communication (smiles etc.) cannot be communicated and perhaps make it harder to achieve a rapport with a family. The patterned behaviour around M1’s long history of alcohol use, domestic abuse, amounted to high-risk behaviours that were evident even in the last couple of months, a score of 7 was giving undue credit to M1’s recent abstinence and represents over-optimism. Significantly at various points the family have stepped in as clearly M1 has been unable to care for the children, yet CSC optimistically didn’t see the same level of concerns throughout Daisy and her sibling’s lives as the family members saw. 6 Family Contribution Consultations with key family members are a very important aspect of any review and the authors and The Safeguarding Partnership are very grateful that Daisy’s family felt able to contribute. The information they shared is contained in this section in the following paragraphs. 7 Contribution from MA Maternal aunt was open, honest, and helpful in her comments. She was able to highlight how she and the wider maternal family had experienced services and how a number of key episodes could have been managed better. MA gave the reviewers her reflections on the relationship between M1 and F1 over the period where there was the reported Domestic Abuse. 8 She feels the family were flagging to services constantly about the struggles M1 had with her own needs and meeting those of her children. She felt not all referrals to the police were then passed onto CSC, or they certainly weren’t always acted upon. The fact that the children witnessed so much of the domestic abuse and the police were routinely seeing this, caused her concern that this didn’t get escalated quicker or that a cumulative view was taken on it. The family felt that any interventions by services always lay at M1s ‘door’ for accountability not with F1. One example given is she believed the limited intervention with F1 around domestic abuse was asked to be carried out by a CYPF Worker, (who is attached to CSC,) and would not have had expertise in Domestic Abuse. MA stated professionals were always involved but information provided by M1 was always taken on face value. There wasn’t enough professional curiosity. MA felt she and the family weren’t ‘heard’. MA stated she made numerous referrals to health, police, CSC and drug agencies but many times they didn’t result in further action. During a time when F1 was in prison M1 started to make small disclosures about her lived experience living in an abusive relationship. At the same time her alcohol misuse also got worse. MA described the changes in social workers at this point made F1’s situation worse, the ‘start again’ processes overwhelming for M1 and them as a family. Key information was constantly being repeated. On one occasion, injuries to M1 were apparently not pursued to establish how they had occurred. The family found the situation difficult because their own relationship with M1 wasn’t always strong however the paramount interests for Daisy and her siblings were their number one priority. Formal meetings such as CIN planning, CP planning were not always attended by family member nor parents. 8 Summary of Lessons and learning and Implications for wider practice To note in terms of good practice changes, the Early Years team and the Nursery have adapted the proforma used to capture initial information from families to make it more informal / accessible to share information on services they are working with. There was disproportionate professional optimism about the safety of the children and on the view that progress could be sustained. Poor quoracy and attendance at strategy meetings and core group meetings would have impacted on not having a consistent working group to exchange information and assess risk, ensuring planning is effective. The voice of the child and child’s journey wasn’t always understood by all professionals, which also resulted in inconsistent application of thresholds throughout. Drift and delay in professional responses at times impacted of the outcomes for Daisy. We know from research that abuse is more likely to escalate after separation and therefore this would have been a risky time for both M1 and the children in her care. These factors and an over optimism of substance abuse addiction and domestic abuse meant services felt they could reduce intervention. The professional engagement and communication with the family throughout involvement with services wasn’t always robust, nor were family members concerns given adequate weight. The use of family network meetings and planning alongside the wider family didn’t support an understanding of how best to protect Daisy from harm. The fact that an older sibling had been placed with MGM on a Special Guardianship Order some years previous should have provided a serious ‘marker’ for M1’s ability to parent. The lack of understanding of the family history in the context of parental capacity didn’t always support decision making. Because the ongoing assessments were not considering the circumstances that surrounded the older child being placed with MGM on a special guardianship order, nor the family’s information around M1’s ability to parent it meant that circumstances were being evaluated based on the current here and now rather than looking at the cumulative effect of these key episodes on the child’s life. During this period services were limited by the implications of covid 19 on service delivery. We heard as part of the review how DIAS for example moved from face to face and drop-in services to telephone contact inhibiting robust engagement and service delivery. 9 9 Recommendations There will not be any recommendations that are already in progress through previous reviews and will be limited to new learning. This review will feed into the formal processes in place for other existing reviews. 1 The Safeguarding Partnership should seek assurances from partners to ensure that Families are more systematically used to inform information sharing, decision making and managing risk. There should be a strong expectation that extended families contribute to the plan for a child. This is at lead professional and early help level, through to child protection level. 2 CSC to ensure they collate a fuller understanding of the family history, and that this is considered in all assessments. When children are placed on an Special Guardianship Order with family members, these children must be included comprehensively in assessments and planning. 3 The Safeguarding Partnership should assure themselves, through multi-agency audit activity, that, The Safeguarding Partnership practice model signs of safety is producing robust risk management in cases such Daisy 4 Police should ensure all incidents are linked to the same family network, so the cumulative impact of Domestic Abuse is understood, and risk is assessed appropriately. 5 Partner Agencies should assure The Safeguarding Partnership that when they are working with an adult and there is a concern that may impact on their parenting capacity, that this is shared with relevant professionals working with children. Safeguarding children and adults policies and training must direct staff to consider the cumulative harm and impact on the children (including their age and vulnerability) and share key information and escalate concerns accordingly. Signed …………………………………………. |
NC52316 | Serious neglect of a 12-year-old boy identified at admission to hospital in April 2020. Learning includes: need to develop clear treatment pathways for specialist services; need for patient information for a family which details what the parental or carer expectations are to support the child's treatment; need for managerial oversight and supervision in complex cases, especially where there are concerns regarding parental engagement and compliance with advice and treatment; past information about a child and their parents or carers should inform the child's future health care; have honest and clear conversations with parents about their role in supporting health needs and what will happen if those needs are not met; be 'professionally curious' about information provided by parents and how that impacts upon the care provided; professionals supplying referral information or agency reports for meetings need to be explicit when there are safeguarding concerns about a child; importance of seeking specialist support to ensure medical tests are completed in a timely manner; have robust conversations with other agencies to ensure they understand the significance of a child not having important medical tests completed. Makes no specific recommendations.
| Title: Learning review report: William. LSCB: Hampshire Safeguarding Children Partnership Author: Hampshire Safeguarding Children Partnership Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Learning Review Report William This review has been undertaken on behalf of the Hampshire Safeguarding Children Partnership (HSCP) by the Learning and Inquiry Group. The review of William’s case is taking place in conjunction with the review a of another child where some similar characteristics of the case were identified, and it was considered that learning in the two cases were likely to have similarities. A summary of the case: William was referred to Childrens Services at the end of April 2020, following an emergency paediatric admission at the age of 12 years. The admitting paediatric consultant was deeply concerned about the level of physical compromise that William displayed; he required intensive medical support to correct his abnormal blood picture and malnutrition. William was subsequently made subject to a multi-agency Child Protection Plan and his case was put before the court in public proceedings. Childhood history: As a baby and young child, William had a reported history of feeding difficulties. His parents described him as a fussy eater. At the age of four he was referred to a paediatrician due to his limited diet. Despite his dietary habits, his growth at the time was noted to be good. Aged six, William was referred to a specialist unit for inpatient assessment of his feeding issues and emotional anxieties. The family felt that the care provided by the specialist unit was not helpful and chose to withdraw William from the assessment. A few months after his withdrawal from the specialist unit, a parental decision was made to withdraw William from the support of Child and Adolescent Mental Health Services (CAMHS). At that time the CAMHS clinician documented that William would learn a pattern of avoidance with any future anxieties he may have if he did not continue to receive professional support to manage and resolve his emotional difficulties. In 2018, aged 11 years, William was seen by the School Nursing Service. As part of the National Child Measurement Programme his weight and height were recorded. William was described as visibly overweight, and this was confirmed by his recorded body mass index. Ten months later, the school expressed concerns that he was as 'pale as a milk bottle' and visibly underweight. The school was concerned that William refused to eat and drink anything during the school day. The school arranged an appointment with William's mother to discuss their concerns. In October 2019, the local CAMHS team received a maternal referral requesting support for William due to his dietary difficulties. At the time of CAMHS acceptance William was only drinking milk. His 2 limited diet was categorised as a condition known as Avoidant Restrictive Food Intake Disorder (ARFID). CAMHS began the process of assessment and requested that William had blood tests completed to determine if he had any dietary insufficiencies. In December 2019, William was on a reduced timetable at school due to his anxiety. There was good communication between the school and the Eating Disorder Team. There was a plan to work on associated anxiety so William's school attendance would increase. By February 2020 William's school attendance was 38%. In March 2020, William was withdrawn from school by his family who indicated that they intended to electively home educate him, so the planned autism assessment by CAMHS could not take place. The family requested that the school did not join the planned meeting with CAMHS to discuss William's needs. The school referred William to Childrens Services via the Multi Agency Safeguarding Hub, expressing concern about his health and about the fact that he was about to be withdrawn from school. From October 2019 to April 2020, there were several discussions between CAMHS and the family about the blood testing. CAMHS requested the GP's assistance in getting the blood tests completed. The family reported attempted visits to the hospital for bloods to be taken, but William experienced high levels of associated anxiety and therefore the bloods were not taken. William's mother told the GP that CAMHS were dealing with the blood tests. In March 2020, William's mother reported concern about completing the blood tests for William due to the risk of COVID-19 infection. At the beginning of April 2020, William and his mother reported that he had been unwell with a bug. The family reported a significant reduction in William's daily milk intake. During a virtual appointment with William, the CAMHS clinician was concerned about his physical appearance and requested that he attended a face-to-face appointment the following week. On 28 April 2020, William was seen in a CAMHS physical observation clinic. He presented as physically very unwell and as a result an emergency referral was made to the local paediatric ward for a full health assessment. Learning points for managers: • To develop clear treatment pathways for specialist services to ensure that children's health needs will be fully assessed, tracked, and monitored. • Develop and provide patient information for a family who are accepted into a service which details what the parental/carer expectations are to support the child's treatment. • A mechanism for managerial oversight and supervision in complex cases, especially where there are concerns regarding parental engagement and compliance with advice and treatment. Learning points for practitioners: • The importance of reading past known information about a child and their parents/carers, which should inform future health care trajectory. • Having honest and clear conversations with parents about their role in supporting health/ medical needs and what will happen if those needs are not met. • To be 'professionally curious' about information provided by parents and how that impacts upon the care provided. • Professionals supplying referral information or agency reports for meetings need to be explicit when there are safeguarding concerns about a child. • Importance of seeking specialist support to ensure medical tests are completed in a timely manner. • Having robust conversation with other agencies to ensure they understand the significance of a child not having important medical tests completed. 3 Learning points for HSCP: • To create broader awareness of health neglect and the impact upon children. Themes in common with other reviews in Hampshire: • Clarity as to who is the ‘Lead professional’. • Use of professional meetings in complex cases. • The challenges of working with families where there is partial engagement and disguised compliance. • That all professionals when discussing a child clearly understand their needs and the potential risks to the child. If you do one thing, take the time to…. • Have a clear and honest conversation with the family about your agency expectations and what potentially will happen if the child's needs are not prioritised or met with specific timescales when relevant. How was learning achieved: A multi-agency review was commissioned by the Learning and Inquiry Group of Hampshire Safeguarding Children Partnership. Hampshire agencies provided written reports. These were reviewed by two senior managers, independent of the case and where required, additional information was sought from professionals involved in the case. HSCP Response: The learning identified in this Learning Review Report has been incorporated into HSCP workstreams. This has included multi-agency training, planned audits, scrutiny work, professional guides, and featured newsletter items. Training and resources: • HSCP Training - HSCP offers training on a variety of safeguarding themes. • HSCP Training 2020/21 • HIPS Procedures • HSCP and IOWSCP Neglect strategy and toolkit • HSCP AND IOWSCP Safeguarding Adolescents Toolkit – Strategy Guide on Neglect • Neglect multi-agency training • Child and Family Engagement Guidance for Primary Care • Child and Family Engagement Guidance for secondary and tertiary care • Spotlight on Disguised Compliance • Published SCR/LCSPR reports and learning summaries can be found in the Learning and Reviews section of the HSCP website. Published Reviews. Publication date: 21 February 2022 |
NC049475 | Death of Child C, a 3-month-old Black British/Caribbean girl, in September 2016 from cardiac arrest, while in the care of her mother. After her death, Child C was found to have multiple fractures consistent with non accidental injuries. Parents received custodial sentences. Child C was born prematurely at 28 weeks and admitted to neonatal unit. Hospital staff made referral to children's services regarding mother's limited visits during her baby's stay and engagement with staff. A child protection plan was made for Child C and her sibling. Mother and children moved in with maternal grandmother, to avoid children being taken into care. Previously, mother of Child C lived between family and friends and turned down offers of housing. Mother of Child C denied a relationship with the father of children but said he was supportive. Child C was travelling in a sling on the bus with her mother. Mother asked passengers for help, saying her baby had stopped breathing. Child C presented at hospital with cardiac arrest and bruising and swelling to her head and eyes. Maternal history of: domestic abuse; abuse as a child; homelessness; and reluctance to engage with services. Findings include: impact of poverty and homelessness on the child (including pre-birth) should always be considered; and investigations of fathers must be pursued even when resistance from mothers. Recommendations include: training for staff working with avoidant and hard to engage families should include identifying disguised compliance; and the relevant LSCB's must get assurance that agencies demonstrate how fathers or absent parents are included in any assessments.
| Title: Serious case review: Child C: final report. LSCB: Barking and Dagenham Safeguarding Children Board Author: Barking and Dagenham Safeguarding Children Board Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review: Child C Final Report Published: January 2018. Contents Page The Circumstances that Led to this Review 3 - 4 Family Composition 4 Summary of the Background 5 - 9 Details of Practice and Analysis 10 - 67 Conclusion and Recommendations 67 - 70 Appendices: Appendix 1 – Methodology 71 - 74 Appendix 2 - Timeline 75 - 94 Appendix 3 - Actions already taken by individual agencies 94 - 100 Appendix 4 - Acronyms and Terminology 101 Appendix 5 - References 102 1.1. The Circumstances supporting the decision to undertake this SCR 1.1.1. Child C was born prematurely at 28 weeks and 5 days gestation at home; following transfer to Newham University Hospital (NUH) she was admitted to the Neonatal Unit. Child C remained in the Neonatal Unit for a period of 65 days; the mother visited the unit on only 18 occasions before Child C’s discharge on 5th August 2016. Staff on the Neonatal Unit at Newham University Hospital (NUH) made a referral to London Borough of Barking and Dagenham Children’s Services regarding the limited visiting of mother and engagement with the staff. 1.1.2. Ten days after Child C’s discharge from the Newham Hospital Neonatal Unit she was made subject to a Child Protection Plan (CPP) in the London Borough of Barking and Dagenham under the category of ‘neglect’ along with her older sibling. 1.1.3. On 28th September the mother of Child C was travelling on a bus with Child C in a baby sling; the baby’s head was covered with a white cloth. The sibling of Child C was also with her and was in a pushchair. The mother asked for help from the passengers saying that her baby had stopped breathing, one passenger carried out Cardiopulmonary Resuscitation (CPR) on Child C prior to the arrival of the emergency services. The ambulance crew that attended the scene were concerned that Child C’s jaw was locked and called the police. Child C was taken to NUH where she was pronounced dead. 1.1.4. Child C presented at NUH in cardiac arrest, she was not breathing, was very cold to touch, and had stiffness in her neck and limbs. She also had bruising and swelling to her head and eyes. 1.1.5. The parents of Child C were arrested on suspicion of the murder of Child C and later charged with a) Murder; b) Assault/ Neglect; c) Causing/ Allowing the Death of a Child. 1.1.6. A skeletal survey conducted post death indicated that Child C had suffered multiple fractures that were old and new fractures which were considered to be consistent with non accidental injuries (NAI) 1.1.7. The case was considered by Barking & Dagenham Safeguarding Children Board (BDSCB) Serious Case Review (SCR) Panel on the 10th November 2016 to consider if the criteria had been met, under Regulation 51 namely: (a) abuse or neglect of a child is known or suspected; and 1 Local Safeguarding Children Boards Regulations 2006 (b) (i) the child has died. 1.1.8. The then Chair of the Board accepted the recommendation to conduct a Serious Case Review, in line with Chapter 4, Working Together2 1.1.9. In May 2017, the parents of Child C were found guilty of causing or allowing the death of Child C. They both received custodial sentences. 1.2. Family Composition 1.2.1. The family members relevant to this review will be referred to as follows: Family member Description used in this report Age at time of Child C’s death Ethnicity Subject Child C 3months Black British / Caribbean Mother of Child C Mother 25 Black British/ Caribbean Father of Child C Father 52 Black British Sibling Of Child C Sibling Older than Child C by a couple of years Black British / Caribbean Maternal Aunt of Child C Maternal Aunt 29 Black British/Caribbean Maternal Grandmother of Child C Maternal Grandmother 50 Black British /Caribbean 1.2.2. Family involvement. The involvement of key family members in a Review can provide particularly helpful insights into the experience of receiving or seeking services. Letters were sent to the mother via her solicitor and directly to the father. To date there has been no response. 2 Working Together. HM Govt 2015 1.3. Summary of the background 1.3.1. The mother of Child C was the sixth of eight children. Following a disclosure by Child C’s maternal grandmother in 2007 of domestic abuse, the family moved to a women’s refuge and then to accommodation in Essex. Child C’s mother returned to live in London in 2010 when her relationship with her mother (the maternal grandmother) had broken down. She had no fixed abode and was reported to live between family and friends. 1.3.2. The mother, now a resident of Newham, continued with her transient lifestyle during her first pregnancy and gave birth prematurely at 34 weeks gestation to Child C’s sibling (April 2014). She avoided professionals and only engaged with services on her own terms, evidenced by sharing different information depending on which agency she was talking to. The mother denied that she was in a relationship with the father of her children but stated that he was supportive. 1.3.3. The mother approached Newham Housing Needs Service on the 7th April 2014 with a letter from the maternal aunt stating that she could no longer allow the mother to stay on a temporary basis in her flat in Tower Hamlets. The mother was offered temporary accommodation in both Forest Gate and Edmonton. She turned down both of these offers, citing proximity to her father and brother whom she had alleged assaulted her for the former, and the latter because it was too far away. Chronology of Housing Offers/Events Date Location Outcome 25 April 2014 Forest Gate Rejected: too close to father and brother 11 December 2014 Chadwell Heath Accepted 11 March 2015 Chadwell Health Cancelled: not living there 17 March 2015 Edmonton Rejected: too far away 7 April 2015 Dagenham Accepted: Signed for on 9 June. Moved in 6th July April 2016 Dagenham Cancelled: not living there 1.3.4. The mother experienced a late spontaneous miscarriage (at 21 weeks gestation) on 16th June 2015, at the father’s home. The mother and the baby were conveyed by ambulance to hospital. The baby was reported by ambulance staff to have shown signs of life but subsequently died. 1.3.5. The mother also self reported a number of early miscarriages (five to seven) and had presented for fertility treatment aged 19. Three births had all been premature and home deliveries with no professional present. 1.3.6. Following nearly 16 months of tenancy arrangements, in March 2016, the London Borough of Newham cancelled the mother’s tenancy for a flat in the London Borough of Barking and Dagenham (LBBD) as it transpired that she had never been resident at this address and they concluded the homelessness duty had been discharged in April 2016. The mother was pregnant with Child C, her third pregnancy in less than three years, and on 2nd June 2016 again delivered prematurely at 28 weeks and 5 days gestation at the address of Child C’s siblings father. Child C was admitted to the Neonatal Unit at Newham University Hospital where she remained for a period of 65 days. 1.3.7. During Child C’s time in the unit her mother visited her on only 18 occasions. Prior to Child C’s discharge a strategy discussion was held and an Initial Child Protection Case Conference (ICPCC) was planned to take place in the LBBD on the 15.08.16. On 5th August Child C was discharged from the Neonatal Unit into the care of her mother who planned to stay with her sister (the maternal aunt) in Tower Hamlets (the third London borough). Date Event Outcome 25 July 2016 Strategy meeting with Police Recommends case progressed to ICPC 29 July 2016 Professionals Meeting held at the hospital Mother to register with GP in Tower Hamlets Tuesday 2 August 2016 Discharge Planning Meeting held at the hospital Child C to stay with mother and sibling at maternal aunts flat in Tower Hamlets Friday 5 August Child C discharged from the Newham Hospital Neonatal Unit At 6pm 15 August Initial Child Protection Case Conference held by LBBD Child C and older sibling made subjects of Child Protection Plans under the category of neglect 17 August Threshold of Care and Legal Planning Care proceedings should be initiated. If Meeting held by LBBD children not seen by 19 August Emergency Protection Order to be considered 19 August Maternal grandmother and maternal aunt offer support to directly avoid children being taken into care Family Support Plan signed and agreed that the family will move to Essex to live with maternal grandmother 1.3.8. At the ICPCC on 15 August convened by the London Borough of Barking and Dagenham (LBBD), Child C and her sibling were made subject to a Child Protection Plan (CPP) under the category of neglect. During the conference the mother was antagonistic and stated that she would not comply; she refused to say who the father of Child C was or where he lived. In view of this further action from the ICPC meeting was for further consideration of a legal planning meeting if the mother’s non-compliance continued. 1.3.9. Concern escalated as Child C had not been seen by a health professional since discharge from the Neonatal Unit at Newham University Hospital and it was unclear where the family was living. A Threshold of Care and Legal Planning Meeting (TCLPM) was convened two days after the ICPCC (17 August); the TCLPM provided a framework for how the case should be progressed and managed. This meeting was attended by LBBD Group Manager CSC, Senior Solicitor, Court Progression Officer, Social Worker and Minute Taker and concluded that care proceedings should be initiated. 1.3.10. On 19 August the maternal grandmother and maternal aunt of the children visited LBBD Children’s Services with the mother and stated that the mother wished to take Child C and the older sibling to live with the maternal grandmother in Essex, who offered to monitor and support the mother as she did not want her grandchildren to “go in to care”. 1.3.11. Following initial investigations, the family moved to Essex on 22 August. Essex Children’s Services were advised of the children’s move into their area and asked to add the names to the list of children on a CPP. 1.3.12. On 23 August the social worker contacted the maternal grandmother to check how things were going and no concerns were raised, and the mother had planned to register with the local GP practice. 1.3.13. On 24 August the safeguarding plans for both children were sent to the TCLPM to report and review the change of circumstances. The TCLPM decided not to proceed with care proceedings for the children at that time. This was to allow for a period of support with the wider family in the care of the children. The TCLPM directed that a safeguarding agreement should be put in place, specifically that if the mother moved out from the grandmother’s address with the children, then the social worker and police must be informed. The Child Protection Plan (CPP) was to continue and more core groups to be held. The maternal grandmother was informed and that she must make contact with SW3 /police if the mother leaves Essex with the children. 1.3.14. On 26 August (this was the Friday of the August Bank holiday weekend) the mother rang the social worker to inform her that the maternal grandmother had “kicked her out”. The maternal grandmother spoke with the social worker and stated that she could not look after her daughter and grandchildren indefinitely and that the LA needed to find accommodation for them. The mother had also forgotten to bring her bank card with her and the maternal grandmother could not continue to support her financially. The maternal grandmother gave a positive report of the mother interacting well with the children. The family had registered with a GP and had made contact with the Essex Housing Department. 1.3.15. The social worker spoke with the mother on 1 September and she confirmed that she and the children were still living with the maternal grandmother and was due to see the Housing Department the same day. 1.3.16. A joint home visit by the social worker and health visitor was carried out on 6 September. This was also convened as a Core Group Meeting. 1.3.17. On 8 September the social worker was unable to contact either the mother or maternal grandmother to get an update on the housing situation. 1.3.18. On 14 September the social worker was again unable to contact the mother but did speak to the maternal grandmother who told the social worker that the mother had taken the children back to London for three days (12-15th September). The maternal grandmother had failed to tell the social worker about the departure despite this being part of the safeguarding agreement. SW3 informed the Team Manager who instructed SW3 to tell the maternal grandmother that she must notify the police of this. SW3 was unable to speak with the maternal grandmother and left a message instructing her to tell the police. 1.3.19. Following an unannounced home visit by the social worker on the 19th September it appeared that the family were co-operating and that progress was being made in relation to: an application to housing, health appointments, outstanding development checks and immunisations for the children. 1.3.20. Shortly after the completion of the visit on 19 September, the mother and the two children again left the address in Essex returning to London; again, the maternal grandmother failed to inform the social worker. The mother sent text messages to the health visitor asking to rearrange a planned home visit scheduled for the 26.09.16. 1.3.21. It is now understood that the mother remained in London with the children. On the morning of the 28 September the mother boarded a bus with Child C in a baby sling; the baby’s head was covered with a white cloth. The sibling of Child C was also with her and was in a pushchair. The mother asked for help from the passengers saying that her baby had stopped breathing, one passenger carried out Cardiopulmonary Resuscitation (CPR) on Child C prior to the arrival of the emergency services. 1.3.22. The emergency services attended and called the police, as there were suspicious circumstances. Child C was pronounced dead at the hospital. 2. Methodology 2.1. For details about the review process and methodology; see Appendix 1. 3. Details of Practice and Analysis 3.1. Introduction 3.1.1. The detail of this SCR has been divided into five time periods. A timeline of key events for each of these time periods can be found in Appendix 2. What happened, and the underlying practice, is considered alongside multi-agency decision-making, assessments and interventions. The appraisal is set out to assess the quality of the multi-agency practice at key points, and identify which are considered to provide the most significant learning. In doing so, it takes into account both the contemporary required standards and also the information that was known, or could have been known, at the time of the events. Where there is information about why practice may not have met required standards, this is explained. 3.1.2. It aims to provide an outline of what happened and how the various professionals responded or took action. This extends to give a clearer view and takes what happened into a discussion about why things may have happened in the way they did. By doing this the Review is seeking to achieve a greater depth of learning about safeguarding practice and the systems that underpin this with all the agencies that were directly engaged. This learning extends beyond the individual circumstances of this situation and will be the basis of each agency’s development activity after the publication of this report 3.1.3. Some important development and learning has already commenced through the process of the SCR panel, the development of each individual Independent Management Report (IMR) and organisations have already considered developments and learning that has direct future impact. This is set out in Appendix 3. 3.1.4. The family had six different addresses in four different local authorities. When the family moved, it resulted in changes to children social care and health service provision particularly the health visiting service. 3.1.5. In order to understand where responsibility for the case rested during the timeframe for the SCR, the local authority with ongoing responsibility has been identified. 3.1.6. What is clear throughout all these circumstances are the ongoing challenges that professionals face working with transient families who have multiple or complex difficulties. This becomes even more difficult with avoidant, hard to engage and resistant families when the need to safeguard vulnerable children is a primary concern, not least the sharing of information in a timely manner when different IT systems are used and they do not align. 3.2. Period 1: October 2013 – July 2014 (Please see summary time line at Appendix 2 pages 76 – 80) Agencies involved: • London Borough of Newham – Adult Services and Children’s Services • Newham Housing Needs Service • Home to Home • GP1 • GP2 • Newham University Hospital • Midwifery Acorn Team • Newham Intensive Hospital Intervention Team • East London NHS Foundation Trust (ELFT) – Health Visiting Team Mother is homeless and pregnant and gives birth prematurely to Child C’s older sibling, the London Borough of Newham (LBN) undertakes a single assessment. During this period the mother presented with housing issues which did not meet the threshold for statutory intervention from children’s social care however the professionals are focused on the issue of housing and pay insufficient attention to: • The mother’s transient lifestyle, • The impact that this has on her ability to parent and • Her resistance to working co-operatively with professionals. 3.2.1. In October 2013 GP1 raised an Adult Safeguarding alert concerning the mother who was pregnant, of no fixed abode and had allegedly been physically abused by her brother and her father. 3.2.2. The London Borough of Newham Access to Adult Services (ASC) team received the alert, being the first point of contact for all adult services. ASC were unable to make contact with the mother, as she did not respond to the telephone calls. A letter was sent to the mother advising her to make contact and to attend the domestic violence service for support. ASC made a referral to children’s services (CSC) regarding the unborn child. 3.2.3. The mother contacted the service in November and gave her consent for a referral to be made for domestic violence support. At this point she stated that she was living with an uncle and she was assessed as not meeting the threshold for assessment and on-going support from ASC. 3.2.4. The mother gave the name, address and date of birth of the father of the unborn baby (Child C’s older sibling); this information was available to Children’s Social Care (CSC) via the Care First IT record system. The contact made by ASC with the mother was by telephone; she was never seen face to face by the service. 3.2.5. The mother attended Newham University Hospital (NUH) for her antenatal booking appointment with her sister (maternal aunt) in October 2013. The mother was correctly identified for priority antenatal care and was referred to the Acorn Team3 due to her homelessness and ‘complex social history”. The mother was reported to be very underweight. 3.2.6. Unfortunately, the Midwifery Acorn team records that are separate from the Maternal Hand Held Records, have not been found and there is therefore a gap in recording how the Acorn Team Midwives worked with the mother during this pregnancy, and what if any additional concerns or risks were identified. Barts Health raised a clinical incident report at the time. They now undertake regular audits to ensure that the Midwifery Acorn records, hand held records and main hospital held records all marry up post delivery. 3.2.7. The father of the baby was identified at this appointment on 29 October 2013 including his address and that he was currently unemployed. No further details were recorded or what level of involvement he would have with the baby. This could have been an opportunity to discuss the relationship and to consider whether the father provided support and stability or posed a risk. 3.2.8. The triennial review of SCRs in March 20164 makes the following recommendation: ‘Efforts must be made to increase the visibility of fathers in practice, policy and research around neglect. Too often mothers are the focus, this can mean that the risks and protective factors that fathers bring to a child’s life may be missed. Local service leaders can enable this through policy review and practice audits’. This is a key lesson for all the agencies who worked with this family. 3.2.9. At the end of October 2013 the father attended his GP2 stating that he felt anxious and depressed and had been buying diazepam5 off the street. A Patient Health Questionnaire (PHQ-9)6 was appropriately completed and he scored 25/27 indicating severe depression and was restarted on an anti-depressive drug and a referral was made for counseling; it is unclear as to whether this was taken up. 3 Vulnerable Woman’s Maternity Team 4 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 -2014 (DfE 2016 5 Benzodiazepine – used for their sedative, anxiety- relieving and muscle relaxing effect 6 A multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression; it is widely used in General Practice. 3.2.10. The GP practice made significant effort to follow up the review of the father’s mental health. The father failed to respond to telephone calls from GP2 practice to come into the surgery for a review of his mental health; this was good practice and demonstrated that GP2 wanted to review the father’s mental health. He eventually attended the GP surgery four months later. 3.2.11. When questioned by GP2 the father stated that he lived alone and this was reinforced by his records indicating that he was a ‘single man’ and there were no linked family members on the GP system. While it is not clear whether GP2 asked the father specifically if he was in contact with any children the information available at the time presented no contra indications Furthermore, at this point neither Child C nor their older sibling had been born. It is now known that he had children from a number of different relationships. 3.2.12. It is clear that GP2 worked on the basis of the information available at that time. 3.2.13. The case was allocated to SW1 who worked in the Newham Intensive Hospital Intervention Team at the beginning of January 2014. This was following the opening and closing of the case until the mother was 22 weeks pregnant. The allocation included supervisory direction for a single assessment to be undertaken. 3.2.14. SW1 demonstrated tenacity at attempting to contact the mother undertaking an unannounced visit and multiple telephone calls but was successful in meeting with the mother on only one occasion when she was advised to present at the Homeless Persons Unit to apply for housing in her own right. 3.2.15. Following this meeting SW1 reported, “It had been impossible to meet with mother as she disengaged from this assessment. The mother’s presenting need is to find a suitable accommodation where she will live with her baby. When she realised that Social Care are not in a position to provide her need at present as she has no live child, she has not thought it necessary to continue to engage with the assessment.” 3.2.16. The assessment recognised that the mother had been a victim of violence perpetrated by her own father and brother but saw the risk as being reduced by the fact that the last incident was in March 2013 and concluded ‘It has been difficult to comment on all areas needed to complete this assessment to make any meaningful recommendations, however, the baby when born does not appear to be at imminent risk except the risk of homelessness and this could be assessed again when the mother presents at the hospital to have the baby’. 3.2.17. Based on the information available to Newham CSC at that time the threshold for further statutory intervention was not met, mother reported that the risk of domestic abuse was reduced as she had moved away from the perpetrators and although she did not have her own tenancy she had found herself a temporary place to stay and was advised to present to the Homeless Persons Unit. 3.2.18. The mother failed to attend two routine ante natal appointments in a row but did attend the next one. She blamed the fact that she had no permanent address and was experiencing problems with her phone; this was a constant feature throughout the review period, when the mother would have a number of different mobile numbers and would say that she had been given the wrong time for appointments. 3.2.19. The Midwifery Service has a ‘Did Not Attend’ pathway in place and staff followed this in managing missed appointments. Staff need to be reminded and remain curious as to why appointments are missed and should always consider the potential for ‘disguised compliance’7 or ‘non-compliance’8 this will be will be discussed under Section 3.7. 3.2.20. In April 2014 Child C’s sibling was born prematurely at 34 weeks gestation and the midwives informed the social work team as instructed; the mother had agreed to work with the social worker regarding housing. 3.2.21. Mother and baby were fit for discharge four days after the birth, but the mother refused to leave and remained in hospital for a total of 12 days post delivery. During this time the father of the baby stayed on the ward for an afternoon whilst the mother went to the housing department, however, the Housing Needs Service does not corroborate this account; it is unclear where the mother went. This was another opportunity for professionals to find out more about the father and the role he played within the family. 3.2.22. The mother had presented to the Housing Needs Service on the 07.04.14 with a letter from her sister (maternal aunt) stating that she could not stay with her any longer, as there was insufficient room at her flat in Tower Hamlets. 3.2.23. The mother also disclosed at this appointment that she had been staying with her uncle in a one bedroom flat but said her uncle did not want any visits from the ‘council’. A subsequent home visit confirmed that the mother had been staying ‘off and on’ with the uncle, but that he had mental health problems and did not want the baby to stay in his flat because he was a smoker. 3.2.24. The mother was referred by Newham Housing Needs Service to ‘Home to Home’ which was a mother and baby unit for young 7 Parents giving the appearance of co-operating with professionals to avoid raising suspicion and allay concern. 8 Parents’ lack of co-operation and /or hostile attitude of parents. mothers. She turned this down due to the property being in the area (Forest Gate) where her father and brother lived (she had alleged they had assaulted her). 3.2.25. Following the birth of Child C’s sibling a new birth notification was received by East London NHS Foundation Trust who are commissioned to provide a range of services including health visiting in the LBN. 3.2.26. The new birth visit9 was completed on the post-natal ward as the mother and baby were still in the hospital due to the mother’s homelessness and her refusal to leave the hospital. HV1 assessed the family as meeting the Universal Partnership Plus10 and a follow up visit was planned for the 16.05.14.11 This was conducted in line with the requirement that the Health Visitor Service is the lead agency on the delivery of the Government’s Healthy Child Programme; pregnancy and the first five years, (DOH, 2009). This states that additional support may be needed by some parents and will depend on their individual risks, needs and choices. The aim is to identify any health or development related concerns as early as possible so that the required level of support and intervention can be agreed and if appropriate refer or signpost to another service. 3.2.27. The mother and baby were discharged to the uncle’s home on 24 April 2014, 12 days after the birth, and the midwife visited the same day. The midwife was concerned about the sleeping arrangements for the baby as it was a one bed roomed flat, there was no cot in evidence, the mother was sleeping on the sofa and the flat ‘stank of smoke’. 3.2.28. A duty social worker visited the property the following day. The social worker raised concerns regarding the cigarette smoke in the home, lack of space and co-sleeping arrangements for mother and baby, which the social worker advised to stop with immediate effect. The duty social worker liaised with housing and advocated on the mother’s behalf and following this, housing agreed to provide mother and baby with accommodation. 3.2.29. The case was closed by Newham Children’s Services on 19.05.2014 on the basis that the presenting issue was housing, which was being addressed by the housing department. 3.2.30. This decision fell below the required standard as it did not gather sufficient information about the lifestyle of the mother, the role of significant others, such as the biological father, reasons for her poor 9 New birth visit is completed 10-14 days after the birth 10 Four levels of health visiting intervention, Community, Universal, Universal Partnership and Universal Partnership Plus: Health Visitor Implementation Plan: A Call to Action (DH 2011). 11ELFT Health Visitor Operational Framework states follow up visit should take place two weeks after the new birth visit. attendance and engagement with professionals and its impact on the baby. 3.2.31. Supervision was provided throughout this period and whilst it gave direction it did not encourage professional curiosity or ensure the assessment was completed in full. It is well documented that in working with families to safeguard children, the sense that professionals make of information they receive will inevitably be vulnerable to common errors of human reasoning (Munro; 1999). 3.2.32. The importance of regular supervision and management oversight for all professionals will be discussed under additional learning, see Section 3.17 3.2.33. The mother cancelled the planned follow up visit made by HV1 for the 16.5.14 by text as she stated that she was not at her uncle’s address and the appointment was rescheduled for four days later (20 May). The mother and sibling were not at the uncle’s address when HV1 attempted the rearranged visit. The mother then requested to see HV1 at the Child Health Clinic (CHC) on the 22.05.14; she arrived nearly three hours late. 3.2.34. This pattern by the mother of cancelling appointments but then wanting to rearrange may have encouraged HV1 to think that she wanted to engage with the service. 3.2.35. On 22 May 2014 The mother told HV1 that she had been ‘kicked out’ by her uncle and she had been staying with the father of the baby. This was the first time that the mother had shared with a professional that she was staying with the father of the baby. 3.2.36. HV1 did not record his address and did not enquire about the role and relationship; this was a further missed opportunity to gain more information and insight in to how much time the mother and sibling spent with him, and what his role and influence was. 3.2.37. The mother failed to attend a further two appointments with the health visiting service, this was despite contacting the mother directly by phone to remind her about the appointments. 3.2.38. HV1 did not share the non-engagement by the mother with GP1, the case had already been closed by Newham Children’s Service (NCS) on the 19.5.14. This was an opportunity for HV1 to consider concerns about disguised compliance.12 While HV1 made a referral back to CSC (see para 3.2.43) on the basis of neglect if the potential of disguised compliance been considered this could have added weight to the referral. 12 This can lead to a focus on adults and their engagement with the service rather than achieving safer outcomes for children. 3.2.39. ELFT have a clear policy for how to manage missed appointments, the ‘Did not Attend’13policy states when two appointments are missed ‘The staff member has an individual professional responsibility to respond to failure to attend an appointment in a manner based on an assessment of the service user’s risk and their identified needs’. 3.2.40. When children do not attend or there are repeated cancellations and rescheduling of appointments by parents, professionals should be curious about why and move away from the response ‘did not attend’ to ‘was not brought’. Recent research into health agency ‘Did not attend’ policies has shown inconsistency and that they can, at times, be a systemic defensive response by agencies to help manage large workloads.14 Non-compliance with appointments may be a parent’s choice but it may not be in the child’s best interest. Repeated cancellations and re-scheduling of appointments for children should be treated with curiosity. A shift away from using the term did not attend (DNA) to was not brought (WNB) would help ‘maintain a focus on the child’s ongoing vulnerability and dependence, and the carer’s responsibilities to prioritise the child’s needs. In some cases it may be considered a sign of neglect. 3.2.41. HV1 followed up with Housing Needs Service on the 24.5.14 enquiring about the progress of the case. 3.2.42. The mother approached the Housing Needs Service on the 12.6.14 stating that she was back living with her uncle. The homelessness caseworker sent a letter the same day asking the mother to submit the requested documents: proof of identity for herself and the child, proof of residence for the past five years and proof of income. The mother is advised in the letter that this information must be sent within seven days to avoid the closure of her case. The Housing Needs Service received no response within the timeframe. 3.2.43. At the end of July 2014, HV1 referred the case to Newham Children’s Care Services citing concerns for the safety and wellbeing of Child C’s sibling as neglectful. The mother had failed to bring Child C’s sibling for developmental checks, outstanding primary immunisations and there was no clarity about where the family was living. 3.2.44. It should be noted that HV1 was a newly qualified health visitor, and it appeared that at this time the onus was for HV1 to seek 13 ELFT Did Not Attend policy guidance 14 Munro, Eileen (2012) Review: Children and young people's missed health care appointments: reconceptualising 'Did Not Attend' to 'Was Not Brought' - a review of the evidence for practice. Journal of Research in Nursing, 17 (2). pp. 193-194. ISSN 1744-9871 and Lisa Arai, Terence Stephenson & Helen Roberts; The unseen child and safeguarding: ‘Did not attend’ guidelines in the NHS; Archives of Disease in Childhood, March 2015; http://adc.bmj.com/content/early/2015/03/16/archdischild-2014-307294 supervision; the danger being that if health visitors do not recognise risk, or the significance of these, then they may not seek out supervision. 3.2.45. ELFT have since implemented a mentoring programme15 for all newly qualified health visitors and regular safeguarding supervision. See Section 3.17. Learning Points: • GPs should be reminded to “Always ask patients with mental health difficulties, learning difficulties or drug and alcohol misuse whether they have significant care responsibilities. Consider their capacity to care for children safely. Record this information in medical records and emphasise it in referrals and correspondence about patients” • Impact of poverty and homelessness on the child (including pre-birth) should always be considered in cases where these issues are present • Parents who are homeless are often the most vulnerable in society. • Clear standards for assessment should be developed, or if they already exists re-affirmed with professionals • All relevant family information should be recorded and appropriate follow-up questions asked. The importance/impact of the father’s role should be acknowledged • Barts Health should consider reviewing the Did Not Attend pathway to ensure that poor engagement and disguised and non-compliance are considered. • Professionals should share experiences of non-compliance • ELFT staff should be reminded of the ‘Did not Attend’ policy and consider reviewing and implementing a ‘Was not Brought’ policy • Mentoring programme for all newly qualified health visitors and regular safeguarding supervision – Actioned 16 ELFT Mentoring Programme for newly qualified health visitors including monthly reflective safeguarding supervision. 3.3. Period 2: August 2014 – June 2015 (Please see summary time line at Appendix 2 pages 80 – 85) Agencies involved: • London Borough of Newham – Children’s Services • Newham Housing Needs Service • Newham Intensive Hospital Intervention SW Team • Police • London Ambulance Service • Midwifery Service Newham University Hospital • Emergency Department at Newham University Hospital • East London Foundation Trust (ELFT) Health Visiting Service • North East London Foundation Trust (NELFT) Health Visiting Service In December 2014, Newham Housing Needs Service placed the mother in Bed & Breakfast accommodation in Chadwell Health in the London Borough of Barking and Dagenham. The Intensive Hospital Intervention Team between 4 August 2014 and 10 February 2015 completes a second single assessment and the case closed in May 2015. The mother has a spontaneous miscarriage at 21 weeks gestation on 16 June 2015. This period of time highlights the challenges encountered by multi-agencies when working with a mother who chooses when and where she wishes to engage with the services, and shares different information with different professionals. This means that information sharing by all the professionals becomes key to protect and safeguard children. 3.3.1. Following the referral from HV1 LBN triage identified issues of neglect and the case was reopened under the Intensive Hospital Intervention Team. It was less than three months since the case had been closed by SW1 working in the Intensive Hospital Intervention Team; SW2 was allocated to work with the family. 3.3.2. The mother’s non-engagement with the ELFT health visiting service continued, she had failed to attend a total of five appointments between July – September (2014). 3.3.3. The failure of the mother to attend the appointments was again not shared with SW2 nor were enquires made with GP1. 3.3.4. HV1 did not follow ELFT policy. Consequently, SW2 thought that the mother did keep appointments with the health visiting service. The mother did attend on the 02.10.14 at the CHC for a follow up health review. 3.3.5. During the time (August 2014 to June 2015) that ELFT health visiting service was in contact with the mother and Child C’s sibling none of the contacts took place in the home setting; there had been no assessment of the home environment. The family was initially assessed as meeting the need for Universal Plus16 but this was then changed to Universal following attendance at Child Health Clinic in the local Children’s Centre where the family was seen by HV2. The explanation provided for this was there was no access to the RIO17 IT system in the clinic setting and HV2 did not check the records on her return to the health visiting base; had she done so then the family concerns would have been noted. 3.3.6. In September 2014 the mother provided Newham Housing Needs Service with the required documentation namely: the full birth certificate of Child C’s sibling, the Child Benefit book and letters confirming Income Support (this was three months after the request to provide the documents within seven days). 3.3.7. On the 11.12.14 Newham Housing Needs Service provided the mother with B&B accommodation in Chadwell Heath18. However, this was cancelled in March 2015 after it was discovered that the mother had never stayed in the Chadwell Health B&B accommodation and told the HNS that she had been advised by SW2 to vacate the room because of a bed bug infestation. 3.3.8. Following the placement of the family into Chadwell Heath B&B accommodation, HV1 contacted the health visiting service19 covering the new address and did a verbal handover. Unfortunately, the full health visiting records were not forwarded and the mother’s records remained active on the RIO system for ELFT health visiting service, this resulted in the full history and contact pattern not being available to the new health visiting team in North East London Foundation Trust (NELFT). The remaining records pertaining to Child C’s sibling were sent in error to Redbridge and it was almost three months before this was rectified and the records received by the health visiting team covering the Chadwell Heath area. There then followed a number of attempted visits to the family in their new accommodation by the health visiting team. At this time NELFT were experiencing a high number of vacancies and health visitors were moved to different areas at short notice to cover Child Health Clinics and New Birth Visits resulting in a fragmented management of 16 Provides on-going support from the health visiting team plus a range of local services including Social Care, Children Centres, GPs and third sector organisations. For example: complex issues including domestic violence, health and social issues and safeguarding issues etc. Families allocated to this package of care will be offered up to maximum of 1 contact per month/minimum of 6 contacts annually dependent on planned interventions requirement. 17 Electronic Care Record System 18 The property was in the LBBD. 19 NELFT; Barking and Dagenham mother and Child C’s sibling. 3.3.9. The single assessment by SW2 took 120 days to complete which falls well below the required standard of 45 days. During this time the assessment was impeded by the persistent failure of the mother to engage. 3.3.10. SW2, like SW1, was tenacious in providing support to address the issue of homelessness and persistently attempted to contact the mother, undertaking unannounced home visits, attempting to contact via telephone and chasing her whereabouts via the uncle and the maternal aunt. 3.3.11. Despite these attempts SW2 met with the mother and baby on only one occasion. 3.3.12. SW2 met with the mother and Child C’s sibling on the 12.11.14 at her uncle’s address and the SW noted, ‘how the mother actively stimulates her child, his attachment and strong relationship with the mother and the uncle’. SW2 also noted that when the sibling was lifted from the car seat, the child was wet through, enough to wet her own clothes when the child sat on her lap. SW2 requested information from the health visiting team and received a response on the 5.2.15 (three months later) HV3 confirmed that Child C’s sibling was up to date with developmental checks and immunisations but had presented with marks on his face and his weight had dropped by 1 centile. HV3 advised the mother to go to her GP1. There was no follow up with the GP by SW2 and these issues were not progressed as SW2 considered that they were health related issues and had been addressed by GP1. 3.3.13. The mother had provided no details of the child’s father and he remained unknown, despite the opportunities to glean information outlined in (para 3.2.7) The absence of information about a family should always be considered in context and must include, both the reasons for the lack of information, and the significance of that information for the child. 3.3.14. The single assessment by SW2 concluded on 6 February 2015 that the mother presented as caring towards Child C’s sibling and capable to meet a range of the child’s needs. ‘From the information gathered it is my view that the neglect of Child C’s sibling’s health needs are no longer a safeguarding concern at this stage’. 3.3.15. The mother had reported that she did not see a need for ongoing support as she loved her baby and would never expose the child to any harm. Her main concern continued to be housing and although she was in Bed & Breakfast (B&B) accommodation SW2 never visited her at this address. 3.3.16. On 5 February 2015, the day before the single assessment was completed, NCS requested police intelligence relating to the mother, the request stated that the information was required for an assessment regarding the mother and Child C’s sibling This information was provided by the police and was known at the time that the case was closed by NCS see para 3.3.25. 3.3.17. On the 06.02.15 an ambulance was called to the address of the father of Child C’s sibling where it was reported that a nine-month old child had a high temperature, rash on forehead, shivery and crying. Following an assessment at the house20 the sibling was taken to NUH where the Co-op GP assessed the sibling;21 Child C’s sibling was discharged home. 3.3.18. SW2 contacted the NELFT health visiting team on the same day asking them to carry out a home visit, a home visit was attempted on the 12.02.15 which was unsuccessful, but a card was left inviting the mother to attend the clinic. The mother attended the Child Health Clinic with Child C’s sibling the following day (13.02.15). This was the only face-to-face contact the health visiting service (NELFT) had with the mother and Child C’s sibling, this included: three attempted telephone calls to book appointments, five effective telephone calls, two pre-arranged home visits (not kept) and two unannounced home visits that were unsuccessful. In all there was input from eight different health visitors. 3.3.19. At the end of March 2015 an offer of temporary accommodation through the private leasing scheme was made. The mother accepted the offer of a flat in the LBBD 3.3.20. In early March (2015) the mother self referred to the midwifery service as she was six weeks pregnant and was seen by the same midwife in the Acorn Team that had booked her for her previous pregnancy. Although mother presented for antenatal care at an early stage she did not attend for all appointments or turned up at the wrong time. 3.3.21. The father’s name was recorded under two different surnames, this was not challenged or explored further, and it was identified that he was age 40 plus (in fact he was 51) and she was 24 years of age. Professionals should always carry out further checks when different names or aliases are given. 3.3.22. It was also recorded that the father had children with another partner and was unemployed. Risk factors were identified: mother’s low weight, previous pre-term delivery before 34 weeks gestation, she did not smoke or drink (although at her first booking she stated that 20 The father’s address 21 Primary care located within the Accident and Emergency Department to review patients that are deemed suitable tor GP management. she did smoke) and she had a social worker due to her housing issues. 3.3.23. At this appointment the mother gave more information about the father including that he had other children; however, this information was not shared with the other agencies and another opportunity to assess the father of the children was lost This may have been because the midwife knew the mother from her last pregnancy and that SW2 had not flagged any concerns with the midwifery team. 3.3.24. On the 10.05.15 the mother took Child C’s sibling to the Urgent Care Centre (UCC) with a head injury. The sibling was aged 13 months at the time. The explanation given was that the sibling had been jumping on the bed and fell and hit their head on a windowsill. At the time there was confusion about whether Child C’s sibling was subject to a CPP as this was flagged on the IT system, they were in fact a Child In Need (CIN). Staff in the unit followed the correct procedure for dealing with a child on a CPP and informed SW2 by fax about the injury. 3.3.25. At this point the case was still open to Newham Children’s Service but no further enquiries were made in respect of the incident by NCS. 3.3.26. While it is impossible to state categorically, it would be unusual for a child of 13 months of age to have the ability to jump up and down on a bed without any support and further exploration of the history should have been undertaken to ascertain his/her gross motor skills and the context of the injury in order to exclude non-accidental injury. 3.3.27. On the 13.05.15 the manager in the Intensive Hospital Intervention Team made the decision to close the case on the basis that the original concern was about the mother not seeking health input for the child and the housing issues and it was recorded that both had been resolved. It is unclear whether the fax sent from Urgent Care was seen by SW2 or the manager as there was no reference to it within the IMR for NSC. It is impossible to determine what happened to this fax though it is clear that SW2 was not aware of the head injury. This meant that an opportunity to follow this up was lost. 3.3.28. At the time of concluding the assessment work SW2 was asked by the authorising manager to establish the mother’s address and send a referral to the relevant Local Authority. This action did not happen meaning that information/assessment was not made available to LBBD. 3.3.29. On the 02.06.15 an ambulance was called, again to the father of Child C’s siblings address in the London Borough of Newham, where it was reported that the mother had given birth to a premature baby. It was reported that on arrival a hostile man holding a child approximately one year of age met the ambulance crew. 3.3.30. The London Ambulance Service (LAS) has in place a safeguarding adults and children policy and practice guidance which are reproduced on its intranet and website22. LAS report that staff come across hostile situations and people regularly, this is sometimes due to the delay in an ambulance attending and sometimes due to the nature of the call and that the people on the scene are upset and distressed. On this occasion following their assessments and attendance it was deemed that a safeguarding referral was not needed. 3.3.31. The baby/fetus was taken to the Emergency Department (ED at NUH); the baby died and a death certificate was issued23. A midwife on the assessment unit spoke to the father on the phone to keep him informed but it is unclear if they had been given his contact details or spoke to him using the mother’s mobile phone. 3.3.32. The father was clearly more involved than the mother was disclosing to professionals. 3.3.33. This was the second time that the ambulance had attended the father’s address in the London Borough of Newham yet the mother continued to deny that she knew where he lived or that they were in a relationship. 3.3.34. There were many different discussions about whether the infant who went to the ED was a neonatal death or a late miscarriage before the viable 24 weeks of pregnancy. Irrespective of whether it was classified as a death or miscarriage the process for allowing mother to spend time with the baby and having mementoes was the same. The mother was referred to the bereavement midwife and was seen for a follow up appointment on 03.08.15. The Acorn team was notified. The care received by the mother at this time was of a good standard. 3.3.35. The mother wanted to arrange for the baby to be buried, however, the Registrar Office at NUH had difficulty making contact with the mother. When contact was made the mother had failed to register the birth and said that she was not in a financial position to pay for the burial. On the 14.10.15 the mother was offered a hospital funeral, the mother turned this down stating she would be unable to attend but still wanted to arrange her own funeral for the baby. 3.3.36. Over the next few months numerous attempts were made by the Deputy Superintendent Registrar to contact the mother including phone calls, leaving messages on the voicemail and by letter. It is unclear as to whether the mother did make contact however the baby 22 http://www.londonambulance.nhs.uk/health_professionals/safeguarding-child_protection.aspx. 23 Death certificate of a live-born child dying within the first 28 days of life, death was due to extreme prematurity. was buried at the end of March 2016 in the City of London Cemetery. Learning Points: • The absence of information should always be considered in context and must include, both the reasons for the lack of information, and the significance of that information for the child. • If there is concern about an injury of a child attending UCC/ A&E Departments the referral must be followed up to ensure that it has been received. • Professionals do not always identify chaotic lifestyle and frequent changes of address as potential child protection issues. Any neglect strategy or guidance should reference these features • Mobility and lack of parental cooperation are common factors and need to be recognised as a risk factor that should heighten concern. • Professionals to be reminded that when different names or aliases appear to be used then further checks with agencies working with the family should be undertaken. • The admitting address is not routinely recorded only the discharge address 3.4. Period 3: July 2015 – July 2016. (Please see summary time line at Appendix 2 pages 85 – 91) Agencies involved: • London Borough of Newham Children’s Services • Newham Housing Needs Service • London Borough of Barking and Dagenham Children’s Services • London Ambulance Service • Midwifery Services • Neonatal Unit, Newham Hospital • North East London Foundation Trust (NELFT) Health Visiting Service Mother is pregnant with Child C, she moves into a tenancy provided by Newham Housing Needs Service in July 2015 in the London Borough of Barking and Dagenham. She abandoned this accommodation and the homelessness duty was discharged in April 2016. Child C is born prematurely at home and admitted to Newham University Hospital Neonatal Unit where she resides for 65 days. This period highlights escalating concerns about the mother’s engagement and her attendance on the Neonatal Unit to visit and care for Child C. Despite the concerns, Child C is discharged into the care of her mother without a period of ‘rooming in’ on the unit. It would appear that ‘professional optimism’ wins out despite the family having no fixed abode and the mother’s poor history of parenting and engagement with relevant agencies to date. 3.4.1. The mother was pregnant and again self referred to the midwife on the Acorn Team in February 2016. The information the mother gave at the booking clinic with regard to the number of miscarriages differed and that she had never smoked. The mother was screened using the Whooley Questions24 and did not disclose that she had been suffering, or had suffered with mental health concerns. The mother was now living in temporary accommodation (in LBBD) with Child C’s sibling. 3.4.2. The father’s name was recorded by the Acorn Team and matched the first name given at their last booking appointment in March 2015; no further enquiry was made. On this occasion, the mother did not meet the criteria for the Acorn Team as she no longer had a social worker and she was living in temporary accommodation; the plan was for shared consultant care. The mother’s attendance for routine ultrasound scans and antenatal appointments was varied; she attended three scans and then failed to attend two. This pattern was repeated with the midwives clinic where she failed to attend three but not consecutively. It would appear that she was doing ‘just enough’ to keep the professionals at bay. The midwives managed her attendance using the Did Not Attend Pathway. 3.4.3. Evidence suggests that women who have had a premature birth are more likely to have a premature birth in subsequent pregnancies. Other risk factors include: being under weight (which may indicate poor nutrition), low income and poor housing. At the booking appointment for pregnancy, women are routinely asked about drug use; the staff did not feel that there was any evidence to suggest that the mother did use drugs, and she consistently denied using substances when asked as part of the booking process. 3.4.4. The Housing Needs Service liaised with the managing agent reference the temporary accommodation as they have a duty to visit 24 NICE guidelines (CG192), 2014 clients once every quarter; it is now clear that they had never found the mother in on any of the visits carried out. The managing agent visited the property on 17.03.16 and a neighbour informed the managing agent that no one stayed at the property. The managing agent entered the property and noticed that there were no signs that anyone lived there; no proper furniture or food was in evidence. The managing agent notified Housing Needs Service the tenancy was cancelled and the mother was reported to have abandoned the property. Following the cancellation, the homelessness duty was considered discharged25 in April 2016. 3.4.5. It was not known where the mother and Child C’s sibling were living at this time. The information was not shared with LBN Children’s Social Care, at this time the case was closed to NSC and the Housing Needs Service were unaware of any concerns regarding the family. Newham Housing appears to have worked on the assumption that the person has gone back to family, or found alternative accommodation.26 3.4.6. Although LB Newham had determined that the family did not meet the threshold for statutory intervention it could be argued that the mother and Child C’s sibling were vulnerable given that housing had been and was now an ongoing risk. Key learning from this is that consideration should be given to implementing an information sharing agreement between Housing and CSC when tenancies are cancelled and there are young children in the household. 3.4.7. Child C was born prematurely at 28 weeks and 5 days27 in early June at the address of the father of Child C’s sibling (in the LB of Newham); this was the third time the mother had delivered at this address 3.4.8. This was the fifth time an ambulance had attended this address however they were spread over a period of more than one year. The London Ambulance Service does not flag addresses for ‘Frequent Callers’ this would only be done if there has been abuse/assault against attending members of ambulance staff and if LAS have been notified by CSC that an unborn child is at risk. At this time there was no flag against this address. 25 The council had accepted the mother’s homelessness application and had provided suitable accommodation. 26 The Homelessness Code of Guidance states: - FAMILIES WITH CHILDREN UNDER 18 11.29. It is important that social services are alerted as quickly as possible to cases where the applicant has children under 18 and the housing authority considers the applicant may be homeless, or threatened with homelessness, intentionally. Section 213A(2) therefore requires housing authorities to have arrangements in place to ensure that all such applicants are invited to agree to the housing authority notifying the social services authority of the essential facts of their case. The arrangements must also provide that, where consent is given, the social services authority are made aware of the essential facts and, in due course, of the subsequent decision on the homelessness case. 27 The earlier a baby is born the higher the risk is of health problems. 3.4.9. The mother and baby were taken to NUH and the baby was admitted on to the Newham Hospital Neonatal Unit; initially the baby required ventilation to assist with her breathing. 3.4.10. The mother refused to stay in hospital and took her own discharge the same day; this was against medical advice. The plan was for her to go and stay with the father of the children for a few days. The address was recorded at discharge was in fact a different flat number, she gave the number as 12 rather than 16. It is not known whether this was a transcribing error or a deliberate act by the mother to give false information. As a consequence of this error, the midwives had difficulty finding anyone at the property when they subsequently attempted a postnatal home visit. 3.4.11 The midwives also reported that it was difficult to make contact with the mother via the mobile phone number that she had provided them with. The midwives managed to make contact by phone on the third attempt and an appointment was made for the postnatal clinic,28 which the mother kept, and the subsequent follow-on appointment. There then followed a period of non-engagement by the mother with the midwifery service. 3.4.12 The baby resided on the Newham Hospital Unit for a total of 65 days; the mother visited her on 18 occasions. The safeguarding advisor instructed the staff on the Neonatal Unit to keep a visiting record as the mother had not visited Child C from the 2-6th June and had made no telephone contact. The staff on the Neonatal Unit on the 21.6.16 made a referral to NCS as the staff were concerned about limited visiting by the mother, requesting food when on the unit and difficulty in making contact by phone. 3.4.13 The staff were advised that the referral needed to be sent to the LBBD, as this was where it was reported that the mother lived. A Multi-Agency Referral Form (MARF) was completed and sent on 27.06.16; the referral stated poor visiting, difficulty in contacting the mother by phone, unable to engage with her to offer support, and that the mother requested food when she came on to the unit, she appeared to have financial difficulties and general lack of preparation for the baby; a copy was also shared with the health visiting team in NELFT. 3.4.14 The referral was received at LDBD Multi Agency Safeguarding Hub (MASH) on the 29.06.16 and the case was considered the next day; it was recommended to be progressed to assessment, the reasoning for this was: concern about the neglect of baby, mother’s lack of concern for her child, Child C’s sibling’s missed health and developmental appointments, the need to consider her parenting capacity and a query about mother’s mental health. MASH spoke with the mother who 28 Postnatal clinics have been in operation since 2011, all women receive an initial home visit post discharge from hospital and then future postnatal care is arranged in collaboration with the women. informed them that she was staying with her sister (the maternal aunt) in Bow and would move back to her address in LBBD when Child C was discharged (it is now known that she no longer had this property, but professionals were unaware at the time). The mother also said that Child C’s father was not involved, although she had discharged herself from hospital to the father’s address; she was described as being very defensive. In fact the mother was lying to professionals about her personal circumstances. 3.4.15. Background reports, referrals and the single assessments from Newham Children’s Services were downloaded from the case record system in Newham on 22 July 2016. There is no record to indicate that these records had been shared before or at the point of the case closure by NCS in May 2015 see para 3.3.28. 3.4.16. Staff on the Neonatal Unit facilitated a telephone conversation with HV3 and the mother, who agreed to attend the CHC the next day but she failed to keep this appointment. 3.4.17 Prematurity and giving birth at home with no medical assistance have been discussed in the SCR biennial reviews29 the impact that the needs of extra demanding pre-term baby places on parents, often compounded by the time spent apart from the new baby who is in the Neonatal Unit. Learning Points: • The importance of triangulating information with other professionals and not only accepting the information given by parents must be considered where there are other parenting engagement concerns. • The importance of checking addresses at point of discharge particularly when leaving against medical advice. THE LONDON BOROUGH OF BARKING AND DAGENHAM COMMENCE WORK WITH THE FAMILY 3.4.18. The case was allocated to SW3 (working for the LBBD) by the Team Manager in the Assessment Service and sets out an interim safety plan with clear tasks and a timeframe. This included seeing the children, establishing the role and whereabouts of the father, setting up a discharge planning meeting as appropriate and completing the single assessment by the 04.08.16. 29 Brandon et al, 2009:55 3.4.19. SW3 visited Child C the Newham Hospital Neonatal Unit and spoke with staff to find out more about the mother’s visiting pattern and to ascertain from the staff on the unit what would be the normal pattern of visiting by parents. The exact number of times that the mother had visited Child C on the Neonatal Unit was not provided at the time. SW3 also asked staff at what point would the possible abandonment of Child C be reached.30 The staff were unable to give any clarification at this point. 3.4.20. It is worth noting that following the allocation of the case all the work undertaken by SW3 took place out of the LBBD area, in Tower Hamlets, Newham and Essex. 3.4.21. On the 12.07.16 the mother failed to attend the Newham Hospital Neonatal Unit for a specific appointment; the mother needed to give consent for a blood transfusion for Child C and supply a blood sample.31 SW3 and the Children’s Safeguarding Advisor were present on the ward so that they could talk with the mother; she failed to arrive at the appointed time and eventually turned up nearly three hours late by which time they were no longer present on the unit. 3.4.22. SW3 contacted the mother by phone and arranged to meet with the mother the following day. SW3 heard a child crying in the background, the mother told her it was Child C’s sibling and asked her not to interfere. She challenged the mother about how difficult it was to contact her and that this was not helped with frequent changes of her mobile number (this was now her third number) the mother told SW3 that she should appreciate that she had answered the phone. SW3 asked the mother where she was currently living, she responded that she was living in Manor Park but refused to give an address but said that she also stayed with her uncle. SW3 told the mother that she was concerned about the following issues: infrequent visits to Child C, living at different addresses in different boroughs, providing two different surnames for Child C’s father, and that professionals had not seen Child C’s sibling; the mother was reported to be defensive and agreed to meet the next day. This was a good conversation that SW3 had with the mother and identified the concerns that she had about the mother’s lifestyle and her sharing different information with professionals. 3.4.23. SW3 (LBBD) did meet with the mother the next day and stated that the information gathered would be recorded as part of the single assessment that she was undertaking. The mother had brought Child C’s sibling with her and it was agreed that SW3 would carry out a home visit at the mother’s address in LBBD. The mother agreed to 30 Child abandonment occurs when a parent, guardian, or person in charge of a child either deserts a child without any regard for the child's physical health, safety or welfare and with the intention of wholly abandoning the child, or in some instances, fails to provide necessary care for a child living under their roof. 31 Babies born prematurely may have a low level of red blood cells causing anaemia. this, even though she was no longer in this property, and failed to inform the social worker; this resulted in a wasted visit by SW3 to the property although SW3 was then able to confirm that the mother had vacated the property some 11 weeks ago because it was being cleaned and cleared of rubbish. This was a clear example of the mother giving false information and continuing to insist that this was the address that she was living at. SW3 attempted to phone the mother but there was no reply. 3.4.24. At this point SW3 had clarified that the mother did not reside at this Barking and Dagenham address however it was still not known where the mother and Child C’s sibling were living. During supervision of the case with the Team Manager (TM) it was agreed that the LBBD should continue to work with the family, as there was still no clear understanding of exactly where the mother and her children were living. 3.4.25. The LCPP32 state that in order to provide mobile families with responsive, consistent, high quality services, London local authorities and agencies must develop and support a culture of joint responsibility and provision for all London children (rather than a culture of ‘borough services for borough children’) 3.4.26. The Named Nurse for Safeguarding at NUH requested a Strategy meeting outlining the ongoing concerns re the mother’s minimal visits to see Child C; the visits were short, lack of provision of clothes and nappies, and multiple addresses and contact details. This is quickly followed by a request for a professional meeting; SW3 responded that she would update the staff following her assessment. 3.4.27 Child C was fit for discharge on the 19.07.16 and the Named Nurse for Safeguarding (NUH) contacted SW3 by email in order to plan a discharge meeting. The mother and Child C’s sibling visited Child C; the mother had again forgotten to bring in any clothes for Child C. It was noted that Child C’s sibling looked well and exhibited no apparent stranger danger awareness,33 and would go off with any member of staff (Child C’s sibling was just over two years old at this time). SW3 raised this concern with mother and that Child C’s sibling was walking on ‘tip-toes’ and there was possible language delay; the mother dismissed the concerns and threatened SW3 that she would ‘never take my children away’. 3.4.28. Supervision took place between the TM and SW3, the safety plan was reviewed; it was agreed that Child C should not be discharged from hospital until the situation about accommodation was clear and deemed safe. The mother had also failed to disclose details about the father of the children and no further information was known. It 32 Chapter 6.1.2. 33Stranger danger is the danger presented to children and adults by strangers. The phrase stranger danger is intended to sum up the danger associated with adults whom adults or children do not know. was also agreed that if the mother’s pattern of behaviour continued then the case would be escalated through Child Protection Procedures. This was good practice with a clear instruction to escalate and recognition that the risks for the children were increasing. 3.4.29. The Team Manager had a telephone discussion with the police and it was agreed that the case did meet the threshold and a Section 4734 enquiry was commenced. The London Child Protection Procedures were not complied with. Specifically: “The strategy meeting / discussion must involve LA children's social care, the police and relevant health professionals.” 3.4.30. The Strategy meeting / discussion should have taken place on the Newham Hospital Neonatal Unit given that Child C was still on the unit and it would allow the maximum number of hospital clinical staff to attend and make valid contributions. Given that staff on the Neonatal Unit made the referral it is difficult to justify why this did not happen and was a serious omission. 3.4.31. Discussion at the SCR panel meeting on the 28 June 2017 highlighted that East London Boroughs have adopted an approach of using an initial telephone call between CSC and police only as an initial response to Section 47 enquiries. Following this there may be a decision to call a S47 Strategy meeting/ discussion. However, there is a risk in this approach in that it can lead to an absence of multi-agency involvement in the investigation and assessment of the family.35The need for this is explicit in the pan London Child Protection Procedures. LBBD now use a telephone conferencing process (implemented in September 2016) so that all agencies are now routinely invited to and able to engage in strategy meetings / discussions. 3.4.32. The mother was still refusing to tell the hospital staff where she was living and accused them of lying about how frequently she had been visiting Child C. SW3 informed the mother verbally about the Initial Child Protection Case Conference (ICPCC) and also sent an invitation to the address in Tower Hamlets (maternal aunt’s home) where she was supposed to be staying after the baby was discharged from hospital. SW3 also arranged to see the mother at the maternal aunts flat the next day. 3.4.33. SW3 visited the property and met with the maternal aunt, the mother failed to attend, as she could not ‘drag Child C’s sibling out of bed so 34 A Section 47 enquiry means that CSC must carry out an investigation when they have ‘reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm’1. The enquiry will involve an assessment of the child’s needs and the ability of those caring for the child to meet them. The aim is to decide whether any action should be taken to safeguard the child. 35 London Child Protection Procedures (2016) Chapter.3.4.11. early in the morning’, the mother refused to say where she was staying. SW3 advised maternal aunt about the concerns, she stated that she did not know where the mother was currently staying but would accompany her to the ICPCC and give her support. SW3 then phoned the mother and arranged for her to attend CSC offices the next day. The meeting was scheduled for 1.30pm, the mother eventually turned up at 4.30, three hours late and was dismissive about the concerns that SW3 had, namely: how difficult it was to contact the mother, that she refused to say where she was living and would not give any details about the father of the children. The maternal aunt accompanied the mother for this appointment. 3.4.34. A discharge-planning meeting was held on 2 August 2016 at NUH, Child C was medically fit to go home. This followed an intense period of communication between the Named Nurse for Safeguarding, staff on the Neonatal Unit and SW3. The mother attended the meeting, but the maternal aunt was unable to attend. The discharge planning meeting should have been chaired by the team manager in line with procedures. This was the first planning meeting and was crucial in setting up the Child in Need plan ahead of the ICPCC. 3.4.35. A discharge plan was put in place and the mother was told that she had to stay with the maternal aunt (in Tower Hamlets) at this address and register with a local GP. SW3 and the new health visitor covering the address in Bow were to visit weekly. The mother had been given plenty of time to register with a GP but failed to do so. Prior to discharge the baby’s milk was changed from prescription milk to regular formula milk, this was because the mother still had not registered with a GP and therefore there was no ability for a prescription to be written and the milk dispensed. The Consultant Paediatrician was of the opinion that Child C’s milk could safely be changed to regular formula milk. 3.4.36. The actions of the discharge planning meeting were recorded in the CSC case records however, there is no evidence that these were distributed to the professionals that attended the meeting or sent apologies. This was a significant omission. The actions of this meeting could have been framed and given the status of the safety plan due to the level of concern that had unfolded during Child C’s hospital stay. This is made even more critical given that the mother was going to be living at an address in yet another authority 3.4.37. The use of a template for CIN plan: plans for children in need upon discharge from hospital should be recorded using the Child in Need plan template, distributed to the relevant professionals, and parent/s and recorded accordingly whilst also being chaired by a Team Manager is an action already taken by the LBBD. Learning Points: • Strategy / discussion meetings must follow the LCPP requirements and be based on multiagency engagement. • Minutes of discharge planning meetings are critical and must be shared in a timely manner with all professionals involved in the care of the baby/ child being discharged from a hospital setting. 3.5. Period 4: 5th August – 22nd August 2016 (Please see summary time line at Appendix 2 pages 91 – 92) Agencies involved: • London Borough Of Barking and Dagenham Children’s Social Care • London Borough of Barking and Dagenham Legal Team • Neonatal Staff NUH • Metropolitan Police • North East London Foundation Trust (NELFT) Health Visiting Service Child C is discharged from Newham University Hospital Neonatal Unit to an address in the London Borough of Tower Hamlets, the third London borough. This was the address of the maternal aunt. An Initial Child Protection Case Conference is held and Child C and her sibling are made subject to a Child Protection Plan under the category of neglect. A Threshold of Care and Legal Planning Meeting is held two days later due to mother’s expression of non-compliance. This period of time highlights the challenges encountered by multi-agencies when working with mobile and avoidant families when trying to protect vulnerable children. 3.5.1. Child C was discharged into the care of the mother on Friday 5th August at about 6pm. Child C received the first dose of the primary immunisations after consent was obtained from the mother. The staff had initially suggested that Child C stay on the Neonatal Unit for 24 hours post immunisation but the mother was frustrated by the this and had made arrangements for a taxi to collect them. The Consultant Paediatrician was happy for Child C to leave the unit. Primary immunisations are given in the community to premature babies and are not observed for a period of 24 hours. Routine advice was given to watch for signs of a fever and to give paracetamol if required. 3.5.2. There is a discrepancy about the actual date of Child C’s discharge from the Neonatal Unit; LBBD had the date of discharge as the 06.08.16 but Barts Health had it recorded as 05.08.16. This discrepancy about the discharge date is of some concern and that the discharge was over a weekend. It was planned that SW3 would visit at the maternal aunts flat on the Monday 08.08.16 where the family had agreed to stay post discharge. 3.5.3. Prior to Child C being discharged from the Neonatal Unit, it would have been beneficial for the mother to have been invited to stay on the unit overnight, ‘Rooming In’, thereby allowing staff to observe how the mother cared for Child C in a supported environment, i.e., whether there were signs that the mother was developing an attachment with the baby and so would be able to meet the needs of a premature baby with whom she had spent very little time. This was an omission and fell below expected practice. 3.5.4. At the point of discharge Child C was reported to be thriving and growing well but there was very little written documentation about Child C’s daily routine, including whether she was an easy or difficult baby to feed, if she was difficult to settle or whether she was happy and contented or cried excessively, and how frequently she was feeding over a 24 hour period. Child C’s weight was recorded as being just under the 25th centile36 Child C’s head circumference is recorded as 33.6cms but there was no record of her length. These growth measurements are an important baseline for professionals so that subsequent measurements can be recorded and plotted on the centile chart. The relationship of all these measurements will identify the need for further monitoring or investigations by professionals involved in her care. 3.5.5. On the 8.08.16 (the first working day following discharge) SW3 made a planned home visit to the Tower Hamlet address where the mother and her two children should have been living, they were not at home but the maternal aunt was and SW3 was invited into the flat. SW3 contacted the mother by phone, she stated that she was out buying milk and would be back in five minutes. SW3 observed that there was no change to the flat from SW3’s previous visit. There was no evidence that the family were living at this address. SW3 waited for 45 minutes; the mother turned up as she was leaving and had a deep cut above her right eye. When questioned by SW3 the mother attributed the injury to a blackout stating that she had a history of suffering from blackouts but refused to allow SW3 to contact her GP1 for further information. The mother had reportedly been referred to the Neurology Team by GP1 to investigate the cause of her reported blackouts. However, it is unclear whether a referral was made, or the mother chose to give this information to deflect further questioning 36 UK WHO growth charts 2016 from the professionals. The mother’s GP medical records have not been available for this SCR despite numerous attempts to locate them. GP1 retired and the patients registered with the practice were allocated to other local practices. 3.5.6. The arrangements in the discharge plan quickly became problematic; the mother and children were not at the maternal aunt’s address or with the uncle. The uncle reported to SW3 when she attempted a home visit that he had not seen the mother for 18-24 months (this was new information and possibly not accurate) and was also reported to say that the mother had undefined mental health issues. 3.5.7. Shortly after this visit the mother contacted SW3 by phone; the mother was aggressive and difficult and swore at SW3; the mother stated that SW3 had no right to go to see her uncle without her permission. It is now known that the uncle contacted the maternal aunt who contacted the mother immediately after SW3 left, to tell her that she had visited; this indicates that there was some level of communication between members of the wider family about professionals’ visits. 3.5.8. SW3 pursued the line of enquiry as directed by the team leader to establish the whereabouts and role of the father. SW3 contacted the community midwifery team and obtained the discharge address that the mother had given the hospital on 2 June 2016 when she took her own discharge, reportedly to the father’s address in Newham. SW3 made a home visit to this address but there was no response (we now know that this was the wrong flat number) The mother continued to state that she was staying at the address in Tower Hamlets with the maternal aunt to SW3. The invitation to the ICPCC was sent to this address, as this was where the mother was supposed to be staying. 3.5.9. The ICPCC was held on the 15.08.16 the mother, Child C and maternal aunt were in attendance. It was clear that the discharge plan was not working; neither Child C nor her sibling had been seen in the past ten days, by any professional, since discharge from the hospital. The Police were present at the ICPC, information was requested regarding the mother and maternal aunt. The mother who attended the conference refused to give any information about the father except his name. This made it difficult for the Police, or other agencies, to undertake checks. Further work was remitted to the social worker as part of the interim safety plan (see para 3.4.18). 3.5.10. Child C attended with her mother; a friend was reportedly looking after Child C’s sibling. (The conference had to be stopped as Child C was hungry and the mother did not have any milk with her, a ready-made feed was obtained). 3.5.11. Child C and her sibling were made the subjects of a Child Protection Plan (CPP) under the category of neglect. During the conference the mother made her unwillingness to comply with the plans very clear; she presented as resistant and antagonistic and stated that she would not comply. This was very concerning and the Chair of the conference recommended that in light of this, that SW3 and the TM review the situation within 24 hours and escalate as appropriate. 3.5.12. The London Borough of Barking and Dagenham should have shared that the children were made subject to a CPP under the category of neglect, with the two London Boroughs where it was known the mother had connections and possibly lived; namely Newham and Tower Hamlet. This was an oversight but the responsibility for the CPP remained with LBBD irrespective of where they were living at this point. 3.5.13. The Team Manager decided to convene the Threshold of Care and Legal Planning Meeting (TCLPM) following the recommendation made by the Chair of the ICPCC. This was a direct response to the escalating risks and the increased concern about how to safeguard the children. 3.5.14. The TCLPM remit is to decide based on a robust analysis of the level of assessed risk whether: ➢ it is in the best interests of the child to provide a further period of support for the family with the aim of avoiding proceedings; or ➢ Whether proceedings should be initiated immediately. Child C and her sibling were referred for discussion at the Threshold of Care and Legal Planning Meeting (TCLPM) on 17th August; two days after the ICPCC, this was timely and resulted in approval for care proceedings to be issued. 3.5.15. A proposed Public Law Outline (PLO) plan identified a number of further assessments to be undertaken; including a psychological assessment and a drug test, this is the first time that drug use has been considered as a possibility, apart from the routine enquiry during her pregnancies, which she answered no to. The safeguarding plan also made it clear that the mother, Child C and her sibling must live at the maternal aunt’s address in Tower Hamlets until all proposed assessments are complete, that the social worker and health visitor will visit on a fortnightly basis to assess the development and progress of the children and that the mother signs the safeguarding agreement. 3.5.16. The father of the children was named in the minutes (although the first name is different) and the mother reported that he had Parental Responsibility37 although SW3 stated that the mother had refused to give the father’s details to professionals. SW3 had asked the mother to provide a copy of the children’s birth certificates in order to see if the father is named, the mother did not provide them at this point in time. 3.5.17. The following day (18.08.16) the maternal grandmother contacted SW3 to say that she would be able to care and support the family. The involvement of the family came at a critical point when a decision had been made to instigate care proceedings and was accepted by the Team Manager and agreed by the Group Manager (a recording is made in the case files by the TM) as providing an appropriate alternative arrangement and was seen as being a positive source of support, which should be tried out. 3.5.18. As a result of this development the maternal grandmother and maternal aunt met with SW3 and the TM on the 19.08.16. At this point the mother was not with them. They left the offices and returned with mother. The maternal grandmother had put herself forward to offer accommodation and practical and emotional support, as she stated that she did not want to see her grandchildren go into care. The maternal grandmother proposed that the mother and her two children move to Essex and stay with her in her two bed roomed flat. It was made clear at this meeting that the maternal grandmother must contact SW3 and the Police if the mother left Essex at any time. 3.5.19. The TM made a case recording as management oversight about the maternal grandmother putting herself forward to offer accommodation, practical and emotional support plus monitoring. Following the initiation of safeguarding checks, the Group Manager agreed the plan for the family to move to Essex. The Group Manger reiterated in an email to SW3 that there must be a strong commitment by the mother to adhere to the CPPs and that they must remain in Essex. 3.5.20. However, given the fact that the maternal grandmother had herself been a victim of domestic abuse and that the mother had grown up in this household further questioning about whether the maternal grandmother was capable of supporting and managing the situation and working with SW3 could have been considered in more depth. It was reported by SW3 during an interview that the maternal grandmother presented as a plausible individual who understood the context of the situation and said she would be able to manage the mother and offer support to the family. It was also noted that the maternal grandmother had removed herself and her children from the perpetrator and was currently living in Essex with her youngest child (see para 3.11.5). It could not have been known at the time that this 37 Jointly registering the birth of the child with the mother, getting a parental responsibility agreement with the mother or getting a responsibility order from a court, in the case of unmarried parents. decision was made that the maternal grandmother would fail to inform SW3 when the mother left Essex with her two children. 3.5.21. A risk assessment of the maternal grandmother and maternal aunt was completed, and the view taken that the maternal grandmother was able to emotionally support the mother and her two children. This was a temporary arrangement and further assessments would be undertaken at a later stage. An assessment should include both the capacity and ability of the person who has put themselves forward as well as considering the potential interaction and sustainability of the relationship they already have with the birth parent (the mother); in this case daughter and sister (the maternal aunt). Learning Points: • Careful consideration should be given for parents with poor visiting patterns to complete a Rooming-In to allow an assessment of the ability of the parents to care for a premature baby and observe the development of bonding. • Staff need to be reminded about the importance of recording vital measurements and developmental milestones, feeding regimes and management of babies leaving the neonatal unit in order to have a baseline to assess growth and development • When children are subject to a CPP in one borough but known to be mobile this information must be shared with other boroughs or local authorities where they have previously lived/ or should currently be living. • An ICPCC is an invaluable forum for the sharing of information especially regarding other relatives, associations or absent fathers. 3.6. Period 5: 22nd August – time of incident resulting in the death of Child C. (Please see summary time line at Appendix 2 pages 92– 94) Agencies involved: • LBBD Children’s Services • LBBD Legal Department • Metropolitan Police • Essex Children’s Services • Essex Housing Department • An Essex Clinical Commissioning Group • A local Provider Health Service in Essex • London Ambulance Service Following the approach by the maternal aunt and grandmother to the London Borough of Barking and Dagenham Children’s Social Care, the mother and her two children move to Essex to live with the grandmother. This period highlights the challenges to safeguarding systems when family members are not transparent with the agencies involved and fail to adhere to the safeguarding plan in place; resulting in an escalation of risks to vulnerable children. 3.6.1. SW3 instigated safeguarding checks with the Police regarding the maternal grandmother and the accommodation in Essex was then checked for suitability. The maternal grandmother lived in a two bed roomed flat with her youngest 16 year old son, he was happy about his sister and her two children coming to stay. Child C’s sibling was going to sleep in his room, as there were bunk beds. It was reported that the maternal grandmother worked nights but would be around during the day to offer practical and emotional support and monitor the mother with her children. 3.6.2. The family moved to Essex by taxi on 22.08.16, they were collected from a street in the Manor Park area; it was reported that the taxi driver had to wait for almost two hours, as the mother was not ready when he arrived. We now know that in fact the address that was shared with the taxi firm was the wrong address and that the mother was possibly collected from the street. 3.6.3. SW3 notified Essex Children’s Services on 23 August 2016 that the children were the subject of Child Protection Plans and were now resident in their area.38 3.6.4. The case was reviewed by the TCLPM (24.08.16), the decision was not to continue with care proceedings and directed that the CPP continue and that a safeguarding plan be put in place in which the mother, Child C and her sibling lived at the maternal grandmother’s address and that the social worker must be informed if she moved out with the children. They also considered whether this plan could be held safely as it would be at least 4-6 weeks before Essex Children’s Social Care would be able to review the case, as the accommodation was temporary. It is unclear how this was communicated to the family apart from an email by the Group Manager to the TM and SW3 reiterating the fact that the mother and 38 Chapter 6:London Child Protection children must remain living in Essex at all times. 3.6.5. The mother registered herself, Child C and Child C’s sibling with a local GP3; mother gave her last address as the flat in LBBD, despite the fact that she had never lived at the address; the mother continued to lie about her personal circumstances. The registration form specifically asked whether any other services were involved with the family or young person e.g. Social Care or Child and Adolescent Mental Health Services (CAHMS). The mother circled Yes on Child C’s form for Social Care but no further details were provided or requested by the practice staff. The mother did not note any social care involvement with Child C’s sibling. 3.6.6. The current patient registration form used by this practice did not specifically contain a tick box to ascertain if the children are subject to CPPs, or if they were Looked After Children (LAC). Currently there are no standard forms widely used in Primary Care when new patients register that asks specifically whether there is active social care involvement, including if children are subject to a CPP. At the point of patient registration the practice is relying on the parents sharing the information, as there may be some delay in previous records and notes being available. When families have a history of mobility and avoidance the potential for selective information to be given is increased. 3.6.7. On the 1 September 2016 a letter was sent by SW3 to the GP3 surgery that stated that the children were subject to a plan under the category of neglect at LBBD and requested that the GP surgery provide detailed information about all contacts made with the mother and children and to provide this within the next 72 hours due to significant concerns that the LBBD had regarding the children. A response was sent back to SW3, on the 5 September stating that the family were registered with the practice and had contacted the mother regarding outstanding immunisations for the children. At this point neither children had been seen by the GP in Essex nor had they attended the local Accident and Emergency Department. 3.6.8. However, the original letter was not embedded within the health records of the children or mother. The IMR author for the GP3 Practice was unable to ascertain why this was the case and surmised that the failure to scan the letter in to the notes was as a result of human error. This particular practice has different sites, all letters/ faxes and correspondence go to the main site to be scanned and then tasked to individual GP’s to read and action. 3.6.9. Action has already been taken by the GP practice to mitigate against this happening and amended the Standard Operating Procedure (SOP). However, the consequence of this omission was that there was no safeguarding alert placed on the EMIS IT system alerting all professionals, within the GP practice, with access to the system that the children were subject to a CPP under the category of neglect. Whilst practice staff were unaware of the child protection plan, the staff working within the surgery did not have any concerns regarding the care or presentation of the children; presentations were positive and the children received their outstanding immunisations. 3.6.10. The mother had been previously registered with this practice (in Essex) until 2010 when she returned to London. It would also appear that Child C’s sibling was registered here in 2014 prior to the alleged move into the temporary accommodation in LBBD. 3.6.11. Previous GP records for the family were unavailable39 from GP1 in Newham see para 3.5.5. This would suggest that Child C was never registered with a GP whilst living in Tower Hamlets at the maternal aunt’s address. Despite numerous efforts to locate the records for both the mother and Child C’s sibling, they have not been located; this has resulted in a gap of information that the mother may have shared with her GP1 in Newham. As a consequence of this potential key information/ learning has been lost. 3.6.12. On the 24.08.16 a transfer in telephone call was made by the health visitor (HV3) in NELFT to the duty health visitor in a local provider health service in Essex. This duty health visitor allocated the case the same day and the assigned health visitor (HV4) made contact with the mother and booked a planned home visit on the 01.09.16. The movement-in visit was required to be completed within 10 working days.40 3.6.13. Although health records were sent to the local community provider a copy of the CPP was not included. The minutes of the ICPCC were circulated to all professionals on the 19 September 2016, 22 workings days later. The standard is 20 working days but the period did cover a bank holiday. However, information about the family and that the children were subject to Child Protection Plan in LBBD under the category of neglect was passed on verbally to the safeguarding network in Essex. In order for health visitors to undertake a robust assessment and understand the context of the family and the rationale for the children being subject to a CPP under the category of neglect, all available information and past records should be read. If all of this information was not available to HV4 then there is an expectation that contact would be made with SW3 in LBBD to discuss the case and ask for a copy of the CPP to be sent immediately via a secure email address.41 This did not occur. 3.6.14. The home visit on 1 September by HV4 focused on the sleeping 39 Transfer of previous GP records should not exceed a maximum delay of 8 weeks, however NHS England was aware of a significant backlog within the contracted notes transferral service that affected a significant volume of patient records. 40 A Local Provider Health Service Essex 41 Each health professional has a NHS secure email address. arrangements of Child C, there was no cot and it was reported that she either slept in the car seat or with the mother; HV4 advised the mother to line a drawer and put Child C in this to sleep until a cot could be obtained. Child C was weighed by HV4 and the weight was recorded in the Parent Held Record (Red book) as stated in the IMR for the local community provider. However the weight was not recorded in the HV records and it is therefore not known what the weight at this time was. HV4 did inform SW3 in a telephone call that the children had been weighed and there were no concerns. The importance of recording and plotting weights and measurements on the centile charts should be reinforced with all staff that come in to contact with children and young people. This was the first time that Child C had been weighed since discharge from the Newham Hospital Neonatal Unit on 5th August and was an opportunity to assess whether she was continuing to grow and thrive. This was also highlighted as a learning point for Barts Health at the point of Child C’s discharge from the Neonatal unit see para 3.5.4. 3.6.15. The mother reported that Child C cried more than their older sibling; though this information was not explored any further. This was an opportunity to explore with the mother what Child C’s routine was and assess whether the mother had realistic expectations of looking after a premature baby. HV4 commented on the cramped conditions within the flat and that it appeared that the maternal grandmother was not very happy that the mother and her two children were staying with her, this was useful information given that it was the family that had suggested that the mother move to Essex with her two children and stay with the maternal grandmother who was recorded as supportive of the plan. 3.6.16. HV4 contacted SW3 later that day; the only information that was shared concerned the lack of a cot and that the children had been weighed and there were no concerns as recorded in SW3 case records. HV4 requested the CPP to be sent, SW3 informed her that she would bring a copy to the Child Protection core professional group scheduled for the 06.09.16 at the maternal grandmother’s flat. Although the core meeting was scheduled for five days later, it would have been best practice for the CPP to be sent that day. 3.6.17. The Core Group took place on 6th September 2016.42 The mother, maternal grandmother, Child C and their sibling, SW3 and HV4 were present. This was the first time that SW3 saw the mother, Child C and her sibling, and the maternal grandmother in their ‘home’ environment in Essex. There were no minutes of the Core Group meeting. This was a significant omission. This meeting was a key opportunity for professionals to review the CPP and the safeguarding agreement whereby the mother and her two children must stay in Essex, and if she did leave then the maternal grandmother must 42 The core group was held late due to children’s change of address and family living out of borough. notify the social worker and police immediately. It is reported that the mother and maternal grandmother were aware of this expectation. What is not clear is how this was communicated to the family - either in writing or verbally. The Core Group provided an opportunity to remind all present about the expectations and conditions set out in the safeguarding plan and CCP. This would have provided clarity to all parties involved about the rules and the escalation if the plan is not being adhered to. Because of the lack of minutes of the Core Group it has not been possible to ascertain whether the conditions of the safeguarding plan were reiterated verbally at this time. HV4 stated that she was unaware of this stipulation when interviewed by the IMR author. The importance of recording and documenting key meetings has been identified and is a key learning point for all agencies involved. The LBBD has also identified the need to strengthen the safeguarding plan/agreement by using a model template which sets out the expectations of the parent/s and any other family members involved; the services to be provided; arrangements for review; and the contingency plan if the agreement is seen not to be working. 3.6.18. During the time that the family were supposed to be living in Essex SW3 made two home visits, the 6th and the 19th September. The 6th was also when a Core meeting took place. SW3 also made contact by phone on four occasions. 3.6.19. It was noted that Child C’s sibling interacted positively with the mother and grandmother, whilst Child C was asleep in a car seat. The mother confirmed that the children were due to be seen by GP3 the next day and that Child C’s sibling was up to date with the immunisation schedule. The mother showed SW3 Child C’s birth certificate; the father’s name was not on the certificate. At this meeting it was established that the mother still had not presented herself to the housing department in Essex and it was agreed that the maternal grandmother would accompany her to the housing department in the next few days. At the end of the meeting HV4 took a signed form by mother, which allowed GP3 to share information with social care. 3.6.20. Child C was examined by GP3 on the 07.09.16, it was reported that Child C was well and had put on weight according to her mother. At this time GP3 was unaware that both children were subject to a CPP, as the records were not flagged on the IT system as outlined in para 3.6.9. It was recorded that GP3 did not have any concerns about the children. The mother did bring Child C for her routine 2nd dose of primary immunisations and an appointment was given for the 3rd dose which was due to be given in four weeks time. 3.6.21. On 8th September, two days after the core meeting (on 6.09.16) the LBBD SW3 attempted to speak to the mother by phone to get an update about the contact with the Housing Department; a voice mail message was left for the mother to respond. Six days later on 14th September 2016, SW3 again attempted to talk to the mother on the phone; again there was no response. At this point SW3 contacted the maternal grandmother, who informed her the children had left with their mother on 12.09.16 to go to London and were due to return on Thursday 15th September 2016. 3.6.22. On Monday 12.09.16 the mother sent a text to HV4 that she needed to go out and could she come to the flat before 3pm. It is reported that the mother was relaxed and chatty during this visit. We now know that this was the day that she left for London accompanied by her two children. 3.6.23. This development was in breach of the safeguarding agreement made to safeguard the children; and after SW3 discussed the situation with her Team Manger she attempted to phone the maternal grandmother to request that she report to the Police that the mother and children were missing. As there was no one answering a message was left on her answer phone (see para 1.3.18). As a consequence, SW3 next visited on 19 September (the third working day after the breach) to make a Child Protection home visit to the family in Essex. The fact the mother had taken the children back to London and that the maternal grandmother had failed to inform SW3 called in to question whether the basis of the CPP was fully secure and safe. It might have been considered appropriate to alert the TLPCM of this development or take other action. 3.6.24. SW3 followed up this breach when she made the unplanned home visit on Monday 19.09.16. When SW3 arrived the mother was about to leave for an appointment with the Practice Nurse for Child C’s Rotarix.43 SW3 asked the mother if she could accompany her to the GP surgery but she refused so SW3 took the opportunity to meet with the maternal grandmother, with whom she felt that she had a reasonable relationship. 3.6.25. SW3 was reassured during the visit when she was shown a card with the details of the housing officer on it, by the maternal grandmother When the mother returned from the GP surgery she appeared to be much calmer, maintained eye contact, accepted that there needed to be changes made and appeared to be very positive about the situation, this was in stark contrast to any of the previous meetings that she had with the mother. Child C’s sibling was observed playing with toys and was particularly fond of tractors, played ‘peek- a- boo’ from behind the sofa and was seen laughing and interacting well. SW3 felt that the sibling did have a relationship with the mother but was always looking for affection and would climb onto adults’ laps. Child C was often asleep or sleepy on the visits that the SW3 made to Essex. 43 Oral vaccine against rotovirus, a common cause of diarrhoea and sickness, administered at 8 and 12 weeks. 3.6.26. This was the last time SW3 saw the family. It is now known that immediately after SW3 left the maternal grandmother’s home the mother left with her two children and took the train back to London (see para 3.10.6.) 3.6.27. HV4 received a text from the mother on the 26.09.16, ‘I can’t remember if we have an appointment but if we do can we please reschedule it. Thank-you.” HV4 responded by text, offering an appointment for the next day; there was no response from the mother. On the 27.09.16 HV4 received another text from the mother ‘it is OK for you to come tomorrow anytime will be fine” HV4 responded by text offering a 4pm appointment for the following day, the mother sent a text back at 12:19 ‘Yes that’s fine’. 3.6.28. It is now known that the family were in London from the 19th and again the maternal grandmother had failed to inform SW3 as stipulated in the safeguarding agreement. HV4 was unaware that the family had left for London immediately after the previous re-arranged visit on 12.09.16. HV4 was also unaware of the safeguarding agreement that was in place (see 3.6.17), specifically that the mother and her two children must remain in Essex, and if they left or attempted to leave then SW3, or the police, must be informed immediately. This arrangement was not included within the CPP at the time of transfer in to Essex. 3.6.29. On 28th September 2016 the mother Child C and their sibling boarded a London bus. During the journey, the mother asked for help as Child C had stopped breathing. Emergency services attended the scene and Child C was taken to NUH where she was pronounced dead, non-accidental injury was suspected; the parents were subsequently arrested on suspicion of murder. Learning Point: • Minutes of core meetings must be shared with all professionals involved in the care of the children in a timely manner. • Written safeguarding plans should be discussed with professionals at point of movement in to new local authority • Staff should be reminded about the importance of sharing information/plans • Staff should remain curious at all times particularly when the attitude or behaviour of an individual changes dramatically and may appear to become more compliant. • The importance of uploading CPP onto GP records and putting a safeguarding alert on all the records so that all professionals with access to the records working in the practice have this information (SOP in place). This has already been actioned 3.6.30. The next part of the report provides the analysis of items set out in the Terms of Reference (TOR) agreed by the Serious Case Review Panel on 28.04.17. Due to the number of different agencies and professionals involved in the provision of care to the family, the named agency / organisation is set out for a clearer and a better understanding. 3.6.31. There is also a section where learning that has emerged from the SCR that is not covered by the TOR will be discussed and analysed. The recommendations made in this section are for all the Safeguarding Children’s Boards involved with this case, unless specifically directed to an individual Board. The individual recommendations made within the Independent Management Reviews are included in Appendix 3. 3.6.32. The areas set out for analysis by the original TOR are: 1. The level and extent of agency engagement and intervention and whether his was appropriate to the assessment of parent’s ability to provide adequate care and supervision of Child C and her sibling. 2. The recognition of safeguarding factors by all agencies and how these were addressed. 3. Were practitioners aware of the needs of the children in their work, and knowledgeable about potential indicators of abuse or neglect and about what to do if they had concerns about a child’s welfare. 4. The quality of assessments on which decisions and actions were taken. 5. Whether there were any factors in the history of any adults that indicated they posed a risk to children. 6. Whether race, religion, culture was a factor in this case and had been fully considered. 7. The extent and quality of partnership working among key agencies and across local authority borders. 8. The effectiveness of working arrangements and information sharing and communication between all professionals and whether this could have been improved. 9. The existence of any factors relating to the ‘capacity and climate’ within agencies which may have impacted upon practice in this case (i.e. vacant posts or staff on sick leave etc 10. In addition to the above the review should consider learning for both the individual agency and how agencies work together through the BDSCB. 3.7. The level and extent of agency engagement and intervention and whether this was appropriate to the assessment of parent’s ability to provide adequate care and supervision of Child C and her sibling. 3.7.1. Throughout the period under review, there was a pattern of poor engagement by the mother with all agencies; the mother engaged almost entirely on her own terms or when professionals informed her that the concern had increased to such a level that further intervention was deemed necessary e.g. the concerns raised by the staff on the Newham Hospital Neonatal Unit that resulted in the Initial Child Protection Case Conference and the intervention of the extended family to prevent care proceedings for the children. At the very least this demonstrated that the mother did not lack an understanding of what was required but showed a very significant will not to work with professionals in the best interests of her children. 3.7.3. In this case the mother’s behaviour included: avoidance,44ambivalence,45 confrontation46 and deceit. To employ appropriate support, and challenge parents when non-engagement or disguised compliance occurs, professionals need to be supported through: adequate supervision, training and management oversight. The way in which the mother sought to “manage” professionals in this situation included: ➢ Cancelling and re-booking appointments ➢ Early self-referral to Midwifery Services and then not attending appointments ➢ Attending appointments at the incorrect time ➢ Doing just enough to keep professionals at bay ➢ Moving from one address to another and refusing to give details 44 When a parent fails to turn up, is unavailable for planned visits or cutting visits short. 45 When a parent is late for appointments and repeatedly make excuses for missing them 46 When a parent disputes the facts and argues with the professional. ➢ Lying about living in LBBD even when the tenancy had been cancelled ➢ Frequent changes of mobile phone numbers ➢ Agreeing to live with maternal aunt following Child C’s discharge from the Newham Hospital Neonatal Unit and then failing to do so. ➢ Failure to disclose father’s details ➢ Giving a variety of reasons why it has been difficult to keep appointments, Child C’s sibling sleeping, unwell or couldn’t find anyone to look after them ➢ Aggressive / defensive responses to professionals and calling them liars ➢ Becomes more compliant when threatened with more invasive action 3.7.4. Although professionals challenged the information that they were being given, the meetings and telephone conversations quickly became hostile and aggressive and the mother was verbally abusive on more than one occasion. The danger of this is that the focus moves to trying to maintain a relationship with the mother and in doing so the ‘lived experience’ of the child(ren) becomes lost or diluted. 3.7.5. Brandon et al (2008)47 note that disguised compliance, by its very nature, makes it difficult for professionals who are involved with a family to maintain an objective view of progress in safeguarding the welfare of a child. Disguised compliance ‘wrong foots’ professionals and can prevent or delay understanding of the severity of harm being experienced by children in the family. 3.7.6. At the most basic level, disguised compliance harms children as it prevents professionals being able to properly assess the risks to children in the household. Professionals are unable to progress work due to a lack of access or where the level or quality of contact with the family is so limited it makes ongoing work impossible. All disguised compliance involves resistance to change and an inability or unwillingness on the part of parents and carers to address risks to their child. Assessments of the parent’s capacity and willingness to change should therefore be carried out alongside assessments of the child’s life. 47 .(http://webarchive.nationalarchives.gov.uk/20130401151715/ https:/www.education.gov.uk/publications/eorderingdownload/dcsf-rr023.pdf) 3.7.7. The mother appeared to try and control different relationships with the professionals involved with her and her family. A range of factors including: experience of seeking help in the past which will influence the present, trust and attachment, experience of authority, any cultural racism/ discrimination or something to hide will all have an influence on how a family or individual will engage. The influence of other adults who are ‘behind the scenes’ including ‘shadowy males’ must also be considered. With the benefit of hindsight what might have been perceived by professionals as disguised compliance or non-engagement at the beginning; it is now evident that the mother and her extended family were giving false information and on occasions lying directly or failing to pass on information in the best interests of the child(ren). 3.7.8. There is a significant need to consider the appropriate levels of support, guidance and challenge for front line professionals (in all disciplines) to ensure that they are protected and supported to recognise and work with the often overwhelming feelings that working with families such as this may evoke. 3.7.9. Professionals need to be able to distinguish between disguised compliance and typical behaviour in families with complex/chaotic needs. Within the context of family intervention work, multiple and complex needs is sometimes used to refer to families who have often reached the stage where they are presenting with externalised behaviours which have negative and very disruptive consequences for themselves and those around them such as persistent offending behaviour or persistent anti-social behaviour. Other terms such as troubled families and families with multiple problems are also used to describe families with multiple and complex needs.48 Front line workers need particular support and to be advised of strategies and practical approaches to cut through any deliberate obfuscation. Policy needs to be clear and followed to both safeguard children and workers in these situations. 3.7.10. The quality of the assessments undertaken by both Newham and LBBD were significantly hampered by the lack of engagement by the mother. Her resistance to work co-operatively with professionals made it difficult to fully grasp the lived experiences of the children. 3.7.11. When LBN were undertaking the assessments the level of concern for the mother, the unborn child and subsequent sibling of Child C was at a lower level and it was determined that it did not meet the threshold for statutory intervention. Though the pre-emptive closure of the case on 15th May 2015 was regrettable 3.7.12. Following the birth of Child C and the referral by staff on the neonatal 48 Providing intense support for families with multiple and complex needs unit at Newham Hospital to the LBBD the concerns escalated about the mother’s behaviour and in particular the refusal by the mother to come to the hospital to give blood, the poor visiting pattern and short duration of these visits and most importantly the perceived lack of interest/ urgency in taking Child C home. 3.7.13. The mother denied any on-going relationship with the father and refused to say where he lived. She shared the name of the children’s father with the midwifery service, albeit two names were given, and she also stated that they were no longer in a relationship but that he was supportive. Further exploration of the relationship and of the expected role of the father did not occur. The father’s shadowy presence continued throughout the review period, though he visited the post-natal ward to care for Child C’s sibling and came to see Child C on one occasion whilst she was on the Neonatal Unit. It is assumed by the ambulance crew that it was the father that was seen when they attended his home address in response to a 999 call; this may suggest that this was where the family lived for most of the time. This information was recorded by the single agencies working with the family, but was not shared, analysed or properly pursued. The two names provided by the mother for the father had the same first name and one of the second (family) names corresponded to that of Child C’s sibling. The potential risks the father posed (and possible strengths he offered) remained unassessed for the duration of the professionals involvement. This was a significant omission. 3.7.14. Engagement by the mother in the antenatal period was poor for all three of her pregnancies. During Child C’s pregnancy the mother attended three out of a possible 14 appointments; though she knew that the risk of having a premature birth was higher, yet she still failed to attend. As previously discussed the mother was not being cared for by the Acorn Team at NUH for vulnerable women during this pregnancy because it was thought that she had been given temporary accommodation and there was no longer involvement from Newham CSC. Poor antenatal attendance is of concern and should have been flagged, the mother appeared to do just enough to convince the professionals that she was complying with her care and that she had mitigating circumstances to explain why she failed to attend her scheduled appointments. 3.7.15. This pattern of poor engagement continued with the health visiting service, firstly in ELFT and continued in NEFLT. Contact was mainly by phone or attendance at CHC, pre-planned visits were either cancelled or there was no reply. As a consequence of this, there was no assessment within the home environment. The initial assessment made by the HV1 (ELFT) was for the highest level of support; this was quickly changed to the Universal Service following attendance at the child health clinic (where she was seen by HV2). When the family moved to the LBBD this resulted in the health visiting service being provided by NELFT. The poor engagement continued and any contact that was made was either by phone or at the clinic (a total of eight health visitors were involved) because of staff shortages, the use of bank staff and that there was no named health visitor for the family. Consequently, there was no assessment of the home environment or consideration of the lived experience of the child. 3.7.16. Following the premature birth of Child C and her subsequent admission to the Neonatal Unit at NUH, staff became increasingly concerned about the lack of visiting by the mother and difficulty in contacting her. The staff correctly identified that the mother’s ability to provide adequate care to her children needed to be further assessed. A referral to LBBD Children’s Social Care was made by staff on the Neonatal Unit and was appropriately responded to. SW3 was allocated to the case and agreement via a strategy discussion with Police, to take the case to an Initial Child Protection Case Conference within the 15 days time frame. There was an opportunity to make some assessment of the mother’s parenting ability, in particular caring for a premature baby, by inviting her to ‘room-in’ on the Neonatal Unit and care for Child C for a period of time prior to discharge, this did not happen and was an omission. It is unclear as to whether the mother was asked to ‘room-in’ and declined or the mother was not asked. The ability to carry out a robust and meaningful assessment was sabotaged by the mother by avoiding planned visits by SW3 following discharge from the hospital and prior to the ICPCC but was not assiduously pursued by the concerned professionals at the time. Both children were made subject to a CPP under the category of neglect; and due to the mother’s behavior and expressed view that she would not comply with the plan an urgent review was carried out 24 hours later to ensure that the children were safeguarded. 3.7.17. The Team Manager decided to convene the Threshold of Care and Legal Planning Meeting (TCLPM) held on 17 August 2016 due to the escalating risks and the increased concern about how to safeguard the children. The meeting resulted in approval for care proceedings to be issued. This was timely and met practice standards. 3.7.18. When the mother and the children moved to Essex there appeared to be some initial better engagement by the mother with the health services. The health professionals worked with the mother to ensure that the children received their outstanding immunisations, and in the case of Child C’s sibling a developmental assessment. A family health needs assessment was not completed whilst the family resided in Essex; they were there for just under five weeks. 3.7.19. What is clear over the course of the time period of this review is that the mother was prepared to lie to the professionals working with her. This included denial of knowing where the father lived, pretending that she was still living in the flat In LBBD 11 weeks after the tenancy had been cancelled. It would also appear that the maternal aunt and grandmother did not inform the professionals engaged in safeguarding the children when the mother was not living at the agreed address. 3.7.20. Mobile or transient families are often able to avoid contact with professionals and as a result individual agency’s systems do not always enable sufficient focus to be maintained on the needs of vulnerable children. When parents are also rude and verbally aggressive to practitioners the management of the case becomes even more challenging. The use of a chronology identifying missed appointments and untruths should have formed part of the historical information available to professionals working with the family so they could triangulate such information and at least catalogue the extent and nature of the “non-compliance”. While this historical information should not determine current thinking it should have significant impact on decision making. Learning Point: • The use of chronologies to identify missed appointments and untruths should be used in cases to support the management and decision making to better safeguard children. • The inability to complete a meaningful assessment when parents do not engage means that the risks to the children cannot be properly assessed • The focus of the professionals must remain on understanding the lived experience of the children, what was their everyday life like? 3.8. The recognition of safeguarding factors by all agencies, with the exception of police and how these were addressed. 3.8.1. There were a number of safeguarding factors evident in the mother’s history and her lifestyle choices that she made. These included: • The mother presented as a young homeless women living between extended family and friends in East London. • The mother had moved with her own mother (maternal grandmother) and two younger siblings to a Women’s Refuge in Essex due to domestic abuse and she had also alleged that her father and brother had assaulted her when she returned to live in London. • The mother also made an allegation against ‘her boyfriend’ (the father of the children) in 2013. • At the time of her first pregnancy she reported that: she was no longer in a relationship with the father of the unborn child, unemployed and in receipt of benefits. • She already had a poor attendance at health appointments and chose what information she was prepared to share with professionals involved with her care. • She had three premature births at home in the space of three years. It is unclear as to whether the professionals considered whether there was any link between these and an environment of domestic abuse. 3.8.2. It is acknowledged that this list is drawn up with some elements of hindsight, though many of those issues were known about, sometimes in individual settings, at the critical decision making opportunities. 3.8.3. During two of the mother’s pregnancies she was under the care of the ‘vulnerable women’ midwifery team at NUH. Her attendance was poor and she seemed to ignore advice given by the midwives. It is difficult to comment further about whether safeguarding factors were considered by the team, due to the unavailability of the records. However, there were a number of factors including: • the mother’s history including self reported early miscarriages • chaotic and mobile lifestyle • poor attendance at antenatal appointments • history of domestic abuse that were significant enough that professionals should have made plans as to how the case would be managed and escalated as appropriate. There was no referral made to NCS by the midwifery team, but this may have been due in part to the premature birth of Child C. 3.8.4. The staff on Neonatal Unit at NUH were very proactive in identifying safeguarding factors and communicated well with the Named Nurse for Safeguarding within the hospital and the subsequent referral to MASH in LBBD. The staff also identified concerns around the discharge plan for Child C and in particular the fact that the family were moving into another London Borough (this was the third) and that the mother had failed to register with a GP in the area prior to the discharge of Child C. There had also been difficulty in identifying the health visiting team that would take on the case in Tower Hamlets. We know that when mobile families move, the current case transfers between health visitors does not guarantee that contact will be maintained with the family which can potentially lead to vulnerable children’s needs being overlooked. The Named Nurse rightly challenged LBBD CSC about health not being included in the Strategy Discussion/ meeting and followed up her concerns by email, The Named Nurse from NUH also attended the ICPCC; this was good practice. 3.8.5. The LBBD identified the concerns following the referral to MASH and allocated a social worker to complete a single assessment by the 4.08.16. The instructions and timeframes were clear and there is good evidence of communication and supervision with the TM. Following the children being made subject to a plan for neglect the CPP were of a good standard with clear timelines and expected outcomes for the children. The Chair of the ICPCC was sufficiently concerned about whether the safeguarding plan would work due to the behaviour of the mother when she attended that she directed the SW to review and escalate the case as required. This showed a firm and clear grasp of the issues of safeguarding at this early stage. 3.8.6. When the family moved to Essex, there was a clear safeguarding plan in place, the focus being that the mother and her children had to remain living with the maternal grandmother, and if she left the house with the children then the maternal grandmother must notify the social worker immediately. The lack of Core Group minutes has already been identified as a significant issue see para 3.6.17. The safeguarding plan needed the full cooperation of the maternal grandmother and when she failed to inform SW3 the first time that the family returned to London it was reasonable to think that this may happen again and should have merited a review of whether the safeguarding plan was robust enough. 3.9. Were practitioners aware of the needs of the children in their work, and knowledgeable about potential indicators of abuse or neglect and about what to do if they had concerns about a child’s welfare? ‘Neglect can be difficult to define because most definitions are based on personal perceptions of neglect. These include what constitutes ‘good enough’ care and what a child’s needs are. Lack of clarity around this has serious implications for professionals in making clear and consistent decisions about children at risk of neglect’ (NSPCC.2012) 3.9.1. It is well known that neglectful parenting is almost inevitably a sign of complex and longstanding problems such as mental ill health, domestic abuse, a poor physical environment or entrenched behaviour by a parent or parents. The understanding of neglect is a partnership requirement and must not just be the responsibility of Children’s Social Care. In this SCR the initial assessment carried out by NCS had focused on the issue of housing and did not fully explore the chaotic and poor engagement in a wider context and assess the parenting capacity of the mother in a meaningful way. The absence of information about the father was a feature throughout. Different information was held by the agencies attempting to work and support the mother and was not pulled together until the third assessment undertaken by LBBD. 3.9.2. The Intensive Hospital Intervention Team in NCSC initially identified potential safeguarding concerns under neglect, in relation to the mother failing to safeguard the health of her unborn child. There was an absence of evidence within the case files of a robust assessment of risk for neglect. The focus continued to be supporting the mother to secure housing with little exploration of the impact on the transient, chaotic lifestyle on the mother’s ability to meet the needs of her unborn child. The sibling remained as a Child in Need (CIN) in Newham until the case was closed in May 2015. During this time there was no Team Around the Child (TAC) Meeting or multi-agency consultation and planning around the decision to close the case, and a missed opportunity to consider the need to update the assessment following the report that Child C’s sibling had suffered a head injury allegedly caused by jumping on a bed. When the social worker requested information from the health visiting team in NELFT it took over three months for the response. There was a lack of urgency and case drift, in part due to the high volume of referrals, high caseloads held by social workers and an over reliance on agency staff see section 3.15. 3.9.3. Staff on the Neonatal Unit at NUH clearly identified risk factors and neglectful parenting and appropriately referred the case to the LBBD. 3.9.4. The work undertaken by the LBBD social worker kept a clear focus on the needs of the children and identified that the mother’s parenting capacity showed indicators of neglectful parenting. The mother’s behaviour had implications for the welfare of the children and the social worker escalated the case, which, resulted in the children being made subject to a CPP under the category of neglect and then consideration of safeguarding action through the court. However, professionals in Essex did not know about the safeguarding plan and specifically the requirement that the mother and the two children must not leave the maternal grandmother’s address. The GP practice in Essex did receive the information about the children being subject to a CPP under the category of neglect in the LBBD. However, this was not uploaded onto the Information Technology system and as a consequence of this the records did not have a safeguarding alert applied see para 3.6.8. 3.9.5. At the time of this review there was no overarching tool to support professionals in assessing and gathering evidence about possible indicators of abuse or neglect. Since then both Newham and Essex have worked on the positive benefits of having a Neglect Strategy and both have one in place. LBBD Care Profile tool49 is in place for social care staff who have received briefings on its use. 3.9.6. Ofsted commented that ‘those local authorities providing the strongest evidence of the most comprehensive action to tackle neglect were more likely to have a neglect strategy and /or systematic improvement programme across policy and practice, involving the development of specific approaches to neglect50 3.10. The quality of assessments on which decisions and actions were taken. 3.10.1. A good assessment, including family history and identification of risk factors, is fundamental to ensuring that a strong and appropriate plan for the level of required intervention is put in place. Professionals need to maintain a healthy curiosity and continually assess at each professional intervention in order to detect any changes in the family dynamics. Risk factors are cumulative, the presence of more than one increases the likelihood that the problems experienced and the impact on the (unborn) child and parent will be more serious. Research evidence from SCRs 51 suggests that history is an important part of assessing current and future parenting capacity. A safe child protection system needs to deal proficiently with risk, probability and impact; it is not enough to respond reactively after an incident of significant harm has been caused to a child. 3.10.2. Risk should be assessed from the perspective of the children and should not be unduly influenced by sympathy for the adults’ experience. In this case the number of opportunities that the professionals, who were attempting to work with the family, had to undertake an assessment was limited. However, the assessments that were completed were not child centered, and crucially did not explore the attachment between the mother and child(ren) or indeed question how she was meeting the basic needs of her children given the chaotic lifestyle she was leading. Perhaps as a consequence of this, the potential and actual risks to the children were not clearly understood. For example, the safeguarding network of professionals did not acknowledge the possible additional impact of poverty and homelessness on the lived experience of the children. 3.10.3. The quality of the assessments undertaken by professionals in this SCR were seriously impeded by the lack of engagement and avoidance and duplicitousness by the mother. The assessments completed by Newham CSC were impeded by mother’s sabotaging 49 Graded Care Profile is an assessment tool used to assist in the identification of neglect. 50 In the Child’s time: professional response to neglect. 51 Brandon et al, 2008 of visits resulting in only two successful face to face contacts and this compromised the extent to which holistic assessments of parental, environmental and social factors could be undertaken. The assessments were not sufficiently child centered therefore the focus remained in supporting the mother to secure accommodation and did not explore complex safeguarding issues. 3.10.4. The importance of and need to support social workers to determine how long to spend on individual cases, and to balance ‘thoroughness and depth’ and ‘timeliness and proportionality’ is a crucial part of management oversight and supervision. Assessments must be outcome focused, the plan reviewed regularly and evidence collected to determine that progress is being made. The analysis of each assessment should be strengthened by critical reflection in supervision and reduce case drift. 3.10.5. As already highlighted in the appraisal of practice the health visitor in ELFT initially assessed the family as meeting the needs of a Universal Partnership Plus and arranged a follow up visit with the mother at home two weeks later (the new birth visit was undertaken on the postnatal ward). This appointment was not kept and there then followed a period of time when the mother either re-arranged a scheduled appointment or turned up late, the result being that there was drift in the case and the mother and sibling were not being assessed. HV1 referred to NCSC when Child C’s sibling was seven months old as she had been unable to assess the mother and child and had missed various health checks and immunisations. 3.10.6. When the case was referred to the LBBD SW3 there were clear concerns about the mother and her avoidant and manipulative behaviour. As previously stated in para 3.3.28. SW2 did not pass on the information to LBBD when the case was closed and the family had moved into accommodation in LBBD. Information held by Newham was provided to LBBD on 16 July 2016. SW3 worked tirelessly to engage with the mother in order to carry out a meaningful assessment. SW3 visited the numerous addresses that were on file for the family in order to see the children and complete an assessment. SW3 showed persistence, flexibility and commitment in her role and was not afraid to challenge the mother’s account despite being verbally abused by the mother. Although the assessment did begin to surface some issues there could have been a firmer focus on the mother’s ability to parent and her bond/attachment to Child C, particularly as the key reason for the referral was attachment and parenting. Nonetheless, the assessment did lead to the escalation of the case and a plan to safeguard the children. 3.10.7. Professionals are dependent on what individuals choose to disclose and this is shaped by the awareness, perception of the workers, and the candour of the individual. There were a number of issues that the mother was not candid about, or actively tried to conceal. These included: • The mother not disclosing the information to all professionals about the father of the children; this may have been because she was unwilling or felt too scared, was unaware of her partner’s background or denied its significance. • The self-reported number of miscarriages experienced by the mother; the ‘blackouts’ and the cut over the right eye may have been as a result of domestic abuse. With the family history of domestic abuse, the maternal grandmother, her own father and brother assaulting her. Professionals had considered the risk of domestic abuse but thought that it had diminished as there had been no reported incidents since 2013 and the mother denied having a partner or being in a relationship. • The mother’s reluctance to allow her GP medical records to be accessed during the assessments undertaken may suggest that there was information that she did not want other professionals to know. 3.10.8. The role of the professional is to remain curious and intrusive about what information is not being shared, and the possible reasons behind this. Learning Point: • Robust systems of management oversight and supervision to allow reflective analysis and development of outcome focused plans to evidence real change for the children • Remind staff about the importance of history, the past may be a significant pointer of the future. 3.11. Whether there were any factors in the history of any adults that indicated they posed a risk to children. 3.11.1. The absence of any checks as to whether the father of the children posed any risk to the family or whether he was supportive and provided stability has already been discussed under the appraisal of practice. The lack of knowledge about him or the drawing together of the various strands or fragments of information left a significant and ultimately defining gap in professionals’ knowledge. Work has commenced in ELFT to ensure that the father’s details are recorded and what role it is understood that he has within the family unit. 3.11.2. It is imperative that fathers do not remain invisible and that investigations are pursued despite reluctance, resistance or any self-reporting that there is no ongoing relationship with a father. 3.11.3. In this case information about where he lived, his possible names and that he had visited both his children following their births in the hospital was known by some of the professionals working with this family but it was not shared or acted on in a meaningful way. 3.11.4. As set out in para 3.2.11, GPs need to do all that they can to establish the circumstances of any adults who present with anxiety, depression and/or substance misuse whether they care for children and in what capacity. In the absence of a national framework setting out GP responsibility to consider the dependents of patients it is useful to reflect on learning gained by the National Society for the Prevention of Cruelty to Children (NSPPC) from a number of serious case reviews in which they state GP’s must: ‘Always ask patients with mental health difficulties, learning difficulties or drug and alcohol misuse whether they have significant care responsibilities. Consider their capacity to care for children safely. Record this information in medical records and emphasise it in referrals and correspondence about patients’52 This is repeated here to reinforce good practice 3.11.5. Safeguarding checks were undertaken to assess the suitability of the maternal aunt and grandmother in providing accommodation and general support to the mother and her children. However as discussed in (para 3.5.20.) there was no individual assessment of the maternal grandmother or maternal aunt in relation to their own capacity and ability to act in the best interests of the children and not to be unduly influenced by their relationship (or lack of it) with the mother. Given that both the maternal aunt and the maternal grandmother had not co-operated with the safeguarding plan that was put in place, and had in fact chosen to be complicit with the mother when she returned to London on 12th September 2016, there should have been more exploration of why the maternal grandmother failed to inform the social worker and whether she could be relied on if it happened again. The decision to allow the mother and children to go to Essex was not wrong. In any event it would have been difficult for the local authority to pursue another course in the face of the maternal grandmother’s determined statement to provide care and avoid the children entering the care system. It was however an on-balance decision that the extended family, and in particular the maternal grandmother, would offer support and stability and allow more time for the LBBD to complete further assessments. 3.11.6. There was also little known about whether the mother posed any 52 https://www.nspcc.org.uk/preventive-abuse/child-protection-system/casereviews/learning/gps-primary-healthcare-teams/. risks or any exploration about whether she would be able to protect her children from harm. This is of particular significance given some of the family background of intergenerational domestic abuse. The mother reportedly lived with different friends and family but the exact whereabouts or who the other adults were in the house was unknown. Her mobile and chaotic lifestyle was a feature throughout the whole time period of this review and despite securing accommodation chose not to live in it. It is well recognised that when families are homeless they experience difficulty in accessing benefits; the mother often made reference to financial difficulties. The mother’s financial situation was not explored in any real depth, nor why she was always hungry on the occasions that she did visit Child C on the Neonatal Unit. 3.11.6. The extended family were viewed as supportive when they came forward at a point of crisis to assist the mother in caring for her two children. When the maternal grandmother ‘stepped in’ to provide accommodation for the family at the time it was seen as a positive and allowed a further period of time to support the mother in demonstrating that she was capable of meeting the needs of her children. SW3 was reported to feel that she had a good working relationship with the maternal grandmother and that she had demonstrated good insight. In light of this it would have been very difficult for the local authority to purse legal proceedings to remove the children from the mother. It could not have been foreseen that the grandmother’s expressed concern and apparent agreement with the arrangements would have been so shallow. There was little to suggest that the maternal grandmother would fail to inform SW3 if the mother left Essex with her two children but having failed to do so on the first occasion it is unclear what reassurances were obtained from the maternal grandmother by SW3 that she would fulfil the agreement to do so if the family left Essex and returned to London. In point of fact on the day that this meeting took place (19.09.16) the mother left for London and was away until the events of the 28th September. Learning Point: • It is imperative that father’s do not remain invisible and investigations pursued even when there is denial or resistance from the mother. • The importance of requesting police information on father’s when undertaking assessments. 3.12. Whether race, religion, culture was a factor in this case and had been fully considered. 3.12.1. There is very little reference made to the self-identity of the family or what pivotal role it might play in the day-to-day life of the family and extended family. It was recognised that a detailed assessment of the family was needed, though not possible in the immediate need to secure mother and children in what appeared to be an available and more stable setting. By understanding the cultural background of the family, professionals can get beneath the surface of assessments of risk by gaining an understanding of risk and resilience, strengths and vulnerabilities. Using this as a starting point, how best to provide services to meet their needs may be better facilitated. There is nothing to suggest that culture or ethnicity was considered in any of the assessments undertaken. 3.13. The extent and quality of partnership working among key agencies and across local authority borders. 3.13.1. The quality of partnership working demonstrated in this case is variable and to a significant extent reflects the difficulties that key agencies experience with mobile and avoidant families. This is further complicated when service provision changes due to the family residing in another London Borough or moving to another local authority. When another layer of different health providers is added it becomes increasingly difficult for professionals within the key agencies to maintain strong working relationships. This becomes even more challenging and difficult when there is no shared IT system even within the health services. 3.13.2. When the initial assessment was instigated by NCS there was some evidence of partnership working between health, housing and social care. However, when the family moved into temporary accommodation in the LBBD this necessitated a change of health visiting provision and NCS found it increasingly difficult to speak to the family health visitor (NELFT) allocated to the family. It is now known that eight health visitors were involved (NELFT site a combination of agency, bank and different clinic attendances as a contributing factor). In these circumstances co-ordinated and close partnership working was almost impossible. 3.13.3. There was good partnership working between the staff on Neonatal Unit at Nehwam Hospital, who liaised with LBBD CSC and the health visiting service in NELFT. There continued to be difficulty in establishing the health visiting team that would provide services whilst the family were living in Tower Hamlets, as a consequence of this Child C was not seen by a health professional until the move to Essex. 3.13.4. There was some good partnership work when the family moved to Essex but it is evident that partners in Essex were not all aware of the full facts of the case, as outlined in the appraisal of practice. This mitigated against professionals in Essex being able to fully conduct their roles. 3.14. The effectiveness of working arrangements and information sharing and communication between all professionals and whether this could have been improved. 3.14.1. Throughout the time period of this review there was a great deal of information that was shared, however because there was no key worker for long periods, an overall plan with clear measurable outcomes was missing. Recent published SCRs 53 highlight the difficulties professionals face with mobile and avoidant families in sharing timely and critical information. Professionals need help to ‘analyse and assess the risks that arise when a vulnerable family moves across boundaries and all professionals change.54 3.14.2. As previously discussed in the appraisal of practice and the specific TOR, professionals working with the mother were not always clear about why NCS had been involved and what the status of Child C’s sibling was. When Child C’s sibling presented with a head injury there was confusion about whether the child was the subject of a CPP or was a Child In Need. The attendance was shared with SW2; GP1 and NELFT health visiting team but no follow up of the family was carried out. This omission was discussed in the appraisal of practice. 3.14.3. There are no prescribed systems in England for case transfer across local authority boundaries for Children in Need (CIN) but there is an expectation that professionals share information. There are however no standards for professionals working within the new local authority to contact or see the child(ren) and once the case is passed on there is no obligation on either LA to keep the case open. 3.14.4. Health visiting services shared information at the point of transfer with a telephone call prior to the transfer of records. The midwifery service completed a communication form and forwarded to the health visitors. However, there was still no clear plan and little evidence that professionals had comprehensive and necessary information about the known or potential risks. 3.14.5. The staff in the Newham Hospital Neonatal Unit and the Named Nurse were clear about the concerns and made an appropriate referral to MASH that resulted in the case being allocated to a senior social worker and an ICPP. 53 Oxford, Tri-borough and Luton LSCBs 54 http://www.oscb.org.uk/wp-content/uploads/Child-Q-SCR-Summary-sheet.pdf 3.14.6. When the children became subject to a Child Protection Plan on the 15 August 2106 the information was not shared with Newham or Tower Hamlets despite the fact that the children were supposed to be living in Tower Hamlets and it was known that they also had been living in Newham, this should have happened. This has been highlighted as a learning point under section 3.5 of this report. 3.14.7. Information was shared with the health agencies in Essex and CSC were also informed that the family had moved in temporarily and the children were subject to a CPP. We now know that this information was not uploaded on to the GP IT system, which meant that professionals working within the practice did not have this information when they family attended for appointments. The previous GP records were not available to the Essex GP practice as previously discussed. 3.14.8. The Core meeting held at the maternal grandmother’s home was an opportunity for professionals to meet and review the Plan, and understand the conditions that the family had agreed to. The minutes or any recording of this Core Meeting, the areas covered including the safeguarding plan, and the actions that each agency agreed were not circulated. Nor have they been made available in this SCR process. This falls below expected practice. Health understood that their focus was to ensure that the children completed any outstanding immunisations and developmental assessments. 3.14.9. Communication and information sharing is vital in ensuring that the professionals working with families understand the full picture and are clear about the issues and concerns that need to be addressed. This becomes even more important with a mobile family where there is evidence of intentional deceit about where they are living and with whom. It is far easier for mobile families to avoid contact with professionals particularly when they move across local authority boundaries, which means that the case is transferred on and other partner agencies such as health visiting are provided by different organisations. 3.14.10 Although the London Child Protection Procedures (LCPP) were generally followed in this case, it is clear that there were gaps in information shared and the identification of the concerns surrounding the family (these have been previously identified in the report see 3.3.1). In the triennial review of SCRs published in 2016, it states: ‘Our reviews of serious case reviews spanning more than ten years suggest that, despite national guidance and legislation, there are deep cultural barriers to effective information sharing among professionals.’ The additional learning is that all staff have a duty to read the records prior to a contact, so that they are clear about what the purpose of their intervention is, and what information is missing in order for them to identify what may be required to ensure a robust assessment is completed. 3.15. The existence of any factors relating to the ‘capacity and climate’ within agencies which may have impacted upon practice in this case (i.e. vacant posts or staff on sick leave etc) 3.15.1. Caseloads in the Intensive Hospital Intervention Team were high, at 30, with additional pressures on the team to support the referral and assessment team. At the time it was reported that the numbers of referrals was high and the through- put was slow. This had a direct impact on the length of time that cases were open and in this case clear case drift. This was recognised in the Single Inspection by Ofsted in 2014, as was the fact that the LBN were also aware of the issues and had a comprehensive plan in place. The implementation of the improvement plan commenced in 2015; resulting in a move to work in locality teams, and the work of the Intensive Hospital Team was subsumed into locality teams. A hospital liaison manager was appointed to ensure that the close working relationship with Newham University Hospital continued. There was also increased management capacity, improvements to the MASH and a new comprehensive quality assurance and performance programme. 3.15.2. NELFT identified the high numbers of health visitors involved with the family whilst living in Dagenham. There were considerable staff shortages and there was a reliance on bank and agency staff that were moved at short notice to cover Child Health Clinics and caseloads in other area of the borough. This had a direct impact on how this family was visited and assessed. There were eight health visitors involved in delivering the service. The health visitors reacted to either information being shared or enquiries being made and an attempt to determine where the family was living. There was no overview of the possible risks and concerns within the family due to the high number of health visitors working on the case. 3.16. In addition to the above the review should consider learning for both the individual agency and how agencies work together through the Safeguarding Children’s Board. 3.16.1. This case highlights the difficulty of ‘keeping track’ of a mobile and avoidant family. All LSCBs should give consideration as to how information sharing across boroughs particularly with housing and health service provision can be strengthened. 3.16.2. The case was accepted by the LBBD as at the time there was an understanding that the family were residents of the borough. At the point that is was clarified that the family were in fact not residents of the borough, the decision was made to keep the case, as it was unclear as to the exact whereabouts of the family. This was a sound decision made in the best interests of achieving continuity. 3.16.3. The lack of focus on the children’s lived experience is stark in this report. In part due to the non-engagement of the mother and therefore the opportunity to assess the children was limited. When professionals did meet the family the focus was very much on dealing with the problems presenting and trying to keep the mother engaged. The ‘voice of the child’ was lost. 3.17. Additional learning identified during the course of the Serious Case Review, the importance of supervision and management oversight. 3.17.1. Brandon and colleagues (2008) stress the importance of effective and accessible supervision. This helps staff put into practice the critical thinking required to understand cases holistically, complete analytical assessments, and weigh up interacting risk and protective factors. 3.17.2. Supervision was provided throughout the period of time that the case was open to the LBN. However, due to the difficulties in parental engagement the case drifted and there was insufficient consideration and analysis of the implications of the mother failing to engage with the process and a lack of a child focus. There was no professional curiosity about where and with whom the mother and her child was living, what risks they may present of if there were protective factors. The decision to close the case, which was supported by the supervisor, was based on a partial assessment. The LBN have identified the need to strengthen supervision within their IMR. A follow up on this action should be a local SCB priority. 3.17.3. The supervision and management oversight provided to SW3 in the LBBD was of the expected standard, with good clear instruction and timeframe from initial allocation of the case. There was regular supervision by the TM to SW3 and also met with the mother and SW3 to agree a plan when the concerns were escalating. When they discovered that the family was not residing in the borough they decided that there was a danger that the family ‘might get lost’ within the system if they transferred the case, and they were still unclear about where the family were actually living. The Team Manager should have chaired the Discharge Planning meeting in line with procedures as this was the first planning meeting and should have been seen as setting up a CIN plan ahead of the ICPCC. There is evidence in the records and through an interview with SW3 that she felt well supported by her manager. 3.17.4. Comments have been set out in para 3.2.44 on the situation for HV1 with regard to accessing supervision in the appraisal of practice. ELFT provide regular safeguarding supervision and use ‘Signs of Safety’55 to support the practitioner to reflect on the strengths and risks present in the case 3.17.5. Primary Care and in particular GP’s have a unique role in working with families. The mother’s GP medical records from GP1 have not been located despite attempts by Newham CCG to trace the records for the mother and sibling. As a result there is a gap in the information and understanding of how and when the mother attended her family doctor and what information she gave to GP1. 3.17.6. As previously discussed, professionals working within Primary Care should be supported to ensure that they consider the possible impact on the adults ability to care for children or dependents when they themselves may be vulnerable due to drugs or alcohol misuse, or suffer from mental health issues. 3.17.7. One other issue that has emerged in this review is that despite very extensive professional contact over the whole period, there was no understanding of the mother’s ability or capacity to read and understand documents, letters or reports. It seems to have been assumed that in light of her somewhat streetwise demeanor/use of texts etc that she was able to read and understand. Though the use of texts and apparent level of articulation may cover considerable difficulties in really understanding official documents. 4. Conclusion and Recommendations. 4.1. Among many lessons this case highlights the difficulties that professionals experience when working with non-compliant, chaotic, mobile and duplicitous families. This family lived at six different addresses (these were the addresses that the professionals knew about), and in four local authority areas, three of which were in London. The mother engaged with the different agencies and professionals on her terms. She often managed to do ‘just enough’ in terms of attending health appointments to suggest she was complying and trying to keep her appointments. She shared different information with different professionals and was verbally aggressive and abusive, she accused professionals of lying or giving her the wrong appointment times. 4.2. The mother made it difficult for social workers to complete meaningful assessments and as a consequence the voice of the child was not always captured. To some extent the professionals got caught up in managing the more immediate impact of her behaviour and responding to her transient lifestyle and very difficult attitude, and an enormous amount of time was taken up by trying to pin the mother down to where and with whom she and her children were living. 55 Framework for the Assessment of Children in Need and their Families, DH, 2000. 4.3. At the point when the LBBD had made the decision to commence care proceedings for the children, her extended family stepped in to support the mother. The maternal grandmother was seen as supportive and suggested to the social worker that she had insight in to the issues that needed to be addressed by the mother. The realistic child protection plans and safeguarding agreement with the additional caveat that the maternal grandmother must report immediately to the social worker if the mother left the address in Essex with the children, was reasonable but undermined by the mother’s actions and the failure of the maternal grandmother to alert the authorities. 4.4. The father of the two children remained a ‘shadowy, invisible’ presence throughout the review period. The mother denied that they were still in a relationship and refused to give details to all the professionals involved with the family. There was information about the father in the single agencies but it was never shared. The consequence of this was the father and his considerable role and influence remained unknown throughout the period under review. Consequently, there was no assessment completed of whether he posed a risk to the children or was a protective factor. 4.5. The mother had grown up experiencing domestic abuse and had moved with her mother (maternal grandmother) to Essex before returning to London at the age of 17. The mother reported that she had been assaulted by her own father and brother and received support for this. There is also a reference to an incident of domestic abuse by her boyfriend in 2013. The SCR panel discussed the possibility of the self-reported miscarriages, the premature births, history of blackouts and an injury to her face as possible signs of domestic abuse; there was no evidence to support this. 4.6. There was concern about the care of Child C and her sibling by the mother, and in particular her transient lifestyle, avoidance of engaging with services and failing to put the needs of her children first. But there was no specific evidence that Child C would experience serious physical harm. In these circumstances, it is reasonable to say neither Child C’s death nor her injuries could have been predicted. However, there was a constellation of factors both in the history of Child C and the older sibling that presented a cumulative picture of risk, neglect and poor understanding of the mother’s wish or capacity to care for Child C. The issue of the father was a singularly significant factor in the risks to both children. 4.7. The recommendations arising out of the learning from Child C’s experience are: Recommendation 1: That LB of Newham consider the most appropriate way of ensuring an information exchange between housing and CSC when a tenancy is cancelled, and when there is a reason to believe that there is a neglect or risk to a child to ensure that wider issues of safeguarding and possible neglect and risk to children are evaluated Recommendation 2: Barts NHS Trust must ensure that staff are made aware about the importance of recording vital measurements including weight, height and head circumference. When babies and young children have been in hospital for extended periods and there are any concerns about parental engagement with child(ren), developmental milestones as well as a summary of feeding and sleeping patterns must be recorded and where considered necessary should be shared at the point of discharge with all community staff and social care. Recommendation 3: The Safeguarding Children’s Boards involved in this case must assure themselves that single and multi-agency training for staff working with avoidant and hard to engage families include the identification of disguised compliance, collusion and deception as part of any existing training programmes, or devise new modules as necessary. Recommendation 4: All agencies need to consider whether the arrangements they have in place, including strategies/policies, procedures, training and supervision for staff and managers, are adequate, specifically to identify neglect and assess its likely impact and risk to children. This must include support and guidance to staff on practical approaches that can be used. Recommendation 5: The relevant LSCBs must seek assurance that all agencies can demonstrate how fathers or absent parents are included in any assessments that are undertaken. This is to ensure that consideration of risks or protective factors are evaluated in order to ensure that practical steps are put in place to safeguard any children. Recommendation 6: The relevant LSCBs need to be assured that a full and robust assessment is undertaken on family members (or anyone that puts themselves forward) to provide support or care for children who have met the threshold for care proceedings. The assessment must include the capacity and ability of the individual and consider the interaction and sustainability of the relationship they have with the birth parent. This must include realistic and frank assessments of any background factors that may have an impact on current behaviour and attitudes. Recommendation 7: The LSCBs need to be assured that systems are in place so that minutes of any Core Group Meetings are shared with all the relevant agencies involved in the protection of the named children concerned. Recommendation 8: Relevant LSCBs must assure themselves that procedures and arrangements are in place to ensure that Child Protection Plans (CPPs) are shared with all key agencies who have a role with either parent(s) or children in relation to the CPP. This must include ensuring the timely distribution of the CPP in the most appropriate way (electronic, fax, uploading to shared systems, or paper copies etc) to ensure that all key managers and staff concerned are sighted on agreed CPPs. Recommendation 9: The relevant LSCBs concerned need to be assured that at their own local level procedures are in place, and are followed, to ensure that health agencies are fully involved in strategy meetings and fully informed of the outcomes. This is already a requirement from the London wide Child Protection Procedures. Appendix 1: Methodology 1.1. Statutory guidance within Working Together requires Local Safeguarding Children Boards (LSCB) to have in place a framework for learning and improvement, which includes the completion of Serious Case Reviews. The guidance establishes the purpose as follows: Reviews are not ends in themselves. The purpose of these is to identify improvements, which are needed, and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action, which lead to sustainable improvements, and the prevention of death, serious injury or harm to children 1 The statutory guidance requires reviews to consider: “what happened in the case, and why, and what action will be taken”. In particular, case reviews should be conducted in a way which: ➢ Recognises the complex circumstances in which professionals work together to safeguard children; ➢ Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; ➢ Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; ➢ Is transparent about the way data is collected and analysed; and ➢ Makes use of relevant research and case evidence to inform the findings. 1.2. The SCR used the traditional methodology of obtaining chronologies and Individual Management Reviews (IMRs) from 12 key agencies involved in providing services to Child C and her family over the time frame from October 2013- September 2016. The period under review covers the pregnancy of Child C’s older sibling, a miscarriage and the pregnancy and first three months of Child C’s life. The process was led by an Independent Reviewer working with the Serious Case Review Panel (SCRP) and included: • 4 meetings of the SCR Panel • Membership of the SCRP was: 1 Working Together 2015 2 Agency Designation of member Chair Group Manager Safeguarding Quality Assurance LBBD Ann Duncan Independent Reviewer BDSCB Business Manager LBBD Operational Director Children’s Care & Support LBBD Group Manager, Children’s Care &Support LBBD Legal Services Principal Solicitor CCG B&D Designated Nurse CCG B&D Named GP Integrated Care Director Metropolitan Police Review Officer Specialist Crime Group Newham CCG Designated Doctor Newham Housing Needs Services Team Leader Newham CSC Head of Service Newham Adult Social Care Senior Advisor Safeguarding Barts Health NHS Trust Named Nurse Safeguarding Children ELFT Health Visiting NELFT Named Nurse for Safeguarding NELFT Associate Director Essex Local Health Provider In Essex Lead for Safeguarding Children CCG Essex Associate Designated Nurse Safeguarding Children Terms of Reference are: 1.3. The SCR seeks to learn lessons for future practice by examining and critically analysing the following key issues relevant to this case: 1. The level and extent of agency engagement and intervention and whether his was appropriate to the assessment of parent’s ability to provide adequate care and supervision of Child C and her sibling. 2. The recognition of safeguarding factors by all agencies and how these were addressed. 3. Were practitioners aware of the needs of the children in their work, and knowledgeable about potential indicators of abuse or neglect and about what to do if they had concerns about a child’s welfare. 3 4. The quality of assessments on which decisions and actions were taken. 5. Whether there were any factors in the history of any adults that indicated they posed a risk to children. 6. Whether race, religion, culture was a factor in this case and had been fully considered. 7. The extent and quality of partnership working among key agencies and across local authority borders. 8. The effectiveness of working arrangements and information sharing and communication between all professionals and whether this could have been improved. 9. The existence of any factors relating to the ‘capacity and climate’ within agencies which may have impacted upon practice in this case (i.e. vacant posts or staff on sick leave etc 10. In addition to the above the review should consider learning for both the individual agency and how agencies work together through the BDSCB. 1.4. The following agencies submitted IMRs: • Children’s Care and Support Service, Safeguarding and Review Service and Legal Services, LBBD • Barts Health NHS Trust (NUH) • Children’s Social Care, LBN • Housing Needs Service, LBN • Health Visiting Service, North East London NHS Foundation Trust • Health Visiting Service, East London NHS Foundation Trust • General Practice Newham CCG (father’s records) • Adult Social Care LBN • An Essex Clinical Commissioning Group on behalf of a GP practice. • London Ambulance Service • Metropolitan Police Force, Specialist Crime Review Group • A Local Provider Health Service in Essex(Health Visiting) 1.5 The author was present at an interview conducted by the Operational Director Children’s Care and Support for the London Borough of Barking and Dagenham with SW3. This interview took place, as the IMR author for the LBBD had been unable to interview her as she was out of the country. This interview provided very useful information and some valuable insight in to how difficult and 4 challenging the mother was to both work and engage with. 1.6 The author of the SCR, Ann Duncan, was commissioned by BDCSB to write the overview report; she was independent of the case and all agencies involved. She has a background in health and worked at executive level for 10 years prior to leaving the NHS. Ann’s final post in the NHS was as Director of Integrated Governance for a Central London PCT. Her responsibilities included: commissioning and quality for services across health care providers, leading for safeguarding and, she was the Trust’s representative on the Safeguarding Children Board. She is an accredited Social Care Institute of Excellence (SCIE) Reviewer and is familiar with both Root Cause Analysis and Domestic Homicide Reviews. To date, the author has completed eight SCRs covering: neglect, neglect and rape, infanticide, unexplained death of a toddler whilst in the care of the father and physical injury to a six-month-old baby. Other work includes: undertaking RCAs for deaths in custody (mainly at Wormwood Scrubs Prison) and an IMR for a school where an honour killing was suspected. 5 Appendix 2 – Summarised timeline of events The table below sets out a summary of the background and main events covered by the SCR report. The sections reflect the time periods addressed in the report Date Event Historical background: 20 June 1964 Father of Child C born (Father) 6 February 1991 Father’s former partner reports that their child aged 12 months had been abducted by the Father. She alleges that she had suffered 2 years of physical and sexual abuse and that her 4 year old child, had been physically abused. The Father denied the allegations and no action was taken NB in 1991 there was not an auditable pathway to notify Children’s Services that these children had come to police notice and there were safeguarding concerns so it is unknown if CSC were notified 28 July 1991 Mother of Child C born (Mother) 2nd November 2004 Father’s home searched for drugs. He advised he was a methadone user to combat ecstasy addiction. No drugs found. He was using alias of LH January 2005 Father linked to violent gang July/August 2007 Mother goes to Essex refuge with her mother (maternal grandmother) and siblings due to domestic violence by father. Referral record 15 Aug in Newham. Referral made to Essex Children’s Services 13 November 2007 GP records start for Father at Newham GP December 2007 Medical records note Father is a cannabis user December 2008 Intelligence suggests Father is selling drugs from his flat 2009 No date given Father comes to police attention 4 times re possible drugs misuse and using his premises for dealing in drugs 30 November 2009 Father first mentions depression to his GP (related to sickness benefits not being paid) 2010 Mother returns to London – relationship with the maternal grandmother had broken down 6 April 2011 Mother attends fertility clinic (aged 19). In a relationship for 2 years Address is at Homeless Young People’s Project, E7 14 April 2011 Letter to Mother’s GP from specialist registrar re clinic visit 20 July 2011 Mother did not attend appointment at infertility clinic 26 July 2011 Letter from consultant to Mother’s GP. Mother discharged from clinic 11 March 2013 Mother attends ED with PV bleeding. Negative pregnancy test July 2013 Mother says assaulted by father in the street 20 September 2013 Mother attends ED having blackouts for years, sometimes failing down. Cannot get GP appointment for referral to neurologist. Asking where to get free pregnancy test. Details taken to make GP appointment 6 Time Period 1: October 2013 to July 2014. Relates to paragraphs at 3.2 onwards 28 October 2013 Safeguarding Adults Referral received from GP – Mother was victim of violence from her father and brother, is homeless and pregnant. She has lost contact with her key worker. Information forwarded to Children’s Service due to pregnancy. No further action – insufficient grounds for concern. Mother to be advised to contact Access Team 29 October 2013 Mother attends maternity booking-in/first ante natal care with her sister (maternal aunt). Referral to Acorn Team due to family history. She is living at her uncle’s address Partner recorded as LH (unemployed) living at an address in the London Borough of Newham 14 November 2013 Mother’s referral from Newham Adults is received by Newham CS. Said to be homeless and living between sister (maternal aunt) and her uncle: father of unborn child will give support. Outcome: case to open to the Hospital Team 16 November 2013 Mother attends Newham Hospital Urgent Care – pregnant (14/40), vomiting and lack of foetal movement. UTI diagnosed and antibiotics given 19 November 2013 Newham CS referral review. As pregnancy only in its 15th week case to be closed and re-opened in the 20th week (23 December 2013). Case can continue to receive support from Adult Social Care 17 December 2013 Mother has maternity appointment – no notes 2014 2 January 2014 Maternity notes of appointment - Mother feeling well etc . 6 January 2014 Newham CS allocates case to complete pre-birth assessment. Action to include genogram, establish current situation and support network and make sure the baby’s father is included in the assessment, liaise with midwifery, NAADV and Adults Services. Single assessment started by Social Worker in the Hospital SW Team 13 January 2014 NCS ring Mother twice – no response. Letter sent to inform of home visit on 23rd Jan at 12noon 23 January 2014 Home visit. No-one answered the door. No response to phone calls 27 January 2014 NCS make contact with Safeguarding Midwife. Midwife also finding it hard to contact Mother. Her next appointment due 26 Feb 31 January 2014 NCS phone Mother. She doesn’t understand need for home visit – advised of duty to assess regarding domestic violence and homelessness. Appointment made for 4 Feb 2 February 2014 Mother attends maternity appointment – has abdominal pains for 3 weeks. Reviewed by midwife and registrar. Nothing abnormal detected 4 February 2014 NCS meet Mother at the hospital. Says she is homeless and has her belongings with her. Mother advised to speak with sister (maternal aunt)/friends/her uncle about spending the night with them and then presenting to the Homeless Persons Unit in the morning. Says was assaulted by her father in July 7 2013, that she is no longer with the baby’s father (after relationship of 3 years) but that he has promised to look after the baby and has had 4 miscarriages 5 February 2014 Mother fainted on a train. Scan normal, foetal movement found. Offered blood test – refused as GP had taken one recently and said it was normal. Told to return if further issues 24 February 2014 NCS get housing update – Mother has not yet presented herself. She was last seen by housing in December 2012 but case closed as she was not a priority. Phone call to Mother but no response 5 March 2014 Assessment completed 10 March 2014 Review: Assessment (allocated 6 Jan) completed on 5th March: Social Worker met Mother once and advised her to present at the Homeless Persons Unity to apply for housing. Social worker found it impossible to engage with Mother after this meeting as she disengaged from the assessment. Actions: Maternity Alert to be sent to all hospitals for professionals to refer back to Newham if Mother is still living in Newham for an in-depth assessment to carried out Referral to Early Childhood Midwifery Service for support and parenting advise after the birth Case to be closed to the Hospital Assessment Team as efforts to contact Mother failed Decision by Manager: case to close by 14th March 2014 11 March 2014 Case closed. Mother advised to contact Children’s Centre for help with securing private property to live in 20 March 2014 Phone call from Mother apologising for lack of contact – says been unwell and gives a new phone number. Says she has applied for income support and needs MAT1 form. Mother directed to the midwife and social worker agrees to assist her with this and to book an ante natal appointment for her. Call made to midwife and new phone number passed on 21 March 2014 Mother attends antenatal appointment (32 +1 weeks). Appears well, bloods taken and scan booked. Social worker due to see Mother same day. Noted that Mother had missed 2 antenatal appointments that had been due at 25 weeks and 28 weeks. (3 missed appointments would have triggered home visit) 25 March 2014 Phone call from Mother at the Job Centre asking for housing update. She is advised to go to the Homeless Unit. 3 April 2014 Mother attends antenatal appointment – all Ok. Social worker joins for the appointment. Labour plans discussed Social worker notes – Mother not attended housing and needs letter from her uncle regarding her homelessness and a supporting letter from midwife and social worker. Mother advised to collect both the latter letters the next day. 8 7 April 2014 Mother approached Housing Needs Service East Ham. Case allocated to homelessness case worker. Interview carried out and home visit requested. Letter from maternal aunt asking her to move out presented. 12 April 2014 Mother brought to hospital by ambulance with contractions at 20.30. Taken to Labour ward. 13 April 2014 Baby (Sibling) delivered in good condition at 34 weeks. Mother admitted to ward post delivery. Documents show Social worker aware of delivery 14 April 2014 New birth notification received via fax from Newham University Hospital. Notification allocated to administrator for processing. Social Worker spoken to and will visit the next day regarding housing. Entry by Social Worker says spoken to Mother re housing and that the social worker would go to talk to the housing again now the baby (sibling) had been born 15 April 2014 BCG appointment letter sent to Mother – but as BCG was given on the postnatal ward the mother phones to cancel the appointment. Child Health Admin Team phone Mother to confirm her address (at her uncle’s address) to identify appropriate health visiting team. Midwives noted to be awaiting social worker input. Mother advised to present herself at housing. Mother says maternal aunt or Father will look after baby(sibling) while she goes to housing. Email sent to housing confirming the baby’s birth (sibling) and requires housing. 16 April 2014 Midwives say baby is fit for discharge. Waiting for results of housing issues Home visit to uncle’s address. He confirms the mother cannot stay with him any longer 17 April 2014 Electronic health notes say baby discharged with mum to home. No mention of housing issue. Paper notes record Sibling’s weight (2125g). EDT Report: contact with midwife – no concerns regarding bonding and care of baby – enquires about the housing situation. EDT worker told that Mother had a home (uncle’s address) to go to but choosing not to, she had been encouraged to seek own accommodation. Mother says she is registered for housing and that her uncle is refusing her return but had refused to give his phone number for mediation. LA could provide temp accommodation but Mother declines. Social Care refer the matter to housing 18 April 2014 Baby (sibling) well. Mother adamant that she does not want to go home until Tuesday (22nd April) 22 April 2014 Phone call from health visitor to arrange new birth visit with Mother. Mother still on post-natal ward. Visit arranged for next day. Baby (sibling) well. Father is on the ward giving support while Mother goes to housing 23 April 2014 Health Visitor sees Mother on post-natal ward. Confirms address as her uncle’s but says is homeless. Advice given on health, registration with a GP and Children’s Centre. Mother says she has a social worker. Health visitor leaves voice message for social worker asking to make contact 9 Site manager has discussion with Mother and her uncle about returning home. Hospital Visit – Mother described past experience of domestic violence by father and brother, states the baby’s father is “L” and although not in relationship they get on well and he plans to be involved with the baby, says she has been living between maternal aunt in Tower Hamlets and her uncles in Newham. Mother advised to go to her uncles as he had agreed for her to stay a few weeks. Discussion with Service Manager: Mother to stay on ward until the next day (24th), to speak to uncle re housing pending Housing Service action. Failing this the hospital will call the police to remove Mother and CYPS will consider care arrangements for the baby (sibling) Referral made to Home to Home agency. Homelessness case worker refers Mother to Mother and Baby Unit 24 April 2014 Mother and baby (sibling) discharged to uncles address in Newham. Email sent by Paediatric Liaison to health visitors Post-natal home visit by community midwife – Mother staying in living room on sofa. No Moses basket, house smells of smoke 25 April 2014 Housing update – referral made to Home to Home accommodation for mothers and babies. Accommodation is available at Forest Gate and contact to be made with Mother on 28 April to view. CYPS informed. 29 April 2014 Mother refused the accommodation offered. Social Worker notes explain reason for refusal (fear of violence) 30 April 2014 Homelessness worker speaks to Mother. Mother explains reasons for refusal (fear of violence). Mother asked to bring in ID and documents of proof of address 1May 2014 Phone call from health visitor to Mother. Mother says she refused accommodation. Home visit planned for one week later. Family places on Health Visiting Universal Plus Care Package 14 May 2014 Phone call from social worker to health visitor to say case closed as family only have housing needs 16 May 2014 Home visit due. Text from Mother to Health Visitor to reschedule home visit for 20 May 19 May 2014 Case closed. Needs are housing related and these are being addressed in the housing department. No further role for CYPS Case records closed at Hospital Social Work Team in Newham 20 May 2014 Home visit not achieved – Mother and baby (sibling) not at home. Phone call in late afternoon agreeing to take sibling to the Children Centre at 11.30am on 22 May 22 May 2014 Mother failed to attend children centre for scheduled time but did attend at 14.00. Says she has been kicked out by uncle and is staying with sibling’s father. Child’s health visiting package stepped down to Universal 23 May 2014 Phone call from Health visitor to family housing requesting update. Health visitor called Homelessness Duty Line to advise Mother was homeless and moving place to place. 10 12 June 2014 Mother visits Housing Needs Service at East Ham. Email sent to Homelessness case worker to say the mother and 3 month old baby were homeless. Phone call and letter to the mother requesting ID and proof of residence again. Gives 7 days’ notice to produce the info or the case would be closed 22 June 2014 Case assigned to another homelessness case worker July 2014 Date unknow. Father attends GP asking for re-referral to mental health services – which he attends 14 July 2014 Mother and baby (sibling) discussed at Family Support Network 15 July 2014 Mother fails to bring sibling for their 12 – 16 week health review and her own Maternal Mood Assessment 18 July 2014 Non-attendance followed up by phone call to the mother by Health Visitor. Care package escalated to Universal Plus. New appointment scheduled for 31 July at the children’s centre 30 July 2014 Phone call and text reminder to Mother from Health Visitor about appointment on 31st 31 July 2014 The mother failed to attend for the sibling’s 12 – 16 week health review for 2nd time. Referral made to Newham Children’s. Triage completed for Mother and baby (sibling) requesting social care assessment and support for the family No record of liaison with the GP. Health Trust’s “Did Not Attend” (DNA) policy guidance not followed. Social worker allocated to the family Time Period 2: August 2014 to June 2015. Relates to paragraphs at 3.3 onwards August 2014 Date unknown. Father states that he lives alone when asked by GP Psychiatrist record notes he is a cannabis users 1 August 2014 Referral from health visitor received. Says that Mother is not responding to attempts at contact, gives summary of housing situation – main concern is health and safety of the child – that it appears that since the case closure the family’s situation had deteriorated. Housing to visit on Tuesday (5th). Outcome: Case opened to the Hospital Social Work Team 4 August 2014 Single assessment started by Social Worker 5 August 2014 Sibling seen late for their 12- 16 week health review and Mother for her maternal mood assessment. Mother declares a miscarriage but not when this was Care Package stepped down to Universal 11 August 2014 Health visitor phones Children’s Social care for update. Invites contact from newly allocated social worker (ML) 15 August 2014 Phone call and text from health visitor to Mother re update on social care referral. Family care package reviewed and changed to Universal Plus 11 Referral from Family Support Worker – concerns re unstable housing and its impact. Mother waiting for diagnosis re her blackouts and has had counselling for domestic violence. Passed to allocated social worker 19 August 2014 Previous homelessness case worker explains to current homelessness case worker that Mother’s ID etc had never been received. Mother is chased for the documents 3 September 2014 Mother provides required documents and has interview with housing. Homelessness Case Worker determines that Mother is not intentionally homeless 4 September 2014 Letter sent to Mother to confirm homelessness application has been accepted 9 September 2014 Phone call to Mother from Health Visitor to confirm social worker visit. Mother says she has a new key worker. Mother invited to attend child health clinic on 17th Sept 17 September 2014 Mother did not attend review appointment for sibling. Rescheduled for 26th Sept Mother attends ED with possible miscarriage, just found out pregnant (approx. 7/40), faint positive test, booked for scan on 18th 18 September 2014 Mother attended scan. Uterus empty. 26 September 2014 Appointment rescheduled to the 29th 29 September 2014 Mother fails to attend health review appointment for sibling. New appointment offered for 2 October October 2014 Date unknown. Father has by now settled into his new medication and attending every few months for Medical Certificates. Date unknown. Mother attends a scan (a follow up to one in September at ED) 2 October 2014 Sibling seen for health review. Family remains on Universal Plus care package – for health review in 6 weeks 29 October 2014 Action: Social worker to contact Mother again re need to escalate concerns as she has not engaged with the assessment. Mother is reported to be living with a friend in East Ham but CYPS do not have an address 12 November 2014 Handwritten notes say numerous attempts to contact Mother but phone is permanently engaged NCS phone call to Mother – says she is at her uncles. Request made to visit in next 10 minutes but Mother says she is on the way to appointment at Job Centre to present her ID. Mother reminded of a text message re the case being escalated to Child Protection if she continues to disengage. Home visit (at uncles) carried out at 2pm – very smoky not conducive for a baby Sibling seen by Newham Children’s Services. (1st and only time seen by Newham social worker). Sibling is noted to have attachment and strong bond with Mother and mother’s uncle. Sibling noted as being wet through but not showing any signs of distress about this 14 November 2014 Mother and baby (sibling) seen for child health check. Rash noted on sibling – advised to see GP. Health visitor to contact housing for update 27 November 2014 Email sent by social worker to housing for update – concern expressed that sibling was now 7 months old and the situation still not resolved. Asked for matter to be addressed with sense of urgency 12 8 December 2014 NCS phone call to housing case worker. The case had been accepted long ago and transferred to Housing Supply. The case is with letting/private sector. Social worker says not acceptable and agrees to email setting out concerns re unmet housing needs of sibling. Email sent same day 11 December 2014 Mother attends interview and is booked into temporary accommodation at Chadwell Heath. Mother also completes her medical assessment form and cites medical problems. Homelessness case officer refers her to “Now Medical” an independent medical advisory service Ongoing concerns about missed appointments for sibling and non-engagement with professionals 22 December 2014 Now Medical assessment is returned to Newham Council. States that although Mother has had episodes of blackouts requiring brief hospital admissions she did not appear to have any substantive medical condition or diagnosis nor that she was currently being treated for any medical condition. They stated there were no other relevant medical issues and no essential housing needs were identified. The report recommended that the floor level, location and type of accommodation offered were not relevant and that there was no medical need to reside within the Borough 2015 27 January 2015 Phone call to Mother from health visitor seeking housing update. New address is given and case handed over to local health visiting team 29 January 2015 Phone call between Health visitor and Barking Health Visiting Team for verbal hand over of case 30 January 2015 Records received from Newham and sent to Seven Kings Team (this is in Redbridge and was an error) 3 February 2015 Electronic records transferred from ELFT to B&D Child Health Team 4 February 2015 Phone call to Health visitor requesting update Phone call to her uncle. Uncle also says unable to contact Mother. He does not know her address Email to housing for update. Response - Mother placed in emergency accommodation. Her booking was cancelled last night as she was about to be made an offer of PRS and officer not able to contact her. Was expected to come to office tomorrow (5th) due to cancellation 5 February 2015 Mother attended ELFT walk in clinic with sibling for weight check. Three red spots noticed on forehead. Notes family address changed to Chadwell Heath. NCS request address update from housing NCS request update from health visitor – response gives address as Chadwell Heath and that the mother had been seen that day – sibling weight had dropped (now 7.89kg) Newham CS phone call to Chadwell Heath Health Centre to request urgent visit. No response Newham CS request for police intelligence to the Child Abuse Investigation Team regarding sibling. No details of father given. Police Merlin shared with Newham CS 6 February 2015 Mother calls ambulance for sibling at 21.28 from the father’s address in London Borough of Newham. Mother attends ED with sibling - possible insect bites. Electronic notes say (incorrectly) that there is a CP Plan from 3 Feb 2014 Sibling seen by co-op GP at 22.54 re red blotches. Discharged back to GP 13 NCS phone call to Chadwell Heath Health Centre. Case received on 3 Feb and waiting allocation. Agreed to do health visitor home visit on 9 Feb and feedback. Single assessment completed (started in August) concludes main concern is about housing and not a safeguarding concern. Mother only seen once in the 6 month period Managing Agent of accommodation emails to say Mother not living at the property – 2 more emails sent on 27 Feb and 6 March Records from Newham received and sent to Health Visitors at Chadwell Heath. There is a phone call between health visitor and social worker. Noted Health visitor only for the next week. Social Worker conveyed family history 10 February 2015 Health visitor update to NCS – visited the property but no one present. Social worker to complete urgent home visit that day. Unannounced visit made to Chadwell Health. No-one home. Mother’s uncle called – he has no contact either but will keep trying Single Assessment signed off 11 February 2015 Sibling’s attendance at ED on 6th Feb is put on RIO NCS email Housing for update. Concern sibling not seen since December 2014. Response is that the address is correct by they are trying to contact her and if she does not make contact they will have to cancel the booking. Housing asked for Managing Agents details to gain access to property 12 February 2015 Email re psychosocial meeting re Sibling’s ED attendance. Health visitor advise to send ED notification to the B&D Child Health Team Opportunistic home visit by Health visitor – no answer. Social Worker informed 13 February 2015 Sibling and Mother seen at drop-in Child Weight Clinic – 8.04kg. Mother says she is going to Stratford Housing Dept. Plan made to visit Mother the next week. Social worker updated 17 February 2015 Phone call from health visitor to Mother to arrange transfer-in home visit. Mother said not at home that day. Plan to visit on 19 Feb 19 February 2015 No one at home for visit. No answer to phone calls to Mother – message left asking for her to make contact 20 February 2015 Health visitor phones Mother – no answer message left Health visitors change at this point – now with Chadwell Heath 27 February 2015 Housing Needs Service receive another email/phone call from temporary accommodation agent to say Mother was not living in Chadwell Heath March 2015 Date unknown. Father sees GP with chronic back pain which is resistant to pain relief. Script for morphine given. 3 March 2015 Phone call from Health Visitor to Mother – home visit agreed for 10.30am. No one home. No response to phone call message left requesting contact 14 6 March 2015 Housing Needs Service receive another email/phone call from temporary accommodation agent to say Mother was not living in Chadwell Heath 10 March 2015 Mother attends maternity booking in. Partner “LH”. Risk factors identified and states there is a social worker due to housing issues. Case to be under Acorn Team. Partner identified as 40yrs + but Sibling not documented. Currently living in B&D in temporary accommodation waiting housing in Newham. No longer with father of sibling but he supports her with care of 1st child. Case not been closed because father not engaged with Social Worker and Housing. Social worker to attempt contact with father and get update on housing Case to subsequently close by 26 March 2015 Paper records show partner is “LW”, unemployed with other children, address in London Borough of Newham Newham Social Worker supervision notes include statement that the sibling is meeting their development needs 11 March 2015 Temporary Accommodation at Chadwell Heath cancelled 16 March 2015 Phone call from Mother to say no where to stay. Appointment arranged for 17 March Attends scan – about 6 weeks pregnant Scan showed Mother was 6 weeks pregnant and later scanned booked in. Mother rescheduled this appointment because she was no longer living in Chadwell Heath because of the bed bugs and was back at her uncles. Mother said the social worker was aware of the situation 17 March 2015 Mother attended viewing in Edmonton but refused property due to distance 20 March 2015 Maternal aunt phones to say Mother has been locked out of Chadwell Heath property Health visitor leaves message for Mother to contact her 23 March 2015 Mother requests change of scan from Barking Birth Centre to Newham as she no longer lives in Chadwell Heath. Now staying with uncle in Newham and a friend. Says social worker aware and helping with housing 24 March 2015 Social worker from Hospital Assessment Team requests alternative temporary accommodation for Mother. Viewing arranged from 7 April 25 March 2015 Mother tells Health Visitor she was evicted and is moving from place to place Health visitor updates social worker 26 March 2015 Scan date changed from 27th to 28th at Newham. Text sent to Mother 8 -12 months check letter sent for appointment on 9th April. Social worker confirms to health visitor that the mother was evicted 27 March 2015 Offer of temporary accommodation made in Dagenham– viewing on 7 April 30 March 2015 Phone call to Mother by Housing for response to letter – no answer. Call made to maternal aunt who offers to contact Mother 15 NCS raises questions with housing that if accommodation offered refused would she be evicted from the current property and also that that property was unfurnished 1 April 2015 Housing response – Mother could return to old address to collect her things Text received from Mother and call returned – encourage to attend viewing 7 April 2015 Entry by Redbridge Health Visiting Team – noticed the address is in B&D and records sent by Newham in error 9 April 2015 Mother did not attend 8-12 months health review for sibling 13 April 2015 Redbridge send records to B&D 22 April 2015 Health Visitor phone call to Social Worker requesting update 27 April 2015 Mother calls to confirm scan details for the next day. Advised to come in 10 minutes early 28 April 2015 Mother failed to attend time of appointment – phone goes to voice mail. She shows up at 16.00 – not scanned because she walked off 30 April 2015 Angry phone call from Mother to midwife. Midwife to set up new scan 10 May 2015 Mother takes Sibling to ED for head injury – discharged. Sibling showing as on CPP (incorrectly) so Children’s Services notified by fax. Address recorded on A&E Sheet as the mother’s uncle’s address but with handwritten note saying Chadwell 12 May 2015 Attends scan. Delivery date estimated to be 4 November 2015. Still living at uncles with the sibling. Allocated flat in Dagenham but waiting for renovations. Is supported by maternal aunt, friend and partner. Letter to GP for iron deficiency. Antenatal scan booked for 16 June 13 May 2015 Notification of sibling attendance at ED received and sent to Child Health Team Management Direction to progress case to closure as real concern was about Mother not seeking health input for sibling and housing issues. Sibling’s father not engaged but sibling does not reside with him. No further role for CYPS 15 May 2015 Mother’s case is closed by social care Time Period 3: July 2015 to July 2016. Relates to paragraphs at 3.4 onwards 9 June 2015 Mother signs tenancy for accommodation in Dagenham 22 June 2015 Mother did not attend appointment. Phone goes to voice mail. Mother text to re-arrange 26 June 2015 Mother attends ED in ambulance. Baby delivered by at the Father’s address in Newham by LAS – dead. Lives with uncle. Referred for bereavement midwife support. Midwife says the mother thinks she has had up to 6 miscarriages. Unclear if miscarriage or neonatal death. Decision to issue neonatal death certificate. Post mortem declined 6 July 2015 Mother moves into accommodation in Dagenham Managing agent remembers Mother being upset and referred to having had a still birth 16 August 2015 Date unknown: funeral papers issued to Mother 3 August 2015 Bereavement midwife follow up with Mother and the death certificate is collected. Numerous (no dates) attempts to contact Mother beforehand. 10 August 2015 ELFT notified of still birth by NUH. Bereavement visit offered and confirmed with Mother where it transpired that she no longer lived at the given Newham address. Maternity ward contacted to confirm the gestational age 17 August 2015 Health visitor phones Mother to confirm home address and arrange bereavement visit 18 August 2015 Bereavement visit not achieved. Health visitors informed by uncle that family had moved to Dagenham. October 2015 Date unknown. Father tells GP he is buying diazepam off the street 12 October 2015 Deputy Superintendent Registrar emails to say they are still waiting for Mother to register the birth of her (dead) child. Mother due to attend Registrar’s office – but does not 14 October 2015 Email states Mother offered a hospital funeral, but she would not be able to attend. This was declined, and Mother said that she wanted to organise her own funeral 30 December 2015 Letter sent to Mother asking her to confirm that she wanted to carry out her own funeral. She was advised that they could not keep the body post 4 weeks and if there was no response the bereavement office would make arrangements 31 December 2015 Letter from Deputy Superintendent Registrar to Mother informing her that if she did not make contact within 10 days they would issue a duplicate death certificate, so the hospital could organise a funeral 2016 February 2016 Date unknown: Mother contacts Acorn midwife direct and informs her that she is pregnant again. Acorn midwife refers her for a scan and pre-term clinic. Date unknown: Mother did not attend the pre-term clinic nor her maternity appointment. Appointment was rescheduled but then rescheduled by the hospital. When she booked LH was identified as the partner. Said she had never smoked, did not drink, was living alone in temporary accommodation and that she had had 5 miscarriages. There was resolved domestic abuse history and Children’s Services had closed her case in 2015. As no new issues identified no referral was made to Children’s Services and Acorn Team declined her. Mother was referred to the Foetal Medical Unit due to her previous obstetric history 15 February 2016 Email sent by the Bereavement Officer to the Deputy Superintendent Registrar saying Mother wanted a funeral of her choosing but had not been in touch. Bereavement officer requested duplicate death certificate, so they could organise a funeral 9 March 2016 Letter from Bereavement Officer to Mother saying that due to no contact they would organise a funeral for 31st March at City of London Cemetery. She was asked to let the funeral directors know if she would be attending 17 17 March 2016 Last time managing agent of accommodation in Dagenham visited the property. A neighbour said Mother never stayed there. On entering the agent found no proper furniture, food or sign of residency. Previous to this there had been quarterly visits by the agent but Mother had never been there and had not responded to letters or phone calls April 2016 Date not known, managing agent notifies Newham Council and cancels tenancy. There was no forwarding address. Notes that homelessness duty had been discharged. 25 May 2016 Mother did not attend appointment with midwife 2 June 2016 Child C born (28 weeks gestation) Midwife called to Mother’s partner’s address early in morning – baby is born. Ambulances take Mother and baby to hospital from the Father’s address in Newham Mother discharges herself against medical advice later that day. Visits neonatal unit at 5pm. Says she will return the next day Birth notification address is Dagenham 3 June 2016 Post-natal home visit – no access to property, no answer on phone 4 June 2016 Post-natal home visit – no access to property, no answer on phone 5 June 2016 Midwife sees Mother at home – no problems - follow up at post-natal clinic 6 June 2016 Staff note that Mother not visited since 3rd June – no answer to phone calls. Safeguarding adviser requests strict visiting record is kept Mother visits SCBU at 18.00 (visit 1) 8 June 2016 Mother visits neonatal unit (visit 2) 9 June 2016 Mother attended post-natal appointment 10 June 2016 Mother visits neonatal unit (Visit 3) 11 June 2016 Mother had to be called to because Child C needed a blood transfusion and she needed to supply a blood sample so this could go ahead immediately. Mother agreed to come the next day and said she would bring in clothes and nappies for Child C. 12 June 2016 When Mother did not arrive, she was called and said that she was having trouble getting someone to look after Sibling and he was ill (flu) so she requested to come in the next day instead of the 16:00 deadline (as bloods need to get to the pathology laboratory for processing), she was advised no. The Social Worker and safeguarding children team were on the unit waiting for Mother to arrive so they could talk with her. Mother arrived at 16:40 and said the traffic had been bad, Sibling did not look like he had flu and mum had the blood test. Prior to Mother arriving on the unit that day it was discussed with the consultant that if the baby (child C) had not been transfused by the next day it would be unsafe for the baby and would need immediate action. 18 June 2016 Date unknown: A strategy meeting was requested by the safeguarding children team to the Social Worker due to issues that included multiple DNAs in ‘community health’ for Mother and Sibling; minimal visits, short durational visits; lack of provisions for Child C; multiple addresses and contact details; Sibling’s lack of contact with health professionals. It was also noted that if the hospital were unable to obtain a vital blood sample from mother then they would request the police to collect mother. 13 June 2016 Mother visits the neonatal unit (visit 4) Mother tells the Social Worker she will visit more. She also reports that she is not living in the current address due to electricity and gas issues that were down to the previous tenants. Safeguarding children team request a professionals meeting and the Social Worker says that she will update all staff following her assessment. 16 June 2016 Mother attended post-natal appointment At 19.00 Mother visits the neonatal unit (visit 5) 17 June 2016 Health visitor attempts new birth home visit. Unable to get Mother on phone or on flat’s intercom 21 June 2016 Referral sent to NCSC – main issue is lack of visits by Mother but she is also asking for food when there Health visitor attempts new birth visit at home. Neighbours says they have not seen Mother for some time 22 June 2016 Hospital Safeguarding Adviser advises neonatal unit staff to contact Mother to ask her to visit 23 June 2016 Mother does not attend post-natal appointment 24 June 2016 Midwife report says Mother forgot about appointment on 23rd June – was offered (but refused) home visit for the 25th June - said would come to post-natal clinic next week. Health visitor unable to contact Mother and wants staff to ask her to call. Staff say referral has been made to SCS but waiting for response. Referral refaxed to Newham CSC. CSC referral to Newham made and shared with Child Health. Child Health ask for referral to go to B&D as well 27 June 2016 2nd CSC sent to B&D at 16.00 28 June 2016 Hospital Safeguarding Adviser visits the neonatal unit and advises staff to contact Mother – no answer, message left 29 June 2016 Mother visits neonatal unit (visit 6). Speaks to health visitor on the phone and arranges visit for the next day Hospital Safeguarding call LBBD CSC Triage. Told case being looked at. LBBD CSC ring back at 17.00 to say case referred to Family Support Worker Police received referral by CAIT for ICIP. Health visitor attempts home visit – no answer 30 June 2016 Mother visits neonatal unit (visit 7) – sibling being looked after by his father. She attends the post-natal clinic, but the clinic is running late, so she leaves – has to pick sibling up from nursery 19 2 July 2016 Mother and a friend visit the neonatal unit (visit 8) 5 July 2016 Mother phones to say she’s been ill but will visit neonatal unit on 6th. Staff seek and get details of social worker There is a planned post-natal appointment but no answer at the house (the father’s address in Newham) and unable to get hold of the mother by phone Emails between Newham Hospital Safeguarding Adviser and SW about keeping up to date to aid discharge planning 6 July 2016 SW visits neonatal unit and leaves details for Mother. Community midwife wants to discharge Mother so speaks to SW and agrees to visit Mother to assess situation 7 July 2016 SW phone both Mother and the Father – no answer. Leaves message for both Mother visits neonatal unit in the evening (visit 9) 11 July 2016 Mother is phoned to say a blood sample is needed from her for Child C’s transfusion. Mother says she will be in on the 12th 12 July 2016 SW visits neonatal unit hoping to see Mother. Mother phones saying trying to get someone to look after Sibling. SW and Safeguarding Nurse wait on the ward. Safeguarding Nurse has discussed with the consultant at what point the issue needs to be escalated – decide if Mother not in by 13th Mother visits (visit 10) at 18.20 to give blood sample so Child C can have blood transfusion 13 July 2016 Mother and sibling visit neonatal unit (visit 11). SW sees both of them and arranges a visit for the 15th 15 July 2016 Mother and sibling visit neonatal unit (visit 12) Team Manager supervision – Child C cannot be discharged until housing issue is sorted out – checks with Newham Housing to be carried out. Case to be escalated if Mother’s behaviour continues SW attempts home visit – Flat has been vacant since 29 April 16 July 2016 Mother visits the neonatal unit (visit 13) 18 July 2016 Child C fit for discharge 19 July 2016 Mother visits neonatal unit with Sibling (visit 14) SW asks for planned discharge date The named nurse wanted to understand why mother was unable to visit and also know if the HV had any concerns about Sibling. She clearly states that whilst she does not want to keep a well baby on neonatal unit she cannot safely discharge whilst she has concerns regarding parental engagement The Named Nurse requested a Discharge Planning meeting (DPM). It is noted that the SW wanted to discuss the case with her team manager. There was an escalation of concerns regarding no accommodation as well as the other concerns previously stated. 20 July 2016 Named Nurse says cannot discharge Child C until there is a safe place to go to 21 July 2016 Mother tries to visit neonatal unit with maternal aunt– issue about visiting hours 20 22 July 2016 Notes say Child C is fit for discharge. SW emails Named nurse to say case escalated and a 87a completed for strategy meeting with the police 23 July 2016 Mother visits neonatal unit (visit 15) – leaves phone number to be told when DPM is 25 July 2016 SW says won’t hold a DPM until the strategy meeting held with the police Strategy meeting held – recommends the case progresses to ICPC 26 July 2016 Mother visits neonatal unit (visit 16). Says she is living in Bow with maternal aunt and sibling is at her uncles. 27 July 2016 Mother visits the neonatal unit (visit 17) ICPC arranged for 15 August. SW tells Named Nurse that mother will live with maternal aunt and a home visit is arranged for 28th July. Professional meeting proposed for 29th and DPM on 1 Aug. Mother tells health visitor her address is her sister’s (the maternal aunt) address in Tower Hamlets. 27 or 28 July 2016 Mother visits neonatal unit with the baby’s father (visit 17 or 18) - entry not dated, just says between 27th and 28th 28 July 2016 SW visit to maternal aunt’s house - Mother did not attend. Maternal aunt says she will support Mother at the ICPC meeting 29 July 2016 (Friday) Professional Meeting takes place. Attendees: neonatal unit Nurse, Named Nurse for Safeguarding. SW met with Mother (with maternal aunt). Mother arrived at 16.30 for a 13.30 meeting. Agreed plan for Mother and children to live with maternal aunt. SW to assess suitability of home 31 July 2016 Mother calls neonatal unit and requests update 1 August 2016 (Monday) SW requests DPM for 2nd August 2 August 2016 (Tuesday) DPM at Newham Hospital. Attendees: Mother, SW, Named Nurse for Safeguarding, Neo Natal Ward Doctor, Neo Natal Ward staff nurse. Apols from Tower Hamlets Health visitor. Date for discharge not set. Not registered with GP Designations of people in attendance written down. Health visitor does not attend but there is a request for an update after the meeting. Maternal aunt’s address is recorded as is Mother’s phone number but it says that she is unavailable. Dr had written notes saying Child C was fit for discharge but needed routine blood tests and eye review next Thursday (4 August?). Someone says that Mother will be at her maternal aunt’s address for about 3 months. Social worker says the home environment is fine and that maternal aunt is sensible. Noted that Mother needed to register with a GP in Tower Hamlets and speak to the cab firm about a car seat. Noted that social worker spoke to Mother about time management and the need to stay at maternal aunt’s address, that the children’s whereabouts needed to be known and that the case would not be transferred to Tower Hamlets at that time. 3 August 2016 (Wednesday) Mother visits neonatal unit. (visit 18 or 19) Also advised to register with GP 21 4 August 2016 (Thursday) Mother asked to come in and sign consent forms for immunisations Time Period 4: 5th August 2016 to 22nd August 2016. Relates to paragraphs at 3.5 onwards 5 August 2016 (Friday) Consent forms not signed Social worker happy for discharge. Doctor advised Mother that babies usually kept in for 24 hrs after immunisations. Mother says will be back at 18.00 and wants to take Child C home. Child C discharged at 6pm Paperwork sent to GP1– Mother not yet registered with GP in Tower Hamlets Discharge says mother’s address is the maternal aunt’s address in Tower Hamlets and that this is the discharge address. Father is “LH” living at an address in Newham. Notes that mother is moving to stay with maternal aunt 8 August 2016 (Monday) B&D Multi Agency CP Conference date set for 15th August SW visits maternal aunt’s address to see Mother and Child C – no answer. Maternal aunt says Mother has said she’d cancelled the visit because Child C was unwell. Mother angry that maternal aunt was contacted. Agreed priority to take Child C to hospital Conference date set for 15 August 9 August 2016 (Tuesday) SW emails Named Nurse to say Mother said she took Child C to hospital on 8th. Named Nurse confirmed Mother did not attend hospital but had called and was advised to go to A&E 11 August 2016 (Thursday) Health visitor tells SW of failed meeting with Mother at Globe Town Health Centre and attempted unannounced home visit but no-one home Tower Hamlets health visitor not attending ICPC as Mother not living in Tower Hamlets and there will be no further support. Responsibility with GP Surgery SW does unannounced visit to try and see Mother and children at her uncle’s address, Uncle presents as vulnerable adult. Says not seen Mother for 18 – 24 months Team Manager approved social worker’s report for the ICPC 12 August 2016 (Friday) Agreed case can go to TCLPM if Mother does not attend or allows the SW to see the children 15 August 2016 (Monday) ICPC held at Barking Town Hall Both children put onto CP Plan Neglect. Child C not seen by a professional since her discharge Named Nurse attended. Her notes say Mother arrived late and left early. No notes from Conference 16 August 2016 (Tuesday) Agreed to escalate case to attention of Group Manager and agreed to be taken to Thresholds of Care and Legal Planning Meeting with Public Law Outline plan Single Assessment recorded as completed on ICS 17 August 2016 (Wednesday) TCLPM held – meets criteria for applying for interim care order. Decide not to remove children now but keep under review. If children not seen by 19th August application for Emergency Protection Order to be considered 22 Unannounced home visit by SW at maternal aunt’s home – no one in. Home visit arranged for 18th Re maternal aunt’s checks – no concerns 18 August 2016 (Thursday) Home visit by SW. Not in, SW phoned Mother who said she would be back in 5 minutes. SW waited for 45 minutes then left. Maternal aunt gave permission to SW to look round – no evidence of Mother and the children living there. SW bumped into Mother in the street and challenged her about where she was living – insisted she lived at that flat 19 August 2016 (Friday) SW sees Mother and children at the office. Plan to relocate to Essex SW requests Police checks on Maternal Grandmother. Mother, Maternal Grand Mother and maternal aunt sign Family Plan. Plan is for Mother to move with the children on 21st August to live with maternal grandmother but live with maternal aunt in the interim. Social Worker to visit on 21st August Time Period 5: 22nd August 2016 to Child C’s death. Relates to paragraphs at 3.6 onwards 22 August 2016 (Monday) SW visits maternal grandmother’s home to check suitability. SW recorded that Mother and children had moved to live with maternal grandmother Core Group originally planned for this date SW told to alert Essex of children on CP Plan moving into their areas and to alert the CP Chair Family relocate to Essex 23 August 2016 (Tuesday) SW contacts CP Chair, Health Visitor in Tower Hamlets and Essex CSC Health Visitor notified by SSW that Mother had moved to Essex on 22nd and that SW would be asking Essex to place the children on a temporary register 24 August 2016 (Wednesday) SW tells health visitor of Mother’s new address in Essex B&D health visitor gives hand over to new health visitor over the phone CP Summary completed by health visitor. Details of next CP Conference records and date of Core Group confirmed Mother registers at GP practice in Essex TCLPM updated. Legal advice is not to issue PLO. Safeguarding agreement to be put in place, work with CP plans. Core group meetings to be arranged. SGO advise to be sought for maternal grandmother if needed Community Health records show a move of children on CPP. Icon is added to record 25 August 2016 (Thursday) GP practice asks Mother to come in with the children’s Red Books. Sibling is booked in for 12 month immunisations that afternoon. Maternal grandmother attends for appointment with sibling 26 August 2016 (Friday) SW receives phone call from Mother saying the maternal grandmother has kicked her out and she needs accommodation in B&D 23 SW speaks to maternal grandmother who says she cannot accommodate Mother and the children indefinitely 30 August 2016 (Tuesday) GP practice rings Mother and advises her to bring Child C in on 7th Sept for immunisations and to see the GP 1 September 2016 (Thursday) Health visitor does home visit to maternal grandmother’s address – sees both children. Another visit/Core Group arranged for 6th Sept SW letter to GP – both children on a CPP at LBBD under category of neglect 5 September 2016 (Monday) GP confirmed with B&D that Mother had registered with their surgery. GP requested Social Care to liaise with Essex Social Care to organise Health Visitor 6 September 2016 (Tuesday) Core Group Meeting held at maternal grandmother’s address. Mother, maternal grandmother, SW, Health Visitor 4 present. 7 September 2016 (Wednesday) GP sees Child C with Mother, Sibling and maternal grandmother. 8 September 2016 (Thursday) GP practice rings Mother to remind her to bring in child C’s Red Book – she does SW phones Mother and also maternal grandmother. Neither answer. Messages left asking them to make contact 12 September 2016 (Monday) Home visit by Health Visitor 14 September 2016 (Wednesday) SW phones Mother – no answer. SW phones maternal grandmother who says that Mother and the children left on 12th September after the visit by the health visitor. Mother is due back on 15th (Thursday) 16 September 2016 (Friday) GP practice phone Mother and make appointment for Child C on 19th 19 Sept (Monday) Child Protection Home Visit by SW. Mother, Sibling and Child C seen at maternal grandmother’s address. Mother on way to GP appointment. ICPC minutes received and sent to professionals and parent GP sees Child C and appointment for Child C’s 3rd round of immunisations is booked 23 September 2016 (Friday) Housing Options Essex ring SW – Mother does not have appointment – case still being checked 26 September 2016 (Monday) Mother cancels Monday’s (26th) visit and re-arranged for Tuesday (27th) by text Family discussed at Children’s Centre Meeting. Family allocated to worker 27 September 2016 (Tuesday) Text from Mother - not available for the afternoon visit from health visitor. Could it be re-arranged to Wednesday afternoon (28th). Visit booked for 16.00 on 28th 24 Case supervision – SW view is that Mother responding better and showing more insight. Decision needed whether LBBD continues to work with the case or to discuss transfer to Essex. Plan to visit every 2 weeks 28 September 2016 (Wednesday) 09.30 Mother boards bus in with Child C in a baby sling and the 2 year old Sibling in a pushchair. After around 20 minutes she arises alarm that Child C is not breathing. Passenger on bus performs CPR LAS and police called to incident and Child C is taken to Newham General Hospital with the mother. 11.30 Child C is pronounced dead. A rapid response meeting was convened and police investigation by the Child Abuse Investigation Team started Mother and Father arrested on suspicion of murder Phone call from maternal grandmother to social worker to say Child C had died Newham Hospital inform team manager of death and likely NAI – 16 weeks and 6 days old Strategy Meeting held at LBBD with GM, TM, Police and health 30 September 2016 (Friday) Specialist post mortem. Cause of death “head injury”. Skeletal survey post death indicated multiple fractures that had occurred on different dates and were consistent with NAI. 1 October 2016 (Saturday) Both parents charged with murder. 25 Appendix 3: Recommendations from IMRs: The recommendations from the Independent Management Reviews demonstrate that ‘learning’ from this case has already happened and changes have been made to practice. Examples include: • ELFT have introduced a mentoring programme for newly qualified health visitors that includes monthly supervision using ‘Signs of Safety’ • LBN and Essex have introduced a Neglect Strategy to support practitioners in the identification and management of neglect • LBBD the use of CIN templates at the point of discharge from hospital • Barts Health to emphasise ‘Think Family” in training programmes and reinforced in supervision • NELFT Health Visitors to consistently use the assessment framework to document needs assessments in children’s records • Essex Clinical Commissioning Group will ensure that their current standard operating procedure reflect that where the patient discloses safeguarding information that this is reviewed by the practice safeguarding leads and appropriate alerts are uploaded to the patient record • Local Health Provider has tightened the process around attachments to record, to ensure it is documented in the electronic record that these have been read by the named clinician. All of the recommendations made in the IMRs should be reviewed by the respective LSCBs. London Borough of Barking and Dagenham: 1. Quality of practice in single assessment and plans Continuing attention and support has to be given to the guidance and training for social workers and case supervisors about: a) Voice of the child: the voice of the child must be strong and ‘jump off the page’ in assessments, plans and case records, including records about health and development needs. There should be further input about practice guidance and ‘what does good look like’ and with particular attention to situations in which there are difficulties with parent/s engaging and in which children are non-verbal. 26 b) Use of research: the principle of drawing on research findings and in this case use of the Research in Practice briefing with the Dartington research about attachment should be evident in assessment and case records to inform and underpin decisions and a plan for support and intervention c) Working with neglect: the Children’s Social Care service should also now put into practice a tool which would be used when carrying out assessments and also ongoing work when neglect is an issue. This would also be with a view to developing the tool for multi-agency working. d) Invisible father: the child/ren’s father remained invisible due to mother (and her family) misleading professionals on a regular basis. Despite this, as happened in this case, investigations should continually remain vigilant as to the possibility that father might be hidden or emerge and then a risk assessment should follow. Self-reporting by a mother should be respected but has to be checked further. e) Working with uncooperative and hard to engage families: a strong theme in this case and a significant challenge for the staff who were trying to fulfil their responsibilities to the children. There is procedural guidance in place on the London Child Protection Procedures but further support through training is also merited. There are no easy answers but input, including training, would give social workers and managers the opportunity to think and reflect further about the issues involved 2. Safeguarding process and procedural points a) Use of template for CIN plan: plans for children in need upon discharge from hospital should be recorded using the Child in Need plan template, distributed to the relevant professionals, and parent/s and recorded accordingly whilst also being chaired by a Team Manager. b) Agreement with parents and families: Child in Need plans or Child Protection plans should be used as the starting point for the formal agreement between parent/s and the local authority. These should be signed by the parent/s as an indication of agreement. Further guidance would be helpful about the use of ‘safeguarding agreements’ if a written agreement is needed further to the plan – referred to as a written contract in the London Child Protection 27 procedures. If used then there should be a model template which sets out the expectations of the parent/s and any other family members involved; the services to be provided; arrangements for review; and the contingency plan if the agreement is seen not to be working. As with the use of CIN or CP plans if the parent does not sign in agreement or the agreement is breached then the contingency plan must be considered including discussion at the Threshold of Care and Legal Planning meeting or more immediate emergency action. 3. Children and families moving across local authority boundaries a) Children on child protection plans moving across local authorities: if a child who is the subject of a child protection plan moves to another local authority then that local authority must be notified. The child protection plan should also be shared at the earliest possible point with any other members of the core group in the local authority area concerned. 4. Disseminate findings and lessons learned The findings and lessons learned will be disseminated through meetings with staff and forums for further discussion such as supervision, team meetings, service meetings and the Practice Improvement + Outcomes Group for Team Managers. Lessons learned will be assimilated in to training provided for social workers, managers and independent reviewing officers London Borough Of Newham: Newham were already sighted on and have begun to address issues flagged in the IMR. Notably: 1. A partnership wide implementation of an evidence based systemic tool for neglect. 2. Driving forward a systemic approach to assuring consistency in practice, quality of assessments and robust reflective supervision 3. Improved and proactive information sharing across agencies. A comprehensive plan was in place to address issues and was 28 operationalised in 2015.16. London Borough Of Newham Adult Social Care: No recommendations London Borough of Newham Housing Needs Service: No recommendations. Newham CCG – General Practice: No recommendations Barts Health NHS Trust: 1. Acorn Teams notes should marry up with the hand-held maternity notes. 2. Notes audit to be conducted on the Neonatal Unit. 3. Neonatal unit Community Nurse to be in place in Neonatal Unit. 4. Audit of the use of the purple sticker within postnatal notes. 5. Meeting proforma to be launched within Neonatal Unit and paediatric ward to cover all multiagency meetings such as strategy and discharge planning meetings. 6. Training and supervision to emphasise more regarding the use of genograms and Think Family approach. 7. Letter to be developed and sent to regularly used CSC that any strategy meetings should take place on Newham hospital site if the child is an in-patient 8. Standard Operating Procedure to be developed in cases of later miscarriages attending ED. 9. Bereavement registrars to escalate to clinical staff if delays in parent(s) attending to receive death certificates and organise funerals. 10. Learning flyer regarding this case to be shared when SCR finalised and share at all sites safeguarding meetings. 11. Teaching around complex discharges from Neonatal Unit 12. Rooming in to be offered to all parents once their baby is close 29 to fit for discharge. 13. Staff to be made aware of escalation processes both internally and with external partners East London Foundation Trust: 1. Review of health visitor’s operational protocol. 2. Monitor staff access to safeguarding supervision and case discussion 3. Review of administrative process for transferring records out of the Trust 4. Improving communication blocks across organisational boundaries. North East London Foundation Trust: 1. Key learning from SCR to be cascaded through managerial frameworks from ISG to frontline practitioners. 2. Key learning from SCR to be shared with Safeguarding Children Supervisors. 3. Health Visitors to be professionally curious and to escalate safeguarding concerns where indicated. 4. Health Visitors to consistently use the assessment framework to document needs assessments in children’s records 5. Areas of emerging learning from SCR are formally discussed in managerial supervision with all universal services practitioners. 6. Practitioners involved in child C’s and her siblings care to be aware of emerging learning from SCR to include notable practice and areas to be strengthened. 7. Health visitors to be clear about Corporate Health Visiting and their accountability. An Essex Clinical Commissioning Group on behalf of a GP practice: 1. Essex Clinical Commissioning Group, ensured the GP practice involved amended their current standard operating procedure to reflect that where the patient discloses safeguarding information that this is reviewed by the practice safeguarding 30 leads and appropriate alerts are uploaded to the patient record” 2. Essex Clinical Commissioning Group ensured the GP practice involved amended their GP patient registration form for children up to the age of 18, to include a tick box that would indicate if children are subject to a child protection plan and/or are a current Looked After Child 3. Cascades (internally) revised contact details for the health visiting service once received following the change to a new provider from the 1st April 2017 The Local Provider Health Service in Essex: 1. Initial Health Needs Assessment Standard Operating Process 2. Transfer in of children on CPP or CIN to be notified to Safeguarding team for review of case. 3. Skills workshop on disguised compliance for 0-19 service clinicians. To include information around late cancellations of appointments and when these should be escalated. 4. Tighten process around attachments to record, to ensure it is documented in the electronic record that these have been read by the named clinician. London Ambulance Service NHS Trust: No recommendations. Metropolitan Police Specialist Crime Review Group: No recommendations. 31 Appendix 4: Acronyms and Terminology ASC Adult Social Care BARTS Barts NHS Foundation Trust CPR Cardio Pulmonary Resuscitation CAMHS Child and Adolescent Mental Health CHC Child Health Clinic CIN Child in Need CPP Child Protection Plan CSC Children Social Care DfE Department for Education ED Emergency Department ELFT East London Foundation NHS Trust GP General Practice / Family Doctor HV Health Visitor HNS Housing Needs Service ICPCC Initial Child Protection Case Conference IMR Individual Management Review IT Information Technology LAS London Ambulance Service LBDD London Borough Barking and Dagenham LBH London Borough of Newham LCPP London Child Protection Procedures MARF Multi agency Referral Form MASH Multi agency Safeguarding Hub MP Metropolitan Police NN Named Nurse NAI Non Accidental Injury NCSC Newham Children’s Social Care NIHIT Newham Intensive Hospital Intervention Team NUH Newham University Hospital NHS Trust NSPCC National Society for Prevention of Cruelty to Children SCR Serious Case Review SCRP Serious Case Review Panel SW Social Worker TAC Team Around the Child TCLMP Threshold of Care Legal Planning Meeting TM Team Manager UCC Urgent Clinical Care 32 Appendix 5: References Working Together to Safeguard Children, A guide to inter-agency working to Safeguard and promote the Welfare of Children (HM Government, 2015) London Wide Child Protection Procedures 2016 Assessing Children in Need and their Families: Practice Guidance (DOH 2000) Research Briefing: Neglect (NSPCC 2012) Developing an effective response to neglect and emotional harm to children. Ruth Gardner University of East Anglia and The National Society for the Prevention of Cruelty to Children (January 2008) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 -2014 (DfE 2016) Brandon M, Belderson P, Warren C et al (2008) The preoccupation with thresholds in cases of child death or serious injury through abuse and neglect, Child Abuse Review, 17 (5), 313-330 Sofia Serious Case Review Tri-borough (Dec 2015) Child J Serious Case Review, Luton Safeguarding Children’s Board (02.06.2107) UK – World Health Organisation Growth Charts (2016) |
NC52466 | Long-term neglect of Child 1 and Child 2 as well as an adult female with Down's syndrome. Learning includes: ensure that children are spoken to on every occasion following contacts to children's social care; when contact relates to home conditions, it is useful to conduct an unannounced visit; self-report information may not necessarily reflect the true home circumstances; review frequent cancellation of appointments under the 'was not brought' policy which should have equal weighting in relation to adults with care and support needs and children who are 'not brought' to appointments; consider alternative services and exercise greater curiosity in relation to home circumstances for obese children; elective home education national guidance needs to be strengthened in relation to safeguarding children, and the review of policies and procedures for the local service; the role of professionals in sharing information and exercising curiosity is critical to increasing professional awareness and understanding, and mechanisms for this should be supported; and to strengthen multi-agency communication around cancelled and missed appointment. Recommendations include: be assured that local safeguarding training and support is available to practitioners in non-traditional safeguarding services (e.g. regulatory services, environmental services and other placed based services as appropriate) to develop and maintain skills in safeguarding; following the implementation of the recent capacity and skills review of the elective home education service, ensuring understanding and awareness of the service is raised with professionals in other agencies; highlight the specific concerns to the Department for Education in relation to the primacy of the safety of children who are educated at home; and review policy in relation to childhood obesity to ensure there is sufficient focus on the potential for this to be a safeguarding issue linked to neglect.
| Title: Combined practice learning review (adult) and local child practice review (children) in relation to Family X. LSCB: Cheshire West and Chester Safeguarding Adults Board and Multi-Agency Safeguarding Children Partnership Author: Maureen Noble Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 CHESHIRE WEST AND CHESTER SAFEGUARDING ADULTS BOARD AND MULTI-AGENCY SAFEGUARDING CHILDREN PARTNERSHIP COMBINED PRACTICE LEARNING REVIEW (ADULT) AND LOCAL CHILD PRACTICE REVIEW (CHILDREN) IN RELATION TO FAMILY X Final Report Author/Lead Reviewer: Maureen Noble January 2021 2 CONTENTS 1. INTRODUCTION AND BACKGROUND Page 3-4 2. CONDUCTING THE REVIEW Page 4-8 3. CHRONOLOGY, KEY CONTACTS & FURTHER INFORMATION Page 8-15 4. LEARNING FROM THE REVIEW Page 15-20 5. CONCLUSIONS AND RECOMMENDATIONS Page 21-23 3 1. Introduction This review has been conducted under guidance set out in Working Together to Safeguard Children (2018) and the Care Act (2014). At the time of the events leading to this review the six members of Family X were all living at the same address. This was a multi-generational household i.e. three generations of the same family living together. Family X consisted of: Adult X1 (Female adult with care and support needs – adopted daughter of Adult X3 and X4) Adult X2 (Birth child of Adult X3 and X4, mother of Child 1 and Child 2) Adult X3 (Adult Female, Adoptive Mother of Adult X1 and Birth Mother of Adult X2) Adult X4 (Adult Male, Adoptive Father of Adult X1 and Birth Father of Adult X2) Child 1 (Oldest Child of Adult X2) Child 2 (Youngest Child of Adult X2) The key subjects of this review are Adult X1, Child 1 and Child 2 1.1. Pen Picture of Family X All four adults in the family appear to have had vulnerabilities. Adult X1 has Downs’ Syndrome and has ongoing care and support needs. Adult X1 was adopted by Adult X3 and X4 in 1987. Adult X2 had an ongoing medical condition for which she was prescribed medication by her GP. The two older adults (X3 and X4) were both in very poor health and suffering from chronic conditions. Child 1 and Child 2 had been electively home educated since 2013. According to neighbours who made the referral leading to this review, they were rarely seen outside of the family home. There had been formal and informal complaints about the conditions outside the property however there were no reports of anti-social behaviour made to the police. NB: During the course of the review a member of the local community who made a contact to Children’s Social Care (CSC) said that Adult X3 had responded in an aggressive manner to complaints made directly by neighbours in relation to parking, dog fouling, litter and furniture outside the property. The family had another facility where they spent regular and extended periods of time (i.e. weekends and school holidays) which was situated close to their permanent address. Records show that some professionals conducted contact visits at this facility, although it was not the family’s registered permanent address. 4 1.2 Events Leading to the Review In July 2019, following a call to CSC by a concerned member of the public (who contributed to the review), social workers visited the family home and found the home conditions to be ‘exceptionally poor’. All six members of the family were living in the property, which was found to have no running water or working toilet facilities. There were a large number of caged dogs in the property, human and animal excrement was present in several rooms and living areas were unclean. Adult X1 was found to be unkempt and unclean. A subsequent health assessment found that she had a number of physical health needs that were unmet. A capacity assessment found that she did not currently have capacity to make decisions that would safeguard her. Both children appeared unkempt and, on further assessment, presented with a number of physical health needs that were of concern. Their literacy was poor, and they had poor communication skills. Information emerging from Achieving Best Evidence Interviews (ABE’s) with both children and with Adult X1 indicate that they had lived in these conditions for several years. The home conditions, and the physical condition of all three subjects of this review give strong indications of neglect. A Section 47 multi-agency strategy meeting took place and both children were removed under Section 20 (this was agreed to by Adult X2). At this time Adult X1 was offered the opportunity to go into respite but declined. She was moved temporarily to alternative accommodation with her family. Following completion of mental capacity assessment the following day Adult X1 was moved to supported living. The three other family members were moved temporarily whilst conditions in the property were addressed. They subsequently returned to the property. A police investigation commenced with the aim of establishing whether the children and/or Adult X1 had been subjected to wilful neglect. This investigation is ongoing. 2. Conducting the Review 2.1 Decision to undertake a combined review and methodology The local Multi-Agency Safeguarding Children Partnership (SCP) met on 2nd September 2019 to consider whether the case met the criteria for a Child Practice Review (previously SCR). It was decided that a statutory review should take place 5 The local Safeguarding Adults Board (SAB) met on 2nd September 2019 to consider whether the case met the criteria for the conduct of a Safeguarding Adults Review (SAR). It was decided that the criteria for SAR was not met, however it was agreed that there was learning to be derived from the case, and that a Practice Learning Review (PLR) should take place. The two Boards agreed that it would be beneficial to commission a joint review using the principles of ‘Think Family’.1 An Independent Reviewer with relevant experience was appointed and a multi-agency panel of senior agency representatives was convened and held its first meeting on 16th December 2019. At this meeting the panel made the following decisions: 2.2 Scope of the review • The review should primarily focus on the two children and Adult X1 as subjects. • The review should focus on the period from January 2013 (when the children began elective home education EHE) to July 2019 when the children were removed under Section 20 of the Children Act and Adult X1 was moved to alternative accommodation under Section 42 of the Care Act. • Agencies should consider the significance of historical events and contacts (these have been included in this report to provide context). • Family members should be notified of the review and invited to participate as appropriate and according to their individual circumstances • Practitioners should be invited to participate in the review via a practice learning event, individual or agency interviews and a practitioner feedback event as appropriate. • The overview report should be a combined report that highlights learning in relation to adults and children. 2.3 Methodology • The review used a blended approach i.e. a systems review involving practitioners, supported by key documentation • An integrated multi-agency chronology was prepared • TORs/Research questions were scoped and agreed at the first panel meeting • Panel members were drawn from key agencies for both adults and children 1 Think Family means securing better outcomes for children, young people and families with additional needs by co-ordinating the support they receive from children’s, young people’s, adults’ and family services. 2. Think Family can also be seen as building the family dimension into everything we do. https://webarchive.nationalarchives.gov.uk/20130323053534/https://www.education.gov.uk/publications/eOrderingDownload/Think-Family.pdf 6 • The review adopted a Think Family approach with specific focus on the two children and Adult X1 • A practitioner event was held to seek views early in the review process NB: A decision was taken to delay the final report pending an Achieving Best Evidence taking place with both children. This interview took place in July 2020, having been delayed by the Coronavirus pandemic. Relevant information from these interviews is contained section 3.1.7 of this report. In October 2020 police conducted an ABE with Adult X1 in October 2020. Relevant information from this interview is contained in section 3.1.8 of this report. NB: This report uses the terms ‘professionals’ and ‘professional curiosity’ to relate to any paid or unpaid worker, in any service, who had contact with the family. 2.4 Key Themes and Research Questions The panel identified three key themes upon which the review would focus, these questions were refined following the first panel meeting and practitioner conversations. Theme 1 – Assessing Vulnerabilities and Risks in complex families • What did practitioners know about the family? • Was historical information available and did practitioners use it to build a picture? • Was Adult X1 able to articulate their own needs? • Was the voice (daily lived experience) of the children sought, heard and acted upon? • Were issues of childhood obesity responded to appropriately? • Were any carer’s assessments undertaken with Adult X1? If so, did they take into account the wider circumstances of the family? • Were capacity assessments carried out (in line with Mental Capacity Act)2, if so did these lead to ‘best interest’ discussions in relation to Adult X1? • What was the significance of missed appointments with Adult X1? How were these managed? • What was the significance of missed and re-arranged appointments with Child 1 and Child 2 and with Adult X1? How were these managed? • Were safeguarding tools and processes used appropriately and in a timely manner? • What role do wider agencies play in safeguarding e.g. environmental services? • What role can/do communities play in safeguarding vulnerable adults and children? • Were there opportunities to escalate concerns and were these taken? • Were there any specific health issues or concerns in relation to the children and/or Adult X1? Theme 2 – Multi Agency working and communication • How did agencies work together to support the family? 2 https://www.legislation.gov.uk/ukpga/2005/9/contents 7 • Were appropriate assessments conducted? What could be done differently? • Was communication between agencies appropriate and timely? If not, what might be improved? • Were there opportunities to put a multi-agency plan in place, if not why was this? • Were any multi-agency meetings held to discuss the whole family, if not what learning can be gained from this case? • Does the local system support multi-agency working for families with complex needs? Theme 3 – System Issues • Are practitioners supported in working with multi-generational complex families? • Is the national system/guidance for Elective Home Education (EHE) robust? Is there enough focus on safeguarding children contained in the guidance? • Do practitioners understand and apply principles set out in the Care Act. Is there sufficient focus on safeguarding the index adult and family members? • What aspects of the local/national safeguarding system (adults, children and families) support good practice? If not, what are the areas in which the local/national system could be improved? • Are there any ‘quick wins’ arising from the case (e.g. parts of the local system that could be strengthened immediately)? 2.5 Family Involvement in the Review At the commencement of the review family members were contacted, as appropriate to their circumstances, informing them of the review, as follows: Adult X1 was informed of the review via an advocate. Adult X1 said that she did not wish to participate in the review. It was agreed that the opportunity for Adult X1 to contribute to the review should be left open in case she changed her mind. Adult X2 was informed of the review in writing. Due to ongoing criminal investigations it was agreed that any invitation for Adult X2 to participate in the review would be deferred until these investigations were concluded. Investigations are ongoing at the time of writing. Adult X3 and X4 were informed in writing that the review was taking place. Subsequent to the completion of the review Adult X3 sadly died. It was agreed that neither Child 1 nor Child 2 would be asked to participate in the review directly. This decision was taken to minimise the negative emotional impact on the children given the circumstances in which they had been living and their removal from the family home. However, the children’s social worker worked in close liaison with the review and ensured that the children were given opportunities to share their lived experience with the review. It was also agreed that information emerging from further enquiries, including the ABEs with Adult X1 and Child 1 and Child 2, would be included in this report. 8 NB: ABE interviews have now taken place with Child 1 and Child 2 and with Adult X1 as set out at Section 3.1.7. of this report. These interviews have provided further insight into the daily lived experiences of the subjects of the review. 3. Contact with agencies/Condensed Chronology 3.1 Contextual information prior to January 2013 According to the General Practitioner (GP) record, Adult X4 sustained a head injury in 1974, the cause is not recorded in available notes (it is thought the injury may have been due to motorcycle accident). The injury resulted in Adult X4 suffering ongoing epilepsy for which he received treatment. Adult X3 and X4 were Foster Carers from 1986. They adopted Adult X1 following her placement with them in 1987. In 1990 another child in the care of Adult X3 and X4 sustained injuries, which were reported to have resulted from falling from a cabin bed. It was deemed that this was not a satisfactory account of how the injuries had occurred and as a result the child was removed from their care. As a result of this incident both Adult X1 and Adult X2 (as children) were subject to a case conference and were placed on the Child Protection Register under the category of neglect. In 1991 they were both removed from the Child Protection Register. Child 1 was born in April 2006. According to health records Adult X2 was married at the time of Child 1’s birth. The relationship between Adult X2 and Child 1’s father appears to have broken down within a short time and the couple separated. In 2007 Adult X2 made an application for rehousing due to reported overcrowding at the property the family were living in at that time (not the current family home). It is not clear what happened to this application; however, it appears that Adult X2 remained living with her parents and step-sibling. Child 2 was born in May 2008. The relationship with Child 2’s father appears to have been abusive, and Adult X2 sought support from an Independent Domestic Violence Advocate (IDVA) and was referred to MARAC3. Adult X2 informed the IDVA that she was concerned about stalking and harassment by Child 2’s father. In 2012 Adult X1 was referred for health appointments, a number of appointments were cancelled by Adult X4 however Adult X1 was seen on 11th June 2012, although the next appointment was cancelled. 3 A Multi Agency Risk Assessment Conference (MARAC) is a victim focused information sharing and risk management meeting attended by all key agencies, where high risk cases are discussed. 9 3.2 Significant Events in the period under review - January 2013 to end of July 2019 3.2.1. 2013 In January 2013 Child 1 and Child 2 became known to the EHE Service following notification from their primary school that both children had been removed from the school roll as a result of a parental decision to electively home educate them. Prior to the children becoming home educated, the school had recorded concerns regarding the children’s level of absence from school. When attendance procedures were escalated with their mother, she advised the school that she was removing the children to home educate them. In July 2013 a specific health service attempted to make a home visit to Adult X1, however they could not gain access. A further appointment was made for October 2013 (which was not attended). In July 2013 the EHE advisor made an appointment to visit the children at home for review of EHE arrangements, this appointment was cancelled by Adult X2 the day before it was due to take place. A further appointment was sent which was cancelled by Adult X2 on the day that it was due to take place. The initial visit by the EHE advisor took place on 15th August 2013. NB: There were two attempted health contacts which were not taken up by the family. Other than this there are no recorded contacts with any service for any member of the family during 2014 3.2.2. 2015 In January 2015 the EHE Advisor wrote to Adult X2 requesting a date for an appointment to review EHE. On 16th February the EHE Advisor received details of education arrangements from Adult X2, who also agreed to a home visit ‘in a few weeks’ time’. On 2nd March 2015 a request was received from the EHE Advisor to establish whether the children had been seen by any health services within the last 12 months. The School Nurse advised that the children had been seen within this period as shown on EMIS records. On 25th May CWAC Regulatory Services (Environmental Health) received a call from a neighbour reporting noise and poor home conditions at the family address. Informal action was taken in respect of noise, accumulations of rubbish and dog fouling. No noise records were returned by the family and the case was closed. In September 2015 the Community Learning Disability Service undertook an initial assessment with Adult X1 (Adult X3 was present). No role was identified for the service and 10 a referral was made to Adult Social Care (ASC). It was noted that Adult X1’s parents were both in poor health. Activities and respite were identified as needs for Adult X1. 3.2.3. 2016 From January Adult X1 was entitled to 13 hours per week support from a personal assistant. In February 2016 ASC received a call from Adult X3 regarding Adult X1 not being happy with the arrangements made for social activities. The social worker looked into this and identified that further benefits could be claimed to support Adult X1. In June 2016 police received a call from Adult X2 that she had received threats from a neighbour that they would kill her dogs (this related to disputes in relation to parking). Police attended the address and spoke to all parties. No offences were recorded. On 22nd June 2016 Child 2 was taken to A&E (this event was noted in the EHE case file). On the same date the EHE case file noted that an appointment had been arranged to make a home visit. The appointment for this visit was cancelled on 13th July and rearranged for 4th August. The visit on 4th August took place as planned. Both children were seen and evidence of education was provided by Adult X2 and there were no concerns noted by the EHE advisor. 3.2.4. 2017 In March 2017 Adult X1 was discharged from a specific health service due to a change in the services provided. The family were advised on how to access treatment and advice if this was required in the future. On 8th March Adult X1 was invited to a Learning Disability annual health check, no response was received to this invitation nor to a second invitation in April of that year. That same day a Care Act Review meeting was arranged to take place with Adult X1 on 14th March (this was subsequently cancelled on 14th March by Adult X3, the reason given was that it clashed with a hospital appointment). A new appointment was arranged for 23rd March, which was subsequently cancelled by Adult X3. The Care Act review was recorded as taking place on 29th March, following which there were a number of phone conversations regarding Adult X1 accessing activities. On 9th March ASC reclaimed unused benefits (paid to Adult X3 in respect of Adult X1) in the sum of £8075. On 11th May health workers attempted an unplanned visit to Adult X3 regarding asthma and respiratory support. They were refused access by a woman who was assumed to be Adult X2. On 15th May the social worker telephoned Adult X1 and spoke to Adult X3 who informed them that they had decided with Adult X1 that she did not wish to access any day or 11 Personal Assistant services, and that in future ‘things would be organised by the family’. It was recorded that the case would therefore be closed with relevant advice about future needs being provided. On 26th May 2017 the case was closed and a closure letter was sent. NB: This was the last contact with ASC until 26th July 2019 in response to the reported concerns. On 9th August the EHE Advisor visited the family home to conduct a pre-arranged visit, however they could not gain access. A calling card was left asking Adult X2 to make contact with the service. This was followed up in early September by the EHE Advisor with numerous calls to Adult X2. On 5th September Adult X2 contacted the EHE Advisor to say the family had been away for the summer. An appointment was arranged for 21st September. This appointment was cancelled by Adult X2 the day before it was due to take place. On 16th October the EHE advisor saw the children at home. It was noted that home conditions were ‘concerning but satisfactory’. The property was noted as smelling of animals and there were a lot of dogs in the house. The EHE Advisor asked about the number of dogs and was told by Adult X2 that she was caring for a friend's dogs. It was recorded that the children were spoken to and that there were no concerns noted. On 30th November Child 1 attended a planned asthma clinic review. It was noted that Child 1 had gained weight, and this was raised with Adult X2 as a concern. Adult X2 advised that Child 1 had a treadmill at home and had increased exercise to address this. Child 1’s medication was stepped up to a combined inhaler treatment and a flu vaccination was administered. A follow up appointment was made for 28th December (to which Child 1 was not brought). On 16th December Child 2 was brought to a nurse appointment. Child 2 attended with other family members requesting a flu vaccination. This was declined as Child 2 was not in an eligible group (due to age). It was recorded in the notes for the appointment that Child 2 was home educated. 3.2.5. 2018 On 8th January 2018 the EMIS Health Record noted that Child 1’s GP had sent a referral to Starting Well Services requesting school nurse follow up in relation to weight management. Child 1 was reported to be borderline obese. On 23rd January 2018 Adult X4 attended the local Accident and Emergency Department (AED) with serious medical issues. Adult X4 was admitted to Countess of Chester Hospital (COCH). During the course of treatment Adult X4 was transferred to another hospital and then returned to COCH. (NB During this period, approximately six months duration, neither hospital has any record of Adult X1, Child 1 or Child 2 visiting the hospital or as living at the family home). It is documented in the records at that time that both Adult X2 and Adult X3 visited the hospital(s). 12 The Starting Well Nurse held a discussion with the Practice Nurse in relation to weight management interventions for Child 1. The conclusion of the discussion was that, as Child 1 was already known to the Practice Nurse (who was monitoring weight and asthma), there was no role for the Starting Well Nurse to offer further advice regarding weight management. On 25th January the School Nurse responded to the GP referral for Child 1, advising that they would not be able to offer any additional support regarding weight management, other than that which the GP could provide. The letter asked if there were any concerns around the care of the Child 1 and whether weight was a safeguarding concern. The letter also suggested the option of a dietetic referral if deemed appropriate (no such referral was made). The Starting Well service e-mailed the GP to confirm this outcome. The Starting Well nurse asked whether the GP had any additional concerns regarding the child's care, whether his social/emotional need were being met and whether the GP considered there to be any safeguarding concerns. The Starting Well nurse requested that the practice nurse contact her should she have any concerns. It is not clear whether the GP was made aware of the letter. On 6th July a referral was received by Community Nurses to advise that Adult X4 was to be discharged from COCH with salbutamol nebulisers. It was advised that he would require support with maintaining oxygen saturations and would require monthly blood tests. (NB There is no record of any further home visits taking place). The discharge notes for Adult X4 clearly indicate that Adult X4 was asked who was present in the household to which he was returning. Adult X4 did not disclose that Adult X1, Child 1 or Child 2 were living in the household, citing that only Adult X2 (his daughter) and Adult X3 (his wife) lived with him. NB: It is important to note that throughout Adult X4’s stay in hospital(s) and on discharge professionals were unaware that Adult X1, Child 1 and Child 2 lived with Adult X4. On 16th August EHE received a cancellation of a planned home visit which was rearranged. In November a letter was sent for an EHE home visit appointment to take place on 5th December. This visit did not take place (it was cancelled by Adult X2). Four further appointments were made and cancelled by Adult X2. (NB the review has noted that appointments were usually cancelled by Adult X2 one day before the visit was due). 3.2.6. 2019 On 25th April an appointment for Adult X1’s annual Learning Disability health check was cancelled by Adult X3. (NB: From June 2019 the practice has reviewed the attendance and response for the Learning Disability health check and is now following up non-attenders with further written invitations). On 5th July Child 1 was not brought to an asthma review appointment. There is no record of this appointment being rearranged. Two anonymous contacts were received from neighbours, as follows: 13 Following an anonymous call made by a neighbour on 8th July, I-ART (part of CSC) contacted the EHE advisor to ask when the children were last visited and whether EHE ‘had any concerns’. The EHE Advisor said that they had not been in the family home since October 2017. The response by EHE was followed up by an e-mail to I-Art saying that, although there were no concerns at that time, the children had not been seen by the service for more than a year as Adult X2 had postponed numerous visits. I-Art were also informed that when the children were last seen they presented well and there were no concerns for their welfare. Home conditions were said to be ‘not great’, but ‘not to the point where there would have been the need to refer’. On 10th July I-ART emailed the EHE advisor to inform them that they had spoken to Adult X2 and Child 2 and were closing the case. It was noted that Adult X2 ‘seemed genuine in her explanations for the skip outside the family home and the cancelled appointments’, and had given assurance that she would accept the next appointment from EHE. The email advised that if the EHE advisor had any safeguarding concerns following their next visit the case could be re-opened to I-ART. (NB the review considers that this was a missed opportunity to hold a multi-agency discussion which would have facilitated a greater understanding of the role of EHE in relation safeguarding). On 15th July Environmental Services received a call from a neighbour regarding the smell and state of the property in which the family were living. The service responded by removing a skip from outside the property. That same day an anonymous referral was received by CSC raising concerns regarding the home conditions. The caller reported that the children were home educated and were never seen or heard. The caller said that there were also a number of other adults living in the property and several dogs which were never walked. The caller also informed there was a strong odour coming from the property and that the curtains were never opened. On 16th July a contact was received from another neighbour raising similar concerns that the children were rarely seen outside the property, and that when they had been seen they looked pale, gaunt and unwell. The caller stated there were approximately 16 dogs in the property and they would be unable to get out to the back garden as it was not passable due to clutter and rubbish. The caller informed that there was a “stench” coming from the property, both front and back which was described as “horrendous”. The caller stated windows were blacked out so that people could not see in. The caller said they had been in contact with Environmental Health due to being so concerned about the health of the children residing in the property. No further action was taken due to previous screening having taken place in relation to the first neighbour report. A Social Worker from the I-Art team screened the case and spoke with Adult X2 on the telephone. Adult X2 denied the allegations made in the anonymous referral and said that 14 she was shocked and upset regarding the allegations. (NB the children were not spoken to in this phone conversation). It was deemed by the I-Art social worker that the threshold for intervention was not met and the social worker recommended that the EHE advisor offered further support. On 24th July the EHE advisor arrived for a planned home visit but received no response and left a voice message. Before leaving the property, a concerned neighbour spoke to the EHE Advisor saying that they were concerned about the children. On returning to the office the EHE Advisor picked up an e-mail and voice message from Adult X2 to apologise for missing the visit. That same day the EHE advisor made a referral to CSC due to the poor state of the property, the smell and noise of animals. NB This referral led to the Section 47 investigation. On 25th July the EHE advisor spoke to Adult X2 and informed her that a referral had been made. Adult X2 expressed ‘shock’ at the referral. Adult X2 offered to meet the EHE Advisor at another location (but not at the family home). This meeting did not take place as child protection procedures were commenced. On 26th July social workers visited the family home. They found home conditions to be extremely poor and ‘uninhabitable’. A Section 47 strategy discussion took place. The outcome of this was that the threshold for significant harm was met. Adult X1 was removed to a place of safety and action taken to accommodate the children under Section 20. A police investigation commenced, which is ongoing at the time of writing. 3.1.7. Further Information – Child 1 and Child 2 In July 2020, as part of the ongoing police investigation, both Child 1 and Child 2 were interviewed by Police (this interview process is known as an Achieving Best Evidence (ABE) Interview). During the interview both children spoke about their home conditions and relationships within the family. Their accounts of family life indicated to police officers that the children appear to have been subject to neglect over many years, and that there were indications that they had been physically abused. The children’s accounts also raised the officers’ concerns in relation to their daily lived experience, with detailed accounts of occasions on which they were physically abused, kept in extremely poor home conditions (including not having beds, no facilities for washing or other personal care, and no toilet facilities). They also said that they were not allowed to mix or socialise with peers or other people. The children reported that they were told not to discuss their home conditions or treatment with anyone. 3.1.8. Further Information – Adult X1 In October 2020, Adult X1 was supported in providing an ABE interview with police. 15 During the interview Adult X1 recounted that she had lived in very poor conditions for a very long time. Adult X1 also said that she had been subjected to physical assault (the inference was that this had happened more than once). Adult X1 also corroborated accounts given by both Child 1 and Child 2 with regard to their very poor living conditions and reports of physical abuse and neglect. Adult X1 said that she missed her family, especially Child 1 and Child 2, but that she was happy and settled in her new home and appeared to be enjoying life. 3.1.9. Summary As these matters are subject to ongoing investigation this review cannot draw conclusions regarding the content of the ABE interviews, however the Review Panel believes that the descriptions of the daily lived experience of Child 1, Child 2 and Adult X1 indicate that they lived in neglectful circumstances and were encouraged to conceal the true nature of their circumstances from professionals, services and members of the public that they came into contact with. The Safeguarding Children Partnership and Safeguarding Adults Board have committed to ensuring that any additional learning arising from the police investigation will be disseminated (see recommendation 5). 4 Learning from the review 4.1 Analysis of Agency Practice in relation to key events in the period under review 4.1.1. Adult Social Care (ASC) • Other than specific contact between February 2016 and May 2017 contact with ASC was routine and practice was person centred in relation to supporting an adult with care and support needs • ASC appropriately advised on additional benefits available for activities • ASC appropriately conducted a Care Act Review in February 2016 which resulted in additional benefits being repaid, this was expected practice • ASC appropriately offered further advice and support following repayment of benefits • In July 2019 ASC acted promptly and conducted a thorough assessment of Adult X1’s needs, including a mental capacity assessment • ASC put immediate safeguarding in place following strategy meeting In summary ASC provided services to the expected level to Adult X1 given her presenting needs. When ASC visited the family home prior to July 2019 they had no concerns regarding home conditions or personal safety of Adult X1. When seen in July 2019 ASC took swift and appropriate action to safeguard Adult X1. 16 4.1.2 Children’s Social Care (CSC) • Child 1 and Child 2 were unknown to CSC until the anonymous contact was made in July 2019 • I-ARTs response to the initial anonymous callers contact included speaking to Child 2 (on the telephone), however subsequent contacts did not result in the voices of children being sought. • Incorrect assumptions were made in relation to the remit of the EHE service in relation to safeguarding leading to the contact being closed by I-Art • Following the referral made by the EHE advisor appropriate action was taken to safeguard the children In summary CSC had no contact with the family until July 2019 (although there had been historical contact). The response to the initial anonymous contact made in July 2019 should have been more robust. The panel felt that this response raises questions about whether contacts from members of the public are given the same weighting as those made by professionals. It would be good practice to ensure that children are spoken to on every occasion following contacts to CSC, irrespective of the source of that contact. As the contact related to home conditions it would have been useful to conduct an unannounced visit, this may have resulted in a timelier assessment of home conditions. 4.1.3. Countess of Chester Hospital (COCH) • COCH provided appropriate care to Adult X4 and liaised when transferred from and to COCH to and from another hospital • The usual discharge procedures were followed, and relevant questions were asked. It is apparent from reviewing the documentation that Adult X4 did not disclose that Adult X1, Child 1 and Child 2 resided at the family home. In summary practice in relation to Adult X4’s admission, care and discharge from hospital were as would be expected. It is clear on reviewing the records that Adult X4 was unwilling to share information regarding who was actually living in the family home and did not disclose all the family members living there to practitioners when he was discharged. This review cannot speculate as to Adult X4’s reasons for not making full disclosure however this highlights that self-report information may not necessarily reflect the true home circumstances. However, in the absence of any other safeguarding concerns practitioners could not be expected to probe further into this self-report information. 17 4.1.4. Cheshire and Wirral Partnership (CWP) • CWP had contact with Adult X1 in relation to a health need. This contact began 2012 following referral by the GP. There were several non-attendances and cancellations, although Adult X1 did attend some appointments. Adult X1 was discharged from the service in 2017 with the offer of accessing treatment if required, which was expected practice. • Whilst the service attempted to rearrange cancelled appointments, there is no indication of any policy in relation to scrutiny of cancelled appointments of an adult with care and support needs (i.e. no evidence of a ‘was not brought’ approach as Adult X1 was known to have care and support needs). • In 2015 the Community Learning Disability Service attempted to engage Adult X1 following referral by her GP. Following several cancelled appointments the service conducted an assessment in September 2015. The service demonstrated good practice in continuing to follow up missed appointments. • CWP also had contact with Adult X3, this is not analysed as X3 is not a key subject of this review, however, the review notes that service did try to make a home visit following a cancelled appointment. • CWP received a referral in relation to concerns about Child 1’s weight which was assessed and discussed appropriately, however obesity as an indicator of neglect could have been further explored. In summary CWP practice was as expected in relation to Adult X1. Whilst Adult X1 was deemed to have capacity to make decisions regarding her own care, there may be an opportunity to review frequent cancellation of appointments under the ‘was not brought’ policy which should have equal weighting in relation to adults with care and support needs and children who are ‘not brought’ to appointments. In relation to Child 1’s weight management there may have been opportunities to consider alternative services (e.g. dietetics) and to exercise greater curiosity in relation to home circumstances (consideration of obesity as an indicator of neglect?).4 4.1.5. Elective Home Education (EHE) • The service was involved throughout the period under review • The EHE advisor worked within national guidance in relation to monitoring the children’s education at home • Managerial supervision and oversight were not evident in the period under review. NB This has been recognised as an area for improvement and will be specified in a revised operational policy • The national guidance in relation to EHE is not explicit in relation to the requirements of Working Together to Safeguard Children (2018), a national recommendation is made in this regard 18 In summary the process of approving and monitoring EHE provision was in line with national guidance, however, the review concludes that this national guidance needs to be strengthened in relation to safeguarding children, and that the policies and procedures for the local service should be reviewed NB the local review has now been completed. Staffing issues within the service impacted some aspects of contact and managerial oversight. Safeguarding supervision and pathways for escalation could be strengthened. Awareness of the role and remit of the service amongst other professionals was not evident (particularly in relation to safeguarding) and this should be strengthened. 4.1.6. General Practice (GP) • The GP saw individual members of the family according to their health needs and had no safeguarding concerns about any member of the family. All members were known ‘as a family’ to the GP who noted that they were ‘unusual’ but not a cause for concern • The GP noted weight gain in Child 1 and referred to CXP which was good practice • The practice uses the ‘was not brought’ policy which the GP felt worked well. However, there are a number of missed appointments with the asthma clinic which do not appear to have been followed up. • Adult X1’s Learning Disability Reviews were cancelled – this was not picked up by the practice (however a system is now in place to do this). This is an area for development, an opportunity to notify other agencies. • Health clinic appointments for Adult X1 were frequently cancelled (usually by Adult X3). • Adult X4 identified as having chronic health needs. The GP observed that discharge information from COCH is generally very good. The discharge documentation was not available (it could have been noted that Adult X4 did not disclose who was living in the family home at the time of his discharge). In summary the GP responded appropriately to the presenting health needs of individual family members. When contributing to the review the GP stressed there were no apparent safeguarding concerns with the family as a whole, although family members had individual vulnerabilities and medical conditions which were addressed by the practice. Some health records were not available as they were being transferred to electronic records system. With hindsight there were numerous missed, re-arranged and cancelled appointments and ‘was not brought’ occurrences for the children and Adult X1. In contributing to the review the GP noted that it would not be feasible to cross reference all missed appointments across the entire family, particularly as there were no safeguarding concerns identified. The GP emphasised that actions in relation to safeguarding need to be proportionate to presenting issues. 19 4.1.7. Regulatory Services had two contacts with Family X when they responded to calls made by neighbours complaining about rubbish and smells on the outside of the property lived in by Family X. These complaints appear to have been responded to appropriately according to local practice. The review raises the question as to whether there is a wider role for such services in recording safeguarding concerns and sharing information, and whether staff in these services currently receive safeguarding awareness training. 4.2 Learning from the Review - Themes Theme 1 – Assessing Vulnerabilities and Risks in complex families Despite several agencies having contact with the family throughout the period under review, it is apparent that no single agency had an overview of the whole family. Historical information was not collated in one place and therefore not available to all practitioners, leading to only a partial picture of important aspects of the family history. The review recognises that this is not unusual and that there is not a single data capture system that records information on whole families. Whilst the review recognises that it would be beneficial for practitioners to have access to integrated records, it is acknowledged that a single system is, at this time unachievable. However, the role of professionals in sharing information and exercising curiosity is critical to increasing professional awareness and understanding, and mechanisms for this should be supported. Practitioners told the review that Adult X1 was able to articulate her own needs and she spoke freely to practitioners in ASC when she had contact with them. However, when assessed in July 2019 it was deemed that Adult X1 lacked capacity, at that time, to make decisions regarding her own wellbeing. This led to appropriate action being taken to safeguard her. The voices and daily lived experience of the children is not evident in professional contact with them from 2013 onwards. The primary contact with the children during the period under review was through the EHE service. The review has identified a need to strengthen the EHE service in relation to safeguarding practice. The GP identified concerns regarding Child 1’s weight gain and made an appropriate referral, however this did not result in Child 1 receiving any specific interventions in relation to weight management, as it was assumed that services that he was already in contact with would be able to raise this with him, when in fact he was not always brought to appointments with this service. With hindsight, there is a clear pattern across the family of frequent missed and cancelled appointments. It is not possible to say with certainty whether this pattern is indicative of attempts by the family to stay out of sight of services, or whether it is an indication of increasing vulnerability and lack of coping skills. 20 Whatever the reasons for the large numbers of missed and cancelled appointments, there is no single system, across agencies, that can track and share information regarding these patterns. Whilst practitioners involved in the review felt it would be desirable to have a complete picture of missed appointments, it was recognised that this would be unrealistic. However, there is no barrier to professionals sharing information about missed appointments where they have safeguarding concerns. Theme 2 – Multi-Agency working and communication There is good practice evident in relation to inter-agency working i.e. between health services and social care in relation to Adult X1, however, the review has identified opportunities to strengthen communication around cancelled and missed appointments (particularly for Learning Disability reviews) and the potential impact on Adult X1. Multi-agency working took place in relation to Adult X1, Child 1 and Child 2 at the strategy meeting that took place in July 2019. Information was shared on health systems about the children’s health needs and contacts with them, which is expected practice. There were missed opportunities to exercise greater professional curiosity about aspects of the family’s daily lives however, as no safeguarding concerns were ever raised by professionals (until July 2019). This mitigated against professionals making enquiries into family life (which some professionals felt could be construed as being intrusive and unsubstantiated). Following ABE’s with both children and with Adult X1 it is clear that the conditions in the family home were extremely poor and that even the most basic of facilities such as access to clean water, clothes and toilet facilities were denied to the children and to Adult X1. Their accounts of daily life and home conditions illustrate that they were encouraged to hide the nature of their circumstances from others, including professionals that they came into contact with. Theme 3 – System Issues The case highlights that there is no single system in place that supports professionals who are working with multi-generational families with a range of complex needs. The case specifically highlights the following barriers impact joint working where: • Safeguarding concerns have not been identified • No single agency has oversight of the whole family • There is no statutory right of entry to the family home The review panel are concerned that the current national guidance in relation to EHE does not fully address the safeguarding needs of home-schooled children and their families. 21 The local system in relation to Care Act principles and practice appears to be sound and robust. Learning in relation to delayed Learning Disability reviews has been identified by the review and is referenced above. 5 Conclusions and Recommendations 5.1. Families who avoid services Although not apparent at the time to professionals involved with the family, it is clear with hindsight that the family avoided some services and stayed ‘below the radar’ with other services. Whilst this is not the case for all services, it is clear that Adult X2’s repeated cancellation of appointments and contacts with the EHE service effectively meant that the children were ‘hidden’ from professional sight for long periods of time. There were a number of occasions on which the children were not brought to medical appointments, or their medical appointments were cancelled or re-arranged at short notice. The review believes that that this had a negative impact on the welfare and wellbeing of the children.5 There are also a number of occasions on which Adult X1’s medical appointments were cancelled or re-arranged by Adult X3, and on which either Adult X1 was not brought to appointments, or the family was not at home when professionals visited. Whilst the review cannot draw firm conclusions (because the family has not participated in the review) the review saw indications that, with hindsight, Adult X1 may have been coerced and controlled (see footnote)6 in relation to attendance at appointments, withdrawal of activities and aspects of her personal care (this has become evident in recent contact with Adult X1 and in the ABE with Child 1 and Child 2). This may not have been apparent to practitioners at the time; however, the Review recommends that practitioner awareness of coercive controlling behaviour could be strengthened (see Recommendation 1). 5 https://www.gov.uk/government/speeches/social-care-commentary-hidden-children-the-challenges-of-safeguarding-children-who-are-not-attending-school 6 The definition of domestic abuse includes coercive controlling behaviour in relation to family members as follows: ‘Any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality’. Both the March 2016 statutory guidance in relation to sections 42-46 of the Care Act 2014 (DH, 2016) and the April 2016 guidance in relation to section 7 of the Social Services and Well-being Act Wales 2014 (Welsh Government, 2016) includes coercive control. This means that a local authority’s duty to make (or ask others to make) safeguarding enquiries and determine what action is needed to protect ‘an adult at risk’ are triggered by ‘reasonable cause to suspect’ that an adult with health and social care needs is experiencing coercive control (where their needs prevent them from protecting themselves). 22 The Review also notes that, whilst professionals may not have witnessed overt evidence of neglect (see earlier definitions), the subsequent ABE interviews provide strong indications of Child 1, Child 2 and Adult X1 living in neglectful circumstances. NB: Accounts emerging from the ABE interviews with Adult X1 and Child 1 and Child 2 further strengthen this finding. Recommendation 1 The SAB and SCP should be assured that partner agencies are able to demonstrate a commitment to supporting staff in exercising professional curiosity and respectful challenge. The SAB and SCP should be assured that local safeguarding training and support is available to practitioners in non-traditional safeguarding services (e.g. regulatory services, environmental services and other placed based services as appropriate) to develop and maintain skills in safeguarding. 5.2 Safeguarding Adults with Care and Support Needs Adult X1’s care and support needs were appropriately met, and professionals worked with X1 and Adult X3 to ensure that she had access to services. Practice in relation to Learning Disability Reviews has already been reviewed and changes have been made in relation to following up cancelled review appointments. No recommendations are made in relation to this aspect of the review. 5.3 Safeguarding Children who are Home Educated There is a need to strengthen the focus on safeguarding in the EHE service in relation to practitioner contacts with home educated children. Recommendation 2 The SCP should be assured that the recent capacity and skills review of the EHE service is successfully implemented. As a result of this review understanding and awareness of the service should be raised with professionals in other agencies, particularly CSC. Recommendation 3 The Safeguarding Children Partnership should share the findings of this review with the Department for Education, highlighting the specific concerns raised in relation to the primacy of the safety of children who are educated at home. 23 5.4 Childhood obesity as an indicator of neglect There should be a local Childhood Obesity strategy which ensures that there is a whole system approach to childhood obesity and that professional understanding of the links between childhood obesity and neglect is strengthened.7 Recommendation 4 The SCP should review policy in relation to childhood obesity to ensure there is sufficient focus on the potential for this to be a safeguarding issue linked to neglect 8 5.5. Outcome of Criminal Investigation Recommendation 5 Any pertinent new information in relation to other previously hidden harms that may emerge from the criminal investigation should be shared with LSCB and SAB and disseminated in the usual way. 7 https://www.rcgp.org.uk/clinical-and-research/resources/a-to-z-clinical-resources/obesity.aspx 8 http://orca.cf.ac.uk/27859/1/Viner%202010.pdf |
NC52828 | Evaluates Patricks journey through the care and criminal justice systems between 2016 and 2022 (12-18-years-old). Patrick experienced 17 placements in two years, mental health problems and routinely went missing from home, care and education. His violent behaviour and criminal activity led to placements in secure settings. Learning themes include: preventing permanent school exclusions; adultification of children; understanding and applying intersectionality; mental health support for children in secure settings; ongoing support for children in semi-independent living; escalation about education; and the childs voice being central to effective help and protection. Recommendations include: seek reassurance on the effectiveness of early help when children are at risk of exclusion from school, including intervention when there are adverse childhood experiences; develop policy, guidance and training on adultification and intersectionality; through ongoing engagement with children placed in secure settings, ensure their experiences of the placement are routinely established with concerns addressed; local childrens services and police to provide reassurance about the effectiveness of return home/return from missing interviews for children placed both in and outside of the borough; revisit recommendations from the Leo case, ensuring the provision of support for young people displaying risk factors for violent offending; ensure children in secure settings and semi-independent living have access to a trusted adult; review the standards expected for personal education plans for children placed in secure settings; ensure CAMHS support is appropriately prioritised for children in care and/or secure settings; and develop means of direct engagement with children in secure settings to hear their voice.
| Title: Thematic study: ‘Patrick’. LSCB: Bromley Safeguarding Children Partnership Author: Nicola Brownjohn Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Thematic Study ‘Patrick’ April 2023 Nicola Brownjohn, Independent Reviewer 1 Contents 1 Introduction ....................................................................................................... 2 2 Key Circumstances, Background & Context ................................................... 4 3 Child Patrick’s Story: In his words ................................................................. 12 Overview of early problems ........................................................................................................................... 12 Key episodes of Patrick’s journey ................................................................................................................. 12 Secure Children’s Home (Wales) ................................................................................................................. 13 Deepening Problems ..................................................................................................................................... 13 Trying to be Independent .............................................................................................................................. 14 Youth Offending Institution ............................................................................................................................ 14 Reflections as an Adult .................................................................................................................................. 15 4 Analysis of Practice ........................................................................................ 15 Children Looked After .................................................................................................................................... 15 Secure Training Centre ................................................................................................................................. 17 Youth Offending Institution ............................................................................................................................ 17 Access to Education ...................................................................................................................................... 19 Interagency Working ...................................................................................................................................... 19 5 Findings and Recommendations.................................................................... 20 Finding 1: Preventing permanent school exclusions needs to be a key feature of Bromley’s early help arrangements. ................................................................................................................................................ 20 Finding 2: The adultification of children masks their needs. ...................................................................... 22 Finding 3: Strong oversight is needed for children in secure settings. ...................................................... 23 Finding 4: Practitioners need to routinely use opportunities to understand the reasons for a child’s behaviour. 25 Finding 5: Children in semi-independent living need ongoing support. ..................................................... 25 Finding 6: The importance of escalation about education ........................................................................... 26 Finding 7: Practitioners need to ‘reach out’ with mental health support, particularly for those in secure settings. 27 Finding 8: The child’s voice was, is and always will be central to effective help and protection.............. 28 6 Appendix 1: Term of Reference ...................................................................... 30 2 1 Introduction 1.1 This Local Child Safeguarding Practice Review (the Review) is focused on the multi-agency arrangements that engaged Patrick during his years in the care and criminal justice systems. It evaluates Patrick’s journey through these systems between 2016 and 2022. 1.2 The Review provides an analysis of practice in the context of Patrick’s complex and often chaotic life. It makes eight findings and 14 recommendations for practice improvement, all of which have been substantially informed by the views of both Patrick and the practitioners / managers with whom he was engaged. 1.3 At the outset, it is important to acknowledge that whilst Patrick has the clear potential to rehabilitate, move forward and contribute positively to society, the Review has neither sought to minimise his past behaviour nor the impact this had upon many, not least his victims, Patrick himself and without doubt, his own family. 1.4 However, Patrick’s experiences during this time-period are known to have been characterised by several issues of concern that cannot be ignored in terms of their correlation to Patrick’s broader outcomes. These relate to the overall effectiveness of the help, care and protection provided to Patrick and the sufficiency of both single and multi-agency practice. More specifically: • Patrick lacked stability. He experienced 17 placements in two years. He routinely went missing from home, care and education and his placements outside of Bromley contributed to the complexity of casework. • The serious and repeated incidents of violence and confrontation involving Patrick are likely to have influenced some practitioners in their focus on Patrick’s needs as a child. • The support provided to Patrick in respect of his emotional wellbeing, including his attempts to self-harm (and his needs more generally), lacked a level of consistency and coordination. 1.5 However, without minimising the impact of these issues, the circumstances of Patrick’s case were not that of a ‘serious child safeguarding case’ and did not meet the criteria for notification to the national Child Safeguarding Practice Review 3 Panel (the Panel)1. In this respect, there was neither a formal requirement to trigger a rapid review nor submit one to the Panel itself. 1.6 That said, the Bromley Safeguarding Children Partnership (BSCP) was clear that there were opportunities to accrue learning. As a result, the Independent Chair of the BSCP made the decision to instigate a review to better understand what had happened in this case and why. The full Terms of Reference can be found in Appendix 1. 1.7 The decision to undertake a review was fully ratified by Bromley’s safeguarding partners and the initial plan was for this work to be framed as a ‘Thematic Learning Review’. However, following more detailed guidance being published by the Panel in September 2022, the status of this report is now that of a Local Child Safeguarding Practice Review. To explain further, the Panel’s guidance states: ‘We know that sometimes safeguarding partnerships propose undertaking an ‘alternative learning review’ or use other terminology to describe different approaches to further review. We support and encourage different methodologies and approaches to review; however, any further review of a case should be referred to as an LCSP…’2 1.8 The BSCP would like to express its gratitude to Patrick for his participation and the way in which he has reflected upon and shared his experiences. It would also like to thank the practitioners and managers who contributed to the Review with both openness and transparency. 1 under 16C(1) of the Children Act 2004 (as amended by the Children and Social Work Act 2017) 2 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1108887/Child_Safeguarding_Practice_Review_panel_guidance_for_safeguarding_partners.pdf Page 19 4 2 Key Circumstances, Background & Context Early Life before Bromley 2.1 Patrick lived with his mother and four half-siblings during early childhood in two neighbouring boroughs. There were reports of sexual abuse of his older sister by a relative, but at that point, practitioners did not suspect that Patrick had been abused. 2.2 At the age of eight, Patrick and his siblings were placed on a Child Protection Plan (CPP) in Greenwich for emotional abuse (later the category was changed to neglect). Patrick’s mother was unable to meet the needs of her children and the behaviour of Patrick’s eldest sibling was causing significant concern. The children’s fathers were largely absent, although once the CPP was in place, Patrick’s father was known to spend more time at the family home providing support. 2.3 Despite the involvement of a range of agencies, Patrick’s behaviour became more difficult to manage. At the age of nine, he was absconding from home and his relationship with his mother was tense. Patrick was excluded from primary school and was placed in a special school. Although he was reintegrated to a new mainstream school, Patrick was again permanently excluded after a couple of months and returned to the special school. Early Life in Bromley 2.5 Patrick subsequently went to live with his father in Bromley at the age of ten years old. Greenwich Children’s Social Care (CSC) removed Patrick from his CP Plan (assessing father as being protective) and recommended that Bromley CSC consider a Child in Need Plan (given Patrick’s recent history). Bromley CSC decided that an early help response was more appropriate, and referrals to local Early Help services were advised. Father agreed with this approach. A Common Assessment Framework was put in place and Bromley Children’s Project worked with the family for a short period. 2016 2.6 In 2016, Patrick started secondary school. He was excluded in year 7. It was reported that a large kitchen knife was found in Patrick’s bag and that he had 5 threatened to bring a gun to school and ‘shoot all of them’. Patrick was arrested. There was also an allegation that Patrick had assaulted his mother. No assessment was triggered by Bromley CSC. 2.7 Patrick was also noted as bringing in a considerable amount of money into school. He expressed fear of physical chastisement if his father was told and was deemed to be at risk of self-harm. 2.8 Patrick’s father could no longer manage his son’s behaviour and there followed a period of Patrick staying with different family members. He regularly went missing and father reported that Patrick’s behaviour had changed in a two-month period. He subsequently became a looked after child under section 20 of the Children’s Act 1989 and placed with foster carers. 2.9 Whilst in care, concerns about Patrick’s behaviour continued. He was alleged to be the leader of a group of around 25 young people that were behaving anti-socially in public. By this time, Patrick was well known to the police, breaching bail conditions and routinely going missing from his foster placement. 2.10 The police were also engaged following father reporting that Patrick was trying to kill himself. Patrick was detained under section 136 of the Mental Health Act and was taken to hospital for assessment. This concluded that Patrick did not have any risks to his mental health and whilst there was follow up by Bromley CAMHS, this was short-lived due to Patrick being placed outside of the borough. 2.11 During 2016, there were further incidents of Patrick trying to harm himself and he was placed in different foster placements. A Family Group Conference was convened, but no family member offered accommodation. 2.12 From an education perspective, it was agreed that Patrick needed to attend a Pupil Referral Unit as he was not manageable in a mainstream school. He attended one for a short time, until his father raised concerns about the influence of other pupils over his son. 2.13 Towards the end of 2016, there was an incident in which Patrick tried to kill himself. Bromley CSC recorded that Patrick appeared to be ‘self-destructing’ although the social worker was unclear why. 6 2.14 He was not following the rules of his placement (in Bedfordshire), stating that he was Patrick, and he didn’t have to. This placement broke down soon afterwards due to a knife being found in Patrick’s bedroom and his foster carer reporting that Patrick was aggressive and non-compliant. An urgent referral had been made to CAMHS, although he was moved to another area before intervention commenced. 2.15 By the end of 2016, Patrick had been living in a variety of placements, from relatives, to foster carers in Hertfordshire and Bedfordshire. He ended the year in Northampton. 2017 2.16 At the start of 2017, Patrick commenced a Referral Order under Northampton Youth Offending Service. He attended a local Pupil Referral Unit but was soon excluded due to violence towards a teacher. 2.17 In March 2017, he was assessed by a CAMHS Consultant Psychiatrist as part of care proceedings that had been initiated by Bromley CSC. The Psychiatrist concluded that Patrick showed behaviours that were in keeping with a diagnosis of Conduct Disorder and that his threats to kill himself had been in the context of adults trying to place boundaries around his behaviour. The Psychiatrist also confirmed that Patrick did not have any neurodevelopment difficulties such as ADHD. 2.18 During the first six months of 2017, Patrick continued to move placements due to him causing serious damage and aggression. He repeatedly went missing. On one occasion he was found staying with his cousin who was a known child sex offender. He was removed and later disclosed to his social worker that his cousin had sexually abused him. Despite this disclosure, Patrick refused to engage with the police investigation. As part of this Review, the police have confirmed that no information has been held regarding this disclosure. 2.19 In November 2017, Patrick was moved to a placement in Birmingham due to his high-risk behaviours. Patrick continued to abscond from this placement and display violent behaviour. 7 2018 2.20 In 2018, Bromley CSC made the decision to apply for a Secure Order on welfare grounds. At this point, Patrick was also on a 3-month Referral Order in Shropshire having assaulted a police officer. He was subsequently placed in a secure children’s home in Wales, although he continued to abscond, and his behaviour escalated. 2.21 Whilst at this placement, there was a serious incident involving violence, aggression, Patrick making weapons, threatening female staff, and influencing the behaviour of other children. This resulted in the police being called. Patrick resisted arrest, was handcuffed and was subjected to a strip search. 2.22 Bromley CSC raised concerns about the secure accommodation not being therapeutic and that it was simply ‘holding’ Patrick. Whilst the provision explained their use of a trauma recovery model, Bromley CSC continued to try to address their concerns – particularly given the relationships between placement staff and Patrick had broken down to the extent where they would not enter his room unless he was sitting on his bed. In June 2018, Patrick was removed from the secure accommodation after seriously assaulting a member of staff. 2.23 He was placed back in Birmingham and Patrick was noted as expressing relief to be ‘free’ of his secure placement. There were questions regarding the appropriateness of Patrick’s care at the secure setting, with Patrick alleging that staff were pushing food into his room using their feet so as not to enter, removing his bed to make him sleep on the floor and taking all his clothes away so he had to ask for clothes to wear daily. 2.24 One of the key workers at Patrick’s new placement expressed a view that being a black boy could have been a contributory factor to his treatment by staff in Wales.3 There is no evidence that this was explored further by Bromley CSC. 2.25 In Birmingham, Patrick had a period of a few weeks in which he did not go missing or display any violent behaviour. However, this stability ended when Patrick was 3 There was no information found in inspection reports and other documents about the secure provision to demonstrate any consideration of equality, diversity, and inclusion. 8 once again moved, this time to a Secure Training Centre (STC). This was due to Patrick being remanded on charges of robbery and two stabbings. Patrick also had a pending case of grievous bodily harm (GBH). 2.26 Whilst at the STC, Patrick reported to his SW that he had been restrained, but not hurt. 2.27 In November 2018, a brief CAMHS assessment was undertaken by a Consultant Clinical Psychologist as part of Patrick’s pre-sentence report. This assessment described Patrick as looking ‘older than 14-year-old’. Patrick was noted to be ‘quite defensive and resistant’ when asked about his childhood. 2.28 The purpose of the assessment was to explore any therapeutic and treatment needs for Patrick in relation to his mental health, conduct difficulties and anger. He was reported to have asked for anger management at the STC but had been told he could not have this until after his trial. Patrick described how he would not instigate physical aggression but would always hit back if someone else started it. He admitted that if provoked, he would react with aggression once in the community. 2.29 Patrick demonstrated that he did not know what Conduct Disorder meant and responded well to the Psychologist’s explanation in terms of his offending behaviour. He was reported to be happier at the STC due to it being a ‘better multicultural fit’ than the secure accommodation. Patrick reported seeing peers he had been to school with, whereas, at the secure setting, his first interaction with another child was to punch them due to a racist comment. 2.30 This assessment also supported Patrick’s diagnosis of Conduct Disorder. He was not showing any signs of anxiety or depression, although the likelihood was acknowledged that he would have been affected by the separation from his family and being placed into custody at such a young age. 2.31 The assessment concluded Patrick to be a ‘very angry young boy’ and that he had ‘little ability to regulate his anger – this is to a clinically unusual degree and should be a focus of any intervention.’ It was also considered that he was minimising the extent of childhood maltreatment. 9 2.32 The Psychologist recommended that, as Patrick was asking for anger management support, intervention to address this should be a priority. Additionally, Patrick needed support to develop his emotional responses. It was recommended that the best outcome would be achieved through Patrick being in a wraparound therapeutic environment, with encouragement to take part in team sports to develop discipline and to use art therapy to help him to express his feelings. 2.33 The assessment did not identify any suicidal ideation from Patrick. However, during this time he was expressing threats to kill others and himself. 2019 2.34 In early in 2019 Patrick tried to hang himself, reportedly due to how he felt following an assault on a staff member at the STC. The STC did not report these events to Bromley CSC for two days. There was no immediate explanation provided for this delay, although Patrick’s social worker challenged the STC Governor on what had taken place. This incident was subsequently reported to the local LADO covering the STC. 2.35 Additionally, there were reported incidents of Patrick threatening another young person, causing damage to furniture, and punching a member of staff in the face. 2.36 In April 2019, Patrick was transferred to another setting, a Youth Offending institution (YOI). It is not entirely clear why he was moved, but there were concerns about the care being provided by the STC. 2.37 However, Patrick found it hard to adjust to this new placement. When seen by his social worker, he reported that he was fearful of other children as they frequently threatened him. 2.38 Some of these children were on remand for the murder of someone known to Patrick. His social worker reported that he also made threats about others. Patrick expressed feeling low because he spent his time alone. At the YOI, Patrick was also given a meal containing nuts, despite it being known he had a severe nut allergy. He required urgent treatment from the health care team who reported that Patrick had not ingested the meal but had swelling around his face, eyes, and lips. This event was reported to the local LADO for investigation. However, the names 10 of prison staff involved were not forthcoming. The outcome of the LADO investigation was for no further action, although there were subsequent changes made at the YOI for those needing access to EpiPens. 2.39 In October 2019 there was a plan to transfer Patrick to a therapeutic unit within the current YOI, but he declined due to the distance from his family. He remained at the YOI and accessed CAMHS to help him manage his emotions and anger. This then changed to an anger management group rather than one-to-one sessions. 2020 2.40 In 2020, a new social worker was assigned to Patrick. At the time of writing, they are still his designated SW. 2.41 In August 2020, Patrick was released on licence with supervision and placed in semi-independent accommodation in Bexley. At this point there was supposed to be a therapeutic element to his care, and whilst undefined, there was a plan to refer to CAMHS. 2.42 Patrick consistently failed to comply with his licence conditions and went missing. When found, at his father’s home, he refused to engage with the return home interview. He then breached his licence due to assaulting another young person at college. This was not reported to the police. He reported to his social worker and youth offending worker that he was the only black man in his class, and he felt there was a need to stand up for himself.4 2.43 Towards the end of 2020, Patrick was struggling to control his emotions and behaviour in the community. He was arrested for damaging a window at his girlfriend’s house. By this time, he had received two written breach warnings and would be recalled if he had a third. He was not accessing any emotional support or counselling. He also started a motor mechanic course. 2021 4 This was discussed with the Review Panel, and it was explained that there would be no role for the YJS worker or SW to risk assess the college environment, as this would be the responsibility of the college. 11 2.44 Patrick continued to have missing episodes and was recalled to the YOI. He attempted suicide once again, which led to another LADO referral. Following this incident, an event occurred in which Patrick was given (in error) a very detailed Asset Plus assessment relating to his recall. This contained details of his victims. Patrick was observed to be trying to make notes and allegedly needed to be restrained to remove the document from him. There were differing accounts from officers regarding the event, and they did not wear their body cameras. Due to the restraint, there was a referral to the LADO. 2.45 Shortly after this incident, a psychiatric assessment was commissioned as part of the parole recall. The assessment stated that Patrick met the criteria for Complex PTSD and, although not exhibiting a depressive disorder, it was recommended he should be monitored by specialist CAMHS. At this point, Patrick was noted to be in very low mood and losing weight. He then started to engage with the clinical psychologist at the YOI. 2.46 In June 2021, Patrick was released on licence and returned to the Bexley placement. He was successful in getting a job at a hotel but had several late returns to his placement. 2.47 In July 2021, he sent a photograph of himself covered in blood, accompanied by a “goodbye” message to his mother. A few hours later, the police were called by motorists reporting that Patrick was attempting to run into moving traffic on the M25. On the arrival of the police, Patrick is said to have attempted to run into the traffic again. He was detained under S.136 of the Mental Health Act and taken to hospital, before being discharged later that evening. 2.48 In August 2021, Patrick went missing after a domestic abuse incident with his girlfriend and after being arrested for six offences associated with this, he was recalled to a YOI. He disclosed domestic abuse by his girlfriend and childhood abuse and neglect. 2022 2.49 Patrick reached the age of 18 in 2022. At his final looked after review, it was agreed that Patrick’s current social worker would continue to work with him until 12 19 to provide consistency and stability. There was also a plan for therapeutic intervention and speech and language therapy (SALT). 3 Child Patrick’s Story: In his words “Try to speak to staff, even if you don’t get along, pretend, so you get support”. Overview of early problems 3.1 During interview, Patrick said he ‘followed’ his older brother who had learning difficulties and behaviour problems, not knowing what was right or wrong. He also struggled with his relationship with his mother, which led to involvement with CSC and Patrick subsequently moving to live with his father. 3.2 Patrick described his father as being old and not in good health. He felt he was doing well living with his dad and attending a new school. He played rugby, which he enjoyed. He reflected that he thought he was doing well in his life, although around this time he was arrested when he was showing off with a knife. From this point, things began to deteriorate rapidly. Key episodes of Patrick’s journey 3.3 Patrick spoke about what he considered to be the key episodes during his time in the care and criminal justice systems. Patrick was 12 years old when he was first taken into care and said that his placements were with older children. He felt he had been groomed to get into drugs and violence, stealing to make money to get a phone to ring home. “It was a crazy time; I had no relationship with anyone”. 3.4 During this time, Patrick kept his feelings to himself. He said he had so many changes of social worker (five). He reflected on the fact that he had no education and would just be in the placement all day, doing nothing. “I should have been able to stay in one place. I didn’t know how to deal with it. There was no one to help me.” 13 Secure Children’s Home (Wales) 3.5 Patrick was very vocal about his experience at the secure setting in Wales. He was there for about three months. He described it as being the worst experience. He said he suffered racism from peers and staff. “I was the only black person there”. 3.6 Patrick stated that he reported the racism to his social worker, however, he did not get on with this worker, and so nothing was done about it. He described how, on one occasion, he was restrained by staff as he would not go back to his room. This led to a member of staff being injured. 3.7 At this point, Patrick gave a vivid description of how he was made to stay in an empty cell, with no furniture and fed nothing other than finger food. He had no phone and even though he wanted to, he could not call home. He became angry, which he says led to an assault on a member of staff, for which he was arrested. Deepening Problems 3.8 Patrick said that he was charged for an assault on a staff member and kept in a police station for three days as CSC had no placements available. He was then moved to Birmingham, to a semi-independent, unregulated, setting. He was 14 years old. 3.9 Bromley CSC tried to find another secure unit, but Patrick explained that nowhere would accept him due to the incident in Wales. He absconded and went to London where he was later arrested at his mother’s home. 3.10 Patrick described how he was on the CAMHS list for years and that at some point he was diagnosed with a Conduct Disorder. 5 5 Conduct disorders are characterised by repetitive and persistent patterns of antisocial, aggressive, or defiant behaviour that amounts to significant and persistent violations of age-appropriate social expectations. There are associations between conduct disorder diagnosis and poor educational performance, social isolation, and increased contact with the criminal justice system. The NICE guidelines set out the need for good assessment of the child’s behaviour, followed by interventions involving parenting programmes, training for foster carers and child-focused social and cognitive problem-solving programmes. (NICE Guidance 158) 14 Trying to be Independent 3.11 Patrick described what happened when he was released from custody. He said he was released for six months, then recalled in 2021 for four months, out for two months, then recalled again in August 2021. These recalls were due to Patrick being arrested for further offences and him being assessed as too high risk to remain in the community. 3.12 Whilst out on release, Patrick had a job at a hotel and was also undertaking training as a motor engineer. He saved money and was living semi-independently. However, Patrick said he had no time for himself due to the licence, his work, and the course. Then his dad became unwell and Patrick was trying to look after him. This was a low time for Patrick. He attempted suicide. He said there was no support from CAMHS at this time. “Everything became too much. I quit my job and stopped everything.” Youth Offending Institution 3.13 Whilst at the YOI, Patrick experienced a life-threatening event due to a severe nut allergy. He described how he had ordered a lamb burger but was told that there was only chicken satay left. He did not know this contained nuts. 3.14 He took the meal to his room. He had one mouthful and knew the signs of a reaction. He threw the meal away and got into bed. His throat was getting tight. He pressed the emergency buzzer. Patrick stated that staff are supposed to respond in two minutes, but no one came. He banged on the door, but no one responded. He said he managed to phone his mum and she phoned the YOI. Staff entered the room but did not get his EpiPen from the health care hub. An ambulance was called, and the paramedics treated him. 3.15 Patrick said there was an investigation, and the food arrangements were changed and that EpiPens are now allowed in the young person’s room. He also received a formal apology. 15 Reflections as an Adult 3.16 Patrick was able to reflect on his childhood experience. He said that the last recall to prison really helped him6. He has been able to speak to staff for help and he feels he is building relationships. “Last 3 years I have had the best social worker, no silly question. I am staying with her until I am 19.” 3.17 Patrick said he is working on his GCSEs and is still keen to do motor vehicle work. He feels he now has a support network around him for when he is released. 4 Analysis of Practice 4.1 The difference made when Patrick had consistent workers, identified support networks, and had access to education is noteworthy. The current social worker and youth offending worker particularly stand out for Patrick. Additionally, the access to therapy and education at his current YOI seems to have made a significant difference to Patrick. 4.2 Patrick feels he will be supported when released which will enable him to get used to being out in society. Whilst there are no guarantees, there is optimism for Patrick. This optimism is enhanced by what is seen as a strengthening in the continuity of care for Patrick and improved integrated working. These can be powerful tools in changing the prospects of the young and vulnerable. Children Looked After 4.3 Until the final social worker took on her role with Patrick, there was little evidence of Bromley CSC providing a stable and consistent ‘corporate parenting’ role for Patrick. This was affected by the regular changes of social worker which meant that no one could establish a trusting relationship with Patrick. In this sense, the ability of practitioners to affect change was seriously hindered. This theme was discussed in depth by the Review Panel, with an acknowledgement that worker stability is a known issue on a national level, influenced by both systems and 6 Patrick was recalled to custody in September 2021 due to having been arrested for six alleged offences against his girlfriend, including theft and violent behaviour. He was not recalled to the initial YOI due to the ongoing legal case regarding the inappropriate use of force and so he was recalled to another YOI instead. 16 workforce pressures. Whilst there are no easy answers in this respect, clear workforce strategies and a leadership focus on manageable caseloads and two areas that are known to improve staff turnover. 4.4 Whilst there were reviews of Patrick as a looked after child, he was noted as not engaging with some of the health reviews. Furthermore, there was limited evidence of attempts to understand Patrick’s early childhood and his potential exposure to any adverse experiences. Given his siblings had disclosed abuse, this should have been considered in more depth. Indeed, this could have created opportunities for Patrick to disclose earlier and this may have facilitated an improved focus on Patrick’s needs. As it was, a stubborn view of Patrick emerged and remained. He was viewed by the multi-agency network as an ‘instigator of poor behaviour’ and seen as a ‘risk to others and himself’ as opposed to being fundamentally vulnerable in his own right. 4.5 Patrick was placed around the country, but there seemed to be limited access to CAMHS to allow for an assessment of his emotional wellbeing, at least not until 2021. Had this happened earlier, then Patrick might have been able to gain some benefit from therapeutic intervention. Additionally, there was insufficient understanding of Patrick’s institutionalised living and the impact of this on his ability to cope with living with the community. 4.6 When Patrick was at the secure children’s home in Wales, he reported that he informed his social worker about racial abuse, but felt that he was not listened to, and that he had no one to help him. 4.7 Patrick was a looked after child and should have had his social worker to call on to hear his concerns in the same way a parent would listen to their child. Whilst Patrick’s concerns about the care he received were eventually identified, they do not appear to have been escalated for any further exploration or considered in Patrick’s care plan. 4.8 From a Bromley perspective, once Patrick had moved out of the borough it was a challenge for professionals to work together. This, alongside the frequent changes in worker, meant there were limited opportunities for local networking that is likely to have improved the understanding about Patrick’s needs. 17 4.9 As a looked after child, Patrick was moved frequently. Every move reinforced the pervasive view of Patrick’s risk towards others, his violent response towards workers and threats against others. The impact of these moves was likely compounded by the lack of any coordinated approach to gaining therapeutic intervention for Patrick. Such support could have helped Patrick learn how to better regulate his emotions and behaviour. Secure Training Centre 4.10 At the age of 14, Patrick was placed at the STC. This was the first ‘stable’ setting since Patrick had been 10 years old. At the time, he seemed to be more settled as it was nearer to home. His family were able to visit, and he knew others there from his primary school. Nevertheless, there were still serious incidents involving Patrick and violence and he was considered to be a risk to others: staff, boys, and girls, as well as to himself. 4.11 In 2019, the STC’s Local Safeguarding Children Board commissioned a Serious Case Review (SCR) in relation to the STC. This was following whistleblowing concerns about the safety of the children and how some staff were violent. Amongst a range of findings, the SCR identified the need to improve children’s access to have their voices heard and greater oversight of practice. 4.12 The STC closed in March 2021. At the time of writing, there is a plan for the first ever Secure School to open at the same site. Secure schools are an alternative to youth offending institutions which place child-focused education, health, and resettlement at the very heart of the youth secure estate. The method of intervention will be underpinned by therapeutic principles designed to build on individual strengths and develop life and social skills that support children’s transition back into the community. At the practitioner event for the current review, there was discussion about the increased options that will be available for a trauma informed approach. Youth Offending Institution 4.13 Patrick was placed in the first YOI in 2019. He experienced a life-threatening episode due to his nut allergy. It is positive that this was investigated, changes made and Patrick received a formal apology. However, this was such a dangerous episode for a child with a history of not being able to trust the adults responsible for providing his care. 18 4.14 The LADO investigation into this incident noted that the YOI took the concerns seriously and concluded that no further action was needed. Whilst noting differences in the account provided by Patrick and the YOI, measures have since been put in place to prevent a recurrence. 4.15 With regards to the incident involving Patrick being mistakenly given a copy of his Asset and parole dossier, his restraint and the injuries he sustained resulted in a referral to the LADO and a child protection enquiry under section 47 of the Children Act 1989. 4.16 The local LADO service has developed strong links with the YOI to provide some independent scrutiny of the use of force by staff. This has meant that the LADO has been involved in restraint minimisation meetings and safeguarding meetings. The LADO service has worked with the YOI to encourage the activation of Body Worn Cameras, as whilst the cameras are mandatory, their activation is not. In terms of Patrick’s experience, the cameras were not activated when he was restrained during the incident with the documents. Had they been it would have helped to analyse how the incident occurred. 4.17 It is understood that the Local Safeguarding Partnership relevant to the YOI raised this issue with the Secure Estate Quality Assurance Subgroup and received a response that a new model of body worn cameras is to be introduced to overcome the issue of short battery life, as cameras constantly record but the batteries do not always work. 4.18 In April 2022, the YOI was subject to a formal inspection by HM Inspectorate of Prisons for England and Wales (HMI Prisons). This was a year after Patrick had left this setting. The findings illustrate that several stubborn challenges remain. • There was a lack of purposeful activity. • Staff did not challenge poor standards on residential units. • Staff had low expectations of the children. • Levels of violence were high, with no plan for violence reduction. • There was insufficient investigation of complaints about discrimination (28 complaints in the previous six months). • Lack of access to mental health support and therapeutic intervention. 19 • There had been improvements in the level of education support for the children. Access to Education 4.19 The timeline regarding Patrick’s Education Health and Care Plan (EHCP) was not clear until September 2020 when the EHCP was finalised. However, there had been assessments recorded since 2015, when Patrick had an educational psychology assessment whilst at secondary school in Bromley. This assessment was to consider his learning, emotional and behavioural presentation. There does not appear to have been a handover from the previous local authority or schools, where his behavioural issues were known. 4.20 There were prior reports that Patrick was performing academically at a level of average to above average. Because of this and given early concerns were in relation to Patrick’s emotional wellbeing and behaviour, his needs did not fit with the SEND categories. In this respect, schools would have been expected to manage Patrick’s disruptive behaviour.7 4.21 By 2018, when the EHCP assessments commenced, Patrick was being placed around the country in various settings. This required engagement from the education providers at these placements. Patrick described how he received no education whilst in Wales. The Virtual School team described how difficult it was to find a good personal education plan (PEP) whilst he was in custody, due to the lack of engagement by placement education teams. Interagency Working 4.22 At the Review Panel and practitioner event, there was good interaction between agencies. However, this was not evidenced in the chronologies viewed as part of the Review. Whilst the police, CSC and YOS were aware of the incidents during Patrick’s journey, there was limited evidence of effective joint working and planning to consider why he was displaying such a high level of violence and what could be done, together, to help. 4.23 A key barrier to working together was that Patrick was not placed in Bromley. The responsibility for intervention was dispersed across a range of agencies local to 7 DFE/DoH (2015) Special educational Needs and Disability Code of practice: 0-25 years. 20 his placements. Up until 2019, there were further complications caused by Patrick having changes in social workers. The challenges in cross-borough working manifested in several ways, most markedly seen in the accurate and timely sharing of information. 5 Findings and Recommendations Finding 1: Preventing permanent school exclusions needs to be a key feature of Bromley’s early help arrangements. 5.1 Behavioural issues, including persistent disruptive behaviour and those that are deemed to create a risk to others can lead to children being permanently excluded from school. Such action can ultimately expose children to pathways to harm, such as exploitation and criminalisation8. Numerous reviews and research have frequently identified the impact of school exclusions on the outcomes for adolescents, especially boys 9 10 with 86% of children in YOIs having been excluded from school at some point.11 12 5.2 Supporting the substantial evidence in this context, The Young Lives Commission recommended: “That the exclusion from school of primary school age children is ended within the next four years, and that schools are supported with the necessary resources to achieve this. Local partnerships with youth services and youth organisations to engage and support young people at risk of crisis. We would like to see teams of youth and community workers in all schools to build relationships and support young people.”13 5.3 The experiences of Patrick reinforce the benefits of keeping children at school wherever possible, and for local safeguarding arrangements to maintain focus on the provision of effective early help to make this happen. 8 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/870035/Safeguarding_children_at_risk_from_criminal_exploitation_review.pdf 9 The National Child Safeguarding Practice Review Panel (2021) Annual Report for 2020. 10 Sutton LSCP (2021) LCSPR: Child V 11 Ministry of Justice (2014) Transforming Youth Custody 12 Commission on Young lives (2022) All Together Now: Inclusion not Exclusion: Supporting all young people to succeed in school. 13 Commission on Young lives (2022) All Together Now: Inclusion not Exclusion: Supporting all young people to succeed in school. 21 5.4 Notwithstanding the complex childhood that Patrick experienced (and whilst also recognising hindsight bias), it is not unreasonable to suggest that had early help been more effective in Patrick’s younger years, then he may very well have followed a different pathway to protection. 5.5 Ideally, this early help should have been looking to address the root causes of Patrick’s behavioural difficulties – as opposed to simply leaving the education system to deal with their consequences. In this respect, the importance of identifying and intervening with Adverse Childhood Experiences (ACEs)14 is key. 5.6 Indeed, Patrick’s story highlights similar themes as those found in the Croydon Vulnerable Adolescents Thematic Review (2019). 15 This also referenced the prevalence of ACEs and the need to intervene with these in mind. Whilst Patrick did not disclose the abuse he had suffered until relatively recently, services involved at the time were aware of the abuse suffered by his sibling and this should have triggered professional curiosity and a more forensic focus on what might have been causing his behaviour to deteriorate. Recommendation 1 The BSCP should seek reassurance on the effectiveness of early help in the context of children being at risk of exclusion / permanent exclusion. The evaluation of sufficiency in this respect should include a focus on the ability of local practitioners to recognise and intervene when there are identified Adverse Childhood Experiences. Recommendation 2 The Local Authority should review / develop a specific exclusions strategy that is formally adopted and embedded as part of the BSCP’s written safeguarding arrangements. As relevant agencies, all schools and colleges will have a statutory duty to cooperate with these written arrangements. Recommendation 3 The Local Authority should routinely report to the BSCP on exclusion rates, and reasons, by ethnic background, gender, age, and number of episodes. 14 Original ACE Study: Am J Prev Med(1998) - V.J. Felitti et al. https://www.ajpmonline.org/article/S0749-3797(98)00017-8/fulltext 15 Spencer, Charlie, Griffin, Bridget, Floyd, Maureen and Croydon Safeguarding Children Board (2019) Vulnerable Adolescent Thematic Review. 22 Finding 2: The adultification of children masks their needs. 5.7 Within the CAMHS assessment completed in 2018, Patrick was described as looking older than his years. In the documentation seen by the Review and through conversations with practitioners, this was a view reinforced by others. Alongside the physical presentation of Patrick, it is not unreasonable to deduce that practitioners were also influenced by Patrick’s behaviours. Indeed, the narrative about Patrick’s violence towards others (whilst accurate) is also likely to have influenced how practitioners saw Patrick as being older than he was. The perception of Patrick as being older is, in the opinion of the Review, evidence of adultification. This ultimately meant that opportunities were missed to better intervene with Patrick as a child. 5.8 Explaining further, Davis16 highlighted how the rights of Black children are often weakened due to them being viewed as perpetrators of crime, rather than being at risk of harm or exploitation. Black children who are subject to the criminal justice system are not always being safeguarded or treated with compassion and support. This leads to the amplification of racism, the application of social stereotypes and insufficient curiosity regarding the lived experience of Black children in secure settings. The result is that Black children can be ‘categorised as undeserving when in need of safeguarding and protection.’ 17 5.9 The impact of this ‘undeserving label’ can perhaps best be seen through Patrick’s experiences in the secure children’s home in Wales. Here, Patrick was the only black person and spoke of the racism he experienced. Whilst not excusing his behaviour, there was no attempt to find out the catalyst for his violent acts, rather the label of a violent young man became prevalent. From conversations with both practitioners and the Review Panel, there was agreement that this perception largely prevented Patrick from being placed in a wraparound therapeutic environment to give him the best chance for a positive outcome in his future. 5.10 The understanding and application of ‘intersectionality’ by practitioners could also have helped facilitate a better understanding of the support that Patrick required. 16 Davis, J. (2022) Adultification bias within child protection and safeguarding. HMIP 17 Davis, J. (2022) Adultification bias within child protection and safeguarding. HMIP 23 Intersectionality1819 enables an individual to be viewed through multiple lenses, e.g. gender, ethnicity, physical or mental ability, employment. Whilst there was evidence of numerous assessment and planning activity, there is little evidence these were sufficiently focused on the full range of factors that needed to be understood in the context of Patrick’s lived experience. Recommendation 4: The BSCP should ensure that policy, guidance and training is developed and launched on both adultification and intersectionality. Recommendation 5: Bromley CSC should undertake a review of the plans for all children placed in YOIs, STCs and Secure Children’s Homes and provide reassurance to the BSCP that these are appropriate. The plans should be evaluated to test whether they consider the full range of factors impacting upon a child (intersectionality) and that intervention in these contexts is not being influenced by adultification bias. Finding 3: Strong oversight is needed for children in secure settings. 5.11 Patrick’s experiences highlight the significant number of placements that children can experience when they are looked after and / or in need of a secure settings. This is far from ideal, with research and practice experience reinforcing that good placement stability often leads to improved outcomes. For Patrick, a child with a disrupted and unstable childhood, his frequent moves will have done little for his sense of belonging, his self-esteem and his ability to visualise a positive future. 5.12 Beyond the existing placement challenges for children requiring care, the extreme challenges in finding secure placements for young offenders in England are well recognised. Such pressures have been highlighted in other reviews which emphasise the urgency for solutions.20 This is undoubtedly easier said than done. 18 UN Gender and racial discrimination: Report of the Expert Group Meeting) https://www.un.org/womenwatch/daw/csw/genrac/report.htm 19 Dhamoon, R. K. (2011). Considerations on mainstreaming intersectionality. Political Research Quarterly, 64(1), 230–243. 20 Croydon SCP (2019) Child Q Overview 24 5.13 However, the sourcing of secure placements is not the only issue of concern in this regard. When placements are identified, they can be high cost and poor quality. Indeed, the Independent Review of Children’s Social Care concluded that YOIs and STCs “are wholly unsuitable for children”21. It recommended that the system is redesigned to be managed regionally under the national oversight of the Department for Education to ensure that there is a greater focus on children.22 5.14 In terms of Patrick, his lived experience is marked with trauma and a professional response that was insufficiently attuned to what life was like for him in these settings. Of relevance to how Bromley can deliver improvements in this area, Walters (2019) recommended that: “All Local Authorities who have children placed in the secure estate or host the secure estate to ensure that they engage with a high level of professional curiosity and ensure they ask and understand the child’s lived experience” 23 The Review makes the following recommendation in this regard. Recommendation 6: Bromley YJS should ensure that they have access to inspection / monitoring reports for any secure settings in use, as well as reports from advocacy services. This will enable them to raise any concerns with the relevant Youth Custody Service. If there continue to be concerns about a secure setting where a Bromley child is placed, the Bromley YJS should escalate through the YJS Executive Board and LSCP. Recommendation 7: As part of ongoing engagement with children placed in secure settings, their wishes, feelings and experiences of the placement should be routinely established, with any concerns being transparently addressed with the provider and/or through the escalation routes defined in recommendation 6. 21 MacAlister, J. (2022) The Independent Review of Children’s Social Care https://childrenssocialcare.independent-review.uk/wp-content/uploads/2022/05/The-independent-review-of-childrens-social-care-Final-report.pdf 22 MacAlister, J. (2022) The Independent Review of Children’s Social Care 23 Medway Safeguarding Children Board /Walters, A. (2019) Serious Case Review ‘Learning for organisations arising from incidents at Medway Secure Training Centre’ 25 Finding 4: Practitioners need to routinely use opportunities to understand the reasons for a child’s behaviour. 5.15 Despite escalating violence, spiralling criminal activity and regular missing episodes, the professional network did not use all available opportunities to come together and think through the reasons for Patrick’s behaviour. 5.16 Of importance in this respect is the information that can be gleaned from children themselves. Their voices can help practitioners better understand those reasons and plan how to mitigate risk. Several defined mechanisms are already in place to help facilitate talking with children, such as through the return from missing interview process. Looking at Patrick’s journey, there was limited evidence that this process was used to best effect. Recommendation 8: Bromley CSC and Bromley Police should provide reassurance to the BSCP about the quality and effectiveness of return home / return from missing interviews for children placed both in and outside of the borough. Finding 5: Children in semi-independent living need ongoing support. 5.17 Patrick was provided with semi-independent accommodation without the support of a trusted adult. The benefits of such support should not be underestimated. Much in the same way that most parents continue to help their 16/17-year-old children, it would be unusual for those in semi-independent living not to have the same needs – if not more. This was a large gap in Patrick’s care plan that should have been filled. Notwithstanding his age, Patrick’s previous offending and violent behaviour should have made it obvious that he required enhanced support not less. As it was, Patrick was left to his own devices and was relatively alone in having to regulate his behaviour. The challenges he subsequently experienced were predictable. 26 5.18 Reflected as a theme in other local reviews, the learning from ‘Leo’24 illustrated the need for Bromley SCP to satisfy itself that the network of preventative services is making effective provision for young people who have risk factors that have an association with violent offending. An enhanced focus should be applied on those in semi-independent living arrangements. Recommendation 9: The BSCP should revisit the recommendations from the ‘Leo’ case and seek reassurance that improvements have been made and are being sustained in respect of the provision of support for young people who have risk factors that have an association with violent offending. Recommendation 10: Bromley CSC should dip sample a range of cases of children living in semi-independent living to ensure they all have access to a trusted adult and that support plans are sufficiently robust. Finding 6: The importance of escalation about education 5.19 Patrick’s experiences illustrate the barriers that some children can face in accessing a good education whilst in secure accommodation. They also demonstrate the positive impact that effective education arrangements can have on children’s outcomes when support is in place and that this is individualised and focused. For example, when Patrick did receive an education, it was noted that he did well, both in academic subjects and in sports. The power of good education should never be underestimated. 5.20 In terms of Patrick’s journey, whilst acknowledging the challenges of placement stability, there were some obvious deficits at Patrick’s secure settings with his educational needs neither being prioritised nor met. There was less focus (and perhaps urgency) about Patrick’s education within the overall plans for his care, and an absence of challenge to those settings that were insufficient in engaging with Patrick’s personal education plan. 24 Bromley SAB (2020) Learning Review: Leo. 27 Recommendation 11: Bromley Local Authority (Education) should review the standards expected for personal education plans for children placed in secure settings. A defined escalation process should be developed that is triggered if secure settings fail to properly engage and implement such plans Finding 7: Practitioners need to ‘reach out’ with mental health support, particularly for those in secure settings. 5.21 Patrick’s experiences illustrate the challenges that exist for some children in swiftly accessing child and adolescent mental health services when in care or criminal justice settings. For those children needing this support, a lack of timely intervention is likely to negatively impact on their ability to address previous trauma and move on in their development. 5.22 Whilst efforts were made to provide a therapeutic environment for Patrick, this was relatively late in his journey. Ideally, this should have been made available when he was first taken into care. Whilst the Review acknowledges both the historic pressures facing CAMHS, alongside the more recent and exceptional surge in demand (following the Covid-19 pandemic), it is hard to think of any cohort of children more in need of support than those placed in secure settings. 5.23 As a collective of ‘corporate parents’ (in its widest sense), the multi-agency network in Bromley needs to ensure that the therapeutic needs of this group are being routinely and effectively met. 5.24 To support this priority group, there is also a need to reflect upon the sufficiency of pathways into key services. For example, whilst recognising the practical requirement for CAMHS to manage demand, an existing approach that closes cases where there is no clear willingness to engage seems limited in terms of ‘reaching out’ to help children and families25. 25 Croydon SCP (2019) Child Q Overview 28 5.24 Indeed, for some children, and perhaps for those with similar issues to Patrick, they might not recognise their need for support. This does not make their needs go away, and even if the first answer to the offer of support is ‘no’, this should prompt the system to be more proactive, not less. In such circumstances, the wider partnership, including CAMHS, needs to default to using creative means to encourage engagement, particularly for those in secure settings and for those who are hesitant or reluctant.26 Recommendation 12: The South East London ICB should provide reassurance to the BSCP regarding how CAMHS support is appropriately prioritised for children who are in care and/or in secure settings and how those hesitant / reluctant to engage are encouraged to do so. Finding 8: The child’s voice was, is and always will be central to effective help and protection. 5.25 Patrick was extremely articulate in describing his experiences. He was able to explain how both his workers and placements frequently changed and how he saw a difference in those practitioners with whom he is now involved. They have clearly made a positive impact on Patrick. Trusted adults make a difference. 5.26 However, in reflecting on his journey, the multi-agency system seems to have been either disinterested or ineffective in routinely hearing Patrick’s voice. This would have been an important omission for any child, but for one living in settings that were less open to the ‘public eye’, the failure to focus on Patrick’s voice was a significant deficit. Hearing children’s voices is established good practice and the rationale for why this should happen does not need to be repeated here. That said, in the context of children involved in criminal activity (or on the periphery of it), listening to them can help practitioners respond effectively and avoid further criminalisation.27 26 Sutton SCP (2020) Child T. 27 Mayor of London (20210) Protocol for reducing Criminalisation of looked after children and care leavers. https://www.london.gov.uk/sites/default/files/reducing_criminalisation_of_looked_after_children_and_care_leavers-_a_protocol_for_london.pdf 29 5.27 Despite some of the historical issues, the Review recognises the positive changes made locally since Patrick’s experiences. For example, practitioners from Bromley YJS were noted as more regularly visiting children placed out of borough. This is likely to help them develop consistent, trusted adult relationships and enable them to talk about their experiences. It will similarly allow practitioners to identify and respond to any concerns. Recommendation 13: Bromley YJS should provide reassurance to the BSCP about how it provides a trusted adult role for children in secure settings and when they are released. Recommendation 14: The BSCP should consider how it can hear the voices of children placed in secure settings by way of its direct engagement with them (i.e. surveys / interviews, health assessments). This activity should be developed and undertaken as a defined part of Bromley’s Learning and Improvement Framework. 30 6 Appendix 1: Term of Reference Decision to Conduct a Review This case was considered at a meeting of the Safeguarding Practice Review Subgroup in March 2021. The Independent Chair concluded that there was a pattern of being moved around to different youth offending services (YOS)/ youth justice services (YJS) and institutions, with lack of consistent support, frequent confrontations and attempts to self-harm. The Chair agreed to a Thematic Review which aims to provide a contextual view of a young person in custody. Period under Review A detailed chronology should be provided by relevant agencies from 01/06/2016 until February 2022 and a summary of any significant events prior to this. Methodology The agencies identified in Section 6 are required to prepare a chronology of the agency’s contact with Patrick. Professionals involved with the family were invited to an Engagement and Reflection Session with the Investigative Author after the chronologies have been reviewed. A further meeting for professionals will be held after the first draft of the Overview Report has been completed. The Independent Reviewer will lead the review and produce an Overview report. The Case Review Group will support the Reviewer, contribute expertise, consider learning from the review and will be responsible for developing an action plan in response to any recommendations. Scope of Thematic Review 1. Establish the context of Patrick’s life prior to his engagement and involvement with social care and the criminal justice system - focusing on timescale of 2016, with background information of earlier life. 2. Develop an understanding of Patrick’s journey through the system from his perspective (via his voice). 3. Establish whether the system made the situation better or worse. In doing so address the following issues: • How does the system reflect a parenting/corporate parenting approach? 31 • What are the systems for identifying adverse childhood experiences of children involved in serious offending? • What is the role of professionals in working together (e.g., YJS and CSC) to safeguard the child and how have agencies responded to meeting his needs overtime? • Why does a young person enter the youth justice system? Use this young person’s voice and story to consider how Bromley can prevent this pathway for other children. • What is the experience of a young person in secure estate/custody? -general care, keeping safe, use of restraint, rehabilitation? • How is a young person's health and wellbeing managed in a secure estate? i.e. what is the healthcare plan within secure estate (mental and physical health)? • How can the LSCP gain assurance about the safeguarding of the local young people placed out of borough in secure estates - research from LSCPRs, NHSEI commissioning of health in justice, Youth Justice Board, YOT etc • What work was undertaken on the reduction of risk for Patrick? Was this considered before moving him to other placements? • Whether the frequent moves between placements is common for young people in custody and how this impacts the young person. 4. Identify the challenges that services face and deal with in protecting and safeguarding children with complex needs that are further exacerbated by being remanded. This should include consideration of: • Confrontations with staff and other young people in custody. How well was safeguarding policy understood by the YOI staff? (To include Restraint Policy, safe environment, de-escalation techniques and conflict centred strategy). Were policies adhered to and what can be learned? • The provision of medical assistance, access to medical equipment and access to advocates (including family) at times of crisis. Was access to medical equipment/assistance readily available and did it follow the YOI policy? Agencies Involved Chronologies were requested from the following agencies: • Children’s Social Care • Youth Justice Service (YJS) 32 • CAMHS • Bromley Healthcare • Early Intervention and Family Services • Metropolitan Police • LBB Placements Team (CPT) • Virtual School • LBB Education (SEN) • GP • Prison Services including Oxleas Prison Healthcare Services Independent Chair and Author The Independent Chair of the SPR Review Group will be Jim Gamble, the BSCP Independent Chair. The Independent Reviewer will adopt an investigative approach. They will be independent of BSCP, and the organisations involved in the case. Family Involvement Consent is not being requested in order to carry out this Thematic Review. The young person will be informed and invited to contribute to the review. |
NC52382 | Life-changing injuries to a 10-and-a-half-month-old infant in November 2013 due to shaking. Mother's partner was convicted of causing grievous bodily harm and was imprisoned. Mother was convicted for neglect and received a suspended sentence. Baby B was the second child in the family. Baby B's parents had separated and both children were living with their mother and her partner. Anonymous report about neglect made to the NSPCC in June 2013; Children's Social Care found no concerns. Baby B was not brought to several health appointments; sibling had high rate of school absenteeism. Concerns about domestic violence; mother's partner's child had been subject to a child protection plan due to domestic violence in earlier relationship. Family is White British. Case review conducted following an investigation in December 2018 by the Local Government and Social Care Ombudsman into complaints made by Baby B's father against East Riding Council. Learning includes: concerns made anonymously should be treated as seriously as those that are not anonymous; health visitors and school nurses provide a useful link between schools and health services; where professionals have personal or professional relationships with a service user or someone closely involved with the service user there is the potential for professionals' boundaries to become blurred. Recommendations include: practitioners must ensure that they are complying with current legislation, statutory guidance and agency polices relating to information; ensure that the minutes of strategy discussions are included within the case record of all agencies involved in the meeting and include the arrangements for review.
| Title: Serious case review overview report: Baby B. LSCB: East Riding Safeguarding Children Partnership Author: Peter Ward Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. East Riding Safeguarding Children Partnership Serious Case Review Overview Report Baby B Author: Peter Ward Report Date: 2nd March 2020 Serious Case Review – Baby B 2nd March 2020 Page 2 of 24 Table of Contents Page 1. Introduction 1.1 Circumstances Leading to the Review 1.2 Report Format 3 2. The Review Process 4 3. Family Structure 6 4. Key Episodes 4.1 Anonymous concern about neglect 4.2 Sib B’s health and school attendance 4.3 Missed health appointments for Baby B 4.4 Information about SF commencing a relationship with MB 4.5 Anonymous concern about possible domestic violence against MB 4.6 Admission of Baby B to hospital with life changing injuries 6 5. Analysis 5.1 Responses to issues around possible neglect 5.2 Responses to concerns about possible Domestic Violence 5.3 Initial response to medical presentations 5.4 Response to concern about possible non-accidental injury 5.5 Professional boundaries and potential conflict of interest 11 6. Significant changes to practice since the time period considered by this review 19 7. Conclusions 21 8. Learning Points 22 9. Recommendations 23 Appendix 1: Initials Serious Case Review – Baby B 2nd March 2020 Page 3 of 24 1. Introduction 1.1 Circumstances Leading to the Review 1.1.1 The subject of this Serious Case Review is Baby B who was admitted to hospital in November 2013 due to fitting and seizures. Medical investigations established that Baby B demonstrated the symptoms of Shaken Baby Syndrome; Baby B was 10½ months old at the time. 1.1.2 Baby B was born in January 2013 as the second child of Baby B’s mother MB and father FB; Baby B’s older sibling was born in 2007. At the time of Baby B’s birth the family lived together and were in receipt of universal services. FB worked six days each week and MB was the primary carer for the children. 1.1.3 By the time of the incident that led to this review, Baby B’s parents had separated and both children were living with their mother who had commenced a relationship with SF. SF has been convicted and imprisoned for inflicting the injuries on Baby B. MB was convicted for her failure to protect Baby B, who was left with life-changing injuries as a result of this incident. 1.2 Report Format 1.2.1 Section 2 of this report explains the process that was followed in undertaken this review. It introduces the report author and lists the membership of the review team. It identifies the sources of information used to inform the review and describes the principles of the review. 1.2.2 Section 3 lists relevant family members and other members of the public who are referred to in this review. These individuals are not named but are described using their connection to Baby B. 1.2.3 Section 4 provides a factual summary of six key episodes of agency involvement with Baby B and family. It is not a comprehensive record of all contacts with the family but focuses on those episodes that are considered to be significant to the way the case developed. 1.2.4 Section 5 provides an analysis of the information using five key themes that have emerged. For each theme, learning points are identified. 1.2.5 Section 6 provides a summary of relevant, significant changes to practice that have occurred since the events considered in the review. 1.2.6 Section 7 contains the conclusions of the review. 1.2.7 Section 8 lists the learning points that are identified in the analysis. Serious Case Review – Baby B 2nd March 2020 Page 4 of 24 1.2.8 Section 9 contains 10 recommendations made to East Riding Safeguarding Children Partnership. These are cross referenced with the individual learning points to which they apply. 2. The Review Process 2.1 East Riding Safeguarding Children Board (ERSCB) decided to commission this Serious Case Review in May 2019. This decision was made following completion of an investigation, in December 2018, by the Local Government and Social Care Ombudsman into complaints made by Baby B’s father (FB) against East Riding Council. Within their report, the Ombudsman recommended that the Council make a referral to the East Riding Safeguarding Children Board Serious Case Review Panel (or its successor organisation when new safeguarding partner arrangements were in place.) The Council made such a referral and, following the emergence of new information, ERSCB decided that the criteria for a review had been met. 2.2 Although Working Together to Safeguard Children 2018 replaced Serious Case Reviews with Child Safeguarding Practice Reviews it was decided that, in this case, a Serious Case Review was the appropriate way forward. This is due to the timeframe being considered and the fact that, at the time of the decision, ERSCB had yet to fully transition to a Partnership. 2.3 Peter Ward was commissioned as the Independent Lead Reviewer for the review. Mr Ward has a background in social care and has worked in management and front line social work. He is qualified to degree level in social work and has a post-graduate diploma in management studies. Since 2005 he has been involved in Serious Case Reviews as an Independent Overview Report Author, Individual Management Review Author or Panel Chair. Mr Ward has undertaken training in respect of using systems approaches1 when undertaking Serious Case Reviews and he is an accredited Lead Reviewer with Review Consulting having successfully completed the SILP2 Lead Reviewer training. 2.4 The Learning and Improvement Manager for East Riding Safeguarding Children Partnership (ERSCP) led the process for the partnership. A ‘Review Team’ consisting of representatives from agencies that had involvement with the family during the time period under review was established to oversee the process. The membership of the Review Team was as follows: Designated Safeguarding Nurse (Chair), East Riding of Yorkshire Clinical Commissioning Group (CCG) Detective Inspector, Protecting Vulnerable People Unit, Humberside Police 1 The systems approach “focuses on a deeper understanding of why professionals have acted in the way they have, so that any resulting changes are grounded in practice realities” (Munro, 2011). It “looks for causal explanations of error in all parts of the system not just within individuals” (Munro, 2005). 2 SILP (Significant Incident Learning Process) is a specific approach to carrying out a review which has been developed and is owned by Review Consulting. Serious Case Review – Baby B 2nd March 2020 Page 5 of 24 Senior Probation Officer, National Probation Service, North East Division Safeguarding GP, East Riding of Yorkshire Clinical Commissioning Group Deputy Headteacher, Primary School Named Nurse Safeguarding Children, Humber Teaching NHS Foundation Trust Named Nurse for Safeguarding Children, Hull University Teaching Hospitals NHS Trust (HUTH) Interim Head of Service, Children & Young People Support & Safeguarding Service, East Riding of Yorkshire Council Service Manager, Children & Young People Support & Safeguarding Service, East Riding of Yorkshire Council Learning & Improvement Manager, East Riding Safeguarding Children Partnership 2.5 All relevant agencies reviewed their records and provided scoping reports and chronologies detailing their involvement with the case, including a brief analysis of their involvement. The agency chronologies were merged and used to produce an interagency chronology. This was used to inform learning and identify areas for further exploration and consideration. The timeframe for the review was agreed as from January 2013 when Baby B was born until November 2013, three days after Baby B was admitted to hospital with the life changing injuries. Chronologies and scoping reports were provided by the following agencies: Children’s Social Care (CSC) Children’s Independent Safeguarding and Reviewing Officer Service (CISRO) Domestic Violence and Abuse Partnership Hull University Teaching Hospitals NHS Trust (HUTH) Humber Teaching NHS Foundation Trust Humberside Police National Probation Service East Riding CCG (regarding Primary Care) School Yorkshire Ambulance Service 2.6 One principle of Serious Case Reviews and Child Safeguarding Practice Reviews is that families should be invited to contribute. The Lead Reviewer and the Learning and Improvement Manager for ERSCP met with MB, FB and PGMB as part of this review. Information they provided is included throughout the report where it informs the learning. The Lead Reviewer and the Learning and Improvement Manager for ERSCP were unable to make contact with MGMB. 2.7 Another principle is that “practitioners are fully involved in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith”. The time period under consideration for this review pre-dated the review by six years which created some practical difficulties with regard to including practitioners in a learning event. However, the Lead Serious Case Review – Baby B 2nd March 2020 Page 6 of 24 Reviewer met with SW1 and SW2 to discuss their involvement with the family during the period under review. 3. Family Structure 3.1 Relevant family members and other members of the public referred to in this review are: Family member: Referred to as: Subject child Baby B Sibling of subject child Sib B Mother of subject child MB Father of subject child FB Paternal grandmother of subject child PGMB Maternal grandmother of subject child MGMB Maternal grandfather of subject child MGFB Other Perpetrator SF Child of perpetrator CSF Perpetrator’s ex-partner MCSF 3.1.1 The family’s ethnicity is white British. There was no evidence in any of the reports submitted by agencies involved with the family that any issues of race, religion, language or culture affected events in this case. 4. Key Episodes 4.1 Introduction 4.1 Key Episode 1) Anonymous concern about neglect 4.1.1 In June 2013, the National Society for the Protection of Cruelty to Children (NSPCC) received information in an anonymous on-line reporting form expressing concern that the children may be in need or at risk due to neglect and being home alone. It did not suggest that the children were at immediate risk of significant harm and did not include details of any specific instances when the children had been neglected. This was faxed to Children’s Social Care who had no previous knowledge of the family. 4.1.2 CSC made enquiries with the home school liaison officer at the school attended by Sib B who reported that the school had no worries about Sib B’s presentation or behaviour although the child had had a period of absence three months previously due to being in hospital and was currently absent from school. CSC also spoke to the health visitor for Baby B and wrote that the health visitor had no worries. As a result of these responses CSC wrote to the parents to advise them of the concern and that no further action would be taken. Serious Case Review – Baby B 2nd March 2020 Page 7 of 24 4.1.3 Two days after CSC received this information, MB told staff at the primary school attended by Sib B that she and FB ended their relationship after FB had got drunk and stayed out all night. MB described the incident leading to the separation as ‘the final straw’. Key staff in the school were advised to keep an eye on Sib B and the home school liaison officer informed the first responder at CSC. 4.1.4 The following day MB attended hospital with a fractured foot and reported having fallen downstairs when drunk. MB was examined in the emergency department and found to have fractured her foot. The GP was informed of the injury and the planned follow up. 4.1.5 Five days after MB fractured her foot she phoned CSC to acknowledge receipt of the letter. She was happy that no action was being taken in respect of the anonymous concerns and did not mention her fractured foot. 4.2 Key Episode 2) Sib B’s health and school attendance 4.2.1 Sib B was unwell in February and March 2013, was taken to hospital three times and spent two nights as an in-patient. Sib B was absent from school for approximately three weeks at the time of this illness. 4.2.2 Sib B continued to have a high rate of absenteeism and at the time CSC contacted the school regarding the anonymous concern about neglect attendance was at 74.2%. Approximately two weeks after CSC contacted the school, Sib B’s class teacher spoke to the parent support advisor about Sib B having missed three out of six academic assessments due to being absent from school. As a result of this discussion, the parent support advisor phoned MB to offer support regarding attendance and missing assessments. MB was willing to accept support and an appointment was made to meet in school. At the subsequent meeting, MB said that she found Sib B’s behaviour to be challenging and said that breaking her foot had put her out of routine. Support was offered relating to attendance, routines and behaviour management. 4.3 Key Episode 3) Missed health appointments for Baby B 4.3.1 Baby B received the first injections and during the first 4½ months of life Baby B was taken to the baby clinic six times to be weighed. Baby B was not taken for a six week check with the GP, a seven to nine month development review, an appointment for immunisations and a rearranged seven to nine month development review. Following the second missed appointment for the development review a letter was sent to MB advising her to contact the health visitor if a rescheduled appointment was required. MB did not respond to this. 4.4 Key Episode 4) Information about SF commencing a relationship with MB Serious Case Review – Baby B 2nd March 2020 Page 8 of 24 4.4.1 From March to October 2013, the child of SF (CSF) was subject to a child protection plan due to domestic violence between SF and his then partner MCSF. The day after CSF had been de-planned, a police officer sent an email to the social worker for CSF stating that SF was believed to be in a relationship with MB. MB’s home address was included as were the names and dates of birth of Baby B and Sib1. It was written in the email that this was third party information that was “Professionals only intelligence, NOT to be disclosed”. SW1 recorded the content of the email in CSF’s records but did not take any other action. 4.5 Key Episode 5) Anonymous concern about possible domestic violence against MB 4.5.1 On a Wednesday evening in November 2013, MB was taken to hospital by ambulance with a four day history of left sided headaches with symptoms progressively worsening. She was subsequently admitted to the acute assessment unit at the hospital where it was believed she had suffered an acute migraine attack. She was discharged in the early hours of the following morning. 4.5.2 Baby B’s paternal grandmother (PGMB) was known to CSC staff in the local social work team in a professional capacity due to her employment. On Thursday morning, PGMB phoned SW2 in the local social work team and told her that MB had been admitted to hospital with headaches on the Wednesday having collapsed at home on the Monday. PGMB added that a third party had told the attending ambulance personnel that MB had been overheard asking SF why he had pushed her, that her arms were covered in bruises and that she had been bitten. PGMB expressed concern that SF might be violent and said she was worried about the children and wanted advice. She also said that she wanted to remain anonymous with regard to this contact. 4.5.3 SW2 advised PGMB to contact Early Help and Advice Team (EHAT) which was the correct course of action as all new contacts3 regarding concerns about children were initially screened in EHAT before being passed onto appropriate services and activities. The subsequent contact from EHAT was forwarded to TM1 in the local social work team and was passed back to SW2 to take action. 4.5.4 TM1 has recorded, on the ‘contact’ from EHAT, that he instructed the social worker (SW2) to go to the hospital to “challenge” MB about what had happened and establish whether there is ongoing domestic violence in the relationship. TM1 has also written that if MB is going to continue in a relationship with SF, Children Services should consider removing the children and if MB was willing to end the relationship then a ‘letter of expectation’ should be implemented. TM1 further recorded that the contact should progress to a referral and a single assessment should be completed 3 The word ‘contact’ is used to describe information provided to Children’s Social Care. It becomes a ‘referral’ if and when a decision is taken that action is required by the Local Authority. Serious Case Review – Baby B 2nd March 2020 Page 9 of 24 within 10 days. TM1 wrote on a case supervision record that if MB would not agree to leave SF then removal of the children would be explored. 4.5.5 SW2 did not undertake these actions but on the Friday afternoon SW2 met MB and Baby B at a local children’s centre. During the meeting MB denied any domestic violence from SF but she said he had anger issues, got jealous, was immature and picked fights. MB told SW2 that she had ended the relationship because she did not want CSC to be involved but that she still loved him. She added that since she had ended the relationship, SF had been persistently calling at her house and she was worried about potential repercussions. PGMB joined the meeting and it was agreed that MB and the children would stay with MB’s father (MGFB) and the children would stay with FB the following week. MB agreed to drop the children off with FB on Sunday or Monday. 4.5.6 Shortly after the meeting, SW2 phoned FB to tell him that the children would be staying with him. FB responded that he and MB had already talked about this and agreed. 4.5.7 PGMB told the Lead Reviewer that she contacted CSC on the Monday and Tuesday of the following week to make them aware that MB and SF had resumed their relationship. However, there are no CSC records of any contact in relation to this case after Friday until late in the afternoon of the following Tuesday when PGMB informed SW2 that Baby B had been admitted to hospital (see section 4.6). 4.6 Key Episode 6 - Admission of Baby B to hospital with life changing injuries 4.6.1 On Tuesday evening four days after SW2 had met with MB, an emergency call was made to Yorkshire Ambulance Service stating that Baby B had been found in the cot by SF having had what appeared to be a seizure. Baby B was taken to hospital by ambulance with suspected febrile convulsion. Baby B was admitted to the Paediatric Assessment Unit for further observation. History was documented of Baby B vomiting and being unwell with a temperature. 4.6.2 Early the following morning SW2 phoned TM1 to advise that Baby B had been admitted to hospital the previous evening due to having seizures. SW2 informed TM1 that MB and SF had resumed their relationship over the weekend. 4.6.3 TM1 has recorded that SW2 was asked to go and have a ‘firm word’ with MB and if she was not willing to end the relationship then CSC would consider child protection or legal advice. The records indicate that CSC did not take any action that day and SW2 told the Lead Reviewer she cannot remember being given the instruction that TM1 has written. 4.6.4 Also on Wednesday morning, a medical review took place as staff were concerned about a change in Baby B’s clinical presentation. An urgent CT Serious Case Review – Baby B 2nd March 2020 Page 10 of 24 scan was requested which was carried out at 18:00 hours. The CT scan identified multiple accumulation of blood in the brain indicating possible trauma to the brain. This was explained to the parents who were told that a referral would be made to CSC. PGMB told the paediatric consultant and nursing staff of her concerns about domestic violence from SF. Nursing staff tried to contact the CSC ‘out of hours’ service and left a message on an answer phone but did not receive a return call. There is no record of the ‘out of hours service’ receiving this message and it is reported that the service did not use an answer phone. 4.6.5 At approximately 22:30 hours on Wednesday evening, PGMB phoned TM1 from CSC. She told TM1 that Baby B had a shadow on the brain and that, although more tests were required, the consultant had said that Baby B may have been shaken. PGMB also told TM1 that SF had moved back to live with MB the previous Sunday. TM1 recorded that following this call he phoned the hospital ward, had a discussion with the staff nurse and said that SF should not come to the ward until an assessment had been undertaken by CSC. The hospital has no record of any contact from TM1 that evening. 4.6.6 The following morning TM1 asked SW2 to urgently complete a letter of expectation in relation to SF not having any contact with the children. SW2 did this and informed nursing staff on the high dependency unit that she had done so. Ward staff confirmed the outcome of the CT scan to SW2 and informed her that an MRI scan would be undertaken later that day. 4.6.7 SW2 contacted EHAT to advise that Baby B was in hospital following a seizure and that PGMB had said consultants had made a suggestion that it could be ‘shaken baby’. 4.6.8 TM1 contacted DS1 from the Police and they held a strategy discussion, the outcome of which was that the S47 threshold was not met as they were awaiting further medical checks. 4.6.9 An MRI scan was completed on the Thursday afternoon which indicated that Baby B had sustained two separate shake injuries. The paediatrician spoke to the parents and contacted CSC and the Police. Two police officers were deployed to the hospital on Thursday evening to commence an investigation into Baby B’s injuries. SF was arrested that same evening. 4.6.10 The following day (Friday), DS1 from the Police contacted CSC TM2 who worked in EHAT and they had a strategy discussion. The outcome of the strategy discussion was that threshold was met for S47 enquiry. It was agreed that the Police alone would progress the investigation into the injuries sustained by Baby B whilst CSC intervention would address the risks to CSF. 4.6.11 Also on the Friday, SW2 and PGMB took Sib B to the GP for what was recorded by SW2 as a ‘health check’. SW2 told the Lead Reviewer that Sib B was taken to the GP at the request of the Police. She added that she did not think this was a child protection medical but was unclear what the reason Serious Case Review – Baby B 2nd March 2020 Page 11 of 24 was for the health check. The GP has recorded an ‘impression’ that there was no underlying neglect or non accidental injury. 5. Analysis 5.1 Responses to issues around possible neglect 5.1.1 Unless there was a good reason not to do so, CSC should have sought parental consent before seeking information about the family from other agencies. Furthermore, any decision not to seek consent should have been recorded with the reasons clearly stated. In this case, there is no record of either parent being contacted or of any reason being identified as to why it was not appropriate to seek consent. Therefore, it appears that the contact with the school and health visitor was inappropriately made without the consent of either parent. 5.1.2 When the home school liaison officer and health visitor were contacted by CSC in June 2013, they said that they did not have concerns that Baby B and Sib B were experiencing neglect. However, there are reasons why CSC should have been cautious about these opinions. At the time of the contact from CSC, the health visitor had only visited Baby B at home on one occasion. This was the new birth visit that had been undertaken five months previously when Baby B was 10 days old. Since then, contact between the service and Baby B was limited to six occasions when Baby B had been taken to the clinic and weighed. The most recent occasion was six weeks before CSC phoned the health visitor. Therefore, the health visitor had limited direct knowledge of Baby B or the family’s home circumstances and no direct knowledge of Sib B. Sib B was absent from school when CSC contacted the school and the home school liaison officer had no direct knowledge of Baby B or the conditions at home. CSC should have contacted the school nurse and GP to seek further information about the family before deciding whether further action was required. If more detailed information about the family was not available it would have been appropriate for Children’s Social Care to have visited the family home, possibly as a joint visit with the health visitor. 5.1.3 When CSC contacted the school, the home school liaison officer said that Sib B was currently absent from school and had been unwell for three weeks in March 2013 due to being in hospital. At the time of this phone call, Sib B’s attendance for the year was 74.2%. Even without the absence in March the attendance would have only been 84.7%, but the information provided to CSC did not indicate such a low attendance level. 5.1.4 The attendance level may have been due to genuine ill health but it could also have been an indicator of possible neglect. Involvement of the parent support advisor at an earlier stage and liaison between the school and the school nurse would have helped to explore the reasons for Sib B’s absences. The school has a clear process which should be followed when there are concerns about a child’s level of attendance. In 2013 this became operative if a child’s attendance fell below 85%. It is now used when attendance falls Serious Case Review – Baby B 2nd March 2020 Page 12 of 24 below 90%. This process does not include any reference to liaison with the health visitor or school nurse4 and information provided by the school to this review suggests a lack of clarity within the school about when such liaison is appropriate and how it should be initiated. 5.1.5 MB’s report of separating from FB could have been seen as a further indicator that the family might be struggling and her description of it as ‘the final straw’ suggested there had been previous incidents. It was good practice on the part of the home school liaison officer to contact CSC with this information. As a result of receiving this information just two days after the initial concern about possible neglect, CSC should have reviewed the decision already made that those concerns were without foundation. There is no indication that this was done. 5.1.6 Non attendance at health appointments can be an indicator of neglect. In 2013, procedures within the GP practice did not require missed appointments to be followed up. Consequently, there was no follow up to the missed six week check or the immunisations. The GP practice now uses a system whereby patients are automatically sent texts to remind them of appointments beforehand and to follow up if any appointment is missed. The practice nurse was not aware of the anonymous concern about neglect so was not in a position to consider this when Baby B was not brought to the practice for immunisations. 5.1.7 The health visitor was aware of the concern and it would have been good practice for her to have informed CSC of the missed development reviews and to have checked with CSC whether any other concerns had been reported since June. She could also have tried to undertake an opportunistic visit to see Baby B at home. She did not do this and there is no evidence to suggest that the she considered whether the missed appointments could be symptomatic of neglect. The letter sent to MB presented the seven month check as an optional check if MB wanted it, rather than a check that was for the benefit of the baby. Whilst it is correct that such health checks are ‘voluntary’, parents should be encouraged to take their babies. The health visitor was not aware of the incidents that had taken place since CSC had contacted her in June 2013, including the parental separation so these would not have impacted on her view of the family. Learning Points 1. Before seeking or sharing information about members of the public practitioners must ensure that they are complying with current legislation, statutory guidance and agency polices relating to information sharing. 2. When gathering information, practitioners should analyse and critically evaluate the information they receive in order to establish how much weight can be given to it. 4 In 2013, school nurses worked with primary age children. Health visitors now fulfil this role. See paragraphs 6.2 and 6.3 for further information. Serious Case Review – Baby B 2nd March 2020 Page 13 of 24 3. Health visitors and school nurses provide a useful link between schools and health services. Schools and other services should involve them when there are possible concerns about a child’s health or wellbeing. 4. Incidents should not be seen in isolation but should be considered within the history of a case so that a pattern can be discerned. Where new information comes to light decisions should be re-considered. 5. There was an over-readiness to dismiss the anonymous concerns that had been made. Although they were vague in nature, these concerns should have been afforded greater scrutiny. 6. Concerns made anonymously should be treated as seriously as those that are not anonymous. 5.2 Responses to concerns about possible Domestic Violence 5.2.1 In view of what was known about SF’s relationship with MCSF it could be anticipated that domestic violence might be a feature of subsequent relationships involving him and that children living in a family group including SF may be at risk. Therefore, it was appropriate for the police to make CSC aware of the intelligence about SF’s new relationship and an appropriate response would have been for CSC to have considered the information to decide whether any action was required. 5.2.2 There are a number of reasons why this was not done. The police intelligence was sent to the individual social worker who was working with CSF and their family when it should have been sent to the ‘Single Point of Contact’ (SPOC) box and screened by a team manager. Because it was written in the email from the police that the information was “professionals only intelligence”, which was “not to be disclosed”, SW1 did not know what should be done with it. Thirdly, SW1 did not consider SF to be a significant risk to children because his ex-partner had been the alleged perpetrator in respect of the incident that had led to CSF being subject to a Child Protection Plan. This view appears inconsistent with the decision that CSF should be subject to a Child Protection Plan whilst SF and MCSF were in a relationship with one another. 5.2.3 Whether or not SW1’s assessment of the potential risk posed by SF was accurate, the notification from the Police should have been considered by a manager in order to decide on appropriate action. 5.2.4 Because SW1 only recorded the police intelligence about SF onto CSF’s records it was not available to EHAT, TM1 or SW2 when PGMB raised concerns about domestic violence or when Baby B was admitted to hospital. 5.2.5 It is difficult to understand TM1’s written decision making when PGMB raised concern that MB might have been subjected to domestic violence from SF. The information provided by PGMB was an unverified allegation of a single incident of domestic violence and was based on hearsay because PGMB was reporting what someone else had reported overhearing. CSC’s only previous knowledge of MB and her children had been the anonymous concerns received in June 2013. The conclusion reached at the time was Serious Case Review – Baby B 2nd March 2020 Page 14 of 24 that this was an unfounded referral and there had been no direct contact with the family. 5.2.6 The use of the word ‘challenge’ suggests that TM1 anticipated the need for SW2 to adopt a confrontational approach with MB but it is unclear why this would be the case. It fails to recognise the importance of reassuring MB in order to facilitate building a relationship with her. There was no apparent justification for considering the removal of the children if MB would not leave SF and CSC had no authority to make such an ultimatum. 5.2.7 The suggestion that the children might be removed if MB would not end her relationship with SF indicates a high level of concern that the children would be at risk of significant harm if this did not happen. Such a level of concern appears inconsistent with the information provided by PGMB. If TM1 had had such concerns he should have arranged a strategy discussion to consider whether Section 47 enquiries were required. This was not done and SW2 understood that she was acting under Section 17 of the Children Act. 5.2.8 In trying to understand TM1’s response to the referral it is worth noting that he was the manager who had made decisions regarding SF’s child. Therefore it could be expected that he would have recognised SF’s name and that this might have influenced his decision making in this case. However, he has said that he was not aware that MB’s partner was SF. He was also unaware of the intelligence provided by the Police in October 2013. 5.2.9 Irrespective of whether or not TM1 recognised SF’s name, before deciding on a course of action, the CSC information system should have been checked to see whether MB and her children, and/or SF was known to the service. If SF’s history as the parent of a child who had recently been subject to a Child Protection Plan, had been known, it would have been appropriate to hold a strategy discussion to consider whether Section 47 enquiries should be undertaken. 5.2.10 The action taken by SW2, differed significantly from the written decision recorded by TM1. SW2 told the Lead Reviewer that she did not see TM1’s written decision on the contact before she visited MB. SW2 added that she understood that this contact was dealt with on a child in need basis, not a child protection one, that she was definitely not told that the children might have to be removed from MB1 and there were no grounds to do so. 5.2.11 Based on the information available to CSC, SW2’s action of contacting MB and arranging to meet with her was proportionate, and the decision to hold this meeting away from the family home enabled MB to talk to SW2 without SF present. 5.2.12 Although MB told SW2 that she had not experienced any domestic violence from SF and that she had ended the relationship her comments about SF’s behaviour and her feelings for him should have cast doubt on her assertion Serious Case Review – Baby B 2nd March 2020 Page 15 of 24 that there had not been any domestic violence and raised concerns that the relationship might resume. 5.2.13 The plan for MB and the children to stay with MGFB over the weekend and the children to stay with FB was a means to ensure that they were all safe over the weekend and the children were not exposed to any arguments or repercussions between MB and SF the following week. The plan was a family arrangement, which seems reasonable and proportionate based on what was known at the time. A letter of expectation was not signed and no arrangement was made for CSC to check that the family had adhered to the plan or that it was being effective. Given the evident concerns about the relationship, it would have been appropriate for CSC to make checks early the following week. SW2 cannot remember what her plans were for the following week but believes that she would have contacted MB to check the effectiveness of the safety plan if events had not been overtaken by Baby B’s admission to hospital. However, SW2 was not told about Baby B’s admission to hospital until Tuesday evening at the earliest. Therefore two full working days passed without her making any arrangements to see MB. 5.2.14 A written record of supervision between TM1 and SW2 on the Thursday was not added to the case record until the following Monday. Therefore, it would not have been available to ‘out of hours’ staff if contact had been made over the weekend. 5.2.15 SW2 was aware of the need to undertake an assessment but does not recall being asked to complete this in 10 days, as TM1 recorded on the contact, and does not think this would have been the case. The timescale for completing a Single Assessment is 45 days and she considered this to be a complicated situation so the assessment would not be quick. Irrespective of the procedural timescale for completing the assessment there was a clear need to commence it promptly. By the time Baby B was admitted to hospital, there was no assessment plan in place. There had been no attempts to contact any of the family members and no information gathering had taken place from other agencies. Learning Points 7. Clarification is needed about how police intelligence should be shared with other agencies and how those agencies should record and act upon such intelligence. 8. Decision making in respect of concerns raised with agencies should not be solely based on that concern but should also consider what is known of the subjects’ histories. 9. CSC case management decisions regarding significant events should be clearly recorded on case records on the day the decision is made so the information is accessible to other staff during and outside office hours. 10. At the point of allocation CSC team managers should make clear their expectations in regard to the purpose of assessment, areas to cover and expected timescales for visiting and providing the manager with an update. This should be included within an assessment plan. Serious Case Review – Baby B 2nd March 2020 Page 16 of 24 11. Safety plans should be clearly written, proportionate to the identified risk and should include arrangements for monitoring and review. They should be shared and understood with all parties involved in delivering the plan, including family members and friends. 5.3 Initial response to medical presentations 5.3.1 During MB’s attendance at the emergency department and the Trauma and Orthopaedic clinic with a broken foot she gave an explanation for the injury that was consistent with the presenting injury. Subsequently, the symptoms MB described to the paramedics and hospital staff when she was taken to hospital with a history of headaches fitted with a diagnosis of migraine. She reported that she had not experienced a recent trauma and that she had no rash. There were no concerns evident and no reason to suspect domestic abuse. There is no indication that any bruising was seen to MB’s arms and no reason why staff would necessarily have seen her arms. At the time of these two incidents, staff in the Emergency Department were not expected to ask patients about domestic abuse as a matter of routine; consequently MB was not asked. 5.3.2 If ambulance personnel had any concern that MB might be a victim of domestic abuse they should have written this on the YAS record and on a sheet they provide to the hospital when they arrive with a patient. Neither of these documents includes any such concern. Therefore, there is no record to support PGMB’s assertion that a third party had provided such information to the paramedics. It is possible that there were omissions in the records but it seems unlikely that a statement such as the one PGMB reported to SW2 would have been entirely omitted (see paragraph 4.5.2). PGMB was not present when ambulance staff visited MB and therefore she had no direct knowledge of what had been said; she could only report what she was told. 5.3.3 YAS staff acted appropriately in conveying Baby B to hospital when it was reported that Baby B appeared to be having a seizure. Baby B received immediate medical attention in hospital and was assessed and treated appropriately in accordance with Baby B’s clinical presentation. This review has not identified any shortfalls in the care received in hospital or any missed opportunities to identify, at an earlier stage, that Baby B had suffered a non-accidental injury. 5.3.4 The written record suggests that when TM1 was informed that Baby B had been admitted to hospital his response was to ask SW2 to take a confrontational approach with MB. This was an inappropriate response as there was the possibility that Baby B was seriously ill, there was no indication as to the cause of the seizures and no-one from the hospital had been in touch to suggest that Baby B might have been deliberately harmed. The information that MB and SF had resumed their relationship would rightly have been a concern to CSC and it would have been appropriate for CSC to make enquiries, including finding out who was looking after Sib B. Hospital staff had not contacted CSC but, subject to considerations regarding consent, it Serious Case Review – Baby B 2nd March 2020 Page 17 of 24 would also have been appropriate for CSC to contact the hospital in order to clarify the situation with regards to Baby B. 5.4 Response to concern about possible non-accidental injury 5.4.1 The results of the CT scan provided the first concern that Baby B might have been harmed deliberately. On receiving the results of the CT scan hospital staff acted promptly in trying to contact CSC. It is not known why this was not received by the ‘out of hours’ service as the correct phone number is recorded in the hospital record. Nevertheless, contact did take place between hospital staff and CSC the following morning and the failure to make contact the previous evening did not have an impact on the children. This was the first communication between the hospital and CSC regarding Baby B. 5.4.2 Working Together to Safeguard Children 2013 states that “whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm there should be a strategy discussion”. Therefore the decision to hold a strategy discussion on Thursday, after the result of the CT scan was known, was correct. The strategy discussion only included TM1 and DS1 from the Police. As Baby B was in hospital, the strategy discussion should have also, at a minimum, included a paediatrician. This would have provided a better understanding of Baby B’s condition and how likely it was that Baby B had suffered a non-accidental injury. This in turn would have informed the decision about whether or not the grounds were met for Section 47 enquiries. 5.4.3 It is not known why SW2 phoned EHAT when she was told that there were concerns that Baby B may have suffered a non accidental injury. SW2 was already the allocated social worker working with Baby B’s family by the time Baby B was admitted to hospital and therefore it was unnecessary for EHAT to be involved. 5.4.4 Following the outcome of the MRI scan the paediatrician acted promptly to inform the parents, CSC and the police. The police attended hospital promptly and made enquiries which led to the arrest of SF that same evening. The Police informed CSC of the arrest the following day. 5.4.5 The strategy meeting should ideally have taken place on the Friday morning and should have involved, as a minimum, CSC, the Police and the paediatrician. It is not known why the strategy discussion did not take place until the afternoon and did not include the paediatrician or any other health representative. It is also not known why the only the CSC representative was a team manager from EHAT who had not been involved with the case during the previous few days and was not involved after the discussion. TM1 and SW2 should have been involved in the discussion as they had relevant knowledge about the case and were likely to be involved in subsequent assessments Serious Case Review – Baby B 2nd March 2020 Page 18 of 24 5.4.6 The outcome of the strategy discussion, that a Police only enquiry would be undertaken regarding the injuries sustained by Baby B, has not been explained. There was a clear need for ongoing CSC involvement with regard to the safety and wellbeing of both Baby B and Sib B. 5.4.7 There is also no explanation as to why Sib B was taken to the GP. Where section 47 enquiries are being undertaken regarding possible physical abuse of a child it is sometimes appropriate for siblings to undergo a medical examination. When an examination is undertaken it should be carried out by a suitably trained paediatrician and not a GP. Although SW2 has said that she did not think she was taking Sib B to the GP for a paediatric safeguarding medical examinations she was not clear what the purpose of the appointment had been. The GP record suggests the GP believed they were giving a view on possible abuse or neglect. Decisions about whether or not paediatric safeguarding medical examinations are required should be made in strategy discussions but this is not well embedded in practice. Learning Points 12. Strategy meetings must be held in a timely manner and attended by all practitioners who can provide relevant information about the situation under consideration and people of sufficient seniority to make decisions. 13. Minutes from strategy meetings should be recorded in the case record of all agencies involved in the meeting and should include a record of the arrangements for review. 14. Revised guidance is required to support decision making around the need for paediatric safeguarding medical examinations where there are concerns that a child may have been harmed. This should address issues including which children should undergo an examination, when examinations should take place, who can undertake such examinations and consent. 5.5 Professional boundaries and potential conflict of interest 5.5.1 PGMB had a close professional relationship with the social work team which covered the area Baby B lived in. Some of the staff in the team, including SW2, also had contact with PGMB outside work. She had work and personal phone numbers for some of the staff in the social work team and on at least two occasions she phoned members of the social work team out of hours to discuss aspects of the case. These calls should not have been taken by the staff members concerned and PGMB should have been advised that if she needed to contact CSC outside normal office hours then she should contact the ‘out of hours’ service. 5.5.2 Section 5.2 of this report identifies that the actions TM1 decided should be taken following PGMB’s contact expressing concern about domestic violence were out of proportion to the concerns that has been raised. It is not known why TM1 took this view but he may have given more credence to the concerns because they were being raised by a fellow professional with whom he worked. Serious Case Review – Baby B 2nd March 2020 Page 19 of 24 5.5.3 Since Baby B was injured, it has been suggested by staff within the local social work team that PGMB’s professional knowledge provided an added safety factor over the weekend immediately following SW2’s first meeting with MB. This was not part of the safety plan and there is no evidence to suggest that it was acknowledged at the time. Even if it had been acknowledged it would have been a potential conflict of interest. 5.5.4 The close working relationship between the local social work team and PGMB created an environment in which it was easy for professional boundaries to become blurred and there are indications that this happened. It could also have compromised decision making. 5.5.5 Because of this, it is considered to have been inappropriate that the local team responded to the concerns PGMB had raised on a personal basis. Learning Point 15. Where professionals have personal or professional relationships with a service user or someone closely involved with the service user there is the potential for professionals boundaries to become blurred. Agencies should have procedures in place to ensure that, where appropriate, the case is dealt with by someone who does not have such a relationship. 6. Significant changes to practice since the time period considered by this review 6.1 This review has considered events that took place around six years ago. The Lead Reviewer has been told about the following changes to policy and practice during the six year time period that are relevant to this review. 6.2 In 2013 health visitors and school nurses caseload managed their work. Work was allocated to an individual named practitioner and details emailed to that practitioner’s email address. Health visitors worked with children up to the age of 5 years and school nurses worked with children from 5 upwards. 6.3 Following the introduction of the Healthy Child Programme 0 to 19, in 2016, Humber Teaching NHS Foundation Trust established an Integrated Specialist Public Health Nursing (ISPHN) 0-19(25) Service which delivers the Healthy Child Programme ‘Pregnancy and the first five years of life’ (2009) and the Healthy Child Programme ‘From 5-19 years old’ (2009). This integrated service is delivered by six professional teams across the East Riding and a whole team approach to the children located in the areas is adopted. Health visitors now manage caseloads of children aged 0-11years and school nurses manage caseloads of children aged 12-19 but there is an overarching approach to who is identified to support children and families. The new service introduced weekly allocation meetings where escalated work and new referrals are discussed and allocated to the most appropriate practitioner. There is also a daily duty officer in each team. Serious Case Review – Baby B 2nd March 2020 Page 20 of 24 6.4 Primary, secondary and tertiary health care services in the East Riding have moved from using ‘Did Not Attend’ (DNA) processes to ‘Was Not Brought’ (WNB) processes when children miss health appointments. This change recognises that non-attendance or apparent non-engagement can be an indicator of neglect, as well as a specific instance in which a child’s health needs are not being met. 6.5 HUTH is working to raise awareness of domestic abuse within the Trust and is expanding the number of situations in which patients are routinely asked whether they are victims of domestic abuse (Routine Enquiry). The Trust has an Independent Domestic Violence Advisor (IDVA) working on site two days each week. The IDVA provides an ‘in reach’ service to support staff and victims of domestic abuse who come into contact with the Trust. The eLearning modules have been extended to cover both Level 1 & 2 Domestic Abuse training (NHS Modules) and Routine Enquiry training. 6.6 A policy for non staff related domestic abuse has been developed in HUTH and is in the process of being ratified through the relevant safeguarding committees. There is an existing policy to support employees experiencing domestic abuse. 6.7 Routine Enquiry is embedded in Maternity Services and there is now a roll out of a programme that has been developed to raise awareness of domestic abuse and Routine Enquiry across HUTH. This three year programme is led by the Named Nurse Adult Safeguarding, the Named Midwife and the Trust IDVA. The programme will focus initially on the departments in the Trust which are first contact areas such as, Outpatient Departments and the Emergency Department. Staff in each department will be invited to complete the on line eLearning which will become part of their mandatory training. Follow up support will be provided in the department for the staff by the programme leads and the IDVA will be based in the department for a set period whilst Routine Enquiry becomes embedded in practice. 6.8 If a child has contact with HUTH and non accidental injury is suspected or there is potential for harm the Trust will follow the safeguarding partnerships safeguarding referral processes to escalate concerns and a safeguarding referral will be made. If CSC considers that the case requires a strategy discussion or meeting the expectation is that this would involve the Trust doctor involved with the case and/or a member of the Safeguarding Team and staff involved in the child’s care. To support the attendance of the doctor at the meetings, every effort would be made to hold any meetings on the Trust site. 6.9 In June 2014 EHAT became the Early Help & Safeguarding Hub (EHaSH). This change was brought about as a result of the co-location of the Police Protecting Vulnerable People (PVP) Team. EHaSH is a single point of contact for professionals or members of the public who have concerns about a child or young person. It provides the first response to all initial enquiries / expressions of concern and determines the most appropriate response to identified needs including: Fast tracking child protection concerns or other complex family situations that might require an immediate safeguarding response. Serious Case Review – Baby B 2nd March 2020 Page 21 of 24 Early, co-ordinated use of the Early Help Assessment. Referring on to Children’s Centres, Youth & Family Support and signposting on to other services. 7. Conclusions 7.1 The information provided by the Police about MB and SF commencing a relationship did not receive suitable consideration or action by CSC. Furthermore, the information was only recorded within the case records of CSF. Consequently, when PGMB raised concern about possible domestic violence in the relationship between MB and SF, this information was not available to the team manager or social worker. Had this information been available, it might have resulted in a strategy discussion being held to consider whether Section 47 enquiries should be undertaken. Based on the information that was available to the social worker, the initial response to the concerns raised by PGMB was proportionate and timely. However, an assessment plan was not made and no follow up action was taken after the weekend. Notwithstanding these shortfalls, and even if CSC had realised who SF was, it could not have been anticipated that Baby B was likely to suffer the injuries that were inflicted just a few days later. Furthermore, even if CSC had become aware on the following Monday or Tuesday that MB had resumed her relationship there would not have been any grounds for removing the children from her care at that time. 7.2 The medical response after Baby B was taken to hospital was appropriate. After it was suspected that Baby B might have sustained non-accidental injuries there were shortfalls in relation to strategy discussions, subsequent Section 47 enquiries and medical intervention with Sibling B. Ultimately this did not impact upon the physical wellbeing of Baby B or Sibling B. 7.3 Section 5.1 of this report identifies several learning points concerning the response to issues around possible neglect in June 2013. Because the concern about neglect was not fully explored and there was no face to face engagement with the family it is not known whether it had any foundation. A more robust response in June 2013 might have led to CSC or Early Help involvement with the family but it is not possible to know how this would have impacted on subsequent events. 7.4 It is believed that the close professional relationship between PGMB and the social work team that worked with the family led to a blurring of professional boundaries and impacted on some of the decision and actions taken by members of that team. 8. Learning Points 1. Before seeking or sharing information about members of the public practitioners must ensure that they are complying with current legislation, statutory guidance and agency polices relating to information sharing. 2. When gathering information, practitioners should analyse and critically evaluate the information they receive in order to establish how much weight can be given to it. Serious Case Review – Baby B 2nd March 2020 Page 22 of 24 3. Health visitors and school nurses provide a useful link between schools and health services. Schools and other services should involve them when there are possible concerns about a child’s health or wellbeing. 4. Incidents should not be seen in isolation but should be considered within the history of a case so that a pattern can be discerned. Where new information comes to light decisions should be re-considered. 5. There was an over-readiness to dismiss the anonymous concerns that had been made. Although they were vague in nature, these concerns should have been afforded greater scrutiny. 6. Concerns made anonymously should be treated as seriously as those that are not anonymous. 7. Clarification is needed about how police intelligence should be shared with other agencies and how those agencies should record and act upon such intelligence. 8. Decision making in respect of concerns raised with agencies should not be solely based on that concern but should also consider what is known of the subjects’ histories. 9. CSC case management decisions regarding significant events should be clearly recorded on case records on the day the decision is made so the information is accessible to other staff during and outside office hours. 10. At the point of allocation CSC team managers should make clear their expectations in regard to the purpose of assessment, areas to cover and expected timescales for visiting and providing the manager with an update. This should be included within an assessment plan. 11. Safety plans should be clearly written, proportionate to the identified risk and should include arrangements for monitoring and review. They should be shared and understood with all parties involved in delivering the plan, including family members and friends. 12. Strategy meetings must be held in a timely manner and attended by all practitioners who can provide relevant information about the situation under consideration and people of sufficient seniority to make decisions. 13. Minutes from strategy meetings should be recorded in the case record of all agencies involved in the meeting and should include a record of the arrangements for review. 14. Revised guidance is required to support decision making around the need for paediatric safeguarding medical examinations where there are concerns that a child may have been harmed. This should address issues including which children should undergo an examination, when examinations should take place, who can undertake such examinations and consent. 15. Where professionals have personal or professional relationships with a service user or someone closely involved with the service user there is the potential for professionals boundaries to become blurred. Agencies should have procedures in place to ensure that, where appropriate, the case is dealt with by someone who does not have such a relationship. 9. Recommendations 9.1 It is recommended that East Riding Safeguarding Children Partnership ensure: Serious Case Review – Baby B 2nd March 2020 Page 23 of 24 1. That staff within all partner agencies are familiar with relevant information sharing guidelines and comply with these. (Learning Point 1) 2. That when gathering information and undertaking assessments, practitioners consider case histories and analyse and critically evaluate the information provided. (LP2, 4, 5, 6 & 8) 3. That communication pathways between schools and the Integrated Specialist Public Health Nursing 0-19(25) Service are well established. (LP3) 4. That partner agencies have a clear understanding of how ‘professional intelligence’ should be recorded and used. (LP7) 5. That CSC reviews its case recording policy with regard to the timeliness of management decisions being recorded. (LP9) 6. That written assessment plans and safety plans within CSC are clear, robust, timely and effectively overseen, and are shared with all involved parties. (LP10 & 11) 7. That strategy discussions and meetings are being held in accordance with the guidance within Working Together to Safeguard Children 2018, including timeliness and attendance. (LP12) 8. That the minutes of strategy discussions are included within the case record of all agencies involved in the meeting and include the arrangements for review. (LP13) 9. That clear, up to date guidance is put in place concerning paediatric safeguarding medical examinations. (LP14) 10. That all partner agencies have procedures in place to identify and address possible conflicts of interest. (LP15) Serious Case Review – Baby B 2nd March 2020 Page 24 of 24 Appendix 1 – Initials CAF – Common Assessment Framework CISRO - Children’s Independent Safeguarding and Reviewing Officer Service CCG – Clinical Commissioning Group CSC – Children’s Social Care DNA – Did Not Attend DS – Detective Sergeant EHASH – Early Help and Safeguarding Hub EHAT – Early Help and Advice Team ERSCB – East Riding Safeguarding Children Board ERSCP - East Riding Safeguarding Children Partnership HUTH – Hull University Teaching Hospitals NHS Trust IDVA – Independent Domestic Violence Advocate ISPHN – Integrated Specialist Public Health Nursing LADO – Local Authority Designated Officer NSPCC – National Society for the Prevention of Cruelty to Children PVP – Protecting Vulnerable People SW – Social Worker TAF – Team Around the Family TM – Team Manager WNB – Was Not Brought YAS – Yorkshire Ambulance Service |
NC045404 | Executive summary of a review into the physical, emotional and developmental neglect of a 3-year-old-girl and her siblings. Abigail presented to hospital with serious concerns about her health and development in November 2012. Parents were charged with criminal neglect and Abigail and her siblings were placed in foster care. Family were well known to a number of agencies and there was a history of professional concerns relating to abuse and neglect. Both parents had significant physical and mental health problems requiring a high level of contact with health professionals. Identifies learning in relation to five key themes, including: limitations of an incident led approach to child neglect; need for professionals to feel valued and listened to and need for professional challenge; and the impact of professionals feeling overwhelmed or desensitised and the challenge of disguised compliance. Makes recommendations including Gloucestershire Safeguarding Children Board to undertake an audit of assessments and child in need and child protection plans to ensure that the child's voice is heard and taken into account. Review was undertaken using the Significant Incident Learning Process (SILP).
| Title: Serious case review: executive summary: subjects: Abigail and her siblings Bobbie, Charlie and Daisy. LSCB: Gloucestershire Safeguarding Children Board Author: Cathy Griffiths Date of publication: 2014 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Gloucestershire Safeguarding Children Board SERIOUS CASE REVIEW Executive Summary SUBJECTS Abigail and her siblings Bobbie, Charlie and Daisy Author: Cathy Griffiths Head of Quality (Children and Young People) Gloucestershire County Council 12th August 2014 1 Index Page Introduction 2 Why the Serious Case Review was done 2 Scope of the Review 3 Method Used for the Review 3 Family Contribution to the Review 4 Case Background 5 Summary of Events examined by the Review 6 Key Themes and Contributory Factors 8 Priorities for Learning and Change as a result of the Review 13 Recommendations and Challenge for Development 15 Conclusions 17 Next Steps 17 2 1 Introduction 1.1 This Executive Summary sets out the findings of a Serious Case Review about "Abigail" (not her real name), a 3 year old girl who lived in Gloucestershire with her parents, brothers and sisters. Abigail was neglected by her parents. When professionals tried to help her parents, or challenged them, they were unable to prioritise the children’s needs over their own or were obstructive. Abigail and her younger brothers and sisters are now thriving, being cared for in foster care or living with family members who are able to meet their needs. In 2014 the full extent of the neglect was laid before a judge and jury after an extensive criminal investigation. Abigail’s parents were convicted and sentenced to a term of imprisonment in June 2014. 1.2 As was anticipated, other significant information about the family came to light during the court process. For this reason, further work was planned into the Serious Case Review process, focussing on practitioners’ reflections after the court process on practice in the 6 months leading up to the parents’ arrest, reflecting on what has changed since that time and on new information which has emerged. 1.3 It became clear from the history available to the review through the Agency Reports, the court process and discussion at the Learning Events, that a number of the older siblings also had similar issues to those now identified in respect of the younger children. These historic issues included poor home conditions, severe head lice and nappy rash, missed appointments, poor attendance at school or nursery and professional concerns about inappropriate diet and the over reliance on cow’s milk. There was ongoing evidence that the parents often avoided professionals and that the children’s mother prioritised her own needs. 1.4 The Serious Case Review has helped inform how the local safeguarding system functions and has provided a focus for improvement to practice. The findings highlight how working with neglect is complex and has to take account the inter play between many different and often contradictory factors. The learning process has led to recommendations and “Challenge Questions” that support learning and improvement. 2 Why the Serious Case Review was done 2.1 The Government provides guidance in “Working Together to Safeguard Children” on when to hold a Serious Case Review (SCR). It is an important learning tool when a child has died, or been seriously harmed because of abuse, and there may be lessons to learn about the way local professionals worked together to safeguard and promote the welfare of a child. 3 The purpose of a SCR is to “identify improvements which are needed and to consolidate good practice1”. The aim is to learn how services could be improved in the future to reduce the risk of other children suffering in the same way. 2.2 In Abigail’s case, there was no statutory requirement for a Serious Case Review to be carried out, however since the GSCB had already identified the category of neglect as a priority for exploration, the Board decided to hold a SCR to learn from the case and what it tells us about the wider safeguarding system. This decision is in line with the GSCB’s commitment to continuous improvement in strengthening multi-agency working, to better safeguard and promote the welfare of children in Gloucestershire. 3 Scope of the review 3.1 The GSCB set the timeframe for this Serious Case Review to be about involvement with Abigail and her siblings from August 2010 when a multi agency Strategy Meeting2 was held because of professionals’ concerns about the children, to November 2012 when Abigail was admitted to hospital. Terms of reference were agreed for the review and upon request of the GSCB, an additional learning event was held after the conclusion of the criminal proceedings. The purpose was to reflect on a) the sentencing remarks of the judge, b) additional information from a Psychotherapist working with another member of the family, and c) additional views from Housing to contribute to wider learning. 4 Method Used for the Serious Case Review 4.1 Working Together says Serious Case Reviews should be done in a way which; recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence inform the findings3. 4.2 In keeping with the guidance in Working Together, the GSCB decided to use a method called “systems learning”. This means learning from an individual case as a ‘window’ on the 1 Paragraph 7, Chapter 4, Working Together to Safeguard Children – HM Government - March 2013 2 A Strategy Meeting is a formal multi agency meeting, convened when it has been assessed that a child may be suffering from significant harm. The Strategy Meeting decides whether a Section 47 child protection enquiry is appropriate and the most effective way to carry out the enquiry. 3 Paragraph 10, Chapter 4, Working Together to Safeguard Children – HM Government - March 2013 4 wider safeguarding system, looking at contributory factors in terms of what helps good practice and what gets in the way. It moves beyond specific incidents and actions to what it tells us about how well the system is working. This “systems” way of reviewing a case is supported by Working Together and helps the GSCB to learn implications for safeguarding practice and service more generally. 4.3 There are several methods for “systems” reviews and the GSCB chose what is called the Significant Incident Learning Process (SILP). This was followed by a Practitioner Learning Event after the court case. Both involved a large number of practitioners, managers and Safeguarding Leads coming together for a series of learning events. 4.4 The Chair of the Gloucestershire Safeguarding Children Board appointed two independent people to lead the SCR: Donna Ohdedar, an independent safeguarding consultant and Nicki Pettitt, an independent child protection social work manager and consultant. They had no previous links with the local agencies that were, or potentially could have been involved in the case, GSCB, or any of its partner agencies. 4.5 The first step for the SILP was each agency involved with the family completing a “chronology” of their contact with the family as well as analysis of the professional practice by their agency. This was provided by the Police; the Hospitals Trust; School Nursing and Health Visiting; the GP; Children’s Social Care; the Education setting and the Children’s Centre. The Independent Authors then led a Learning Event for practitioners involved in the case; then a recall session for professionals to consider the Overview Report, to feedback on the contents of the report and make sure it reflected their experience, views and learning points. 4.6 The method for follow up learning after the trial was adapted from ‘Systems analysis of clinical incidents: The London Protocol’ (Taylor-Adams et al, 2004) and James Reason’s ‘Swiss Cheese model’. These are used to learn from incidents in systems such as aviation, engineering and healthcare. The model uses the analogy of human systems of working being like multiple slices of Swiss cheese stacked side by side, illustrating that although many layers of defence lie between hazards and accidents, there can be ‘holes’ in each layer that, if they line up, can allow the accident or incident to happen. This was a helpful way of thinking for practitioners to review “contributory factors” to good practice and to issues that got in the way. 5 Family Contribution to the Serious Case Review 5.1 Abigail's parents were made aware of the SCR from the start and were contacted in order to make sure their views were heard and considered as part of the review. They were assured 5 the learning process was not about their court case but about what the agencies themselves needed to learn about their own practice, but neither parent agreed to meet with the SILP Independent Reviewers. The review did however learn from one of Abigail’s older siblings and one of her Grandparents, which was enormously helpful to learning from the voices of children and of wider family. Following the trial, Abigail’s parents were again asked if they wanted to contribute to the learning. They have declined to take part in any discussion at this time. 6 Case Background 6.1 This family had been known to a number of different agencies for over 16 years. Both parents had physical and mental health issues and a high level of contact with health practitioners. At times there were also serious concerns about all the children, for example when developmental milestones were not reached, health issues not always addressed by the parents, and the house being dirty, untidy and smelling of faeces. 6.2 A key feature in the background to the case was peaks and troughs in concerns about neglect; In 2007 an Initial Child Protection Conference4 was held but the children were not made subject to a Child Protection Plan5, because by then there had been improvements. A Review Conference was arranged, but was cancelled as this improvement was thought to have been maintained. However the mother went on to have more children against a backdrop of previous psychological problems, a history of post-natal depression and chronic pain, with a partner who had mental health issues of his own including suicidal gestures. Some of the mother’s mobility issues were never able to be investigated and are unexplained, due to lack of engagement. 6.3 There were a number of contacts and communications made to Children’s Social Care (CSC) and the children were as a result subject of assessment and interventions, including an assessment under the Common Assessment Framework6 (CAF). Things improved somewhat but the impact was minimal because of the parents’ limited engagement. 6.4 Abigail herself was born in 2009, and in the same year there were concerns about poor 4 A formal meeting of professionals from key agencies such as Health, Police, Children and Young People’s Services and those professionals who have worked with and know the family. The purpose is to decide the level of concerns for any child in the family and whether they are at risk of significant harm or will likely be in the future. 5 Child Protection Plans are put in place as a result of a Child Protection Conference, if the threshold for significant harm is met, to set out who will take what action and in what timescale. Core Group meetings are held between Conferences and involve the key professionals and the parents in order monitor the progress of the Plan. 6 A CAF is a four-step process whereby practitioners identify a child's needs early; assess those needs; deliver coordinated services; and review progress. The CAF is for children who have additional needs to those being met by universal services. The process is voluntary; consent by the family is mandatory and they can choose what information they want to share. 6 school attendance for some of the older children. Professionals on home visits described chaos, clutter, dog faeces in the home and a smoky atmosphere. There were concerns that her parents were not taking on board or acting on professional advice. 6.5 During 2010 two of Abigail’s siblings were referred to the hospital due to concerns about poor physical and developmental progression. The children were discharged from the hospital doctor’s care after some improvement was reported and following an initial assessment of need, no further action was taken by Children’s Social Care. 7 Summary of Events examined by the Review 7.1 In terms of professional interventions with the family during the scope of the review, this can be divided into four distinct phases of professional interventions; The first phase scrutinised in the SCR was between August 2010 and January 2011, looking at what happened after a multi agency Strategy Meeting was held7. The meeting acknowledged that there was a CAF in place and that it did not meet the needs of the children. However it was agreed that the threshold for a Child Protection Conference was not met8, but that a social worker should complete a Core Assessment of Need under section 17 of the Children Act 19899. However, the assessment was actually completed by an experienced family support worker, a practice that is no longer acceptable in Gloucestershire and has not been since 2012. This by law required the permission and cooperation of the parents. The opportunity to complete a core assessment was taken and lots of concerns were shared between professionals, but not always as forcefully as would have been hoped. The Serious Case Review revealed that Abigail’s mother could be aggressive, and on occasion swore at professionals if she felt challenged. Indeed her refusal to work with the schools in this first key episode of this review did not lead to a reconsideration of the need for a child protection response, but to an unconsciously collusive agreement that this could be avoided if mother agreed to work with the Health Visitor. While this was agreed in the spirit of partnership, the needs of the children were not prioritised over their mother’s. 7 A Strategy Meeting is a formal statutory, multi agency meeting, convened when it has been assessed that a child may be suffering from significant harm. The Strategy Meeting decides whether a Section 47 child protection enquiry is appropriate and the most effective way to carry out the enquiry. 8 The threshold for a Child Protection Conference is met where child protection enquiries are indicating that a child may be suffering, or be at risk of suffering, significant harm as a result of abuse. 9 A Core Assessment is done either under Section 47 of the Children Act for a child protection enquiry, or it is done under Section 17 if working with a Child in Need where it is clear that a greater depth of assessment is needed in some complex areas to clarify exactly what the needs are and what types of service will meet the child's needs. 7 7.2 The second key phase of involvement was from February 2011 to May 2011, when emerging concerns about Abigail were becoming clearer. The SCR found significance in the way the family did not cooperate with key issues such as attending appointments with the paediatrician, following dietary advice for the children, engaging with all of the relevant professionals including the schools. At this point with hindsight the need for a child protection conference should have been considered, but at the time professionals were seeing partial improvements and not some of the significant gaps in the children’s care. 7.3 The third phase of professional interventions was between June to July 2011, when there were concerns about the older pre-school children. There were signs that the professionals working with the children were becoming increasingly demoralised about both the family and the likelihood of the matter being seen or responded to as a safeguarding issue by the statutory agencies. This episode was significant because further concerning information was being noted, but none led to a referral formally requesting the intervention of CSC. During this time Abigail was assessed by a hospital doctor, but the information noted was mostly as reported by her parents and Abigail was discharged. 7.4 No significant issues emerged during the next 6 months, but the fourth key phase from February 2012 onwards examined in the SCR shows an escalation of concerns after missed appointments for one of the children and ongoing concerns about neglect, leading to a multi agency professionals meeting. The SCR found this episode was dominated by lack of effective action, with one of the key contributory factors being that the parents were successfully avoiding professionals. Despite persistent efforts from the Health Visitor to see Abigail, and the GP’s efforts to make sure her serious nappy rash was treated, the parents’ reluctance to engage and blatant avoidance of professionals continued, meaning that the understanding of all agencies about the seriousness of the situation was delayed. In October 2012 the Health Visitor made a referral to CSC and Abigail’s case was appropriately opened for assessment. This did not begin till the end of October, because CSC mistakenly thought that as a number of professionals were actively involved, and the nappy rash had been an issue since June, urgent action was not necessary. In November however a Strategy Discussion was held and it was agreed to complete a Core Assessment under Section 47 of the Children Act.10 During this time a psychotherapist working with 10 The Core Assessment provides a structured framework for social workers to gather evidence during a child protection enquiry, which under Section 47 of the Children Act is when there is reasonable cause to believe that a child has suffered or is likely to suffer significant harm, for example a child is suffering or likely to suffer significant harm in the form of physical, sexual, emotional abuse or neglect. The social worker contacts the other agencies involved with the child to inform them that a child protection enquiry has been initiated and to seek their views. Parental permission to undertake these inter-agency checks is not mandatory and can be overridden if this would be prejudicial to the child’s welfare, or there is concern that the child would be at risk of further significant harm. 8 another member of the family, independently of the local agencies, was shocked to see the state of the home and the children, and contacted CSC. They were told that the family were to be the subject of a child protection meeting due to a referral received previously. A professionals’ meeting was held in November and it was decided to progress to Initial Child Protection Conference. However, Abigail was admitted to hospital on 23 November 2012 with severe nappy rash, found to have anaemia, malnutrition, head lice infestation and decreased bone mineralisation, and was not returned home. 7.5 Throughout the period under review, the Housing department overseeing the family’s tenancy were not aware of any concerns from a housing perspective, apart from the use of a wood burning fire in the property, which is not an issue related to the neglect of children. Reassurance has been given that all Housing staff members undertake training in safeguarding and are aware of the need to report concerns to the lead safeguarding officer. It is good practice that staff are all trained in safeguarding, but another perspective on the family might have been gained if they had been more involved at the time. 8 Key Themes 8.1 Contributory Factors to Good Practice 8.1.1 Joint Working The SCR highlighted a commitment to early intervention which led to professionals trying to help the family through a Common Assessment (CAF), and professionals’ understanding of the principles of partnership led to them working hard to secure the trust of the parents and work alongside them. A culture of joint working was evident in some clear examples of a number of professionals providing the children and family with a high level of support and assistance. The family were given good consistency of care from health and education professionals, who provided extra support and services to the family for many years. All undertook regular home visits. There were good examples of CSC doing joint visits with other professionals, in both the first and last key phases of professional intervention. When meetings were held, whatever the status of the meeting, they were very well attended. This reflects the amount of concern in the professional network, but also the strong commitment to the children. The schools talked to each other regularly. Information on the children was transferred appropriately and there was a good understanding of the challenges the children faced from their peers due to their problems. There was positive communication from the Health Visitors to the GP, particularly during the fourth key phase. 9 8.1.2 Professional persistence Health Visitors showed persistence in getting access to the house when appointments were regularly missed. Professional challenge was evident from the schools and the Health Visitors in particular, but also from doctors in primary and secondary care. The police demonstrated very considerable persistence in bringing criminal charges and Abigail’s parents have been successfully prosecuted. 8.1.3 Child Focussed Remedial Action Since the children were removed from their parents’ care the Local Authority has been proactive in placing them and securing appropriate orders to ensure their future. Since the children have moved into a caring and loving environment they have shown encouraging signs of improvement, receiving help to recover both physically and emotionally from the significant harm they have endured. 9 Contributory Factors that made working with this case difficult 9.1 Despite these examples of good practice, with hindsight there were a number of complex contributory factors that hampered the process of protecting the children from neglect, within a culture at the time where neglect was seen as less serious than other types of abuse. Key contributory factors drawn out through the SCR are highlighted below. 9.2 Understanding the Nature of the Neglect A key feature of this case was the complexity of recognising and responding to neglect. Exploration of why this is the case pointed to the fact that incidents in this case were often observed in isolation. With hindsight, the list of neglect factors present in this case would seem to clearly indicate neglect – tooth decay, head lice, poor growth and weight gain, delayed development, anaemia, missed appointments, failure to use medication, severe nappy rash, poor hygiene, poor attendance at school, non-compliance with advice from health professionals - but at the time, establishing the cumulative picture was hindered. There were clear difficulties at the time in ensuring that all the information on all the children was available to be drawn together. This meant that overall the professional concerns about neglect were never sufficiently supported by evidence collected and collated on a multi-agency basis which resulted in appropriate decisions not always being made. A contributory factor was that staff were working within a system that, at the time, did not recognise the risk that physical and emotional neglect poses to children, compared to other cases they were dealing with such as physical or sexual abuse. There was a pattern of delayed responses, for example delay in pulling together meetings and an understanding 10 about the serious long-term effects of neglect was not clear across all the organisations. As a result it took the critical incident of Abigail’s severe nappy rash and malnourishment to ensure her removal from the family. 9.3 Peaks and troughs Peaks and troughs in episodes of neglect highlighted in the Judge’s sentencing remarks were reflected on by professionals who worked with the family, in the context of the ‘Disguised Compliance’ they had experienced. This involves the parent giving the impression of co-operating with services, in order to diffuse professional intervention. The effect was to neutralise the authority of the professionals to take further action, for example in this case in the sporadic increased school attendance, attendance at medical appointments, engagement with health professionals or the cleaning of the home before visits by health professionals. In addition the SCR found it noteworthy that during the review period, Police attended the family home on 6 occasions for non child protections matters and none of those occasions gave rise to concerns about the children at the time. CSC also made unannounced visits to the family which did not raise concerns. Photographs picturing the level of chaos and decay in the house used during the court case were reflected upon during the learning event, it was confirmed that these were taken 2 months after the children had left the home and did not represent how workers saw the home during home visits. 9.4 Disguised Compliance An Ofsted 2014 report about neglect noted that in those cases where children were not making positive progress, a common feature was lack of parental engagement with the process; however, many social work professionals failed to challenge these parents and only a few multi-agency groups showed clear strategies for tackling non-compliance. The SCR found that in this case, a predominant feature was how the mother avoided professional interactions. Despite some committed interventions by a number of practitioners, there was little success in effectively engaging the family and so implementation of the support to Abigail was significantly compromised. A key contributory factor was disguised compliance. This involves a parent or carer giving the appearance of co-operating with agencies, to avoid raising suspicions, to allay professional concerns and ultimately to diffuse professional intervention. The challenge of working with parents who are manipulative and/or show disguised compliance was a key theme when reviewing this case. There was no doubt throughout the SILP and the additional work after court, that both parents had adopted this stance as a way of avoiding the agencies who had voiced concerns about the children. This view was strengthened by the experience shared by Abigail’s grandparent and older sibling, who gave examples of manipulative, hostile behaviour by Abigail’s mother and disguised compliance such as squeezing out the 11 prescribed cream for Abigail’s nappy rash so as to make it appear that it had been used. The Psychotherapist involved with another member of the family felt the mother had a diagnosable and powerful personality disturbance, not able to prioritise her children’s needs above her own. 9.5 Focussing on the child Obstacles to focussing on the child identified during the SILP included elements that are usually good practice; preservation of the family, the partnership principle, empowerment, respect for parents’ rights. However the SCR emphasises how the mother’s fierce stating of her rights, and the lack of parental permission for all agencies to work fully with each other led to a failure to see the children in this case, both literally and metaphorically. The children’s parents both had health and psychological problems of their own, which demanded a lot of professional attention. Practitioners involved in the SCR however confirmed that there had been no clear evidence of physical disabilities being the reason for neglect of the children, but rather a case of the parents placing their own needs above those of the children. A number of the professionals felt they had to carefully negotiate their position to avoid losing any opportunity they had to engage with the family. They had the dilemma of how to build a relationship with the parents, without angering the children’s mother and isolating themselves as a help to the children. A powerful way to combat this is to speak directly to the children. It is true that the children may well have faced emotional and psychological barriers in talking to professionals, out of loyalty to their family. Nevertheless, the SCR found insufficient evidence of efforts to speak with the children. During the SCR Abigail’s sibling felt safe enough to tell the review that the mother would lie to professionals constantly and many of the positive updates that other professionals recorded about the children were based on information from their mother. 9.6 Sharing Information Sharing full information was complicated in this case. Abigail and her siblings were being worked with as Children in Need under Section 17 of the Children Act, which meant parental consent to share information was vital. Abigail’s mother did not give consent for all professionals to share information with each other. This meant they were not free to gather information from all sources to identify whether this revealed persistent neglect; to do so would have been to illegally escalate an inquiry during which information was shared, without enough supporting evidence to do so. 9.7 Start again syndrome Despite brief periods where some improvement was noted, concerns intensified during the 12 period being considered by the SCR. However there appeared to have been an incident led approach and ‘start-again syndrome’ - in these situations the case history is not considered sufficiently. The SCR found that this led to a lack of analysis of parenting capacity, including their motivation to change. The Agency Reports and the professionals at the learning events acknowledged that decisive action was not taken in relation to the on-going issues, with delays in the provision of appointments at the hospital; the start and completion of the Core Assessment; and in the holding of key meetings. On occasion there was over-optimism about the relationship between the mother and her children and improvements in the children’s development, hygiene and attendance at appointments. 9.8 Systemic Paralysis Serious case reviews have often commented on the difficulty, in child neglect cases, for professionals to decide when ‘enough is enough’ and that when staff feel helpless, this leads to avoidance and drift. The Psychotherapist working with another member of the family at the time felt systemic paralysis was happening, with professionals unconsciously colluding with a parent’s denial of the situation. Although not all professionals reflecting back agreed with this, it was clear within the SCR that professionals who had known the family over years felt confused and overwhelmed by the complexity of the needs of the parents and children in this family. Some became desensitised to the family’s way of living. Some took the view that keeping the family on-side and making the system easily accessible was the most practical way of handling the situation. 9.9 Professional Splitting The powerful personality displayed by Abigail’s mother appeared to give her the opportunity to divide professional opinion between the psychotherapist and her colleagues, described as a case of ‘professional splitting’. Abigail’s mother was reported to have the ability to ‘literally fill the room’ and by doing so was able to divide opinions amongst the team, thereby ‘splitting the group’. This experience was recognised by local professionals in the context of their own experience of the parent’s complaints about one organisation to another. This directly linked to the contributory factor of child protection thresholds reported to have been reached by some professionals but not all. This had allowed the parents to split professional opinion about thresholds for intervention and what actions were needed which resulted in the child's needs being hidden. 9.10 Resolving Professional Disagreements/Healthy Challenge The review acknowledged the hard work that school staff and Health Visitors put into this family, and the attempts they made to communicate concerns, even when parents had refused permission for full communication. It was clear within the SCR that at the time, a 13 number of professionals struggled to make themselves heard, unhappy with the progress the children were making but feeling ‘powerless’ when told it did not meet the threshold for child protection. The SCR acknowledged it is understandable that professionals felt demoralized and not listened to about their concerns. It also noted a number of opportunities for concerns to be escalated via the Escalation Protocol; on occasion, letters from one professional to another were taken to be for information rather than requesting a service, and the escalation protocol was not sufficiently recognised or used at the time. 10 Priorities for learning and change as a result of the review 10.1 The SILP overview report emphasises that the practice examined was, at the time of reviewing this case, at least 12 months old, and much had changed since then. The Independent Reviewers recognised improvements made across all relevant areas since the time of the incidents being considered and outline those in detail, as significant and positive contextual information However recommendations were made to consider further learning or where lessons already learnt need to be reinforced; 10.2 Lesson 1: Professionals in the agencies involved in this case had difficulties in keeping a clear focus on the needs of the children, due to the need to negotiate the many demands and difficulties of the parents. Supervision needs to play a clear role in ensuring that assessments, plans and interventions listen to the child’s voice and consider this information when taking actions. To quote Working Together 2013 ‘Ultimately, effective safeguarding of children can only be achieved by putting children at the centre of the system, and by every individual and agency playing their full part, working together to meet the needs of our most vulnerable children.’ Lesson 2: The child’s experiences should be at the heart of all plans. Robust, time bound and outcome focused plans need to be in place for all children where there are concerns about the capacity or motivation of the parents to improve the children’s circumstances. These plans should include extended family members. Lesson 3 The following issues remain of concern and require a clear message to all agencies: The need for clarity regarding sharing information on children and their siblings and parents, when they are not identified as a ‘child protection case’. The need for clarity about the option of holding professionals meetings without 14 the parents attending, which may have been useful in this case. The need for clarity regarding the ability of all agencies to request a strategy meeting. Lesson 4 It is the robustness of the plan, which must include a contingency plan and the involvement of all agencies and the family, which will ensure the needs of the children are assessed and met. Not the status of that plan. In this case it is clear that the plan should have made it clear that if the parents did not cooperate fully with what was required to ensure the children’s needs were met, that legal advice would be sought. Lesson 5 All assessments of risk should consider and analyse the historical information held across agencies. Lesson 6 All professionals working with children and families need to be trained and supported, to include the provision of reflective supervision, in the identification and challenge of parents who use manipulation and disguised compliance, to ensure the needs of the child remain the priority. Lesson 7 All agencies need to have the confidence to challenge or question decisions taken by other professionals in partner agencies. Clear guidelines and training, supported by supervision, needs to give professionals the confidence to challenge each other and to escalate any concerns they have via the resolution policy. The review has heard that agencies defer to Social Care when it comes to decisions about the need for services to be provided to children in need and in need of protection. GSCB need to ensure that they advertise the message, including in training, that professional disagreement is a positive sign of a healthy safeguarding system. Lesson 8 Staff across all agencies must have a shared understanding of neglect and its impact on the safety, wellbeing and development of children. All professionals working with children should be trained and supported in regards to recognising child neglect, and be provided with the tools to work effectively with children and families where there are concerns about neglect. This includes a focus on building a shared understanding of the children’s history by incorporating all of the information held on the family across the agencies involved. 15 11 What is being done differently 11.1 The SCR noted that children’s services in Gloucestershire improved their safeguarding services after concerns were identified in the 2011 Ofsted inspection, which was when the serious concerns about Abigail were emerging, and that the inspection in 2012 found improvements had been made. The Independent Reviewers noted relevant improvements such as provision of neglect training, a clearer ‘request for service’ process when contacting CSC, the roll out of professional reflective meetings, improved auditing schedules, increased evidence of children’s voices seen in internal audit and an Ofsted thematic inspection of Early Help in Gloucestershire. The Independent Reviewers concluded that there have been positive improvements since Abigail and her siblings were referred into the system. 11.2 In addition, professionals reflected that whilst there still needs to be more clarity about the thresholds for neglect, the Levels of Intervention document published since the time of the case, has helped,. Professionals are more aware of the Escalation Protocol; feel that there is a better understanding of when a strategy discussion is needed, that plans for children are tighter and where necessary police are involved in the process sooner. 12 Recommendations and Critical Challenges for Future Development 12.1 Recommendation 1: GSCB to undertake an audit of assessments and of child in need and child protection plans to ensure that the child’s voice has been heard and is taken into account in the conclusion of the assessment and throughout the plan. Recommendation 2: The GSCB should support a framework of meetings which allow professionals involved in particular cases to meet and reflect on professional dynamics and disagreements without the presence of children and families. Recommendation 3: That the GSCB review its model of reflective supervision, to ensure that it is fit for purpose in assisting professionals to gain confidence in working with parents who are manipulative and show disguised compliance. Consideration is to be given to using this model with more complex Child in Need cases, as well as those subject to a Child Protection plan. Recommendation 4: That the GSCB’s new Levels of Intervention model includes a clear link to the professional 16 challenge policy, and is clear that requests for explanations of why decision have been made should be sought as applicable. Recommendation 5: That GSCB review their neglect training to ensure that it has improved the shared understanding of neglect across agencies. This review should include a request that all agencies review professional training and qualification courses locally to ensure they include training on child development and the impact of neglect. 12.2 Having considered the SILP overview report, Gloucestershire Safeguarding Children Board have agreed to consider the following “challenge questions” to inform the formal GSCB Response Plan. This is in addition to the recommendations being implemented as a result of the SILP. The following challenges for local services are provided in relation to the learning from the case, within the context of systems learning: Should further training be developed for professionals to enable them to remain focused on the purpose of a home visit and take the lead in the conversation rather than following the lead of the parents or carers? Is there sufficient understanding of the concept of ‘professional splitting’ across partners? Are professionals across the child protection system able to recognise when systemic paralysis may be occurring? Should training be made available to assist professionals to recognise the symptoms of professional splitting and systemic paralysis? Is the importance of the role of housing recognised in child protection work locally? How do we ensure there is a better understanding of ‘right of access’ in respect of the condition of homes owned by LAs or social landlords? How do we enhance the understanding of housing professionals of the impact of housing conditions on families e.g. on a child’s education? How can we progress collaborative working with Housing professionals and should the model of basing family support staff within Housing agencies operating within Families First be replicated? Should the GSCB provide more information and training on how to deal with families who employ disguised compliance? Peaks and troughs were observed in this case, a better understanding of the long term impact of neglect demands a long term perspective in understanding whether families are able to make sustained improvements. How can GSCB promote good planning and clear milestones? Are professionals now better able to balance conflicting needs within families so that parents needs do not take priority over the needs of the children? Are we confident that practitioners respect each other’s views regarding thresholds and avoid unintentionally colluding with challenging families? 17 13 Conclusion 13.1 The Department of Health definition of neglect is the persistent failure to meet a child’s basic physical and psychological needs likely to result in the serious impairment of the child’s health or development. This definition is clear – yet it is also clear that for social workers and other professionals working with this family, there were complex contributory factors to not collating a complete picture sooner, including establishing the evidence, thresholds for intervention, and parents’ rights under law about information sharing. 13.2 The family were provided with preventative interventions and early help strategies for a number of years, but a shift to child protection processes was made more difficult by several contributory factors including the limits to information sharing where parents have the right to withhold consent in non child protection cases; disguised compliance; and an inadequate culture at the time of healthy mutual challenge. These complex factors caused task problems which in turn led to frontline professionals feeling the full force of the difficulties associated with working with this family. 13.3 Professionals at the learning event were able to confidently identify areas of improvement and ‘moving on’ in terms of current practice, with increased experience of ‘joined up’ working, more priority given to the child’s voice and practitioners welcome a stronger culture of mutual, healthy challenge. However, given the complexity of the safeguarding system and how this case revealed what can happen when several contributory factors line up to cause weaknesses within it, there is a need to check and to reinforce all the lessons learnt and recommendations made within this SCR. 14 Next Steps Recommendations from this Review will form the basis of a formal GSCB Response Plan. This will be overseen by the GSCB Executive Group and regularly monitored by the GSCB Serious Case Review Sub Group. The SCR and Response Plan will not be the subject of a formal evaluation by Ofsted; that arrangement was ended in July 2012. However the SCR and the associated responses will be examined as part of the unannounced inspection of arrangements to protect children that takes place in all Local Authorities. |
NC50552 | Death of a young person and their mother by suicide in 2015. Both jumped together in front of a moving train. Mother and young person were known to community services; children's social care; housing department; SEN services; school; GP; mental health services; police and college. There had been considerable involvement between 2004 and 2007 when the family was known to children's social care, but little meaningful involvement with these services since 2009.The review concluded that the deaths could not have been prevented. Mother and young person had both left suicide notes and there was no information in these that led to concerns about professional practice. Ethnicity or nationality of the mother and young person is not stated. There is no learning arising from this review regarding events before the day of the suicide. There are no recommendations arising from this review.
| Title: Serious case review overview report in respect of a Young Person. LSCB: Hillingdon Safeguarding Children Board Author: Barry Raynes Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 | P a g e Serious case review overview report in respect of a young person Barry Raynes Director Reconstruct May 2016 CONTENTS Introduction Page 2 Methodology Page 2 Panel Page 2 Independence Page 2 Chronology Page 3 Family involvement Page 3 Timescales Page 3 Findings Page 4 School and college Page 4 GP Page 4 Police Page 4 Conclusion Page 5 2 | P a g e 1. INTRODUCTION 1.1 In 2015, somewhere in England, a mother and the young person who was her child committed suicide by jumping together in front of a moving train. The Independent Chair of the Local Safeguarding Children Board decided in July 2015 to commission a serious case review. The review started in September 2015. 1.2 This review, which was thorough, found no new learning because there had been little meaningful involvement with professionals since 2009. It concluded that the event that led to the tragic death of a young person and her mother could not have been predicted or prevented. 2. METHODOLOGY 2.1 A serious case review panel was convened: their role was to produce terms of reference1 for the review and oversee and quality assure the work of the lead reviewer and author of this report, Barry Raynes. Serious Case Review Panel 2.2 The serious case review panel met on four occasions between September 2015 and May 2016. The overview report was ratified at the local safeguarding children board meeting on 1st July 2016. 2.3 The panel comprised of: Designation Organisation LSCB board manager The safeguarding children board where the mother and young person lived at the time of their deaths Designated Nurse Safeguarding A clinical commissioning group Detective sergeant The police Designated Nurse Safeguarding Clinical commissioning group Director of Learning Young person’s college LSCB board manager The safeguarding children board where the mother and young person had previously lived Safeguarding manager Children’s social care where the mother and young person had previously lived Head Mental Health Services Head teacher Young person’s school Assistant director Children's social care where the mother and young person lived at the time of their deaths Independence 2.4 The lead reviewer was Barry Raynes. Barry is a non-executive director of Signis, a company that owns Reconstruct which provides child care training and consultancy to managers and staff throughout the United Kingdom. Reconstruct also supplies advocacy, independent visiting and participation services to children in England. 1 Guidance specifying how the review was to be managed. 3 | P a g e 2.5 Barry has thirty five years’ experience of child protection social work. He has been involved in over 30 serious case reviews since 2007 – either overseeing the work of Reconstruct’s consultants or producing overview reports. He has written web-based child protection and child care procedures for more than 50 LSCBs and local authorities in England, Wales and Scotland. Barry has a Masters degree in public sector management and has researched to a PhD level. Barry attended all panel meetings. Chronology and narrative 2.6 Each agency who had been involved with the family was asked to check their records and produce a chronology of events. The following agencies produced a chronology. Community services where the mother and young person had previously lived Children's social care where the mother and young person had previously lived Housing department where the mother and young person had previously lived SEN services where the mother and young person had previously lived The young person’s school GP Children's social care where the mother and young person lived at the time of their death Housing where the mother and young person lived at the time of their death Schools admissions where the mother and young person lived at the time of their death Mental Health Services where the mother and young person lived at the time of their death The police The young person’s college 2.7 Each chronology compiler was asked to comment upon any learning that arose from their chronology. Some comments were made but none produced lines of enquiry pertinent to learning lessons from the deaths of the two people. These chronologies were integrated to form a joint chronology (running from 2002 – 2015) and, from this, the lead reviewer produced a narrative of events. 2.8 That narrative of events was shared with each agency’s chronology compiler and they were asked to comment further upon any matters of practice and no responses were received. 2.9 The young person and her mother had both left suicide notes which were in the possession of British Transport police (BTP). The Panel were assured by BTP that there was no information in the notes that would have led to any concerns about professional practice. Family involvement 2.10 The grandmother of the young person was contacted and asked if she wanted to be involved in the review; she declined. There were no details of any other family members available to the Panel. Timescales 2.11 The serious case review took 12 months to complete. This is longer than the time prescribed by Government guidance2. Delays were caused by the summer break in 2015 and the timetabling for the report to be signed off at a quarterly Board meeting. 2 Working Together to Safeguard Children (2015) 4 | P a g e 3. FINDINGS 3.1 The narrative identified that there had been considerable involvement between professionals and family members between 2004 and 2007 when the family were known to children’s social care. The case was closed in 2007 and was never opened again to a social worker. The involvement between 2004 and 2007 appears to have been effective, proportionate and in keeping with procedures in place at the time. 3.2 The only professional contact with the family from 2009 until the event that ended the young person’s life came from the family’s GP, the young person’s school and the police. The Panel considered three questions: 1. should the child’s school (and latterly college) have requested more support for the family? 2. did the family’s GP consider whether the mother may have had mental health problems and were there opportunities or circumstances that could have indicated welfare concerns in relation to the young person or her mother? 3. did the police deal appropriately with the contact they had with the mother? School and college 3.3 The head-teacher of the young person’s school attended one of the Panel meetings to discuss the school’s involvement with the family. The panel was satisfied that there had been no concerns that warranted any action other than those taken by the school. 3.4 The director of learning at the young person’s college attended all Panel meetings. There had been an incident in 2015 where the young person had fallen out with peers and the police had been called. The Panel were satisfied that the action that the staff at the college had taken was appropriate, proportionate, considerate and correctly followed their procedures. GP 3.5 The Panel and the lead reviewer were aware that there had been contact between the mother and her GP and wondered whether the GP could have noticed any mental health issues or any sign that she was contemplating suicide. 3.6 The lead reviewer, along with the GP chronology compiler, (a named GP for safeguarding working in the area and independent of the practice) visited the practice and had a conversation with the GP and practice manager about the mother. The GP remembered her as an easy going, relaxed woman who was often tired and had problems with her joints. There had never been any difficulty with her behaviour and nothing had suggested that she had mental health problems or was contemplating taking her own life, or encouraging her child to do the same. 3.7 Further examination of the notes indicated that the mother had visited the GP on six occasions in the 12 months before the suicides; this was not considered to be excessive by the Panel. Police 3.8 There was some contact between the police and the family in 2009 and 2010, then no contact until 2015, caused by the incident at college described above where police had been called. There was discussion at Panel regarding this involvement. It was the view of the Panel that the police intervention was appropriate, proportionate and in keeping with procedures. 5 | P a g e 4. CONCLUSION 4.1 The decision to hold this serious case review was made because there appeared to be considerable agency involvement with the family and that, along with the unusual nature of the deaths of the mother and her child, meant that the decision to hold the review was reasonable. 4.2 Once each agency had provided their chronologies it became clear that the information held on the family was, in the main, from 2005 and 2006 – nearly 10 years before the event that ended the young person’s life. Further analysis of those earlier events confirmed that intervention had been appropriate and successful. Discussions with professionals who had been involved with the family more recently and analysis of the case records that did exist, demonstrated that recent intervention, such as it was, had also been appropriate. 4.3 There is therefore no learning arising from this review regarding events before the day of the suicide. 4.4 Records show, just before the suicides, that the mother went to an information desk at the station where they committed suicide and asked a member of staff when the next through train would be arriving. It appears that no action was taken following this request other than to supply the mother with a correct answer. The safeguarding manager of the local safeguarding children board who commissioned this review has been in contact with British Transport police and has discovered that training has now been offered to staff at the station in question. 4.5 There are therefore no recommendations arising from this review. |
NC044058 | Executive summary of a review into the death of a 10-week-old baby boy in March 2011, as the result of a severe blow to the head. Further examination revealed older injuries to Baby A. Mother's partner, Mr C, was found guilty of murder and mother was found guilty of causing or allowing the death of a child. Maternal grandmother was 16-years-old when mother was born and mother was 18-years-old when Baby A was born. Mother separated from Baby A's father before Baby A's birth and reported that the relationship had been abusive. Issues identified include: mother's vulnerability; mother, father and Mr C's involvement with children's services as children; Mr C's abuse of a family pet as a child and "thoughts of doing bad things to his sister"; and Baby A's presentation at GP service with bruising for which mother gave inconsistent explanations. Identifies a lack of professionals' knowledge around services and guidance available to them.
| Title: Serious case review in respect of Baby A: executive summary and revised action plans LSCB: Gateshead Local Safeguarding Children Board Author: Barry Raynes Date of publication: 2013 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 SERIOUS CASE REVIEW IN RESPECT OF BABY A EXECUTIVE SUMMARY AND REVISED ACTION PLANS October 2012 Updated May 2013 2 1. INTRODUCTION 1.1 Baby A was a child from Gateshead who died at the age of 10 weeks. His death was caused by a head injury. Subsequent tests indicated a number of injuries including a fractured skull, a subdural haemorrhage, retinal haemorrhage, a fractured arm, rib fractures and a number of bruises. The injuries were considered by medical staff and the police to be non-accidental. 1.2 Baby A was born in Tyne and Wear. His parents, Miss A and Mr B, had separated during the pregnancy and Miss A had started a new relationship with Mr C whilst pregnant. 1.3 Following his discharge from hospital Baby A lived in Gateshead all of his life. He was too young to be considered to have a first language or religion however the first language of all of his family is English. Baby A had no recorded physical disabilities 1.4 Miss A and Mr C were both questioned in relation to Baby A’s death. Both initially denied causing the injuries to Baby A, however during court proceedings in relation to Baby A’s murder, Mr C admitted shaking Baby A when he would not stop crying, but denied intending to kill him. Mr C was found guilty in court of Baby A’s murder and Miss A was found guilty of causing or allowing his death. 1.5 When a child dies and abuse or neglect is suspected, the Local Safeguarding Children Board (LSCB) has a statutory responsibility to carry out a review of the case in order for any learning to be identified about the way that agencies worked with the family. This is known as a serious case review. The purpose of a serious case review is not to identify who killed the child but whether or not agencies working with the family could have done things differently. 1.6 A serious case review involves a series of meetings between independent people and senior managers from all of the services who work with children and their families in the area. The whole process is overseen by a panel of senior managers, called a Serious Case Review Panel. The result of a serious case review is a series of single agency reports, called individual management reviews (IMRs), a detailed overview report and this report, called an executive summary. At the end of the process all of the reports are submitted to Ofsted for evaluation and the Department for Education (DfE) for information. 1.7 The serious case review was completed in line with Chapter 8 of Working Together to Safeguard Children (2010). Following the conclusion of the Ofsted evaluation and any criminal or related proceedings in the case 3 there is a requirement for LSCBs to publish both the executive summary and the anonymised overview report. NB the serious case review process has now changed and, as of 5 July 2012, there is no longer a statutory requirement for LSCBs to submit serious case reviews to Ofsted for evaluation. 1.8 In the serious case review with respect to Baby A the Serious Case Review Panel was independently chaired by Sue Taylor, a barrister who specialises in family law. The overview report and executive summary were originally written by Barry Raynes, who is the chief executive of Reconstruct, a consultancy company providing services to child care agencies throughout the UK. 1.9 The Serious Case Review Panel consisted of: Sue Taylor – Independent Chair Area Manager – Central Gateshead Council Designated Nurse – Safeguarding Gateshead Primary Care Trust Designated Doctor – Safeguarding Gateshead Health NHS Foundation Trust Detective Inspector – Gateshead Public Protection Unit Northumbria Police Head of Litigation Gateshead Council Head of Offender Management Northumbria Probation Trust Head of Service – Children, Families and Young Offenders Service Gateshead Council LSCB Business Manager Service Manager – Safer Communities Team Gateshead Council Service Manager – Safeguarding, Quality and Improvement Gateshead Council 1.10 IMR reports were prepared by a number of services in Gateshead Council, including Children’s Social Care, Northumbria Police, health agencies in Gateshead, including both acute and community services, and also a 4 health agency based outside of Gateshead where Miss A and Baby A had accessed services. 1.11 The Serious Case Review Panel established Terms of Reference which identified the main questions which needed to be addressed. The time frame for the review covered a period from a date in 2010 (which was around the time that Baby A was conceived) until the date he was admitted to hospital with injuries in 2011 and also took account of the backgrounds of the adults involved. 1.12 Some members of Baby A’s family (who were not suspects in the investigation into his death) were invited to participate in the process however they decided that they did not want to be involved. Because Baby A’s mother was the suspect in an ongoing investigation into his death while the serious case review was underway she was not invited to take part but was notified via her solicitor that her son’s case was the subject of a review. 1.13 Baby A’s father was offered the opportunity to hear the findings of this serious case review prior to publication. 1.14 Following an evaluation by Ofsted, additional Terms of Reference, overview report and a revised executive summary (this document) were written by the Practice Review Sub Group of Gateshead LSCB. The two overview reports and executive summary will be published following the conclusion of the police investigation into Baby A’s death and the subsequent criminal trial. 2. SUMMARY OF EVENTS 2.1 Miss A was aged 18 at the time of Baby A’s birth and had separated from Baby A’s father during the pregnancy. She subsequently began a relationship with a new partner, Mr C, who later moved in with her and Baby A. Following the breakdown of the relationship with Mr B, Miss A told some professionals that there had been some violence in their relationship. 2.2 As a young child, Miss A and one of her siblings had been involved with health and social work professionals due to concerns regarding neglect. The family later left the Gateshead area before returning when Miss A was a teenager. 2.3 Miss A had reportedly experienced abuse during her childhood from a member of the extended family and also had a history of depression. Miss A later disclosed these issues to her midwife during her pregnancy and her midwife felt that, as the problems were in the past, she did not need 5 any extra support. As a consequence, the midwife did not complete a fuller assessment which might have concluded that there were some factors in Miss A’s history which meant that any child she had may be vulnerable and that she would indeed benefit from additional support. Miss A also told her midwife after she had separated from Mr B that he had been violent towards her. Again, because the midwife felt these issues were in the past, she chose not to carry out any further risk assessment around Miss A and her unborn baby. 2.4 There was also no referral made to the Family Nurse Partnership programme in respect of Miss A and her unborn child by the midwife. The programme is a service for all first-time teenage mothers in Gateshead which provides further support until the baby’s second birthday. Miss A would have qualified for this programme as she was aged under 20. 2.5 Miss A was seen for routine midwifery appointments before she gave birth to Baby A. Professionals were aware of the breakdown of her relationship with Mr B and took steps to ensure that she felt safe during her appointments, however no additional antenatal risk assessments were carried out. 2.6 Miss A and her new partner Mr C were involved in a car accident whilst she was pregnant. They both attended hospital and neither were found to be seriously injured. Tests were also carried out on the unborn baby and no concerns were noted. 2.7 Baby A was born just over three weeks early. He was initially well but required medical support a few hours after his birth and needed a stay in hospital for just over a week. While he was receiving treatment in hospital professionals also shared the previous concerns about Miss A and Mr B’s relationship. 2.8 Miss A and Baby A saw various professionals (Early Years workers, doctors and health visitors) on 12 occasions in the weeks following his discharge from hospital. There were no concerns expressed about Miss A’s care of Baby A and many professionals commented positively about her care. Mr B had weekly contact with Baby A which was supervised by Miss A’s family 2.9 Baby A attended his GP practice for a routine 6-8 week development check. He was initially seen by a health care assistant who was concerned as she noted two small marks on his face, which she described as bruises. The health care assistant was also concerned that Miss A appeared to change her explanation for these marks and had also said that “my baby bruises easily”, “even when just being held”. The health 6 care assistant asked Miss A whether this was because Baby A was being roughly handled, but she denied that this was the case. 2.10 The health care assistant decided that she would speak to the GP who was scheduled to see Baby A as part of the check, prior to the appointment. The GP thoroughly examined Baby A in line with usual practice for a 6-8 week check but found nothing of concern. The GP was satisfied with Miss A’s explanation of events and the marks on Baby A’s face, which he described as marks and not bruises, and recorded that no bruises were seen. 2.11 Baby A’s health visitor visited him the following day for a scheduled home visit. At that stage the health visitor was unaware of the health care assistant’s concerns and spent 90 minutes in the address with Baby A, Miss A and Mr C and discussed a range of issues. The health visitor did not notice any marks on Baby A. Miss A informed her that Baby A bruised easily. The health visitor was reassured as Miss A stated that she had told the GP about this. 2.12 The health care assistant continued to be worried about Baby A and discussed the issue with the practice nurses in the GP practice who advised her to contact the baby’s health visitor. It took a further seven days before the health care assistant and the health visitor were able to discuss the issue as they were both very busy. Following the discussion the health visitor also spoke to the GP and they decided that she should speak to Miss A about the concerns and any other issues. They agreed to do this on a specific date when Miss A was expected to come to a drop-in clinic with Baby A, however she did not attend as expected. 2.13 Miss A and Baby A attended a baby clinic at another clinic a week after the health visitor’s home visit. Baby A was seen by another health visitor and was weighed and given immunisations. No concerns were identified. 2.14 Several days later, and six days before Baby A’s death, Miss A took Baby A to the A&E department of a local hospital as she was worried that he was vomiting and had a cold. He was thoroughly examined by a doctor who could find nothing seriously wrong and prescribed infant Gaviscon. 2.15 A few days later Baby A was brought into the A&E department of a local hospital by ambulance. When the ambulance had arrived at the home address Baby A had no pulse and was not breathing for himself. He was later transferred to another hospital and sadly died the following day. 7 3. KEY EVENTS AND ISSUES 3.1 The aims of the serious case review, in line with Chapter 8 of Working Together to Safeguard Children (2010), were: • to establish whether there are lessons to be learned from the case and the way in which local professionals and agencies work together to safeguard and promote the welfare of children • to identify clearly what those lessons are, how they will be acted upon, and what is expected to change as a result of the review outcomes • to improve interagency and intra-agency working and better safeguard and promote the welfare of children 3.2 The Serious Case Review Panel identified three key events and considered these in detail. They were: • the decision by the community midwife not to complete a more detailed assessment • the events at the GP practice when Baby A attended for a 6-8 week check • the examination of Baby A by the doctor at A&E six days before the death 3.3 The original Terms of Reference for the serious case review were judged by Ofsted to provide a framework for the majority of the issues in relation to the case but were found to be insufficiently specific in relation to two key matters; practice relating to non-mobile babies presented to professionals with facial or other unusual injuries and processes to identify all adult family members and their role within the family. 3.4 The revised overview report therefore also considered: • whether practice, decision making and procedures relating to non-mobile babies presenting to professionals with facial or other unusual injuries were appropriate • whether processes were in place to identify all adult family members, their role within the family and whether or not they posed a threat to a new born baby because of their respective histories. 4. FINDINGS OF THE SERIOUS CASE REVIEW 4.1 Historical involvement 4.1.1 Miss A’s history shows a number of areas of vulnerability. There is no information recorded to suggest that Miss A was living in Gateshead when the alleged abuse occurred or where in the country she was actually living 8 (as the family moved around on a number of occasions) or whether this was reported to the police and local Children’s Social Care. Miss A accessed counselling services in Gateshead in her teens when the family returned to the area, and she should have been questioned further so that her history was clearer. 4.1.2 Mr C also had input from professionals during his childhood and lived with his grandmother from an early age. Mr B and his family had limited contact with a number of professionals during his childhood. This was not analysed in depth for the purposes of the serious case review as it was not judged to be relevant. 4.1.3 By the time Miss A and Mr C became a couple he was already the father to a one-year old daughter and no concerns had ever been raised about his parenting. He was viewed by both professionals and his ex-partner to be caring and appropriate towards his daughter. 4.2 Involvement with the family while Miss A was pregnant 4.2.1 There were at least two occasions where Miss A was seen by her midwife when there were indications of an additional level of vulnerability which should have triggered further risk assessment (which would have in turn triggered further safeguards). 4.2.2 Miss A’s history shows a number of areas of vulnerability. In isolation these historical concerns would not necessarily lead professionals to be concerned about any potential risks to Baby A, however when viewed in combination with the alleged concerns about Miss A and Mr B’s relationship and other vulnerability factors surrounding Miss A. This should have led to more detailed risk assessments of the pregnancy being carried out. 4.2.3 The Serious Case Review Panel agreed that Miss A and her unborn baby met the criteria for further support and it would have been appropriate for the community midwife to ensure that this would happen by completing an additional risk assessment known as an AN2. The midwife chose not to do this as she felt that Miss A’s problems were in the past and judged her to be a confident young woman. 4.2.4 If an AN2 assessment had been completed in relation to Miss A and her unborn baby then the GP, health visitor and health care assistant would have been aware that there was a level of vulnerability in Miss A’s background and additional concerns. Whilst this would not have highlighted sufficient enough concerns to start child protection procedures, this may have made other professionals more sensitive to the possibility that Baby A could be at risk. 9 4.2.5 Miss A should also have been referred to the Family Nurse Partnership for additional support as a young first time mother. 4.3 Involvement with the family after Baby A’s birth 4.3.1 The main area that the Serious Case Review Panel considered was the events of the 6-8 week check at the GP practice. The health care assistant was worried about Baby A as she saw marks which she thought to be bruises and was not comfortable with Miss A’s explanation. The GP carried out a thorough examination of Baby A and did not find any bruises on his body. He noted two small marks on Baby A’s face which he did not think were bruises and later stated that he only saw these as health care assistant pointed them out. He was satisfied with Miss A’s explanation and decided that there was no need for further explanation. 4.3.2 The GP was able to reassure the IMR author who reviewed his practice that he would be able to respond appropriately if he had indeed found bruising to Baby A’s face or head. There are clear procedures in place in Gateshead for managing cases where unusual or suspected non-accidental injuries are found in children, particularly bruising in non-mobile babies. The GP stated in interview that he would have followed these procedures had he been at all concerned that Baby A had bruises to his face and/or head and/or was displaying signs or symptoms of abuse. To date the GP is still clear that there were no bruises on Baby A when he examined him. 4.3.3 Professionals continued to discuss the health care assistant’s concerns after this date. Unfortunately there were delays in professionals speaking to each other about this and no one was able to challenge Miss A further about the concerns. Unfortunately Baby A died before the health visitor was able to speak to Miss A about the marks/bruises and her previous comments. 4.3.4 Baby A was thoroughly examined in A&E a few days before his death when he presented with cold symptoms and vomiting. The doctor in A&E saw no bruises on Baby A’s body and found no reason to be concerned enough to order further tests or discuss him with other colleagues. 4.3.5 The post mortem examination carried out after Baby A’s death showed that whilst his head injury was caused during a single incident shortly before his admission to hospital, some of his other injuries were older (but could not be dated precisely). It remains unclear whether Baby A had any fractures when he was seen in A&E that evening but the doctor saw nothing in Baby A’s presentation that would warrant an x-ray or other form of imaging. 10 4.3.6 The Serious Case Review Panel discussed whether or not the doctor took the correct course of action. The IMR report author who examined the doctor’s practice found it to be appropriate. It would be highly inappropriate to conduct x-rays or CT scans on babies presenting to an A&E department where this was not indicated, as was the case with Baby A on this occasion. The IMR author and Serious Case Review Panel were satisfied that, had the doctor been concerned that Baby A was injured, she would have followed the correct procedures from both a clinical and safeguarding perspective. 4.3.7 Throughout this case it is clear that that no one agency or practitioner had a true full understanding of Baby A’s living arrangements and the history of all of the adults with whom he was in contact with. Key practitioners should have asked Miss A more detailed questions about her and Baby A’s living arrangements and about those people who Baby A was having significant contact with during his short life. 5. CONCLUSION 5.1 All serious case reviews are conducted with the benefit of hindsight and inevitably identify areas for improvement. Whilst the serious case review identified some areas where practice could and should have been different it is unlikely that Baby A’s death could have been predicted or prevented and it can not be attributed to the failings of any one professional or agency or the way that agencies in Gateshead worked together. 5.2 The Serious Case Review Panel examined the case of Baby A and found that, on the whole, inter-agency working and individual working was sound. There were occasions when professionals were required to use their judgement to determine whether to view this case as one of concern and, with hindsight, some of these professionals could have made different decisions. 5.3 The Serious Case Review Panel were provided with a number of examples of good practice where agencies worked well together and there are appropriate procedures in place to safeguard children and young people in Gateshead. There were, however, occasions where some professionals used their own judgement and felt that there were not enough concerns to follow additional procedures e.g. the midwife’s decision not to complete an AN2 risk assessment and the GP decision not to respond to Baby A’s marks/bruises and Miss A’s comments as a concern. 11 5.4 Lessons have been learned in this serious case review in relation to: • documentation and record keeping • understanding a family’s circumstances • antenatal risk assessment and some professionals’ understanding of guidance and available pathways • managing bruising in non-mobile babies and listening to what parents say in addition to a child’s physical presentation • the serious case review process itself 5.5 Recommendations were made in a number of the IMR reports, the original overview report and the revised overview report. These are detailed below and in the action plan. 6. RECOMMENDATIONS FOR ACTION 6.1 Additional recommendations 6.1.1 The LSCB Policy and Procedures Sub Group should revise the Gateshead LSCB Serious Case Review Procedures in line with new guidance within three months of the publication of the revised Working Together to Safeguard Children. The revised local procedures should contain a requirement that serious case reviews should not be signed off by the LSCB or submitted to Ofsted/DfE until post mortem examinations have been completed, regardless of whether this is set out in the new statutory guidance or not. Action lead/responsible person: Joanna White, Chair of LSCB Policy and Procedures Sub Group Timescale: High (three months from the date of publication of the revised Working Together to Safeguard Children) 6.1.2 Guidance for completing AN1 and AN2 forms should be revised to include a requirement to discuss the unborn child in supervision. Action lead/responsible person: Judith Corrigan, Named Nurse, Safeguarding Children Timescale: High (0-3 months) 6.1.3 Guidance for completing AN1 and AN2 forms should be revised to include a requirement to share completed AN2 forms with the mother’s (and unborn child’s) GP practice. Action lead/responsible person: Judith Corrigan, Named Nurse, Safeguarding Children Timescale: High (0-3 months) 12 6.1.4 Guidance should be developed so that GP practice are able to flag cases where an unborn child has been the subject of an AN2 risk assessment in a similar way to cases that are flagged when a child is subject to a child protection plan etc. Action lead/responsible person: Brian Liddle, Named GP, Safeguarding Children Timescale: High (0-3 months) 6.1.5 Guidance should be developed so that GPs can use body maps to document injuries and marks to children. The body maps and guidance should be easily accessible to GPs on the GIN portal. Action lead/responsible person: Brian Liddle, Named GP, Safeguarding Children Timescale: High (0-3 months) 6.2 Original Overview Report recommendations 1. The chair of the LSCB should write to the Director of Patient Safety, SOTW Community Health Services, to request that NICE safeguarding guidelines When to suspect child maltreatment (2009) be adopted by all GP practices. 2. The chair of the LSCB should write to the Director of Patient Safety, SOTW Community Health Services, to stress the need for a Named GP for safeguarding to be appointed and to seek assurances about interim arrangements 3. Gateshead Clinical Commissioning Group should ensure that a safeguarding link post (a GP) in each practice is enhanced as outlined in the “safeguarding GP toolkit”. 4. All GP practices in Gateshead should be able to identify that safeguarding standards are being met in GP practices. 5. Gateshead LSCB Inter-Agency Child Protection Procedures should reinforce the importance to healthcare professionals of listening to parents and taking appropriate action to ensure that children are safeguarded. 6. Gateshead Health NHS Foundation Trust should ensure that all families who are eligible for the Family Nurse Partnership scheme are routinely referred. 7. Gateshead Health NHS Foundation Trust should ensure that A&E staff are aware of the previous attendances of all babies under 1 year of age. 8. Newcastle NHS Hospitals NHS Foundation Trust should ensure that all healthcare professionals in maternity services are aware of male partners when working with families. 9. SOTW Community Health Services (Gateshead PCT) should ensure that information is shared with a child’s named health visitor when pre-school children are seen by GATDOC. 10. SOTW Community Health Services (Gateshead PCT) should establish a protocol for the GP led Well Baby Clinics, which identifies the Healthcare Assistant Role and competencies. 6.3 Single agency recommendations 1. Gateshead Council Early Years Service should ensure that staff are consistent in the way they deal with and record concerns about children. 2. Gateshead Council Early Years Service should ensure that child protection issues are addressed in supervision. 3. Gateshead Council Early Years Service should ensure that all staff and visitors are aware of their responsibilities for safeguarding. 13 4. Gateshead Council Children’s Services should ensure that the social work therapy team are aware of their client’s full history. 5. Gateshead Council Children’s Services should ensure that any disclosure of abuse or violence made within a therapy session is responded to appropriately. 6. Gateshead Health NHS Foundation Trust should consider whether it is appropriate for junior medical staff in A&E to discharge children without senior overview. 7. Gateshead Health NHS Foundation Trust should ensure that all letters generated by the coding department should reflect accurate information. 8. Gateshead Health NHS Foundation Trust should ensure that record keeping within the maternity department is accurate and comprehensive. 9. Gateshead Health NHS Foundation Trust should ensure that all midwifery staff record appropriate safeguarding information. 10. Gateshead Clinical Commissioning Group should ensure their safeguarding link post (a GP) is enhanced in each practice as outlined in the “Safeguarding GP toolkit”. 11. The safeguarding audit for GPs on standards of safeguarding practice must be completed. 12. The Associate Director for Quality and Patient Safety will write to the chair of the LSCB requesting that the LSCB Inter-Agency Child Protection Procedures make explicit the importance of GPs listening to parents. 13. The Newcastle upon Tyne Hospitals NHS Foundation Trust should ensure that all healthcare professionals in maternity services are aware of male partners when working with families. 14. Gateshead PCT should implement guidance and thresholds of information received in Antenatal Vulnerability forms (AN1/AN2) for health visitors. 15. Gateshead PCT should develop level 3 training for health visitors relating to bruising/marks in non-mobile babies. NB. No recommendations were made to Northumbria Police in either their IMR report or the Overview Report. |
NC52564 | Arrest of a 16-year-old boy arrested on suspicion of murder in November 2021. David was a looked after child who had been the victim of criminal exploitation. Learning includes: developing positive, strengths-based relationships with parents and carers supports safety planning; robust, child centred, and focused support plans must be in place for Special Guardians and these need to be regularly reviewed and adapted; children and young people at risk of criminal exploitation need consistent professional involvement and relationships; safeguarding agencies need to regularly review their approach to child criminal exploitation by listening to the experiences of young people and applying this learning to practice; contextual safeguarding meetings should have the same 'status' in safeguarding partnerships as child protection case conferences; practitioners need to develop their understanding of culturally sensitive practice and consider how a young person might experience oppression, discrimination, and risk. Recommendations include: test and evaluate the use of contextual safeguarding meetings; pilot a 'child safeguarding pathway' for exploited children and use the evidence to inform future practice; consider learning from other safeguarding partners and agencies who have developed effective contextual safeguarding practice, particularly implementing 'Signs of Safety' as a practice model; develop a safety planning toolkit which supports practitioners in their child criminal exploitation work; children's social care to test out having a single social work practitioner to support children experiencing exploitation; consider how to implement a trauma informed approach to practice, including how to support staff with vicarious and secondary trauma and develop arrangements for critical debriefing.
| Title: Local child safeguarding practice review: David. LSCB: Berkshire West Safeguarding Children Partnership Author: Ian Vinall Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Berkshire West Safeguarding Children Partnership Local Child Safeguarding Practice Review David October 2022 Independent Review Author – Ian Vinall 2 Contents Section Title Page Number 1 Introduction 2 2 Chronology 3 3 Emerging Practice Themes - March 2018 to March 2020 5 4 Emerging Practice Analysis - March 2020 to November 2021 13 5 Summary of additional learning 16 6 Evidence of good practice 17 7 Conclusions 17 8 Recommendations 19 1. Introduction Introduction to David 1.1 David is a black British 18-year-old man. At the start of the review process, he was aged 16. He has lived for most of his life with a family member. People who know David have described him as being a lively, polite, thoughtful young person with a wicked sense of humour. 1.2 Pre-birth David was exposed to his mother’s substance misuse and his childhood experiences were one of disrupted attachments and physical neglect. David was removed from his mother’s care and placed into foster care aged 2 years and by the age of 6 years he had been in 6 different foster placements. 1.3 He moved into the care of family members aged 6 under a Special Guardianship Order (SGO)1 and they have remained as his main carers. However, David has also been in foster and residential care placements since 2018. David has 3 step siblings and there has been contact between them. Throughout 2019 and 2020, David was missing from his care placements and his family home and had there were ongoing concerns that he was being criminally exploited. In early 2020, David was seriously assaulted, and he sustained a head injury which required a significant operation and induced sedated state to enable his recovery. There are long term effects of this injury. 1.4 In November 2021, David was arrested for murder and remained on remand until his trial in the summer of 2022. Introduction to the Review 1.5 This local child safeguarding practice review was completed in two parts. The first part of the review focused on the events in David’s life from 2018 to March 2020. Following David’s arrest for murder in November 2021, the review author was asked to review David’s circumstances from March 2020 to November 2021. The chronology, review learning and recommendations have therefore been combined into one document. 1.6 Following government advice regarding the Covid-19 pandemic, the Rapid Review was progressed via written submissions only in March 2020. The Berkshire West Safeguarding Children Partnership completed this work following David’s assault and the panel agreed for a Local Child Safeguarding Practice Review to be carried out. It was felt strongly that local safeguarding partners had an opportunity to learn from David’s experiences and his involvement with services. A Review Panel was appointed and has met five times. David’s main carers and his birth father were interviewed for the review and provided significant insights into their experience of services and support. Attempts were made to engage David in the review, but he declined. Written records from the local authority, together with 1:1 interviews with practitioners who have worked with David contributed to this review together with a Practitioners Learning Event. There was a positive willingness to be 1 Special guardianship orders (SGOs) are orders made by the family court (or the Family Division of the High Court) which confer parental responsibility on the special guardian for a child up to the age of 18. SGOs were introduced by amendments made to the Children Act 1989 by the Adoption and Children Act 2002 and were described as a new legislative option for providing legal permanence for those children for whom adoption was not appropriate (Department of Health, 2000). 3 open and transparent throughout the review process. Practitioners and family members were able to comment on what worked well for David and what did not. 1.7 The Berkshire West Safeguarding Children Partnership requested an updated report following David’s arrest for murder in November 2021. The original review had not been published or widely shared and it was felt that there was an opportunity to review any impact of the previous review process, report, and recommendations on practice. The terms of reference were agreed as follows: • What has happened since the conclusion of the review in March 2020 to November 2021 and identify key episodes? • Taking into account that the outcomes of the previous Local Child Safeguarding Practice Review have not been published or widely shared, how has the process of the review influenced or changed practice and what obstacles remain? • How effective have the agency responses and interventions been in the last 18 months to safeguard and address David’s increasing level of exploitation and offending? The methodology for this updated review was agreed as follows: • Joint chronology to be pulled together from March 2020 to November 2021. • Identify key episodes and interview relevant practitioners and managers. • Review strategic and operational developments in child criminal exploitation in Wokingham and bordering authorities since March 2020. • Engage David and appropriate family members 2. Chronology March 2018 – March 2020 2.1 David experienced the breakdown of his SGO carers relationship in early 2018 and the carers report not being able to manage David’s behaviour prior to their separation. The carers self-referred for support via the Adoption Service in March 2018. 2.2 Practitioners were aware that since June 2018, and possibly before this date, David had been a victim of criminal exploitation and was involved with drug dealing. He was himself using cannabis as a coping strategy. There were several indicators of his criminal exploitation including unexplained money and clothing, additional phones, threats from adults, missed curfews, missing episodes and money laundering. David had been arrested for 3 allegations of robbery, possession of a knife and BB gun and involvement in drug supply. Agencies know that David was the victim of at least 2 physical assaults from other groups of youths prior to his significant injury and threats of violence were a regular concern. David was the subject of early help and child in need plans and many multi-agency meetings, including specific meetings regarding children and young people at risk of criminal and/or sexual exploitation. There has been good information sharing at these forums, but this did not extend into the wider support network. There is evidence that the action planning and follow and follow through of actions had not been consistent. 2.3 David had considerable instability in his care during the review period including being cared for by his SGO carers, maternal grandmother, 5 emergency foster placements and 3 periods of activity based residential care some distance from his home authority. There is evidence that he was both exploited and exploiting others in the last of those residential placements. His birth mother, from whose care he was removed, continues to reside with his maternal grandmother. The issues relating to David’s removal from her care remain present now. David has been very consistent in not wishing to be away from his family and resented his periods in care. 2.4 David was at high risk of exclusion from school owing to his behaviours and despite his placement moves, he remained on roll at his senior school. David’s school have remained consistent in David’s life, and he has a positive relationship with one member of staff in particular. David had a number of different social workers and other professionals working with him during the review period. 4 2.5 In February 2020, David moved to another foster placement with a plan to reunify with his special guardianship carers. This plan was in its early stages when David was seriously assaulted. March – May 2020 2.6 Following David’s serious assault in March 2020 and his significant period in hospital, he was made the subject of a child protection plan and he was discharged to the care of his sister in another part of the country. This was described as a ‘family arrangement’ and therefore there was no legal status given to this arrangement. In mid-April and then on one further occasion, David absconded from his sister’s home. On the second time, he went missing for 7 days and was located in another part of the country. Concerns were raised about his involvement in “county lines drug running” and at least 3 police areas raised concerns about his risk to himself and others. In early May, David became the subject of an interim care order and secure order, and he was placed in secure accommodation. The local authority care plan was described as ‘triple planning’ and included a return to his SGO carers, family members or residential care. In June 2020, the secure order was extended for 3 months. August – September 2020 2.7 The local authority applied for a 6-month extension to the secure order which was opposed by his guardian and David’s family. The court refused the order and David was moved to a residential unit with a reunification plan for David to return to the care of his SGO carer. There was ongoing work with David and the carer to ensure this arrangement had the best chance of success. David was still considered at high risk of criminal exploitation and remained on the EMRAC monthly meeting. October – December 2020 2.8 Introductory and overnight visits took place with his SGO carer, and he returned home in late November. The final care plan, including attendance at college, was agreed. However, the college closed because of the pandemic and concerns were raised about David’s ‘unstructured’ time. There were several occasions when David was not at the family home and the carer was concerned about the number of times David was out of the house. David had access to 2 mobile telephones. January – March 2021 2.9 David was made the subject of a 6-month supervision order following the conclusion of the local authority care proceedings and was a child in need. There were a further 2 Section 472 strategy meetings and 2 child in need reviews held in this period. There were concerns about David’s presentation and attitude and it was believed he was running a ‘drug line’. A decision was made to hold a ‘contextual safeguarding meeting’ to consider the risks to David outside of the family home. This was a new initiative but did not hold the same weight as a child protection planning meeting. In late March, David presented at hospital with injuries which prompted a further section 47 strategy discussion. April – June 2021 2.10 David was flagged to another police area and concerns raised about his county lines activity. The decision was made in May to hold an initial child protection case conference because of the escalating risks to David and he was made the subject to a child protection plan in June under the category of at risk of physical harm. David’s case was transferred internally to the child protection team. June – September 2021 2.11 David’s SGO carer had found knives and weighing equipment in his bedroom. This followed a 2-day missing period and a suggestion that David returned home with someone he met in secure accommodation. A decision was made by children’s social care not to extend the 6-month supervision order as David was subject to a child protection plan. The SGO carer was reporting not feeling safe in her house as a result of David’s activities. Alternative care was considered. In August there was a police report that David had been involved in a robbery at knifepoint. The police searched David’s home address and found £1000 and 5 mobile telephones. In September there were 2 occasions where David became very distressed, upset, and 2 Section 47 of the Children Act 1989 5 angry fearing that he would be physically harmed and beaten by others. On the second occasion, David had mentioned to the police that he was in ‘real trouble with lots of enemies’ and was crying in the back of police van. The risks were not considered ‘new risks’ and there was felt to be a robust support plan in place, so no further action was taken. October – November 2021 2.12 David was not attending college and his SGO carer was struggling to care for him and keep him safe. She felt at risk in her own home and requested David be accommodated. A professionals meeting was held with colleagues in Reading to consider the contextual risks and David’s association with others. No placements were identified for David. He was arrested on suspicion of murder in early November. 3. Emerging Practice Themes – March 2018 to March 2020 David’s and his carers experience of services and support 3.1 David’s childhood history and his experiences of childhood trauma had little bearing on the development of an effective Special Guardianship Support Plan when he was placed with them in 2010. The referral from children’s services who placed David with his carers in 2010 informed the family’s ‘host local authority’ that ‘no welfare issues’ were identified. With no detailed plan of support and guidance his carers were tasked with caring for him with limited support, guidance, and advice.3 Despite this, his carers have demonstrated love and commitment in the face of the challenges they have experienced. 3.2 Most children going through the care system have suffered significant harm and therefore any future care giver must have the resources, skills, and support to enable them to care for children who have experienced significant trauma. Whilst keeping children within family groups is consistent with good practice, this must be with appropriate levels of understanding of children’s experiences and the likely impact of those experiences as they grow up. Best Practice Guidance has been published by the Family Justice Council regarding the provision of Special Guardianship Orders4 and the expectations on local authorities to support effectively SGO carers. 3.3 David’s carers have highlighted that throughout his childhood he presented with behaviour challenges, but this increased as he reached adolescence. The couple separated in early 2018 sighting David’s behaviour as one of the reasons for their separation. However, they have both remained committed to him and he continues to reside with the female carer. 3.4 David’s carers approached the adoption support service themselves in early 2018 and a support plan was developed including direct work with the family. The assessing social worker very quickly identified the risks associated with the criminal exploitation of David and referred appropriately to children’s services. 3.5 Both carers report feeling let down by professional support agencies. They described feeling judged, not listened too and when asking for help they did not receive it. They both felt unable to manage David’s behaviour and risks and struggled with putting boundaries in place. The couple report attending many meetings but felt little was done to provide practical and emotional support. The couple became aware of the risks of criminal exploitation of David, particularly with his presentation, but felt agencies were not able to put a coherent plan in place. Their frustrations with the lack of support, the increased risks, and the perceived judgement on them of failing, led to them asking for David to be accommodated. The carers describe being physically and emotionally exhausted with the situation. 3.6 There did appear to be a lack of compassion for the SGO carers and some professional frustration at their willingness to engage in support and safety plans. There was a professional view that the carers wanted a ‘quick fix’ behaviour change from David and the only solution was him being placed into care. Their own guilt about letting down David was not considered when they ‘disrupted’ care arrangements with promises of David returning home. The dynamics in the family and professional relationship was not reflected upon 3 Special guardianship review: report on findings Government consultation response December 2015 4 Special guardianship BPG report.docx (judiciary.uk) 6 in supervision or professional discussions. Behaviour management and relationship building became the focus of interventions without considering the ability of the carers or David to effectively respond to that intervention. 3.7 David and his carers were involved in discussions about his care arrangements and David was given opportunities to contribute but did not always engage with planning for him. Some of those plans developed were unrealistic, such as suggesting David should not be in contact with gang members and reflected a lack of knowledge of what safety planning could be put in place. 3.8 It was clear that David was very reluctant to return to the care system and his disrupted placements in 2019 are evidence of his ability to sabotage those arrangements and return to the care of his family. It is possible that he may have been re-traumatised by the thought of returning to the care system which let him down so badly in his early childhood. 3.9 The carers are clear that the support now being provided is positive but was only put in place in response to the significant assault that saw David hospitalised. Learning Point: The impact of individual practice approaches can have a significant impact on case direction, family engagement and safety planning. Children’s social care need to enable opportunities for learning and reflection from other practitioners when managing children who are exploited and focus on ‘harm outside of the home’. Organisational changes to practice have not been embedded across the system since the previous review was concluded. Learning Point: Parents and carers managing children and young people’s complex needs, behaviour and risks need compassion and understanding. Developing positive, strengths-based relationships with parents and carers support safety planning. Learning Point: Robust, child centred, and focused support plans must be in place for Special Guardians. They need to be reviewed and adapted to the needs of the child as they grow older. Trauma informed and relationship-based practice 3.10 There has been an increased recognition and understanding of the impact on young children of adverse childhood experiences5. David experienced chaotic and inconsistent care before the age of two and was deprived of consistent love, safety, and security until the age of six. Trauma informed practice has focused on neuroscience, the impact on the brain of adverse childhood experiences and the biology of stress. It links adverse childhood experiences to future emotional and physical responses to stimuli. It sees behaviours as well-developed coping strategies to stress. This approach moves professionals away from pathologizing children and adults to understanding why behaviours occur, understanding what has happened to them and why they behave in the ways they do (Penna 2020)6. The trauma informed approach has been well developed in some local authority areas and is based on a trauma informed, relationship-based methodology. 3.11 Evidence would suggest by the time David moved to his SGO carers; he was already struggling to ‘connect’ to any care givers. Those working with the family propose that David would have developed mechanisms at a young age to not trust adults for fear of being further let down. There was some reparative parenting provided by his SGO carers, but they were undertaking this task with no support and limited understanding of trauma. 3.12 From the age of six, David had some level of family stability despite these challenges. He reports as having a deep longing to be part of his family and it was highly unlikely that foster or residential care was going to be successful. 5 Trauma-Informed Social Work Practice, Jill Levenson, Social Work, Volume 62, Issue 2, April 2017, Pages 105–113, 6 Guide to trauma and a trauma-informed approach. Author: Sue Penna 15.1.21 Community Care 7 3.13 David was positively described as an engaging and polite young person, but this persona was reported to hide a deep vulnerability and a mistrust of adults and social workers in particular. David’s own experiences of trauma and his emotional and behavioural responses were not the prime focus of plans and interventions. 3.14 The focus on ‘fixing’ the immediate issues, particularly with care placements and behaviour management techniques, took little account of David’s history and the experiences of his carers. Expectations placed upon on him, and his carers could be seen as unrealistic. 3.15 From 2019, the whole system around David, including his care givers, were in a state of heightened anxiety and stress and everyone was responding to immediate and daily risks. The agencies involved with David were in a constant cycle of crisis, with professionals constantly reacting. This level of heightened anxiety impacted on those professionals involved. The deep anxiety that David was likely to be seriously injured or killed was real for practitioners and his carers. 3.16 The impact of managing the heightened risks on individual practitioners and the wider safeguarding system was not well considered. The professional frustration at the carers for not fully engaging with support, the lack of a coherent and agreed safety plan and the constant managing of the daily risks and issues led to a level of compassion fatigue. The sense of hopelessness in trying to safeguard David was evident and was pervasive. The high levels of risk being managed by the safeguarding system led to high levels of anxiety. These levels of risk and anxiety can be well managed by a safeguarding system that is functioning well and when there is agreement and a shared accountability about how risks can be mitigated against. When the system becomes overwhelmed, with no shared accountability, the system becomes fractured and leads to professional disagreement and a lack of shared accountability for the risk. This effectively led to the social worker and their team manager feeling overwhelmed with the constant, almost daily risks, and issues. At no point did the safeguarding system collectively stop, reflect, challenge, and support each other in understanding how the heightened risks had impacted decision making, accountability and responsibility. 3.17 Secondary or vicarious trauma7 has been the subject of research and practice guidance. This consideration is less well developed in safeguarding practice. Whilst individuals described feeling well supported by their managers and senior leaders, this did not lead to a shared sense of responsibility and accountability for David across the safeguarding system. 3.18 The level of openness and honesty from practitioners in the Practitioners Learning Event should be encouraged and supported across the safeguarding partnership. Understanding the impact on practitioners and consequently the safeguarding system on managing high risk situations could have real benefit in collectively managing highly complex children’s situations. 3.19 During the period of this review, the local authority was in a state of flux with a number of interim senior managers in children’s services and partnership working had been impacted as a result. This scenario added to the effectiveness of joint working and accountability. This situation has shifted with a permanent management team in the local authority and a recognition that better joint accountability and working together is needed. 3.20 In the period between March 2018 and March 2020, David had several social workers and practitioners working with him. Some of those had developed strong and effective relationships with him and he had developed real connections with some. Systems, procedures, processes, enforced team changes and David’s care status all led to many changes in his professional network. This prevented real opportunity for those who David engaged with and trusted, to really work alongside him consistently. 3.21 David has been unable to share detail and speak about his experiences of child criminal exploitation. This could be for the fear and anxiety about the likely consequences of disclosing such information. A finding from the National Child Safeguarding Practice Review Panel in their report in 20208 highlighted that 7 Secondary trauma and compassion fatigue: a guide to support managers and practitioners, Lori Goossen, 19 July 2011 8 ‘It was hard to escape’, Safeguarding children at risk from criminal exploitation. National Child Safeguarding Practice Review Panel 2020. 8 children and young people require a ‘strengths based, relationship driven approach’ and that building a trusting relationship is key to successful engagement with this group of children. In David’s case, practitioners expressed their frustration with the ever-changing key workers. Particularly frustrating were those practitioners who developed a very positive relationship with David, only to be removed from his professional network because of his ‘status’ in practice systems. Learning Point: Repeated changes of worker will have a negative impact on engagement. The local authority is encouraged to test out new approaches to case management that ensures the child and family remains with the same worker. Learning Point: Safeguarding professionals need to work in a culture where an understanding of secondary or vicarious trauma is the norm and agencies actively promote good self-care matched with multi-professional supervision and support, particularly in case work that is high risk and complex. Learning Point: Children and young people at risk of child criminal exploitation need consistent professional involvement and relationships. Changing professionals who work with children, young people and families should be based on the needs of the child and family rather than the organisational parameters. The understanding of child criminal exploitation, thresholds, and the shared accountability for managing risk. 3.22 There remains no statutory definition of child criminal exploitation, but the government defines child criminal exploitation where ‘an individual or group takes advantage of an imbalance of power to coerce, control, manipulate or deceive a child or young person under the age of 18. The victim may have been criminally exploited even if the activity appears consensual’. This is a wider definition than ‘county lines’ which are drug dealing networks and gangs exploiting children and young people to move, hold and sell drugs. Safeguarding children and young people in these circumstances is seen as the priority, seeing the child first and the criminal activity second. 3.23 Between June 2018 and March 2020, David had been the victim of 5 previous assaults prior to the significant assault in 2020. He had 78 police reports, 23 reported missing episodes, 5 child protection reports, and a ‘Risk Management Occurrence’ related to child criminal exploitation. There were 20 police ‘intelligence reports’ referring to weapons, drugs, and gang association. None of these intelligence reports were shared beyond the police and there is an acknowledgment that these should have been referred through to the MASH. 3.24 When David was first referred to the adoption support service there was an appropriate referral made to children’s services by the adoption social worker highlighting the concerns related to criminal exploitation. The initial child and family assessment completed had a distinct lack of information about David’s history and his early childhood and how those early experiences impacted upon him. David’s self-report that he was not involved in county lines drug running and not being criminally exploited appears to have been accepted. There was an appropriate completion of a Child Exploitation (CE) Indicator and Analysis Tool which highlighted his high risk. The subsequent referral to early help support after the conclusion of this assessment appeared incongruent with the identified risk. Whilst people working with David have been unable to delve deeper into his role in criminal exploitation his childhood experiences make him highly vulnerable to exploitation. 3.25 David reported his involvement with gangs and expressed his fear and anxiety more than once to practitioners working with him. David has been clear that to engage in conversations about his gang activity would place him at significant risk and therefore he chooses not to discuss those issues with safeguarding professionals. That identified fear is clearly indicative of his coercion into criminal activity and its consequences for him. 3.26 Based on the available evidence, David had become involved in county lines drug running and was being groomed into moving, storing, and dealing drugs on the behalf of others. County lines and the exploitation 9 of children and young people to distribute drugs is described as an extremely lucrative business model, operated, and enforced by gangs through fear9. Professionals are unclear at which point David became involved in child criminal exploitation, but evidence of drug dealing, and the provision of designer clothing was evident early in his teenage years. Children’s services believed that most of David’s criminal associations were within 2 local authority areas and there was an assumption made that David was not involved in county lines drug running. There did not appear to be a well-developed policy or strategy for managing the risks associated with child criminal exploitation in the borough and a lack of professional understanding about how to mitigate or manage the risks. David himself told practitioners working with him that ‘professionals’ knowledge of exploitation was outdated’. 3.27 The assessments written about David consistently refer to David placing himself at risk of harm and whilst highlight the risks presented, this language is indicative of a child who has made effective choices to be involved in risk taking activities rather than being coerced into doing so. This subtly changes the perception of David and his active involvement in criminal activity. David’s consistent view that he was not being exploited may have reinforced this view, but this use of language needs to be carefully considered as it reinforces the view that David makes informed choices. Research undertaken on victims of child criminal exploitation highlight that the majority of children and young people fail to realise they are being manipulated and exploited. Their view being that their criminal activity is one of ‘choice’ and that by complying, gangs will respect them and give them a sense of belonging. This is challenged in that the use of violence and intimidation exerts control and a level of ownership over the young person from which it is difficult to escape.10 3.28 The role David’s carers played was key to his safety however the initial focus on family relationships, parenting behaviour and behaviour management techniques alienated them. Despite the risk assessment tools being completed and highlighting high risks of exploitation, the interventions focused on the presenting family dynamics. This led to resentment and frustration from his carers. The changes in social worker did not assist this situation with no practitioner developing an honest and empathic relationship with the carers. 3.29 Subsequent Section 47 enquiries and accompanying assessments maintained the view that David’s situation should be managed via early help and child in need arrangements, The Section 47 enquiry held in April 2019 concluded with a request for an initial child protection case conference but in discussion with senior managers it was agreed to keep the case at child in need level. The threshold document in the local authority was updated in August 2020 so it is not clear whether David was assessed under a different threshold criterion. 3.30 David’s exploitation and risk exhausted the resources of agencies locally and in particular the police. There was clearly a disagreement between the police and other agencies as to whether David was a perpetrator of criminal activity using up valuable resources or a victim of criminal exploitation. This professional disagreement led to pressure being applied to remove David from the borough to alleviate the risk. There were ongoing discussions about whether the threshold was met for a Secure Order when David was a looked after child and this plan was supported by his carers. The threshold for a Secure Order was not considered met and therefore never actively pursued. 3.31 Decisions to place him out of borough were made quickly and were based on placement availability rather than whether those placements would meet his needs. His social worker was proactive in ensuring those placements were appropriate, yet David was very reluctant to engage with a plan to remove him to another part of the country. He was distressed by being away from his family. This again reflected agency anxiety about holding risk effectively. 9 Hesketh, RF and Robinson, G (2019) Grafting: “the boyz” just doing business? Deviant entrepreneurship in street gangs. Safer Communities. ISSN 1757-804 10 Grace Robinson, Graduate Teaching Assistant, Edge Hill University, 2017 10 3.32 There was a genuine wish to alleviate the risks by placing David away from his criminal exploiters and any potential assault, but this was always a short-term solution. The sense of safety being geographical distance took little into account of David’s criminal exploitation and his risk to be being exploited or to engage in this activity across the country. These decisions took no account that David was highly likely to be involved in county lines drug running locally and that this might have presented an opportunity to his exploiters to further develop their network. David’s behaviour in the last residential placement evidenced his ability to exploit other young people in the home. Learning Point: Gang culture and identity need to be better understood by the professional network. The sense of belonging, identity, and criminal ways of earning money are intertwined and need different approaches to addressing the risks. Learning Point: The reliance on out of borough care needs to be seriously considered against other alternative care planning considerations. Care options, including the child remaining with family members, needs to be robustly risk assessed and regularly reviewed. Whilst risks can be mitigated against, all agencies need to be able to ‘hold’ the risk for children and young people. Learning Point: Child criminal exploitation is consistently changing and adapting its ‘business model’ and safeguarding agencies need to regularly review their approach to safeguarding children and young people in this context. Professional agencies need to take time and resource to hear and listen to the experiences of children and young people who have been criminally exploited. This learning should be applied to practice development. Training alone will not address professionals understanding of the issues and how to respond. Information sharing and the impact of meetings. 3.33 Processes to strategically safeguard children subject to criminal and sexual exploitation were in place in the local authority through a monthly multi-agency meeting that reviewed the risk assessments and safety plans for children and young people. The meeting had a good level of representation and had strategic oversight of children who were being exploited in the borough and did share information about David and his situation. This forum was partly successful in that it identified and mapped individuals and groups and developed actions for agencies to support the management of the risk. There was, however, a lack of intelligence sharing from the police and the actions being taken for disruption of the criminal activity. This resulted in safety planning and interventions that were flawed. 3.34 This forum was not a case management forum and the professional network appeared confused and unclear as to its purpose. A referral to this forum was seen as part of safety planning for children rather than a strategic group to address places, networks, and disruption activity and therefore from a practitioner’s viewpoint, it had limited impact. It was felt that the forum did not jointly hold accountability for the risks, and much was placed on the responsibility of the social worker and children’s services. This forum had healthy differences of opinion but then lacked a shared ownership and accountability for the risks and coherent safety planning. Differences of professional opinion were encouraged but this added a layer of complexity that then hindered effective multi-agency planning. The proposal to move David out of the borough was one area of disagreement between forum members, with the police particularly advocating this approach. 3.35 There was also evidence that forum members did not follow up and follow through with identified actions and the forum itself did not hold those services to account. There were no escalation routes if agencies did not comply with actions. Therefore, assessments and interventions drifted, and decisions lacked multi-agency ownership. It was not clear who the forum was accountable too and what governance arrangements were in place to oversee its work. The safeguarding partnership, the community safety partnership, the office of the police and crime commissioner, public health and the youth justice board all have vested interest in this forum, but it was unclear what governance and audit arrangements were in place to review its effectiveness. 11 3.36 This forum has subsequently been the subject of review and there have been changes to reflect some of the feedback about its effectiveness. It appears to still rely on the chair to follow up the actions of partner agencies. 3.37 Outside of this forum, David was the subject of a large number of other professional meetings, some of which he and his carers were invited to be part. The carers reported feeling frustrated and angry with these meetings as from their perspective they achieved little. This led to withdrawal of the carer’s involvement in these meetings. There was also professional disagreement about the care planning and some practitioners reported never seeing any minutes of meetings held. Some agencies working with the family were not being informed of changes to his care plan or changes in practitioners working with him which led to professional frustration. There was no opportunity in these meetings to just highlight the shared professional anxiety and professional responsibility being felt by practitioners. When something unexpected or worrying occurred, the default position was to hold a meeting, but the purpose and outcomes were unclear. There remained a disconnect between school, the adoption support service, the youth offending service, and children’s services when the risks escalated for David. The focus on risk management, daily reports and placement searches led to communication between those agencies suffering as a result. 3.38 David was referred to the National Referral Mechanism (NRM) in late December 2019, but it is not clear as to the purpose of this and whether there were expectations of the NRM to support safety. 3.39 The local authority has implemented a ‘signs of safety’ approach11 as their practice model. This includes using the framework in professional meetings led by children’s services. The view of practitioners is that whilst it has assisted safety planning for some children, the implementation and use of the approach has been mixed. This approach has been well evaluated and the most recent report from the What Works Centre for Children’s Social Care12 offered some critique of the approach which is helpful in considering its effectiveness in working within contextual safeguarding, ‘..signs of safety, is primarily a psychosocial intervention and to ensure that it is practiced in a manner that does not reinforce existing inequality, the wider social, political, and economic contexts within which the families exist should be explicitly recognised and addressed in practice (Featherstone et al. 2018)’. There is ongoing evaluation being carried out between the Contextual Safeguarding Practice Network and Signs of Safety leads to see how these two approaches can work together13 and it may be helpful for the Safeguarding Partnership to be involved in that research. Learning Point: Intelligence gathering across the safeguarding partners and other agencies requires clarification and consistent application. If this approach is intended to safeguard the child or young person and members of the public, the agencies need to have a more formal framework in place. Learning Point: Contextual safeguarding meetings should have the same ‘status’ in the safeguarding partnership as child protection case conferences. Learning Point: Strategic forums considering risks to children of exploitation need to reach out to authorities who have a more advanced understanding of child criminal exploitation to share learning. Whilst quarterly pan authority forums exist that discuss data and trends, the strategic forums that consider exploitation for children and young people living in the borough, placed in the borough or who have strong links between the local boroughs should be the subject of shared updates between those strategic forums. Learning Point: Effective meetings at all levels require a clarity of purpose and effective action planning. A ‘strengths based’ approach to facilitating meetings will go some way to address anxieties regarding risk and 11 The Signs of Safety practice approach created by Andrew Turnell and Steve Edwards (Turnell and Ewards,1999) sought to address the default paternalism or colonisation of child protection systems where professionals believe they know what is wrong and what must be done to solve the problems. 12 SoS systematic review GD Edit.docx (ctfassets.net) 13 Signs of Safety and Contextual Safeguarding Key Messages for Practice February 2021 12 safety planning. Children and young people’s situations can be very unpredictable yet there needs to be a realistic discussion about risk and risk management. Learning Point: Effective meetings at all levels require a clarity of purpose and effective action planning. A ‘strengths based’ approach to facilitating meetings will go some way to address anxieties regarding risk and safety planning. Children and young people’s situations can be very unpredictable yet there needs to be a realistic discussion about risk and risk management. Learning Point: Communication and information sharing leads to more enhanced safety planning. Intelligence across the safeguarding system needs to be appropriately and proportionately shared to enhance understanding and lead to more effective safety planning and risk management. Cross authority working 3.40 David has lived with his main carers and his maternal grandmother in 2 local authorities that border each other. David’s missing episodes, offending, drug running and involvement in gangs, crossed between both local authorities. He also lived in other local authorities in the country. There was no available evidence of joint or cross borough working to mitigate the risks for David and others involved in criminal exploitation. There were handovers to local services in local authorities, but this repeated a pattern of new practitioners becoming involved without a good understanding of David and his needs. The ‘ownership’ of young people placed outside of their home local authority needs to be reinforced. 3.41 The multi-agency arrangements in place to strategically safeguard young people at risk of exploitation did not liaise or work across other multi-agency partnerships. This led to no joint intelligence gathering and safety mapping. One of the local authorities appears to have developed more effective safeguarding arrangements for young people at risk of criminal exploitation yet there appeared no mechanisms for joint work or learning across the local authorities. Culturally aware practice 3.42 David describes himself as black and the assessments refer to him as white and black African. His SGO carers and his birth mother are white, his father is black African. Culturally aware practice could have led to a consideration of David’s safeguarding risks and needs, in the context of his race and culture, yet this was not considered in any of the assessments undertaken and does not appear to feature in multi-agency safety planning, David lived in a predominantly white demographic. The fact that he is a young black person in this context should have been better understood. The practitioners working with David feel more needs to be done to inform culturally aware practice at all levels and challenge perceptions and unconscious bias. 3.43 The Child safeguarding Practice Review Panel produced a report in 2020 entitled ‘It was hard to escape, safeguarding children at risk from criminal exploitation’. This report highlighted that ethnicity and gender were factors in criminal exploitation and that boys from black and minority ethnic backgrounds were more vulnerable to harm from criminal exploitation. ‘Culturally competent practice places children’s well-being and their protection within their cultural context, Absence of cultural competence can lead to inaccurate assessments and decision making’14. 3.44 David has explored his own identity with practitioners. Significantly, he has raised that family breakdown brings him closer together with other young people involved in gang activity than their race, culture, or ethnicity. Learning Point: Practitioners need to develop their understanding of culturally sensitive practice. They need to engage with opportunities for learning and understanding. Practitioners need to consider a young person’s identity and how those young people might experience oppression, discrimination, and risk. This should form part of assessments and interventions. 14 The Child Safeguarding Practice Review Panel Report 2020 13 4. Emerging Practice Analysis – March 2020 to November 2021 4.1 David’s carers refused to sign an agreement for David to become ‘looked after’ under Section 20 of the Children Act 1989 and therefore David was moved to his sister’s address under a ‘family arrangement’. This effectively meant that the local authority was not legally bound to support care planning for David after his discharge from hospital following his significant injury. This arrangement, despite the carers refusal to sign paperwork, did place the local authority in a difficult position. There was no legal basis to this arrangement and no viability assessment was undertaken as part of a Regulation 2415 placement arrangement. Without this framework, this arrangement was highly likely to fail and with a matter of weeks the arrangement had broken down. Learning Point: Moves for young people to family members needs to be formalised. Local community and statutory services need to be engaged before the placement is made to ensure effective safety and care planning is in place. Learning Point: When children move to other local authority areas as part of a care plan, children’s services in the ‘home’ local authority should continue to effectively manage the care plan in consultation with the care placement and ‘host’ authority to ensure effective care planning and risk management. 4.2 Senior leaders in children’s social care were involved in the subsequent decision making regarding the applications to court, however, there were reported disagreements as to how to proceed and front-line staff described feeling ‘left to it’. 4.3 The decision to make an application to court for the secure order and interim care order was based on the increasing risks to David from harm outside of the home, including his missing episodes and the hospital attendances with injuries. However, this approach had negative connotations for David’s carers, who felt judged and criticised in the process. The court application, whilst justified given the increasing risks, pushed David’s carers into a repeated position of defensiveness and mistrust of the local authority. It presented unhelpful barriers to the working relationship. They felt the process was a judgement on their care of David and it left them feeling that ‘they were not fit to care for David’. Given their experiences of services and support up to this point, this further reinforced this perception for them. 4.4 David’s period in secure accommodation was considered a success. He was described as engaging and stable and work was undertaken with him on gang culture and drug running. His carers felt that David had ‘turned a corner’. David consistently denied ever being exploited or coerced in any way. He repeated that services should do ‘less talking’ and do ‘more looking’. This statement suggested that services be more observant of what was happening in and around David’s world and spend less time in meetings discussing the risks. This insight was very helpful in considering how best to safeguard yet did not feature in safety planning. David described services as ‘reading off a script from Top Boy16’ rather than understanding the reality of his situation. Despite this period of stability, there remained some evidence of his engagement with drug and gang culture and on one occasion in secure accommodation, he was found with £200 in cash. Some professionals felt that David was ‘biding his time’ and he would swiftly return to criminal activity once he returned to the community. This was balanced against the sense from his carers that he had made significant progress in secure accommodation despite their initial concerns. David and his carers significantly influenced the decision to end the secure order in September despite the local authority view that this should be further extended. This led the local authority to carefully plan the next steps. 4.5 The relationship between David and his carers has been consistent and they have maintained their support of David throughout. They have been exposed to and experienced considerable distress, challenge and criminal activity way beyond their previous lived experience and have lived in a constant turmoil of guilt and shame. David is desperate not to feel abandoned by his family and they have maintained their position 15 https://www.legislation.gov.uk/uksi/2010/959/regulation/24/made 16 Top Boy is a British television crime drama series focusing on gang culture which first aired in 2011 14 of love and care for him, possibly to the detriment of themselves. Relationships with professionals are important and it is disheartening that the local authority chose to move David’s case between the children’s looked after service and the child protection team again, therefore severing professional relationships and the sense of ‘start again syndrome’. This has been a shared frustration from the carers and some practitioners. Equally, there has remained some irritation from practitioners about how they have felt ‘manipulated’ by David and his family. There were professionals who maintained their involvement throughout this timeframe, and it was positive that the looked after reviews and child protection case conferences were chaired by the same Independent Reviewing Officer. There was also some consistent mentoring support for David from 2 practitioners during this period which at times, he engaged with. 4.6 The triple planning for David during the care proceedings was appropriate yet it was clear that he wished to return home to his carers. Some of the planning at that time, did seem a little disjointed. The police did not agree with the transition home, and they did not feel fully consulted before this decision was made. David’s mentor also did not feel David should return to his community and may be had more insights into the risks presented than was given credit. Clearly, the local authority and the court recognised the risks of David returning home and the alternatives available to keep him safe were limited. This presented decision makers with limited options and the decision was deemed child focused yet other options were considered ‘riskier’. The transition arrangements and his time in residential care following the conclusion of the secure order were well considered and supportive. As soon as David had access to a mobile telephone as part of a reward system, his cooperation with the plan began to wane. There was in place a robust plan of support to manage David’s transition home including college and support arrangements yet there was a view that the plans set out for David post secure accommodation were ‘service led rather than family led’. 4.7 This tight plan sadly fell apart following the Covid-19 restrictions, through no fault of any agency and David began disengaging with support. As soon as David returned to the care of his carers in November, he almost immediately began engaging with his ‘county line’ and became quickly involved in old behaviours. The decision to transfer him yet again to another team because his care status changed, indicated children’s social care’s lack of flexibility, and was not based in the development of relationship-based practice. There was a slight sense of relief experienced by practitioners at the point of transfer and whilst this was not the reason behind the decisions, it is understandable given the risks and needs associated with David and his family. 4.8 Whilst the transition plan was robust, the sheer number of professionals involved and the expectations on the family to engage with support services led to a disengagement from family members. The introduction of new services and professionals had the perverse effect of pushing the family away rather than engaging them in intervention. There were ongoing meetings held about David to assess the risk including the EMRAC meeting which considered attempts at disruption activity. The voracity of that activity is difficult to judge as there is limited available evidence that any proactive work was undertaken to disrupt the county line and through the chain of command. EMRAC is still viewed by practitioners and managers as a formality rather than supporting operational practice and this perception needs to change. It is not clear how the MAPPA and EMRAC processes dovetail and this may an opportunity for further consideration. 4.9 The relationship between the family and the police remained strained throughout and whilst there were positive attempts at engaging the carers, trust and confidence had waned. They presented as occasionally hostile to police involvement yet equally feeling guilt and shame particularly when police would raid the house in search of evidence. The carers had invited this arrangement to help with the safety and support plan, but again this had the reverse effect on professional confidence. 4.10 The safeguarding department in Thames Valley Police are responsible for managing child criminal exploitation risks. The teams are geographically based and work primarily to that locality. These local policing arrangements all work differently depending on the needs of the locality, but this can lead to a difference in practice and approach, including the naming of different meetings with the same functions. Whilst this may be appropriate, it can lead to some confusion from partner agencies about the roles and responsibilities of local policing arrangements. 15 Learning Point: Thames Valley Police need to consider their current arrangements for the safeguarding department and consider how effective having different arrangements in localities works for consistency. 4.11 There has been an attempt to remain balanced and victim focused, yet there remains evidence that the police considered David a criminal first and a victim second. The approach taken was ‘catch and convict’. The intention being that they could disrupt his involvement in the county line and therefore make him safer. When David was ‘stop checked’ by police however, there was always no evidence of criminal activity. This targeting of David does not seem to have been seen by officers in the context of his ethnicity and how this approach by police may have been perceived by David, thus potentially alienating him further from police who were wanting to provide safety. 4.12 The approach to intelligence gathering was fractured and lacking and despite regular operational meetings, this issue was not resolved. Expectations were placed onto the police for intelligence gathering and disruption activity yet there was not an arrangement in place to share intelligence amongst professionals who had contact with David and his family. Whether this was the role of EMRAC is not clear but subtle and innocuous intelligence was being gathered daily and this was not routinely shared in the agency network and particularly with the police. There is an agency perception that the police were involved in operations to disrupt the county line, but they were not involved or informed of these operations. There were some perceived frustrations with the police about their lack of proactivity. The police would argue that at times in meetings with other professionals, they were the last to know about incidents or information which could add value to the intelligence gathering around David which made their role much harder. 4.13 There were no harsher consequences or restrictions placed upon David to contain his behaviour and this was felt to be a missed opportunity. The police accept there should be more focus and drive in tackling the ‘exploiter’, but this cannot be undertaken in isolation. This does require an honest, open, and trusting relationship with professionals and families to achieve this. David’s carers feel that the police could have done more to safeguard David and that the police knew he was associating with some very dangerous criminals. 4.14 As the risks escalated, David once again became the subject of a child protection plan, yet it has become clear that David was involved in criminal activity far ‘deeper’ than the professional network understood. The team manager and the social worker alongside partner agencies developed a very robust and clear safety plan which included opportunities to meet cross borough to address the safety issues for several young people involved in criminal exploitation. This was a very positive development, and these meetings were maintained up until David’s arrest. The approach of the team manager and social worker had a positive influence on the engagement of the carers and refocused the risks and safety planning for David outside of the family home. The social worker worked alongside the carers and there were regular contact arrangements put in place in the agency network to highlights issues, risks, and challenges. The carers were fully engaged in this plan, which included the searching of David’s room by police when required. This sensitive and relationship-based approach to the carers ended when David’s case was again transferred to the looked after children service following his youth custody. 4.15 Significantly, there were two days in September 2021, where David had broken down and disclosed the level of vulnerability he was experiencing. David expressed fear and anxiety to his SGO carer as he was worried that he would be physically assaulted at college because he owed money to someone. He returned home and his carer called the police as David was emotionally distressed, shouting, screaming and head butting his wardrobe. The police conducted a voluntary search of his bedroom and found a kitchen knife, expensive clothing, and equipment for cannabis use. David did not wish to return home and police interviewed him in the back of a police van. David requested that they switch off their body worn cameras and then he disclosed that he was in serious trouble, that he ‘wanted to kill himself’ and that he was ‘done’. He was crying into his hands. Police took him to the male carers address and reported that, in all their time working with David, they had never seen him behave in this way. Once this information was passed to his social worker the following day, David had retracted all the statements, denying any knowledge. The police 16 safeguarding team for Wokingham made an NRM17 referral as the local response officers delayed this process. The NRM referral has confirmed that David is being exploited. It is not clear as to why the response officers that day did not consider David’s vulnerability and use their police protection powers to safeguard him. David returning to the care of the male carer may have been seen as offering safety, yet the description of David and his disclosures was a clear missed opportunity to proactively intervene in his life and potentially safeguard him. The safety planning did not involve any precipitating plan should David disclose and present as vulnerable and this may have influenced decision making that evening. Learning Point: Safety planning for children and young people being exploited should include statements of ‘agency intent’ if a child or young person discloses their vulnerability to exploitation. 4.16 There have been a number of initiatives and working party’s on contextual safeguarding and there has been increased learning for individuals in safeguarding agencies, yet operational practice has not significantly changed since the last review concluded. Practice and procedure have not been embedded into practice and the agencies remain challenged by working with this cohort of children and young people. Leaders have not grasped the opportunity to be more creative and flexible in their approach and some practitioners have remained isolated, not listened to and unsupported. 4.17 Building upon the initial development of ‘contextual safeguarding meetings’ which were initiated in David’s case by the Independent reviewing Officer, the safeguarding partnership might wish to consider piloting a bespoke ‘child protection pathway’ as recommended in the Independent Review of Children’s Social Care18. 4.18 Whilst not part of this review process, there have been significant challenges for the family and professionals to work alongside the prison estate since David’s arrest. This may well be an issue that needs addressing post David’s trial. 5. Summary of additional learning 5.1 Safeguarding professionals need to be cognisant of victim blaming language. 5.2 Escalation processes need to be embedded in the safeguarding system at all levels to ensure effective challenge of decision making. 5.3 Schools and local communities have a key role to play in the support of children and young people involved in child criminal exploitation and they should form part of both operational and strategic safety planning. 5.4 Critical debriefing sessions should be available to the professional network where opportunities for open and honest reflection can assist in supporting practitioners and their managers in risk management. 5.5 Safeguarding partners should produce and then share accountability and decision making ‘trees’, so agencies can be clear about where escalation issues can be raised. 5.6 The Covid-19 pandemic impacted and influenced the transition plan significantly yet there was no contingency plan in place should this fail. 5.7 David and his carers developed some strong and positive relationships with some social workers. With the focus on ‘harm outside of the home’, the carers felt less judged and alienated from engaging in safety planning. 5.8 In a bid to ensure the plan was robust post the Secure Order, many professionals became involved. This was overwhelming for the family and did not add value to the interventions. 5.9 Harsher consequences, restrictions, and deprivation of liberty alongside effective and focused rehabilitation in order to break the cycle of criminal exploitation should be considered as part of any safety plan. 17 The National Referral Mechanism (NRM) is a framework for identifying and referring potential victims of modern slavery and ensuring they receive the appropriate support. 18 The Independent Review of Children’s Social Care (May 2022) 17 5.10 The local authority had commissioned appropriate ethnically diverse mentoring arrangements. 5.11 Some interventions had not been the subject of monitoring through care planning meetings. 5.12 Culturally sensitive practice, cultural sensitives and strengths needs to be reinforced by senior leaders and pervade policy and procedures. 5.13 An analysis of the role of EMRAC alongside MAPPA might assist in safety planning. 6. Evidence of good practice 6.1 Some practitioners have developed strong and meaningful relationships with David, and he engaged with them well. They have been persistent in working with him. 6.2 There has been consistent support and therapy funded through the adoption service. 6.3 David’s school have been a consistent part of his adolescence and have provided ongoing support. 6.4 Practitioners who have worked with David have been committed to keeping him safe and want to achieve the best for him. 6.5 David was given opportunities to be involved in his care planning. 6.6 Practitioners have been open, honest, and reflective in the review process. 6.7 Some practitioners have a good understanding and more up to date knowledge of child criminal exploitation and could be used to mentor others. 7. Conclusions 7.1 Professionals have invested heavily in supporting David. He is well liked and there is much affection for him. This is coupled with a deep anxiety of him being seriously injured or killed. Professionals have felt distress and frustration with not being able to make his situation safer. 7.2 The incident that led to this review had been predicted by David, his carers and the professionals working with him. The seriousness of the incident and the injury to David was a shock to the safeguarding system locally and it has reverberated around the safeguarding system since that time. However, whether this was preventable is subject to conjecture. There is learning from his situation which can influence assessment, planning and intervention with David and other young people involved in child criminal exploitation in the future. 7.3 David’s situation has prompted significant reflection, changes to process and procedure and to a better understanding of child criminal exploitation. It has also led to more coordinated, considered, flexible and proactive care and safety planning for David. His SGO carers report that the support they are receiving now should have been in place before his injury and feel this was only in response to the incident itself. 7.4 The review has highlighted a number of factors that influenced practitioners and practice at the time. Whilst not in the remit of this review, the decision to place David with his family members under an SGO without a robust plan of support and therapy was flawed. It took no account of David’s early childhood experiences, his complex coping strategies and how therefore he should be therapeutically parented. This left his SGO carers vulnerable, leading to them feeling emotionally, mentally, and physically exhausted. This scenario reinforces the need for expert assessment and judgement as to the suitability of family members resuming the care of highly traumatised children without the necessary understanding, guidance, and ongoing support. 7.5 The safeguarding partners have recognised that there understanding of child criminal exploitation at a multi-agency level was lacking. Whilst individuals in the network had well developed understanding of this form of exploitation this did not result in effective multi-agency joined up assessment, planning and interventions. The assessments undertaken focused heavily on the child and carers relationship without fully recognising or understanding the risk and influences outside of the family home. Assessments did not result in effective multi-agency safety planning where child criminal exploitation was a significant risk factor and thresholds for intervention were confusing. There seemed little confidence in the child protection 18 process in mitigating the risks for David and limited flexibility in developing standalone and nuanced arrangements such as contextual safeguarding meetings which had the same status as the child protection case conference. This has been an area of development in the local authority but there remain some frustrations as to its efficacy if not given equitable status to child protection planning. 7.6 David’s safety and welfare was the cause of much joint discussion and consideration. Some information was shared, yet what happened as a result of that information being shared to support safety planning and intervention was less clear. At times, agencies were working in isolation of each other with poor or non-existent communication. David’s school had a key role to play in the management of risk but were excluded from some discussions and were not party to other significant information about David and his circumstances. 7.7 Agencies and children’s services in particular, were caught in a daily spiral of reactive practice and risk management. This sense of helplessness and what to do next to alleviate risk, impacted on individual practitioners and the safeguarding system. The shared ownership of the risk became fractured and professional disagreements emerged about how best to keep David safe. The social worker and their manager were left holding an unacceptable level of risk. Professional support and supervision were available to practitioners and senior leadership teams in safeguarding agencies were aware of David, yet this did little to alleviate the impact on practitioners working with him. There appeared to be a shared sense of helplessness. Secondary or vicarious trauma and its impact on individuals and the system was not considered at the time and there was no opportunity for the multi-agency network to stop, reflect and plan together proactively. The honest reflections of practitioners about compassion fatigue when working with highly complex risk is crucial to ongoing learning. This also helps practitioners understand the lived experiences of carers in those circumstances and how they might behave and react to situations out of their control. 7.8 The multi-agency strategic forum discussing children and young people at risk of exploitation did not appear to add value to the risk management strategies and became as ‘stuck’ as the other professionals in the network. Practitioners understanding of the forum was confused and the repeated statement that this was a ‘strategic group’ missed the reality of managing David’s risk every day. This group appeared somewhat devoid of ideas to manage the risks, despite the availability of best practice guidance and toolkits to support safety planning. The professional disagreements that emerged from this meeting and the lack of shared ownership of the risks may have been a reason for this lack of coordination. Similarly, ever changing senior leadership would have influenced decision making and effectiveness. 7.9 The authority has made changes to this forum, but this appears to be work in progress rather than fully functioning and performing well. There have been additional strategic forums set up in the borough in recent months, these include an exploitation subgroup, focusing on key data, trends and themes linked to exploitation and how this influences the development of local services and a Pan Authority Partnership Group undertaking similar activities. Operationally, there has been a number of initiatives developed to address the needs of children and young people who could be or are being exploited. 7.10 Decisions regarding David’s safety and welfare were made in the context of available information at the time. The short-term strategy of moving David from the borough was designed to alleviate the risks, but this did not take into account the clear evidence that David was involved in drug running and likely county lines activity. The search for suitable placements for David became the focus of interventions. 7.11 David’s significant injury became a trigger point for action yet there were other occasions where David showed vulnerability, anxiety, and worry. These trigger points of vulnerability were an opportunity to get alongside David, particularly those with whom he had developed positive relationships. Yet the lack of flexibility shown in the allocation of work, processes and procedures led to unhelpful changes in practitioners working with David. 19 8. Recommendations 8.1 Statement: Shared accountability and responsibility for safeguarding children and young people should be reinforced through the safeguarding partners, the Community Safety Partnership and other strategic multi-agency forums. 8.2 The safeguarding partners alongside other relevant agencies should test and evaluate the use of contextual safeguarding meetings. Task and Finish Groups should devise methods that enable the co-production of safety planning with children, young people, parents, and carers alongside the school and local community. 8.3 The safeguarding partners (children’s social care, integrated care board, and police) working alongside the Serious Violence and Exploitation Group should consider piloting a ‘child safeguarding pathway’ for children exploited and use the evidence to inform future practice and staffing changes. 8.4 The safeguarding partners should consider working across and learn from other safeguarding partners and agencies who have developed effective contextual safeguarding practice, particularly in implementing Signs of Safety as a practice model. 8.5 The safeguarding partners alongside other relevant agencies and working collaboratively with other strategic forums should develop a safety planning toolkit which supports practitioners in their work with children and young people criminally exploited. This should include safe and effective plans for children and young people exiting exploitation. 8.6 Children’s social care are encouraged to test out having a single social work practitioner for children experiencing exploitation. 8.7 The safeguarding partners with the Community Safety Partnership should review the multi-agency forums set up to address exploitation across the safeguarding system and build in quality assurance arrangements to evaluate their role and function including evaluating the impact on children and young people and the effective use of assessment tools to evaluate risk. 8.8 The safeguarding partners alongside other relevant agencies should consider how to implement a trauma informed approach to practice across the safeguarding system, including how to support staff with vicarious and secondary trauma and develop arrangements for critical debriefing post incident. 8.9 The safeguarding partners should reassure themselves that practitioners are using culturally sensitive and racially aware safeguarding practice through a process of multi-agency audit. This should include the voices of children and young people. 8.10 The safeguarding partners should undertake a review of all children in the Borough who are subject to exploitation to assure themselves that safety planning is effective, and enforcement and disruption activity is ongoing. 8.11 The safeguarding partners should review the existing agency escalation policy and include references to multi-professional meetings. 8.12 Thames Valley Police should review and identify the differences in practice in the safeguarding department and develop a plan for consistency. 8.13 Thames Valley Police should develop a clearer framework for intelligence sharing amongst practitioners working with children and young people who are exploited, including expectations of safeguarding partners. This should include details about intelligence sharing from the police to other agencies. |
NC041028 | Review into the death of a 5 year old boy (Child G) and his 2 year old half-brother (Child H) in December 2010. Both children were suffocated by their pregnant mother who committed suicide. Family had contact with several agencies because of concerns over the impact of custody and contact disputes. Mother was involved in 2 separate sets of proceedings, one involving her three older children and the other in relation to Child H. Recommendations include: social services to establish a clear working arrangement with CAFCASS Cymru that facilitates discussions about contact arrangements between families known to social services; and school staff to receive awareness training on the impact of custody related matters on children and families.
| GWYNEDD AND ANGLESEY LOCAL SAFEGUARDING CHILDREN BOARD SERIOUS CASE REVIEW ON CHILD G AND CHILD H EXECUTIVE SUMMARY 25th OCTOBER 2011 1 | P a g e E x e c u t i v e S u m m a r y v . 3 CONTENTS PAGE Foreword 2 Key to family members 3 Brief outline of the case 3 - 4 How the case review was carried out 4 - 5 Summary of agencies’ involvement with the family in the period covered by the review Health involvement 5 Social Services involvement 6 - 7 Police involvement 7 - 8 Education Department involvement 8 CAFCASS Cymru involvement 9 - 11 Good practice points 11 Lessons learned 12 Conclusions 12 - 14 Recommendations 14 - 16 2 | P a g e E x e c u t i v e S u m m a r y v . 3 FOREWORD This report is published by the Gwynedd and Anglesey Local Safeguarding Children Board. This is a multi-agency group that has responsibility to oversee how services and professionals cooperate and work together to safeguard children and to make sure that the inter-agency arrangements in place within the two counties bring about positive outcomes for children. The Local Safeguarding Children Board in Gwynedd and Anglesey operates under Government Regulations that came into force in 2005. These Regulations require all Local Safeguarding Children Boards to set up a serious case review when abuse or neglect of a child is known or suspected and a child dies or sustains a potentially life-threatening injury or serious and permanent impairment of health or development. This review was set up following the death of two young children at the hands of their mother, who also took her own life. The main objectives of the review were to: establish whether there were lessons to be learned from the case about the way in which local professionals and agencies work together to safeguard children; identify clearly what those lessons were, how they would be acted upon, and what was expected to change as a result; and as a consequence: o identify issues in inter-agency working in order to better safeguard children; and o identify examples of good practice. The review was conducted under the guidelines set out in the Welsh Assembly Government document Safeguarding Children – Working Together under the Children Act 2004. 3 | P a g e E x e c u t i v e S u m m a r y v . 3 KEY TO FAMILY MEMBERS Adult 1 Mother of Child 1, Child 2, Child 3, Child G and Child H Adult 2 Adult 1’s ex-husband, father of Child 2 and Child 3 and step-father of Child 1 Adult 3 Mother’s ex-partner and father of Child H Child 1 Adult 1’s eldest child (female) and Adult 2’s step-child Child 2 Adult 1’s second child (male) and Adult 2’s eldest child Child 3 Adult 1’s third child (male) and Adult 2’s second child Child G Adult 1’s fourth child (father unconfirmed) Child H Adult 1’s fifth child (fathered by Adult 3) _____________________________ BRIEF OUTLINE OF THE CASE 1. This serious case review looked into the case of a 5 year old child (Child G) and his 2 year old half-brother (Child H), both of whom died at the hands of their mother, who also took her own life. The case review covered the period from January 2005, when Adult 1 had her first ante-natal appointment when pregnant with Child G, until the death of Child G and Child H in December 2010, i.e. a period of almost 6 years. 2. As an adult, Adult 1 first came to the attention of Social Services as a result of concern about her children following her separation from her husband, who was the father of her second and third children. Although her husband was not the father of her first child, he brought the child up as if she were his own. 3. After the separation from her husband, Adult 1 formed a relationship with the person who became the father of Child G. Soon after the birth of Child G, she began a relationship with Adult 3, who was to become the father of Child H. 4 | P a g e E x e c u t i v e S u m m a r y v . 3 4. In the 6-year period covered by the case review, the family had contact with several agencies. Most of the contacts arose as a result of concerns about the impact of custody and contact disputes between Adult 1 and Adult 2 (in relation to Child1, Child 2 and Child 3), as well as between Adult 1 and Adult 3 (in relation to Child H). These custody and contact disputes were a key feature of the case, with Adult 1 involved in two separate sets of private law proceedings at the same time, one involving her three older children and the other in relation to Child H. 5. Although some of the concerns raised about the children in the period covered by the review were to do with their safety and welfare, none of those concerns were viewed as serious enough to justify taking any child protection action beyond carrying out initial investigations into some of the reported incidents. On those occasions when Adult 1 was offered help, none of the offers made were taken up. 6. The bodies of the children and their mother were discovered on the day that Adult 3 called at the home of Adult 1 to collect Child H for his first overnight stay with him. HOW THE CASE REVIEW WAS CARRIED OUT 7. Following the death of the two children and their mother, the Local Safeguarding Children Board met and agreed that a serious case review should be carried out to examine the involvement of agencies with the children and their family, starting from the first antenatal contact with the child’s mother when she was pregnant with Child G and ending when the children died. 8. The serious case review panel was made up of representatives from Public Health Wales; the Betsi Cadwaladr University Health Board; Anglesey Social Services; Anglesey Education Service; Gwynedd Social Services; Gwynedd Education Service; North Wales Police; Anglesey County Council Legal Department; CAFCASS Cymru and Barnardos Cymru. The panel was chaired by the Assistant Director, Barnardos Cymru. 5 | P a g e E x e c u t i v e S u m m a r y v . 3 9. Each agency that had been involved with the children and their family was required to produce a chronology of their involvement, together with a report identifying key aspects of that involvement. The chronologies and reports were then used as a basis for an overview report that was compiled by an independent author appointed by the Local Safeguarding Children Board. The full report, which contains 10 recommendations and an action plan, will be sent to the Welsh Government. SUMMARY OF AGENCIES’ INVOLVEMENT WITH THE FAMILY IN THE PERIOD COVERED BY THE REVIEW Health Involvement 10. From the point at which Adult 1’s pregnancy with Child G was confirmed until the death of Child G and Child H, most of the contact that health professionals had with the family took the form of routine appointments for universal health care. Throughout that whole period, there was little that came to the attention of health professionals to indicate that there were concerns about Child G or Child H and nothing to suggest that they were at any risk of harm from their mother. 11. There were occasions in this period when health professionals were aware of concerns about Adult 1 and her children, but these were more often about her older children rather than about Child G and Child H. Although, as early as November 2007, the health visitor was aware of the stress that Adult 1 was under as a result of custody/contact disputes with Adult 2, there was nothing to suggest that this was any more than a normal and common reaction to a difficult situation. 12. In summary, despite being aware of the tension within the family resulting from the ongoing custody and contact issues in relation to Child H and Adult 1’s three older children, there is nothing to suggest that health professionals should have done more than they did in this case. Furthermore, none of the health staff who had contact with the family could have anticipated that there would be such a tragic outcome for Adult 1 and her two youngest children. 6 | P a g e E x e c u t i v e S u m m a r y v . 3 Social Services Involvement 13. Most of the involvement that Social Services had with the family took place between November 2005 and December 2010. In this period, their contact was mostly in relation to concerns about Child 1 and Child 3. For the most part, these concerns were seen as connected with the custody and contact disputes between Adult 1 and Adult 2 and the concerns related to the care the children were receiving in their mother’s home as well as in the home of their father and his new wife. 14. In relation to Child G and Child H, Social Services received a total of 6 separate referrals between December 2008 and August 2010, i.e. a period of 20 months. On three of these occasions, they decided to take no action and in relation to only one of the three referrals did they make enquiries with other agencies before making their decision. These three referrals were about an attempted attack on Child H by a dog in the home of Adult 1; a pinprick on Child H allegedly caused when Adult 3 consented to a blood sample being taken from Child H; and allegations that Child G and Child H were neglected by their mother. On the basis of the information available to Social Services at the time, their decision to take no further action in relation to these referrals was a reasonable response to incidents that were not serious enough to justify intervention. 15. The remaining three referrals were made in the space of a three-day period in August 2010 and they took the form of allegations about the standard of care provided by Adult 1 to her children. Social Services responded to these allegations by carrying out an initial assessment as opposed to a child protection investigation. This was an appropriate response and, when the assessment revealed that the allegations made were unsubstantiated, they took no further action. 16. In summary, it is fair to record that Social Services responded to the referrals they received in an appropriate way. The most serious matters were investigated and there 7 | P a g e E x e c u t i v e S u m m a r y v . 3 were never sufficient concerns to justify taking any child protection measures. In relation to Child G and Child H, observations by Social Services, together with information from the police, indicated that both children were well and happy, with no evidence of mistreatment or neglect by their mother and certainly no evidence to suggest that they were at any risk of physical harm from their mother. Police Involvement 17. In the period following the birth of Child G up to the time of the deaths of Child G, Child H and their mother, the police had sporadic contact with the family. Most of this was in connection with concerns about Child 1 or Child 3. 18. The only occasion on which the police response can be criticised was in February 2007, when they were informed by Adult 3 that Adult 1 had gone missing from home and had left a suicide note in which she stated her intention to kill herself and Child G. Although the police responded quickly to this report and subsequently found Child G and his mother safe and well at the home of Adult 1’s mother in the Midlands, the matter ended there and there is no record of the police informing Social Services about it. Given the circumstances, this matter should have been reported to Social Services, who would then have carried out background checks to help determine whether there was any significant risk of harm to the child. 19. Although there is no certainty about what response would have followed if the matter concerning Child G had been reported to other agencies, a full child protection investigation should have been carried out. Had that happened, even if it did not lead to a child protection case conference being convened, other agencies would have been given the information, which might have created a greater concern among partner agencies about subsequent reports in relation to Adult 1’s care of her children. However, given Adult 1’s apparent reluctance to accept help from Social Services, there is little to suggest that intervention in February 2007 would have had any direct impact on the eventual outcome for Child G and Child H almost 4 years later. 8 | P a g e E x e c u t i v e S u m m a r y v . 3 20. In summary, on all of the occasions that the police were asked for assistance, they responded quickly and appropriately and, on all but one occasion, they shared relevant information with partner agencies. The one exception was in relation to the February 2007 incident. Education Department involvement 21. The Education Department were involved with Child G, as well as with Child 1, Child 2 and Child 3. They had no involvement with Chid H, who was not of school age. 22. Most of the issues that were of concern to the Education Department in their dealings with Adult 1 and her children were matters concerning Child 1. 23. It wasn’t until September 2009 that Child G started school and, in the following 15 months, there was only one matter of concern noted in relation to him, which concerned his awareness of the conflict between his mother and his (step)father (Adult 3). However, there is nothing in the record to indicate that there were any child protection concerns in relation to Child G. 24. From the school perspective, there was nothing to indicate that Child G might be at risk of harm from his mother, who is reported as visiting the school quite often and being happy, friendly and courteous whilst there. Only three weeks before the deaths of her children and herself, while Adult 1 was helping with preparations for the school Christmas concert, school staff noted that she had a natural and happy relationship with Child G. This positive view was reinforced on the day of the Christmas concert, which took place less than two weeks before the deaths. 25. In summary, the Education staff involved with the family responded to the concerns that they had in an appropriate way and there is nothing to suggest 9 | P a g e E x e c u t i v e S u m m a r y v . 3 that they could have done anything to predict or prevent the deaths of Child G and Child H. 10 | P a g e E x e c u t i v e S u m m a r y v . 3 CAFCASS Cymru involvement 26. CAFCASS Cymru’s involvement with this family was solely in respect of private law applications made by the parents of the children, mostly in respect of residence and contact matters. 27. The first involvement that CAFCASS Cymru had with the family was in 2001, at which point Adult 1 was in the process of obtaining a divorce from Adult 2. CAFCASS Cymru had no further involvement with the family until June 2008, when they were requested to prepare a report for the court on residence arrangements for Child 1, Child 2 and Child 3. While these matters were still unresolved, Child H was born and CAFCASS Cymru became involved in the preparation of reports on contact and residence issues in relation to him. 28. In the course of preparing reports for the court on custody and contact arrangements for Child H, the Family Court Advisor (FCA) dealing with that part of the family received representations from Adult 1 and Adult 3 about concerns they had about each other. These concerns included allegations that each had harmed Child H in some way. Adult 3’s allegations included his fear that Child H would be harmed in future. The FCA took the view that only one of the incidents reported to her needed to be referred to Social Services. 29. In a report to the court in November 2010, the FCA reported that, despite the concerns raised by Adult 1 and Adult 3 about each other, there was a “tacit level of agreement” between them that Child H should spend time with each of them. The matter was resolved with the agreement of both parents at a court hearing on 13th December 2010, when staying contact was agreed for Child H with his father (Adult 3). 30. In his statement to the police, and in interview as part of the case review, Adult 3 stated that he believed that Adult 1 posed a risk to Child G and Child H and he said that he had told others (notably CAFCASS Cymru) about his fears. He still feels strongly that his concerns were not taken seriously. He also believes that, had CAFCASS Cymru worked more closely with Social Services and recognised 11 | P a g e E x e c u t i v e S u m m a r y v . 3 that they were dealing with a family in crisis, Adult 1 may have received the support she needed, which would have prevented the deaths of the children. However, whilst more could have been done to ensure that all agencies had a fuller picture of the family, there is nothing to suggest that this would have led to a different outcome. 31. One matter about which Adult 3 and the FCA had very different views was in relation to Adult 3’s belief that the FCA did not take seriously his concern about the incident in February 2007, when Adult 1 allegedly left a suicide note declaring her intention to kill herself and Child G. Adult 3 believed that this indicated that Adult 1 was a potential threat to her children, a view shared by Adult 2. Despite this, there is nothing in the records to suggest that either Adult 2 or Adult 3 believed that Adult 1 should not have care of her children. Nor was there any indication that Adult 1 intended to take her own life and those of her two youngest children. 32. The records available certainly indicate that, towards the end of 2010, Adult 1 was under considerable stress because of the contentious issues in relation to custody and contact involving Child H and Child 3, together with difficulties she had been having with Child 1. As a person who reportedly liked being in control, there were several things over which she appeared to have very little control at that time. On top of that, she was reported to have some financial difficulties. However, none of this created worries that she would end the lives of her two youngest children and herself. What it possibly should have done was lead to a discussion within CAFCASS Cymru and with other agencies about how best to offer support to the family to help alleviate the levels of stress they were obviously experiencing. This did not happen. 33. In summary, CAFCASS Cymru were involved with the family almost continuously from June 2008 until December 2010. In that time, the FCAs dealing with the family were aware of virtually all of the incidents that were referred to either Social Services or the police. Like those two agencies, the 12 | P a g e E x e c u t i v e S u m m a r y v . 3 FCAs concluded that only one of the concerns may have reached the child protection threshold and, for that reason, they did not refer any of the others to Social Services. Whilst that was a fair judgement on the basis of the information they had, it would have been advisable for them to discuss their concerns with their managers in order to gain support for their decisions or, alternatively, pursue a different approach. Good Practice Points 34. Throughout this case, there were examples of good practice from all agencies, as follows: i. in compiling their reports for the court, the FCAs: a. did all that they could to ascertain the wishes and feelings of the children involved; b. made appropriate enquiries of other agencies; c. attempted to mediate and gain agreements before court hearings; ii. when the two FCAs dealing with the family became aware of each other’s involvement, they discussed the cases and shared their previous court reports; iii. the health visitor sought appropriate advice when Adult 3 requested verbal information about Child H’s health; iv. overall, there was good communication between Social Services and the police when responding to referrals from or about the family; v. the ambulance staff who attended the family home on the day of the deaths made a clear record of the reasons why the SUDI Policy was being overridden. 13 | P a g e E x e c u t i v e S u m m a r y v . 3 Lessons Learned 35. There are several lessons to be learned from this case, as follows: i. the importance of being aware of the safeguarding concerns that can arise in complex private law cases, particularly when children are repeatedly drawn into parental disputes; ii. the importance of sharing safeguarding concerns with partner agencies so that decisions about assessment and/or intervention can be based on a full picture of family circumstances and needs; iii. the need to consider how best to provide help and support to families where there are many concerns that do not reach the child protection threshold; iv. the need to review the practice of copying CID 16s to health colleagues, together with the need to establish a process within health for acting on the information received. CONCLUSIONS 36. This tragic case has identified only one procedural gap, which was the failure by the police to notify partner agencies when Adult 1 and Child G were reported missing in February 2007. Although it is difficult to know whether knowledge about this event would have made any difference to the subsequent actions of partner agencies in this case, it is unlikely to have changed the outcome, giving that the unreported event happened almost four years prior to the deaths of Child G, Child H and their mother. 37. What is striking about this case is the complexity of the family relationships and the absence of any substantial child protection concerns that might have led to help being provided to Adult 1. Although concerns were raised about Child G and Child H, all by other family members, investigations and assessments carried out 14 | P a g e E x e c u t i v e S u m m a r y v . 3 found those concerns to be unsubstantiated. In fact, it was other children in the family, notably Child 1 and Child 3, about whom most of the concerns were raised in the period covered by the case review. 38. Even if Social Services had been aware of all the information that CAFCASS Cymru had about the family, it is unlikely that they would have done any more than offer services to Adult 1. On the three occasions that they did offer help, Adult 1 stated that she did not need it. Since none of the concerns reached the child protection threshold, it is difficult to know what more could have been done at the time. 39. In the absence of sufficient grounds for convening a child protection case conference, one option that was open to Social Services, as it was to other agencies, was to convene a child in need meeting. This would have provided an opportunity for partner agencies to share their concerns about the family and consider whether offering help might alleviate the continuing tensions in the relationships between Adult 1 and Adult 2/Adult 3. However, the potential benefits of a child in need meeting would have relied on agreement from Adult 1 that such a meeting would be helpful and there is nothing to suggest that she would have taken that view. In the circumstances, it is not surprising that none of the agencies involved with the family considered a child in need meeting as an option. 40. From the perspective of Adult 3, and to a lesser extent of Adult 2, this was a mistake because Adult 3 certainly believed that Adult 1 posed a threat to her children and Adult 3’s view was, and is, that a child protection case conference should have been convened. However, there were not sufficient grounds at the time to initiate the child protection procedures in this case. 41. Whilst Adult 3’s view that those agencies involved with the family failed to respond appropriately to the risks that he and others identified, it is difficult to know what could have been done to prevent the deaths of the children and their mother. Arguably, the only way of protecting Child G and Child H would 15 | P a g e E x e c u t i v e S u m m a r y v . 3 have been to remove them from the care of their mother and there were never any grounds to do so. SECTION E: RECOMMENDATIONS 42. The following recommendations all relate to some aspect of inter-agency work. Health i. BCUHB, Social Services and North Wales Police should establish a consistent approach to the sharing of CID16s across North Wales. In the interim, the BCUHB will strengthen governance arrangements by implementing guidelines for staff who receive copies of CID16s which identifies their responsibilities on receiving these forms until such time a consistent North Wales approach is agreed. Social Services ii. Social Services should establish a clear protocol or working arrangement with CAFCASS Cymru that facilitates discussions about complex or ongoing contact arrangements between families known to Social Services. iii. Social Services and Health should establish a system that allows Health to make secure electronic referrals to Social Services. Education iv. The Education Department should ensure that school staff receive awareness training about the impact of custody-related matters on children and their families. This should include the importance of sharing relevant information with partner agencies. Social Services and Education v. Social Services and the Education Department should establish a clear working protocol between children’s teams and TAC1 regarding sharing of information, 1 The TAC is to be known as Team around Family (TAF) as a result of changes resulting from Families First implementation. 16 | P a g e E x e c u t i v e S u m m a r y v . 3 working arrangements and prevention work in cases that do not meet the child protection threshold. North Wales Police vi. North Wales Police should consider the introduction of refresher training or additional education on child protection for all frontline staff to ensure that they are aware of their responsibilities to share relevant information with partner agencies. vii. The Head of Strategic Public Protection within North Wales Police should review the current Missing Person Procedures to ensure that all relevant Missing Persons results in a CID 16 Child Protection or Vulnerable Adult Referral being created and shared with partner agencies. The Children and Young People’s Partnership viii. The Children and Young People’s Partnership should ensure that, when the new implementation model for the TAC/TAF in Gwynedd is introduced, it should include protocols to ensure that relevant information is shared with other agencies to ensure that vulnerable families receive appropriate support. CAFCASS CYMRU ix. CAFCASS Cymru should ensure that, when FCAs are involved in the preparation of reports concerning families known to other agencies, managers help them to identify and discuss any safeguarding issues within those families. x. In relation to access to records held by Social Services, CAFCASS Cymru should: a. seek to resolve the situation with Gwynedd County Council over access to their case records; 17 | P a g e E x e c u t i v e S u m m a r y v . 3 b. consider raising the matter with the Heads of Children’s Services across Wales with a view to establishing a national agreement; c. raise with the Welsh Assembly Government the possibility of amending legislation to give FCAs similar rights of access in private law as they have in public law. ___________________________________ |
NC52567 | Death of a 16-month-old boy due to non-accidental injuries in August 2019. Mother's partner was charged with murder and Mother was charged with causing or allowing the death of a child. Learning themes include: the effectiveness of local multi-agency safeguarding children thresholds and pathways; the child's lived experience; the formulation and management of child protection plans and core groups; working with parents who are reluctant to engage; the impact and management of house moves on safeguarding systems; responses to domestic abuse; parenting education; parental drug and alcohol misuse; and the use of written agreements. Recommendations include: local children's agencies, midwifery services and adult services review their assessment guidance and procedures to ensure curiosity about and consideration of the welfare of other household or family members, especially children under 5-years-old; a review of the protocol for re-housing families where children are subject of child protection plans to minimise moves away from the borough and key safeguarding networks, except where a move is essential to safeguarding a child or parent; relevant staff in partner agencies to have sufficient training in domestic abuse awareness, including the use of risk assessment tools and when to refer a case to a Multi-Agency Risk Assessment Conference (MARAC); a review of the use of written agreements with families when they are not part of agreed Child Protection Plans or Public Law Outline work, with guidance needed on when to share information about these agreements with key partner agencies.
| Title: Child safeguarding practice review: Lloyd and Mark. LSCB: Wandsworth Safeguarding Children Partnership Author: Malcolm Ward Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Child Safeguarding Practice Review Lloyd and Mark May 2022 1 Contents Page 1. Executive Summary 2 2. Reason for review and methodology 4 3. Family Background Information 5 4. Summary account of events and agencies’ involvement 6 with Lloyd and Mark’s family 5. Practitioners’ involvement in the review 11 6. Analysis and Key Learning 12 7. Recommendations 39 8. Appendices: Panel Membership 44 This report was originally endorsed by the Wandsworth Safeguarding Children Partnership in the summer of 2021, and recommendations were agreed. Following the Crown Prosecution Service [CPS] decision in December 2021 to charge the mother and her partner it was agreed to update the report considering local developments since the original report was endorsed by the Safeguarding Children Partnership. Use of Footnotes The Review contains Footnotes to explain safeguarding processes and terms for those who are less familiar with them. The agreed processes for safeguarding children are set out in statutory guidance Working Together to Safeguard Children which applies to England. The version used here is 2018, in which, there are some small changes from the 2015 version which would have been applicable during the earlier part of the period under review. Working together to safeguard children - GOV.UK (www.gov.uk). There are agreed multi-agency procedures and guidance for London and for Wandsworth which amplify how the national procedures are to be used locally. London Safeguarding Children Procedures: (londonscp.co.uk). The procedures have a useful search facility for key words. The local Multi-Agency Procedures and the locally agreed Threshold Document for Wandsworth can be found on the website for the Wandsworth Safeguarding Children Partnership, Home - Wandsworth Safeguarding Children Partnership (wscp.org.uk) 2 1 Executive Summary 1.1 The Review was commissioned after Lloyd’s death in 2019 (age 16 months). Given the family circumstances and the history of involvement with local multi-agency child and family services over the previous five years it was agreed that the analysis and learning should be drawn from the multi-agency work to support both Lloyd and his older brother Mark (age 4 years at Lloyd’s death) and their mother, Ms A. They had been in receipt of universal, early help and later child protection services. 1.2 Attempts to work with Ms A were disrupted by several moves to temporary or safe housing across four London Boroughs. The moves broke links with practitioners from midwifery, domestic abuse, early help, social care, and preschool services. Ms A had a troubled history, was subject to domestic abuse in different ways and reported her own previous problems with alcohol and drug use, because of child and adult trauma. 1.3 Ms A often avoided workers and did not keep to agreements to use local child and parenting services. There were, at times, gaps of several months when no workers saw the children even though they were assessed as vulnerable and met thresholds for early help intervention; however, early help services are not compulsory. 1.4 From autumn 2018, when Mark briefly attended a nursery, increased concerns were noted, a thorough multi-agency assessment was undertaken, and the children were made subject of Child Protection Plans in December. The family was moved urgently to an out of borough refuge for protection from domestic abuse and coercive control. 1.5 The Child Protection Plan initially concentrated on the immediate risks of that domestic abuse but was not then later further refined to meet the assessed underlying needs and neglect identified in the Child and Family Assessment. 1.6 The move out of borough again disrupted the professional network; and key agencies such as Housing were not represented in the Core Group. Ms A appeared to respond to some of the domestic abuse counselling but did not engage fully. Mark's signs of developmental delay had been noted but were not being fully assessed or dealt with. 1.7 After a few months, the family moved again to temporary accommodation in a third borough before soon returning to Wandsworth, once more disrupting the Core Group of professionals, and working relationships with Ms A and the children. In July 2019, the Child Protection Plan ended. Despite disagreement by practitioners newer to the case the decision to step down from child protection to a “robust child in need” plan was not escalated. From that time Ms A avoided contact with professionals and the boys were not seen again before Lloyd’s tragic death, in late August. 1.8 After Lloyd’s death it was learned that Ms A had started a new relationship, which she had previously denied when questioned, at the time. It was also discovered that the children had been exposed to adult drug use, over time. 1.9 In December 2021, Mr D was charged with Lloyd’s murder and Ms A was charged with causing or allowing the death of a child. Their trials are scheduled for February 2023. 1.10 The Review has used this case as an example of how the wider agency and multi-agency child safeguarding systems were operating at the time. 3 1.11 Learning and recommendations are made in the following areas: The need for better monitoring of family support at the Universal Plus Level within the National Healthy Child Programme Pathway, when families do not cooperate. The need to have curiosity about children under 5 who are not being seen in pre-school services where there is non-engagement by parents, and how agencies form and record a clear picture of children’s daily lived experience, including siblings when only one child is being seen or considered. Child Protection Plans must fully address children’s underlying needs as identified in assessments even when having to respond in crisis to new acute threats of harm, such as newly disclosed serious domestic abuse. Core Groups must closely monitor Child Protection Plans and their progress and change their planned outcomes and interventions if there is insufficient progress. It is important that key agencies are fully represented in Core Groups, including Housing or Police or other domestic abuse services, as needed. Moving families across Local Authority boundaries from the services disrupts professional networks and the established professional relationships with children and parents. Priority re-housing systems need to be well understood by frontline staff and their managers. Such moves can allow parents who are reluctant to engage the chance to avoid concerns as workers can get caught up in practicalities and a history of parental avoidance can be lost as workers change. Housing provision has become complex in the mixed economy of local authority, private, independent, and voluntary sector providers. There must be good cooperation in child safeguarding at a strategic level as well as at a practice level across this complex and often confusing sector. The Review has shown that although risk from domestic abuse was recognised, responses were not as well co-ordinated as they should have been, with some workers expressing lack of confidence in this area. At the time there was no clear multi-agency leadership of domestic abuse responses at a strategic level. Ms A avoided contacts with professionals and made agreements that she did not keep. This was not sufficiently challenged. Ms A was a young woman with a troubled childhood and adolescence, with a known history of trauma leading to alcohol and drug misuse. She was often asked about drug or alcohol use and her denials were accepted. This area of practice may require greater support to practitioners about challenge and exploration of drug use. Ms A avoided ante-natal and post-natal support services. For Mark she was a young, vulnerable, and new mother and later had difficulty parenting him. This raises a question about how best to ensure parenting education and support to young and, or first-time parents. The recommendations and their rationale are explained in Section 6, and they are collated together in Section 7. A separate action plan for delivering them will be created. 4 2 Reason for review and methodology 2.1 Lloyd died from significant non-accidental injuries in late August 2019, aged sixteen months. He was also assessed to have significant injuries caused over several episodes before the fatal injury. 2.2 The Wandsworth Safeguarding Children Partnership (WSCP) commissioned a Rapid Review1 and agreed that a Child Safeguarding Practice Review (CSPR) should be undertaken. The CSPR was to learn from local agency services provided to Lloyd and his older half-brother Mark (aged four years) as it was assessed that Mark had also experienced significant harm over time. 2.3 The purpose of a CSPR is to learn through a systems analysis of the family dynamics and of the single and multi-agency work undertaken to assess and support the child and family. The review should make recommendations where changes may be required in the way that local services for children and families are provided. The process seeks to involve family members and practitioners as much as possible, to learn from their perspective. 2.4 It was agreed to concentrate on the two years from the pregnancy with Lloyd but also to analyse and learn more generally from agency involvement during the period from the previous pregnancy with Mark. 2.5 Ms A, Mark’s Father, Mr B, and Mr D, Ms A’s Partner, were advised of the review and invited to contribute. They did not respond. Lloyd’s father had had no contact with him from birth and no services had been in touch with him. 2.6 The criminal investigation into Lloyd’s death was impacted by a long period awaiting the results of the post-mortem and biopsies; this is a known systemic issue for such investigations which impacts on learning reviews as well as criminal justice processes. The Chair of this Review Panel has written to the National Child Safeguarding Review Panel to highlight this issue. 2.7 During the main period of the review, the Covid-19 pandemic prevented face to face meetings. An online reflective focus workshop was held with practitioners and their immediate managers who had worked directly with the family to learn from them. 3 Family Background Information 3.1 At the time of Lloyd’s death, at the end of August 2019, the family composition was: Lloyd Subject Aged 16 months Died August 2019 Mixed White British & Black British heritage Mark Subject Aged 4 years Mixed White British & Black British/Caribbean heritage Ms A Mother Aged 29 White British Mr B Father to Mark Aged 42 Black British – Caribbean heritage Mr C Father to Lloyd Not known. Mr C had no contact with any local services Not known but described as Black Mr D Mother’s partner in 2019 Aged 29 White British Ms A also had occasional contacts with her mother and a brother. 1 A Rapid Review is required by statutory guidance Working Together to Safeguard Children 2018. One of the outcomes may be a Child Safeguarding Practice Review as set out in Chapter 4. https://www.gov.uk/government/publications/working-together-to-safeguard-children--2 5 Background 3.2 Ms A (aged 5) and her siblings first came to the attention of Children’s Services from 1995. Concerns, over time, included an allegation of indecent assault to Ms A, domestic abuse, alcohol abuse, poor supervision, poor school attendance, neglect, and physical abuse. 3.3 Ms A (aged 14) and her siblings were made subject of Child Protection Plans2 for neglect, following concerns about physical chastisement. There were also later concerns about the children using alcohol and cannabis. 3.4 Ms A’s father subsequently left the family home, and sometime later died, when Ms A was 23. She found the circumstances of his death particularly traumatic and said that it had led to her abusing alcohol. 4 Summary account of key events and agencies’ involvement with Lloyd’s and Mark’s family 2014 – August 2019 4.1 Ms A and her family were in receipt of public welfare services for several years because of domestic abuse, universal services provision around the births of Lloyd and Mark, concerns about parenting, housing, and later education, and about the children’s development. The pathways of support from universal to child protection services and step down to Early Help were affected adversely by the movement of the family across different boroughs. July 2014 to September 2015 - Pregnancy and birth of Mark (February 2015) 4.2 Ms A was rehoused several times in different boroughs for her own safety before returning to Wandsworth. There was a missed opportunity to consider a child protection approach before Mark’s birth. There was no liaison between two boroughs, each undertaking its own separate Child and Family Assessment. Ms A did not cooperate with assessments or subsequently with offers of Early Help.3 Domestic abuse services were hampered by Ms A not responding and information not passing, as expected, from MARAC4 to MARAC and finally back to Wandsworth. There was a pattern of non-engagement by Ms A. 4.3 Both Midwifery and Health Visiting Services observed the interaction between Ms A and baby Mark as good. Without the fuller prior history, and with reassurance from Ms A that she was not in contact with Mr B and that she was supported by friends and a Children’s Centre the decision was made to offer her the Universal Plus Health Visiting Pathway5. 2 Child Protection Plans are multi-agency agreements setting out the actions that families and local agencies will take to safeguard children who have been assessed to be at risk of significant harm. The decisions are made at a Child Protection Conference with key agencies and the parents present. The plans are reviewed regularly until the risk is minimised or until different actions are required to protect children. More information can be seen in the statutory guidance for England: Working Together to Safeguard Children, 2018; Working together to safeguard children - GOV.UK (www.gov.uk); pages 49 – 54 3 3 See the local Threshold for services to children. Thresholds for intervention - Wandsworth Safeguarding Children Partnership (wscp.org.uk) 4 MARAC – Multi-Agency Risk Assessment Conference is a local multi-agency meeting with a primary focus on the safety of adult victims who are at high-risk of domestic abuse. - 12. Risk Management of Known Offenders (londoncp.co.uk) 5 Universal Plus Pathway Pathways - NHS Healthy Child Programme A Universal Plus Pathway can be agreed where a Health Visitor has assessed that a child or family needs additional support because of an identified vulnerability 6 4.4 In September, a Team Around the Child Meeting decided that Mark was making good progress. Children’s Social Care withdrew, and the Health Visitor took over the Lead Professional role. Mark and Ms A were thought to be attending a Children’s Centre, but that was not so. There were concerns about the number of missed contacts with professionals and whether Ms A was using excess alcohol. These were not followed up. 4.5 From September 2015 to January 2016 no service had contact with Ms A or Mark. 2016 (Mark 11 months to 1 years 10 months) 4.6 In March, Mark was assessed in clinic to be developing well (aged thirteen months). Ms A reported attending the Children’s Centre; this was not so. It was agreed with Social Care that there were no grounds to step up to child in need services. Ms A agreed to attend a Parenting Course and to take Mark to Play Sessions, plus other support but she did not follow through on these. 4.7 In July, Police were called twice to the home. There was a fight between adults, involving drugs and alcohol, Mark was present, but Ms A was not. Ms A refused to assist the Police enquiry. Later Police attended a third-party referral that Ms A’s ‘partner’ was refusing to leave but Ms A said that the allegation was untrue. A new Child and Family Assessment resulted in a Team Around the Child meeting to devise a plan. Ms A did not attend, and it was thought that there were no grounds for child protection measures. Ms A subsequently avoided meetings with the Health Visitor and / or Social Worker, despite agreements to do so. In October she finally met the new social worker and signed a written agreement to keep unsuitable visitors from the home. Children’s social care ceased its involvement in November. Mark was 21 months old. 2017 to May 2018 – birth of Lloyd (April 2018) 4.8 No agency seems to have seen Mark from the summer/autumn of 2016 until May 2017. This review has found no evidence that he attended any Early Years Services, a GP, or a hospital. The Health Visitor tried unsuccessfully to visit in January, March, and April. Mark was not brought to his Two-Year Development Check in March 2017. 4.9 By persistence and unannounced visiting the Health Visitor was able to get Ms A to respond in May 2017. Ms A said that Mark was immunised and that she was seeking a nursery placement for him; there is no evidence of that. Mark’s development was in line with his age (27 months). Good interaction was noted between Ms A and Mark. Ms A described his tantrums and said that she knew that she was not consistent in managing them. The Health Visitor gave advice. There was no evidence for concern of neglect or harm for Mark that could be noted in that contact. 4.10 In July, Police were called to a domestic disturbance involving Mr B. They completed a risk assessment, but had no concerns about Mark and gave Ms A advice. Ms A was referred to Social Care and to the Community Safety Independent Domestic Violence Advisor Service but did not respond; the case was not therefore progressed to an assessment. 4.11 No agency had contact with Mark (from aged 2 years 5 months to 2 years 10 months) or Ms A from July until December 2017 when she made a late antenatal booking (at 22 weeks). 7 4.12 The Midwife noted the history of concern. Ms A declared cannabis use and tested positive for this. When asked in routine enquiry about risk of domestic abuse Ms A said that it was not an issue for her. Ms A missed several ante-natal appointments and declined to be seen at home by the Community Midwife. It was noted that Social Care had closed the case in 2017. This appeared to lead to an assumption that there were no grounds for concern whereas the closure had been because of non-engagement. No consideration was given to informing the Health Visitor – the Lead Professional. 4.13 Lloyd was born in April 2018. The Community Midwife followed up with several visits in May and initially had no concerns. However, she later referred the family to Children’s Social Care as Lloyd was in a ‘chaotic household’ and at risk of neglect. It is not clear from records if the Midwifery Services saw Mark, during visits. May 2018 to mid-October 2018 (Mark 3 years 3 months to 3 years 8 months; Lloyd 1 month to 6 months) 4.14 The Health Visitor decided that the Universal Plus Health Visiting Service was the appropriate level of intervention given Ms A’s vulnerability. Mark was not seen and was said to be attending nursery 15 hours per week; but no evidence of that has been found. Children’s Social Care started a new Child and Family Assessment. Both boys were seen and there were no concerns about them. The Social Worker and Health Visitor visited jointly in early June. Mark was seen and said to be in nursery, which was accepted. The Health Visitor assessed Lloyd at the six-week check and had no concerns. Good mother-baby interaction was noted. A new Health Visitor was introduced. 4.15 At the end of June, Police were called to the home to check on a baby’s welfare. The Police saw a woman and child but did not check that this was Ms A and Lloyd and there is no information that Mark was seen. The woman said that the call was malicious and denied any domestic disputes. The call out was not shared with Children’s Social Care. A DASH risk assessment was not done. This was a missed opportunity to alert children’s agencies. 4.16 The Child and Family Assessment concluded that there was no role for Children’s Social Care as Ms A “was co-operating with the Health Visitor”. There was no evidence of this. 4.17 The only service to have contact with the family after the end of July seems to have been Mark’s new Nursery, which he started in late September. October to December 2018 (Mark 3 years 8 months to 3 years 10 months; Lloyd 6 months to 8 months) 4.18 In October Mark’s nursery referred the family to Children’s Social Care concerned about Ms A’s parenting abilities and engagement and worried about neglect. Ms A was not being truthful or co-operating with the nursery’s attempts to resolve issues. Mark was hungry and dirty, and he smelled strongly of cigarette smoke. There were concerns about Ms A’s and Mr B’s behaviour and on the few occasions they were seen at the nursery they appeared disorientated. The nursery queried cannabis use. A further Child and Family Assessment was agreed. Ms A stopped bringing Mark to the nursery. 8 4.19 A Social Worker visited at the end of October, unaware of the allegation of drug dealing. The home was in good condition. The Social Worker followed up Mr B’s renewed involvement. Mr B’s Probation Officer was unaware of Mr B’s contact with Ms A. The Health Visitor was advised of the concerns. It became apparent that despite advice from professionals Mr B was very much part of the children’s lives. 4.20 In early December Lloyd and Mark were made subjects of Child Protection Plans for Emotional Abuse. Mr B posed a risk to the children and Ms A was unlikely to co-operate with services. There were concerns about Mark’s delayed speech development and he was to be referred for a speech and language assessment. In the Child Protection Conference Ms, A said that Mr B was abusive and controlling and that she was scared of him. As a result, the family was immediately moved to temporary accommodation and then to a refuge out of the borough. 4.21 Because of responding to the immediate safety issues the Core Group did not further refine the Child Protection Plan to clarify what changes were required to keep the children safe and meet their needs. The case should have been referred to MARAC but was not. Housing should have been a key agency to form part of the Protection Plan but was not included. The move of borough also required a change of Health Visitor. January 2019 to August 2019 (Mark 3 years 11 months to 4 years 6 months; Lloyd 8 months to 1 year 4 months) 4.22 The refuge offered counselling to Ms A, including work on Power and Control6 in abusive relationships, and about future housing. She was thought to have shown insight and to have benefited from this. There were no concerns about her care of the children. 4.23 An investigation into an unrelated, serious assault on Mr B suggested that he may have been dealing in drugs from the family address from which Ms A and the children had been moved. 4.24 The new Core Group met at the beginning of February at the out of borough Children’s Centre. The initial outline Child Protection Plan was not further refined, as it should have been. 4.25 In late February there was a further Core Group meeting. The Health Visitor and Housing Officer did not attend. The children were well, and Ms A was “cooperating”. The referral to Speech and Language Therapy had not been progressed. 4.26 The first Review Child Protection Conference was held at the beginning of March, in Wandsworth. The meeting was technically inquorate but went ahead. Housing, the Police, the Children’s Centre and the nursery were not in attendance. Ms A and the boys were still in the out of borough refuge. Ms A was said to be increasing her understanding of risks from domestic abuse. Mark had settled into the local nursery and “Lloyd was attending a Children’s Centre” with his mother. (In fact, he only attended on four occasions.) Mark had speech delay but had not been referred. The Health Visitor and Social Worker recommended that the children should be stepped down to children in need. The refuge worker abstained; said to be the refuge’s policy. The Independent Chair of the conference did not agree and decided that the children would continue on Child Protection Plans for Emotional Abuse. No professional dissented to that decision. 6 Power and Control Wheel http://www.stopdomesticviolence.org.uk/violence-wheel/ 9 4.27 At the end of March, Ms A, Mark, and Lloyd were moved to temporary accommodation in Croydon and then back to Wandsworth in late April; again, disrupting the Core Group of professionals. The Social Worker visited the children at home. They were said to be well, but the disruption caused by moves over the last few months was noted. Ms A reported that she was not taking drugs or smoking and that she was not in a relationship. 4.28 In the second week of June the new Core Group was held at the family home, to support Ms A’s attendance. The children were said to be attending a children’s centre; however, the centre was not invited to the meeting. The children’s immunisations were not up to date. There had been no progression of a referral for Mark’s speech delay. A support worker was looking for a school place for Mark from September; (he was now four years and four months old). She reported that she was not using cannabis or alcohol. Information from after Lloyd’s death shows that Ms A had been using drugs during this period. 4.29 Ms A did not attend the children’s centre until the end of the first week of July, despite agreements. The Health Visitor liaised with the children’s centre manager and stressed the need for a place for Mark and his need for Speech and Language therapy. There was also a worry that Ms A said that she was not able to control Mark’s behaviour and that he may need to be referred to the Child and Adolescent Mental Health Service (CAMHS) for under 5s. 4.30 Lloyd’s development check was completed in July (age 1 year and three months). His development and abilities were age appropriate. Ms A’s relationship with Lloyd was noted to be responsive. There were continued concerns about Mark’s speech and Ms A said that she often left him to his own devices and on-screen activity to avoid tantrums. 4.31 A Core Group was held, again in the family home. The new children’s centre had not been invited. Mark had not been taken for a planned Speech and Language therapy appointment. Ms A had not yet consented to his referral to CAMHS. Mark was described as lashing out at Lloyd. She agreed to take the boys to play group sessions and Mark to CAMHS. Ms A said that she had no contact with Mr B and that she was not using drugs. A view was formed that there was progress in the Child Protection Plan and that the children were doing well. 4.32 The Review Child Protection Conference was held in late July. Ms A was reported to have made some progress, but there were still actions from the original outline Child Protection Plan which had not been progressed. The Health Visitor and children’s centre representatives who were both new to the case recommended that the children should remain on a Child Protection Plan. However, it was agreed that the case could be stepped down to Child in Need with a “robust Child in Need Plan”. This was to include referrals to CAMHS and to Speech and Language therapy for Mark. 4.33 Subsequently, Ms A prevented visits from the Social Worker, one because they were “on holiday”. When asked by phone if she was in a new relationship, she said “no”. Information gained after Lloyd’s death shows that Ms A did not go on holiday with the children and that she was in the new relationship with Mr D. 4.34 At the end of August, Lloyd (aged one year and four months) was brought to hospital, in cardiac arrest. He had significant bruising to his head, eyes, face, and body. These were assessed to have been non-accidental. Mr D was present in the home and was said to have found Lloyd in a state of collapse. 10 4.35 No agencies were aware of Ms A’s relationship with Mr D or that he was visiting or probably living in the home. Information about Mr D, gained after Lloyd’s death, showed that he had history of drug misuse and violence. He had separated from his partner at the beginning of August. 4.36 Ms A and Mr D were both arrested and the criminal investigation into Lloyd’s murder began. 4.37 Lloyd died from blunt force trauma to the head. He had sustained multiple impacts to his body, head face and abdomen, over the preceding weeks, throughout August. 4.38 Mark was taken into protection. Child protection medicals and skeletal surveys showed no signs of physical abuse to him. Evidence showed that he had been exposed to cannabis and cocaine use, probably passively. 5 Practitioners’ involvement in the review 5.1 An online Reflective Workshop7 was held for practitioners and first line managers from Children’s Social Care, Health Visiting, Children’s Centres, Nursery, the Refuge, and the Police. The practitioners in the event were involved mainly between September 2018 to September 2019. Some of them had only limited or one-off contact with the family, others more frequent. The Police representative had not worked with the family. 5.2 The practitioners endorsed the learning identified by the Panel. It was suggested by them that that families like Ms A’s and responses like these were not uncommon in wider practice. 5.3 There was a view that the fundamental question about the cause of Lloyd’s death was still unanswered. However, that is not the task of a Child Safeguarding Practice Review but that of a criminal investigation. 5.4 The Practitioners’ analysis and their response to the Panel’s suggested learning are included in Section 6 of this report. Several of the practitioners noted that their reflections were now influenced by hindsight. This is unavoidable. We can learn from hindsight but must try to understand what dynamics or systems prevented the information or conclusions from being seen at the time. 6 Analysis and Key Learning 6.1 The Review’s purpose is to use the case as an example of how well the local child welfare systems were or are working singly and together, and whether there are any actions which should be taken to improve services and their delivery to reduce possible harm to other children. 6.2 This review highlights some learning for local agencies, some of which are sadly familiar, and some are not. It is easier to see these with hindsight and it would be unfair to judge practitioners and services by what was not apparent at the time, or which could not have reasonably been obtained. There were, however, missed opportunities to identify risks to Lloyd and Mark. 6.3 The analysis seeks to understand the assessments made and the actions taken in the context of the agencies within which practitioners were working and the dynamics of multi-agency systems. 11 6.4 It should be noted that the review covers a longer period than would normally be analysed because of the significance for these children; analysis of practice five years earlier may not reflect the quality of current service delivery. It does inform how later decisions were made in this case. Key Learning Early learning from the Rapid Review 6.5 The multi-agency Rapid Review held shortly after Lloyd’s death noted the following areas for consideration as possible learning. No specific actions in relation to these were agreed at that time as the practice of Rapid Reviews under new guidance was being developed. Now there would be a separate action plan to address any identification of need for changes from a Rapid Review.8 Domestic abuse practice and the vulnerability of babies and young children with regard to domestic abuse. Working with disguised compliance. Children’s emotional and developmental indications of abuse and neglect. They are more fully considered in the analysis below. Learning from the Child Safeguarding Practice Review The effectiveness of local multi-agency safeguarding children thresholds and pathways 6.6 Assessments and responses to levels of family need are decided against locally agreed “threshold criteria”.9 Ms A, Mark and Lloyd were in receipt of universal services at level 2 of the Wandsworth Threshold Document until the child protection plans in December 2018 (level 3). Several assessments were completed by individual agencies, such as Midwifery or Health Visiting; or were multi-agency Child and Family Assessments led by Social Care. 6.7 When the children were seen with their mother Health Visitors and Social Workers noted apparent positive relationships. Ms A appeared well presented and responded well. There appeared to be no evidence to make the boys subject of child in need plans until they were stepped down from child protection plans in July 2019. 7 Practitioners were asked to reflect on their experience of the work with the family at the time (rather than through hindsight). Some were seeing a more complete picture than was available to them at the time. The Review Panel’s draft learning was shared to gain practitioners’ perspective of work with families like this one and of working in the wider multi-disciplinary safeguarding system. 8 It was noted that the circumstances of Lloyd’s death were particularly traumatic for the staff involved in the case and in the Rapid Review and that this impacted on the quality of the Rapid Review, at the time. 9 The Wandsworth Safeguarding Children Partnership Threshold Document can be accessed at: Thresholds for intervention - Wandsworth Safeguarding Children Partnership (wscp.org.uk) 12 6.8 A systemic question arises for local Commissioners and Providers of Health Visiting and Midwifery Services about the local application of the National Healthy Child Programme Pathways10. It seems appropriate that after the births of both children and given that there was no clear evidence of current risk, that the Universal Plus Health Visiting Service was agreed, in recognition that Ms A needed additional support. Health Visitors made good attempts to meet with Ms A and the boys, including pro-active opportune unannounced visits when there was repeatedly no response from her to the contacts by Health Visitors. It is not clear to this review, however, how the need for that that level of service was then monitored and what the expected visiting or contact frequency is now, or how a decision is made to end a Universal Health Visiting Plus level of service. 6.9 A contextual systems issue to be noted in this case and more widely is that the contract for the provision of Health Visiting services changed from one Provider to another in 2018, during the period under review. As well as the change of provider there was a change in the commissioning specification for the overall Health Visiting services to be delivered to families like this. 6.10 This review has led us to ask: How does Health Visiting Management keep an overview of those children who require an enhanced level of Health Visiting, such as Universal Partnership Plus? Mark became lost to services on several occasions. This became more of concern as he was rarely receiving any other services such as pre-school, children’s centre or nursery which could have picked up his changes in circumstances and emerging development delay – especially speech delay. This must be seen in the context of available Health Visiting resources and high caseloads, which are set by the commissioning specifications. This review was advised that the Health Trust has since adopted the London Continuum of Need as a guide to monitoring a family’s ongoing need for services. Recommendation 1 The Wandsworth Public Health Services, as Commissioners of local Health Visiting Services, with the Providers, and with consultation from the Clinical Commissioning Group, should commission an audit of a random sample of cases, across teams, at "targeted" level of service (Universal Plus) which, are not multi-agency child in need or child protection cases, to review how such cases are supported and monitored over time. The purpose of this audit of frontline health visiting practice is to provide assurance that when families have been assessed to require a higher level of Health Visiting Service that cases continue to be monitored by the agreed method and frequency to ascertain if any change (particularly increase) in provision is required. Wandsworth Public Health Services should report the outcome of this review to the Wandsworth Safeguarding Children Partnership. 10 Pathways - NHS Healthy Child Programme www.healthychildprogramme.com/pathways/links-to-national-pathways 13 The Child’s Lived Experience Seeing children and holding them in mind 6.11 A challenge in this case is that Mark, and then Lloyd, were not seen for significant periods until they became subjects of Child Protection Plans. When Mark was seen there were concerns about his speech and language development, appearance, head banging and tantrums. These are signs that he was possibly experiencing neglect or emotional abuse. This was seen in the Child and Family Assessment prior to the children being made subject to child protection plans but later took second place to concerns about domestic abuse to Ms A and its impact on her and on the boys. From the time that the children were made subject of Child Protection Plans there were several changes in professional workers and the work appears to have concentrated more on preventing domestic abuse and re-housing rather than on the children’s needs. 6.12 Regarding universal services there are questions for Midwifery, and possibly the Police, about when observing or considering a child how they also consider the welfare and needs of another child in the same household. It is not clear if midwives saw Mark as he does not appear in their records, yet he would have been evidence of Ms A’s parenting ability. This may be a recording issue. 6.13 Given what was known of Ms A avoiding services, a question in hindsight is: Was Mark being kept hidden from view and, if so, why? Local children’s welfare systems need to promote and ensure curiosity about children under five who are not in services and who are not being seen when parents or other children are in contact. Recommendation 2 Services which assess children or parents, and their welfare or safety must take into account all the children who are usually resident in the household, or children in frequent contact, as their welfare may be an indicator of well-being or need for other household / family members. Local children’s agencies, Midwifery Services and Adult Services should review their practice guidance, information gathering and sharing arrangements and supervisory arrangements to ensure that when one child or parent is being seen and considered that there is curiosity about and consideration of the welfare of other household members or family members in regular contact, especially children under 5. 14 6.14 As noted in the timeline, a challenge was that on occasions when Ms A and one or both boys were seen the children appeared to be physically well cared for and to be “developing well” when they were infants, especially in pre-arranged visits, but not later for Mark. The observed parent-child interaction was seen to be good, in the here and now of single contacts, all that is often available for a brief one-off assessment. It is easier for parents to meet a professional’s expectations in short visits or contacts. It was when the nursery was able to gain a clearer picture of Mark over a few days from late October 2018 that his needs and potential neglect began to be recognised more fully. This led to the referral under the local threshold for an assessment, first as a possible child in need and then for a child protection assessment. 6.15 There is no clear picture in agencies’ records over time of Mark’s and Lloyd’s daily lived experience; nor are there records about how the children’s appearance and behaviour were reflected on and considered as possible signs of neglect or emotional abuse. 6.16 Mark’s needs, and potential neglect, were well-recognised in the Child and Family Assessment which was provided for the Initial Child Protection Conference of December 2018, but they were not translated fully into the Child Protection Plan and were not later acted on. 6.17 It is noted that Mark had tantrums and headbanging, but it is not clear which professionals saw this and how this was later taken into account. 6.18 There were good attempts by the Social Worker during the period of the Child Protection Plan to do some direct work with Mark, even though he had speech problems; and there was consideration about his identity and possible need for safe contact with his father, Mr B. 6.19 It can often be the case that the welfare needs of very young children (under 5) can be overlooked if they are not engaged in pre-school activity where they can be observed. When Mark was seen in nursery the staff quickly became concerned about his welfare and potential neglect and referred him to Social Care appropriately. Recommendation 3 The Wandsworth Safeguarding Children Partnership Safeguarding and Continuous Learning Subcommittee should commission agency and multi-agency practice audits to ascertain how services are assessing and recording the daily lived experience of children, including those in a household who are not the index child. These audits should consider how children’s behaviour and appearance are recorded and taken into account when assessing their welfare and safeguarding needs, in addition to what children say, for those able to speak. From this audit a decision can, be made whether additional practice guidance is needed. This review should include children who are identified as vulnerable but who are not seen as often as they should be. 15 Use of the Local Threshold Arrangements at Tier 3 – Referrals and Multi Agency Assessments 6.20 At Tier 3 an assessment should be led by a social worker. Between March 2016 and July 2018 Children’s Social Care received a total of four referrals leading to three separate assessments and one child protection assessment. Three were in relation to alleged domestic abuse incidents and identified several similar risks and concerns, and in turn concluded that there was no role for Social Care. Ms A appeared to have an ability to both evade professionals and yet provide them with enough reassurance that all was well. 6.21 Supervisors and managers have an important role in stepping back and checking that all the previous history and contacts have been considered to quality assure new assessments. This was not done for the first three assessments and so the overall picture and possible pattern was missed. It was not until the referral in October 2018 that all the information was brought together to form a complete and more worrying picture. 6.22 In relation to Lloyd and Mark, the assessments fell short of expected standards. Some of the reasons this may have happened were seen to include: A variety of workers and managers were involved so there was little or no consistency in dealing with Ms A. This may have contributed to each having an individual view of the concerns in isolation and in the present rather than seeing the whole picture and adding sufficient weight to the history. There appeared to be a lack of professional curiosity about the risk factor of Mr B being back in the family’s life. The evidence that the couple were not in a relationship was never tested and this applied on several occasions; referrals suggest that he was part of the family’s life. The referrals and contacts came in before the MASH11 in Wandsworth was operating in the way it is currently. Now the MASH triages all referrals and undertakes mapping to consider all the information available. Previously this history and information gathering would have been the responsibility of individual workers. Although this would have been good practice, it is acknowledged that this was not custom and practice in Wandsworth during this period. Much of the earlier work with this family was during the time that Wandsworth Children’s Social Care was operating at less than an optimal level. It received an “Inadequate” judgement from OFSTED in February 2016. Much has improved in the service since that time and progress in relation to the quality of the “front door” was noted in the subsequent inspection in May 2018. Meetings with Ms A seem to have allayed professionals worries and she was able to demonstrate that her care of her children was good enough. Much of the content of the assessments relied on information provided by her and this was not challenged or checked with information held by other agencies. There is no evidence that the poor practice associated with this period was ever raised as a practice issue either by an audit process or other Quality Assurance activity (e.g., by the Child Protection Co-ordinator). An audit conducted in February 2019 noted the previous involvement but does not comment on the quality of the practice in this earlier period. 11 MASH – Multi-Agency Safeguarding Hub A service which receives and triages new requests for assessments of children and families, using information held by several agencies and involving officers form social care police and health. 16 6.23 It is difficult to explain the lack of curiosity about Ms A’s own childhood and self-reported abusive experiences and how they were impacting on her ability to prioritise her children’s needs. This information was available as it is summarised succinctly and clearly in the original pre-birth assessment conducted in 2014/15. Consequently, the assessments did not lead to provision of services, no formal plans were made or implemented to assist Ms A or the children, and they were stepped down to Early Help and Universal Services. Child Protection Assessment and Child Protection Conference October to December 2018 6.24 In autumn 2018 Mark’s new nursery was appropriately concerned about several factors relating to his care. The new (to the case) Social Worker was concerned about the immediate and longer-term welfare of the children. The assessment was a thorough piece of work which analysed the family history, the previous involvement by local agencies and which highlighted the potential risks for the children. It took account of all the information held by Children’s Social Care and presented a clear, cogent evaluation of the children’s experiences. This led to the Initial Child Protection Conference in December 2018. This was good work at the expected level. 6.25 The assessment and the other information presented at the Initial Child Protection Conference was the first time the concerns over the previous four years were brought together coherently and a formal plan was made to seek to reduce the risks to the children. It was also the first time that Ms A had been properly challenged in terms of her children’s safety and confronted with the reality of her circumstances. The decision to make the children subject to Child Protection Plans was unanimous and appropriate. 6.26 The Conference was split in its management so that both Ms A and Mr B (father of Mark) could attend, which was good practice. After Mr B left the meeting Ms A alleged that he was abusive and controlling but that she could not end the relationship as she feared him. 6.27 The decision to take immediate protective action for her and the children and the social work practice over this period was excellent. It was balanced between showing compassion and being mindful of the risks. It included conversations with Wandle Housing to ensure that the family were not temporarily moved to an unsafe area, close to Mr B. Effectiveness of the Child Protection Plan and Core Groups (December 2018 – July 2019) 6.28 In line with procedure, common in many Children’s Social Care systems, the family’s case was transferred from an assessment service to a longer-term service, the Child in Need Service. This led to a further change of Social Worker to lead the multi-agency Child Protection Plan. This is a systemic issue in that parents get to know and possibly start to form a working (therapeutic) relationship with a social worker through an assessment but then must change workers because the system requires this when the case must move on to another team for longer term work. This change of worker can also lead to a parent being able to deny conversations and resist the previous worker’s perceptions. 17 6.29 A Child Protection Conference in agreeing that a child should be the subject of a Child Protection Plan sets the Outline Plan, led by the experienced, senior and independent chairperson. The key members of the Core Group to work with the parents on achieving the Plan are also agreed. The procedural expectation is that this Outline Plan will then be refined further by the Social Worker and confirmed by the Core Group. This latter step rarely seems to happen, and the Outline Plan remains the Plan until it is reviewed at the next Child Protection Conference. It is a difficult task for a new to the case Social Worker, assuming the Keyworker responsibility, to lead the refining of the Plan when they do not yet know the case. An additional systems complication in this case was that the Social Worker and Manager who were to take over responsibility for the case were not present in this important Child Protection Conference. 6.30 There were two Core Group meetings before the Review Child Protection Conference (RCPC) in March 2019. The first one just before Christmas 2018 did not further specify the Child Protection Plan but focussed on the immediate crisis of the moves of accommodation to a refuge for safety from domestic abuse and related practical matters. This was understandable; however, it would have been beneficial also to ensure that Ms A understood what changes she needed to make in relation to her care of the children, especially for Mark. There should also have been further exploration about her possible use of alcohol and drugs. These were well-noted in the assessment and in the conference but not in the specific tasks forming the outline Child Protection Plan. The circumstances made it possible for these concerns to be deflected on to Mr B’s abusive behaviour rather than, in parallel, possible neglect of the children – Mark in particular, by Ms A. The Core Group was to include the nursery, which Mark had ceased attending when Ms A withdrew him and did not include Housing which was to become a key agency, given the need to move Ms A for her and the children’s safety. 6.31 The second Core Group Meeting was held six weeks later and had a completely new network, the new Social Worker, and a new group of professionals from outside the borough. No-one who had known Ms A previously and who was fully aware of the concerns was present. There was no Housing representative who would have a key role in supporting a final move back to permanent and safe housing after the period in the refuge. It is not clear in the record why they were not present or if they had been invited. This raises a common practice and systemic question about how well Core Group Meetings are supported administratively, and whether this falls on the shoulders of busy social workers. Also, the need to support workers to think reflectively when cases transfer across networks or borough boundaries. A key question is: Who holds the history – including intuitively? 18 6.32 The Core Group did not discuss the progress of the Child Protection Plan and whether Ms A understood its purpose. Because of the crisis of the domestic abuse disclosure the outline Child Protection Plan made at the Initial Child Protection Conference was not further developed by the new Core Group. It was strong in terms of trying to achieve some stability for the family and reducing the risk of domestic abuse but actions to meet the original Social Worker’s assessment of neglect were missing. Useful additions would have included some further assessment of Ms A’s own childhood, including her self-reported negative experiences. It would have been useful to agree to arrange a Family Group Conference to assess the strength of support being provided by her family who were described by Ms A as “supportive” and “helpful”, but this had not been tested. Mark’s behaviour was already a cause for concern but there was nothing specific in the Plan to support his development and help him manage his emotions or speech. Finally, given the seriousness of the domestic abuse the Child Protection Plan should have agreed to refer Ms A to the Multi Agency Risk Assessment Conference (MARAC). There is a record on file of this being done but there is no outcome from the referral recorded and the Wandsworth MARAC has no record of having received the referral. 6.33 The Keyworker is expected to chair and provide the notes of Core Group meetings as well as to work within the meeting to manage parents’ reactions and feelings. The first Core Group meeting should refine/confirm the Child Protection Plan and subsequent Core Group meetings should monitor the progress of the agreed actions against the Plan and amend it, as needed, in the light of changes in circumstances. 6.34 Recent audits had shown that good Child and Family Assessments could lead to good Child Protection Plans, but although practice was improving there was still, in late 2020, variability in practice. Child Protection Coordinators were assisting with a lot of the detailed case planning in the conferences. 6.35 Work was done in the Social Care Department (from January 2021) to revise the process and to develop more outcome-focussed Child Protection Plans, including introducing a new contemporaneous template for summarising the conference and plan which would aid specificity of what was to be achieved, by whom, rather than simply stating tasks. These new style plans are to be monitored in case supervision by the Social Care Manager to ensure that the plan is moving forward. 6.36 The Child Protection Coordinators carry out mid-way reviews with the Social Worker and Team Manager to monitor and advise on the plan’s impact and if outcomes are being achieved between conferences. 19 6.37 In addition, the Core Group will now be expected to meet four weeks prior to each Review Child Protection Conference. The expectation is that all relevant agencies and parents will attend and provide an update on the progress of the plan. Professionals are expected to provide a written report in support of the evidence of the family’s progress. The allocated Social Worker will chair this meeting and review all the information provided. In complex or challenging cases, it is expected that the Team Manager may chair this meeting. The Core Group will then consider the recommendation of either continuing the Child Protection Plan or ending it at the upcoming Review Child Protection Conference. This provides time for parents to review the information, understand the recommendations and prepare better for the upcoming review conference. The Social Worker will be able to include the most up-to-date information in their report and share it prior to the Review Conference with everyone involved. This will help to make conferences concise as there will be less information previously unknown to the Core Group; and parents and young people will be clearer about the decision making. This revised approach was being introduced from January 2021 by the Safeguarding Standards Service. This development will sit alongside introducing motivational interviewing training as part of the introduction of Family Safeguarding by Wandsworth CSC from October 2021. Based on learning from this review it was agreed that as part of this revised Child Protection Plan process, the Core Group can and should be reconvened early if there is any significant change in level of concern, family dynamics or whenever a family moves home to ensure that the changed level of need and risks of harm are fully understood by the (new) core group. Practice Guidance is being produced to support practitioners develop best practice in Core Groups. 6.38 The Safeguarding and Continuous Learning Subcommittee of the Wandsworth Safeguarding Children Partnership Safeguarding will be leading Multi-Agency Audits of this revised approach and the contribution that partners make to Core Groups. Internally CSC Quality Assurance will be auditing Core Group quality as part of the yearly audit programme. It was also noted that more work was needed to support social workers with the knowledge and skills to chair multi-disciplinary meetings such as Core Groups. This is planned for 2021. Recommendation 4 Formulation of and Management of Child Protection Plans and the Management of Core Groups Given the centrality of Child Protection Plans and Core Groups to multi-agency safeguarding systems the Wandsworth Safeguarding Children Partnership is recommended to monitor the progress of the local initiatives to focus and strengthen Child Protection Plans and Core Groups by requiring feedback from the Safeguarding and Continuous Learning Subcommittee on the impact of Child Protection Plans and Core groups; initially at six months and then at least annually. Such quality assurance data should also include information about agency attendance at Core Group meetings. 20 6.39 The Child Protection System has been developed so that subsequent Child Protection Conferences scrutinise the multi-agency practice and the levels of risk and agree levels of priority and thereby access to resources. Conferences also have the benefit of an independent and experienced practitioner as chair, whose task is to reflect on the children’s needs, including safeguarding and whether progress is good enough. 6.40 The first Review Child Protection Conference in February 2019 was held in Wandsworth which retained the case responsibility (as per protocol). Attendance was poor (due to the family’s temporary move to a new borough and the necessary changes in personnel). It is not clear if thought was given to convening the Conference in the new borough where the refuge was based to facilitate attendance by the new Core Group members. The first Review Conference was inquorate, and the Chair made the decision to go ahead so that the Plan could be reviewed. This was appropriate. Only the new Social Worker and the new Health Visitor were able to express a view about progress, risk, and whether the plans should continue. It is understood to be a policy of refuges that their staff do not give views on this. No other agencies were represented, including a nursery (for Mark) and the children’s centre that Ms A and Lloyd were said to be attending, on occasion. 6.41 The social work assessment presented to the February 2019 Review Child Protection Conference was about the family in the present and did not draw on the analysis of risk in the previous thorough assessment to think more widely about the historic issues for Ms A and their possible impact on her parenting of the boys. This raises a question about how social workers’ practice and reports to conferences are supported by reflective supervision by managers so that the core issues of neglect or harm do not get lost as additional new and real practical issues come forward, or how seeming changes for the better are tested for their realism and sustainability. 6.42 The newer professionals present recommended “step down” to Child in Need. This did not take into account the history of concern such as the previous lack of engagement and that Mark was showing signs of harm in his behaviour and speech delay. It is a known phenomenon that the quality of parenting can improve when families are in 24-hour care environments with good support, caring relationships, and supervision. There is a systemic risk, however, that this can be a temporary improvement, because of the regular scrutiny by professionals; but an improvement that is not consolidated into every day and ongoing parenting. 6.43 Several dynamics may have come into play here. Ms A and her history, including her own behaviour and at times apparent avoidance of professionals, were not well known to the current network because of her move from Wandsworth. There was a possible honeymoon period where the care, support, and scrutiny of the living-in environment of the refuge enabled Ms A to provide an observable good enough level of parenting to the children. 6.44 The Conference Chair overruled the recommendation to step down to Child in Need and retained the Child Protection Plan for both children. This was a good decision, given the brief length of the plan at that time, the uncertainty of the situation, and the aspects of the Child Protection Plan that required more work. 21 6.45 The Child Protection Plan was revised at this Conference and was reduced. The minutes are not clear about the progress of the previous Outline Plan and what had been achieved but several things were removed from the Plan even though they had not been completed. These had originally included: advice about a non-molestation order, access to parenting support, access to mental health support and some work by Ms A about drug and alcohol use. These issues were lost in the second version of the plan and there was no clarity about Ms A’s parenting capacity. There was also a new and unanswered question whether Ms A may have some additional learning needs, but no plan was made to explore this further. 6.46 The next Core Group, held at home, did not take place until June, nearly four months later. In this time the family had moved from the refuge back to Wandsworth, via a short residency in Croydon. The new Children’s Centre was not invited to the Core Group meeting. The Core Group membership changed three times in the space of eight months. Mark’s possible need for Speech and Language therapy had not been resolved. 6.47 The final Core Group, in July, was also held at the family home, with the children present. This would not have been conducive to a productive meeting. This raises a policy and practice question about the location of such meetings, especially when they are possibly being held at the family home to ensure attendance. It also raises a question about how parents are supported with childcare to attend such important meetings. It is not clear why the Children’s Centre was not used. 6.48 At the final Review Child Protection Conference, in July 2019, there was a small network present (the Social Worker, the new Health Visitor and staff from the new Children’s Centre). As the family had recently moved, the Social Worker was the only consistent person from the previous Child Protection Conference. The new Health Visitor and new children’s centre had little direct contact with the family. 6.49 This conference followed the pattern of the others, there was not enough time to sufficiently consider Ms A’s history and the impact of her own childhood and later abusive experiences as an adult, or her frequent non-engagement with professionals to support her as a parent to meet her children’s needs. 6.50 The new assessment described Mark’s behaviour as ‘excessive’. His tantrums and aggression were acknowledged as going beyond those associated with his stage of development but were not analysed in the context of what the underlying causes may be, what he may have witnessed or experienced, and the lack of boundary setting for him. His behaviour was put down to the number of moves and the period of upheaval the family had faced. 6.51 The Social Worker recommended that the Child Protection Plan should be stepped down to a “robust” Child in Need Plan. The staff of the new Children’s Centre and the new Health Visitor were not yet fully familiar with the case and thought it was too soon to take the children off a Child Protection Plan. They dissented from the decision to end the Plan but did not later consider using the formal escalation procedures to ask for the decision to be reviewed. There was no contingency plan built in to check Ms A’s compliance with a new Child in Need Plan. 22 6.52 The Social Care independent analysis submitted to this Safeguarding Practice Review concluded that the quality of the assessment to the conference was probably because of an underlying wider systemic issue and not just related to this meeting, as these issues had not been discussed in depth at the core group meetings or during case supervision sessions. This limited the overall understanding of how Ms A was functioning as a parent. This was exacerbated by changes in the network due to the moves which the family had experienced, not just in this period but also in prior involvements. Although Ms A had completed some work about the impact of domestic abuse whilst resident at the refuge, she had not completed other agreed domestic violence courses, due to her non-attendance. This was never challenged. Work on parenting and on possible alcohol or drug use, although identified as needed, had not been arranged. Mark’s need for assessment of his speech and language had not been achieved. 6.53 The practitioners who knew Ms A told this Review about how plausible Ms A could be. She appeared to be a loving parent and had shown strength by moving away from an abusive partner. This presentation and positive aspects of assessments contributed to the decisions made at the time. Parental engagement and effective working relationships with parents / Working with parents who are reluctant to engage 6.54 Some of the practitioners told this review that they found Ms A to be friendly and co-operative and in single sessions she appeared to engage well. She seemed, at times to listen to advice, such as work using the Power and Control Wheel12 at the refuge, which was noted to have increased her understanding of different forms of abuse. Ms A allowed health visitors to see the boys, mainly in unannounced visits, she would be co-operative and agree to follow up referrals to other services, however, she did not then keep to those agreements. 6.55 One senior practitioner, who had some overview of the case at the time, thought that there was evidence that Ms A was able to engage with some practitioners and form working relationships but that these were disrupted too frequently by the moves. This practitioner also thought that a longer and trusting working relationship was required which would enable Ms A to look at her own life experiences in more depth and how these may be affecting her role as a parent. The current systems for work organisation (including volume of cases and other pressures) often do not permit such in-depth helping relationships to develop and continue over time. 6.56 There was suspicion at the time that Ms A delayed workers’ entry to the home in order to tidy up before they came in. Several noted, in retrospect, that she did not always tell the truth. A supervisor noted that Ms A’s own background history and long experience of working with children’s services would have enabled her to know what information social workers and others were seeking and how they may use it and so lead her to be more careful about what she would share or how she behaved. 12 http://www.stopdomesticviolence.org.uk/violence-wheel/ 23 6.57 In retrospect, some practitioners have reflected that Ms A was probably actively concealing information from them. She was asked at the time, after the case was stepped down from the Child Protection Plan if she was in a new relationship, but she said not and although there was active curiosity about this there was no evidence. Another noted “It is important for practitioners to understand why parents may not be honest with professionals – they fear losing their children.” “There is a need to push professional curiosity and look for evidence of change”. Another comment was that “Professionals do not always feel confident in challenging parents who do not comply with Child Protection Plans”. It was also noted that “Information about fathers is often missing and sometimes mothers are reluctant to give it”. 6.58 There are many reasons why parents will not want to engage with child care professionals such as midwives, health visitors and early years’ workers, more so with social workers and police. These can include fear of interference or that social workers will seek to remove a child. The barriers can be compounded by a negative history of childhood experiences impacting on the ability to form trust and relationships, including later working relationships with professionals. Women subject to coercive control, as Ms A appears to have been, can also be reluctant to engage with helping agencies for fear of retribution if they seek help. 6.59 Ms A avoided contacts with staff from different agencies and did not follow through on agreements she had made. However, she gave the impression that she was cooperating with plans. Core groups were arranged at the family home to ensure that Ms A attended. Hindsight has shown that Ms A did not answer truthfully about use of drugs in the home or about having a new partner. 6.60 “Disguised compliance” is an unfortunate and unhelpful, pejorative term which has come in to child protection thinking as a kind of short hand for non-cooperation when the behaviours behind it are more complex than avoidance or resistance. A question is, however, “how well are the child care workforce across health, education, early years, and social care able to recognise and work with and build trust with ambivalent parents?”. David Wilkins helps us see that “disguised compliance” is not a helpful term and that it may be more productive for frontline practitioners to focus on building working relationship.13 6.61 At the time of the work to support Mark, Lloyd, and Ms A there was not a strong approach to building strong working and trusting relationships between workers and parents. 6.62 Working with parental non-engagement is an essential skill in child protection work. Wandsworth Social Care informed this review that a pilot of multi-agency group supervision has been introduced which will tackle this possible dynamic to support healthy scepticism, evidence based work and positive use of history, genograms, and chronologies to support reflective thinking about the experiences of children, to ensure trauma informed practice. 13 We need to rethink our approach to disguised compliance - Community Care 24 6.63 Across 2021 Wandsworth Children’s Services implemented two significant changes in the approach to practice across the system. Systemic practice in Children’s Social Care and Early Help now work focusses upon the centrality of respectful, trusting relationships with families and ensuring children can grow up within a family to thrive and meet their potential. It is evidence and strengths based. Systemic practice supports working to manage uncertainty in confidently holding risk and in reflection upon our practice and value. In implementing systemic practice practitioners and leaders have been offered systemic training and Systemic Family practitioners are now in post to work alongside families and practitioners . 6.64 Family Safeguarding Approach was launched in January 2022. It is a whole systems change to support families where children are at risk of neglect and abuse to remain safely within their families. It is strengths based, collaborative and focusses upon relationships with families. The model provides for specialist adult facing domestic abuse, mental and substance practitioners to work as part of multi-disciplinary children’s safeguarding teams, ensuring that families are holistically supported. Family Safeguarding uses motivational interviewing as one of its tools and relevant to the learning identified within national and local CSPRs as addressing the trio of vulnerability and is reflected within the make-up of multi-disciplinary family safeguarding teams. The model has been independently evaluated14. Its introduction in Wandsworth is being externally monitored and evaluated as part of the What Works for Children’s Social Care national work on best practice.15 6.65 The next section explores some of the systems dynamics which may have prevented effective challenge and trust building with Ms A, and parents (female and male) like her. The work in this case raises the question about what more needs to be done locally to build greater competence and confidence in practitioners within and across agencies to improve working with particularly avoidant parents, given that most parents will not want childcare agencies prying in to their family life. Recommendation 5 Wandsworth Children’s Social Care should report the findings of the What Works in Children’s Social Care ongoing evaluations of the Approach in Wandsworth to the Safeguarding Children Partnership. This will enable Partnership to monitor its impact on the delivery of safeguarding services to families identified to be at risk. In addition, the Partnership should ask its other member agencies how practitioners (child or adult facing) are being supported to maintain the knowledge and skills to build effective working relationships with reluctant and harder to engage parents, to maintain professional curiosity, use appropriate challenge and to hold the needs and vulnerability of the child in mind. Audit Practice review week Annual conference This will enable the Partnership and local agencies to decide what further actions, if any, are required to support this core and challenging area of practice that has been seen to underly a number of case reviews where children have been harmed. 14 Evaluation: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/932367/Hertfordshire_Family_Safeguarding.pdf 15 Family Safeguarding Model – Trial Evaluation - What Works for Children's Social Care (whatworks-csc.org.uk) 25 Learning from the coordination of the multi-agency assessments and support to safeguard the children and its possible implication for the wider local safeguarding system 6.66 The early work within Children’s Social Care in relation to the family shows a lack of agency oversight of the needs of the children, which led to several assessments over a short period of time. Practice was not properly scrutinised and supported by management or any other Quality Assurance activity. Supervisors, managers and Child Protection Co-ordinators need to routinely raise practice issues with senior managers to help the organisation identify any concerns about practice. The Child Protection Co-ordinator has a particular role in ensuring that the Child Protection Plan is robust and is being implemented to keep children safe. 6.67 The Child Protection Plan was not fully developed and did not address the long-standing issues in the family, such as Ms A’s own adverse childhood experiences and their possible impact on her current behaviour (including the possibility of alcohol and or drug use), the current influence of her family, her avoidant behaviour with professionals, and Mark’s troubled presentation. An opportunity was missed to use the analysis in the good quality assessment presented at the Initial Child Protection Conference to formulate a more robust Child Protection Plan. There is a challenge for child protection co-ordinators to ensure that outline Child Protection Plans reflect and address all the safeguarding concerns, not just the immediate safety of a family. Also, when a crisis, such as the disclosure in the conference of the alleged level of domestic abuse, coercive control, and fear, diverts attention, it is important that someone in the system, such as a supervisor or child protection co-ordinator, holds the children in mind to ensure that the original presenting and identified problems are not lost. There is a risk that the social worker will be diverted by the time-consuming practical tasks of emergency rehousing and rebuilding a network of professionals rather than refining the Plan to meet all the concerns from the assessment. This is made more complex if the social worker is not the same person who led that assessment as they may not own the assessment as fully. 6.68 Supervision should be a place to support the workers with reflective thinking and that the risks are fully noted and translated into an effective plan. 6.69 The practitioners who attended the Learning Event / Focus Group, as part of this review, to contribute their own thinking made the following comments in relation to learning about the Coordination of Multi-Agency Assessments and Work to Safeguard Children. Understanding relevant psycho-social history and other key information when undertaking assessments There is a challenge to ensure that new agencies joining the network are aware of relevant history, especially if they do not have the reports and records of previous Child Protection Conferences. Practitioners noted the issue of consent to share – but that is more applicable to early help or child in need work, not child protection work. Mark’s nursery in 2018 was surprised to learn, at this Review’s Focus Group, about the complex and potentially damaging family history, which had been unknown to them while they were trying to engage with Ms A. A question was raised whether the Signs of Safety Model16, in use at the time, gave sufficient weight to family history. Child Protection Conferences need to hold in mind relevant previous 16 Signs of Safety https://www.signsofsafety.net/what-is-sofs/ At the time of drafting this report the Wandsworth Multi-Disciplinary Model is shifting to a different model. 26 family and parental psycho-social history and how it may affect the here and now functioning. This would help there to be more focus on the possible longer-term impacts on parenting. There was a view (in hindsight) that it is important to understand history and family dynamics as well as holding a focus on acute risk such as domestic abuse. There may need to be a greater understanding and use of ACEs (Adverse Childhood Experiences) and how they can affect parenting.17 Wandsworth Social Care and partner agencies are adapting the Signs of Safety model as a core methodology to a revised Family Safeguarding Approach18. Sustaining effective change, A Manager reported having noted at the time, that, given the long history of negative experiences and her short-term protection, containment and managing in the refuge that Ms A may be challenged to remain resilient on her own outside the refuge, without other supports being in place. Information sharing did not work well. Several practitioners noted that they did not have all the relevant information, particularly history, including recent history and recent events. Better handovers are needed as families move through the support and safeguarding systems, such as midwifery and health visiting and between teams when families move across local authority or service boundaries. Universal services were not aware at times that there was a social worker for the family. One Practitioner in universal services said that in their experience some social care workers seemed to believe that other council services had access to the Social Care database and to family records and could read about families there. This is not the case. This led them to question whether in child protection cases other council children’s services providers should be able to see such records. It also raised the need for partner agencies’ practitioners to be more assertive in seeking out information from social care keyworkers. Effective networks Key agencies were not invited to Core Groups. Strategy meetings are not helpful if they do not involve the professionals who know the family and child. It was noted that recent use of online strategy meetings in 2020, because of Covid19, was securing the right people who know the family. Thresholds After the family’s first move to temporary housing the new Health Visiting team did not assess the family as needing additional support, but nothing had changed, and so the family had lower priority in large and busy caseloads. (This was prior to the Child Protection Threshold being seen to be met.) Contributing to risk analysis in Child Protection Conferences and Plans Practitioners questioned why some professionals will not take part in “scaling”19 the likely/probable risk to children. These colleagues were seen to be from Domestic Abuse Services where their abstention was understood to by agency policy, of which other services were unaware. Managing disagreements in the network with regard to threshold decisions At the final Child Protection Conference there was disagreement between professionals about whether the children should remain on a plan. Professionals newer to the case were unhappy about the 17 Adverse Childhood Experiences ACEs. A useful introduction and signpost to wider research to aid understanding the impact of Adverse Childhood Experiences on adults/parents and the pros and cons of using them in assessments is to be found in Children & Young People Now October 2020 pages 35 – 46, Special Report: Policy, Adverse Childhood Experiences www.cypnow.co.uk 18 Family Safeguarding Approach This is based on the Family Safeguarding Model introduced in Hertfordshire. Hertfordshire family safeguarding model | Hertfordshire County Council 19 “Scaling” refers to an exercise in the Signs of Safety Model to grade the possible strengths and risks in family functioning. What Is Signs of Safety? - Signs of Safety 27 proposal and the decision to step-down to child in need. Although their dissension was minuted they did not discuss this with their own safeguarding managers to consider escalating the decision under the agreed local and London procedures20. They had subsequently learned of the need to inform and discuss with a manager or specialist the need to consider escalation, where this occurs. Parental rather than child focus Some practitioners believed that the plans focussed more on the mother than the children. There is no doubt that Ms A was at risk of domestic abuse, but this served to obscure other issues in the care of the children which were not specifically related to domestic abuse. Venues of Child Protection Meetings Practitioners were aware, beyond this case, of examples where meetings were sometimes held at a family home to support parents’ attendance. The advantages and disadvantages of this had not been explored but it was felt that this was a way to engage some parent/s. Family supporters in child protection meetings It was noted by one practitioner, in hindsight, that there was a family supporter in one of the Child Protection Conferences who kept interjecting and disrupting the meeting. Moves of home, their management and impact on the safeguarding system 6.70 The timeline shows that Ms A’s moves, particularly those outside the home borough, disrupted the ability of the safeguarding systems to assess, support and monitor. As a result, Ms A had antenatal care, domestic abuse support, social care and health visiting and some little pre-school service for Mark from several boroughs. This meant that for those services which do not follow the family across boundaries, such as Midwifery, Health Visiting and Community Safety, the history and concern had to be transferred to new professionals. Wandsworth Social Care had difficulty over several months to trace Ms A when she first moved to Croydon. The Croydon MARAC referred her to the Lambeth MARAC, but she had by then been moved back to Wandsworth and we have found no evidence that she was then referred on to Wandsworth domestic abuse services. The Health Visiting Service for the refuge sought to transfer responsibility for her to the Croydon Health Visiting Team which could not find her as she had already moved again, back to Wandsworth. 6.71 This systemic problem, compounded by division of responsibilities within Housing Departments and by the range of housing providers, has potential to disrupt the safeguarding support from housing agencies and means changes in the working and therapeutic relationships with parents and children. With parents who are harder to engage it is important as much as possible to have continuity in the professionals and the multi-agency network, especially where this is a Team Around the Child or a Child Protection Core group. 20 11. Professional Conflict Resolution (londoncp.co.uk) 28 6.72 Practitioners must pass on their concerns and how they have been working to support the family, but they cannot always identify the relevant service or people, and there is a risk that they will get lost. The nursery which recognised the concerns of neglect about Mark in late 2018 told this review that they never discovered to whom they should transfer their records about his brief period with them after they referred him to Social Care and Ms A then withdrew him from nursery. This disruption can mean that the history of concern can be lost, thereby making it easier for distortion, or apparently compliant behaviour to be seen without a longer-term view of how genuine it may or may not be. 6.73 Temporary housing, eviction, re-housing for safety, availability of safe placements, unsuitable placements, and concern about the possible use of a temporarily vacated family home as an alleged base for the sale of drugs were key dynamics in this case. Housing agencies as assessors and providers need to be key stakeholders in the safeguarding network. 6.74 This Review discovered that practitioners and managers were unaware of the existence of the Priority Rehousing Protocol between the Wandsworth Housing Department and Wandsworth Children’s Social Care. The Independent Reviewer was personally aware that historically Wandsworth Council had a Safeguarding Protocol whereby families with children subject of Child Protection Plans could be nominated by senior managers in Social Care for priority re-housing, as part of a safety plan. This cohort of children, assessed to be at risk of significant harm, is among a Local Authority’s highest priority of families. The Wandsworth Safeguarding Children Partnership, as a result of this review agreed an interim recommendation to examine the need for and use of a Priority Housing Protocol to ensure that the whole system, including housing agencies, contributes to children’s safeguarding. It may be necessary top update that Protocol in line with the new provisions of the Domestic Abuse Act 2021.21 6.75 The challenge systemically in this housing and safeguarding review will be to include key housing stakeholders such as Housing Providers from the private and voluntary sector. Such a Protocol should include clear expectations not only about housing responsibility but also the contribution to Child Protection Plans and Meetings. 6.76 Clearly, there will be times when a move of Local Authority Area is important for the safety of children or one of their parents, usually a mother. The London Procedures allow for this and when a move is permanent rather than temporary the case responsibility can also transfer permanently. Recommendation 6 Wandsworth Council (Children’s Social Care and Housing; with Adult Social Care for access to Refuge Provision) should undertake a review of the Protocol for Priority Rehousing and its use for re-housing families where children are subject of child protection plans to minimise moves away from the borough and key safeguarding networks, except where a move from the borough is essential to the safeguarding of the children or a parent. Such a review will ensure safe housing as a key dynamic within a family’s safeguarding system and should enable continuity of frontline practice from safeguarding agencies monitoring and for effective networks of key professionals, including housing providers, to support families and to protect children. This recommendation was agreed during the period that the review was still being undertaken. 21 The Domestic Abuse Act 2021 Part 4 section 57 deals specifically with the Local Authority’s strategic duties with regard to the housing needs of survivors of domestic abuse. 29 6.77 A further overall systems and strategic dynamic to be considered arises from the diverse provision and management of social housing and the co-ordination of the safeguarding arrangements for assessing and supporting families in need of or in receipt of housing across Council Services and independent, social, and private landlords and associations. This also raises the question of the relationship of such independent or community housing assessors and providers with Local Safeguarding Children Partnerships and their role in safeguarding practice within a local authority area. Historically the strategic relationship would have been with a Local Authority’s Housing Services, which fall under section 11 of the Children Act 2004. The safeguarding requirements on other large providers such as Housing Associations do not carry the same Section 11 mandate. This is a national issue. The place of housing services within the overall strategic response to safeguarding children and mothers 6.78 This review has noted that the Housing Association responsible for Ms A’s permanent tenancy had no direct relationship with the Wandsworth Safeguarding Children Board (and later Partnership). 6.79 A family’s housing and its management can be crucial to safeguarding. The Social Worker contacted the Housing Association on at least two occasions but noted that it was difficult to know who to speak with about Ms A’s case. The Housing Association has no record of invitations to Conferences or Core Groups; but notes that its recording may be incomplete. 6.80 The Housing Association referred Ms A back to Wandsworth Housing for an urgent management transfer on grounds of safeguarding as she could not return to the property, which was thought to be being used for drug dealing. From this point Ms A was a temporary tenant of the Housing Department. However, it seems no action was taken about the alleged drug-dealing from the property and the tenancy was not ended by the Housing Association until August even though Ms A had given it up in March. The Housing Association said it would usually work with the Police when a property had been identified as a source of drug-dealing. It is not clear that referrals were made to the Police or to Community Safety about these allegations. Recommendation 7 The Wandsworth Safeguarding Children Partnership should review its relationship with local large Housing Providers to ensure that they are included both strategically in the Partnership’s work and in the dissemination and training of best safeguarding practice. This should include advice on best practice in local safeguarding arrangements and policies for Housing Providers. In pursuing this recommendation, the Wandsworth Safeguarding Children Partnership should refer this issue to the Wandsworth Safeguarding Adults Board and involve the Wandsworth Housing Department in agreeing a way forward. 30 Practitioners’ views to this Review on the systemic risks arising from families’ moves 6.81 A Health Visitor manager noted the need to ensure that relevant information is passed on quickly to the new support team when families in need or at risk move across local authority boundaries. Such moves across Local Authority boundaries are disruptive to good working relationships with parents. A Social Care manager noted the need to build new networks quickly when families move. There was agreement that the disruptions from such moves could interrupt the work needed and the efficiency of multi-agency teams where some key practitioners had to change. Managers in a school and in universal services noted the systems risk that a service could be unaware of the concerns when a family moves to their resource, and they are not quickly brought into the Team Around the Child or Core Group and receive the relevant history. 6.82 Practitioners noted an intrinsic systems dynamic, in that, in a new case, when a child first becomes the subject of a Child Protection Plan there will most likely be an automatic change of social worker and supervisor to a new longer-term team at a crucial time. In this case, an additional systemic issue was that neither the new social worker or line-manager was able to attend the Initial Child Protection Conference; being present in the meeting makes it easier to own the history and the plan. Responding to and preventing harm from Domestic Abuse 6.83 The risks and damage from domestic abuse, including coercive control to children and mothers are well known. Good examples were found in this review of practitioners seeking to work with Ms A about the abuse she had experienced. During antenatal care she was asked about risk of domestic abuse through routine enquiry. She did not say that she was at risk of such abuse. Following the serious assault in Croydon on Ms A by Mr B the Croydon Community Safety service responded appropriately. An Independent Domestic Abuse Advisor met with and advised Ms A, but Ms A did not continue in work with the advisor despite their attempts to engage with her. Ms A was advised about steps to take including Non-Molestation Orders. She said that she had used them, but it is not clear that this was checked. 6.84 Wandsworth Community Safety has an over-arching responsibility on behalf of the Community Safety Partnership (and the Safeguarding Children Partnership) for ensuring the effective working of the Domestic Abuse MARAC22 to reduce the risk to victims of domestic abuse. Whilst Community Safety does not currently have responsibility for management of Emergency Accommodation services (such as refuges) it does have a key co-ordinating role and links with Adult Social Care which commissions the local Emergency Accommodation services for victims of domestic abuse. Community Safety holds the lead for co-ordination of the Violence against Women and Girls Strategy, inclusive of Domestic Abuse. It employs the Domestic Abuse MARAC Co-ordinators, and commissions local Independent Domestic Violence Advocates services. 22 MARAC – Multi-Agency Risk Assessment Conference is a local multi-agency meeting with a primary focus on the safety of adult victims who are at high-risk of domestic abuse. - 12. Risk Management of Known Offenders (londoncp.co.uk) 31 The role of MARAC as a multi-agency system to co-ordinate responses to known cases of domestic abuse 6.85 Inter-borough referrals There are no records of any contact with the local Wandsworth MARAC about Ms A. Lambeth MARAC has no record of receiving a referral from Croydon MARAC. Good practice would have been to pass this on to the Wandsworth MARAC when it became known that Ms A had moved back to Wandsworth. Following this Child Safeguarding Review, Wandsworth Community Safety undertook a review (2021) of the local MARAC to MARAC Protocol to ensure that transfer issues are fully understood and used appropriately. A revised Transfer Protocol became operational from 2022 and is included in MARAC Training. 6.86 Repeat incidents Repeat domestic abuse incidents in this case were not referred to the MARAC by Police or other agencies (such as health visiting or social care). The current MARAC Protocol states, “In Wandsworth, where there have been three or more reported domestic violence police crime reports in a 12-month period the case will be referred to the MARAC.” This is recognised best practice. Wandsworth Community Safety completed a review of the operation of the MARAC in 2021, including the escalation criteria for repeat incidences of domestic abuse to be referred to MARAC. Work after that review led to a 50% increase in referrals to MARAC by the end of 2021, with a better quality of referrals. Incidence of domestic abuse impacting on mothers and children 6.87 An examination of national data for 2020-21 shows the larger number of referrals to MARACs in London (Metropolitan Police area) came from the Police (31.7%) or IDVAs (28.4%). The Wandsworth figures are April 2020 – March 2021: Police (30%) IDVAs (20%) and Children’s Services (11%) with much lower numbers referred by other agencies. For January to December 2021 (part year) they were Police (39%), IDVA (20%) and Children’s Services (5%), in Wandsworth. Given the high numbers of children in households referred to MARACs it could be argued that more referrals to MARAC, through the completion of DASH (or DARAC) could be anticipated from social care, health, and education agencies. It must be noted, however, that Domestic Abuse cases known to Children’s Social Care should also be known to the Police which may explain lower referral numbers from children’s services agencies. A key question for Wandsworth agencies, including health and schools, is: Are practitioners aware of how and when to refer cases to MARAC and are they doing so? 32 Use, competence, and confidence in using formal Domestic Abuse risk assessments by the wider workforce. 6.88 The Police were called to incidents/allegations of a domestic nature on several occasions. For most, but not all, of these the attending police officers completed a Safe Lives “DASH risk assessment”. The DASH (Domestic Abuse, Stalking and Honour Based Violence), a risk assessment tool, is the nationally recognised and locally used means of assessing risk at a moment in time. 23 They provided evidence of a sequence of events that merited an automatic referral to a MARAC. Each of these risk assessments is shown as having been assessed as “Standard”. In addition, there are examples in the timeline of other agency contacts with Ms A where a DASH was not completed when there were risk factors, such as pregnancy; children in household; abuse occurring more frequently; use of objects to cause injury; strangulation; sexual nature of assaults; presence of alcohol/drugs. This raises hindsight questions about professional curiosity and about opportunities to explore the degree of domestic abuse through completion of DASH risk assessments and assurance as to the levels of knowledge and training in respect of domestic abuse and DASH for frontline staff in other agencies as well as by police officers. 6.89 A DASH risk assessment was not completed following Ms A disclosing abuse, coercive control, and fear at the Initial Child Protection Conference in December 2018. The risk was determined as high enough to require a move to emergency safe accommodation. This was a missed opportunity to refer to the MARAC, the multi-agency panel for monitoring and supporting high risk domestic abuse cases. 6.90 There was a strong view from the Practice Learning Focus Group to this review (September 2020) that practitioners from different services were not confident in domestic abuse work and had insufficient training. Except for Domestic Abuse specialists, practitioners in other services were not confident in the use of the Safe Lives DASH Check List24. This Review was informed in January 2022 that since 2020 many practitioners across different services had received additional training in working with domestic abuse and the role of the MARAC. This had resulted in better understanding of domestic abuse and domestic abuse procedures by frontline practitioners. The training continues to be provided regularly to meet the challenge of staff turnover. 6.91 In 2021, The Children’s Social Care Department completed a review of the use of the Barnardo’s Domestic Abuse Risk Assessment for Children, DARAC, based on the earlier Barnardo’s Domestic Violence Risk Identification Matrix for assessing the risks to children from domestic violence25. It is seen to be more child focussed and is in line with the London Child Protection Procedures approach to differentiate risk assessment tools for adults and children26. From March 2022, as part of the introduction of the Family Safeguarding Model (see 6.61 above) and the embedding of Domestic Abuse Coordinators within Family Safeguarding Teams there will be clarity about which assessment tool should be used; this will provide greater consistency and focus on the impact on children as well as adults. 23 Source: http://www.safelives.org.uk/sites/default/files/resources/Dash%20for%20IDVAs%20FINAL_0.pdf 24 https://safelives.org.uk/practice-support/resources-identifying-risk-victims-face 25 barnado_s_domestic_violence_risk_identification_matrix__dvrim_.pdf 26 London Child Protection Procedures 28.10 Assessment and intervention (from domestic abuse) 28. Safeguarding children affected by domestic abuse (londoncp.co.uk) 33 Recommendation 8a The Wandsworth Community Safety Partnership or the new Violence Against Women and Girls Strategic Group with the Wandsworth Safeguarding Children Partnership and Wandsworth Children’s Services should clarify local procedures and guidance for all local agencies on the parallel use of formal and systematic tools for domestic abuse risk assessments (DASH and/or DARAC) upon all disclosures of domestic abuse, and their reporting to MARAC. Recommendation 8b In line with this the Community Safety Partnership or Violence Against Women and Girls Strategic Group with the Safeguarding Children Partnership should also seek assurance from local Agencies that relevant staff and officers have received sufficient training in respect of domestic abuse awareness and the use of tools such as the DASH (for adult victims) and/or DARAC (for child victims) risk assessments; and when to refer a case to MARAC. Oversight and Governance of Local Multi-Agency Domestic Abuse Response Coordination 6.92 At the time of this case there was no local Strategic Group that oversaw the multi-agency response to Domestic Abuse in Wandsworth. A local Domestic Abuse Operational Group was introduced in the summer of 2019 that was used to inform and develop a local needs assessment in respect to Violence Against Women and Girls (VAWG). The operational group was in a formative stage and did not operate a scrutiny function in respect of the VAWG Agenda or MARAC. National best practice suggests that a MARAC Steering Group should oversee the activity of the local MARAC.27 Frequently this sits as part of a work stream of an overarching Strategic Group for VAWG. It is noted that the Community Safety Plan has now adopted such a strategic approach. 6.93 In February 2022, a new Violence Against Women and Girls (VAWG) Strategy for Wandsworth for 2022-25 was agreed. This will ensure accountability for the local MARAC and the coordination of multi-agency responses to domestic abuse under the VAWG strategic partnership board. The Strategy Priority Workstreams will report regularly to a Strategic Partnership Board to ensure there is singular and central oversight of the workstreams and provides the link to the Community Safety Partnership and Greater London Authority28. This will provide co-ordinated leadership to the local delivery of the Statutory Guidance under the new Domestic Violence Act 202129. 27 Source: http://www.safelives.org.uk/practice-support/resources-marac-meetings/resources-steering-groups (Accessed March 2020) 28 https://wandsworth.gov.uk/media/10605/violence_against_women_and_girls_strategy_2022_25.pdf 29 Domestic abuse: draft statutory guidance framework (accessible version) - GOV.UK (www.gov.uk) See: Chapter 4 https://www.gov.uk/government/consultations/domestic-abuse-act-statutory-guidance/domestic-abuse-draft-statutory-guidance-framework#chapter-4--agency-response-to-domestic-abuse Chapter 5 https://www.gov.uk/government/consultations/domestic-abuse-act-statutory-guidance/domestic-abuse-draft-statutory-guidance-framework#chapter-5--working-together-to-tackle-domestic-abuse Chapter 6 https://www.gov.uk/government/consultations/domestic-abuse-act-statutory-guidance/domestic-abuse-draft-statutory-guidance-framework#chapter-6--commissioning-response-to-domestic-abuse 34 Recommendation 9 It is recommended that the new Violence Against Women and Girls Strategic Group formed in 2022 should ensure that an Annual Report is provided to the Wandsworth Safeguarding Children Partnership on the multi-agency work to tackle domestic abuse in the borough in relation to children and families, and on the progress of that work. This is in line with the Domestic Abuse Act 2021, section 59, and will enable the Safeguarding Children Partnership to both scrutinise and contribute to local strategic responses to domestic abuse as it affects children and families at both a strategic and practice level. Training and the competence of frontline practitioners in recognising and responding to domestic abuse 6.94 In 2020, the Community Safety Service noted the need to: Seek assurance that professionals are sufficiently well versed in the completion of DASH assessments and display the professional curiosity to explore the risk domestic abuse with service users. The Wandsworth Community Safety Partnership, as noted above, has since been providing regular domestic abuse training across the multi-disciplinary workforce, including MARAC training - through the Council’s Learning and Development Team. This is multi-agency training and is conducted on a voluntary basis. In January 2022 a planned training needs analysis and review of the delivery of Domestic Abuse Training across services had not yet been completed and it was stated that responsibility for domestic abuse training was held in different places by Community Safety Services (Council’s Learning and Development Team), Children’s Services Social Work Academy and the Safeguarding Children Partnership. Awareness of ‘Clare’s Law’ in frontline practice 6.95 Clare’s Law is the colloquial name for the Domestic Violence Disclosure Scheme30 through which a person can make enquiry about possible risk from a prospective partner. Ms A was in a highly abusive and violent relationship with Mr B. Subsequently she was in a relationship with Mr C, father to Lloyd. There is no evidence that he was physically abusive to her, but it can be argued that he took advantage of her as he had no intention of a long-term relationship. In the summer of 2019 Ms A started a relationship with Mr D although this was unknown to practitioners at the time. It is not clear whether at any time any practitioners working with Ms A to support her advised her of her right under the scheme to seek information about a prospective partner. Informing women about their rights under Clare’s Law could be a core tool with abused women to assist them in understanding possible risks and to empower them to be able to make informed decisions about future relationships. 30 https://www.met.police.uk/advice/advice-and-information/daa/domestic-abuse/alpha/request-information-under-clares-law/ and Domestic Violence Disclosure Scheme factsheet - GOV.UK (www.gov.uk) 35 6.96 Practitioners advised this review that they were not aware of or currently advising service users about Clare’s Law. It was noted that this is not referred to in local Wandsworth procedures or training. Comment: It is explained in the London Child Protection Procedures, to which Wandsworth is subscribed, as a possible useful tool (with safeguards) for practitioners to use31. Recommendation 10 It is recommended that the new Violence Against Women and Girls Strategic Group should agree the overall governance of the different strands of commissioning and delivery of Domestic Abuse Training by local services and providers to ensure co-ordination of training needs analyses, delivery of cross-cutting priorities and evaluation and that within this the needs of vulnerable children are recognised and met. This should include: the recognition of domestic abuse in its various forms32, including repeat incidents, the impact on children as well as mothers of domestic abuse, the use of appropriate assessment tools for adults and children (DASH/DARAC), the role of MARAC, and how local practitioners and services are supported regarding when and how to inform service users about Clare’s Law (The Domestic Violence Disclosure Scheme) and its value. It is understood that the Welsh Strategic Model may provide a good basis for this33. A public health approach and awareness raising about domestic abuse in the community 6.97 At the time of the original review this issue was not identified as specific learning from this case. At the further review in 2022, after the adults were charged with Lloyd’s death it, was noted that in Wandsworth good progress had been made in this area and that the Council had been awarded White Ribbon status in November 2021.34 There had been widespread training and Ambassadors had been appointed in schools, and colleges to promote community engagement. Awareness of Clare’s Law could also feature under this approach. Also in 2021, Wandsworth Council’s Housing and Regeneration Department was accredited with the Domestic Abuse Housing Alliance Chartermark for its robust response to domestic abuse.35 31 https://www.londoncp.co.uk/chapters/sg_ch_dom_abuse.html?zoom_highlight=clare%27s+law 32 See the revised definition of domestic abuse as set out in the Home Office draft Statutory Guidance Framework (Oct 2021) to be made final and published in 2022 under the Domestic Abuse Act 2021. Domestic abuse: draft statutory guidance framework (accessible version) - GOV.UK (www.gov.uk) 33 Guidance-for-Local-Strategies.pdf (welshwomensaid.org.uk) 34 https://www.wandsworth.gov.uk/news/2021-news/news-november-2021/white-ribbon-accreditation-for-wandsworth-as-it-prepares-for-16-days-of-action-against-domestic-violence/?dm_i=XWH,7MZOE,G70JHT,V42ML,1 35 Accreditation for Wandsworth's response to domestic abuse - Wandsworth Borough Council 36 Parenting Education and the delivery of the NHS Healthy Child Programme 6.98 Ms A was a first-time parent, for Mark. The review of this case raises questions for Midwifery Services and perhaps for Public Health Services (as commissioners with lead responsibility for supporting parenting education) and the Health Visiting Service about how first-time parents are supported in the perinatal period to understand the needs of babies and the impacts they can have on parents, and then later the parenting of older children. 6.99 Given Ms A’s own self-reported and known history, there were likely to be challenges for her in parenting. The NHS Healthy Child Programme sets out the range of support that is best practice. This case shows a particular challenge when parents, including fathers, do not engage with the universal antenatal and postnatal services for maternal and baby care, advice, and support. 6.100 Ms A did not engage well with Maternity Services in Croydon or Wandsworth. This raises a question about how Health Services are commissioned to respond in the Healthy Child Programme, given their high workloads and that the services are voluntary for parents, unless there are clear signs of possible future harm. A supplementary question is whether there has been an over-reliance on leaflets as a way to pass information on to parents. On their own, leaflets are known to be a less effective tool. 6.101 At the Initial Child Protection Conference in December 2018, it was agreed that Ms A (and Mr B) should participate in a Family Recovery Project Parenting Course. There is no evidence that this was followed up, including at subsequent Core Group meetings, perhaps because the response to the acute domestic abuse took priority. Later Ms A reported that she was having difficulty with Mark and his tantrums. She was given advice but admitted that she gave in to him rather than managing his behaviour. 6.102 Lloyd died from serious injuries, inflicted over time by an adult or adults. Such injuries can often be the result of parental or carer frustration or reaction to a child’s crying or, in older children, their behaviour. This raises a question about how universal parenting education seeks to support parents, including fathers, in understanding children’s behaviours and adults’ reactions and how to anticipate and manage responses to children. At the time of this report the outcome of the criminal investigation into Lloyd’s death was still awaited. This may reveal other reasons for the injuries. However, there is sufficient information in this case to question Ms A’s preparedness and ability to manage day to day parenting. She had not engaged in prebirth parenting education and used very few parenting supports after the children’s births. 6.103 From pregnancy to a child’s second birthday are crucial36. A question for the Wandsworth Health and Well-being Board and the Safeguarding Children Partnership is how the provision of basic parenting education and parenting support at a population wide level fits in to the overall strategic plan for the delivery of services in Wandsworth and whether sufficient provision is included in perinatal and early years services to offer parenting education to new parents, including managing their own reactions to babies and toddlers. The recent Department of Health and Social Care report (March 2021) The Best Start for Life: A Vision for the 1,001 Critical Days, The Early Years Healthy Development Review Report37. 36 NHS England » 1,000 days to make a difference 37 The_best_start_for_life_a_vision_for_the_1_001_critical_days.pdf (publishing.service.gov.uk) 37 Recommendation 11 The Wandsworth Safeguarding Children Partnership should request a review from the Commissioners of Health Services of the rationale for and provision of universal parenting education and parenting programmes by Midwifery Services and through the Healthy Child Programme within the borough and of any actions that may be required. This may be as part of the national initiative and actions set out by the Government in The Best Start for Life. Parental Drug and Alcohol Misuse 6.104 Ms A was known to have a history of alcohol and drug use. There was good routine enquiry by some practitioners about her alcohol and drug use, to which she replied that she was not currently using. She admitted to cannabis use and tested positive with the Midwifery Service during the pregnancy with Lloyd. This suggested that Mark may have been affected by parental drug use. There were also occasions when alcohol use was a cause of concern in relation to visitors to the household and the care of Mark. The nursery raised concern for Mark about smelling of cigarette smoke but there is also a suggestion that he may have smelled of cannabis; a suggestion which was reported to have angered Ms A. The Police also had soft intelligence that the family home may be being used for drug-dealing (after Ms A and the children had moved to the refuge). This was not shared with Children’s Social Care, or with the Community Safety Partnership which also has a lead responsibility for tackling drug use in the borough. 6.105 Mr D had been a known serious drug user but there was no knowledge of him being associated with the household and so any risk from him could not be assessed. 6.106 After Lloyd’s death tests showed that Mark had been exposed to drugs over some time. 6.107 This case serves as a reminder of the possible prevalence of drug use by parents and the need for practitioners to be vigilant and curious about this in their assessments. It is not clear how much this is a part of all Child and Family Assessments. Parental drug use is not only a concern in relation to children’s possible direct or indirect exposure to drugs but also to the impacts of their use on the thinking, judgments and behaviour of parents and their reactions to children’s behaviour. For women who are subject of domestic abuse, including through coercive control as Ms A was, there may also be a risk of further exploitation by use of their accommodation for drug using or dealing. 6.108 Workers were aware of the risks of drug use in this case and did ask Ms A about it. This was good safeguarding work and is a reminder of the need for services to support frontline staff in being competent and confident in asking about alcohol and drug use and assessing the responses. Information provided to this review suggested that in general front-line workers are not confident in this area and look to specialist drug workers. It was suggested that staff in some services are unaware of how to recognise possible drug use and its indicators. 38 6.109 The Wandsworth Safeguarding Children Partnership may wish to explore further with the Metropolitan Police what response may be appropriate when soft intelligence about drug misuse relates to a property associated with children. When should such, as yet unevidenced information be shared with other agencies as part of safeguarding assessments or child protection plans? The Wandsworth Safeguarding Children Partnership may also wish to assure itself of the content of training in recognition and response to drug use by parents for frontline workers. Use of written agreements 6.110 Ms A signed a written agreement following concern about a family member and others using her property, in her absence, placing Mark at risk. She agreed to exclude the family member. Such agreements have become common in child protection social work. There has been limited research into their use and efficacy. It is not uncommon for them to be unenforceable or for breaches not to be followed up. In this case the family member was later noted by a colleague from another agency to be present in the house despite the written agreement. The colleague was unaware of the written agreement. It is not clear whether subsequent social workers were aware of the existence of the agreement. 6.111 Practitioners outside social care told this review that they were unaware how such agreements are used by Social Care and asked how these are supported and enforced, especially if colleagues from partner agencies are unaware of them. It is important that where such a written agreement is used that colleagues from partner agencies are aware of it so that it can be enforced, if necessary. Recommendation 12 Wandsworth Social Care is recommended to review its use of written agreements with families, when they are not part of agreed Child Protection Plans or a formal agreement reached as part of work under the Public Law Outline38. Guidance should include when to share information about the content of a written agreement with key partner agencies. 38 Public Law Outline A process of legal work with families as part of pre-proceedings when a Local Authority is considering seeking a court order to protect a child under the Children Act 1989. Stages are described in Statutory Guidance: DFE stat guidance template (publishing.service.gov.uk) After negotiation with parents about the concerns and what must change, and usually with the parents’ legal advisors, a letter is sent by the Local Authority setting out the agreed actions by all parties. This is effectively an agreement. 39 Managing multi-agency disagreements in the network with regard to threshold decisions 6.112 At the final Child Protection Conference there was disagreement between professionals about whether the children should remain on a lan. Professionals newer to the case were unhappy about the proposal and then decision to step-down from child protection to child in need. Although their dissension was minuted they did not later discuss their view that this was not the right decision with the safeguarding managers within their own agencies to consider escalating the decision under the agreed local Inter-Agency Escalation Policy39 or London Child Protection Procedures40. 6.113 Some professionals can feel disempowered and lack confidence in the face of decisions made by social care staff and need to understand that there are agreed arrangements for questioning and challenging such decisions where there are grounds to do so. This may need advice and support from a senior manager within their own agency. It is important that local agencies inform and support their staff to challenge such decisions, where there are grounds to do so. 6.114 All agencies should also ensure that this Escalation Policy is included in safeguarding training commissioning and delivery. 39 https://wscp.org.uk/media/1329/inter_agency_escalation_policy-v2.docx 40 London Child Protection Procedures section 4.11 4. Child Protection Conferences (londoncp.co.uk) 40 7 Recommendations This Review makes the following recommendations and has also raised questions which the Safeguarding Children Partnership is asked to consider as possible areas for further work. If these are adopted by the Safeguarding Partners, they should be transformed into an Action Plan with clear achievable outcomes, timescales and areas of lead responsibility and monitored by the Safeguarding and Continuous Learning Subcommittee. The effectiveness of local multi-agency safeguarding children thresholds and pathways Recommendation 1 (See paragraphs 6.6 – 6.10 for context) The Wandsworth Public Health Services, as Commissioners of local Health Visiting Services, with the Providers, and with consultation from the Clinical Commissioning Group, should commission an audit of a random sample of cases, across teams, at "targeted" level of service (Universal Plus) which, are not multi-agency child in need or child protection cases, to review how such cases are supported and monitored over time. The purpose of this audit of frontline health visiting practice is to provide assurance that when families have been assessed to require a higher level of Health Visiting Service that cases continue to be monitored by the agreed method and frequency to ascertain if any change (particularly increase) in provision is required. Wandsworth Public Health Services should report the outcome of this review to the Wandsworth Safeguarding Children Partnership. The Child’s Lived Experience – Seeing children and holding them in mind Recommendation 2 (See paragraphs 6.11 – 6.13) Services which assess children or parents, and their welfare or safety must take into account all the children who are usually resident in the household, or children in frequent contact, as their welfare may be an indicator of well-being or need for other household / family members. Local children’s agencies, Midwifery Services and Adult Services should review their practice guidance, information gathering and sharing arrangements and supervisory arrangements to ensure that when one child or parent is being seen and considered that there is curiosity about and consideration of the welfare of other household members or family members in regular contact, especially children under 5. Recommendation 3 (See paragraphs 6.11 – 6.19) The Wandsworth Safeguarding Children Partnership Safeguarding and Continuous Learning Subcommittee should commission agency and multi-agency practice audits to ascertain how services are assessing and recording the daily lived experience of children, including those in a household who are not the index child. These audits should consider how children’s behaviour and appearance are recorded and taken into account when assessing their welfare and safeguarding needs, in addition to what children say, for those able to speak. 41 From this audit a decision can, be made whether additional practice guidance is needed. This review should include children who are identified as vulnerable but who are not seen as often as they should be. Formulation of and Management of Child Protection Plans and Management of Core Groups Recommendation 4 (See paragraphs 6.28 – 6.38) Given the centrality of Child Protection Plans and Core Groups to multi-agency safeguarding systems the Wandsworth Safeguarding Children Partnership is recommended to monitor the progress of the local initiatives to focus and strengthen Child Protection Plans and Core Groups by requiring feedback from the Safeguarding and Continuous Learning Subgroup on the impact of Child Protection Plans and Core groups; initially at six months and then at least annually. Such quality assurance data should also include information about agency attendance at Core Group meetings. Working with parents who are reluctant to engage – “disguised compliance” Recommendation 5 (see paragraphs 6.56 – 6.66) The Wandsworth Safeguarding Children Partnership should plan a review of how the Family Safeguarding Approach in Children’s Social Care and Early Help is impacting on the delivery of safeguarding services to families identified to be at risk. In addition, the Partnership should ask its other member agencies how practitioners (child or adult facing) are being supported to maintain the knowledge and skills to build effective working relationships with reluctant and harder to engage parents, to maintain professional curiosity, use appropriate challenge and to hold the needs and vulnerability of the child in mind. This will enable the Partnership and local agencies to decide what further actions, if any, are required to support this core and challenging area of practice that has been seen to underly a number of case reviews where children have been harmed. Moves of home, their management and impact on the safeguarding system Recommendation 6 (Paragraphs 6.71 – 6.77) Recommendation was agreed during the review. Wandsworth Council (Children’s Social Care and Housing; with Adult Social Care for access to Refuge Provision) should undertake a review of the Protocol for Priority Rehousing and its use for re-housing families where children are subject of child protection plans to minimise moves away from the borough and key safeguarding networks, except where a move from the borough is essential to the safeguarding of the children or a parent. Such a review will ensure safe housing as a key dynamic within a family’s safeguarding system and enable continuity of monitoring and for effective networks of key professionals, including housing providers, to support families and to protect children. Recommendation 7 (Paragraphs 6.79 – 6.81) The Wandsworth Safeguarding Children Partnership should review its relationship with local large Housing Providers to ensure that they are included both strategically in the Partnership’s work and in the dissemination and training of best safeguarding practice. This should include advice on best practice in local safeguarding arrangements and policies for Housing Providers. 42 In pursuing this recommendation, the Wandsworth Safeguarding Children Partnership should refer this issue to the Wandsworth Safeguarding Adults Board and involve the Wandsworth Housing Department in agreeing a way forward. Responses to domestic abuse Recommendation 8 (See paragraphs 6.84 – 6.92) Recommendation 8a The Wandsworth Community Safety Partnership or the new Violence Against Women and Girls Strategic Group with the Wandsworth Safeguarding Children Partnership and Wandsworth Children’s Services should clarify local procedures and guidance for all local agencies on the parallel use of formal and systematic tools for domestic abuse risk assessments (DASH and/or DARAC) upon all disclosures of domestic abuse, and their reporting to MARAC. Recommendation 8b In line with this the Community Safety Partnership or Violence Against Women and Girls Strategic Group with the Safeguarding Children Partnership should also seek assurance from local Agencies that relevant staff and officers have received sufficient training in respect of domestic abuse awareness and the use of tools such as the DASH (for adult victims) and/or DARAC (for child victims) risk assessments; and when to refer a case to MARAC. Recommendation 9 (See paragraphs 6.93 – 6.94) It is recommended that the new Violence Against Women and Girls Strategic Group being formed in early 2022 should ensure that an Annual Report is provided to the Wandsworth Safeguarding Children Partnership on the multi-agency work to tackle domestic abuse in the borough in relation to children and families, and on the progress of that work. This is in line with the Domestic Abuse Act 2021, section 59, and will enable the Safeguarding Children Partnership to both scrutinise and contribute to local strategic responses to domestic abuse as it affects children and families at both a strategic and practice level. Recommendation 10 (See paragraphs 6.95 – 6.97) It is recommended that the new Violence Against Women and Girls Strategic Group should agree the overall governance of the different strands of commissioning and delivery of Domestic Abuse Training by local services and providers to ensure co-ordination of training needs analyses, delivery of cross-cutting priorities and evaluation and that within this the needs of vulnerable children are recognised and met. This should include: the recognition of domestic abuse in its various forms41, including repeat incidents, the impact on children as well as mothers of domestic abuse, the use of appropriate assessment tools for adults and children (DASH/DARAC), the role of MARAC, and 41 See the revised definition of domestic abuse as set out in the Home Office draft Statutory Guidance Framework (Oct 2021) to be made final and published in 2022 under the Domestic Abuse Act 2021. Domestic abuse: draft statutory guidance framework (accessible version) - GOV.UK (www.gov.uk) 43 how local practitioners and services are supported regarding when and how to inform service users about Clare’s Law (The Domestic Violence Disclosure Scheme) and its value. It is understood that the Welsh Strategic Model may provide a good basis for this42. Parenting education and the delivery of the Healthy Child Programme Recommendation 11 (See paragraphs 6.99 – 6.104) The Wandsworth Safeguarding Children Partnership should request a review from the Commissioners of Health Services of the rationale for and provision of universal parenting education and parenting programmes by Midwifery Services and through the Healthy Child Programme within the borough and of any actions that may be required. This may be as part of the national initiative and actions set out by the Government in The Best Start for Life. Use of written agreements Recommendation 12 (See paragraphs 6.111 – 6.112) Wandsworth Social Care is recommended to review its use of written agreements with families, when they are not part of agreed Child Protection Plans or a formal agreement reached as part of work under the Public Law Outline43. Guidance should include when to share information about the content of a written agreement with key partner agencies. ____________ Malcolm Ward B.Soc.Sc., Master of Social Work Independent Lead Reviewer May 2022 42 Guidance-for-Local-Strategies.pdf (welshwomensaid.org.uk) 43 Public Law Outline A process of legal work with families as part of pre-proceedings when a Local Authority is considering seeking a court order to protect a child under the Children Act 1989. Stages are described in Statutory Guidance: DFE stat guidance template (publishing.service.gov.uk) After negotiation with parents about the concerns and what must change, and usually with the parents’ legal advisors, a letter is sent by the Local Authority setting out the agreed actions by all parties. This is effectively an agreement. 44 Panel Membership Panel Members were independent of the management of the case and able to speak for their agency and professionally on applicable standards Lead Reviewer: Malcolm Ward, Independent Social Worker, and Child Protection Consultant Chair of the Panel: David Peplow, Independent Chair/Scrutineer WSCP Panel Members Central London Community Health Trust (CLCH): Associate Director of Safeguarding Named Nurse Safeguarding Children Metropolitan Police: Detective Sergeant, Specialist Crime Review Group, Metropolitan Police NHS London South West Clinical Commissioning Group (CCG): Head of Safeguarding / Designated Nurse Named GP Wandsworth St Georges Hospital NHS Trust: Head of Safeguarding (for part of the Review) Named Midwife for Safeguarding Wandsworth Council: Head of Safeguarding Standards - Children Social Care Vulnerabilities Manager - Community Safety Partnership Housing Policy and Performance Officer - Housing Services Wandsworth Safeguarding Children Partnership: Business Manager Senior Business Support Officer ---------- Malcolm Ward May 2022 |
NC51232 | Death of an 18-year-6-month-old male in May 2017. Child T had been in hospital for three months prior to his sudden and unexpected death. At admission, he was in an extremely poor physical and emotional state; he had type 1 diabetes which he had developed at age 13 and diabetic control was inadequate. Agencies had been involved prior to January 2014 due to concerns that he was morbidly obese at primary school and attendance was low in secondary school. Ethnicity or nationality of Child T is not stated. Findings: prior to admission to hospital there was limited consideration of the child's lived experience; trust was placed on what the mother was saying without considering the impact on Child T; mother's avoidant behaviour was not effectively identified or challenged; professionals need to remember a person is a child until they are 18 years old; despite processes being in place to identify neglect when a child is Did Not Attend/Was Not Brought, they were not used in this case and a lack of professional curiosity and ownership of the case led to on-going neglect. Recommendations: to share the learning from this review with both adult and child safeguarding boards; to ensure that any child with a serious health condition has a written down multi-agency plan to coordinate and review the child's health care and support needs; to ensure that education providers take responsibility and the initiative to make available appropriate diabetes education and practical information in schools and colleges.
| Title: Serious case review: Child T. LSCB: East Sussex Local Safeguarding Children Board Author: Nicki Pettitt Date of publication: 2019 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Published on 25.06.19 Serious Case Review Child T Contents 1. Introduction page 1 2. The process page 2 3. Family engagement page 2 4. The case page 2 5. Analysis and learning page 4 6. Recommendations and questions page 14 1 Introduction 1.1.1 The East Sussex Safeguarding Children Board (ESSCB) agreed1 to undertake a Serious Case Review (SCR) in respect of a young man to be known as Child T2. They recognised the potential that lessons could be learned from this case about the way that agencies work together to safeguard children and vulnerable young adults in East Sussex3. 1.1.2 Child T died in hospital aged 18 years and 6 months. His death was associated with his type 1 diabetes which he had developed at the age of 134. Child T’s diabetic control was extremely poor. There was a long history of missed appointments along with poor school attendance. 1.1.3 Child T had been in hospital for over three months. At admission he was in an extremely poor state, both physically and emotionally, and his presentation indicated severe neglect which had started during his childhood. An adult safeguarding enquiry was being undertaken at the time of his death in May 2017. 1.1.4 Child T lived with his Mother prior to his admission to hospital. Mother told professionals that he had no contact with his father. 1.1.5 Learning has been identified in this review regarding the need to ensure that frequent missed appointments and poor compliance with medication for a life threatening condition receives a robust response that considers the risks associated with the lack of engagement. This should include children being treated within adult services between the ages of 16-18. Learning was also identified about the need to consider a child’s lived experience, improving consideration of mental capacity and knowledge of self-neglect, and the need for a written down and reviewed plan, involving the appropriate professionals and the family that identifies the support required. 1 Decision made in February 2018 2 It is acknowledged that Child T was an adult at the time of his death, however, much of this review also concerns his childhood. Rather than interchange language e.g. child, young person, young adult etc. the SCR will use the term ‘child’ to refer to ‘Child T’. 3 The case was initially referred to the Safeguarding Adults Board (SAB) for consideration of a safeguarding adult review. However, in view of the fact that Child T had only fairly recently turned 18 and his death arose as a result of complications of his diabetes secondary to the very poor management in childhood, the SAB concluded that this case would be most appropriately considered by the ESSCB. 4 The immediate cause of death was aspiration which is likely to have been a consequence of impaired stomach motility due to damage to the nerve supply to the stomach as a result of long-term very poor control of blood sugar levels. 2 2 Process5 2.1.1 A chair and an independent author were commissioned6 alongside a panel of local professionals who met on a regular basis to undertake the review. Chronologies and Individual Management Reviews (IMRs) were requested from all the agencies involved, and professionals involved at the time were involved in discussions about the case. 2.1.2 This report has been written with the intention that it will be published, and only contains the information about Child T and his family that is required to identify the learning from this case. 3 Family engagement 3.1.1 Family engagement was planned with Child T’s mother (to be referred to as Mother in this report) and members of Child T’s maternal family who were involved at the time. Mother did not respond to attempts to meet with her. Members of the maternal family spoke to the lead reviewer at the end of the process. The police investigated the matter following receiving information shared during the SCR, and a decision was made in March 2019 to take no further action. 4 The case 4.1.1 The SCR looked in detail at agency involvement with Child T and his family from January 2014 until he died in May 2017. However there had been involvement prior to this date due to concerns that Child T was morbidly obese when in primary school, and that his school attendance was poor when he was in secondary school. This report will focus on the latter involvement in order to ensure that the learning identified is most relevant to current systems and practice in East Sussex. It is clear however that Child T had a number of predisposing vulnerabilities and there had been long-standing concerns about the level of care and support provided by Mother, including in respect of his health needs and Mother’s willingness and ability to accept medical advice. 4.1.3 Child T was diagnosed with type 1 diabetes7 in 2012, when he was 13 years 4 months old. He was provided with support by the paediatric diabetes team (PDT) at his local hospital and received additional monitoring and prescriptions from his GP. It became apparent very quickly that Mother was not complying fully with the insulin regime and dietary advice given. As he got older, Child T was not engaging in his own diabetes care as would be expected of a child of his age. 4.1.4 A referral was initially made to CAMHS8 in 2010, but Child T did not meet the criteria for a service. He was again referred in 2014 and did not attend the appointment offered. Child T then consistently refused to agree to a referral for any psychological support. 4.1.5 Child T should have attended the diabetic transition clinic9 from age 15. It emerged, when Child T was seen in the clinic for the only time in May 2014, that both Mother and Child T were struggling to comply with the required insulin regime and more generally with accepting the diagnosis. Mother admitted that Child T’s last injection of insulin was in August 2013, around nine months previously. Child T only attended the diabetic transitional clinic once, and was transferred to the adult diabetes and endocrinology service (ADES) in September 2014. All appointments with ophthalmology for retinal screenings were also missed. 5 It was the aim of the review to be compliant with Working Together 2015 which states SCRs should be conducted in a way that; recognises the complex circumstances in which professionals work together; seeks to understand precisely who did what; considers the underlying reasons that led to actions; seeks to understand practice from those involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. 6 Chair David Kemp is Head of Prevention at East Sussex Fire & Rescue Service. He is the Safeguarding Lead for adults and children and is responsible for developing the strategic direction of the suite of prevention strands delivered by the Service including liaison with wider partners. Author Nicki Pettitt is an independent social work manager and safeguarding consultant. She is an experienced chair and author of SCRs and is independent of ESSCB and its partner agencies. 7 Children diagnosed with type 1 diabetes require on-going medical support. It occurs when the body does not produce enough insulin. This means that glucose produced in the breakdown of food (digestion) stays in the blood. Those with type-1 diabetes are insulin dependent. 8 Child and adolescent mental health services 9 In order to ensure the smooth transition of children into adult services a transition clinic is available for children aged 15, before they enter the adult system after their 16th birthday. It is an opportunity for children to meet the professionals they will be working with going forward. 3 4.1.6 Child T’s school attendance was around 67% early in 2014 and he was noted to have lost a lot of weight. Education attendance officers were involved, and Mother was informed of their intention to prosecute her in July 2014. School attendance then increased for a short period and Mother avoided prosecution. During his time in Year 11 (2014-15) Child T often reported to the school first aid room with headaches and stating that he felt unwell. This information was not shared. 4.1.7 After around a year of non-attendance, Child T and his mother attended the ADES diabetic clinic in July 2015. His health had clearly deteriorated due to poor diabetic control, and a podiatrist diagnosed nerve damage in his feet10. Child T refused to see a psychologist despite admitting he rarely took his insulin. The GP was informed and no further action was taken by either the ADES or GP. 4.1.8 Child T started a college course in September 2015. He was noted to be unmotivated and often complained of feet and back pain. By December 2015 Child T was no longer attending college, and Mother later informed them that due to his health issues he would be leaving. This was not challenged or questioned further. 4.1.9 In November 2015 the GP saw Child T and Mother and was sufficiently concerned about the poor diabetes management to ask his receptionist to contact CSC. After a discussion between the CSC screening social worker and the specialist health visitor (the health representative within the screening team) it was agreed that it was a health issue that was best managed by the GP and diabetic service. 4.1.10 A call was made to the MASH11 in February 2016 from a family member. They were very concerned for Child T, stating his weight had dropped ‘from 23 stone to 9 stone’, that he was emaciated and had been bedridden since Christmas 2015. After a check with the GP surgery it was agreed that it remained a health responsibility to monitor the issues. There is no evidence that anyone at the GP surgery followed this up. 4.1.11 Following this there were a number of DNA/WNB12s but Child T was seen again at diabetic clinic in April 2016. The diabetic consultant agreed to speak to the GP about concerns about weight loss, back pain and missed appointments. Nursing staff were concerned about how ill and malnourished Child T looked, and escalated their concerns to their line manager and the ESHT adult safeguarding team (see 5.3.4 below). Child T missed all other appointments including a joint clinic with the diabetes specialist nurse and dietician in September 2016. He was not seen again at clinic until his hospital admission in February 2017, around ten months later. 4.1.12 The post-16 education team were also trying to contact Child T over these months. They had no response despite trying phone calls, letters, and social media contact. 4.1.13 In February 2017 Mother called an ambulance and Child T was taken to hospital, with the reason for the call being recorded as ‘worsening loose stools’. He was referred to adult social care and police as a safeguarding issue by the hospital and the ambulance service due to serious concerns about self-neglect and possible neglect and physical abuse from Mother. His diabetes management, general health and physical condition were extremely poor and he was reported by Mother to be depressed and anxious. She claimed he had stated the day before that he wished to die. 4.1.14 Child T’s immediate medical needs were addressed. The priority was to try to improve his blood sugar control, help him gain weight, treat his pancreatic insufficiency and encourage him to mobilise. It was generally recognised by professionals that he might require a long period in hospital before being suitable for rehabilitation. The mental health liaison team and the liaison psychiatrist became involved and saw Child T on the ward. There were no assessed indicators of an acute mental health need. The impact of poor diabetes management over a number of years was evident with Child T having a number of physical health problems and the physical signs of neglect. This included 10 Peripheral neuropathy 11 Multi-Agency Safeguarding Hub (the front door for a CSC assessment or a child protection investigation.) 12 Did not attend/Was not bought 4 evidence of unusually early onset of diabetic neuropathy13. He also had a diagnosis of exocrine pancreatic insufficiency.14 4.1.15 While in hospital, Child T often refused to cooperate. This included refusing medication (he only took his insulin on occasion and also often refused other required drugs); occupational therapy and physiotherapy; podiatry treatment; to wash or have his sheets changed; to be weighed; to move to an air mattress (despite pressure sores emerging); to have mobilising electric treatment for the pain in his knees and feet; and to eat appropriate food. While in hospital his diet was described as erratic, resulting in high blood sugar levels, and he had regular hypoglycaemic attacks. 4.1.16 Mother visited daily and would not adhere to the stipulated visiting times. Child T preferred her to undertake his physical care needs and she usually spoke for him. She was made aware of the safeguarding concerns early in his stay, and the need for Child T to remain in hospital while this was further considered. Concerns continued to be voiced by nursing staff about her understanding of Child T’s diabetes and the required treatment, her attempts to undermine health staff, and about the overly dependent relationship between Child T and Mother. 4.1.17 Child T died on the ward on 23 May 2017. His death was sudden and unexpected15. The response to Child T’s death will be considered in the analysis below. 5 Analysis and learning The review has established that analysis is required in the following areas, and it is here that learning can be identified. Child’s lived experience Transition Persistent DNA/WNB and neglect Self-neglect and mental capacity Plans and working together Child’s lived experience: 5.1.1 Those who knew Child T have stated that, with hindsight, it can be seen that his life was ‘wretched’. There is no direct knowledge about the conditions he was living in at home as no visits were undertaken during the scope period of this review. The ambulance crew who attended in February 2017 made no comment on the state of the home. Considering his physical state and having information from the time he spent in hospital, it can be assumed that the environment at home was very poor. 5.1.2 Those who got to know Child T, including staff at the college he attended and hospital staff, believed he had no thoughts of the future, and that he had given up on life. With his extreme weight loss, his loose bowels, his pain and lack of feeling due to nerve damage, he was described as ‘fading away’. Child T was severely obese with a weight of 117 kg (over 18 stone) when he was 9 years old. Following the onset of diabetes his weight plummeted. He weighed 59 kg (9 stone) at 14 years of age and was 45.5 kg (7 stone) when weighed in hospital in March 2017. Only one weight was taken in hospital due to Child T’s refusal to be weighed again. 5.1.3 As a teenager Child T appears to have had a sad existence. There had been no concerns about him in primary school other than his weight, and early assessments undertaken by CSC (in 2005) observed a warm relationship between Child T and his mother and between Child T and his maternal grandmother. It is not clear when or why things changed. Child T spoke of his deceased 13 Nerve damage due to sustained high blood sugar levels in the circulation. 14 EPI can cause frequent diarrhoea and weight loss. 15 Although he had a long history of very poor diabetic control he did not die from diabetic ketoacidosis, which is the most common cause of death for those with poorly controlled diabetes, but from the impact of damage to the nervous system controlling the stomach, which is also linked to poorly controlled diabetes 5 grandparents with affection, and it appears that when they were no longer involved in his care there was a deterioration. When asked by a teacher how the holidays had been, Child T stated he had nothing to do so he stayed in bed. Child T had two accidents that professionals were aware of, firstly a broken arm at around age 14 when playing football, and then when he fell down stairs and fractured a vertebra at age 15, leaving him with back pain. This, along with a degree of eyesight loss, may have led to him becoming increasingly isolated and withdrawn. 5.1.4 While in hospital Child T presented as a much younger child. He had very little awareness of how to care for himself, and did not appear to be concerned about lying in soiled clothing or bedding. He would have been entirely dependent on Mother prior to his admission, as he was bedbound, his only link with the outside world would have been Mother and his i-pad. There is no evidence that Mother requested any help or support, other than when she contacted CSC in May and November 2015. Firstly because they were homeless and required accommodation, advice was provided. Secondly when she requested a referral for O.T support, stating that Child T had not bathed for 6 weeks, had lost a lot of weight, and had spinal issues. No action was taken by CSC as this was deemed to be a health issue and the information was not shared with those who knew Child T in health, such as the Adult Diabetes and Endocrinology Service (ADES). 5.1.5 Attempts were made to improve the situation for Child T when he was younger, for example the school nurse trying to engage Mother in managing Child T’s obesity and making a referral to CSC when Mother did not respond, the threat of prosecution for poor school attendance, and the referrals to CAMHS. However Child T appeared to effectively be invisible to services for much of his teenage years. There were few attempts to engage with Mother or Child T to offer support other than what was required due to his diabetes. It is possible that assumptions were made that Mother would not be willing to accept support, as she had not agreed to family support when asked by the school nurse in 2007. Mother told staff in hospital prior to Child T’s death that she suffered with depression and was prescribed anti-depressants. 5.1.6 Neither Mother nor Child T appeared to have any trust in professionals. It is not entirely clear why this was, but it became evident in hospital that Mother was very concerned that Child T may be taken away from her. It is likely he was aware of this too. When Mother tried to discharge him from hospital and was told this was not possible, Child T said he would discharge himself, but never did. In fact he stated that he wished to remain in hospital long-term. There were a number of examples of Mother undermining professionals in front of Child T, and examples of Child T influencing Mother and persuading her to do as he wished, despite the advice of professionals. While he was in hospital the two social workers involved in the case spent time trying to get to know Child T and they recorded that Child T had stated that Mother needed him and he saw himself in the role of looking after her. They concluded that the relationship was complex and interdependent. 5.1.7 It was hard for professionals to hear and listen to Child T’s voice. He was described as painfully shy. He rarely maintained eye contact with professionals and would look to his Mother to answer any questions. The voice of his Mother is what is most evident in agency records, and those involved described her as answering questions aimed at Child T, and speaking over professionals and anyone else in the room. This led to the voice of the child actually being the voice of the parent in the majority of contacts. 5.1.8 Mother was not always honest, and often deflected or avoided professional concerns. For example when questioned regarding his weight loss, it is his Mother’s voice that is recorded and she stated that this was as a result of his improved active lifestyle and healthier diet since diagnosis. The Paediatrician involved recalls doubts about Mother’s explanation but did not have further opportunities to follow this up due to non-attendance at clinic appointments. 6 Learning 1. Prior to admission to hospital there was limited consideration of the child’s lived experience when professionals were working with the family. Trust was placed on what Mother was saying without considering the impact on Child T, and without speaking to him directly about his life. 2. Mother’s avoidant behaviour was not effectively identified or challenged. This was a risk in a case where Child T had a potentially life-threatening health condition. Transition 5.2.1 The review has identified a number of transitions in the period covered by this review. They were all likely to have had an impact on Child T, and on the professional involvement with him. The family moved and had what appears to be a period of homelessness staying with a family member, Child T moved from school to college, he changed GP surgery in July 2015, and he transitioned to adult services for his diabetes. 5.2.2 When moving to the care of the ADES there was a risk that any relationships that Child T had made with professionals in the CDT could have been lost, and the ADES would not have had the same awareness of Child T’s history, including the poor engagement and non-compliance with medication. It is good practice that the PDT starts talking to families and children when a child is around 12 years old about the need to work towards the independent management of their diabetes. There are also hand-over meetings with adult diabetes nurses to ease the transition. The lack of any meaningful engagement with the transitions service (just one appointment was attended) meant that Child T became the responsibility of the ADES with very limited transition. For some children and parents this transition time is difficult and a big adjustment. For Child T, who had a history of missed appointments, it is not clear how difficult this was for him. 5.2.3 When a young person with diabetes joins the adult service there are entirely new staff to get to know, the clinic times are different, and the involvement of the parent/s reduces. The consultants increasingly speak to the young person rather than the parent. There are capacity and practical issues for adults requiring diabetic support. The PDT has around 120 children in its care at any one time, whereas the ADES have thousands. The PDT knows every child well, but this level of knowledge and relationships is harder in the ADES, and with Child T’s poor attendance there would have been very little opportunity for building relationships. 5.2.4 When Child T left school and went to college, this would also have been a big change for him. No written information was shared from the school to the college. He left before the end of the first term. YES16 were not informed that he had then become NEET1718. When YES found out that he was NEET due to illness and was receiving employment and support allowance, they made efforts to meet him. Due to the family moving they did not manage to find him19, and this has identified learning for the agency regarding the need to gain access to other data bases for this type of information. 5.2.5 During this time there were some indicators that Mother may have needed help with Child T, and may have accepted support. In Oct 2015 Mother spoke to college staff about her worries that Child T was increasingly withdrawn and that she was struggling to meet his dietary needs. This may have been an opportunity for an intervention to see what support they required, but with the college unaware of the concerns about missed appointments and inconsistent compliance with the medication regime, this was not identified, responded to, and shared. 16 Targeted information, advice and guidance (IAG) service for 16-18 year olds. Commissioned by East Sussex County Council and delivered by Medway Youth Trust. 17 Not in Education Employment or Training. 18 Section 13 of the Education and Skills Act 2008 places a duty on all educational institutions (maintained schools, academies, colleges, and education and training providers) to tell their local authority when a young person is no longer participating. This duty is applicable if a young person leaves an education or training programme before completion (i.e. ‘drops out’) and enables local authorities to take swift action to encourage the young person to re-engage. 19 Local authorities have a duty to track all 16 and 17 year olds. 7 5.2.6 Mother had contacted CSC in 2015 asking for housing and OT support. She had also spoken to the GP in November 2015. However there is no indication that Mother had raised concerns or sought assistance regarding Child T's medical needs and deteriorating health in the period between his last diabetic clinic appointment in April 2016 and his hospital admission in February 2017, at which point his presentation can only be described as one of severe neglect. 5.2.7 NICE Guidelines were published on transition in February 2016, less than a year after Child T’s 16th birthday. They note the importance of a planned and coordinated transition period for a young person with health or care and support needs. They suggest that a single practitioner should act as a 'named worker' to coordinate the transition care and support before handing over their responsibilities as named worker to someone in adults' services. It is also stated that they should be someone with whom the young person has a meaningful relationship. 5.2.8 It is acknowledged that once young people have transitioned to adult services there is potentially a need for support after transfer. NICE states that if a young person has moved to adult services and does not attend meetings, appointments or engage with services, adult health and social care, working within safeguarding protocols, should: try to contact the young person and their family, follow up the young person, and involve other relevant professionals, including the GP. 5.2.9 A national diabetes transition audit, considering data from 2003 – 2014, was published in 2017. It considered the impact of transition to adult services and found that there was relatively little difference in key indicators such as HbA1c20 ttesting following transition. There are a higher number of diabetic ketoacidosis (DKA)21 admissions post-transition however, but it was thought that this may be due to the fact that DKA rates increase with increasing duration of diabetes. In Child T’s case, while his diabetes was very poorly controlled, and he had high blood sugars and hypoglycemia at times, there is no evidence he had any DKA episodes after diagnosis or while in hospital. 5.2.10 The transition to adult diabetes services and from school to college allowed a child who was already isolated and suffering with ill health due to poor compliance with his diabetes care to avoid services, be neglected and neglect himself, as will be developed further below. Learning: 3. At times of transition there can be increased risk for children with serious health needs. However it provides a good opportunity to seek and share information, reassess, re-engage and put plans in place for the child’s future care and support. 4. Professionals need to remember that a person is a child until they are 18 years old. Appropriate safeguarding supervision should be sought and children’s procedures followed when required. Persistent DNA/WNB and neglect 5.3.1 There is evidence that there had been concerns about Child T and the parenting he received from 2005, none of which met the threshold for safeguarding interventions. In 2007 the school nurse was concerned that Child T was overweight and that Mother was not cooperating with support or advice given. She made referrals for support from the community paediatrician and dietician, followed by a referral to CSC as Mother had avoided all appointments. Mother withdrew her consent following the referral, meaning the school nursing service had no further formal involvement. The school nurse had been persistent in trying to engage Mother and her referral to CSC shows her concern, particularly because Mother would not agree to a referral for family support. The case was not 20 Check for levels of glucose in the blood and glycated haemoglobin. Will give an average blood glucose level over two to three months. 21Where there are consistently high blood glucose levels a DKA can occur. A severe lack of insulin means the body cannot use glucose for energy and the body starts to break down other body tissue as an alternative energy source. Ketones are the by-product of this process. Ketones are poisonous chemicals which build up and, if left unchecked, will cause the body to become acidic – hence the name 'acidosis'. DKA is a life-threatening emergency. (Diabetes.org.uk) 8 discussed with safeguarding leads in the Trust however, and the focus was on the medical issue and non-engagement rather than the lived experience of the child. No formal family assessment was expected to be undertaken by school nurses or other health professionals such as the dietician at the time. 5.3.2 Once Child T was diagnosed with type-1 diabetes, the risk to his health and wellbeing from non-engagement increased. The PDT recognised the lack of meaningful engagement and offered support, including home visits and a referral to CAMHS, as they thought at least part of the issue was a lack of acceptance of the diagnosis. As there was sporadic attendance this may have reassured professionals about on-going compliance. Missed appointments would be reappointed in the hope that Child T would be bought to the next appointment. Patterns of DNA/WNB in this case were that Mother would bring Child T on occasion, and would have excuses for missed appointments. The level of missed appointments accelerated as Child T got older. He missed 5 of the 6 appointments for the transitions service between March 2014 and July 2015. 5.3.3 From 2014 Child T experienced rapid weight loss, showed signs of poorly controlled diabetes and by 2015 he had developed peripheral neuropathy. At this time Mother stated that his poor blood sugar control could be because she would sometimes forget to prepare Child T’s insulin for him to administer, that he also did not like to inject himself, and that they preferred to manage his diabetes by diet. Information about the fact that this was not possible with type 1 diabetes was shared a number of times with Child T and his Mother. The focus for professionals remained upon education and compliance with treatment and it is not documented whether it was considered that the safeguarding threshold was reached. 5.3.4 In April 2016 concerns about Child T’s weight loss and poor diabetes control led to a referral to ESHT Adult Safeguarding Team by the ADES manager and an entry was put onto Datix22 (Risk Alert). There is no record of this in the ESHT Adult Safeguarding case notes however so it is not known if advice was given or support offered, or what the outcome of the risk alert was. As Child T was a child at the time, the matter should have been redirected to the ESHT Child Safeguarding Team. Again, there is no evidence that this happened. Interviews undertaken with professionals as part of the SCR indicated that shorter clinic appointments in adult services and lack of engagement restricted their assessments. The focus was more upon his mental and physical health, and non-attendance would impede professionals challenging the family or recognising other issues. There was no exploration either to assess if neglect or abuse could have been a contributing factor in Child T’s case. The Mother seemed plausible to staff and they did not make the link between non-attendance and neglect. 5.3.5 Child T was appropriately referred to the Child and Adolescent Mental Health Service (CAMHS) and then to the psychologist attached to the ADES. One of the referrals described Child T and said he was ‘shy, non- communicative and avoided eye contact’ during consultations. This sort of behaviour appears to have been interpreted as a sign of Child T not having accepted the diabetes diagnosis, a view reinforced by Mother. Child T did not attend any of the CAMHS or psychology appointments and declined the offers of further support that were made on a number of occasions. No action was taken about the lack of attendance other than informing the referrer and the GP. 5.3.6 The nutrition and dietetic department also experienced a pattern of non-attendance for clinic appointments. They went on to discharge him in 2017 when he failed to attend his final appointment. Those involved across disciplines knew that attendance was an issue in the family and did not challenge this rigorously or adequately question why this was an issue. There were clear signs when Child T was seen that his health was deteriorating. On one occasion Mother admitted in the diabetic clinic that Child T had not had his insulin for nine months. There was no professional curiosity regarding why Mother did not seek help and there was no assessment of the risk to Child T of him not taking such a crucial medication for his condition. Mother also later admitted not giving Child T his vitamin D for 6 months as she didn’t want to upset his stomach. 22 An incident reporting system. 9 5.3.7 When Child T was in hospital issues were identified with his eyesight. Child T stated he had never had an eye test. The RNIB website states that ‘if you have diabetes, it’s really important for you to have regular eye tests and diabetic retinal screenings. It’s important that the changes diabetes causes in your eye are picked up early because if treatment can be given at the right time, it can help prevent sight loss’. The PDT were informed, as was the GP, that Child T had not attended any of the ophthalmology appointments he was invited to. 5.3.8 There appears to have been an assumption that Child T was ultimately the GPs responsibility, and all letters regarding missed appointments were sent to the GP, although the information regarding the refusal of services such as psychology was not explicitly shared. Child T was registered with two GP practices during the period being considered, moving in July 2015. The GPs working at the second surgery, when concerns about lack of compliance were escalating, were mainly locums and the surgery has since closed. The assumptions that appear to have been made that the GP was seeing Child T and would discuss and consider the DNA/WNB was optimistic, without checking whether this was the case. Safeguarding is everyone’s responsibility and in this case the dots were not joined together and assumptions were made about what other professionals were doing. 5.3.9 Single agency learning has been identified during this review in regards to GP services. Particularly that there was very limited action taken when multiple appointments were missed and that prescriptions were being issued without any adequate follow up or contact. 5.3.10 In children’s services DNA/WNB is recognised as an indicator of neglect. This is not the same in adult’s services, where an adult with capacity can choose whether to attend or not. In this case there were a large number of missed appointments while Child T was a child in the eyes of the law. It appears that DNA/WNB were not consistently picked up with regards to 16-18 year old children in health agencies at the time. Health safeguarding supervision also didn’t cover 16–18 year olds. There are reported improvements in regards to both these areas since Child T was receiving services. A recommendation has been made in respect of this. 5.3.11 As well as missing the majority of appointments with health professionals, school and college attendance was also an issue. His school reported that Child T had a good relationship with his year head; however his school attendance was poor, especially in the later years of secondary school. When Child T was 15 years old (in Year 10) he was referred to ESBAS23 as his overall attendance was 62.8% and the school stated that Mother did not communicate with them about the absences. There is no evidence of what the school tried to improve attendance before making the referral. Child T and his Mother attended a meeting with an ESBAS practitioner and the school. It was noted that Child T was type 1 diabetic, that they had been homeless and were now living with a family member, and that Child T did not like school. There is no evidence that the meeting discussed how Child T’s health was, including the significant weight loss that was evident at this time. There is no mention in the referral to any wider concerns which the school may have had. It appears that the diabetes was accepted as the reason for poor attendance but there is no evidence that this was checked with health professionals, with the recommendation for the school to discuss Child T with the school nurse not completed. This may have been because Mother had previously refused permission for the school health nurse to be involved. This was not challenged or readdressed with Mother at this stage. 5.3.12 The school recognise that they did not communicate with health care professionals about the concerns around Child T’s health and weight loss generally or following this meeting. Assumptions were made about his weight loss and poor attendance being an understandable part of his health condition. They acknowledged that their expectations of Child T were low. 5.3.13 The college that Child T moved to in Year 12 had a lot of contact with Mother and found her attentive and caring to Child T, and staff found her approachable. She notified the college team of hospital appointments and concerns she had, which she said were shared by professionals, around 23 Education Support, Behaviour and Attendance Service. Sits within the local authority Inclusion Special Educational Needs and Disabilities Service. 10 his weight. Child T would often appear sad and unwilling to engage with peers. His mental state was described as ‘depressive’ by those who knew him. He could get quite ‘angry’ and ‘agitated’, reporting to his college mentor that he ‘did not like what he had become’. Arrangements were put in place in college for Child T to have comfortable seating to help with his pain. He was offered time out of class with the support of his mentor, and a referral was made to one of the college’s Intensive Personal Advisors (IPAs) who offered Child T 1:1 sessions to discuss any issues, concerns, feelings and problems he may have been experiencing. Child T engaged once with this service. The college were aware that Child T’s poor attendance then removal from college were due to his health issues, but did not speak to any health professionals regarding this. This was partly due to a new team providing the course that Child T had enrolled on, with inadequate staff awareness of how to identify and escalate safeguarding concerns. 5.3.14 The reason for an absence or DNA/WNB should always be sought and there should be professional curiosity regarding this, along with consideration of other missed appointments within and outside of the service. In this case the missed appointments and poor attendance at school and college meant that Child T’s health, educational and social needs were not being met. This was a case of neglect that potentially required assessment and safeguarding intervention. This was not considered by professionals any time before his admission to hospital at age 18. 5.3.15 CSC identified single agency learning when considering the response to the anonymous referral made in 2015, and recognise the need for CSC to understand their role when the needs of a child with a life threatening or serious health condition are not being met. They also identified the need to consult with and be advised by health professionals. In cases like these assessments need to be holistic and consideration should be given to how to safeguard the child, including the legal options available to CSC and Health 5.3.16 ESHT Acute also identified helpful learning that will ensure improvement action is taken. This includes the need to ensure that non-engagement during transition clinics should be raised with the safeguarding team and a plan of action documented in the child’s record, and that any complex medical cases affecting children where non-engagement is a feature must have safeguarding support via supervision. Consideration should also be given to undertaking a home visit. Learning: 5. Despite processes being in place to identify neglect when a child is DNA/WNB, they were not used in this case, and a lack of professional curiosity and ownership of the case led to on-going neglect of/by Child T. 6. All 16 and 17 year olds being treated within adult health services should be subjected to children’s safeguarding procedures if the need arises. 7. Schools and colleges should seek information from health professionals and share concerns they have for a child’s health. It is noted that NICE guidelines place the emphasis on health professionals, however education staff should also take the initiative and responsibility. A joined up approach is essential. 8. Non-health professionals should understand more about the impact of diabetes on children, including the links between mood and blood sugar levels and the wider emotional impact of the condition. Self-neglect and capacity 5.4.1 It is a difficult balance for professionals between protecting adults from self-neglect and allowing them to make decisions for themselves that may not be in their best interests. The Care Act Guidance 2014 recognises self-neglect as a category of abuse and neglect and this is reflected in the Safeguarding and Self Neglect section of the Sussex Safeguarding Adults Policy and Procedures 11 of the East Sussex Safeguarding Adult Board (ESSAB) website (written in 2013 and reviewed in 2014) with training in this area. Safeguarding in relation to self-neglect applies whether the adult has mental capacity or not. There is no evidence that these were used in respect of Child T although concerns were expressed by A&E and ambulance staff on his admittance to hospital in February 2017. It was also evident Child T was self-neglecting whilst he was an inpatient on the hospital ward. Self-neglect had not been identified as an issue for Child T prior to his admittance, although on admission to hospital he was found to be in a serious state of neglect and / or self-neglect that occurred whilst he was living in the community. 5.4.2 College staff stated that Child T did not present as a young person who was being neglected or who was neglecting himself, however they noted that Child T’s clothes would ‘hang off him’ and appeared to be too large for his frame. They had not known him when he was very overweight, so would not have seen the drastic difference in him after he lost over half of his body weight. Staff from Child T’s school and college accept they had little knowledge about diabetes and the signs of neglect / self-neglect that they should have been looking out for. There was limited communication with the PDT and no contact with ADES and education professionals did not know that Child T’s attendance at appointments and compliance with medication was so poor. 5.4.3 It is significant that Child T’s maternal grandmother had type 2 diabetes. This appears to have led to a belief being held by Mother and Child T that his type 1 diabetes could be managed without insulin and by him losing weight, as is often the case with type 2 diabetes. In clinics Mother stated that Child T refused to inject insulin and that he preferred to have his diet managed instead. Practitioners regularly gave verbal clarification that he had type 1 diabetes and needed a regular insulin regime. There was little indication that Mother and Child T accepted this and his compliance remained poor, even when he was an inpatient in hospital. 5.4.4 Child T experienced rapid weight loss from 2014, and showed other serious signs of poorly controlled diabetes, including nerve damage. Mother demonstrated resistance to the idea of re-adjusting the insulin regime if that meant increasing the number of injections per day. Both Mother and Child T were honest about him not always taking his insulin. The professional response was to offer psychological support, which was again refused. The focus for professionals remained upon education and compliance with treatment without consideration of the risk to Child T and whether this was a safeguarding issue. 5.4.5 When he was admitted to hospital Child T was very unwell, and in a poor general physical state. It is reported that ‘he looked dishevelled and malnourished, had broken teeth, poor eyesight, open sores on his head and legs, and bruising to the groin and other body areas. There was a dressing, reported to be four months old, on his right foot which required surgical treatment to remove it. He was in urinary retention and had a four-month history of loose stools prior to this admission and associated continence issues’. He was reviewed by the consultant in diabetic medicine the morning after admission and a plan was put in place regarding the treatment required for management of his diabetes and further investigations which were required. The hospital does not have a ward specifically for patients with diabetes. 5.4.6 While he was in hospital there were concerns about Child T’s willingness to help himself, his understanding of his condition, and Mother’s insistence on undertaking much of the care of Child T herself. Mother would engage well at times, be polite and open to suggestions and recommendations, and at other times she could be quite abusive to the professionals she encountered. Her interactions were described by hospital staff as ‘erratic’. Child T responded by regressing and being very child-like in Mother’s presence. On the occasions when Mother was not present Child T was more likely to engage in superficial conversations with staff. 5.4.7 Child T was assessed by the mental health liaison team and a psychiatrist while he was an inpatient. Despite there being no identifiable mental health disorder, the MHLT continued to offer low level support and assessment while Child T and his mood was often described as low. Child T was 12 prescribed Zopiclone24 whilst in hospital, Consideration of the effects and side effects of this drug, prescribed dosage and frequency for Child T needed to be considered in relation to its potential impact on his ability to self-care and make decisions with regards to his overall health and wellbeing. 5.4.8 There was consideration from hospital staff on a number of occasions regarding Child T’s capacity25. Early in his hospital stay a mental capacity assessment was undertaken in respect of the need to insert a catheter and a best interest decision26 was made as Child T was unable to understand why the procedure was so important. No further best interest decisions were made as Child T was assessed as having capacity at other times. Diabetes and urinary infections can cause disturbance of mental functioning and have an impact on capacity. Physiological issues having an impact on capacity should be considered by professionals when undertaking MCA assessments. 5.4.9 There were concerns about Child T’s cooperation with what was required to help improve his physical condition while he was in hospital; Child T was administering his own Creon27 medication, but the dietician asked nurses to do this as Child T didn’t seem to be clear how much he was taking; he refused medication to stop his blood clotting after an operation; he stated he was scared of standing in case he fell, and this was why he refused to do any of the exercises the physiotherapists and nursing staff suggested; and he regularly refused to take his insulin. There was no evidence that self-neglect was considered or that the Mental Capacity Act (MCA) might be relevant in regards to ‘inherent jurisdiction’ (see 5.4.10 below). This could have been triggered in hospital due to Child T not engaging with treatment and his very poor self-care. 5.4.10 The High Court is able to intervene in the life of a vulnerable adult who possess capacity but still require protection for certain reasons. This includes not being able to take a decision freely because of coercion, undue influence or constraint. Child T could have been identified as one of these vulnerable adults, if legal advice had been sought in this case by health or social care professionals. 5.4.11 There was no consideration of Child T’s capacity prior to his hospital admission. The MCA applies from 16 years old. It appears no one knew him well enough to recognise the signs of control and coercion by Mother and the co-dependency between mother and son. There was also an opportunity to consider a MCA assessment for Mother as a carer due to concerns about her mental capacity in relation to Child T’s needs and her seeming inability to understand his type 1 diabetes. 5.4.12 The ESSAB28 published a safeguarding adult review in October 2017 regarding Adult A, and issues of self-neglect were central to the case. Learning was identified in regards to the need to raise staff awareness about self-neglect and in regards to thresholds for section 42 safeguarding enquiries, including the use of complex case procedures and multi-agency meetings in challenging cases. This learning is also relevant to Child T. Learning: 9. There is a need for all professionals to understand inherent jurisdiction and when it should be considered in relation to safeguarding concerns involving self-neglect and coercion and control in adults. 10. There is a need for robust application of the Mental Capacity Act with service users who are between 16-18 years old. 24 a nonbenzodiazepine hypnotic agent used in the treatment of insomnia, it may also be prescribed for other conditions. 25 As defined within the Mental Capacity Act 2005. Designed to protect and empower people who may lack the mental capacity to make their own decisions about their care and treatment. It applies to people aged 16 and over. 26 A Best Interest decision should be made where a Person (16+) lacks mental capacity to make a decision and needs others to make those decisions on their behalf. The consultant followed the ESHT guidelines on the Mental Capacity Act. 27 CREON (pancrelipase) is a prescription medicine used to treat with pancreatic insufficiency. 28 East Sussex Safeguarding Adult Board. 13 Plans and working together 5.5.1 In 2015 Mother appeared to have made some small attempts to gain help and support with Child T. She attended the new GP surgery with Child T, resulting in a conversation between the GP receptionist and CSC, she told the college she was worried about Child T, and she asked CSC for help with getting OT support. None of these actions resulted in any assessment or multi-agency liaison. 5.5.2 A number of agencies were working with Child T in isolation and had concerns that they did not share. There was no holistic plan for Child T and no meaningful professional overall ownership of his health care. Mother was plausible and this was reassuring, but it was clearly evident that she was not capable of ensuring her child’s health and care needs were met. The limited engagement regarding Child T’s serious health condition required improved communication and a plan to ensure the risks of the lack of engagement were considered and communicated to all of those involved, and were responded to prior to the health crisis that ultimately resulted in Child T’s death. 5.5.3 The appropriate plan could be a multi-agency healthcare plan or a team around the child plan as part of CAF/ early help or child in need provision. Either would have improved an understanding of Child T’s lived experience and very poor health, and would have provided him and Mother with support and challenge. These plans would have required consent however, and Mother and Child T were known to be difficult to engage. How the idea is sold to a family and how they are encouraged to accept it is crucial, and there is no evidence that any attempt was made to discuss the benefits of such a plan with Mother and/or Child T. 5.5.4 The school and college acknowledge they had very little insight into Child T’s health needs, and did not adequately consider the need for support or intervention. Diabetes UK29 provide details of individual health care plans (IHP) that can be used to detail exactly what care a child needs in school, when they need it, and who is going to give it. This should be drawn up with input from the child (if appropriate) their parent/carer, the PDT and/or diabetic transition team, the school nurse, and relevant school staff. It should include all of the information required about testing and use of insulin, the symptoms of hypo and hyper glycaemia, meals and snacks, and any other areas that the school needs to be aware of. It should be reviewed annually. In Child T’s case there was no plan in place. 5.5.5 When Child T became a hospital inpatient in 2017 safeguarding was recognised as an issue on admission and it was agreed that he required a safeguarding plan. The police were informed and decided not to investigate the matter as a potential child neglect issue. This has since been reviewed and the case was investigated while the SCR was being undertaken. A decision was subsequently made to take no further action. As his stay in hospital extended the safeguarding plan was not reviewed and completed. There were important issues left outstanding, for example the plan to request that the hospital photographer take photographs of Child T’s injuries. The safeguarding plan included practical steps, such as there being no closed curtains around Child T’s bed when Mother was visiting. What was missing however was a thorough and timely multiagency planning and risk assessment meeting to agree an action plan to mitigate risks identified in relation to Child T. 5.5.6 Child T’s safeguarding enquiry had been open for over 3 months and had not concluded at the time of his death. It is noted that he was not expected to die, although it should have been acknowledged that this is always a risk with long term very poorly managed diabetes. The Care Act 2014 requires local authorities to make enquires or cause others to make enquiries when they think an adult with care and support needs may be at risk of abuse or neglect in their area and to find out what, if any, action may be needed. This applies whether or not the authority is actually providing any care and support services to that adult. ASC have recognised more should have been done in the initial stages of the safeguarding enquiry to seek and share information and undertake a comprehensive risk assessment, and that a multi-disciplinary planning meeting should have been held at the beginning of the process. This may have resulted in a better understanding of the events that led to 29 A charity for people living with diabetes in the UK 14 Child T’s admission. MDT team meetings were held in hospital and they considered Child T regularly. They were however large meetings where Child T was discussed along with all other patients on the ward, with no case specific records made. No meeting was called to discuss Child T’s case, and the safeguarding concerns were not adequately investigated. 5.5.7 When it was mooted that there was the possibility that Child T could be discharged, a safeguarding outcome meeting was requested. This did not happen as there was appropriate challenge from the social worker regarding the plan for discharge as the diabetes remained unstable and Child T was still not mobile, so his discharge and the safeguarding meeting were postponed. The lack of a timely safeguarding meeting to plan the enquiries, with a review meeting after a set period of time, meant that there was no clearly recorded plan for the enquiry and no record of progress. The safeguarding enquiry was on-going at the time of Child T’s death. 5.5.8 The diabetic specialist nurse visited Child T on 11 occasions while he was in hospital. Certain medical plans were not followed through however, this included an appointment to see a gastroenterologist that was requested but did not happen. In light of the cause of Child T’s death, this appointment was essential. It appears that the request was lost within the hospital system. The hospital undertook a Serious Incident and RCA Investigation review shortly after Child T’s death and found systemic issues regarding the way that these referrals were made and responded to. An improvement plan is in place. 5.5.9 As his health improved in hospital, it was recorded that Child T’s mood appeared to improve. He showed increased engagement with those supporting him. When he was initially seen by the psychiatrist he was assessed as being of low risk of suicide, but there was a risk of continued self-neglect. It was stated that he was ‘at very high risk of seriously and possibly fatally neglecting himself.’ This was discussed with Child T and Mother. The psychiatrist recorded in February his intention to request that Child T be considered for a further MCA assessment to consider his capacity to make decisions freely due to coercion and undue influence or constraint of Mother, and that there might be a need to involve the court’s inherent jurisdiction. As shown above, this did not happen. 5.5.10 When a safeguarding enquiry is underway, it can be good practice to appoint an advocate. Given the complex nature of the relationship between Child T and Mother, an advocate could have been considered for Child T. This didn’t happen, the review was informed, because the social workers involved believed that Child T was able to express his views and understood what was happening. They believed that involving yet another person may complicate matters. 5.5.11 Issues have also been identified with the investigation following the death of Child T. The hospital ward followed the usual adult death procedures which included informing the Coroner as the death was unexpected. However, where a person dies having been subject of a safeguarding referral or enquiry, and the death is associated with the circumstances of the referral, as it was in this case, it should be reported to the Police. The Coroners officers were unaware of the previous safeguarding referral, so they also did not inform the police officers with responsibility for adult safeguarding concerns. It appears that the problem was that Child T had been on the ward for some time, the ward was not used to unexpected deaths in young people and did not know the process, the police had not remained involved following the initial referral, and the safeguarding assessment had not been progressed or completed. Learning: 11. Any unexpected death of a person, where neglect or abuse may have been a contributory factor, should be referred to the police. 12. Where there is more than one agency involved with a child and there are concerns, the professionals involved have a responsibility to initiate a plan that is written down and reviewed as necessary that outlines the expectations of professionals and family. 13. Where there are concerns regarding self-neglect, the hospital multi-disciplinary team (MDT) has a responsibility to implement the Safeguarding and Self Neglect procedures at the earliest opportunity and to consider the involvement of an independent advocate where coercion and 15 control is suspected or known. Mechanisms and processes to enable this need to be considered and applied including provision by the MDT of case specific multi-agency planning and risk assessment meetings to develop an action plan to mitigate identified risks 6 Conclusion and recommendations 6.1.1 Child T was an unwell, isolated and neglected young man. When he was admitted to hospital the level of self-neglect and neglect from his caregiver shocked those involved. Opportunities to provide preventative services were largely missed prior to his admission to hospital. There was a lack of professional persistence and awareness, particularly in light of Mother’s apparent lack of willingness to accept help. Safeguarding concerns were not identified until Child T was an adult and was admitted to hospital in a very poor state. Despite death being a known outcome of poorly controlled diabetes, while he was in hospital there was insufficient awareness of the gravity of this case by inpatient health care services to anticipate that his death was a real possibility. 6.1.2 There were a number of opportunities for prevention and protection that were not taken in this case. They include: The DNA/WNB policy not being appropriately followed when there was very poor attendance at the transitions clinics The diagnosis of nerve damage due to lack of compliance in July 2015 which was not recognised as potential neglect Lack of response to Mother’s admission that Child T had not had his insulin for a significant amount of time The school did not consider Child T’s health and support needs No support was offered when Mother told the college that she was not managing The GP recognised that Child T’s diabetes was not being managed and recognised he should share this information with CSC, but asked his receptionist to call The anonymous call to CSC in November 2015 sharing serious concerns that were not assessed The need to ensure all tests and assessments were completed in a timely way while Child T was an inpatient Lack of consideration of inherent jurisdiction following the psychiatric assessment in February 2017 despite significant concerns being raised about the possibility of serious and potentially fatal self-neglect 6.1.3 The need for communication from and to health professionals when a child or young adult has a serious health condition was a key finding of this review. In this case Child T was not as visible to the agencies with a responsibility for him as he should have been when he was living at home. When he was an inpatient and seen every day he was inappropriately assessed and supported. There was a lack of focus on his lived experience, limited understanding of his relationship with his Mother and carer, and no clarity about his capacity to care for himself going forward. 6.1.4 Children with a life threatening condition, including those within adult services at age 16 and 17, require a robust response to frequent missed appointments and poor compliance with medication. The response should consider the risks associated with the lack of engagement, and whether this is a safeguarding issue. 6.1.5 Extensive single agency learning has been identified, and a number of single agency recommendations have been agreed. They ensure that the need for improvement action that has been identified by the review is responded to with single agency SMART action plans. Some of the learning identified in this report is addressed by the single agency recommendations and by the thorough RCA / Serious Incident Process that was undertaken following Child T’s death. The lead 16 reviewer is also aware of other improvement actions being undertaken by the ESSCB and their partner agencies. This includes work being undertaken to strengthen transition arrangements. 6.1.6 Having considered the learning from this review that has not yet been addressed, the following additional recommendations and questions to be considered by the ESSCB and the ESSAB are provided for the relevant boards and their partner agencies to ensure that improvements are made. Recommendation 1 That this report is shared with the ESSAB. Recommendation 2 The ESSCB and ESSAB must ensure that the learning from this review is extensively shared and, through a quality assurance process, ensure that the required improvements have been made. This could include the key single agency learning identified in the IMRs. Recommendation 3 That the ESSCB makes a formal request to the Department of Health that the NICE guidance regarding service provision for children with diabetes is reviewed to ensure that education providers are also invited to take responsibility and the initiative in ensuring that appropriate diabetes education and practical information is in place for school and college age children. Recommendation 4 That the ESSCB makes a formal request to the Department of Education that the guidance for supporting children with medical needs in schools is reviewed to include clarity regarding the need for education providers to take responsibility and the initiative in ensuring that appropriate diabetes education and practical information is in place in school and colleges. Recommendation 5 The ESSCB and its partner agencies to ensure that any child with a serious health condition has a written down multi-agency plan to coordinate and review the child’s health care and support needs. Question 1 - for ESSCB How can you be assured that children between 16-18 with serious health conditions are recognised as children by all the professionals who work with them? This should include safeguarding training and supervision, and robust use of the DNA/WNB policies. Question 2 – for ESSCB and ESSAB How can the ESSCB and ESSAB be assured that professionals are supported in identifying and challenging self-neglect, lack of engagement, lack of compliance and avoidance by the main care giver, person with parental responsibility, young people and adults? Question 3 – for ESSAB How can the ESSAB be assured that professionals in a hospital setting are supported in identifying self-neglect and applying the relevant procedures in a timely manner to mitigate risk? |
NC042849 | Death of a 10 year old girl in October 2011 by hanging. Amy had been in contact with Specialist Children's Services (SCS) at various points regarding allegations of sexual abuse: in 2006, following suspicion that Amy had witnessed another child being abused and in 2008, following an allegation of abuse reported to the police by her father and later confirmed by Amy. Neighbours contacted both SCS and Amy's school with allegations of physical abuse and neglect and school staff had concerns regarding Amy's unkempt appearance and insufficient lunches. Amy's behaviour was characterised as suggestive of ADHD by her mother and GP as early as 2006, with a diagnosis being made in February 2010. Following the initiation of the Common Assessment Framework in late 2010, Amy was described as borderline Child in Need and it was agreed that a Team Around the Child (TAC) be set up. Amy's parents did not respond to a number of attempts to set up an initial TAC meeting; however a plan of intervention including referral to an educational psychologist and to an early intervention service were agreed in February 2011. Review considers issues of focus on the child; disability needs; working with hostile or resistant families and makes various interagency and single agency recommendations covering education services, children's social care and health services. Key recommendations include: the use of CAF and referral to children's social care are well understood and consistently implemented; schools have the necessary safeguarding systems in place and to a good standard; development of guidance for commissioners of health services so that, if Health Overview Reports are required in future serious case reviews, authors will have clear expectations as to their purpose and expected contents.
| Title: Amy: a serious case review LSCB: Kent Safeguarding Children Board Author: Kevin Harrington Date of publication: September 2012 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. This report is the property of the Kent Safeguarding Children Board. Page 1 of 41 Kevin Harrington Associates Limited AMY A SERIOUS CASE REVIEW Kevin Harrington JP, BA, MSc, CQSW On behalf of the Kent Safeguarding Children Board Chair Maggie Blyth Serious Case Review Panel Chair Keith Ibbetson September 2012 This report is the property of the Kent Safeguarding Children Board. Page 2 of 41 TABLE OF CONTENTS TABLE OF CONTENTS ................................................................................................. 2 1. INTRODUCTION ..................................................................................................... 4 2. DECISION TO CONDUCT THIS SERIOUS CASE REVIEW ......................................... 4 3. SERIOUS CASE REVIEW PROCESS .......................................................................... 4 4. METHODOLOGY USED TO DRAW UP THIS REPORT ............................................. 8 5. CHRONOLOGY ........................................................................................................ 8 5.1 Introduction ............................................................................................................. 8 5.2 Key events ............................................................................................................... 8 6. THE FAMILY .......................................................................................................... 11 7. THE AGENCIES ...................................................................................................... 12 7.1 Introduction ........................................................................................................... 12 7.2 Kent County Council, Specialist Children’s Services ............................................ 12 7.3 Kent County Council, Education, Learning and Skills ........................................... 13 7.5 Kent Community Health NHS Trust ...................................................................... 15 7.6 The General Practitioners ..................................................................................... 17 7.7 Maidstone and Tunbridge Wells NHS Trust ......................................................... 19 7.8 Kent and Medway NHS and Social Care Partnership Trust ................................. 19 7.9 Kent Youth Offending Service ............................................................................... 19 7.10 Kent Probation .................................................................................................... 20 7.11 Housing Provider ................................................................................................. 20 7.12 South East Coast Ambulance Service NHS Foundation Trust ............................ 21 7.13 KCA Drug and Alcohol Services ........................................................................... 21 7.14 Health Overview Report ..................................................................................... 21 8. ISSUES IDENTIFIED IN THE TERMS OF REFERENCE FOR THIS REVIEW ............... 21 8.1 What were the facts in this case? ......................................................................... 21 8.2 Did agencies listen to the “voice of the child”? Did agencies know what life was like for Amy? ................................................................................................................ 21 8.3 Were Amy’s needs appropriately assessed, with particular reference to the consequences of sexual abuse and neglect? .............................................................. 24 8.4 How were the outcomes of assessments used to inform practice and decision making in relation to Amy? Were Amy and her family appropriately engaged and involved by agencies? ................................................................................................. 26 8.5 How far was Amy helped to cope with the adverse circumstances in her life, particularly her sexual abuse? .................................................................................... 27 8.6 Did assessments and services take sufficient account of the family’s race, culture, language, and religious needs, and any disability needs? ........................... 27 8.7 Were Kent Safeguarding Children Board and individual agency procedures followed? ..................................................................................................................... 28 9. ISSUES ARISING FROM AN OVERVIEW OF THE CASE ......................................... 28 9.1 Good practice and service improvements ........................................................... 28 9.2 The circumstances of Amy’s death ....................................................................... 29 10. REVIEW PROCESS .............................................................................................. 30 11. CONCLUSIONS: KEY LEARNING POINTS AND MISSED OPPORTUNITIES .......... 31 12. RECOMMENDATIONS MADE IN THE MANAGEMENT REVIEWS OF THE PARTICIPATING AGENCIES ...................................................................................... 33 This report is the property of the Kent Safeguarding Children Board. Page 3 of 41 12.1 Introduction ......................................................................................................... 33 12.2 Kent County Council, Specialist Children’s Services .......................................... 33 12.3 Kent County Council, Education, Learning and Skills ......................................... 33 12.4 Kent Police ........................................................................................................... 33 12.5 Kent Community Health NHS Trust .................................................................... 34 12.6 Kent and Medway NHS and Social Care Partnership Trust ............................... 34 12.7 Maidstone and Tunbridge Wells NHS Trust ....................................................... 35 12.8 General Practitioners .......................................................................................... 35 12.9 Health Overview Report ..................................................................................... 35 12.10 Kent Youth Offending Service ........................................................................... 35 12.11 Kent Probation .................................................................................................. 35 12.13 South East Coast Ambulance Service NHS Foundation Trust .......................... 36 13. RECOMMENDATIONS FROM THIS OVERVIEW REPORT ................................... 37 13.1 Introduction ......................................................................................................... 37 13.2 Recommendations to the Kent Safeguarding Children Board .......................... 37 APPENDIX A: Biographical details of Independent Chair and Overview Report Author ...................................................................................................................... 39 APPENDIX B: References ......................................................................................... 40 This report is the property of the Kent Safeguarding Children Board. Page 4 of 41 1. INTRODUCTION 1.1 Amy Singleton1 died in 2011. She was ten years old and was found hanging by a belt from a window in her bedroom. The circumstances of Amy’s death, in a context of substantial current and historical involvement of various agencies with her family, led the Kent Safeguarding Children Board (KSCB) to conduct a Serious Case Review (SCR). This is the Overview Report from that review. 1.2 The death of a child is distressing for staff who have known that child and their family. This review has been greatly assisted by the co-operation and commitment of staff from all contributing agencies. 2. DECISION TO CONDUCT THIS SERIOUS CASE REVIEW 2.1 Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 requires Safeguarding Boards to undertake reviews of serious cases. The Regulation defines a serious case as one where (a) abuse or neglect of a child is known or suspected; and (b) either – (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 2.2 In this instance it was alleged that Amy had been sexually abused by a member, or members, of her extended family. Allegations of neglect had also been made. It was therefore agreed that the criteria for conducting a SCR were met. The review was initiated in February 2012. 2.3 In line with statutory guidance, Ofsted2 should be immediately notified of the decision to conduct the SCR. As a result of an oversight that formal notification was not sent until 30/7/12, although this did not lead to any delay in the process of the Review. Guidance indicates that the target timescale for completion of SCRs is 6 months. It became clear that further time was needed to determine the scope of the Review and complete it. An extension to the timescale was agreed by the LSCB Chair and the review was duly completed in September 2012. 3. SERIOUS CASE REVIEW PROCESS 3.1 The purposes of SCRs are set out in “Working Together to Safeguard Children3 1 This is not the real name of the child who is the subject of this review. The names of all family members have been changed to protect their anonymity. ” (Para 8.5). They are to 2 The independent body, reporting directly to Parliament, responsible for inspecting and regulating services to children and young people. 3 Working Together to Safeguard Children (2010) – referred to in this report as “Working Together” – is a government publication containing statutory guidance on how organisations This report is the property of the Kent Safeguarding Children Board. Page 5 of 41 • establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; • identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and • improve intra- and inter-agency working and better safeguard and promote the welfare of children. 3.2 During February 2012 arrangements were made to appoint the independent people who are required to contribute to the conduct of SCRs. Mr Keith Ibbetson was appointed to lead the review and Mr Kevin Harrington was appointed to produce this Overview Report, with an accompanying Executive Summary. Further details can be found at Appendix A. 3.3 The LSCB constituted a SCR Panel (the Panel) to manage and oversee the conduct of the review. The membership of the Panel is set out below. Name / Designation Organisation Role Mr Keith Ibbetson Independent Independent Chair Head of Safeguarding Kent and Medway NHS and Social Care Partnership Trust (KMPT) Panel Member Named GP for Safeguarding Children NHS Kent & Medway Panel Member Acting Head of Safeguarding (or deputy) Kent County Council, Specialist Children’s Services (SCS) Panel Member Designated Dr. for Safeguarding Children East Kent Hospitals University NHS Foundation Trust (EKHUFT) Panel Member Designated Nurse for Safeguarding Children NHS Kent & Medway Panel Member Team Manager, Safeguarding Children Kent County Council, Family & Children Services (Education) Panel Member Assistant Head of Integrated Youth Services Kent County Council Panel Member District Manager – Dover Kent County Council, Family & Children Services (Children’s Social Care) Panel Member and individuals should work together to safeguard and promote the welfare of children and young people in accordance with the Children Act 1989 and the Children Act 2004. This report is the property of the Kent Safeguarding Children Board. Page 6 of 41 Detective Superintendent, Public Protection Unit Kent Police Panel Member Senior Probation Officer Kent Probation Panel Member Manager Kent Safeguarding Children Board In attendance Mr Kevin Harrington Independent Overview Report author In attendance Administration Assistants Kent Safeguarding Children Board In attendance 3.4 It was determined that the following agencies should contribute to the Review. Those agencies with substantial and / or recent contact would be required to submit full Individual Management Reviews, in line with statutory guidance, whereas agencies with less or less recent involvement should provide reports for background information. AGENCY NATURE OF CONTRIBUTION Kent County Council Specialist Children’s Services Individual Management Review (IMR) Maidstone & Tunbridge Wells NHS Trust IMR NHS Kent & Medway IMR / Health Overview Report 4Kent Probation IMR NHS Kent & Medway General Practitioners IMR Kent Police IMR South East Coast Ambulance Service NHS Foundation Trust IMR Kent Community Health NHS Trust IMR Kent County Council Youth Offending Service IMR Kent County Council Education Services IMR Housing Provider IMR KCA Drug and Alcohol Services IMR Kent & Medway NHS & Social Care Partnership Trust IMR Medway NHS Foundation Trust Information Report 3.5 Amy’s death has also been considered by the Coroner – to establish cause of death, and by police / Crown Prosecution Service – to consider whether a crime may have been committed. It was decided in October 2011 that there would be no criminal proceedings. The inquest was concluded in June 2012, with the recording of 4 Working Together (Paragraph 8.30) requires that in every SCR the appropriate Primary Care Trust should draw up a health overview report focusing on how health organisations have interacted together, which will also constitute the IMR for the PCTs as commissioners. This report is the property of the Kent Safeguarding Children Board. Page 7 of 41 an open verdict. The Kent Police representative on the SCR Panel acted as the link between this Review and coronial and criminal investigations. The final report from this Review will also be considered by the Kent Child Death Overview Panel.5 3.6 The key issues for consideration in the review are summarised below. Agencies were asked to: • provide detailed accounts and analysis of their contact with the family from 2006 to 2012 and summarise any earlier contact with the family • consider the “voice of the child” and what life was like for Amy • evaluate whether Amy’s needs were appropriately assessed and met • assess whether Amy and her family were appropriately engaged and involved by agencies • consider how far Amy was helped to cope with the adverse circumstances in her life, particularly her sexual abuse. • establish if assessments and services took sufficient account of the family’s race, culture, language, and religious needs, and any disability needs. • review whether Kent Safeguarding Children Board and individual agency procedures were followed. 3.7 In the early stages of gathering information it became clear that the extended family composition was complex and that there was a great deal of information across a number of agencies about members of that extended family. This raised the immediate issue of needing to ensure that children in the extended family were safe. This was referred back to operational services and was immediately followed up by them. 3.8 There were indications that agencies might have lessons to learn from their involvement with extended family members. However it was judged that it would be unhelpful to incorporate an examination of involvement with the extended family into the review arising from Amy’s death. It would take a great deal of additional time and would complicate the task of ensuring that this report was appropriate for publication. Consequently it was decided to limit the scope of this review to considering Amy and her immediate family. Reference to extended family members is made only where it is relevant to an understanding of Amy’s circumstances. The LSCB has accepted a recommendation that they should conduct a separate exercise to identify any lessons to be learned from agencies’ involvement with members of the extended family. 3.9 In conducting this review agencies were asked to give particular attention to practice since August 2010 when an inspection by Ofsted led to a formal Improvement Notice because “the overall effectiveness of Kent’s safeguarding and services for looked after children (was judged) to be ‘inadequate’. 5 The establishment of Child Death Overview Panels, reviewing the deaths of all children under 18 and reporting to the LSCB Chair, became a mandatory requirement in April 2008 This report is the property of the Kent Safeguarding Children Board. Page 8 of 41 Service improvements relevant to issues arising from this review are considered throughout this report. 4. METHODOLOGY USED TO DRAW UP THIS REPORT 4.1 This Overview Report is based principally on the agency IMRs, background information submitted and subsequent Panel discussions and dialogue with IMR authors. Family involvement is discussed at section 6 below. 4.2 The report consists of • A factual context and chronology. • Commentary on the family situation and their input to the SCR. • Analysis of the part played by each agency, and of their IMR. • Closer analysis of the specific issues identified in the Terms of Reference, detailed above. • An account of issues arising from an overview of the case. • Conclusions and recommendations 4.3 The government has introduced arrangements for the publication61) take reasonable precautions to prevent the identification of the child concerned or other family members in full of Overview Reports from Serious Case Reviews, unless there are particular reasons why this would be inappropriate. This has implications for the extent to which certain matters can be detailed. This report is written in the anticipation that it will be published. Consequently the information it contains is limited in order to 2) protect the right to an appropriate degree of privacy of family members 3) avoid the possibility of heightening any risk of harm to other children. 5. CHRONOLOGY 5.1 Introduction 5.1.1 Each of the agencies involved in this review submitted a detailed chronology, in tabular form, of their involvement with the family in the period under review. Those submissions have been co-ordinated into an integrated tabular chronology. This document is some 230 pages in length. This section of this report aims to summarise that chronology in an accessible way. It does not include every contact, or failed contact, and does not provide a detailed account of all the work carried out. 5.2 Key events 5.2.1 Amy started school in September 2005. Her health visiting records cannot be traced so no background information is available before this date. There was early 6 See letter from the Parliamentary Under Secretary for State for Children & families dated 10th June 2010 This report is the property of the Kent Safeguarding Children Board. Page 9 of 41 recognition that she needed additional help and an Individualised Education Program (IEP) was set up. 5.2.2 In 2006 police and children’s services investigated a report that a member of Amy’s extended family had sexually assaulted a child. Mr Singleton expressed consequent concerns for Amy and she was taken to the family GP. The GP discussed this with the Named Nurse for Child Protection, but no action was taken as a result. In August the GP made enquiries with child mental health services (CAMHS) about treatment for Amy for ADHD. At that time it was felt that she was too young for this to be reliably diagnosed and treated. 5.2.3 Later that year SCS received an anonymous referral alleging neglect of Amy. There was a delay of several weeks before SCS followed this up by writing to the family. Mr Singleton responded, denying any cause for concern. Amy’s school reported that they had no serious concerns. No home visit was made, Amy was not seen by SCS and no further action was taken. 5.2.4 Mrs Singleton met with staff at Amy’s school regularly during 2007, and saw the GP once, because of concerns that Amy’s behaviour was difficult and, in her mother’s view, suggestive of ADHD. In school, although some academic targets were being met or exceeded, her behaviour remained difficult to manage. There was continuing concern about her coming to school unkempt and poorly clothed but these were not raised directly with her parents. 5.2.5 In 2008 Mr Singleton reported to police that Amy had been sexually abused by a member of her extended family, who denied this. The allegation of abuse was confirmed by Amy. After an investigation by police, with limited input by SCS, it was decided that there was insufficient evidence to support any further action. There is no indication of consideration being given at that time to measures to protect Amy, or other children with whom the alleged perpetrator might have contact. 5.2.6 A neighbour made allegations in June 2009 that Amy was physically abused and neglected. Neighbours also reported that they had seen Amy displaying sexualised behaviour in public. No action was taken by SCS for several weeks. A social worker then visited the home but it does not appear that the allegations of child abuse and neglect were investigated, or that the children were seen alone. The follow-up to the interview was focussed on financial problems the family were said to be experiencing. The case was closed by SCS in September. There had been no assessment under child protection arrangements despite the nature of the original referral. 5.2.7 Towards the end of the year Amy was assessed in school because of her special educational needs. That assessment found that although Amy’s reading ability was above average, her self-esteem and “emotional literacy” were very low. Various strategies were suggested to assist the school in addressing these issues and the school started a programme of specialist therapeutic play work with her. This report is the property of the Kent Safeguarding Children Board. Page 10 of 41 5.2.8 In February 2010 Amy was diagnosed as having ADHD and was started on medication for this. Around this time her school had also tried to initiate a Common Assessment Framework (CAF)7 assessment. Although initially in agreement with this, her father said that he would not co-operate if there were any involvement from SCS. This led to considerable delay and the CAF was not initiated until September, when agencies agreed that there would be no SCS involvement. 5.2.9 In March a member of Amy’s extended family pleaded guilty to a charge of “engaging in sexual activity with a child” and received a custodial sentence. He had previously been the subject of allegations of sexual abuse in respect of Amy. 5.2.10 A neighbour contacted the Head Teacher of Amy’s school later that month to express concerns about her. The school decided not to pass these reports on to SCS, on the basis that SCS were already aware of general concerns about the family. The school subsequently received three letters, all apparently from concerned neighbours, expressing concerns about Amy. These letters did not lead to any action being taken. School staff had concerns that Amy’s packed lunch was insufficient and offered to fund free meals but report that her parents declined this offer. 5.2.11 The CAF was initiated towards the end of 2010. It was decided that the approach should be consistent with Tier 2 of the CAF arrangements – there is a fuller discussion below but Tier 2 involvement indicates that the level of need was not judged to require referral to SCS. Amy was described as “borderline Child in Need 8 ” – Children in Need should be seen as requiring intervention under Tier 3 of the CAF arrangements. The Special Educational Needs Co-ordinator (SENCO) at the school was identified as the Lead Professional. It was agreed that a Team Around the Child (TAC) be set up including Amy’s parents, a local parenting support service, school staff, the School Nurse and an ADHD nurse. It was suggested the TAC might consider referral to an early intervention service, Support Services for Kids and Young People (SSKY). 5.2.12 There were a number of attempts to set up the initial TAC meeting but Amy’s parents did not respond. In mid-December Amy made comments to a member of school staff which suggested that she was concerned about being sexually abused by members of her extended family. This was discussed with her father who said that 7 The CAF was established by the former Department for Children, Schools and Families. It is described on the Every Child Matters website as “a standardised approach to conducting assessments of children's additional needs and deciding how these should be met…The CAF promotes more effective, earlier identification of additional needs, particularly in universal services. It aims to provide a simple process for a holistic assessment of children's needs and strengths; taking account of the roles of parents, carers and environmental factors on their development” 8 Children in need are defined in law as children who:- • need local authority services to achieve or maintain a reasonable standard of health or development • need local authority services to prevent significant or further harm to health or development • are disabled. This report is the property of the Kent Safeguarding Children Board. Page 11 of 41 these people were no longer considered part of the family and would not be visiting the home. There was no referral to SCS. 5.2.13 The first TAC meeting was held in February, attended by Amy’s mother, the SENCO, the headteacher, class teacher and school nurse. A plan of interventions was agreed including referral to the educational psychologist for assessment and referral to SSKY. The ADHD liaison nurse was to be asked to review Amy’s weight. That plan was pursued throughout the year, during which there were continuing concerns about Amy’s health, presentation and general wellbeing. A review in September judged that a “Tier 2” approach remained appropriate and the situation did not meet the criteria for a referral to SCS. 5.2.14 In October Amy was found hanging from the window of her room. Her parents called an ambulance which arrived within minutes. Amy had been put to bed at 21:30 after taking medication. She came downstairs once more and then returned to her room, apparently untroubled. Her father checked on her at 23:30 and found her hanging by a fabric belt attached to the window. Advanced life support was commenced by the attending ambulance crews but her condition did not improve during this time. She was taken to hospital without delay and a Consultant Paediatrician attended from home but her life could not be saved. 5.2.15 Police had been routinely notified of the incident by ambulance staff and attended the hospital. There was no evidence of injuries or signs of sexual assault. Police spoke with Mr Singleton who told them about an incident of attempted sexual assault on Amy by a member of her extended family some months previously. This had not been reported to any agency at the time. Police then went to the home address, noting a range of concerns about the home conditions. 5.2.16 There was no evidence to suggest Amy was depressed or intended to take her own life. No suicide note was found. The police investigation considered the hypothesis that Amy could have been experimenting with a practice where an individual gets a “high” by self asphyxiating but there was no evidence to substantiate this. Computers were recovered from the house but none were found to contain material which raised any concerns. Police concluded that there was nothing to indicate the involvement of any other person in Amy’s death. 5.2.17 A decision was made to conduct a child protection investigation as there might be concerns for other members of the family. A joint investigation by police and SCS subsequently found no evidence to indicate that any further action was necessary. 6. THE FAMILY 6.1 Amy’s parents were contacted twice during the process of the Review to see if they wished to contribute in any way. They declined invitations to meet the chair of the Review and the author of this report. Mrs Singleton replied to the second invitation, advising that she and her husband were still trying to come to terms with This report is the property of the Kent Safeguarding Children Board. Page 12 of 41 what had happened. She said that they had been optimistic that good progress was being made in relation to Amy’s ADHD, although they remained disappointed that this could not have been diagnosed earlier. 6.2 In that correspondence Mrs Singleton spoke warmly of the assistance the family had received from Amy’s school, which she felt was evidenced in her school reports. She said that police had also been helpful, both at the time that the abuse of Amy was reported and around the circumstances of her death. However, Mrs Singleton said that they were disappointed that SCS had not been involved more fully in supporting the family. 7. THE AGENCIES 7.1 Introduction 7.1.1 Each of the agencies contributing to this review has carried out an internal review (IMR), detailing and analysing their involvement with the family. This section of this report confirms the nature of that involvement and comments on the analysis contained in the IMR. 7.2 Kent County Council, Specialist Children’s Services 7.2.1 This report confirms that SCS had contact with Amy’s family on a number of occasions before her death, as a result of allegations or concerns about physical or sexual abuse or neglect. The report notes evidence of unnecessary delay and failure to carry out appropriate checks with other agencies. There was only one Initial Assessment when there were at least three occasions when a more comprehensive assessment should have been carried out. 7.2.2 The report highlights the significance of the weak response to the allegation made by Amy’s father in 2008 that Amy had been sexually abused. Although a Strategy Meeting took place, SCS were not otherwise involved in the investigation, which was carried out solely by police. This incident seems to mark the onset of Mr Singleton’s animosity to SCS. It was a missed opportunity for SCS to intervene with the family at a point where “it was accepted by both professionals and her family (my emphasis) that (Amy) had experienced sexual abuse”. The Panel was provided with evidence of considerable efforts to improve collaborative working between police and SCS and was satisfied that this was not now a systemic problem which required a recommendation from this Review. 7.2.3 The report goes on to detail the delay and subsequent failure to follow child protection procedures by SCS in response to allegations of neglect in 2009. The children were not seen, the circumstances in which they lived and slept were not thoroughly investigated and routine checks with other agencies were not carried out comprehensively. This report is the property of the Kent Safeguarding Children Board. Page 13 of 41 7.2.4 One other service within SCS had been involved. SSKY is a local authority early intervention service. The worker who made initial contact with the family shared similar concerns to other agencies about Mr Singleton’s hostility to SCS and about differential treatment of Amy within the family. 7.2.5 A number of issues are detailed as having led to these weaknesses in the service provided to Amy and her family. Many of the aspects which give cause for concern were identified more widely across the county in the Ofsted inspection in 2010. Of key importance is the lack of management oversight and direction to underpin any of the agency’s responses to matters of serious concern. There were a number of instances of delay and lack of purpose which may have been linked to major problems of high vacancy levels across the organisation. It is clear that there were very serious difficulties arising from the introduction of a new computer system in 2008 which led to problems in tracking incoming work. Mr Singleton’s overt hostility to social workers is correctly highlighted as probably having contributed to some of the weak responses. The reaction to the family’s presentation, across all agencies, indicates a disturbing lack of knowledge and skill in recognising and responding to concerns about sexual abuse. 7.3 Kent County Council, Education, Learning and Skills 7.3.1 This report considers the involvement of Amy’s school and the local authority’s Special Educational Needs services. The report summarises the general perceptions held by education staff: “Amy … presented as needy in terms of seeking adult attention and experiencing difficulty with peer relationships. .. sometimes untidy, occasional issues regarding adequacy of diet. .. cleanliness and hygiene” 7.3.2 The school was not adequately involved in the investigation, in 2008, into the alleged sexual abuse of Amy. The headteacher is said to recall discussing this with police at the time but kept no written records. There were inappropriate responses by the school in 2010 to a number of expressions of concern. Information from a neighbour that there were concerns locally about the treatment of children of the family was not passed on by the school to SCS. Some weeks later the headteacher discussed the issue with the Area Children’s Officer for Child Protection9 (ACOCP). This officer advised that the information should still be reported to SCS but it does not appear that this was done. After the summer break the school received three written expressions of concern about the children but did not make a referral to SCS. 7.3.3 The implementation of the CAF was stalled for 6 months as a result of Mr Singleton’s overt hostility to any SCS involvement. This seems to have been accepted at face value by the school, rather than prompting concerns as to why he should allow this to impede the arrangements to help his daughter. This again suggests a lack of confidence in the relationship between the two agencies, and / or a lack of familiarity with CAF arrangements. 9 An officer with an advisory role on safeguarding for education staff. This report is the property of the Kent Safeguarding Children Board. Page 14 of 41 7.3.4 A further concern arises from the school’s response to comments by Amy suggesting that she feared sexual abuse by members of her extended family. The school did not share this information with SCS. Instead the headteacher spoke to Mr Singleton – an action which in some circumstances might have placed Amy at greater risk – and accepted reassurances from him that no further action was necessary. Even if, as the IMR points out, this had been a reference to historical abuse, it was both an error in judgment and a missed opportunity for agencies “to have a discussion and come to some joint understanding about Amy’s wider needs in respect of her previous experiences of alleged sexual abuse”. 7.3.5 The final report of concern about Amy was made to the school by neighbours in March 2011. This led the headteacher again to talk to the ACOCP. There is no recording of this discussion but the IMR reports that “ In the absence of further new evidence and given father’s hostility to SCS it was on balance thought to be more effective to concentrate on developing an effective working relationship with the school and seek assistance elsewhere for the difficulties with neighbours. The school therefore contacted the housing association and local police community support officer”. Effectively the concerns of neighbours about the welfare of the children were not shared with the appropriate agency but were redefined as a housing problem / neighbour dispute. 7.3.6 There is a more encouraging account of the school’s direct work with Amy and, eventually, of the beneficial consequences of the CAF: “At the time that the school last saw Amy it appeared that after a long period of concerns about her home life there was evidence that she was benefitting from their input and that the family were at last co-operating with plans for the children”. 7.3.7 Overall, there is a positive picture of the school’s commitment to Amy, both through the input of individual members of staff and more widely. Equally however analysis of their involvement indicates that the school did not understand or follow safeguarding requirements. The principal contributory factors appear to be a failure to keep abreast of those requirements and an ineffective working relationship with SCS. 7.4 Kent Police 7.4.1 Police involvement consisted of their part in the 2008 allegation of the sexual abuse of Amy. The IMR is satisfied that, although this should have been a joint investigation, it was appropriate that police went ahead when SCS were unable to provide any input. The police investigation is judged to be satisfactory and the report notes that “interviews were conducted with professionalism and took into account the needs, views and wellbeing of Amy”. This report is the property of the Kent Safeguarding Children Board. Page 15 of 41 7.4.2 Police had no other contact with Amy before her death. However there is cumulative evidence of a range of inappropriate and illegal sexual conduct, by various members of this extended family, over a period of years. This evidence was not seen in its totality, and did not lead to assessments co-ordinated with other agencies. For example, when a member of the extended family was imprisoned for sexual abuse “there was no consideration given to his potential threat to child members of his own family; including Amy. In view of the family history, some form of risk assessment would have been appropriate”. 7.4.3 This IMR also recognises the threat arising from the ingrained nature of inappropriate sexual conduct across this family. When the person mentioned in the previous paragraph was released from prison, in a very short space of time he was living with a woman with young children, in total disregard of his Sexual Offences Prevention Order (SOPO): “This again shows how (he) had little regard for the consequences of his actions”. 7.4.4 The decision about how widely to “cast the net” is a difficult one for police. It may lead to the accumulation and requirement to analyse very large amounts of material, much of which may not be directly relevant to the principal focus of an investigation. The extensive information gathered in this review about criminal activities of members of the extended family is a case in point. However the IMR notes that “one of the people interviewed remarked, “We can’t go looking for victims”. and the IMR author responds that “In some cases this is exactly what we should be endeavouring to do”. Police do hold and have access to very extensive information about people and a key learning point from this review turns on the need to put that information together and make best use of it. 7.4.5 The IMR identifies some lapses in routine record-keeping and notes the possible consequences of referrals being received “out of hours”, when agencies may have more limited resources. This was the case when the abuse of Amy was reported, and police proceeded on a single agency basis. The report also raises the issue of how agencies might improve their response to situations where a young person is alleged to be the perpetrator of a sexual offence, which may be indicative of that young person also being the victim of abuse. 7.5 Kent Community Health NHS Trust 7.5.1 The author of this IMR attempted to research the agency’s early involvement with Amy and her family, which would have been held in Health Visiting notes, but these could no longer be traced. There has consequently been very little information available about Amy’s early life. This is a matter of concern for this review and more widely. Health records should be stored and kept appropriately until the person to whom they refer reaches the age of twenty-five. As the IMR notes, the consequence This report is the property of the Kent Safeguarding Children Board. Page 16 of 41 is that information about Amy’s early years and the family’s relationship with health visitors is lost. “The missing health visiting record may indeed have had a significant impact on the understanding of Amy's pre school life… (particularly because)…within two months of entering school, Amy needed an individual education plan”. 7.5.2 The Panel accepted that all appropriate steps had been taken both to investigate this issue, and to confirm that current arrangements were satisfactory. Consequently this Overview Report, in line with the IMR, does not make a recommendation about this matter. In the light of the records being missing the report principally addresses the involvement of health services in the management of Amy’s ADHD and their collaboration with the other agencies involved in the TAC. 7.5.3 Amy was originally referred by her GP for investigation of possible ADHD when she was under six years of age. It is explained that in normal circumstances this is too young for ADHD to be diagnosed and treated with medication. She was re-referred by her school when she was a little over eight years old and “her behaviour had deteriorated to the extent she had difficulty with friendships, her sleep was an issue, she would compromise her safety by walking out in front of traffic and would talk to strangers”. 7.5.4 She attended for paediatric assessment with her father who told the paediatrician about the sexual abuse of Amy. There was subsequently a specialist assessment leading to the diagnosis of ADHD and treatment which continued throughout Amy’s life. Overall there seemed to be a positive reaction and an improvement in Amy’s behaviour. Specialist ADHD staff joined and contributed to the TAC from February 2011 onwards. 7.5.5 The report identifies that the information about the sexual abuse of Amy, which was disclosed to the paediatrician initially assessing her, did not prompt any further enquiries and was not included in the referral to the ADHD Clinic. One ADHD nurse has confirmed having no knowledge of this until after Amy’s death. The overall report from that service is that the history was taken into account in her assessment and treatment but there is no explanation of how they became aware of it. If they did take it into account – and there is no evidence that they did – it is clearly unsatisfactory that an agency should be allowing such a potentially significant issue to be considered without making any reference to it in records. 7.5.6 The IMR comments on any possible association between Amy’s ADHD and her state of mind at the time of her death: “The … medication for ADHD which Amy was on at the time of her death lasts approximately 10 - 12 hours. After this time there would be no residual drug left in the system leaving the person essentially non-medicated, from approximately 8 pm until the following morning…. During interview ( the …paediatrician) stated that at the time of her death Amy may not have had any medication in her system so the ability to moderate her risk taking behaviours was reduced”. This report is the property of the Kent Safeguarding Children Board. Page 17 of 41 7.5.7 The clear conclusion of the IMR is that Amy’s ADHD was diagnosed appropriately and managed well. It is similarly clear in questioning how the knowledge that she was said to have been sexually abused by a family member could not have prompted any further enquiry. “Possible sexual abuse did not appear to be considered in a holistic assessment. No one appeared to consider was the perpetrator still in contact with Amy, how long had the abuse being going on and how was it discovered”. The doctor to whom the comment was originally made reported that “As Mr Singleton stated the police had been involved (she) did not believe at the time that she should make any further enquiries as she considered the case had been investigated and closed”. 7.5.8 This leads to a fundamental concern which is to some extent captured in this IMR – the sub-optimal response to the issue of sexual abuse and, to a lesser extent here, neglect. This comes in a context, otherwise, of the professionals working well together to tackle Amy’s diagnosed condition of ADHD. There are reports of improved supervision arrangements and reassurances that this would not happen now, but there must be a key learning point about improving professionals’ understanding of their responsibility for sharing information. 7.5.9 The issue of Amy’s weight was explored by the Panel. “Amy’s weight was on the 75th centile at 5 years 3 months, was between 75th and 50th centile by 8 years 6 months dipped to just below the 50th centile at 9 years 1 month and remained steady until a small reduction by 9 years 7 months with another slight reduction by 10 years 1 month to between 50th centile and 25th centile”. This pattern in itself was judged by the Medical Advisor to the Panel to be not unusual. However, in the context of other evidence, including concerns about general neglect, the IMR notes that this pattern of slower growth than might be anticipated could give cause for concern. 7.5.10 Finally this agency has provided information about reported associations between suicide and the ADHD medication taken by Amy. It notes that “There are theoretical risks of increased suicide with …However nothing has been proven, and research has not shown an increased incidence of suicide over the normal rates in those on medication. The Medicines and Healthcare Products Regulatory Agency (MHRA) information …states ‘1 report of suicidal ideation and /or suicide attempt has been received in patients treated with (this medication)… The incidence of suicidal ideation is uncommon, and incidence of suicide attempts not known” The report concludes that there was no reason not to use this medication because of possible risk of suicide. 7.6 The General Practitioners 7.6.1 The IMR considers information held by the GPs for Amy and her extended family. For the purposes of this SCR, this Overview Report focuses on Amy and her immediate family. This report is the property of the Kent Safeguarding Children Board. Page 18 of 41 7.6.2 Mr and Mrs Singleton have experienced a range of illnesses and conditions. Mr Singleton has been seriously unwell, requiring treatment that will have significantly affected his daily living. The report is satisfied that, medically, these matters were generally dealt with thoroughly. Their emotional / psychological consequences might have been further explored but Mr Singleton does not appear to have welcomed this. There is no indication of any consideration of the consequences of the parents’ health issues for their parenting responsibilities. The report notes that Mrs Singleton had been in hospital very recently before Amy’s death and makes a general observation that “the time prior to and following the procedure (may) affect the ability to care for dependants and this is something we should consider supporting as a health service during pre-operative assessments” 7.6.3 In 2006 Mr Singleton sought the GP’s advice because Amy was reported to have been present while another child was sexually abused. The GP appropriately discussed this with the Named Nurse for Child Protection, but this did not lead to any cross-checking to ensure that SCS were fully aware. Similarly, when more conclusive evidence of Amy’s sexual abuse emerged, this was not shared by SCS with the GP. This Review has also identified a difficulty in the information sharing arrangements more generally in relation to sexual abuse between children. Even when information was shared in respect of the abused child, that information sharing did not extend to the child perpetrating the abuse and other siblings. 7.6.4 The GP appropriately followed up concerns about Amy’s ADHD, enabling early diagnosis and treatment (if it is agreed that such a diagnosis could not reliably have been made at age six, when the concerns were first raised). There are no concerns about the GP’s continuing involvement in the management of her ADHD. 7.6.5 The report contains further information from the GPs about Amy which may be significant: “ In 2003 Amy was ‘pointing at herself when weeing’ - there is no clear documentation regarding the duration of these events or how this was investigated at all, just that the examination was normal” Amy also has recurrent presentations with head lice, continuing until shortly before her death. “(These) were perhaps a missed opportunity as this is often an indicator of possible neglect”. 7.6.6 There were practical difficulties: “Unfortunately there was no informed global family assessment and this would have been very helpful. As the whole extended family (was)… also registered across Kent this fragmentation does not allow any full cohesive analysis of this vulnerable family” This “fragmented” approach, and consequent flawed assessments, are key factors in understanding the failure of agencies to grasp the substantial, cumulative evidence of indications of child sexual abuse. This report is the property of the Kent Safeguarding Children Board. Page 19 of 41 7.7 Maidstone and Tunbridge Wells NHS Trust 7.7.1 This report deals with hospital services provided to Amy and her family. Amy had one direct contact with Maidstone Hospital following a minor accident when she was four. Other members of her immediate family had treatment throughout the period under review for a range of conditions, including serious illness. Amy died at Maidstone Hospital and the report describes the circumstances of her death. 7.7.2 The IMR raises the issue of the effects on front-line staff of child deaths or serious injury. In this case those effects will have been aggravated by comments made by Mrs Singleton, who spoke to a nurse about the sexual abuse of Amy. The report appropriately makes a recommendation about the need for staff in such critical situations to have time and support which enable them to reflect on the events with which they have had to deal. There are no other matters arising for this agency to be considered in this Overview Report. 7.8 Kent and Medway NHS and Social Care Partnership Trust 7.8.1 This agency (KMPT) was involved only after Amy died. The family GP referred a sibling for assistance in coping with Amy’s death. The referral was made in late October and prompted a series of attempts to elicit more information and gain written confirmation that the GP’s referral had been made with parental consent. There was no response from the family and, in January, the GP, concerned that the situation had deteriorated, made a further referral. 7.8.2 Amy’s sibling was eventually seen once in February, as a result of which it was decided that there was no need for secondary mental health support but a referral was made for bereavement counselling. The report comments that “Feelings of significant loss are a natural response following sudden unexpected death. It does not necessarily mean that there is a need for secondary mental health involvement” 7.9 Kent Youth Offending Service 7.9.1 Kent YOS contributed to this review as a result of their involvement with members of Amy’s extended family. The review appropriately focuses on the detail and outcomes of their work in relation to one young person’s criminality and finds “much to commend the work for in terms of the focus on both meeting needs and on reducing the risk of reoffending” 7.9.2 However, the most striking issue for the purposes of this review is that the YOS was apparently entirely unaware of allegations that he had sexually abused Amy in 2008. They remained ignorant of this until their involvement in this Review. Although the events preceded their involvement it is of concern that routine checks with partner agencies did not bring this to light. This report is the property of the Kent Safeguarding Children Board. Page 20 of 41 7.9.3 This concern is aggravated by the fact the YOS did understand from March 2009, as a result of routine checks in December 2008, that there had been other allegations of sexual abuse within his family by this young person. This was not taken into account in any of the work undertaken by the YOS. Even when there was liaison, agencies did not share this important information: “There was no discussion of this risk when there was liaison between YOS and Children’s Social Services which occurred in September 2009 at the point when he became homeless”. 7.9.4 The consequences of this for the YOS’ work will be considered as part of a separate management review but, for the purposes of this review, it raises again a persistent concern about the quality and reliability of information – sharing between agencies. This is aggravated by the account of the agency’s understanding that their relationship was effective: “In addition to the Case Manager contact there was regular informal contact between YOS and CSS which was described as positive by the Practice Supervisor and Team Manager. They felt that the relationship between YOS and CSS allowed the teams to discuss young people and their families, and through doing so to identify solutions to issues or to share information that might assist in service delivery. Both YOS and CSS are based in the same building and would frequently have discussions about young people”. 7.9.5 The agencies need to review their arrangements for liaising with each other and sharing information, as the allegations should certainly have been the subject of further discussion between them. A number of recommendations from the IMR seek to address this. 7.10 Kent Probation 7.10.1 This report relates solely to a member of Amy’s extended family who was convicted of “engaging in sexual activity with a child”. He minimised the seriousness of this and sought to blame the child involved. The report then provides evidence of his disregard for the requirements of his release on License and his status as a convicted sexual offender. Within a short time of his release from custody he was known to have been living at addresses where children were also resident. He also failed to notify this Offender Manager of various changes in his circumstances. The report does not include any information about Amy but it adds to the cumulative concerns about sexual abuse running through this family. 7.11 Housing Provider 7.11.1 This agency is not named in order to protect the anonymity of the family. It was the landlord for the Singleton family. It dealt with neighbour disputes involving the family and staff were aware of neighbours’ concerns that Amy was being mistreated. These allegations were apparently passed to them by Amy’s school (who did not pass them to the appropriate agency, SCS). The Housing Provider accepts This report is the property of the Kent Safeguarding Children Board. Page 21 of 41 that they should also have approached SCS about this. There are no other matters arising from the information supplied by this organisation. 7.12 South East Coast Ambulance Service NHS Foundation Trust 7.12.1 For the purposes of this Review this Trust was significantly involved only on the occasion of Amy’s death. The Trust gave appropriate advice and attended without delay. There are no matters arising for this agency which concludes that “At the time of Amy’s death, SECAmb provided a very rapid response to the 999 call and all possible advanced life support interventions were undertaken, sadly without success” 7.13 KCA Drug and Alcohol Services 8.13.1 This agency was involved with a member of Amy’s extended family. No matters relevant to this review arise from that contact. 7.14 Health Overview Report 7.14.1 The Health Overview report considers the submissions made by all the NHS agencies involved in this review. It largely echoes the findings of those reviews and those contained within this report. However the report does not identify any issues relevant to the commissioning of health services. This is its principal purpose. 7.14.2 This does reflect a wider, national issue about how Health Overview reports might best contribute to the SCR process. New (draft) guidance does not clarify this. It may be that in future the LSCB and health commissioners will decide whether there should be a specific report of this nature. In this case there is a recommendation that the LSCB and health commissioners produce a brief guidance note so that if such reports are commissioned in future authors will have clear expectations as to their purpose and expected contents. 8. ISSUES IDENTIFIED IN THE TERMS OF REFERENCE FOR THIS REVIEW 8.1 What were the facts in this case? 8.1.1 The factual content of the IMRs and chronologies has been drawn together and summarised in Section 5 of this report. This has been accepted by all the agencies as, for the purposes of this review, an accurate description of the events leading to the death of Amy Singleton and the involvement of the participating agencies with Amy and her family. 8.2 Did agencies listen to the “voice of the child”? Did agencies know what life was like for Amy? 8.2.1 There is substantial evidence, across the agencies, that Amy herself was not given an adequate priority in their responses to the various issues which raised This report is the property of the Kent Safeguarding Children Board. Page 22 of 41 concern. Professionals did feel for her and tried to support her. Overall though, the requirement to understand her individual circumstances, and respond appropriately was not given sufficient weight. 8.2.2 The agency with the greatest direct involvement with Amy, as would be expected, was her school. The IMR recognises that “Schools have day to involvement with children and through this are probably best placed amongst all professionals to identify and act upon any concerns about children” 8.2.3 In Amy’s case the school identified her particular educational needs quickly and responded appropriately. They “had prepared an individual education plan (IEP) within two months of her commencing school”. This was followed by continuing support through a School Action10“Amy’s needs as a sad isolated and vulnerable child, who sometimes sought adult attention inappropriately”. programme. The school also recognised, to some extent, her broader social and emotional needs: they were aware of Consequently arrangements were made for her to be involved in therapeutic play at school. This confirmed a “need to be nurtured and a wish to do more “girly” things”. 8.2.4 The IMR concludes that “Amy felt sufficiently trusting to express her worries and concerns to a range of adults in school”. However, the concerns for Amy were not seen by the school as particularly unusual: “The school responded to what they were seeing - a sad child, with a difficult home life – in this way not unlike other children in the school”. This Review has demonstrated that Amy’s experience was probably very different to the home lives of other children in the school. 8.2.5 The report from SCS is more straightforward in accepting that “assessments…did not fully consider the context of her life or attempt to understand her family fully. The children’s voices were not heard, or sought and therefore their view and understanding of their life was unheard”. This report also highlights the way in which agencies redefined the issues that they were considering. After the 2009 assessment the family’s financial situation became a leading concern, although their poverty and its consequences were accepted at face value – there was no recorded attempt to explore how the family spent its money. Amy’s school had offered financial assistance to enable Amy to participate in extra-curricular activities and to arrange for her to have free school meals, all of which was refused by Mr Singleton. 8.2.6 Police visiting the home on the night of her death also found that 10 This is the initial stage of the statutory arrangements for supporting children with Special Educational Needs. This report is the property of the Kent Safeguarding Children Board. Page 23 of 41 “the living conditions were far below the standard (one) would expect for a family with young children…the house was very untidy and very dirty and had clearly not been cleaned for quite some time. The children’s beds had sufficient bedding on them but again, the bedding was very dirty and had obviously not been washed for a number of weeks”. 8.2.7 The possible significance of Amy’s behaviour with adults was not recognised. The GP IMR notes that “Once under the Community Paediatric team it was clear that Amy was showing recurrent “stranger danger (and) lack of awareness and cuddling people she hardly knew inappropriately”. This could be an indicator of familiarity with adult sexualised behaviour, or the craving for attention of a neglected child or both. 8.2.8 Little is known about Amy’s relationship with her mother and, equally, there is little information about Mrs Singleton herself. There is evidence that she was struggling with illness, her husband had had major surgery and the family’s financial circumstances were difficult. She was unemployed for some time during the period under review. Before that her work would have required her to be away from home for long spells during the day and evening. Mrs Singleton largely co-operated with the school’s attempts to assist Amy but did miss a number of TAC meetings. She was aware of at least some of the evidence suggestive of child sexual abuse within her family. In May 2011 she indicated to the TAC meeting a knowledge of some sort of inappropriate behaviour involving Amy. This failed to arouse any professional curiosity or prompt any further investigation, but equally there is no indication of her taking action to protect her daughter. 8.2.9 Mr Singleton seems to have been the dominant figure in the household and there is evidence that his aggression towards agencies may have intimidated them. The school preferred to communicate with Mrs Singleton. He was consistently hostile to SCS, threatening violence to any social worker who visited him after Amy’s death. We know little about his relationship with Amy. 8.2.10 There are strong indications of both neglect and sexual abuse of Amy and a number of allegations of child sexual abuse across her extended family, which might explain her presentation. Her presentation may have been “normalised” by her school, where she was said to be not significantly different from other needy children. It was not identified by SCS in their contacts with her. There appears to have been a reluctance to recognise that abuse, and particularly sexual abuse, might provide an explanation for Amy’s presentation. A range of organisational pressures and individual weaknesses contributed to that and also affected the one joint investigation with police. All the agencies involved with this family could have done more to protect her. This report is the property of the Kent Safeguarding Children Board. Page 24 of 41 8.3 Were Amy’s needs appropriately assessed, with particular reference to the consequences of sexual abuse and neglect? 8.3.1 Amy’s ADHD was identified, assessed and treated appropriately. The Designated Doctor for Child Protection, who was a member of the Review panel, confirmed that national (NICE) guidelines were followed and appropriate medication was given. There was, of course, a perverse consequence of this diagnosis – all her difficulties could be attributed to this condition, both by family members who might wish to avoid investigation of other causes, and by professionals who might also, perhaps unintentionally, be seeking to avoid the possibility of other factors. It is clear that, whether through failure to keep adequate records, read records fully or because professionals genuinely did not have access to the information, the alleged sexual abuse of Amy was not fully taken into account in assessing and responding to her needs. Moreover, as the Education IMR notes, “the diagnosis of ADHD may have contributed to some professionals identifying concerns for Amy rather than considering fully the wider family and environmental issues”. 8.3.2 Amy’s needs as a child who had probably suffered sexual abuse and neglect were never adequately assessed. The only formal agency response to concerns of sexual abuse was the action taken following Mr Singleton’s allegations, in 2008. This led to a police investigation but SCS were not involved in that investigation and took no subsequent action to assess what Amy’s and her family’s support needs might be. At this time there was already knowledge “in the system” of allegations of historical abuse involving various members of the extended family. A comprehensive assessment should have pulled together this accumulating evidence to identify all the indications of sexual abuse and inappropriate sexual activity across this extended family. 8.3.3 Agencies received four allegations of neglect and inappropriate treatment of Amy from neighbours. There was never a formal assessment by SCS. The most substantial response to any of these allegations was the action taken in 2009 in response to a neighbour reporting a range of concerns - neglect, physical, and emotional abuse and the use of sexualised language and access to inappropriate magazines by Amy. This was recorded as a child protection referral but was not then followed up as such – there should have been a strategy discussion and a timely multi-agency response. Instead there was a single agency response from SCS, three weeks later, consisting of one visit by appointment, following which the only issue followed up was the family’s assertion that they were living in poverty. The child protection aspects of the referral were either neglected or avoided. As the SCS IMR suggests this suggests a “neglect case mindset”11 - where acceptance that there may be neglect serves to move any analysis away from considering that a child might also be physically and / or sexually harmed. 11 Brandon M, et al, (2009) Understanding Serious Case Reviews and their Impact, DCSF This report is the property of the Kent Safeguarding Children Board. Page 25 of 41 8.3.4 Amy and her family were engaged, at the time of her death, in a CAF process. As described above, these are national arrangements for helping children who have needs additional to those being met through universal services. The CAF is not an appropriate way of tackling the issues of neglect and sexual abuse which feature prominently in this case. An informed appraisal of Amy’s circumstances at this time against the authority’s guidance12“They also had considered the revised Threshold and Eligibility criteria …and did not feel that the criteria for a Tier 4 child protection referral were met whilst acknowledging that Tier 3 services would require parental consent – which would not be given”. would have indicated that Amy’s experience required the need for the direct involvement of SCS, through child protection, or, at least initially, child in need arrangements. Given Mr Singleton’s hostility to SCS, it is unlikely that he would have co-operated with child in need provision, so that the case would probably then have been escalated to Tier 4, the threshold for implementation of child protection arrangements. There is an indication in the IMR that the school took this into account in deciding that Tier 2 represented the appropriate level of concern: Anticipating parental opposition should be an aggravating feature, leading to escalation of intervention rather than to the school stepping down their approach. 8.3.5 The use of CAF does indicate the recognition, principally at school, that Amy did have additional needs, building on the early action to support her educational special needs. The initiation of the CAF was delayed by six months as a consequence of Mr Singleton’s professed hostility to SCS and the school’s lack of challenge to that. That lack of challenge raises questions about the school’s own relationship with SCS – collusion with Mr Singleton’s judgment effectively endorsed it and suggested that the school did not view it as entirely unreasonable. 8.3.6 In any event the CAF process became the main opportunity for the professionals involved to work together and develop interventions to support Amy. The agencies formed a Team Around the Child (TAC). That TAC had met three times before Amy died. Collaboration from Amy’s parents had been patchy. Mr Singleton had not attended any meetings. Mrs Singleton attended the first two. A number of meetings were cancelled because the parents sent apologies. The range and combination of services which the agencies sought to put in place to help Amy build resilience and self-esteem was impressive. KCHT judge that “The CAF process in itself was thorough and highlighted many issues”. 8.3.7 The difficulty is that these services were all predicated on the assumption that a CAF intervention was appropriate. This was reviewed by the Head Teacher and the SENCO after the third TAC meeting and they concluded that this was still the correct method and level of intervention. To some extent this is understandable – the threshold guidance is in some respects equivocal about levels of intervention and about which factors lead to which conclusions. But there was enough knowledge in the system, if it had been properly researched, to reveal that there had been 12 Threshold criteria.pdf This report is the property of the Kent Safeguarding Children Board. Page 26 of 41 multiple concerns about sexual abuse in the family. Police had discussed this with the Head Teacher during their investigation in 2008. There was also knowledge of anxiety in the community about Amy’s general welfare. 8.3.8 It is disappointing that the Head consulted twice with the education service’s child protection adviser for the school but this did not lead to action to escalate the agencies’ approach. These were general discussions, not supported by a search of what was known to the various agencies. Yet the fact that there were two such consultations reflects the underlying unease about Amy. 8.3.9 The Education IMR reminds us of the increasingly difficult position of Head Teachers: The issue of supervision and support of Head Teachers in dealing with pastoral care and welfare issues…may become more of an issue as schools and Head Teachers become increasingly autonomous (and possibly isolated). Senior staff in schools often perceive themselves as having increased responsibility for welfare issues and managing risk but feel that their support systems in this field are variable across the county. In this case the support and advice from the ACOCP was found to be very helpful but the ACOCP role is an advisory function with no line-management responsibility”. The support and advice from the ACOCP was effectively a false reassurance. 8.3.10 This combination of factors – a lack of shared knowledge about the background of concern, the (false) reassurance afforded by applying the CAF process, the lack of challenge to Mr Singleton’s resistance and the lack of confidence the school felt in SCS – contributed to a failure in inter-agency working which meant that the levels of risk and harm to Amy were under-estimated. 8.4 How were the outcomes of assessments used to inform practice and decision making in relation to Amy? Were Amy and her family appropriately engaged and involved by agencies? 8.4.1 As indicated above there was no appropriate assessment, perhaps the most fundamental failing arising from this review. Even the ADHD assessment, which has been judged to be medically sound, may not have been fully informed by knowledge of previous alleged sexual abuse. The CAF assessment was certainly not adequately informed by all the evidence which would cause concern for Amy. 8.4.2 Had there been a thorough assessment one would have expected that a lack of engagement by the family would have featured prominently as a cause for concern. That should have been considered in the light of Mr Singleton’s hostility to SCS and the apparently perverse refusal to accept the school’s offers of funding extra-curricular activities and free school meals. 8.4.3 Amy herself appeared to participate enthusiastically in any activity in which her parents allowed her to take part. In terms of therapeutic and supportive measures the most significant input was through the play therapist but she was also said to This report is the property of the Kent Safeguarding Children Board. Page 27 of 41 enjoy Brownies and other “normal” activities. Despite the problems in her family, and her overall presentation, the agencies’ descriptions of her do not suggest that they were seeing a child who was consistently unhappy – which may go some way towards explaining the weaknesses in the overall response. 8.5 How far was Amy helped to cope with the adverse circumstances in her life, particularly her sexual abuse? 8.5.1 The evidence submitted to this SCR suggests that the adverse circumstances in Amy’s life were her special educational needs, her ADHD, emotional abuse and neglect within her family and sexual abuse within her extended family. 8.5.2 There was an impressively swift and sustained effort to help Amy to meet the challenges arising from her educational needs. Her ADHD was diagnosed early and accurately, the prescribed treatment for the condition was appropriate and compliance with that treatment was good. The agencies and professionals involved in the CAF process tried hard to use those arrangements to support her – the matters which may have served to weaken all these initiatives have been set out above. 8.5.3 Emotional abuse and neglect were not sufficiently clearly identified. Her school recognised that she was needy and did a great deal to support her, in the face of a lack of consistent co-operation from her family. Those efforts were undermined by a failure across the agencies to recognise the nature and extent of emotional abuse and neglect, evidenced in her presentation, the referrals by neighbours and the ways in which her parents responded to attempts to assist her. 8.5.4 There is compelling evidence to suggest that Amy was sexually abused by one or more members of her extended family, and there is further evidence of sexual offences against children and inappropriate sexual activity across that extended family. The most clearly evidenced sexual abuse of Amy was when she was six or seven years old. There was a disjointed approach to the assessment of that concern, with no adequate input from SCS. Amy was offered no specialist help targeted at the consequences of that experience. Her GP was not made aware of it. Her school were not adequately informed about what had happened and consequently were not in a position to offer targeted support. There is no evidence that her family provided continuing support. From the evidence we have seen she was very much alone. 8.6 Did assessments and services take sufficient account of the family’s race, culture, language, and religious needs, and any disability needs? 8.6.1 Amy’s ethnicity was white British and there does not appear to be any racial diversity in the family. This would not be unusual in the area in which the family lived. When she died her mother declined any religious support and there is no indication of any family member having religious beliefs. This report is the property of the Kent Safeguarding Children Board. Page 28 of 41 8.6.2 The potential significance of ill health and disability in the family is widely recognised by the agencies. There is evidence that Mr Singleton had an active lifestyle before suffering a life-altering condition. One of the IMRs suggests that this may have led some professionals to be over-tolerant of difficult and aggressive behaviour from him. His wife had a number of medical conditions and had undergone a surgical procedure the day before Amy’s death. An exclusive focus on Amy’s ADHD may have contributed to the failure of agencies to conduct a more comprehensive assessment. 8.7 Were Kent Safeguarding Children Board and individual agency procedures followed? 8.7.1 There is evidence of non-compliance with child protection procedures across the agencies. The extent of this non-compliance ranged from the failure by SCS to ensure that they were appropriately involved in the 2008 investigation of sexual abuse of Amy, to failures by the police and the school fully to record all that they had done during that investigation. 8.7.2 Non-compliance with procedures is a “dry” judgment. The important issue for a review like this is to identify the factors behind that failure. They range from individual lack of thoroughness to a number of systemic weaknesses. There are clear indications of an unsatisfactory working relationship between school and SCS, which is likely to have contributed to the poor communications evidenced here. The police were over-tolerant of the failure by SCS to become fully involved in the investigation of sexual abuse of Amy – possibly indicating that they had low expectations of SCS input into investigations. If the ADHD team were aware of the issues relating to sexual abuse they did not make a record of them. The YOS was unaware, throughout their extended contact with a young person, that he had been the subject of an investigation into alleged sexual abuse of Amy. The paediatrician who saw Amy in 2009 and referred her to the ADHD service did not pass on the information that she had been sexually abused and, in interview, suggested that the responsibility to do so was still not fully understood. 9. ISSUES ARISING FROM AN OVERVIEW OF THE CASE 9.1 Good practice and service improvements 9.1.1 SCS have detailed a number of fundamental changes to service arrangements. These largely arise from the wider task of improving services in response to Ofsted’s judgment in 2010 that the overall effectiveness of Kent’s safeguarding services was inadequate. They are significant to the issues arising from this case review. The supervision of staff has been overhauled to become more reflective, supporting staff in considering “what life is like” for the children with whom they are working. More work is being done to ensure that children are directly involved in assessments. The management and oversight of assessments has been improved and supported by more helpful, analytical performance data. The co-ordination of CAFs has been specifically targeted for improvement with new staffing resources within SCS. Overall This report is the property of the Kent Safeguarding Children Board. Page 29 of 41 the authority is committed to changing organisational culture, so that learning and service improvements are prioritised and supported. 9.1.2 The school mentioned in this review demonstrated a clear commitment to Amy and worked hard to lead the establishment of arrangements to support her and promote her development and learning. The individual commitment of key staff is clear and the plans made under the CAF arrangements provided a broad range of initiatives designed to support Amy and promote her education and development. 9.1.3 The clinical assessment, diagnosis and treatment of Amy’s ADHD were thorough. This was in part a consequence of very early intervention from the GPs. 9.2 The circumstances of Amy’s death 9.2.1 It is not the purpose of SCRs to identify the cause of death. That task falls to the Coroner who has returned an open verdict and commented that "I am satisfied there is no suggestion it was (Amy’s) intention to take her own life”. 9.2.2 We do know that suicide and suicidal ideation are common among children who have been mistreated and are at risk of continuing mistreatment. These children often have many different problems and are unable to form good relationships with peers or others to help them build resilience. Being suicidal is essentially about the intent to cause self-injury or death, regardless of the cognitive ability to understand finality, lethality, or outcomes more generally. 9.2.3 A number of aspects of the circumstances of Amy’s death are not suggestive of suicide. Suicide is often preceded by self destructive behaviour and repeated self-harming, of which there is no evidence here. Similarly there is no evidence of Amy having researched suicide on the internet, again a factor often associated with suicide. There have been media reports of incidents of children who have allegedly committed suicide as a result of persistent bullying at school and, although she was said not to make friends easily, there is no evidence of Amy being bullied. 9.2.4 The Panel heard that there had been some discussion about whether Amy had been experimenting with something called the “choking game” where people get a “high” by holding their breath or using a ligature around the neck. The Education IMR confirms that there was an incident of this nature in Kent during 2011. Information about this was subsequently sent to all Kent schools. We do not know whether Amy was aware of the “choking game”. There is no evidence to link this with her death. 9.2.5 We cannot tell what was in Amy’s mind when she died. The evidence from this Review suggests that agencies did not give adequate weight to the impact of abuse, and may have underestimated how unhappy she was. However there is no evidence that she ever had suicidal ideas or plans. Nor is there evidence of extreme distress or recklessness. Agencies could not have been expected to take the eventuality of her tragic death into consideration in their work with Amy. This report is the property of the Kent Safeguarding Children Board. Page 30 of 41 10. REVIEW PROCESS 10.1 The Panel needed to spend some time determining the scope of this review, so that it adopted the most efficient way of considering the issues leading to Amy’s death, while also ensuring that wider concerns were addressed. Once that had been resolved the process of this Review has been satisfactory. There has been full co-operation from all agencies and all timescale targets have been met. As described above, there has been no family input but that was perhaps understandable, in all the circumstances. The Panel was satisfied that nothing further could have been done about this. This report is the property of the Kent Safeguarding Children Board. Page 31 of 41 11. CONCLUSIONS: KEY LEARNING POINTS AND MISSED OPPORTUNITIES 11.1 There was a lack of awareness across the agencies of the nature and prevalence of sexual abuse. When Amy was known to have been abused, the alleged perpetrator suggested that the allegations against him could be attributed to Amy having access to pornography. In the unlikely event that this was true, it would in itself have been the cause of harm. In the context of this family it was highly suggestive of more extensive and damaging abuse. There was an equally improbable acceptance that this was an isolated event, when a thorough consideration of agency records would have identified the numerous concerns about inappropriate and illegal sexual conduct across the extended family. 11.2 Where there was knowledge of abuse, there was a limited understanding of its potential consequences for those involved. An over emphasis on disclosure or physical / forensic evidence, and a lack of confidence in challenging the denial of abuse, left Amy at continuing risk. 11.3 There was a failure not only to draw together a composite picture of the concerns felt about the family but also to appreciate the cumulative consequences of neglect and abuse. Where broader safeguarding concerns were raised – four times by neighbours directly, as well as three written expressions of concern and the issue of alleged sexual abuse of Amy – there is no evidence that staff looked back, to understand the history of the family’s contact with child protection services. This has been recognised by a number of the agencies which have made recommendations about systematic use of chronologies when assessing and working with families. 11.4 None of the agencies involved with her identified and responded appropriately to the isolated position of Amy within her family. The school were unable to build an effective working relationship with the father so worked almost exclusively with Amy’s mother. They did not challenge parental behaviour such as delaying the implementation of the CAF, and refusing free school meals for Amy, while complaining of the family’s poverty. Her father’s antipathy to social workers was accepted at face value and went unchallenged. 11.5 There is almost no evidence of agencies working together to assess and deal with child protection concerns. SCS were not involved in the most clearly evidenced allegation of sexual abuse. Neither they nor police should have allowed the investigation to proceed on that basis. For most of the investigations which were carried out, the evidence of agency checks and subsequent feedback is minimal. 11.6 There were a number of organisational and resource issues. The SCS IMR notes that “There appeared a general lack of management oversight or supervision in any of the interventions prior to Amy’s death”. That report also identifies management practice which is even more concerning than a failure to supervise, referring to a manager who This report is the property of the Kent Safeguarding Children Board. Page 32 of 41 “appeared to attribute much of the responsibility (for unacceptable delay) to other team members”. 11.7 There was a great deal of information about this extended family in agency records. None of the agencies’ investigations and assessments were fully informed by the information they held. Even during the course of this Review it has become clear that agencies had been working with family members without being aware of important information. The introduction of a new computer system had been extremely problematic for SCS, although it is not clear that there were specific consequences for the management of this case. It is acknowledged that there are real challenges in drawing together relevant information from health records held, in this case, by five GP practices and numerous other healthcare providers. However, while acknowledging that some records may not have been kept or accessed, the more significant problem was the failure to take account of what was known about the family. This was a practice issue, not a technological challenge. 11.8 The prioritisation of referrals by SCS, and the thresholds applied, were based on immediate risk. There is little evidence of arrangements which promote the capacity of staff to deal with abuse which is not directly evidenced. Police similarly could have taken a broader view and researched historical information more thoroughly to inform their decision-making. 11.9 A number of agencies have expressed their optimism about the improved management of future cases as a result of the establishment of the multi-agency Central Referral Unit (CRU). They may well be right but this is a service for receiving new referrals. Its introduction will not necessarily address issues arising in cases where there is already continuing involvement. The Panel pointed out that this provision will also not be dealing with children with disabilities or unaccompanied asylum seekers, both widely evidenced as particularly vulnerable groups. 11.10 In some ways the CAF process served to redefine and contain the problem of Amy’s continuing unhappiness rather than bring its causes to light. The agencies have not yet developed arrangements for evaluating the quality of CAF interventions and this review demonstrated a looseness in the interpretation of guidance on thresholds. This report is the property of the Kent Safeguarding Children Board. Page 33 of 41 12. RECOMMENDATIONS MADE IN THE MANAGEMENT REVIEWS OF THE PARTICIPATING AGENCIES 12.1 Introduction 13.1.1 This section of the report details the recommendations made by agencies, in so far as they relate to the issues considered in this Review. Some agencies have made recommendations which relate to wider concerns and members of the extended family. As explained above, those matters are being followed up in separate processes. 12.2 Kent County Council, Specialist Children’s Services 12.2.1 Specialist Children’s Services should ensure that there is consistent use of chronologies in accordance with procedures. 12.2.2 Specialist Children’s Services should ensure that there is a continued improvement in the quality of analysis contained in social work assessments. 12.2.3 Specialist Children’s Services should raise awareness of the recognition, assessment and complexities of sexual abuse. 12.2.4 Specialist Children’s Services should raise awareness of the challenges and approaches when working with hostile and resistant families. 12.2.5 Specialist Children’s Services should ensure that social work staff have a greater understanding of the complexities of working with neglect. 12.3 Kent County Council, Education, Learning and Skills 12.3.1 Amy’s Primary School should be reminded of the importance of maintaining accurate written records of any contact with statutory agencies such as the Police and Children’s Social Services. 12.3.2 A more pro-active stance in following up concerns with other agencies should also be addressed as part of the learning for the schools involved in this case. 12.3.3 Where there is parental refusal to consent to a CAF or significant delay then schools and those advising them need to be reminded of the advice contained in the Thresholds and Eligibility Criteria March 2011 to consider the impact of this on the child and whether a consultation with or referral to CSS is required. 12.4 Kent Police 12.4.1 When an allegation of familial sexual abuse has been made against a child, consideration should always be given to establishing whether there has been similar This report is the property of the Kent Safeguarding Children Board. Page 34 of 41 abuse committed toward siblings or other children within the extended family. Where appropriate, an assessment of risk should be conducted in relation to those children. 12.4.2 The introduction of the Central Referral Unit (CRU) should improve the joint response of both the Police and Social Services Department to incidents reported during ‘out of hours periods’. Once the CRU has been properly established, it should be the subject of a post implementation review, and this anticipated improvement in ‘out of hours’ activity should be tested. 12.4.3 Officers working within Child Protection should be reminded that decisions made following the report of alleged child abuse or neglect must not only be recorded, but the reason for making those decisions should be made clear. 12.4.4 When a child is alleged to be the perpetrator of a sexual offence, this may be indicative of that child also being the victim of abuse. In such cases, information should be shared with Children’s Services and decisions then made as to whether any additional safeguarding activity is required. 12.5 Kent Community Health NHS Trust 12.5.1 Where a history of possible sexual (or any) abuse is shared there must be a written record of how this is considered, managed and informs the assessments of the child. 12.5.2 In situations where the family details are complicated or when understanding the family make up is necessary a genogram should be completed and kept in a prominent position in the records. 12.5.3 All staff should be reminded of their responsibility to keep accurate records which reflect communication and decisions in the assessment processes. 12.5.4 A genogram is beneficial and should support an assessment of the likely impact of bereavement, or any loss of a significant person, on a child or young person. 12.5.5 The child should be at the centre of all assessments and the ‘voice of the child’ heard and not be lost in the chaos of family dysfunction and issues. 12.5.6 Non engagement and low levels of compliance should be assessed in relation to the impact of those behaviours on the child. 12.6 Kent and Medway NHS and Social Care Partnership Trust 12.6.1 Review Screening process of all referrals to Child and Adolescent Mental Health services (CAMHS) Tier 3. This report is the property of the Kent Safeguarding Children Board. Page 35 of 41 12.7 Maidstone and Tunbridge Wells NHS Trust 12.7.1 The Trust should ensure with immediate effect that safeguarding supervision is offered to staff in Accident and Emergency Departments. 12.8 General Practitioners 12.8.1 Safeguarding training of the primary care teams involved to take place so as to be fully compliant with forthcoming CQC requirements. 12.8.2 Safeguarding training to address the need to communicate with all agencies and with other GP practices where the family is fragmented and registered with multiple practices. 12.9 Health Overview Report 12.9.1 This report details the recommendations from the health agencies involved in the review but makes no further recommendations. 12.10 Kent Youth Offending Service 12.10.1 Kent YOS should review the present practice guidance (August 2011) for both YOS and SCS staff to ensure that it supports effective joint work with children / young people and their families where there is a shared case responsibility. 12.10.2 Kent YOS and SCS should evaluate the costs and benefits of seconding SCS Social Workers into YOS teams. 12.10.3 Ensure that staff within both SCS and YOS can, as appropriate to role and responsibilities, access the electronic case records used by both services. 12.10.4 Kent YOS should ensure that all assessments and plans produced by YOS are quality assured and counter-signed by Practice Supervisors and Team Managers in line with YOS procedures. 12.10.5 Kent YOS should ensure Team Managers and Practice Supervisors include within supervision the opportunity for reflective practice as required by the YOS Staff Supervision Policy. 12.11 Kent Probation 12.11.1 When supervising offenders and, on receipt of information regarding convicted sexual offenders residing in accommodation with children, consideration must be given by Offender Managers to making a referral to Children’s Social Services in order to safeguard the welfare of children. This report is the property of the Kent Safeguarding Children Board. Page 36 of 41 12.11.2 Offender Managers must identify full family composition when working with offenders, ensuring a holistic assessment of the individual in order to identify at an early stage whether there are any potential safeguarding issues. 12.12 Housing provider 12.12.1 The housing provider should ensure that any information received relating to potential safeguarding concerns is passed to appropriate agencies, i.e. Police or SCS, even when it is believed that the agency is already aware. 12.12.2 The housing provider’s safeguarding procedures should ensure that staff in the agency participate fully in all aspects of local interagency arrangements for safeguarding. 12.12.3 The housing provider should take steps to improve the accessibility and accuracy of available information that is relevant to safeguarding. 12.13 South East Coast Ambulance Service NHS Foundation Trust 12.13.1 No recommendationsThis report is the property of the Kent Safeguarding Children Board. Page 37 of 41 13. RECOMMENDATIONS FROM THIS OVERVIEW REPORT 13.1 Introduction 13.1.1 These recommendations arise from this Overview Report which reflects the views of the SCR Panel and the independent Overview Report author. They have been endorsed by the KSCB. Where they are particularly significant they may overlap with the recommendations, set out above, made by individual agencies. They are in line with the Government’s guidance13 “focus on a small number of key areas with specific and achievable proposals for change”. that Serious Case Reviews should 13.1.2 In this case those “key areas” relate largely to fundamental safeguarding practice. This was not a review where the principal lessons to be learned are new, complex or intricate. Some of the recommendations necessarily arise from the review and are detailed here even though the agencies have already taken action to address those issues. There is one recommendation that relates to the process of any future Serious Case Reviews. 13.2 Recommendations to the Kent Safeguarding Children Board 13.2.1 The Board should, with reference to the findings of this review, ensure that there are satisfactory, multi-agency arrangements for a) recognising and responding to cases of sexual abuse within families b) recognising and responding to cases of chronic neglect and that agencies’ compliance with those arrangements is routinely monitored and evaluated. This recommendation is not restricted to new referrals: agencies should also address its implementation in their continuing work with families. 13.2.2 The Board should promote an emphasis on ensuring that the “voice of the child” is heard across all partner agencies, that practice in this regard is evidenced and monitored and that agencies are able to show how their policies and practices are influenced by the children and families with whom they work. 13.2.3 The Board should, by dissemination of the lessons learned from this review, emphasise to staff in all agencies the importance of ensuring that assessments are informed by thorough research into any previous contacts between agencies and families and that chronologies and reference to previous contact are routinely used to inform assessments of risk. 13.2.4 The Board should ensure that there are clear arrangements for working with hostile or resistant families, that front line staff are appropriately supported in this work. The Board should regularly review arrangements in this area across all partner agencies. 13 “Working Together” (2006) Paragraph 8.34 This report is the property of the Kent Safeguarding Children Board. Page 38 of 41 13.2.5 The Board should review and strengthen as necessary a) arrangements for sharing information within and between agencies about children and young people who may be perpetrators of sexual abuse b) arrangements for working directly with children and young people who may be perpetrators of sexual abuse 13.2.6 The Board should satisfy itself that the implementation of the CAF is helpful in leading to more purposeful interventions with children and their families and that thresholds between non-intervention, the use of the CAF and referral to children’s social care are well understood and consistently implemented. 13.2.7 The Board should seek to ensure that all schools have the necessary safeguarding systems in place and to a good standard, and that the relationship between schools and the local authority allows for the proper level of support and challenge. The local authority should satisfy itself and the Board that the level of input to schools is proportionate and appropriate. 13.2.8 The Board should liaise with commissioners of health services to produce a brief guidance note so that, if Health Overview Reports are required in any future SCR, authors will have clear expectations as to their purpose and expected contents. This report is the property of the Kent Safeguarding Children Board. Page 39 of 41 APPENDIX A: Biographical details of Independent Chair and Overview Report Author Independent Chair: Mr Keith Ibbetson Keith Ibbetson began his career as a residential social worker in 1981 in Lambeth. For the next 16 years he worked as a social worker and manager in children’s services in Hertfordshire and London. Since 1997 he has worked as an independent consultant in children’s services, specialising in child protection, quality improvement initiatives and the development of preventative services. He has been involved in more than thirty Serious Case Reviews and independent management reviews, as panel chair, overview report writer and in implementing the findings of reviews. Independent Author of Overview Report; Mr Kevin Harrington Kevin Harrington trained in social work and social administration at the London School of Economics. He worked in local government for 25 years in a range of social care and general management positions. Since 2003 he has worked as an independent consultant to health and social care agencies in the public, private and voluntary sectors. He has a particular interest in Serious Case Reviews, in respect of children and vulnerable adults, and has worked on more than 35 such reviews. Mr Harrington is involved in professional regulatory work for the General Medical Council and for the Nursing and Midwifery Council. He has served as a magistrate in the criminal courts in East London for 15 years. This report is the property of the Kent Safeguarding Children Board. Page 40 of 41 APPENDIX B: References Footnotes have been used to indicate specific quotations from or references to research, practice guidance and other documentation. This Overview Report has been generally informed by the following publications • Working Together to Safeguard Children,(HM Government 2010) • The Victoria Climbie Inquiry (Lord Laming 2003) • The Protection of Children in England: A Progress Report ( Lord Laming 2009) • The Annual Report of Her Majesty’s Chief Inspector of Education, Children’s Services and Skills 2007/08 • Safeguarding London’s Children: Review of London Serious Case Reviews First Annual Report (London SCB 2007) • Joint Area Review, Haringey Children’s Services Authority Area Review of services for children and young people, with particular reference to safeguarding (2008) • Improving safeguarding practice, Study of Serious Case Reviews, 2001-2003 Wendy Rose & Julia Barnes DCSF 2008 • Analysing child deaths and serious injury through abuse and neglect: what can we learn – A biennial analysis of serious case reviews 2003-2005 • Understanding Serious Case Reviews and their Impact - a Biennial Analysis of Serious Case Reviews 2005-07 DCSF 2009 • Developing an effective response to neglect & emotional harm, Gardner 2008 • Child maltreatment in the United Kingdom: A study of the prevalence of child abuse and neglect ( Cawson, Wattam, Brooker, Kelly November 2000) • Review of the involvement and action taken by Health Bodies in relation to the case of Baby P ( Care Quality Commission (2009). • Learning together to safeguard children: developing a multiagency systems approach for case reviews. ( SCIE 2009) • The Munro Review of Child Protection: Final Report (HMSO May 2011) • The Munro Review of Child Protection: Interim Report (HMSO February 2011) • Publication of Serious Case Review Overview Reports: Letter from Parliamentary Under Secretary of State for Children and Families 10th June 2010 • ADHD - Quick Reference Guide (NICE 2008) • ADHD as a cultural construct (Timimi & Taylor, British Journal of Psychiatry 2004) This report is the property of the Kent Safeguarding Children Board. Page 41 of 41 |
NC52749 | Death of a 7-week-old infant boy in August 2020. The cause of death was ruled as sudden unexpected death in infancy (SUDI). Learning themes include: risk assessment and decision making; child neglect; substance misuse; and safe sleeping. Recommendations for Kent Safeguarding Children Multi-Agency Partnership include: undertake an audit of the processes of convening child protection conferences to review the attendance of key agencies and the quality of reports submitted by agencies; consider learning from the Child Safeguarding Practice Review Panel's report The myth of invisible men to ensure the overt engagement of men in risk assessments across the partnership; raise awareness and understanding of the Public Law Outline (PLO) process so that practitioners are clear of the processes and aware of opportunities to influence risk assessment and decision making; children's services review the arrangements for risk assessment and decision making in the PLO process and the interface between the legal advice received and the decisions taken to ensure this is a constructive process with sufficient challenge; review the neglect strategy to develop a clear shared understanding of good enough home conditions that provide practitioners with an agreed baseline; develop a substance misuse strategy, with a specific focus on cannabis use, to support a shared understanding of risks, appropriate interventions and decisions on the threshold for escalation; and to promote and raise awareness of the need to deliver safe sleeping advice, particularly when there is substance misuse by parents.
| Title: Local child safeguarding practice review: Child S: review report. LSCB: Kent Safeguarding Children Multi-Agency Partnership Author: Alex Walters Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Local Child Safeguarding Practice Review Child S REVIEW REPORT Independent Reviewer: Alex Walters FINAL REPORT Published November 2022 Kent Safeguarding Children Multi-Agency Partnership 2 CONTENTS Item Page Introduction 3 Process for conducting the review 3 Relevant background information prior to the timeframe under review 4 Family Structure 4 Involvement of agencies in LCSPR time frame and single agency learning 9 Findings & analysis - Risk Assessment and Decision Making - Understanding of Neglect - Substance Misuse - Safe Sleeping 15 Effective practice 19 Recommendations 20 3 1. Introduction 1.1. Kent Safeguarding Children Multi- Agency Partnership (KSCMP) commissioned a Local Child Safeguarding Practice Review (LCSPR) in November 2020. This followed a Rapid Review process and a discussion with the National Child Safeguarding Practice Review Panel. It was agreed that the circumstances met the criteria for an LCSPR because a child had died, the initial circumstances of the death indicated potential neglect, the child was subject to a Child Protection Plan and it was recognised that there were opportunities for further agency and system learning. 1.2 In the case, a child known as Child S died aged 7 weeks in August 2020. At the Inquest in February 2021, the cause of death was subsequently ruled as Sudden Unexpected Death of Infant (SUDI). The post-mortem had ruled out neglect overlay. Child S had been sleeping with his parents and testing found substances in both parents’ systems. No criminal offences were considered to have been committed. 1.3 Child S had one older sibling and one older half sibling who had both been made subject of Care Orders in June 2019 and had been placed for Adoption in March 2020. Child S had been subject to a Child Protection Plan since April 2020 initially as an unborn under the category of neglect. 1.4. The time period of this practice review includes the beginning of the Covid 19 pandemic and the first national lockdown in March 2020. This context is important as many of the processes used by agencies became virtual and will have impacted on the practitioners and family. Most practitioners worked from home, however with this family, the Midwife, Health Visitor and Social Workers /Social Work Assistants continued to undertake home visits. The pandemic also impacted on overall recruitment and retention in agencies and for some practitioners, access to supervision and covering for absent colleagues resulted in increased demand/higher caseloads. 1.5. The purpose of a LCSPR, as confirmed in the current statutory guidance,” Working Together to safeguard children 2018”: Chapter 4 is clear that the focus is on learning for agencies and practice to secure improvement and not to hold individuals or agencies to account. 2. Process for conducting the LCSPR 2.1. KSCMP recognised the criteria for undertaking a LCSPR were fully met and there was potential to learn lessons from this review regarding the way that agencies work together in Kent to safeguard children. 2.2 There was a delay in initiating the LCSPR and the first Panel meeting was held in March 2021. In June 2021, the Partnership commissioned an Independent Reviewer, Alex Walters, an independent safeguarding consultant, experienced Local Safeguarding Children Board (LSCB) chair and SCR/LCSPR Independent Reviewer, fully independent of KSCMP and its partner agencies. 2.3 A further Panel meeting was held in July 2021, which agreed the scope, and the Terms Of Reference. It was agreed the time frame of focus would be October 19-August 2020. The methodology was a hybrid model including agency reports, access to key documents and discussions with practitioners and the family. An Agency Authors briefing was held in August 2021 led by the Independent Reviewer to discuss the Terms of Reference and the process of the Review. Kent Integrated Children’s services (ICS) had already undertaken an internal review. This 4 was discussed with the Children’s Social Care lead and shared with the Independent Reviewer and updated into an agency report shared with other agencies. 2.4 Full agency reports were completed, providing agencies with the opportunity to consider and analyse their practice and identify any systemic issues. They were received from: Kent Police; Kent Integrated Children’s Services; Housing-Borough council; Maidstone and Tunbridge Wells NHS Trust (MTW); Kent Community Health Foundation Trust (KCHFT) and Kent and Medway CCG. Reports from East Kent Hospital University Foundation Trust (EKHUFT), Medway NHS Foundation Trust (MFT) and Kent and Medway SCP were also received covering their historical involvement. The reports provide details of the learning from the case within their agency, but also allowed agencies the opportunity to reflect on actions and make recommendations for improving their own practice. These reports were discussed with the agency authors and the Panel together in October 2021 to consider the learning and further information and clarification was subsequently sought. The Independent Reviewer requested and received key documents including Child Protection conference and core group minutes but was not able to see the legal planning minutes. 2.5 Discussions were held from January 2022 with key staff including the community midwife and named safeguarding health professionals in MTW; the social workers, social work assistant and managers including the service manager involved with the case from ICS. Unfortunately the main Health Visitor and her manager were on long term sick leave and others had left the service. Practitioners considered key themes identified by the Independent Reviewer, and the perspectives and opinions of all those practitioners involved at the time were most helpful and reflective and have significantly informed the LCSPR report. 2.6. The contribution of family members is an important part of the review. It was agreed that both father and mother would be informed of the LCSPR process, which was helpfully undertaken in person by the Practice Review Manager and one of the family’s previous social workers. The Independent Reviewer subsequently attempted to make contact by telephone, as agreed with Mother on a number of occasions but without success. It is hoped the report can still be discussed with the parents prior to publication. 2.7. This practice review has been undertaken in a proportionate way to ensure the key learning is identified to support improvements in practice. It is, therefore, deliberately not detailed but provides a summary of the family and key agencies’ engagement with the family. 3. Relevant background information on parents prior to the timeframe under review 3.1. There is an extensive history of Children’s Social Care involvement with the wider maternal family dating back to 2001 which involved Mother and some siblings being removed from her mother’s care due to neglect, drug misuse and domestic abuse. Mother went to live with her Maternal Grandmother from 6 to 12 years of age and then returned home. Mother became pregnant aged 17 but did not sustain a relationship with the Father of Sibling 1. Mother was referred to mental health services at 18 by the GP for depression/self harm/anxiety but she did not engage. Mother clearly had experienced adverse childhood experiences which will have impacted on her parenting. 3.2 There is little information on the Father of both Sibling 2 and Child S’s background from the information provided to the review. However, it is known that he does have criminal convictions for violence and historical domestic abuse and was known to Probation services in relation to historical offending, which ended in January 2019. There was no mental health involvement. 5 3.3 Kent Integrated Children’s Services (ICS) involvement with Sibling 1 began in January 2018 following several referrals regarding domestic abuse incidents, substance use, homelessness, and neglect. Mother was 18 years old and ICS was not able to meaningfully engage Mother in the support services offered. Father to Sibling 1 played no part in his life. An Interim Care Order was granted in June 2019 and Mother was offered the opportunity to go to a parent child placement but was only able to remain for 12 hours. By this time Mother was nearing term with Child S youngest sibling –Sibling 2 who upon birth joined Sibling 1in foster care and both were subsequently adopted in March 2020. Towards the conclusion of the care proceedings Mother became pregnant with Child S and when aware the Midwife made a request for support for the family to Children’s Social Care in January 2020. 4. Family Structure. 4.1 The relevant family members in this review are: Family member To be known as: Subject child Child S Father to subject child Father Mother to subject child Half Sibling to subject child Sibling to subject child Mother Sibling 1 Sibling 2 5. Brief chronology of events from October 19- August 20 5.1 During the review period, which covered the pregnancy and birth of Child S, the family received universal health services from the GP, involvement with Housing and Police, universal plus services from Midwifery and Health Visiting to reflect their support needs and specialist involvement from Children’s Social Care services in Kent (ICS) from January 20. Neither parent had involvement with mental health or engagement with substance misuse services. 5.2 In January 20, a referral was received by ICS from the midwife for unborn Child S. It noted the known history including mother’s poor mental health, domestic abuse, substance misuse and current homelessness. ICS noted little time had passed since the end of care proceedings for the unborn baby’s older siblings and highlighted a similar situation. 5.3 The Housing Department offered temporary accommodation to Mother and Father in March 20. A Child & Family Assessment (C&F) was completed by ICS and recommended a strategy discussion. This was held on 20.03.2020 and included representation from police, midwifery, health and housing, and some professionals with recent involvement with Child S’s siblings. The outcome was to progress to Initial Child Protection Conference (ICPC) and it was noted a Legal Planning Meeting was also to be convened to consider Public Law Outline (PLO) /Care Proceedings and agree the next steps 5.4 On 17.04.2020, the Initial Child Protection Conference (ICPC) unanimously agreed (unborn) Child S should be supported by a Child Protection Plan under the category of neglect. Mother reported she was smoking one joint of cannabis a day to help her sleep. Father reported he was smoking cannabis throughout the day but wished to stop. Neither reported any current issues with 6 their mental health. Police information noted most recent domestic abuse notification as November 2019. The agreed Child Protection Plan was as follows: • Mother to attend health / midwifery appointments • Both parents to reduce drug use and work towards being drug free • Both parents to maintain the tenancy agreement, including paying rent and keeping the flat clean • Both parents to adhere to COVID-19 guidelines • Domestic abuse support / intervention to be explored to focus on healthy relationships and the impact on children, including 121 work via the allocated social worker if services not available due to COVID-19 • Pre-Birth Planning meeting to take place • Midwifery to support Mother to claim maternity grant and explore with Mother how she was feeling with a view to referring to services if necessary • Allocated social worker to also explore feelings with Mother and support access to Adult Services for Mental Health if necessary and provide helpline numbers. • Pre-birth assessment to include safety planning (was not completed) • Family Group Conference referral • Legal Planning Meeting 5.5 On 19/5/20 the first Core Group meeting was held. 5.6 On 18/5 and 19/5 20 there were 2 domestic incidents involving the parents and the Police, which were not referred to ICS. 5.7 An Initial Legal Planning Meeting was held in May 20, with the outcome to progress to Public Law Outline procedures and a period of pre-proceedings. At the time Child S’s estimated date of delivery was 07.07.2020. A Senior Social Work Practitioner was allocated to complete a Parenting Assessment and a referral for a Family Group Conference was made. There is recognition that there was some delay in these processes being initiated given the original referral was in January 20. 5.8 The second Core Group meeting was held virtually on 12.06.2020 involving Mother, the two Social Workers, Midwife and Housing. The minutes note the baby was measuring small and Mother may need to be induced. The Pre-Birth Plan was shared by the Social Worker to the Midwifery team; the plan notes that “unborn is subject to CPP, Children's Social Care must be informed of birth; Social Worker notes that if Mother and S are well then can be discharged home (if no Midwifery concerns); the plan further notes that ‘owing to the child being on a Child Protection Plan the unborn is at risk of neglect and poor supervision. There is not an immediate risk to the child as Mother has cared for children in the past. There have been some noted improvements made in her insight and situation, hence why legal orders are not being sought at birth. The Local Authority are currently in pre-proceedings process and there are not currently plans to remove the unborn from their care after birth, thus the unborn will be returning to the parent’s home which has been visited and assessed’. 5.8 On 22.06.2020, the ICS Area Assistant Director agreed to issue care proceedings at birth. However, at the Review Legal Planning Meeting held on the same day the plan reverted to remaining under the Public Law Outline in pre-proceedings with Child S returning to his parents care once born. The meeting was held just over 3 weeks after the Initial Legal Planning Meeting 7 and the overarching view of attendees appears to be that ‘threshold wasn’t met.’ Both Social Workers felt the circumstances for Child S were better than for the siblings and a narrative was developed around things being ‘not bad enough to warrant removal.’ 5.9 There is a further virtual Core Group meeting on the 23.06.2020. Parents were excused to participate in a Parenting Assessment session and the midwife confirms Mother will be induced the following day. The Core Group discussed the visiting arrangements following Child S’s discharge home from hospital. A Social Work Assistant (SWA) was assigned to work alongside Social Workers and support the family. The Core Group minutes of 23.06.2020 note “the Core Group” were concerned about two parents under the influence of substances but there was no further challenge to the proposed safety plan shared by the Social Worker, which required one parent to remain sober. 5.10 On 25.06.2020 Child S is born by caesarean section. The call from the hospital midwives to Kent OOH service to alert them note there are concerns the parents used drugs whilst in hospital i.e. smell of cannabis after a walk. However, this is not communicated to the allocated Social Worker. Due to COVID -19 a physical discharge planning meeting did not take place. Records indicate the Social Worker spoke to a lead midwife at the Hospital on 26.6.2020 and outlined the plan for Child S including level of visiting post discharge and ongoing assessment and care planning. Parents were reported to be appropriate and attentive and neither appearing to be under the influence of substances. 5.11 On 27/6/20 Child S is discharged from hospital home with parents. 5.12 The following home visits were undertaken over the next 7 weeks-both announced and unannounced: 29/5/20- Midwife 30/6/20 Midwife 1/7/20- Social worker 2/7/20- Social Work Assistant 3/7/20-Social Worker 7/7/2- Parenting Assessment (PA) Social Worker 8/7/20 -Health Visitor 10/7/20 -Midwife 14/7/20- PA Social Worker 15/7/20 -Social Work Assistant 19/7/20 -Midwife 22/7/20- Social Worker 29/7/20- PA Social Worker 31/7/20 –Social Worker 2/8/20- Police –following allegation 8 6/8/20-Police following allegation 6/8/20- Duty Social Worker and Social Work Assistant 7/8/20- Health Visitor 5.13. On 13.07.2021 the Review Child Protection Conference was held virtually. Information / reports were provided by the Social Worker, Police, Housing, Health Visitor, GP and KMPT. By the time of the Review Child Protection Conference, the decision had been made that Child S would remain in the care of his parents whilst Public Law Outline (pre-proceedings) continued. Information from the Police incidents in May and the fluctuating home conditions were not shared. Child S remained subject to a Child Protection Plan. 5.14 On 17.07.2020 Initial Pre-Proceedings meeting held. The parents did not attend but were represented by solicitors. 5.15 On 29.07.2020 the Parenting Assessment concluded with a positive outcome. The social worker felt the basic care the parents gave was good enough, they had engaged well, were insightful of the concerns, which had led to the removal of Child S’s siblings and there had been no concerns re domestic abuse or substance misuse. It concluded with recommendations for further support. 5.16 During the period 31.07.20 – 06.08.20 (bank holiday weekend) there was ICS Out of Hours /ICS involvement resulting in 2 police welfare checks due to concerns for the care Child S was receiving from his parents/domestic abuse. Child S was well, but alcohol use was noted to be a contributing factor. Telephone follow up with parents was undertaken, who did not initially disclose full details of what occurred to the Social Worker. 5.17 Following additional information from an anonymous source, a Duty Social Worker and Social Work Assistant undertook a visit to the family on 06.08.20 as the allocated Social Worker was on leave. Before and following the visit, they discussed their concerns with ICS legal adviser in detail who suggested the Social Worker to visit the following week and to discuss the written agreement with the parents. 5.18 On 07.08.2020, the Health Visitor raised concerns by email to the Social Worker about the home conditions and bruising to mother which it is assumed related to events a few days earlier. 5.19 On 10/8/20 a Core Group Meeting was held with the Social Worker and Health Visitor and recent events/concerns discussed. The Social Worker was due to visit on 14/8/20. Sadly Child S died that morning. 6. Involvement of agencies October 19– August 20 and single agency learning HOUSING 6.1 Mother and Father had been sofa surfing for a number of months but presented to the Housing Department in March 20 and were placed in temporary accommodation. The Housing team had minimal engagement with Child S or his parents during the review period but demonstrated good liaison with ICS to help resolve their housing situation. In addition, Housing were involved in all Child Protection/Core Group meetings and correct action was taken by the housing manager to flag 9 concerns to ICS around the incidents on 11/8/20 when alerted by the Housing Provider. No additional learning identified by the agency Author or Reviewer. MIDWIFERY 6.2 Midwifery from the Maidstone and Tunbridge Wells NHS Trust (MTW) became involved in March 20 following a good quality handover referral from midwifery at EKHUFT. One Midwife undertook all antenatal care and post natal care in the community, which enabled a consistent trusting relationship to be developed. In addition, the midwife provided extended Midwifery post natal care for Mother and Child S for a period of 28 days which involved 5 home visits. This is above the normal standard and reflected the Midwife’s good understanding of the vulnerability of the family. The Midwife attended the ICPC and Core Groups but was not invited to the RCPC. Safe sleeping advice was provided to the family on each occasion in this post-natal period. The Midwife engaged well with Mother and Father and maintained good liaison with the Social Worker and Health Visitor and informed them of the cessation of her involvement on 22/7/20. The Midwife had no safeguarding concerns around the quality of the care provided by parents although noted that the home conditions were untidy on occasion but that Child S was thriving. Subsequent changes/improvements in practice for Midwifery identified by the agency author: • The Named Nurse Safeguarding Children will strengthen the training on Professional Curiosity in line with the recommendations from previous reviews and the current Intercollegiate Document • The Midwifery Safeguarding team will highlight to staff the importance of Professional Curiosity and having ‘difficult conversations’; Safeguarding supervision will highlight and document discussions on Professional Curiosity • Although staff are aware of the challenge/escalation process this will be highlighted during training and supervision • Information sharing with Community Midwifery team leaders/senior managers HEALTH VISITING 6.3 During the review period health visiting was provided the Kent Community Health NHS Foundation Trust (KCHFT). The Health Visitor completed two home visits and three telephone discussions with the family. 6.4 The Health Visitor attended the Strategy discussion in March 20 but was not invited to the Initial Child protection Conference (ICPC) in April 20 but proactively requested information from the Social Worker. When liaising with the GP, there was good antenatal communication and professional liaison, however, liaison with the GP would have been good practice following the 6–8-week review, as there seemed to be a lack of information sharing with the GP once Child S was born, especially as parents were yet to register Child S with a GP. 6.5 On 08.07.2020 during the first home visit the parents had been encouraged to clean/tidy up. It was also noted that Mother had fallen asleep on the sofa with Child S’s head unsupported. The Social Worker requesting both midwife and Health Visitor revisit and reinforce information regarding safe sleeping. Health Visitor replied to this email to both Social Worker and midwife advising about the observations at the new birth visit and that safe sleeping was discussed with parents. Health Visitor acknowledgement that home conditions were likely good enough as a result of Social Worker Assistant intervention. Health Visitor advised Social Worker that she would reinforce safe sleeping at next contact in 2 weeks’ time and again at 6-8-week contact. 10 6.6 Safe sleep advice was consistently given by the Health Visiting Service and documented well within the records. 6.7 The Health Visitor did have increased concerns at her 2nd home visit on 7/8/20 around the home conditions and also bruising seen on Mother and proactively raised these with the Social Worker and agreed the Social Worker would visit later that week. Subsequent changes/Improvements in practice for Health Visiting identified by the agency author: • Already part of an internal Action Plan for the Health Visiting Service, an action to demonstrate and document professional curiosity when parents/carers report information about themselves and engagement with other services by liaising with such services. • Health Visiting Service/Children & Young Peoples Operational Services to follow Local Safeguarding Partnership “Resolving Professional Disagreements and Escalation of Professional Concerns” procedures if they are concerned with partner agency’s management/lack of escalation regarding a case. GP 6.8 Father was registered at Practice A but not seen during the time period but was not on any regular medication. There was no information or communication from the ICS service that Father was the father of a child who was subject to a Child Protection Plan. Mother was registered at Practice B and partial Temporary Registration at Practice A but had no face-to-face consultations in the practice during the time period and no medications were issued. 6.9 There was one discussion with NHS 111 at 4 am on 10/4/20 which is significant in that Mother was approximately 23 weeks pregnant and shared she had sex with her partner and ‘things got a bit rough’. She reported bruising to her vaginal area. One of the GPs from Practice B attempted to ring her back on 3 occasions to follow up but there was no response. 6.10 This information was shared in response to request from ICS for information from GP services regarding an Initial CP Case Conference (ICPCC) on 17th April 2020 for unborn Child S. The GP shared the tight deadline for providing a report and the information from the April NHS 111 contact. This issue is significant given the history of domestic abuse in the Parent’s relationship and raises the possibility of non-consensual sex. The GP also shared that Mother booked late at 17/40 weeks for her maternity care on 24/02/2020. 6.11 However it would appear that this information was not received/shared at the ICPC held on 17/4/20 and this may have been due to late receipt of the letter. This does not appear to have been known to the social worker. Improvements in practice identified for GP services by the agency author: • Due to patient choice within the NHS Constitution (2012), parents can also choose to register at different GP surgeries. Mother did not register Child S birth despite repeated requests from the practice; particularly as Child S was on a CPP. The Agency Author recognises sharing this information with ICS would have provided more support for the practice as the family social worker could also help support the parents to register Child S. • There is a national issue around Temporary registration. It lasts for 3 months and only limited records are shared from the Practice where a patient is fully registered. 11 INTEGRATED CHILDRENS SERVICES- KENT COUNTY COUNCIL 6.12 From January 2020, there was comprehensive engagement by all social workers/social work assistants involved with the family. All statutory processes were followed i.e. Social Work assessments, Strategy meetings, Child Protection Conferences, Core Groups, PLO processes and Child S was made subject appropriately to a Child Protection Plan. There is however recognition that these processes could have been undertaken in a more timely manner which impacted on a reduced timeframe to consider and assess risk. In addition, a specific pre birth assessment which was identified in the Initial Child Protection Conference in April 2020 was not undertaken although a social work assessment had been completed. It is recognised that consideration needs to be given to the support offered to parents who have experienced care proceedings and whose children have been recently removed and there is evidence of other loss and trauma for the parents. ICS have since produced additional guidance for practitioners to clarify pre birth processes and expectations. 6.13 The ICPC in April 2020 was well attended by partners (other than the Health Visitor who was not invited) and the history and risks to unborn Child S were all clearly identified in the Social Worker’s reports and minutes. The identified Child Protection Plan actions were undertaken and overall communication between the agencies involved with the family was timely and effective. 6.14 The case was allocated to a Social Worker who was an experienced senior practitioner who had previous knowledge of the family though the previous care proceedings. The Social Worker developed a good trusting relationship with the parents. The social work report to the RCPC in July 20, 2 weeks after the birth of Child S was strengths-based and evidenced positive interactions between Child S and parents. The Social Worker believed the situation was very different to the previous time they were involved, referenced fewer police reports, a lessening of the parents’ chaotic lifestyle and lack of domestic abuse reports at that time. The Social Worker saw no reason to doubt the parents’ contention they had stopped using drugs and their presentation was significantly different from when they worked with them previously. Concerns about the fluctuating home conditions were mitigated, in part, by the fact they now had a stable home and multi-agency work to address the identified concerns would continue. In addition, the Social Worker felt parents demonstrated insight into the concerns which led to the removal of the older children. 6.15 A parenting assessment had been commissioned and undertaken by a senior social work practitioner over the 4 weeks post birth and the narrative developed with both social workers around the situation being ‘good enough’ for Child S to remain in his parents’ care under the Public Law Outline as parents had shown insight and appeared to be taking on board advice from professionals. Home conditions were overall acceptable for the age of an immobile child. However, there was no benchmark set or agreed and shared with the multi-agency network for what ‘good enough’ looked like, and / or how this could be achieved or tested and what their contributions might be. The narrative assumed the circumstances for Child S were not ‘as bad’ as they were with his siblings and it appears the baseline for ‘not good enough’ was perceived as immediate removal. Practitioners noted that home conditions are often variable in families which makes risk assessment challenging and also the reality of differing professional and personal perceptions of “good enough”. 6.16 With hindsight, there is no evidence the parents undertook any work, or intervention provided to address any of the issues which led to the siblings being removed. Although they engaged with Social Workers and Health practitioners, they did not engage with the FGC over 3 months, with substance misuse services or obtain legal advice on their own for the PLO process as this was 12 undertaken with the support of the Social Worker. The Parenting Assessment relied heavily on how reflective the parents were being during sessions and their perceived level of engagement. The evidence suggests disguised compliance may have been a factor but there is no doubt of the parent’s desire to effectively parent Child S. 6.17 Practice could have been strengthened by co-ordinating with other agencies and the SWA to inform the parenting assessment. There is evidence that what practitioners observed about the fluctuating home conditions in unannounced or planned visits conflicted with what the parents were telling the Social Workers about the changes they were making. In addition, the Parenting Assessment did not consider information from the General Practitioner in April 2020, the Police’s information from incidents in May 2020, the information about a cannabis grinder seen at the flat, the co sleeping incident or include updated agency checks. These omissions should have led to more scrutiny of the parents’ self-reported improvements, motivation and capacity to sustain change. It did not include the Police incidents in July 2020 but they took place just after the assessment concluded. However, in terms of risk factors, none of the practitioners witnessed or smelt cannabis use during the 7-week period other than the observation of the cannabis grinder. 6.18 The positive feedback from the Parenting Assessment was instrumental in the decision to continue the Public Law Outline at the Legal Planning Meeting on 22/6/20 rather than issue care proceedings, even though the Parenting Assessment was incomplete at this point and not reviewed /quality assured. There was challenge to this view from the Service Manager, but legal advice was that there was insufficient evidence for separation and therefore alternative placements i.e. Parent and child were not considered. However supported accommodation for vulnerable families with CCTV might have been a preferable option. This has identified learning for ICS around issues of threshold, test for interim separation and care planning. 6.19 Learning also highlights the necessity of ensuring the quality assurance of assessments is robust and considered in the wider context, by those who have sufficient experience, knowledge, and skills to critically analyse and reflect on the evidence base. In addition, there also needs to be a clear agreement at the start of specialist assessments such as a Parenting Assessment which identifies exactly what is being assessed, including baseline information and minimum expected / required outcomes, which may or may not include parenting “teaching” sessions to support assessment. This should be understood and endorsed by the network of professionals working with a family. Improvements in practice in children’s social care as identified by the agency author: ICS have undertaken substantial learning and review from this case prior to the decision to undertake a LCSPR. The following outlines the activity and development to date to address learning. • Delays- The importance of the Pre -birth assessment period as a framework to analyse the likely care Child S would receive from his parents, and whether this could be achieved safely. The parenting assessment did consider parents’ preparations for the baby, however, was not started until very near to Child S’s birth. Intervention in relation to managing & maintaining home conditions also started around the time Child S was born when there were earlier opportunities. • Supervision/Management oversight- There were several practitioners involved with the family, this was a strength as practitioners had existing relationships and knowledge of the family history. Practitioners would have benefited from joint supervision; this could have 13 helped an analysis of parental capacity to change, baseline parenting skills, needs & expectations and supported an understanding of “good enough” parenting. This should be extended to multi-agency partners. There may be future opportunities to extend joint supervision to include key multi agency professionals working with a family. • Substance Misuse- Expectations and planning regarding substance use need to be specific. Assessment & planning should involve expertise from specialist substance misuse services to properly assess and develop interventions and safety planning and inform professional networks about risk and impact of substance use. ICS report a pilot multiagency workshop commenced in September 2021 where ICS commissioned senior practitioners from domestic abuse, substance/alcohol and mental health services to lead on a group discussion on an identified case. This is supporting understanding of the different perspectives as well as informing best practice regarding any of the factors or a combination. This is now going through the scale up process to be delivered across KCC. • Trauma informed practice-ICS has implemented training and development regarding trauma informed practice, this will support understanding and assessment when working with trauma- experienced parents, in this case, parents who have previous children removed. • Care proceedings/PLO Where there may not be the threshold for separation, consideration should always be given as to whether care proceedings should be instigated where previous children were recently removed from parental care. This will ensure judicial oversight when testing out the sustainability of positive parental change in the context of disguised compliance and to avoid any unnecessary delay to permanency planning for the child. There may be an opportunity to develop partner agency understanding of the Public Law Outline - this could strengthen external challenge regarding decision making-see multi-agency recommendation. A thematic audit into the pre-proceedings process was undertaken which involved surveys being completed by the multiagency and provided important further learning in this area. • Assessments-Practitioners should ensure they review and use all available information from the multi-agency network when completing assessments, reports and reviews. Practitioners need to challenge poor quality or late reports for Conference. KENT POLICE 6.20 Kent Police have been involved with Mother since 2005 when child protection concerns were raised in relation to her, her siblings and her mother. A number of records are held in relation to domestic abuse incidents within her family when she was a young person. Father has been known to Kent Police since 2003. He has a number of criminal convictions including offences of violence, drugs and domestic abuse incidents, 6.21 In August 2019, September 2019 and November 2019 there were three incidents of domestic abuse between the parents both involving intoxication of both. The incidents were recorded and no further action taken. In relation to the August incident, the file had been sent to CPS for a charging decision, it was returned in December 2019 with an action plan. However, by the time 14 the file was returned to CPS it was out of statutory time limits for charging (6 months) in relation to common assault. This has led to single agency learning. 6.22 On 18/5/20 there were two incidents involving the Police. In the first, a neighbour reported an argument to police but was unsure if it was at the parent’s property. Police attended the property and spoke to both parents who denied any argument stating they had been watching television and there had been no incident. The address had a flag on the police system that requested that any calls to the address be notified to Social Services. This did not happen on this occasion. 6.23 The next day several calls were received from members of the public in relation to a male and female arguing and the female being assaulted at the property. Police attended twice and Mother was described as intoxicated. Later after midnight neighbours reported screaming and arguing, that it had been going on all day and that police had already attended previously but the shouting had continued. Officers attended and located Mother who stated the shouting had been her partner not wanting her to leave the property as she was upset but she had ‘no issues’ with her partner. Mother was escorted back to the property. It was apparent that this was an on-going incident to the calls recorded on the 18th. Unfortunately, a CP referral, as required, was not made to ICS on either occasion. 6.24 On 11th July 2020 a police report was prepared for the RCPC, 13/7/20. The incidents on 17th and 18th May 2020 are referenced but they not discussed at the RCPC and Police did not attend the meeting. 6.25 Following Child S’s birth, Police involvement with the family was attendance on two occasions. On both occasions officers submitted CP referrals due to their concerns. 6.26 On 31/7/20 a Social Worker called police stating that she had received a call from a member of the public concerned that they had seen Mother bang the baby buggy hard up and down with the baby inside and then left baby in the buggy outside a property alone in another area. Officers attended the home address to conduct a welfare check but there was no response. It is apparent there was confusion as to where the individuals were at the time of the incident. The Police attended again but it was two days -2/8/20 before police successfully conducted a welfare check at the home address. Child S was checked and considered to be well, but it was noted that the property was filthy and cluttered and not appropriate for a newborn. A Child Protection referral was appropriately submitted. 6.28 In addition, late on the 31st July into 1st August 2020 SECAMB called Police to report that they had attended a call to a woman having a cardiac arrest. On attendance the female was very intoxicated and became abusive to her partner and walked off. It transpired the female was Mother and she was near to MGM home. Officers attended the property and spoke to MGM who would not allow them into the property and stated Mother was intoxicated but asleep. It later became apparent that there was no reference or knowledge of a baby and the two incidents of concern on the 31st July/1st August were linked, following which a welfare visit was conducted as outlined above, which led to a CP referral being submitted. 6.29 Late on 6/8/20 a security officer from the building in which Mother lived called police to report a female arguing loudly and being aggressive towards a male, a baby could be heard crying, the caller was unsure which flat the noise was coming from. Officers attended and confirmed the arguing couple were Mother and Father. Father was described as intoxicated and advised to leave the property for a period to ‘cool down’. Child S was asleep in his Moses basket at the time of officers’ attendance. He was checked appeared to be fine and considered to be safe in the care of his mother. A Child Protection referral was submitted. The incident was assessed as medium risk. 15 Improvements to Practice for Kent Police identified by the agency author: • The practice of flagging persons/addresses with a marker of “Child Protection” concern to be reviewed to establish whether this process remains effective or requires improvement. • Further work is required to ensure Police specialists in child safeguarding are aware of terms and the meaning of ”professional optimism” and “respectful uncertainty”. • A review of child death investigations is currently being commissioned (not homicides conducted by Major Crime Unit). • In common assault cases officers must expedite cases to ensure statutory time limits do not prevent a prosecution to give the court opportunities to further protect victims. • The minutes of RCPC’s must be reviewed by a Detective Sergeant to ensure they are in agreement with any decisions taken. At the current time this is a requirement in Police Policy (SOP O23a, para 3.18.9). From the research undertaken by the Agency Author, it appears that minutes of the meetings are rarely assessed on receipt and are often simply filed electronically. It appears that at this time Police do not have a ‘voice’ at RCPC’s other than providing a report with any new information. Additional learning relates to the non notification by Police to ICS following the May DA incidents which did not follow procedure despite unborn Child S being subject to a CPP and impacted on the risk assessment. This issue is identified for Kent Police as a single agency action. 7. FINDINGS and ANALYSIS 7.1 Child S sadly died at the age of 7 weeks from SUDI. Child S’s parents had demonstrated they wished to parent positively for Child S and had engaged with practitioners well. In the first 5 week period there was no evidence of substance misuse or domestic abuse impacting on the care of Child S. However, in the last two weeks there was evidence of 2 incidents of alcohol misuse and domestic incidents which may have led to practitioners reassessing the risk to Child S. 7.2 As with any review, the process of reflection has identified some areas where the current systems and processes could be improved. All the agencies involved in Child S’s family have identified their own learning and have captured a number of single agency recommendations into action plans. The themes identified below capture additional learning identified by the Independent Reviewer and has resulted in ten recommendations. Theme One-RISK ASSESSMENT AND DECISION MAKING 7.3 Child Protection Processes- a) It was highlighted that in the majority of Agency Reports, particularly those submitted by Health services, that minutes from the Child Protection Conferences or Core Group were not shared with those present. In addition, the Midwife was invited to the pre birth ICPC but not the July RCPC conference, which meant that her information following significant involvement over 28 days was not included. The Health Visitor was not invited to the pre birth ICPC which would have helped her understanding of the history and the potential risks to Child S. Effective administration processes for Child Protection Conferences are crucial to the effectiveness of risk assessment and decision making. The family had moved location during the period of involvement and this will have impacted on communication /changes in practitioners but this issue needs to be prioritised by the CP Conference service. Recommendation 1 16 b) The Police attended the pre birth ICPC but not the Review Child Protection Conference. There is an impact on Child Protection conferences being held without all the key significant agency representation. The Police agency author identifies that the minutes are “reviewed” by Police but there is no Police voice/analysis of risk. These are Statutory Partners and should be invited and should attend these statutory multi agency Child protection fora. Recommendation 1 c) Families are often mobile with changes of addresses and GPs. It may be helpful at the start of each CPCC, for the Chair/IRO to ascertain whether there are any changes of address or GP practices since the last Conference. Recommendation 1 d) Key information in the General Practitioner’s (GP) ICPC Conference Report was not discussed at the ICPC or RCPC. This could have provided an opportunity to gain an insight into the dynamics of the parents’ relationship and assess whether the changes they were reporting were evidenced. The GP’s report for ICPC is in the form of a letter dated 22.04.2020 and is not noted on the minutes of the ICPC as being received but may have been received after the ICPC. Standard templates and audit of engagement by agencies to be undertaken by KSCMP. Recommendation 1. e) The quality assurance of information being provided by partner agencies. It was felt that more awareness raising on the importance of quality assuring information submitted for all child protection meetings was needed. Within this case, there were emails sent to the Child Protection Conference from Mental Health with very little information, and no analysis of risk / potential risk. The GP reports came in the form of letters, and the police report for RCPC was received very late and contained many “blank” sections. Each agency will have their own accountability mechanisms to quality assure and sign off reports for Conference however the above approach does not reflect the statutory multi-agency requirements of Child Protection processes and support effective decision making. Recommendation 1 f) Core Group effectiveness- Core Groups were held but their effectiveness was limited by them often sharing information rather than reviewing progress against the CPP. The Social Work Assistant was also not invited and the Health visitor was not invited until post birth. g) The GP for the Father was not involved or invited to child protection processes by ICS and the practice were unaware of previous involvement and removal of children or that Child S was subject to a CPP. A robust “Think Family” approach would have been challenging for the GP practice if Father had presented with mental health issues, drug misuse or disclosed domestic abuse. This lack of knowledge around Father’s history would also have impacted on the voice and lived experience of Child S. This issue continues to reinforce the theme of “Invisible Fathers” by agencies, which was the subject of a thematic review by the National Child Safeguarding Practice Review Panel in 2021. This identified the frequency in which Fathers are not identified or involved by agencies in risk assessment and decision making processes. Recommendation 2 h) Escalation and professional challenge- KSCMP and individual agencies have done much work to raise awareness of the procedure and to encourage constructive professional discussion. The review is assured that practitioners used safeguarding supervision to discuss concerns and were aware of how to escalate. The key learning issue in this review is that practitioners need to be supported to understand the processes of care proceedings and PLO and the relevant thresholds in order to best placed to raise any concerns. Care Proceedings and use of the Public Law Outline (PLO) process. 17 i) The learning from this case highlights the need within ICS for there to be a review of the current arrangements and impact of the legal advice provided to front line practitioners which will consider the effectiveness of these arrangements and the impact on decision making. Recommendation 4 j) It has also became clear to the Reviewer from discussions with practitioners that agencies are not clear about the Public Law Outline processes and evidence thresholds and how decisions link into the multi-agency child protection processes and procedures. The professional terminology used by ICS can be difficult to understand and potentially impact and provide some misplaced assurance. k) In addition the legal planning meetings and PLO meetings do not include other partner agencies and the minutes are deemed confidential and cannot be shared. Other agency practitioners are therefore not able to actively inform the assessment of risk presented by the Social Worker/s in these meetings and importantly may not understand the rationale for decisions. A multi-agency survey initiated by ICS in 2021 demonstrated that partner agencies know what the term PLO means but less than half of those involved with a family during a period of pre-proceedings felt they had been involved ‘always’ or ‘often’ in the discussions about increasing levels of risk and decisions to seek legal advice. Only around a third of those practitioners during a period of pre-proceedings felt they were kept up to date about assessments & interventions and considered they or their agency had contributed to assessment or intervention during pre-proceedings. The significant majority of all agencies felt they or their agency needed further input to improve their confidence in pre-proceedings. Recommendation 3 Theme Two-DEFINITION AND UNDERSTANDING OF NEGLECT. 7.4 The parents of Child S had had their older children removed due to concerns around neglect as well as domestic abuse and substance misuse. After Child S returned home to his parent’s care in June 20 there were home visits undertaken by the Midwife, Health Visitor, Social Worker, Social Worker undertaking the parenting assessment and the Social Work Assistant. In addition the Police undertook two home visits following concerns raised. 7.5 It is clear that the home conditions varied significantly over this 7-week period. Some practitioners described the home as “clean and tidy”, a day later as “filthy and poor conditions”. The issue within this family was their ability to sustain good enough home conditions and ensure that these conditions did not adversely impact on their child. These ongoing concerns around sustaining change aligned with the later incidents identified by the Police of substance/alcohol use and domestic abuse between parents may well have led to escalation and a decision to review the current plan for Child S. 7.5 In discussions with practitioners, it became clear that the KSCMP neglect strategy had not existed at the time of the incident. However, although there is now a Neglect strategy and toolkit developed by KSCMP and published in January 21, it is generally not seen as a helpful guide and not clear enough in its descriptions of neglect in the home, and both the impact of poor home conditions and the impact of inconsistency of poor home conditions on children. Practitioners felt it was dependent on their subjective judgement on what constitutes “good enough” home conditions but this didn’t feel particularly evidence based. 7.6 Additionally in this family, the parents were receptive to practitioner concerns and attempted to improve the home conditions but this effort was not sustained. It would have been helpful for a multi-agency shared log of the home conditions to have been maintained so the inconsistencies could have been more easily identified as well as descriptors of “good enough”. The 18 inconsistencies in professional observations of parenting and home conditions over a very short period likely reflected the lack of an agreed professional baseline to support ongoing assessment, and lack of parental understanding of what was expected, alongside gaps in parenting ability. Recommendation 5 Theme Three-SUBSTANCE MISUSE- 7.7 Both parents had a history of substance misuse which had contributed to the removal of their older children. Understanding of parent’s substance use is important in assessing risk. At the ICPC Mother reported she was smoking one joint of cannabis a day to help her sleep. Father reported he was smoking cannabis throughout the day but wished to stop. During a statutory Child Protection home visit at the parent’s new property on 3/6/20, both reported to the social worker they were smoking one joint of cannabis at night to help them sleep. The Social Worker agreed to refer to the local substance misuse service, but parents didn’t engage due to the imminent birth of Child S but did not pursue further. However, both parents following birth of Child S confirmed they had stopped smoking cannabis. At the parenting assessment visit on 7/7/20 by the Social Worker undertaking the Parenting assessment notes significant concerns describing conditions as “filthy” with clutter and rubbish all over the floor and surfaces” and a cannabis grinder was observed on the table. 7.8 None of the practitioners witnessed or smelt cannabis use during the 7-week period other than the observation of the cannabis grinder. The parents’ contention they had ceased using cannabis however required further challenge or testing, during the child protection process and Public Law Outline and the safety plan showing little exploration or analysis informing the plan, i.e. how much was being used, what was the impact on parenting capacity and how feasible was it to expect parents to use separately and safely, including where parents would be using, how they obtained the drugs and if this meant other adults were coming to the property etc. 7.9 The ICS Agency Author states Social Workers felt as the parents were being open and honest about their drug use, it was unnecessary to consider Hair Strand Tests (HST) within Child Protection or during Public Law Outline. Hair Strand Tests would have provided a baseline picture of usage and provide further evidence to support the assessment within the pre-birth period. This would also have supported ICS in understanding whether the parents were being honest about their drug and alcohol use and confirm or refute the contention the parents were making changes. 7.10 In discussion with social work practitioners, managers and the Reviewer, they described the threshold needed via an internal Panel to obtain HST funding given the associated financial costs. Their view was clear that this threshold had not been met. Practitioners also described the unreliability of some forms of testing and the challenge for all practitioners of understanding/measuring the risk of all substance misuse on parenting. 7.11 It has become clear to the Reviewer that substance misuse and in particular cannabis use has become normalised within many families. There are issues about practitioner understanding of the strengths and impact on parenting. Unless a threshold is reached, although addressing substance misuse may be part of a child protection plan, it relies on parental consent to engage with any agencies and this is frequently not undertaken. Health practitioners described the challenges of being aware of the need to refer concerns around substance misuse. However, their view is that unless there are other safeguarding concerns this is unlikely to meet a threshold for ICS assessment. 19 7.12 My conclusion is that substance misuse may be identified as a risk factor by agencies but the response to addressing the potential risk and the expectations about how to address the concerns are not clear or understood by practitioners on the frontline. This feels an opportunity for the KSCMP to develop a Substance Misuse strategy to support front line practitioners to agree a multi-agency definition and an agreed partnership response to families where substance misuse is a feature including the regular use of HST to monitor rather than rely on self reporting. Recommendation 6 Theme 4 – SAFE SLEEPING 7.13 It is clear from the agency reports and discussions that all practitioners involved with the family frequently reminded the parents around risks and provided safe sleeping advice and to use the moses basket for Child S. Discussions with parents and reinforcement of the safer sleeping and prevention of Sudden Infant death (SIDS) information was well documented in the Health Visiting and Midwifery records. However, Child S had been found in the sofa bed with his parents and both parents were found to have differing substances in their systems. 7.14 Safe sleeping guidance and advice for infants has been promoted and undertaken by KSCMP and agencies to raise awareness with practitioners, the general public and parents. However, it remains a key feature of this case and the link between use of substances and risk of co sleeping needs to continue to be raised in a public campaign with clear practical advice to all practitioners. Recommendation 7 8. Effective practice 8.1. The focus of this Review is to learn and improve services. As such, it is important to learn from practice that is considered effective and supports good outcomes for children. Good practice from professionals has been acknowledged and this includes, 8.2 Overall the practitioners from all agencies worked well together and shared information effectively. The Community Midwife continued her engagement postnatally for 28 days reflecting her understanding of the vulnerabilities of this family and her documentation was of a high standard. The Social Worker wrote and shared a Pre-Birth Plan with Midwifery and Health Visiting staff and home visits were undertaken by social work practitioners despite the impact of Covid. Antenatal communication between the health providers was particularly good from the GP, Midwifery in the Acute health provider Trusts (MTW and EKHUFT) and the Health Visiting service, particularly at a time when the whereabouts of Mother were broadly ‘unknown’. All practitioners involved with the family engaged well and made significant efforts to work sensitively, constructively and transparently to support this family to care for Child S. 9. Recommendations 9.1. The Review concludes with recommendations to the Kent Safeguarding Children Multi-Agency Partnership (KSCMP), which build on the recommendations and actions already identified for learning by single agencies during the process of researching their involvement in this case. In a number of cases, actions have already been taken to improve arrangements/systems. The following additional recommendations are provided to ensure that Kent SCMP and its partner agencies are confident that any other areas are addressed and that the Kent SCMP is able to monitor progress. 20 Theme One-Risk Assessment and Decision making 1. KSCMP to undertake an audit of the processes of convening child protection conferences to review the attendance of key agencies, the quality of the reports submitted by agencies and that minutes are undertaken and distributed in a timely way. A specific focus should be on ensuring that all relevant GPs are involved particularly with mobile families. 2. KSCMP to consider the learning from the National Safeguarding Practice Review Panel’s thematic report “Invisible men” to consider how learning can be disseminated across the partnership of the need to ensure the overt engagement of men in risk assessments. 3. KSCMP to undertake work on raising awareness and understanding of the Public Law Outline process across all agencies so that practitioners are clear of the processes and aware of opportunities to influence risk assessment and decision making. 4. ICS to undertaken audit activity to review the arrangements for risk assessment and decision making in the PLO process and the interface between the legal advice received and the decisions taken to ensure this is a constructive process with sufficient challenge. Theme Two- Neglect 5. KSCMP to review the current Neglect Strategy to discuss how to develop a clear shared understanding of “good enough” home conditions that provide practitioners with an agreed baseline. Theme Three- Substance Misuse 6. KSCP to develop a Substance Misuse strategy with a specific focus on cannabis use to support practitioners to have a shared understanding of the risk, appropriate interventions and decisions on threshold for concern/escalation. Theme Four- Safe Sleeping 7. KSCMP to continue to promote and raise public and practitioner awareness of the need to deliver safe sleeping advice particularly where substance misuse by parents is a feature for the parents. Alex Walters – 7/6/22 |
NC043738 | Death of an 11-month-old boy in September 2011, as the result of a head injury. Father said the injury took place when Child K was knocked over by the family dog. Medical opinion was that the injuries were not consistent with this explanation and that non accidental injury was a likely cause of death. At the time the case review report was written no charges had been brought. Child K lived with mother and father at the time of the incident; father was Child K's primary carer. Father was known to children's social care in relation to his older child with another partner. Paternal history of: neglectful parenting; anger management; Attention Deficit Hyperactivity Disorder (ADHD); depression; domestic abuse perpetration; substance misuse; a serious health condition; criminal activity and imprisonment. Child K attended hospital in December 2010 with an injury to his ear; Child K was referred to a medical registrar in the acute medical team with concerns about possible non-accidental injury but was subsequently discharged with no cause of the injury identified. Issues identified include: failure to properly consider the significance of earlier injuries and weight loss; father's sense of isolation as the main carer of Child K, particularly as he found it difficult being the only man in baby and toddler groups; and lack of consistency in the health visitors work with the family. Recommendations include: safeguarding board should consider what action it can take to promote the involvement of fathers in baby and toddler groups; the Named Doctor for Safeguarding Children should ensure that paediatricians are provided with additional guidance regarding the need to consider and record possible causes of injuries; and the Head of Midwifery should ensure agreements are made with neighbouring hospital trusts when a woman is going to receive postnatal care from a different Trust to the one where she received ante-natal care or gave birth.
| Title: Serious case review: concerning Child K: overview report. LSCB: Barnsley Safeguarding Children Board Author: Peter Ward Date of publication: [2013] This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Barnsley Safeguarding Children Board Serious Case Review Concerning Child K Overview Report Author of Overview Report – Peter Ward, Independent Social Work Consultant 6 June 2012 Overview Report concerning Child K Page 2 of 115 Table of Contents Page 1 Introduction 6 1.1 Purpose of the Review 6 1.2 Circumstances leading to decision to carry out a Serious Case Review 6 1.3 Scope and Terms of Reference of the Review 7 1.4 Contributors to the Review and Methodology 10 2 Details of Family 13 2.1 Family Composition 13 2.2 Relevant Family Information 13 2.3 Information provided for this Serious Case Review by FK 13 2.4 Information provided for this Serious Case Review by MK & her family 14 2.5 Discussion with "FK's Previous Partner" 17 2.6 Comments from IORA and SCR Panel to issues raised by family members 17 3 Summary of Agencies Involvement 18 3.1 Description of Agencies Providing IMRs and Reports 18 3.2 Chronological summary of agency involvement – Background 20 3.3 Birth of "FK's first child" – 1st Child Protection Review Conference 21 3.4 1st Child Protection Review Conference – 2nd Child Protection Review Conference - Information relating to "FK's first child" 22 3.5 Removal of "FK's first child" from Child Protection Register – Final Separation of FK and "his previous partner" 25 3.6 Final Separation of FK and "his previous partner" End of Period Covered by Review 28 Overview Report concerning Child K Page 3 of 115 3.7 Information relating to "Child K's sibling" and Child K - Background (April 2008 – April 2009) 34 3.8 MK and "her child's" move to Sheffield – Birth of Child K (April 2009 – October 2010) 34 3.9 Involvement with Child K, "his sibling", MK and FK from the birth of Child K until he sustained the injuries that led to his death (October 2010 – 26 September 2011) 38 3.10 27 September 2011 onwards 45 4 Analysis 53 4.1 Introduction 53 4.2 ToRs 3 & 4 What were the key relevant points / opportunities for assessment and decision making in relation to Child K and his family? Do assessments and decisions appear to have been reached in an informed and professional way? Did actions accord with assessments and decisions made? Were appropriate services offered / provided, or relevant enquiries made in the light of the assessments? 53 4.3 ToR 1 Were practitioners aware of, and sensitive to, the needs of the children in their work and knowledgeable, both about potential indicators of abuse or neglect, and about what to do if they had concerns about a child's welfare? 75 4.4 ToR 2 Did the organisation have in place policies and procedures for safeguarding and promoting the welfare of children and acting on concerns about their welfare? 76 4.5 ToR 5 Were there any issues in communication, information sharing or service delivery, between those with responsibilities for work during normal office hours and others providing out of hours services? 77 4.6 ToR 6 Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of 78 Overview Report concerning Child K Page 4 of 115 disability relating to Child K and his family? Were they explored and recorded? 4.7 ToR 7 Was the work in this case consistent with each organisation's and the LSCB's policy and procedures for safeguarding and promoting the welfare of children, and with wider professional standards? 79 4.8 ToR 8 Were there any organisational difficulties being experienced within or between agencies? Were these due to a lack of capacity in one or more organisations? Was there an adequate number of staff in post? Did any resourcing issues such as vacant posts or staff sick or on leave have an impact on the case? 80 4.9 ToR 9 Was there sufficient management accountability for decision making? 86 4.10 ToR 10 Were senior managers or other organisations and professionals involved at points in the case where they should have been? 87 4.11 ToR 11 Establish whether there are any overlapping issues between this review and the Child H, Child L Serious Case Reviews and, if so, what has been put in place to address the issues? 88 4.12 ToR 12 What was the agencies' involvement with anger management for FK? 90 4.13 ToR 13 Provide a commentary on the context of drug usage by FK and was this likely to have impacted on the family and the care of Child K. 91 4.14 ToR 14 Was the information sharing and passing of referrals between agencies, with prior knowledge of FK, adequate and appropriate? 92 4.15 ToR 15 Had referrals been made for domestic violence between FK and "his previous partner". Were agencies sufficiently aware of this and the potential 94 Overview Report concerning Child K Page 5 of 115 impact on Child K and his family? 4.16 ToR 16 Establish whether the large number of health visitors contributed to concerns not being addressed adequately with regard to the care of Child K. 95 4.17 ToR 17 Establish whether there are protocols in place which identify actions agencies should have /will take if birth parents do not take a child to appointments and another family member attends and if this contributed to concerns not being adequately addressed in relation to child K. 96 4.18 ToR 18 How effective was the multi-agency response to "Child K's sibling" in terms of safeguarding their position. 96 4.19 Challenge of IMRs 99 5 Conclusions 100 6 Recommendations 106 Appendices 1 Genogram 108 2 Integrated Action Plan 109 3 Abbreviations 134 4 References 135 Overview Report concerning Child K Page 6 of 115 Introduction 1.1 Purpose of the Review 1.1.1 This Serious Case Review (SCR) was commissioned in compliance with regulation 5(1) (e) and 5(2) (a) & (b) (ii) of The Local Safeguarding Children Boards Regulations 2006 which came into effect on 1 April 2006. In accordance with the guidance issued in Chapter 8 of ‘Working Together to Safeguard Children – A guide to inter-agency working to safeguard and promote the welfare of children’ (HM Government 2010), this Overview Report has been undertaken by an Independent Author and completed in accordance with the terms of reference set out in section 1.3 of this report. 1.1.2 Working Together to Safeguard Children 2010 states that a SCR should be undertaken when a child dies and abuse or neglect is known or suspected to be a factor in the death. The purpose of this Review is to: � establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; � identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and � improve intra- and inter-agency working and better safeguard and promote the welfare of children. (Working Together to Safeguard Children 2010, 8.5) 1.1.3 Consequently this report is not intended to be a judicial opinion or to apportion blame but to consider, with the benefit of hindsight, whether there are lessons to be to be learnt from this case in relation to the way in which professionals and organisations worked together to safeguard and promote the welfare of Child K. The Review also sets out to identify clearly what the lessons are, and as a consequence improve intra and interagency working and better safeguard and promote the welfare of children. 1.2 Circumstances leading to decision to carry out a Serious Case Review 1.2.1 Child K was born in October 2010 and lived with both his parents. He died in hospital on 28 September 2011, aged 11 months. 1.2.2 Child K was admitted to hospital in Barnsley on 28 September 2011 having reportedly collapsed at home when in the care of his father. He was described as going ‘floppy’ and was unconscious when he arrived at hospital. FK reported that on 27 September 2011, Child K had been knocked over by the family dog and had hit his head on the concrete step. The parents did not seek medical attention that day although Child K was described as sleepy and had a runny nose and he was given Calpol. Also on 27 September 2011, a member of the public had contacted the Health Visiting Service and reported that she was concerned about a child (who turned out to be Child K) because he had bruising to his face. The member of the public reported to the health visitor that she had advised FK Overview Report concerning Child K Page 7 of 115 to seek medical attention. The health visitor advised the member of the public to ring Children’s Social Care if she was concerned. 1.2.3 Following Child K’s arrival at hospital, on 28 September 2011, emergency medical treatment was provided, he was thoroughly examined and a CT scan was carried out. Child K was found to have a number of bruises around his head and neck and a CT scan showed skull fractures on 2 sites and a small subdural haematoma. Arrangements were made for Child K to be transferred to the Paediatric Intensive Care Unit (PICU) at Sheffield Children’s NHS Foundation Trust (SCNFT) and the transfer was undertaken by EMBRACE, SCNFT’s specialist transport service. On arrival at SCNFT Child K was taken straight into x-ray for a repeat CT scan. This confirmed that there was severe damage to the brain and he had coned (the lower part of his brain had herniated, i.e. pushed down into the top end of the space occupied by the spinal cord). Child K was transferred to the intensive care unit where he continued to be in a critical condition. Due to progressive deterioration in his condition, the decision was made with MK and FK to withdraw treatment. He was taken off the ventilator and handed over to MK to cuddle at 19:25 hours and was certified dead at 19:50 hours. 1.2.4 Medical opinion was that the injuries sustained by Child K were not consistent with the explanation given by FK and that non accidental injury (NAI) was a likely cause of death. This view was supported by initial Post Mortem investigations which showed that Child K had three fractures to his head, a brain bleed, which was not in the locality of the fractures and haemorrhaging to his eyes. As a result of the above information, a meeting of the Serious Case Review Sub Group of the Barnsley Safeguarding Children Board (BSCB) was held on 21 October 2011, and a decision was made to recommend that a Serious Case Review be undertaken in accordance with Chapter 8 of Working Together to Safeguard Children. The Chair of the BSCB accepted this recommendation on 28 October 2011. 1.2.5 Following the initial post mortem investigations, further specialist post mortem investigations have been sought in relation to the injuries to Child K’s skull, brain and eyes. At the time of writing this report the specialist reports have not all been received. Throughout the period that this Serious Case Review has been undertaken, FK has been on Police bail having been arrested in connection with Child K’s death. At the time of writing no charges have been brought. 1.3 Scope and Terms of Reference of the Review 1.3.1 It was initially determined by the SCR Panel that the period of the Review would be from July 2009, when it was indicated that MK and FK had begun their relationship, until 1 October 2011, three days after Child K died. 1.3.2 Information was provided to the initial SCR Panel meeting, on 21 October 2011, that FK had had previous involvement with other agencies, notably South Yorkshire Police (the Police) and Sheffield Children Young People and Families – Social Care (Sheffield Social Care), in respect of issues Overview Report concerning Child K Page 8 of 115 relating to domestic violence, anger management and substance misuse and it was recommended that these should be explored, within the IMRs, as identified in the Terms of Reference below. 1.3.3 On 26 October 2011, the Head of Safeguarding and Welfare at Barnsley Children, Young People and Families – Social Care (Barnsley Social Care), requested by letter to the Chair of Sheffield Safeguarding Children Board (SSCB) that consideration be given to the appointment of an author for an Individual Management Review on the basis that partner agencies of Sheffield Safeguarding Children Board namely Sheffield Children’s NHS Foundation Trust (SCNFT) and Children’s Social Care have been involved with the care of child K and his father. 1.3.4 Subsequent enquiries revealed that FK had an older child, whose name had been placed on the Child Protection Register in Sheffield following their birth in June 2007. It was therefore decided to extend the time period of the Review to begin when this child was born and the scope of the Review to consider agency’s involvement with "this child" and their mother. Although FK separated from "his previous partner" around January 2009 it is clear that he continued to have a substantial amount of contact with both "her and his first child". Therefore Sheffield agencies’ involvement with "FK's previous partner" has been considered for the full period covered by this review. "FK's previous partner" is aware of the death of Child K; she was informed by letter that a SCR was taking place and the Manager of Safeguarding Services in Barnsley visited her to explain the Serious Case Review Process and the extent to which the review has considered issues relating to her. Although numerous references are made to "the previous partner" in this Overview Report these are in the context of her being the partner of FK and mother of "FK's first child". Records in her name, such as medical records, have not been considered as part of the review. 1.3.5 BSCB made contact with the Local Safeguarding Children Boards (LSCBs) in Nottingham, Nottinghamshire and Derbyshire all of whom confirmed that MK was unknown to them. Based on this information, the SCR Panel decided to include information about MK in the SCR only after the date she moved to Sheffield. 1.3.6 The following Terms of Reference were agreed: 1 Were practitioners aware of, and sensitive to, the needs of the children in their work and knowledgeable, both about potential indicators of abuse or neglect, and about what to do if they had concerns about a child's welfare? 2 Did the organisation have in place policies and procedures for safeguarding and promoting the welfare of children and acting on concerns about their welfare? 3 What were the key relevant points / opportunities for assessment and decision making in relation to Child K and his family? Do assessments and decisions appear to have been reached in an informed and professional way? Overview Report concerning Child K Page 9 of 115 4 Did actions accord with assessments and decisions made? Were appropriate services offered / provided, or relevant enquiries made in the light of the assessments? 5 Were there any issues in communication, information sharing or service delivery, between those with responsibilities for work during normal office hours and others providing out of hours services? 6 Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability relating to Child K and his family? Were they explored and recorded? 7 Was the work in this case consistent with each organisation's and the LSCB's policy and procedures for safeguarding and promoting the welfare of children, and with wider professional standards? 8 Were there any organisational difficulties being experienced within or between agencies? Were these due to a lack of capacity in one or more organisations? Was there an adequate number of staff in post? Did any resourcing issues such as vacant posts or staff sick or on leave have an impact on the case? 9 Was there sufficient management accountability for decision making? 10 Were senior managers or other organisations and professionals involved at points in the case where they should have been? 11 Establish whether there are any overlapping issues between this review and the Child H, and Child L Serious Case Reviews and, if so, what has been put in place to address the issues? 12 What was the agencies' involvement with anger management for FK? 13 Provide a commentary on the context of drug usage by FK and was this likely to have impacted on the family and the care of Child K. 14 Was the information sharing and passing of referrals between agencies, with prior knowledge of FK, adequate and appropriate? 15 Had referrals been made for domestic violence involving FK. Were agencies sufficiently aware of this and the potential impact on Child K and his family? 16 Establish whether the large number of health visitors contributed to concerns not being addressed adequately with regard to the care of Child K. 17 Establish whether there are protocols in place which identify actions agencies should have /will take if birth parents do not take a child to appointments and another family member attends and if this contributed to concerns not being adequately addressed in relation to child K. Overview Report concerning Child K Page 10 of 115 18 How effective was the multi-agency response to safeguard any other children. 1.4 Contributors to the Review and Methodology 1.4.1 Peter Ward, the Independent Overview Report Author (IORA), has a background in social care and has worked in management and front line social work. He is qualified to degree level in social work and has a post-graduate diploma in management studies. He is now the Director of a Social Care Consultancy and as such undertakes investigations and other consultancy work on an independent basis. Since 2005 he has been involved in several Serious Case Reviews as an IORA, Individual Management Review (IMR) Author or Panel Chair. His appointment is in accordance with the guidance at 8.33 in Chapter 8 of ‘Working Together to Safeguard Children 2010’ which states that: “The overview report should be commissioned from a person who is independent of all the local agencies and professionals involved and of the LSCB(s). The overview report author should not be the chair of the LSCB, the SCR sub-committee or the SCR Panel.” 1.4.2 The chair of the BSCB is Simon Hart. The independent chair of the Serious Case Review Panel for this Serious Case Review is Paul Sharkey who is an Independent Safeguarding Consultant and a qualified social worker of 25 years experience. He has worked as a practitioner and at middle and senior management in both the statutory and third sector in the child protection and safeguarding arenas. He has chaired five Serious Case Reviews since 2002 and has been the Overview Author for six SCRs during this period. He achieved Independent Author and Chair accreditation in March 2010 with the (former) National Safeguarding Delivery Unit of the Department for Children, Schools and Families (now the Department for Education). He has an M.A. (distinction) in Child Care Law and Practice from The University of Keele and a Masters in Public Administration (MPA, distinction) – the Public Sector MBA - from the University of Warwick Business Hospital School. Mr Sharkey has had no previous involvement with any of the agencies associated with this SCR and can therefore claim to be independent. Mr Sharkey’s appointment is in accordance with the guidance at 8.16 in Chapter 8 of ‘Working Together to Safeguard Children 2010’ which states that: “The Chair of the SCR sub-committee should be an experienced person and could be the independent Chair of the LSCB, or a member of the LSCB. The Chair of any SCR Panel should not be a member of the LSCB(s) involved in the SCR, an employee of any of the agencies involved in the SCR or the overview report author. The SCR Panel Chair can be the independent LSCB Chair, someone from another LSCB which is not involved in the SCR or from an agency which is not involved in the case.” 1.4.3 In addition to the chair the following people were members of the SCR Panel: Overview Report concerning Child K Page 11 of 115 � Assistant Executive Director, Safeguarding Health and Social Care, Barnsley Children Young People & Families (CYP&F) � Head of Children’s Social Care, Barnsley CYP&F � Head of Safeguarding and Welfare, Barnsley CYP&F � Assistant Director, NHS Barnsley � Designated Nurse Safeguarding Children, NHS Barnsley � Medical Director and GP Representative, NHS Barnsley � Designated Doctor Safeguarding Children, BHNFT � Public Protection Unit Manager, South Yorkshire Police � Assistant Director Nursing, Directorate of Nursing Clinical Governance and Safety, South West Yorkshire Partnership NHS Foundation Trust (SWYPFT) � Lead Nurse Children and Young People, Sheffield Teaching Hospitals NHS Foundation Trust (STHFT) � Sheffield Safeguarding Children Board (SSCB) Board Manager (Panel member from 26 March 2012 onwards) 1.4.4 The SCR Panel met on 21 October 2011, 14 December 2011, 23 January 2012, 26 March 2012, 27 April 2012 and 24 May 2012 in connection with this SCR. The author of the Overview Report was not a member of the Serious Case Review Panel but attended all the Panel meetings, with the exception of the one on 21 October 2011, in connection with writing the Overview Report. Legal advice was available to the SCR Panel from the Assistant Borough Secretary (litigation) within Barnsley Metropolitan Borough Council. 1.4.5 The SCR Panel received and considered IMRs from the following agencies: � Barnsley Hospital NHS Foundation Trust (BHNFT) � Barnsley Children, Young People and Families – Education (Barnsley Education) � Barnsley Children, Young People and Families – Social Care (Barnsley Social Care) � NHS Barnsley – Health Overview Report � NHS Barnsley - Primary Care (Primary Care) � Sheffield Children’s NHS Foundation Trust – Health Visiting (Sheffield Health Visiting) � Sheffield Children’s NHS Foundation Trust - Hospital Services (SCNFT) � Sheffield Children Young People and Families – Social Care (Sheffield Social Care) � Sheffield Teaching Hospitals NHS Foundation Trust (STHFT) � South West Yorkshire Partnership NHS Foundation Trust (SWYPFT) � South Yorkshire Police (The Police) � Yorkshire Ambulance Service (YAS) 1.4.6 The authors of the Individual Management Reviews are all independent in accordance with the guidance at 8.33 in Chapter 8 of ‘Working Together to Safeguard Children’ which states that: Overview Report concerning Child K Page 12 of 115 “Those conducting management reviews of individual services should not have been directly concerned with the child or family, or have been the immediate line manager of the practitioner(s) involved.” 1.4.7 The IMR from BHNFT was written by a Named Nurse for Safeguarding Children and the Named Doctor for Safeguarding Children both of whom are employed by BHNFT. The named nurse had no involvement with the care of Child K but the named doctor is Paediatric Consultant 2 who was briefly involved in providing some information about Child K to the Police and Barnsley Social Care the day after Child K died. Details of this are outlined in this Overview Report. Furthermore, the named nurse who co-wrote the IMR for BHNFT had a period of extended leave whilst the review was being undertaken and some work was carried out by another named nurse. This colleague had a phone conversation with the health visitor on 28 September 2010 following Child K’s admission with the injuries that resulted in his death later that day. Details of this phone conversation are outlined in this Overview Report. Neither the named doctor nor the named nurse have attempted to provide an analysis of their actions in respect of the case and the IORA is satisfied that the authors of the BHNFT IMR are sufficiently independent from the case. 1.4.8 A comprehensive integrated chronology of agency involvement and significant events for the period June 2007 to October 2011 has been compiled from the chronologies provided within the IMRs. This has been analysed by the SCR Panel. 1.4.9 The Overview Report author undertook this review by making reference to the terms of reference, IMRs and other reports listed above and through discussions at SCR panel meetings and face to face, telephone and email communication with IMR authors and panel members including a meeting with IMR authors on 11 November 2011. 1.4.10 In addition the SCR Panel considered which family members should be involved in the review and how and when to involve them. The Panel decided that MK and her parents and FK and his mother would be invited to meet with the IORA and the Designated Nurse for Safeguarding Children from NHS Barnsley (hereafter referred to as the Designated Nurse). A meeting subsequently took place with FK on his own and MK and her parents together at their respective homes. FK’s mother was present in the house when the meeting took place with FK but she did not take part in the meeting. These meetings took place in March 2012, whilst the Police were still investigating Child K’s death. Prior to the meeting, the IORA consulted with the SCR Panel representative from South Yorkshire Police to ensure that the meeting would not impact upon possible criminal proceedings. 1.4.11 In writing this Overview Report, the IORA has been mindful of the revised approach to the evaluation of SCRs described by the National Director, Development and Strategy for Ofsted in a letter dated 14 December 2011 to Directors of Children’s Services and LSCBs. Overview Report concerning Child K Page 13 of 115 2. Details of Family 2.1 Family Composition Child K Date of Birth October 2010, Date of Death 28 September 2011 Relationship to Child K Date of Birth Referred to as Ethnic Origin Mother June 1985 MK White British Father August 1984 FK White British Maternal Grandmother Not known White British Maternal Grandfather Not known White British Paternal Grandmother Not known White British A genogram of the family is included as Appendix 1 of this Overview Report. 2.2 Relevant Family Information 2.2.1 This review considers the previous family units of FK and MK. It is understood that MK moved to Sheffield in April 2009 and lived with "family" for a year before MK and FK moved to the Barnsley area in April 2010 by which time MK was pregnant with Child K. Child K was born in hospital in Sheffield but lived his entire life in Barnsley with both parents. FK lived with a previous partner at the start of the period covered by the review and with MK and Child K at the end of that period. In between times he lived with "a family member" for a period of time. 2.3 Information provided for this Serious Case Review by FK 2.3.1 A number of times during the meeting with FK he said that his memory was not very good and that MK would be able to provide more accurate information about who provided services and when things happened. 2.3.2 FK said that he moved to the Barnsley area with MK prior to Child K’s birth. He thinks this was in June 2010. Prior to that, MK and FK had each been living "with members of their respective families". He was in a previous relationship for 5 years before they split up and then he was single for a while before meeting MK. 2.3.3 FK spoke very positively about living with MK and Child K when he was born. FK added that he and MK did not go out drinking or clubbing but did family things like going fishing and to the zoo. 2.3.4 MK worked and FK looked after Child K. He went to a session at the library once but felt uncomfortable as he was the only Dad there. FK said that he felt that professionals tried to include him but that it would be better if more men attended and it should be targeted at men as well as women. FK added that he thought he went to the Antenatal Clinic once with MK but that they did not attend antenatal classes. Overview Report concerning Child K Page 14 of 115 2.3.5 When asked, FK said that he could not remember seeing a Health Visitor at all after Child K was born but he added that his memory is not good. He did however talk about the two hospital attendances that Child K had in December 2010. Regarding the attendance at BHNFT he said that Child K had a rupture in his throat which caused bleeding in his mouth. Regarding the admission to SCNFT FK said that Child K had swung his head while MK had been holding him and had bashed on her head and hurt his ear. He said that hospital staff had assessed them as a family and observed how they cared for Child K and had realised that Child K was well loved. He stated that the hospital said they would contact MK and him regarding results of blood tests and to arrange a scan of Child K's ear but they did not do so. Consequently the family had to ring SCNFT themselves after Child K was sent home. 2.3.6 When asked about how he felt the family had been treated during previous social care involvement he said the social workers were “spot on” and visited regularly. He stated he was involved in all the meetings held with Social Care, and commented “It’s obviously not nice but we dealt with it and did what was asked.” 2.3.7 FK also talked about the situation when Child K collapsed and was rushed to BHNFT in September 2011. He explained that staff at Barnsley Hospital said they were stabilising Child K to transfer him to Sheffield. However, when he arrived at Sheffield a Doctor said there was nothing that they could do for Child K. This was a shock because staff at BHNFT had seemed positive. FK did not feel that staff at BHNFT had done anything wrong but felt that they were not specialists. FK also commented that Child K was developing bruises whilst he was in the care of the hospital staff; he added that Child K bruised easily and that he and MK had previously told the Health Visitors this. 2.3.8 Talking about the present time FK stated that he saw a Counsellor once before Christmas but will get back in touch with his GP and request that he is referred to a Counsellor again. 2.4 Information provided for this Serious Case Review by MK & her family 2.4.1 MK said that in April 2009 she returned to Sheffield. MK did not really see anyone from the Health Visiting Service until after Child K was born and she was living in Barnsley. MK observed that the Red Book talks about developmental assessments but different areas undertake these at different times. MK wanted to know why this was, so the Designated Nurse briefly explained. 2.4.2 MK said that she moved to Barnsley in April 2010 but she was booked in to give birth at STHFT and she continued to receive antenatal care from Sheffield midwives, which was her choice, although she told them that she had moved to Barnsley. A health visitor visited after Child K was born; MK pointed out that to the IORA and Designated Nurse that this was six months after she had moved to Barnsley. MK said that at this visit the health visitor told MK that HV4 would be her named health visitor but HV4 Overview Report concerning Child K Page 15 of 115 never made any visits to her home. On one occasion a visit was arranged, which MK thinks was probably for the six week check. She waited in all day but no-one came so she finally rang up and got through to an answer machine. After this, a different health visitor tried to visit without an appointment but MK was out and when she returned home she found a card through the door. MK attended clinic approximately every six weeks until she returned to work and this is the only place she ever saw HV4. The IORA asked MK if she felt that she received enough support from the health visitors and she responded that she did not feel that she needed extra help. However she also commented that no health visitor ever came to check how Child K was after his discharge from SCNFT when he had a haematoma on his ear. With hindsight MK wishes that the health visitor had followed this up. When Child K was in hospital with the haematoma to his ear, HV4 rang MK to see if he was okay. HV4 also phoned MK on the day Child K was admitted to hospital the last time to see if she was alright. 2.4.3 MK’s family member said that MK and FK had had two dogs and she questioned why HV4 never went to the house or checked to make sure everything was alright. 2.4.4 With regard to the haematoma on Child K’s ear, MK said FK and her have been questioned since child K's death as to why they attended hospital in Sheffield instead of Barnsley and she explained it was because they were more familiar with Sheffield. MK said that the consultant told them Child K might have mild haemophilia and that a follow up appointment would be made for him. However there was no follow up after discharge so MK phoned up for the test results and was told by a nurse that no follow up was required. 2.4.5 MK compared the lack of follow up at SCNFT with a situation, the previous week, when MK attended BHNFT with Child K because he was coughing up blood. On that occasion blood tests were undertaken and someone rang with the results two hours after they arrived home with Child K. MK added that she was happy with the explanation the doctors at BHNFT gave as to why Child K had coughed up blood. Whereas no-one from SCNFT ever gave her an explanation as to why Child K had the haematoma. 2.4.6 MK herself told the IORA and the Designated Nurse that she believed the haematoma had been caused when she was holding Child K and he had banged his ear against her head. 2.4.7 MK considered the maternity care she received to have been “really good”. During the pregnancy she saw the GP in Sheffield as she was depressed and feeling really tired; the GP referred her to the Mental Health Service at STHFT where she was prescribed anti-depressants but she was reluctant to take these. A community midwife then checked MK’s iron level which was found to be low. She started to take iron tablets for the low iron level and her mood lifted so she never took the anti-depressants. The counsellor from STHFT rang to follow up with MK to ensure all was well. In May 2010 MK felt dizzy and her blood pressure was low so she was signed off work for three days. Overview Report concerning Child K Page 16 of 115 2.4.8 MK changed her GP to one in Barnsley around June 2010 and at her new patient health check her blood pressure was found to be high. The GP said the community midwife would check this again. 2.4.9 FK attended the first scan with MK but was unwell on the day of the second scan so MK’s mother accompanied her. FK did not attend antenatal clinic appointments. He also felt uncomfortable attending playgroup and reading sessions as he was the only man there. 2.4.10 MK felt that there were good facilities at the Children’s Centre where there was singing for babies, messy play and positive parenting with the outreach workers. 2.4.11 When MK went back to work in May 2011 FK looked after Child K on Monday and Tuesday; he then stayed with MK’s parents on Tuesday night and Wednesday. FK did not want to go to groups with Child K because he was the only man there and he does not drive. However he took Child K to the park on Mondays and Tuesdays. 2.4.12 When Child K was at BHNFT after his collapse in September 2011 there were two paediatricians present and she said that Child K had only been walking for one week and was unsteady on his feet. MK felt that one of the paediatricians seemed shocked by this and looked sideways at the other one, who said it is quite normal. This made MK lose faith in the paediatrician who had seemed shocked and they then questioned his judgement. 2.4.13 MK said that the family were put in a room at BHNFT where they waited while Child K was given medical treatment. The IORA asked if they had been kept up to date with what was happening with Child K. MK responded that they wanted staff to be caring for Child K rather then coming to them to explain what was happening. 2.4.14 MK said that one of the doctors at SCNFT said that he knew there was no hope for Child K when he saw the first scan. Given this MK questioned why he was transferred to SCNFT. She felt it might have been better to have let the family have more time with him at BHNFT rather than medics spending time stabilising him and transferring him to SCNFT if it was inevitable that he was not going to survive. The family also felt that they were given some conflicting information as they were told that Child K was stable before he was transferred but he then deteriorated during the journey to Sheffield. 2.4.15 MK said that everything felt rushed at the hospital and wishes that the second CT scan had been carried out at BHNFT rather than SCNFT as then the family could have had longer with Child K. MK added that she would like the opportunity to speak to the paediatrician as she has a list of questions and would like to have the medical evidence explained to her. It was questioned whether the Police would be prepared for the paediatrician to meet with MK at this stage as criminal proceedings are ongoing. It was agreed that the Designated Nurse will liaise with the paediatrician and the Family Liaison Officer (FLO) regarding this issue. Overview Report concerning Child K Page 17 of 115 2.4.16 MK said that the current FLO has been good and has a gentler manner than the previous one. However the previous FLO gave straight forward answers. MK was unhappy with one aspect of the way she and FK had been treated by the Police the day after Child K died. They both attended the Police station to be interviewed and were told that they were likely to be about two hours. MK thought they would both be interviewed at the same time by different officers. However they were interviewed one at a time and her interview lasted four hours. Consequently FK was waiting on his own throughout this time. MK said that if she had known FK was going to be waiting like this she would have arranged for someone to sit with him whilst he waited. She added that she has good family support but FK has “naff” support. 2.4.17 Although MK has been living in Sheffield since Child K died she has continued to be registered with the GP surgery in Barnsley. The GP has checked that she is okay and has given support but has not been intrusive. MK has found this approach “really good”. 2.4.18 Finally MK referred to two things that have happened recently that have concerned her. Firstly she said that Sheffield Social Care have taken over from Barnsley. The IORA agreed to discuss this with Barnsley Social Care. Secondly MK explained that she was told she could return to work but after a few days was suspended. She understands why she is suspended but she is unhappy that she was incorrectly told that she could return. 2.5 Discussion with "FK's Previous Partner" 2.5.1 The Manager of Safeguarding Services for Barnsley Metropolitan Borough Council explained the purpose and process of a SCR and the extent to which this SCR would contain reference to her and "her child". The Manager of Safeguarding Services also explained the publication arrangements for the Overview Report and Executive Summary including the fact that they will be fully anonymised before publication and that publication is unlikely to take place for some time as there are matters still to be resolved. 2.5.2 "FK's previous partner" was given several opportunities to ask questions but did not have any at that time. Before leaving the Manager of Safeguarding Services invited her to make contact if she wanted to ask any questions after the meeting finished. 2.6 Comments from IORA and SCR Panel to issues raised by family members 2.6.1 It was difficult to establish exactly what session FK was referring to when he said he went to a session at the library. The IORA believes that he was talking about a toddler and baby group which he went to after Child K was born. One issue identified in this review is a difficulty organisations sometimes experience engaging with fathers and other male carers. This will therefore be addressed within this Overview Report. Overview Report concerning Child K Page 18 of 115 2.6.2 The comments made by MK and FK that SCNFT did not contact them as promised with the result of blood tests need to be investigated by SCNFT. 2.6.3 After her relocation to Barnsley records show that MK did not change GP until September 2010, not June 2010 as she told the IORA and Designated Nurse. This was four to five months after she moved and she had not told her previous GP that she had moved address. The Health Visiting Service in Barnsley would not have become aware that MK had moved into their area until after MK changed GP. 2.6.4 The issue of Child K’s transfer to SCNFT was discussed at the SCR Panel meeting on 26 March 2012. It was explained that BHNFT is not a specialist children’s hospital and it was necessary to transfer Child K to the specialist hospital where appropriate facilities were available and to ensure that as much as possible was done to save his life. 2.6.5 In response to MK’s request to meet with the consultant paediatrician at BHNFT the Designated Nurse consulted with the Police and the consultant paediatrician. Subsequently the consultant paediatrician met with MK in early May 2012. 2.6.6 In response to the concern raised by MK in paragraph 2.4.18, the author of the Barnsley Social Care IMR told the IORA on 19 March 2012 that the relevant manager within Barnsley Social Care was aware that there had been a problem with information sharing between Barnsley Social Care and Sheffield Social Care but that this was being resolved. The IORA contacted MK that same day and passed this information onto her. 2.6.7 Family members who have contributed to this SCR, will be contacted by BSCB before publication of the review and will be given the opportunity of meeting with someone to discuss the report. 3. Summary of Agencies Involvement 3.1 Description of Agencies Providing IMRs and Reports 3.1.1 BHNFT provides a range of in patient and out patient health services within Barnsley and the surrounding area. The services which had contact with Child K and his family during the period covered by the review were the community midwifery services following Child K’s birth, the Children’s Assessment Unit, in connection with one hospital attendance in December 2010 and the emergency department at the hospital in connection with the incident that led to Child K’s death. 3.1.2 "Child K's sibling" was seen in the Children’s Assessment Unit at BHNFT in September 2011 following the death of Child K. This was the only contact the BHNFT had with "this child" and there was no contact with "FK's first child". 3.1.3 Child K was only 11 months old at the time of death and was never in receipt of educational provision. Overview Report concerning Child K Page 19 of 115 3.1.4 Barnsley Social Care delivers the Local Authority’s statutory social care services within Barnsley Metropolitan Borough. Child K was not known to Barnsley Social Care until he was admitted to hospital with the injuries that led to his death. The IMR from Barnsley Social Care considers the services provided from that point onwards. 3.1.5 The Primary Care IMR considers the family’s contact with General Practice during the period covered by the Serious Case Review. This includes contact with GPs in Sheffield and Barnsley, background information when MK lived in Derbyshire and historical information relating to FK. 3.1.6 Sheffield Children’s NHS Foundation Trust (SCNFT) is a dedicated paediatric Trust. The Trust provides inpatient and out patient hospital based services including paediatric medicine and surgery, radiology, transport services and paediatric intensive care on a regional basis. In addition, in April 2011, nursing and health visiting services across Sheffield were transferred to the Trust as part of the integration of Community Health Services. 3.1.7 SCNFT have provided two IMRs for this SCR. One considers the hospital based services provided and the other considers health visiting services the vast majority of which were provided before the integration of Community Health Services in April 2011 which resulted in Nursing and Health Visiting Services being transferred to SCNFT. SCNFT did not provide any health visiting services to Child K as he lived in Barnsley throughout his life. 3.1.8 Sheffield Social Care delivers the Local Authority’s statutory children’s social care services in Sheffield. 3.1.9 STHFT is a large acute Trust which comprises five adult hospitals and adult community services, including midwifery services. MK received antenatal care from STHFT in respect of her pregnancy with Child K who was born in one of the Trust’s hospitals. MK received postnatal care from BHNFT as she was living in the Barnsley area by the time Child K was born. In addition to the provision of maternity services in respect Child K, STHFT was involved with FK from 2007 until November 2009 in respect of treating a viral infection. 3.1.10 SWYPFT provides a range of community, mental health and learning disability services across a number of Local Authority areas in South and West Yorkshire. Through most of the period covered by this review, in the Barnsley area, these services were provided by NHS Barnsley, Care Services Direct but in May 2011 NHS Barnsley, Care Services Direct was taken over by SWYPFT. SWYPFT’s involvement with the subjects of this review was limited to providing health visiting services in respect of Child K from November 2010 onwards. 3.1.11 South Yorkshire Police had several contacts with FK from the start point of the review until December 2009. After that time there was no further Overview Report concerning Child K Page 20 of 115 involvement from South Yorkshire Police until September 2011 when officers were alerted that Child K was in cardiac arrest and was being taken to hospital. Officers were then involved in investigating the incident in which Child K had sustained these injuries. 3.1.12 YAS provide an ambulance service across the whole of Yorkshire. During the period covered by this review YAS had contact with Child K on the day he died. Chronological summary of agency involvement 3.2 Background 3.2.1 "FK's first child" was the first child of FK and "his previous partner" who were living together as a couple. As a result of "the partner's" history a Common Assessment Framework (CAF) was completed by a community midwife in which led to Sheffield Social Care undertaking a pre-birth assessment and starting a Core Assessment prior to "the child's" birth. 3.2.2 Although this SCR considers events from the birth of "this child" onwards, STHFT maternity records in respect of the birth of "the child" have not been accessed. Maternity records are held under the name of the mother and as "the previous partner" is not part of Child K’s family, the SCR Panel took the view that it was not appropriate to seek access to her records unless there was a compelling reason to do so. The SCR Panel was informed by staff from STHFT that the maternity care provided to "the partner" was of a high standard and that the undertaking of a CAF and subsequent events demonstrated good practice as evidenced by the fact that an assessment took place in hospital prior to discharge. Consequently the SCR Panel decided that the likely benefits of detailed consideration of the maternity records were outweighed by the confidentiality issues involved. Furthermore, the majority of the contacts that maternity services from STHFT had with "the partner" were prior to period covered by this review. 3.2.3 Background information provided to this SCR shows that FK has a history of Attention Deficit Hyperactivity Disorder (ADHD) as a teenager, with associated anger management issues, drug use, including heroin and criminal activity. He has been imprisoned three times in relation to crimes committed in order to maintain his drug habit and contracted "an infection" as a result of his drug use. Records suggest that he was last released from prison in June 2005 and was successfully detoxed in 2006. Information provided to this review does, however, indicate that FK has used cannabis and amphetamines during the period covered by the review. 3.3 Birth of "FK's first child"– 1st Child Protection Review Conference - Information relating to "the child" 3.3.1 Following "FK's first child's " birth, mother and baby remained in hospital whilst a five day assessment was undertaken by the ward and a pre-discharge meeting was held. It was agreed at this meeting that "the child" would be discharged from hospital to the care of their parents and that a Overview Report concerning Child K Page 21 of 115 Child Protection Conference would be convened. Discharge took place the following day, and a social worker visited the family "four days later" to share the Core Assessment. The Child Protection Conference was held "two days later" and was attended by FK and "his previous partner". It was decided that "the child's" name would be placed on the Child Protection Register in the category of neglect. 3.3.2 Over the next three months, prior to the first Child Protection Review Conference; the social worker visited the family home on eight occasions; three of which included a Core Group meeting. In June the health visitor received communication and a handover record from the community midwife. The Health Visiting Services first postnatal contact with the family, also took place when HV1 attended a Core Group meeting at the family home and carried out a postnatal contact. Both parents and "the child" were present and HV1 documented information about all three people. 3.3.3 The social worker recorded that at the Core Group meeting, FK said that he had delayed some medical treatment for himself to ensure that he was able to support "his partner" and be involved in parenting "the child". This relates to treatment he required for "an infection". Preparation for the treatment began "next month" but the actual treatment did not begin until "the following year" The author of the STHFT IMR has written that assessments made prior to the treatment commencing showed that FK had a history of intermittent drug use and custodial sentences. There is no indication that staff in the Infectious Diseases Team were aware of his history of ADHD or of any issues relating to anger. 3.3.4 The health visitor made four further visits to the family home prior to September; these included attendance at Core Group meetings. "FK's previous partner and child" were seen at all these visits but FK was only present on two occasions and it was recorded that he was now working full time. Records for all the contacts that the health visitor and social worker had with the family during this period refer to "the child" developing well and there being no concerns about their well being. In July both the social worker and HV1 made records referring to FK being involved in the care of "the child" but needing to increase his confidence. 3.3.5 In August the Police received two calls concerning FK and/or "his previous partner" the first of which has no bearing on or relevance to this review. The second incident was when "the partner" contacted the Police and reported that FK had assaulted her and hit her in the mouth. FK was arrested for common assault, interviewed and released following advice from the Crown Prosecution Service that there was insufficient evidence for a charge to be pursued. "The child" was present at the house when this incident took place and police officers completed the necessary paperwork to alert other professionals. Records suggest that "the partner" was intoxicated at the time of this incident but FK was sober. Although this was the first recorded domestic incident between "the parties" during the period covered by the review, it is recorded that, prior to the birth of "their child" they told the health visitor about an incident that had taken place the previous year which they described as an “overheated argument”. Overview Report concerning Child K Page 22 of 115 3.3.6 In August the social worker visited the family home where FK, "his partner and child" were all present. A discussion took place regarding the two domestic incidents and a written agreement was made with FK and "his partner" that they should not drink alcohol whilst caring for "the child" who should not be exposed to “any domestic incidents”. 3.3.7 Three days later, Sheffield Social Care received information from a member of the public alleging that a couple who were staying with "a members of FK's extended family" may pose a threat to " the child" when they stayed there overnight. The social worker spoke to FK and "his partner" who stated that they were not aware that the couple posed a risk to children but signed a written agreement that "their child" would not stay at "this" home whilst further assessments were undertaken. 3.3.8 The following day HV1 visited FK, "his partner and child" although FK did not stay for the whole visit. "The partner" told HV1 about the two domestic incidents and also about the situation with the couple staying with FK’s "extended family". HV1 discussed details of the home visit with the child protection supervisor and was advised to liaise with the social worker. It is unclear from the records whether there was any communication between HV1 and the social worker about these issues. 3.3.9 In September a MAPPA meeting was held regarding the couple "who may pose a risk" staying with FK’s "extended family". It was agreed that they would leave" within 3 weeks" and that "the child" would not visit the address until after they had left. Later records state that they left "5 days later". Also on "the same date" the first Review Child Protection Conference was held and it was agreed that "the child" would remain on the register for a further six months due to the concerns that had emerged about FK associating with persons posing a risk. 3.4 1st Child Protection Review Conference – 2nd Child Protection Review Conference - Information relating to "FK's first child" 3.4.1 Following the Review Child Protection Conference in September, the next contact with the family was "five days later" when a Core Group meeting was held at the family home. HV1 recorded that both parents were present and "the child" was thriving, sociable and interacting well. HV1 also recorded that "the child" had an abrasion on their right ear which had been caused by a ring which was being worn by FK. FK stated that he was upset about this and was no longer wearing rings as a result. The record of this Core Group meeting does not contain any reference to the abrasion to the ear so it is unclear whether or not the social worker was aware of it and whether it was raised as an issue at the Core Group meeting. 3.4.2 "A week later", HV1 discussed "the child" with the child protection supervisor. This is the first of several occasions when it is recorded that Sheffield Health Visitors discussed "the child" with the Child Protection Supervisor. Initially this was because they were on the Child Protection Register. Subsequently, when "the child" ceased to be on the Child Protection Register they were vulnerable and met the criteria for Child Overview Report concerning Child K Page 23 of 115 Protection Supervision as in the Safeguarding Children Supervision Policy for Clinical Staff in Sheffield. 3.4.3 Following on from the Core Group both HV1 and the social worker continued to have frequent contact with the family and reports continued to be positive about "the child's" development and the relationship between FK and "his partner". When the social worker visited "the partner" and FK in September they talked about the possibility of getting married in the future. 3.4.4 Three weeks later, FK contacted the Police and stated that "his partner" was attacking him. When the Police attended the property there was no sign of a disturbance and FK had no visible injuries. FK admitted having taken drugs and he was taken to "a family member's" home. The Police recorded that "the child" was upstairs in their cot, had not witnessed the incident and appeared happy. The incident was assessed, by the Police, as standard and Sheffield Social Care were informed. Later that day "the partner" contacted the out of hours service within Social Care to inform them of the incident. She stated that she wished to end her relationship with FK. 3.4.5 A Core Group meeting took place the following day and again it was reported that "the child" was developing well with good weight gain. FK was not present and the main focus of the meeting was the incident from the previous day, with "the partner" stating that she was unsure whether she wanted to resume the relationship with FK. It was agreed that SW2 would visit FK to ask him to sign a child protection agreement pending having a mental health assessment. It was also agreed that contact between FK and "the child" was to be facilitated by "another family member". Finally there is reference to "the partner" having another dog and both dogs being in a cage during the meeting. The health visitor recorded that concerns were expressed to "the partner" about the dogs. This was the second time that the health visitor discussed, with "the partner", the potential danger of dogs with young children. The first time was prior to the "child's "birth. Sheffield Social Care have no record of this core group meeting although the health visitor record suggests that the social worker did attend. 3.4.6 As a result of the incident, FK saw his GP who prescribed antidepressants and "8 days later" FK told HV1 that he had seen a social worker and did not require a mental health assessment. Sheffield Social Care have no record of the social worker seeing FK during that period and it is not possible to verify whether there was a contact during the period in question. In October, the social worker carried out a home visit and has recorded that FK, "his partner and child" were all present; FK and "his partner" stated that they had split up for a few days but were now back in a relationship and also that FK was going to assist more with household tasks. 3.4.7 Through November and December HV1 and the social worker continued to have contact with the family and Core Group meetings took place. FK and "his partner" were both taking antidepressants and it was recorded that Overview Report concerning Child K Page 24 of 115 they were feeling well. "The child" was reported to be thriving although in December the social worker recorded that they had recently been unwell with a viral infection and the parents had taken appropriate action by taking them to the GP. 3.4.8 The first recorded contact with the family next year was made by the social worker in January. The social worker visited the family home where "the partner and child" were present. "The partner" stated that she and FK had separated because FK wanted to have his own space. She added that "their child" was to continue to have contact with FK and she would promote this. A Core Group meeting was held one week later but it is unclear from the IMRs provided to this SCR whether FK was present at that meeting. At the Core Group meeting it was noted that "the child's" assessment had been completed and they were developing well and thriving but possibly had a squint in their left eye and would be referred to Orthoptics. In February the social worker visited "the partner and child" at home again. "The partner" reiterated that she and FK were separated; but that they were working together in order to promote contact. 3.4.9 In February, in between the Core Group Meeting and the social worker’s visit to "the partner and child", FK was stop searched by the Police and found to be in possession of cannabis. He was arrested and given a warning. Because this incident occurred in the street and no child was present Sheffield Social Care were not notified of the incident and therefore the social worker had no knowledge it. 3.4.10 In February a letter was sent from STHNFT to FK to inform him that his treatment for "an infection" was to commence in March. 3.4.11 A Review Child Protection Conference was held in February which was attended by both FK and "his partner". It is recorded in the Sheffield Health Visiting IMR that FK and "his partner" said at the Review Conference that they might resume their relationship. It was acknowledged that "the child" was developing well, growing and thriving and had a good attachment to their parents, both of whom were able to meet their needs. It was also acknowledged hat there had been some Police involvement with FK and "his partner" as a result of the domestic incidents but it was felt that these were a reflection of the immature behaviour of "both parties" and were not of significant concern. There was unanimous agreement at the review conference that "the child's" name would be removed from the Child Protection Register. 3.4.12 The SSCB manager has provided the IORA with information that it was known by members of the conference that the father was about to commence treatment for "an infection" but the consequences of this was not discussed and there was no information provided that this could have an impact on his mood or behaviour and so should be a factor in the decision making. The SSCB manager has also confirmed that no child in need plan was made as this was not felt to be necessary but that universal services would continue to provide services. However, since 2009 all Child Protection plans that end are followed up by a Child in Need Plan so this would not be the case again. Overview Report concerning Child K Page 25 of 115 3.5 Removal of "FK's first child's" name from Child Protection Register – Final Separation of FK and "his previous partner" - Information relating to "FK's first child" 3.5.1 Following "FK's first child's" removal from the Child Protection Register the only professional having regular or frequent contact with the family was HV1. "The child" remained an open case to Sheffield Social Care until July but there was no further direct contact between Sheffield Social Care and the family during this period although in May and July the Police made Sheffield Social Care aware of incidents involving the family and these will be described at the appropriate place in this summary. 3.5.2 HV1 visited "FK's partner and child" in March, just over a week after the Review Child Protection Conference and recorded that there were no concerns and that "the partner" was to attend clinic or request a home visit if needed. The next contact HV1 had with "the partner" was in March when HV1 phoned her because she had not taken "the child" for the Orthoptic appointment. It was agreed that "the partner" would phone for a new appointment. The next time "the child" was seen by anyone from the Health Visiting Service was in April when "the partner" took them to the Community Forum Clinic. Again it was recorded that they were thriving and gaining weight. 3.5.3 FK commenced his treatment for "an infection" in April and the author of the STHFT IMR explains that a letter was sent to FK’s GP that day to outline details of the treatment. In the STHFT IMR it is written that: “It was identified that as part of FK’s treatment he could suffer significant emotional side effects and for that reason he was referred to an adult social worker linked to the specialist clinic (employed by Sheffield City Council). It was noted that the social worker would normally continue to monitor patients throughout the course of their treatment, but in this case the social worker was identified as leaving the service and a further appointment to the post had not been made; therefore support services were requested from the GP in this letter.” 3.5.4 The author of the Primary Care IMR states that this letter asks if services are available should the patient need them. The IMR author explains that FK’s mood was assessed by the GP who did not feel any other support was required. 3.5.5 From the start of FK’s treatment in April to his discharge in November next year he attended 15 out patient’s appointments at STHFT; initially he was seen weekly but as the treatment progressed this was reduced. There were also 10 times when he failed to attend for appointments but these were followed up and he attended rearranged appointments. At these appointments, amongst other things, there was discussion about how FK was feeling emotionally and on six occasions he described emotional issues such as feeling ‘snappy’ and/or anxious. In addition, in November he reported financial stress and the possibility was raised of him seeing the social worker if this was not resolved at the next appointment. However, in the event he did not feel it necessary to see the social worker. More detail Overview Report concerning Child K Page 26 of 115 about these appointments will be provided at relevant points in this summary of agency involvement. It is clear from the records that there was discussion about how the treatment was affecting FK’s relationship with "his previous partner". 3.5.6 Whilst FK was receiving treatment the Infectious Diseases Team wrote to his GP on three occasions and phoned the GP surgery once. There was no communication from the GP to the Infectious Diseases Team. The Health Visiting Service did not have contact with the Infectious Diseases Team or the GP in connection with FK’s treatment whilst it was taking place. 3.5.7 In May FK contacted the Police and said that he had been forced to flee the premises. Shortly after this, FK spoke to the call handler again and said that it was family business and he did not require the Police. Nevertheless, officers were dispatched to the premises and spoke to FK who stated that it had been a verbal argument only. The Police reported this incident to Sheffield Social Care who undertook screening checks and decided that no further action was required. 3.5.8 In June HV1 carried out a home visit to the family and reported that FK looked thin and pale having started his medical treatment. It appears that HV1 was unaware, until this visit, that FK had resumed a relationship with "his previous partner". It also appears that HV1 was unaware of the incident in May that had resulted in Police involvement. 3.5.9 Records indicate that, after this date, FK and "his previous partner" continued to live together until January 2009. 3.5.10 In June FK had an out patient’s appointment in relation to his treatment. It is recorded that he was feeling ‘snappy’ and was advised that this was due to the treatment. FK responded that it was manageable. 3.5.11 At 18:09 hours on 8 July 2008 YAS received a 999 call in which it was explained that "FK's first child" had sustained a laceration to the forehead when a wallpaper stripper had fallen from a security gate in the house and hit them on the head. The caller stated that "FK's previous partner" was her aunty. An ambulance took "the child" to SCNFT and YAS staff informed the Police of the incident. Officers attended the family home and found that the injury was not of a serious nature; they completed a Gen 118a “Concern for a Child” form1 as they took the view that the incident did not meet the threshold for child protection but that other agencies should be made aware it. "The child" attended the emergency department at SCNFT with "their mother" and was found to have a 4cm cut on their forehead but that there were no abnormal neurological signs. The wound was closed with glue and "the child" was discharged home with written and verbal advice. 1 This form is used by South Yorkshire Police to inform Children’s Social Care when they attend an incident that does not warrant instigation of Child Protection Procedures but there are some concerns regarding a child. Overview Report concerning Child K Page 27 of 115 3.5.12 Sheffield Social Care received a Police notification of this incident on 14 July 2008, six days after it had occurred, and it is recorded in the Sheffield Social Care IMR that the explanation given for the injury was accepted by the Police and medics. The social worker contacted the Health Visiting Service on 15 July 2008 to speak to HV1 to seek an update on "the child". HV1 was on annual leave and the social worker informed HV3 of the injury. It is recorded within the Sheffield Health Visiting IMR that HV3 would discuss this with HV1 on her return from leave, which she did. It is also recorded that the social worker informed HV3 that Sheffield Social Care were to close the case and this was done on 21 July 2008. HV1 tried to visit "FK's previous partner and child" at home on 29 July 2008, without an appointment, but no-one answered the door. 3.5.13 Also in July, FK had an out patients appointment regarding his treatment. It is documented that he was feeling bad tempered, and that there was discussion of possible triggers and options. "Later that month" the Nurse Practitioner from the infectious diseases team sent a letter to FK’s GP to provide an update on the treatment given. After this, FK continued to attend out patient’s appointments approximately once/month. He did not attend a planned appointment in October but attended the following day and explained that his non-attendance had been due to a family death. At these appointments FK typically reported that he was feeling short tempered and there is consideration to the impact this is having on his relationship. At an appointment in November FK reported financial stress and the possibility was raised of him seeing a social worker at his next appointment if this had not been resolved. This was mentioned in a letter sent to FK’s GP that day. At a subsequent out patient’s appointment in December FK said that he had not yet needed to contact the social worker about financial issues. 3.5.14 In August the Police were alerted to a disturbance outside FK’s flat. It appears that FK was inside the property with "his previous partner" and had locked her outside following an argument. By the time the Police arrived access had been gained to the flat. Police officers spoke to all parties involved and submitted the necessary domestic violence paperwork which led to Sheffield Social Care being informed of the incident. Sheffield Social Care state that they undertook screening checks although there is no record from Social Care or Sheffield Health Visiting Service to suggest that the Health Visiting Service was informed of the incident. 3.5.15 In September HV1 visited the family home and found it to be empty. This was the first time HV1 had tried to see the family since an unsuccessful home visit two months earlier in July. The last time HV1 had seen the family was nearly four months previously in June. 3.5.16 Following the attempted home visit in September, HV1 contacted Child Health to try to find a new address and an address was identified in a different area of Sheffield. The Health Visiting Team covering the new area was notified of this. A letter from the Health Visiting Team in the new area was sent to arrange a home visit for October 2008 but this had to be rearranged. The visit eventually happened later in October when HV4 visited. Therefore in total there had been a gap of nearly five months, Overview Report concerning Child K Page 28 of 115 since June, when there had been contact between the Health Visiting Service and the family. At one point during the visit FK left the room and HV4 raised the issue of domestic abuse with "his partner" who responded that she was safe and happy and there was no ongoing domestic abuse. HV4 felt that "the child" was making progress with their development and interacting well with their parents. It was agreed that "the child" would be taken to the clinic each month. The author of the Sheffield Health Visiting IMR has explained to the IORA that this refers to the Well Baby Clinic organised by the Health Visitor which enables the Health Visitor to assess the child and family in venues outside the family home. 3.5.17 "FK's previous partner took their child" to the clinic in November and reported that they had been unwell the previous week with an ear infection but had now recovered having received treatment from the GP. Clinic staff observed "the child" to be bright and playful and recorded that "the partner" was well and coping. It was agreed that "the child" would attend clinic again in early January but "the partner" phoned the health visitor that day to say that they could not attend due to a viral illness and the appointment was rearranged. 3.5.18 In December HV4 discussed "the child" in child protection supervision. 3.5.19 In the early hours of January next year Police were "contacted about a domestic abuse incident". Police officers attended the property where all was calm. FK was taken to another address for the night and the situation was assessed, by the Police, as standard. Officers completed all necessary paperwork to enable details of the incident to be shared with partner agencies. However, Sheffield Social Care do not have any record of receiving information about this incident. 3.6 Final Separation of FK and "his previous partner"– End of Period Covered by Review - Information relating to "FK's first child" 3.6.1 "FK's first child" was due to attend the rearranged clinic appointment in January but did not do so. HV4 phoned "the previous partner" to find out why she had not attended and was told that she was presenting herself as homeless because she and FK had split up and the tenancy was in his name. HV4 said that she would phone again two days later which she did. "The previous partner" informed HV4 that she and "her child" were both well, were staying with a friend and had an appointment with the Homeless Assessment and Support Service (HASS). HASS is a multi-disciplinary service that works with homeless families to ensure that they have access to health and other services when they may be at their most vulnerable. One week later, "the previous partner" phoned HV4 to inform her that she was now in bed and breakfast accommodation with "her child". HV4, in turn, contacted HV5 in the homeless team and gave a verbal handover of "the child", including that they had been subject to a child protection plan but that there were no recent concerns. HV5 visited "the previous partner and child" in bed and breakfast accommodation; HV5 completed a HASS assessment, gave her contact details and information regarding local GPs and arranged to visit again when they had moved into interim accommodation. The next visit from HV5 took place on in February when Overview Report concerning Child K Page 29 of 115 "the child" was observed to have a small bruise on the side of their face. "The child's mother" said this bruise had been sustained when they had fallen out of bed; she added that she now had a cot for them. HV5 accepted this explanation. 3.6.2 The author of the Sheffield Health Visiting IMR has informed the IORA that The HASS Health Visitor was aware that there was a history of domestic abuse between "the child's mother" and FK and also a previous partner. The HASS Health Visitor did address the issue of domestic abuse with "the child's mother" who identified that there had been no recent events and that she had no current contact with FK. The Health Visitor did not see FK at the properties whilst visiting but if she had been aware of any current domestic abuse she would have reassessed the situation and taken appropriate action. 3.6.3 Following FK and "his previous partner's" separation in January, FK failed to attend out patient’s appointments, in respect of his treatment for "an infection" , on 3 occasions in January and February. He was contacted by telephone in January but attempts to contact him on 3 occasions in February were unsuccessful. FK eventually attended for an appointment in February; he explained that he had not attended the previous appointments because of problems in his relationship and had not received letters or phone messages because he had moved out of the family home. It is recorded that when FK attended the appointment he was with his partner but the identity of the partner is not recorded. Other IMRs provided for this SCR suggest that FK had not met MK by this stage but it is possible that this partner is someone completely different. Subsequently FK failed to attend two appointments in March. FK was due another out patient’s appointment in April but he cancelled this due to being unwell. He was sent another appointment and attended in April where he said that he felt well now his treatment had stopped and although he had some raised anxiety he was coping. Medical investigations were completed to confirm whether FK’s treatment had been effective and he was advised by the nurse practitioner to see his GP should he have any concerns. In May FK was contacted by telephone and informed that his treatment had been successful, although further investigations would be required in six months time to confirm this. 3.6.4 In April 2009 HV5 carried out a home visit to "FK's previous partner and child" and undertook a CAF in order to apply for a two year nursery place for "the child". Later in the week HV5 discussed "the child" in child protection supervision. This was the last contact that HV5 had with "FK's previous partner and child". The next record in the IMR from Sheffield Health Visiting is nearly two months later, on 28 May 2009 when a member of the public contacted HV6 and reported that a young family had moved into the area and a ‘baby’ could be heard crying late at night for prolonged periods. HV6 made enquiries and established that the family in question was "FK's previous partner and child". 3.6.5 Following further enquiries, and discussion between HV6 and Sheffield Social Care, HV6 carried out a joint visit to "FK's previous partner and child" in June 2009 with a support worker from a housing agency. They Overview Report concerning Child K Page 30 of 115 found the flat to be sparsely furnished but with essential items in place, including a stair gate. HV6 felt that "the child" was developing as expected and "the mother" was handling them confidently and with affection and was prioritising their needs. "FK's previous partner" stated that "the child" stayed overnight at "family member's" every two weeks. It was agreed that the support worker from the housing agency would support "the previous partner" in decorating and furnishing the property and applying for funding for a washing machine and cooker and would also accompany her to a local toddler group. A GP appointment was arranged for 19 June 2009 and HV6 also arranged to visit that day to review "the child's" progress. After the visit HV6 contacted Sheffield Social Care to discuss the visit; it was agreed that there were no current concerns that required Social Care involvement but that an enhanced health visiting service would be delivered. 3.6.6 When HV6 made the planned visit the property was clean and tidy but there was no change in the furnishing. "The child" was seen to be dressed appropriately and steady growth was demonstrated. At the end of the meeting HV6 arranged to meet again next month to review progress with housing, look upstairs, clarify FK’s address, inform "his previous partner" of the outcome of the two year nursery application and review her feelings of depression. 3.6.7 Before this next planned visit from HV6, Sheffield Social Care received an anonymous referral expressing concern that "the child" could be heard continually crying, a number of people smoked cannabis at the property and arguments could be heard between "the previous partner" and her partner. The social worker spoke to the support worker from the housing agency who reported that the property was clean and tidy. The support worker also said that "the previous partner" had said she was not in a relationship with FK but she allowed him to spend time at the property to ‘normalise’ things for "the child". Records from HV6 suggest that a social worker from the screening team tried to contact HV6 but that they did not manage to speak to one another. A social worker then visited "the previous partner and child" and undertook an initial assessment which resulted in a decision that the complaint had been malicious. In the Sheffield Social Care chronology it is written that there was no mention of whether FK was living at the property. 3.6.8 Two days after the social worker had carried out an initial assessment, HV6 made her next planned visit. No further progress had been made with furnishing or decorating the house but "the previous partner" had received funding to repair the washing machine and buy a cooker. It is recorded that she told HV6 about the visit from Sheffield Social Care following an anonymous referral and said that she thought the referral had probably been made by FK because he wanted to resume his relationship with her and she had said no. At the end of the visit it was agreed that HV6 would arrange another visit in three to four weeks but no date was set. 3.6.9 Four weeks later, HV6 wrote to "the previous partner" to arrange a visit in August 2009 but when HV6 visited that day there was no reply at the door, the curtains were closed and the letterbox sealed. HV6 did manage to Overview Report concerning Child K Page 31 of 115 contact her by phone later that day and she apologised for missing the visit, saying that she had forgotten about it and also that "the child" had been allocated a nursery place. A subsequent visit planned for later in the month was cancelled as "the previous partner" reported that she had swine flu and "the child" was staying with FK. The next face to face contact between HV6 and "the previous partner" was in September 2009 when HV6 dropped off a home safety pack and briefly saw "the child" at the door and the next visit of any substance was later in September when HV6 undertook a planned home visit. At this visit "the previous partner" referred to "her child" having met FK’s girlfriend but she added that the relationship had now ended. 3.6.10 In September FK failed to attend an out patient’s appointment in connection with his treatment. This should have been his first appointment since he was told in May that treatment had been successful but that further investigations would be required in six months time. After further failed appointments in October and staff being unable to contact FK by letter or phone he was discharged from the service. The GP was informed of FK’s discharge in November 3.6.11 There is no record of HV6 seeing "FK's previous partner or child" during October 2009, but HV6 did have telephone contact with her and liaised with the support worker from the housing agency and with the nursery 3.6.12 In November Sheffield Social Care received an anonymous referral relating to "FK's previous child". Sheffield Social Care spoke to the HV6, the GP and the support worker none of whom raised any concerns and social workers visited "FK's previous partner and child" and undertook an initial assessment. After completing the investigation, Sheffield Social Care closed the case. 3.6.13 During the social workers’ visit "the previous partner" told them that she and FK had been considering resuming their relationship but that they had since fallen out over money and decided not to do so. She indicated that she did not want to have contact with FK but that FK had contact with "his child" and she did not mind this continuing. 3.6.14 "Six days later FK's previous partner" contacted the Police and stated that she had been assaulted by FK, who she described as her partner. She initially requested an ambulance but then changed her mind and no ambulance attended. FK was arrested for assault occasioning actual bodily harm; he admitted causing damage to the property but said that both parties were involved in a scuffle; no further action was taken against him. 3.6.15 It is recorded in both the Police and Sheffield Health Visiting IMRs that a member of staff from Sheffield Social Care visited the property whilst the Police were present and this member of staff was made aware of the situation at the time. It is also recorded in the Sheffield Health Visiting IMR that the social worker made HV6 aware of the incident 2 days later. Sheffield Social Care have reported that this incident was addressed within the initial assessment that was undertaken as a result of the anonymous referral. Overview Report concerning Child K Page 32 of 115 3.6.16 The author of the Police IMR states that officers ensured that the appropriate domestic violence forms were completed and shared with the PPU. 3.6.17 Following the incident in November, HV6 made two unsuccessful attempts to contact "FK's previous partner" by phone and then wrote to her to arrange an appointment. However, when HV6 visited on the scheduled date there was no reply. Eight days later HV6 saw "FK's previous partner and child" in the street; it is recorded that the child looked well and clean and when HV6 discussed the recent incident with FK "his previous partner" said she was okay and had not seen FK for about two weeks. HV6 arranged to carry out a home visit in December 2009 and following this visit recorded that "the child" was developing well and attending a local playgroup and nursery. "FK's previous partner" reported that she had not had contact from FK for a month. After this visit HV6 had a lengthy conversation with the housing agency support worker regarding progress with "FK's previous partner" and "his child's" challenging behaviour. It was documented that "the child" was not reported to have seen their dad but did go to their grandparent's home at weekends. 3.6.18 In December FK was arrested in the street for possession of cannabis and a warning was issued. 3.6.19 HV6’s next planned visit to "the previous partner" was in mid-February 2010 but she cancelled this. HV6 then made contact with a housing support worker who explained that there were no outstanding housing issues and the agency was to end their involvement. The support worker raised some issues about "the previous partner's" lack of engagement and not being consistent with strategies to manage "her child" who, in turn, was displaying some aggressive behaviour. The support worker also informed HV6 that "the child" had not seen their father but had had contact with "another family member" . 3.6.20 When HV6 visited next it is recorded that "the child " was developing well and having contact with their father every weekend at "another family member's" home. Because the housing agency were closing the case "the previous partner" agreed to HV6 making a referral for Family Support. This was done in March when HV6 visited and completed a CAF which was signed by "the previous partner". During the visit HV6 heard, what sounded like, an adult moving around upstairs. "The child" pointed upstairs and said what HV6 thought was “Daddy”. "The previous partner" however implied that "the child" had said “trousers”. 3.6.21 During the completion of this SCR, HV6 told the author of the Sheffield Health Visiting IMR that she did not ask who was upstairs because of "the mother's" response to "the child's" comment and because of previous violence between the couple. However HV6 added that she planned to ask who had been upstairs at the next contact and subsequently did so. 3.6.22 After the home visit in March HV6 contacted the nursery and was told that "the previous partner" had authorised FK to collect "their child" from Overview Report concerning Child K Page 33 of 115 nursery and he had done so the previous week. HV6 contacted Sheffield Social Care and was told that there was no child protection agreement in place with regard to contact between "the child" and their father. 3.6.23 In March HV6 visited "the previous partner and child" with a family support worker. When asked about FK and the previous visit, "the previous partner" said that FK had been collecting his belongings, explaining he had a new partner and was living in Barnsley. She added that she felt okay about this and felt safe around FK. FK had reportedly separated from "his previous partner" about four months before she moved into this property so it is unclear what belongings he would have had at her house. 3.6.24 In April 2010 "FK's previous partner" took "her child" to the emergency department at SCNFT. It was reported that "the child" was playing in the garden of one of their mother’s friends with a plastic see-saw. They stood next to the see-saw as they pressed the seat down and the seat is reported to have flipped back up and hit them in the face. On examination they had a small graze/bruise on the upper gum and a small graze to the bridge of the nose. It is recorded in the Sheffield Social Care IMR that they were contacted by SCNFT following this hospital attendance and were told that "the child" had been discharged with written advice and that the injury was thought to be consistent with the explanation. The author of the Sheffield Social Care IMR explains that the hospital contacted Social Care because "the child" had previously been on the Child Protection Register. This was in line with a process in place at that time and no action was taken by Sheffield Social Care. 12 days later the Health Visiting Service received a discharge summary regarding this hospital attendance. 3.6.25 In June 2010 HV6 attempted to undertake a pre-arranged visit to "FK's previous partner and child" but there was no reply. HV6 then spoke to the family support worker who reported regular contact with them including a visit the previous week. The family support worker reported that "the child" appeared calmer. HV6 was due to see them in July 2010 but "the previous partner" cancelled the appointment due to other commitments. Also on that date HV6 was told that the family support worker had closed the case and was no longer involved with the family. It appears that this was closed without any prior discussion with HV6. Subsequently, HV6 spoke to the deputy head at "the child's" nursery to discuss the family history and their speech development. 3.6.26 In July HV6 carried out a home visit to "FK's previous partner and child" and completed a "health development" questionnaire. This was the first time HV6 had seen "the child" since March. HV6 was informed that FK had paid for floor covering in the living room and was helping out practically, rather than providing child support. "The previous partner" said she was happy with this arrangement and was on good terms with FK. She said again that FK has a new partner, who is pregnant. She added that the new partner has a child and they do not live in Sheffield. "The partner" stated that "her child" stays with FK from Friday to Sunday and she feels this is a positive arrangement. HV6 told the author of the Sheffield Health Visiting IMR that she asked "the previous partner" where FK was living and she said that she was not sure of the address. Overview Report concerning Child K Page 34 of 115 3.6.27 HV6 involvement with "the previous partner and child " continued throughout the remainder of the period covered by this review but there are no further references to FK after this visit in July, although he was continuing to have contact with "his child". 3.6.28 Although there are no further references to FK after July it is recorded in the YAS IMR that in October the Police contacted YAS and requested that they attend "the previous partner" who had been assaulted and had sustained a large lump on the top of her head. The author of the YAS IMR explains that staff that attended the incident remembered there being children in the property but Social Care were not notified and the YAS staff do not recall whether hospital staff were informed about the children. YAS staff did, however, ensure that the children were not left alone when "the previous partner" was taken to hospital. There is no information to indicate who had assaulted her or where the assault had taken place, therefore there is no evidence to suggest that FK was involved. The Police have been unable to find any record of this incident. 3.6.29 The child care setting that "FK's first child" attends had FK named as their father and records that indicated that there had been previous Family Support Team intervention. They were aware of limitations placed on FK’s contact with "his child" since the death of Child K but had no information about limitations to contact prior to that time. This is consistent with information in other agencies which demonstrates that, until Child K’s death, there was no concern that FK might pose a risk to "his first child" 3.7 Background Information relating to "Child K's sibling" and Child K 3.7.1 "MK's first child" was born in the Midlands. It is recorded in the medical records that the pregnancy was unplanned and that MK split from the child's father soon after the birth and moved to another address in the Midlands. This SCR has confirmed that MK "and her first child" were not known to the LSCBs in either of these two areas and based on this information it was decided that IMRs would not be sought from agencies in either county. However historic records provided in the Primary Care and SWYPFT IMRs suggest that there were no significant health issues for MK "or her first child" and no concerns in relation to Safeguarding Children. 3.8 MK and "her first child's" move to Sheffield – Birth of Child K 3.8.1 MK and "her first child" moved to Sheffield between April and June 2009 when they moved into the home of "family members". YAS, the Police and Sheffield Social Care all report that they had no contact with MK or "this child" until after Child K sustained the injuries that led to his death. 3.8.2 It is recorded in the Primary Care IMR that MK met FK in July 2009 although it is unclear where this information has come from. 3.8.3 MK and "her first child" registered with a GP in Sheffield in June 2009 and the GP surgery informed the Health Visiting Service that they had moved in to the area. HV8 visited the family home when "the child" was 14 months old and a nursery nurse visited the following day to complete the 6 – 13 month assessment and Family Health Profile. Overview Report concerning Child K Page 35 of 115 3.8.4 MK told HV8 that she had recently separated from the father of "her child" and had returned to live with her "family", whilst information provided in the medical records suggests the separation had occurred soon after "the child's" birth. MK also explained that she worked three days/week at a nursery in the Midalnds and that she took "the child" with her twice/week and they stayed in Sheffield with "family" on the third day. MK also told HV8 that she supervises "her child's" contact with their father but there is no explanation of this in the health visiting notes. HV8 believes they would have asked why contact was supervised but cannot remember the response. 3.8.5 HV8 documented that there were no domestic abuse, mental health, alcohol or drug issues. The nursery nurse recorded that the lounge area of the house was clean and tidy, that "the child" was developing as expected and that MK had the support of close family. MK and "her child" did not present as being vulnerable and it was decided that the core offer of the Health Visiting Service would be delivered to the family. No further home visits were planned but MK was given details of how to contact the local Health Visiting Team and clinic. There is no documentation to indicate that "the child" attended a Well-Baby clinic in the area and no information to suggest that the Health Visiting Service had any further direct contact with MK or "her child" whilst they lived in Sheffield although a health development questionnaire was completed and filed in the Family Health Record in 2010. MK herself told the IORA and Designated Nurse that HV8 visited twice soon after she moved to Sheffield but that there were no further visits after this. 3.8.6 The first GP consultation was in September 2009 when "MK's first child" attended with an ear infection. "The child" also visited the GP Practice in December 2009 with eczema when they were seen by GP12 and February 2010 when they were seen by Practice Nurse 2. "The child" also had two consultations with the GP during 2010; these were in May for an Upper Respiratory Tract Infection and July for another ear infection. The Primary Care IMR does not contain any details of these consultations other than a record in the chronology that they occurred. 3.8.7 In February 2010, eight days after "MK's first child" was seen by the Practice Nurse at the GP Practice, they were taken to the Emergency Department at SCNFT with a history of screaming and holding their genitalia when passing urine. It was documented that they had become unwell nine days before with fever and screaming on passing urine and was treated with antibiotics for an ear infection. Fever and ear pain is said to have subsided as did the screaming with passing urine, but the latter had recurred in the four days prior to the hospital attendance. This history is consistent with the report in the Primary Care IMR of attendance at the GP Practice in February. 3.8.8 The author of the SCNFT IMR has written that when "the child" was examined, they were noted to have some redness and it was thought that they either had an infection or a urinary tract infection. Attempts to collect a urine sample from "the child" for investigations were not successful so Overview Report concerning Child K Page 36 of 115 they were discharged home with painkillers and a fungal cream and arrangements were made for the urine to be collected at home and handed in at a later date. 3.8.9 Nine days later, "the child" was taken back to the Emergency Department at SCNFT by MK. The presenting complaint on this occasion was fever and ear-ache and it was reported that they had been unwell for about three days. "The child had some redness" and red swollen tonsils and red ear drums. This time they were thought to have tonsillitis or infection but urinary tract infection was still a possibility since their urine was yet to be examined. They were given some antibiotics and discharged home to continue treatment with the fungal cream and for MK to collect a urine sample. 3.8.10 Discharge summaries relating to both hospital attendances were sent to the Health Visiting Service and it is documented on the second of these that MK had been trying to obtain a urine sample from "her child" for five days. There is no record of a urine sample being provided to the hospital or of "the child" attending the hospital again. Furthermore, they did not have another appointment with the GP until May 2010. 3.8.11 In February 2010, in between "the child's" attendance at the GP Practice and their first attendance at SCNFT Emergency Department, MK was referred to STHFT for a termination of pregnancy and was initially seen two days later. This referral came after MK referred herself to Sheffield Contraception & Sexual Health Service which was part of Sheffield NHS Primary Care Trust at that time. Documentation states that part of MK’s decision to terminate her pregnancy was that she was unable to cope with another baby at that time. It is also documented that she was upset but sure of her decision and that she had support. However there are no further details about the support. 3.8.12 Later in February, in between "the child's" two attendances at SCNFT, MK contacted the gynaecology department to state that she was unsure of her decision to have a termination and she was offered further counselling and a follow up appointment, which she attended. Subsequently, MK booked for pregnancy care and, after completion of a booking history, it was deemed appropriate for the midwife to be the lead professional, as the pregnancy was low risk. 3.8.13 A full social history was taken at the pregnancy booking. FK was detailed as the father of the unborn baby and MK said that they were not in a relationship or living together at that time. Information was recorded that FK already had a child, who lived with their mother, and also that FK had Attention Deficit Hyperactivity Disorder (ADHD) but there was no exploration of how this affected his day to day ability. No information was recorded about FK receiving treatment for "an infection" , his previous drug use or his involvement with Sheffield Social Care during his relationship with "his previous partner". MK was asked about domestic abuse and responded that she had not experienced it in her relationship with FK. MK was also asked about mental health and said that she had no previous mental health issues. The author of the STHFT IMR explains that when Overview Report concerning Child K Page 37 of 115 the father of an unborn child is named no further routine checks are undertaken by the midwife, unless there are specific concerns raised within the social or medical history that warrant further investigation. Consequently no enquiries were made about FK’s history. 3.8.14 STHFT faxed an antenatal contact/hospital referral form to the Health Visiting Team. FK was named as the unborn baby’s father and it was written that MK and FK were not together. 3.8.15 Whilst this SCR was being carried out MK told the IORA and Designated Nurse that she moved into a property in the Barnsley area in April 2010 and it is recorded in the chronology from STHFT that she told the midwife this at the time. However it is recorded in the IMR from the Sheffield Health Visiting Service that "KF's previous partner" told HV6, one month earlier, in March 2010, that FK had moved to Barnsley to live with his new partner who was pregnant. Despite moving to Barnsley in April 2010 MK did not register with a GP in the Barnsley area until September 2010, just one month before Child K was born and the Health Visiting Service in Barnsley were not made aware of the family’s arrival in their area until September 2010. 3.8.16 Through her pregnancy MK had frequent and regular antenatal appointments, predominantly with the same midwife. For the majority of appointments MK attended on her own but on one occasion she attended with "another family member". Records suggest that FK did not attend any antenatal appointments with MK although MK and FK both told the IORA and Designated Nurse that FK had been present when MK had her first scan. Maternity care for MK continued to be provided by STHFT after her move to Barnsley and MK was booked to deliver her baby at hospital in Sheffield. 3.8.17 In June 2010 MK had a consultation with GP11 due to ‘low mood’. She was referred to the Maternity Mental Health Team where she was seen and assessed. According to information in the Primary Care IMR, MK’s mental health showed evidence of mild to moderate depression, and also evidence of low self-esteem. In the STHFT IMR it is recorded that MK was reviewed by a clinical manager for maternal mental health services in July 2010 and it was recorded that she exhibited strong features of clinical depression and that a follow up appointment was planned for four to five weeks time. The author of the Primary Care IMR states that MK was seen in the Maternity Mental Health Team in August. The author of the Primary Care IMR also explains that it was suggested that MK go on anti-depressant medication but that her mood and sleep pattern improved with treatment with iron tablets and she never did go on anti-depressant medication. Information provided by MK to the IORA and Designated Nurse confirms that her feelings of depression during the pregnancy were short lived and that she did not take any anti-depressants. 3.8.18 In the Primary Care IMR it is recorded that, through counselling by the Perinatal Mental Health Unit, it emerged that MK had mental and physical difficulties with this pregnancy, suffering from dizzy spells, headaches and low blood pressure. Also that her sleep pattern was poor and she worried Overview Report concerning Child K Page 38 of 115 that the unborn baby (Child K) may suffer from ADHD inherited from FK. MK herself reported to the IORA and Designated Nurse that she only felt dizzy on one occasion during the pregnancy and as a result was off work for three days. 3.8.19 A home visit was undertaken by an STHFT midwife in September 2010 to ascertain if home conditions were suitable and whether appropriate preparations had been made for the birth of the baby. By this time MK was living in the Barnsley area and the author of the STHFT IMR explains that the midwife to whom MK was allocated had arranged for a colleague who lived near MK to perform the home visit as this area was not routinely covered by Sheffield community midwives. The author of the STHFT IMR further explains that home birth assessments were introduced into practice following a previous SCR and that the assessments are seen as an opportunity for midwives to ensure home conditions are suitable for a newborn baby with appropriate equipment in place and it also provides midwives with an opportunity to assess any changes to family circumstances. 3.8.20 In September 2010, a Health Visitor Transfer Summary Sheet was completed by HV8 as MK and "her first child" had moved out of the area. The only information documented on the summary was “routine health visiting”. No mention was made of MK being pregnant. 3.9 Involvement with Child K, "his sibling", MK and FK from the birth of Child K until he sustained the injuries that led to his death (October 2010 – 26 September 2011) 3.9.1 Following the birth of Child K in October 2010 MK stayed in hospital for two days during which time normal postnatal care was provided. MK and Child K were then discharged to the care of community midwives employed by BHNFT. In accordance with current STHFT hospital policy a telephone call was made to BHNFT to inform them of the discharge of MK and Child K and to provide a verbal summary of the care provided. Also, as part of routine practice the postnatal midwifery care records, baby chart, daily postnatal observation chart and a discharge summary report generated following input from the midwife on PROTOS (an electronic midwifery recording system) were sent home with MK for use by Barnsley midwives. A copy of the discharge summary was also sent to the GP. 3.9.2 It appears that BHNFT was not provided with a social history for the family and did not gather this during visits to the family. The authors of the BHNFT IMR explain that midwives in Barnsley usually gather a social history during the antenatal period and consequently do not routinely gather such information post-natally. 3.9.3 Following Child K’s discharge home, community midwives from BHNFT visited the family home on four occasions (days 3, 5, 7 and 11 of life) before transferring the care of MK and Child K to the health visiting service. These four visits were all undertaken by different community midwives. The authors of the BHNFT IMR state that MK was reported to be postnatally well and coping well with the care of Child K who she was Overview Report concerning Child K Page 39 of 115 breastfeeding. The IMR authors explain that a social history would normally be taken in the antenatal period but in this case Barnsley midwives did not undertake any antenatal visits because they did not know about the family until after Child K was born. It appears that they did not record a social history when they visited the family after Child K was born and made no record of who was present at the contacts other than Child K and MK. 3.9.4 The first contact with the family from health visitors from SWYPFT was in November 2010 when Child K was 12 days old. This was the day after the final visit from a midwife. Based on information contained within the BHNFT and SWYPFT IMRs it appears that no written information was passed from the Barnsley midwife to the health visitor despite the fact that the midwife should complete a discharge form and pass a copy of this to the health visitor. 3.9.5 This visit in November was also a ‘movement in’ visit in respect of "MK's first child". The author of the SWYPFT IMR explains that a ‘movement in’ visit occurs when a family with a child or children aged 0-5yrs registers with a local GP and that, in this case Barnsley Child Health Services became aware of the family movement into Barnsley in September 2010. There was therefore a gap of nearly two months before the visit took place. The health visiting service had received a written summary of previous health visiting involvement which did not highlight any concerns about their development or the care they were receiving. 3.9.6 The visit in November 2010 was carried out by HV1 but the allocated case holder for the family was HV4. This situation arose because HV1 was moving to a different Health Visiting Team whilst HV4 should have transferred into the team covering the area in which Child K lived, in October 2010 but did not actually do so until December 2010. 3.9.7 The author of the SWYPFT IMR states that during the birth visit, HV1 noted that this was a two parent family. The author adds that details of the father were not recorded and there is no documentation which identifies that questions were asked about any previous relationships. There is no information recorded about the attachment in relation to the mother or bonding between mother and child. The Maternal Mental Health Care Pathway was not in place at this time. Two weeks later, in November 2010, MK took Child K to clinic where Child K was weighed and was found to be just below the 98th centile. 3.9.8 Following this clinic attendance, the only contacts that health services had with "MK's first child", until after Child K died, were in June 2011 when they saw GP5 as they had tonsillitis and July 2011 when they saw GP 6 with post viral sinus congestion. On the second of these occasions "the child" was taken to the surgery by "another family member". 3.9.9 In December 2010 FK attended an appointment with GP4; this was a routine follow up regarding his treatment for "an infection" . This was the first appointment that FK had attended in relation to this since he had become non-compliant with treatment in November 2009. It was confirmed Overview Report concerning Child K Page 40 of 115 that FK was cured of "his infection" but was potentially a risk to himself and his partner due to his failure to continue follow up. This appointment in December 2010 was FK’s only contact with health services during the period from October 2010 onwards. 3.9.10 In December 2010 Child K visited GP1 for a six week check which showed no abnormalities; in particular the mouth was examined and found to be normal. MK had a postnatal examination by the GP at the same time as Child K’s six week check; it was noted that she was breastfeeding and her mood was recorded as being good. The only GP appointments that MK had after this were for "routine health care". 3.9.11 The day after the six week check, MK returned to the GP with Child K as he was coughing up blood. On this occasion Child K was examined by GP2 who referred him to the Child Assessment Unit (CAU) at BHNFT. GP2 wrote a letter for the hospital in which Child K was described as a well baby with no previous problems, who is breastfeeding and thriving. The letter stated that no other signs of bleeding or bruising had been noted; it did not highlight any safeguarding concerns and asked the Paediatrician to “please advise”. 3.9.12 Child K arrived at the paediatric unit at 19:00 hours on that day in December 2010 with both parents. He was seen by a paediatric registrar who took a medical and family history and undertook a full clinical examination. MK and FK reported that Child K had had a cough for three days and at approximately 17:30 hours he had coughed a couple of times and blood had come from his mouth. The registrar described Child K as having a “snuffly” nose and recorded him having “raw mucous membrane on left of soft palate”. The registrar’s recorded diagnosis was “Viral URTI” (upper respiratory tract infection) – and that K had “coughed up blood due to burst blood vessel in pharynx”. The registrar documented that this was discussed with parents and blood tests were arranged. Child K was discharged home at 23:30 hours with advice to return if concerns were ongoing or his condition deteriorated. An electronic discharge letter was completed which included a summary of the admission, diagnosis and details of the blood results. 3.9.13 Information about this hospital attendance was sent from the hospital to the Health Visiting Service via SystmOne four days later. This was opened by the administrator in the Health Visiting Team two days later and forwarded to HV4 who became aware of the incident at 12:11 hours that day. A discharge summary from BHNFT was scanned into the Health Visiting Records on SystmOne later that day and opened by HV4 four days later. 3.9.14 In December 2010, before the health visiting team became aware of Child K’s attendance at hospital, HV3, a Health Visitor Bank Nurse working with the service, made an unsuccessful planned visit to the family home to undertake Child K’s 6 to 8 week contact. HV3 undertook the visit due to the fact that HV4 had only been with the team for 2 days and had been allocated a caseload of approximately 380 cases including around 12 where Safeguarding Children was an issue. Child K was almost eight weeks old at the time of this visit and the author of the SWYPFT IMR Overview Report concerning Child K Page 41 of 115 explains that, at that time, it was in keeping with policy to carry out a check between six and eight weeks of age. However in January 2011 the Health Visiting Service adopted the ‘Healthy Child Programme 0-5 Years Health Visiting Standards’ which clearly identifies that a contact of this nature should be undertaken at six weeks. 3.9.15 Three days after this unsuccessful visit, MK took Child K to the Emergency Department at SCNFT with a three day history of a swelling of his right pinna (outer aspect of the external ear). Records show that MK did not provide any suggested explanation for the swelling but told the registrar in the Emergency Department that Child K had woken three days earlier with a slight swelling of the pinna and this had worsened rapidly. Records also show that MK told the registrar about Child K’s attendance at BHNFT a few days previously. 3.9.16 The Emergency Department registrar was of the view that the swelling was either a haematoma, a blood containing swelling which usually develops from small blood vessels bursting following blunt trauma or a seroma, a swelling containing fluid called serum which may occur following trauma or surgery or may be spontaneous. The Emergency Department registrar referred Child K to the Ear Nose and Throat (ENT) surgeons so that the swelling could be drained. The Emergency Department registrar wrote in the notes that if the fluid drained from the swelling was found to be bloody, NAI should be considered. 3.9.17 Child K was then reviewed by an ENT registrar (ENT1) who was also of the opinion that the swelling could be a haematoma or a seroma and who arranged for Child K to be admitted to a ward to be prepared for theatre to drain any fluid it contained. The ENT registrar spoke with MK who provided a similar history to that given to the Emergency Department registrar although on this occasion MK stated that the swelling had occurred two days previously. 3.9.18 The following day, Child K was taken to surgery and a blood stained fluid was drained from the swelling and, after discussions in ENT, child protection concerns were raised. As a result of these, the next day a junior doctor in ENT referred Child K, by phone, to a medical registrar in the acute medical team, to look at child protection issues. Child K was still an in-patient at SCNFT at this time. The author of the SCNFT IMR explains that the specialty teams are aware that they can refer children directly to social care, but they do not have the expertise to do child protection medicals and therefore established practice is that they refer to the medical team. The IMR author adds that this arrangement is not peculiar to SCNFT but occurs in other hospitals across the country. 3.9.19 Also on that date ENT1 contacted BHNFT and obtained the results of a clotting screen which had been carried out when Child K had been seen earlier in December 2010; these were normal. ENT1 also contacted HV4 to ask about any concerns the Health Visiting Service had in relation to Child K. Records show that HV4 phoned back and explained that there had been nothing abnormal detected at the birth visit other than dry skin and that the parents had acted on advice to attend the GP with this issue. HV4 Overview Report concerning Child K Page 42 of 115 also informed ENT1 that Child K had only been seen once by a health visitor and the family were not home for the six to eight week assessment that HV3 had tried to undertake. There is no evidence to suggest HV4 and ENT1 discussed the possibility of contacting the designated or named doctor for advice or of referring Child K to Children’s Social Care and no such contacts were made. 3.9.20 At 17:20 hours on that day a medical specialist registrar, MSPR 1 saw Child K and reviewed the history. MK again said that she noted bruising on the right pinna on 3 days before and it was documented that MK said the colour of the bruise was lighter the next day and swelled up on day two. MK also told MSPR1 that Child K had been seen at BHNFT after coughing up blood which was attributed to a cut on his palate (roof of the mouth). It was documented that Child K was breastfed, although it is recorded in the chronology prepared for this SCR that, when Child K was seven days old, MK told the midwife that the breastfeeds were being topped up with formula milk. MK added that Child K had bruised more when his blood investigations had been carried out in BHNFT. Finally, MK was quoted to have said that Child K was noted to have a cut inside the pinna of his right ear soon after birth which had healed after treatment from the GP but that this cut had reappeared. However, there is no record in the Primary Care IMR for this SCR of Child K seeing the GP at a few days of age or of ever seeing the GP because of a cut in his ear. The first contact with the GP had been when Child K was 31 days old as a result of dry skin around the ears and on the legs. 3.9.21 MSPR 1 discussed two possible causes of the swelling on Child K’s ear. These were, swelling following minor trauma due to a clotting disorder or swelling due to forceful trauma. MSPR1 explained that either way, further investigations were needed and arranged for a more detailed clotting screen to be done the next day. From the examination of Child K that was carried out by MSPR1 in December 2010, it was documented that Child K had a small fading bruise on the radial (lateral) aspect of his right forearm near the elbow. 3.9.22 The following day Child K was reviewed on the ward round by MSPR2. Child K was examined and said to be doing well and the plan was for a clotting screen to be done and Child K to stay overnight. The blood test was carried out but the sample clotted so no results were obtained. MSPR 1, reviewed Child K at 20:00 hours with both MK and FK and explained this to them. 3.9.23 The following day Child K was reviewed by the ENT team and declared fit for discharge home from ENT point of view. He was also seen by MSPR 1 during which, the difficulty with bleeding Child K was discussed. The outcome of this discussion was to discuss with the Paediatric Medical Consultant whether Child K could be discharged home to come back in a couple of weeks for the bloods to be repeated but in the event blood was obtained that day for the tests which were normal. Child K was discharged home that day, but there is no documentation regarding who discharged him and time of discharge. The plan at discharge, as documented in a discharge summary created by ENT2, was for follow up to be arranged by Overview Report concerning Child K Page 43 of 115 the medical team. However, there is no record of any medical follow up arrangement being made by the medical team. This is consistent with the statement made by MK to the IORA and Designated Nurse that she was told that a follow up appointment would be made but this never happened. 3.9.24 Two days after Child K was discharged, he attended the ENT dressing clinic for removal of stitches and was discharged from ENT follow up. 3.9.25 It is clear from the above, lengthy account of Child K’s admission to SCNFT that, although ENT staff referred him to the acute medical team because of concerns about the possibility of NAI, this was not thoroughly investigated by the acute medical team and Child K was discharged without anyone identifying the cause of the swollen pinna. 3.9.26 Shortly after the phone conversation between HV4 and ENT1 in December 2010, HV4 left a message on MK’s mobile phone asking her to make contact to arrange the six to eight week assessment. The next day MK phoned HV4 in response to the phone message left by HV4 the previous day. MK explained that the haematoma on Child K’s ear had been drained. An appointment for the six to eight week assessment was made for a later date but MK phoned HV4 again on to explain that Child K was still an in-patient at SCNFT and she would call again when he had been discharged. The author of the SWYPFT IMR identifies that the phone call from MK was logged at 13:00 hours but the visit had been arranged for 10:30 and there is no indication as to whether a visit had been attempted at that time. The author also identifies that HV4 did not contact SCNFT to confirm whether Child K was still an in patient. 3.9.27 Child K received his first primary immunisation in January 2011 and the next contact between the family and the Health Visiting Service took place in February 2011 when he was weighed at clinic and his weight was recorded as 7.35 kg. The following week, HV4 carried out the six – eight week assessment. It is written in the SWYPFT IMR that the six – eight week assessment was carried out by HV4 during a visit to the family home but MK told the IORA and Designated Nurse that HV4 never visited her home and this assessment was carried out when she took Child K to clinic. Either way this was the first time that HV4 had met the family. Child K was 16 weeks old by the time the six to eight week assessment was carried out and the delay was recorded as being due to Child K having been in hospital and a changeover of health visitor. 3.9.28 Aside from the lengthy delay in carrying out the six to eight week assessment visit the author of the SWYPFT IMR raises a number of concerns about how it was carried out. These include the scorecard for the Edinburgh Postnatal Screening not being completed and no record of the relationship between Child K and either parent being discussed. At this assessment Child K’s weight was recorded as 7.29 kg which is 0.06 kg lighter than the previous week. The author of the SWYPFT IMR identified that Child K’s weight had fallen from just below the 98th centile in November 2010 to just above the 75th centile at this visit. However, this is not recorded in the case notes. Overview Report concerning Child K Page 44 of 115 3.9.29 Later in February 2011 "MK's first child" started attending a local children’s centre one day per week and this continued for five months until they moved to a nursery school. The IMR from Barnsley Education reports that no significant events or incidents occurred over this period. Staff at the centre considered that MK and FK were affectionate and attentive with "their child" and communicated well with centre staff. 3.9.30 In March 2011 Child K attended for his third primary immunisation and one week later, HV2 weighed Child K at the clinic where his weight was recorded as 7.94 kg. This was an increase of just 0.65 kg from the 6 - 8 week assessment six weeks earlier which meant that Child K’s weight had now fallen below the 75th centile. HV2 did not make any mention of the drop in centile or of any bonding or attachment issues. 3.9.31 In April 2011 MK attended a weaning session presented by a nursery nurse and later that month Child K attended clinic for a six month assessment. This assessment was carried out by HV4 who had previously seen Child K at the six to eight week assessment. Maternal wellbeing was discussed during this assessment and the postnatal depression screening was undertaken. As was the case at the six to eight week assessment the scorecard for the Edinburgh Postnatal Screening was not completed and there is no recorded information in relation to the attachment or bonding in relation to Child K and MK was provided. At this assessment Child K weighed 8.55 kg and was back on the 75th centile. 3.9.32 Children’s Centre staff informed MK about support groups and programmes that were available and MK chose to attend the Positive Parents Group which was held over a six week period commencing in May. Childcare was provided with this group and Child K attended all sessions and presented no issues for the staff. 3.9.33 In June 2011 student HV1 saw MK and Child K in clinic where Child K’s diet was discussed. MK expressed concern that Child K “develops red marks easily on his skin when he bumps into things which disappear quickly”. The author of the SWYPFT IMR considers that this statement would have presented an opportunity for safeguarding supervision. 3.9.34 The final direct contact that the Health Visiting Service had with Child K was in August 2011 when he attended clinic aged 41 weeks, the only information documented about this visit was Child K’s weight which was 9.9 kg. 3.9.35 "MK's first child" started at nursery in September 2011and attended in the afternoon from Monday to Friday each week. Both FK and MK attended the initial meeting for new parents and were inquisitive about the setting but did not raise any concerns. Nursery staff’s perception was that "Child K's sibling" was initially very shy and close to MK and FK and took time to settle. The author of the Barnsley Education IMR considers that "the child's" behaviour was typical of a child who had not spent a great deal of time in a child care setting. Child K was usually present when "his sibling" was brought to and collected from nursery and therefore nursery staff often Overview Report concerning Child K Page 45 of 115 saw Child K. However, they never had any concern about the appearance of either child or the behaviour of MK and FK. 3.9.36 Neither the Police nor Barnsley Social Care had any contact with the family after their move to Barnsley until after Child K sustained the injuries that led to his death. 3.10 27 September 2011 onwards 3.10.1 At 12:30 hours on 27 September 2011 the nursery received a phone call from a friend of MK and FK in which they were informed that "Child K's sibling" may be late as there had been an accident involving Child K. Nursery school records indicate that "the sibling" was a little bit late but there is no record as to who brought them to the nursery or whether Child K was in attendance. 3.10.2 At 14:00 hours on 28 September 2011, HV5, who worked in the same team as HV4, documented information about a phone call taken from a member of the public at 17:10 hours on 27 September 2011. This member of the public was also a service user of HV4’s and the record was placed on the record of the member of the public. The text of the record reads as follows: ‘T/C from (name of member of the public) at 17:10 hrs on 27/09/11(the member of the public) was upset because she had seen a child with his Dad in the street who had scratches on his face which looked red and angry and in her opinion needed to be checked by a Dr. She told the Dad this and he stated he was going to take the baby to the GPs when his mum returned home from work. (The member of the public) rang for reassurance that she had done the right things but she did not know the name of the baby and didn’t want to “get involved”. Advised she could ring the police or social care duty team if she wanted to report what she had seen anonymously. (The member of the public) preferred not to do this as she felt sure the child’s Mum would go to see the GP when she got home. Reassured and advised to ring back in the morning if she found out any more information and we could help any more.’ 3.10.3 On 29 September 2011 this information was entered on Child K’s record. 3.10.4 It is unclear from the SWYPFT IMR exactly how and when the Health Visiting Team became aware that the child referred to by the member of the public was Child K. It seems probable that this was established by finding out, from the hospital, the identity of the child who had been admitted that morning. 3.10.5 In the course of undertaking this SCR the author of the SWYPFT IMR has spoken with HV5 who has provided additional, more detailed information about the telephone call. Interviews carried out by the author of the SWYPFT IMR have also revealed that HV5 contacted HV4 during the evening of 27 September 2011 and informed HV4 about the phone call from the member of the public. No record was made of the phone call between HV5 and HV4. Overview Report concerning Child K Page 46 of 115 3.10.6 On 28 September 2011 Child K was admitted to BHNFT by ambulance, was subsequently transferred to SCNFT and died that evening. Numerous contacts were made by a range of agencies and these are described in detail below. As far as possible they are described in the order they occurred but in some cases there is no accurate record of the time. There are also some discrepancies in the records of different agencies as to when discussions took place and what information was exchanged. 3.10.7 At 10:00 hours YAS received a 999 call from an adult male for Child K who was apparently unwell. An ambulance was dispatched to the address given, which was the family home. At 10:15 hours the ambulance left the scene to convey Child K to hospital and nine minutes later Child K arrived at BHNFT following which YAS EOC informed YAS Clinical Team Leader regarding the seriousness of the call and the crew’s concerns for the injuries to Child K. 3.10.8 Attending YAS staff completed a referral to Children’s Social Care and made the YAS Safeguarding Team aware of the incident. Barnsley Social Care have no record of receiving a phone call from YAS although a member of clerical staff remembers receiving the call and believes that it was about the same time as the calls from the Health Visiting Service. The member of clerical staff in Barnsley Social Care believes the details of this call were passed on to social work staff but none of the social workers who were on the ‘duty’ system that day, remember being told. The Barnsley Social Care IMR also refers to a follow up fax received from YAS at 13:34 hours. None of the social workers on ‘duty’ that day had any recollection of having ever seen, or known about this fax. 3.10.9 The author of the Barnsley Social Care IMR explains that this fax was filed on Child K’s record on the Local Authority’s ‘R’ drive, which is where items are stored which cannot be scanned onto ‘ERIC’, the computerised information system used by Barnsley Social Care. The fax was scanned and filed on the ‘R’ drive on 30 September 2011, two days after it was received and this is likely to have been done by the member of clerical staff as this would be usual practice. There is no record on ERIC to link Child K’s ERIC record to this fax held on the ‘R’ Drive although there is a record of a subsequent fax received from the health visitor on 30 September 2011. Consequently, a person looking at Child K’s ERIC record would not be aware that a fax had been received from YAS. 3.10.10 At 10:36 hours the Police received a call from YAS to advise them that Child K was in cardiac arrest and being taken to hospital. Police Officers attended at the hospital to ascertain the nature of the child’s injuries. They were told by medical staff that the parents’ account was that he had been knocked over by the family dog, sustaining injuries. It is recorded in the Police IMR that officers were told by staff at the hospital that, in their opinion, the injuries were compatible with the initial explanation given. The author of the Police IMR has told the IORA that a consultant said that Child K had a small bruise which did not seem to be suspicious. There is no reference to this discussion in the BHNFT IMR but it is recorded that Child K had “a number of bruises on his forehead”. Overview Report concerning Child K Page 47 of 115 3.10.11 At 11:15 hours Staff Nurse 1 in the Health Visiting Team received a call from the member of the public who had contacted HV5 the previous evening. The member of the public reiterated the information she had given the day before but is recorded as stating that the baby’s face was “smashed in” which father had stated was because the baby had “fallen down the bottom step”. The member of the public informed Staff Nurse 1 that she had seen an ambulance take the child from the house that day. Staff Nurse 1 advised the member of the public to ring Social Care and gave the telephone number of the Children’s Social Care duty team. Staff Nurse 1 left HV5 a message about this phone call in the message book. 3.10.12 According to the SWYPFT IMR, HV4 contacted Barnsley Social Care 15 minutes later, at 11:30 hours, and informed a social worker (SW2) of the situation with Child K. HV4 apparently told SW2 that Child K had a fractured skull and bleed on his brain and he was being stabilised before transfer to SCNFT. The Barnsley Social Care IMR records three phone calls, in quick succession from the Health Visiting Service to Barnsley Social Care. The first of these was taken by a member of clerical staff and it is probable that the second was also taken by the same person. Social worker 2 may well have taken the third but the recording does not have that social worker’s initials and it is the individual’s practice usually to initial such records. There appear to be some discrepancies around the time of the calls, with Barnsley Social Care records having everything later than other agencies do. In the Barnsley Social Care IMR it is written that the first contact from the Health Visiting Service was recorded as being at 15:17 hours but could have been received up to half an hour earlier. The Health Visiting Service had it recorded as being made nearly four hours earlier. 3.10.13 Having been informed by YAS of Child K’s admission to hospital, Police Officers attended BHNFT to ascertain the nature of the child’s injuries. They spoke to MK and FK and also to the Emergency Department consultant. They were told by the Emergency Department consultant that the parents’ account was that Child K had been knocked over by the family dog, sustaining injuries. At that point, the officers were told by the Emergency Department consultant that Child K had been unconscious when he was admitted to hospital but had been resuscitated and was now sedated whilst further tests were being carried out. The Emergency Department consultant also told officers that Child K had some bruising on his forehead but the Emergency Department consultant did not think it was anything serious. The report from the Police Officers states that, in their opinion, there was nothing suspicious about the account of the accident and hospital staff brought nothing suspicious to their attention. 3.10.14 An officer attended the family house where Child K had allegedly been knocked over by the dog and Barnsley Social Care was updated at that point. The author of the Barnsley Social Care IMR has written that the case recording states explicitly that at that stage the Police were not regarding the injuries to Child K as suspicious and they would contact Social Care again if that view changed. Overview Report concerning Child K Page 48 of 115 3.10.15 The record written by the Emergency Department consultant describes Child K’s condition on arrival briefly, noting that breathing was inadequate and needed support with bag and mask ventilation followed by anaesthetic input. This record makes no mention of any discussion with the Police. The record written by the Anaesthetist notes inadequate breathing requiring intubation and ventilation. 3.10.16 In mid afternoon the named nurse at BHNFT received a phone call from HV4 in which HV4 explained that a phone call had been received the previous day from the member of the public. The SWYPFT IMR doesn’t include any record of HV4 phoning the named nurse but it does record that the named nurse phoned the Health Visiting Team and undertook to try to get an update of Child K’s progress. 3.10.17 Having received information from HV4 the named nurse at BHNFT made enquiries from the Emergency Department and consultant paediatrician at the hospital. The named nurse then spoke to the social worker to ensure that Barnsley Social Care were aware of the situation. It is written in the BHNFT IMR that SW1 said that Barnsley Social Care were aware of the situation but that Police stated that it was not suspicious. The named nurse expressed concerns to the contrary based on the information provided by the health visitor about the phone call from the member of the public and the nature of the injuries. The named nurse suggested that the social worker should immediately speak to the consultant paediatrician who had seen the child and could give a full account of the injuries and reported history. 3.10.18 Shortly after this, the consultant paediatrician did speak to the social worker; the consultant paediatrician recorded that the following points had been discussed during the phone conversation: 1. "Child K’s CT scan results and poorly condition. 2. Parents being made aware of Child K’s condition and informed that a referral had been made to Children’s Social Care. 3. The social worker confirmed that the family were not known to Barnsley Social Care. 4. The social worker was informed that a letter and CT scan had been sent to the Consultant Radiologist at SCNFT requesting his expert opinion. The social worker was given his contact details and advised to ring him if needed as the consultant paediatrician was not working for the following few days. 5. The social worker was made aware of the health visitor and neighbour’s concerns 6. The social worker was made aware that FK was the only person to have witnessed Child K’s accident". 3.10.19 The IMR from Barnsley Social Care also states that the social worker had phone conversations with the named nurse and the consultant paediatrician at BHNFT and states that these were at 16:00 hours and 16:10 hours respectively. Unlike the record in the BHNFT IMR, the one in the Barnsley Social Care IMR of the conversation between the social worker and named nurse does not refer to any discussion about whether or not the injuries might be suspicious. The record, in the Barnsley Social Overview Report concerning Child K Page 49 of 115 Care IMR, of the conversation between the social worker and consultant paediatrician largely covers the same points as those in the consultant paediatrician’s notes but two points are of particular note. Firstly, it is recorded that the social worker told the consultant paediatrician that the Police were not treating this as suspicious at the time and the consultant paediatrician responded that this was rightly so as there were still a number of questions to be answered. Secondly, there is no reference in the IMR from Barnsley Social Care to the consultant paediatrician telling the social worker about "a sibling". As a result of the information contained within the BHNFT IMR the author of the Barnsley Social Care IMR has checked again with staff within the social work team and they are certain that no-one mentioned another child to them at the time. The author of the Barnsley Social Care IMR considers it likely that if the social worker had known about the existence of another child in the family then this would have been recorded, even if a decision had been made not to try to see the child. 3.10.20 Following the phone call between the social worker and the consultant paediatrician, the social worker discussed the case with the team manager and assistant team manager. The content of their discussion is recorded at the end of the contact in as follows: “Awaiting the outcome of current Police investigations and updates from Paediatric staff with regards to K`s condition/injuries. At this time Police indicate they are investigating circumstances but are not currently treating this as suspicious. Police and medical staff will update Dept which will then inform Social Care decision making and any actions required. Discussion with Team Manager and agreed above.” 3.10.21 This was the last contact that the assessment team had regarding this case on 28 September 2011. 3.10.22 On arrival at BHNFT Child K was taken to the Emergency Department where resuscitation attempts continued led by the emergency department consultant and anaesthetic consultant. Meanwhile the paediatric registrar started taking a history from FK. 3.10.23 An urgent CT scan of Child K’s head was undertaken and this was reported on by the radiologist as showing skull fractures on two sites and a small subdural haematoma. Initial full blood count and clotting studies were planned. 3.10.24 A consultant paediatrician attended the Emergency Department and examined Child K. The consultant paediatrician took a history from the parents and maternal grandmother which Paediatric Registrar 2 transcribed onto the Child Protection Pack. Because the nature of the injuries was unclear, the family were told that Social Care would be notified. Later that same day Paediatric Consultant 1 and Paediatric Registrar 2 went through the notes and discussed the case. Social Care, the Police, the health visitor and the named nurse for safeguarding children were all informed and Paediatric Consultant 1 wrote to the paediatric Overview Report concerning Child K Page 50 of 115 radiologist at SCNFT requesting the radiologist’s opinion in interpreting the CT scan in the light of the history provided by MK and FK. 3.10.25 Paediatric Consultant 1 told the author of the BHNFT IMR that his instinct was that due to the circumstances of the injury being unclear, the bruising, and few witnesses, the possibility of a NAI should be considered. He felt, however, that he could not say this with any certainty and required the opinion of the consultant radiologist. He stated, however, that he was clear that a multi-agency process needed to be followed as NAI was to be considered as a possibility and that it was clear that he was considering the possibility of NAI based on his actions and the documentation used. 3.10.26 The paediatric registrar at BHNFT contacted a paediatric consultant at SCNFT to secure a bed within the Paediatric Intensive Care Unit (PICU). The paediatric consultant told the author of the SCNFT IMR that the paediatric registrar was advised to contact the neurosurgeons prior to contacting EMBRACE, SCNFT’s specialist transport service in order to establish how urgent the transfer needed to be. In the event, however, the CT scans were not immediately available to the neurosurgeons and the EMBRACE team attended BHNFT on the understanding that the neurosurgeons would be in touch once they had seen the scans. 3.10.27 The neurosurgical registrar and paediatric consultant at BHNFT identified from the CT scan that Child K had two skull fractures and a small subdural bleed (a bleed on the surface of the brain) but that the brain was normal. Based on this diagnoses it was agreed that Child K did not require a very urgent transfer to the PICU at SCNFT but could be transferred by EMBRACE. When the paediatric consultant at SCNFT reviewed the scan at around 14:00 hours he identified findings consistent with severe cerebral oedema (brain swelling). The consultant radiologist then reviewed the scan and agreed that there was evidence of severe cerebral oedema. This information was passed onto the EMBRACE consultant who was told that Child K still did not require a very urgent transfer but that there may be problems with raised intracranial pressure (ICP – pressure within the head). 3.10.28 Prior to leaving BHNFT the EMBRACE team told the paediatric registrar that they had noted blood on the tip of Child K’s penis when they were catheterising him. This blood had not been noted when Child K was examined by the paediatric consultant at BHNFT. 3.10.29 The EMBRACE team from SCNFT left BHNFT with Child K at 16:30 hours on 28 September 2011 in order to transfer Child K to SCNFT. During the journey Child K’s condition deteriorated and the ambulance stopped for treatment to be given. Child K was then transferred urgently to SCNFT where, on arrival he was taken straight into x-ray for a repeat scan which confirmed that there was severe damage to the brain and he had coned (the lower part of his brain had herniated, i.e. pushed down into the top end of the space occupied by the spinal cord). 3.10.30 From x-ray, Child K was transferred to the intensive care unit where he continued to be in a critical condition. Due to progressive deterioration in Overview Report concerning Child K Page 51 of 115 his condition, the decision was made with MK and FK to withdraw treatment. He was taken off the ventilator and handed over to MK to cuddle at 19:25 hours and was certified dead at 19:50 hours. Child K was transferred to the bereavement suite at 23:40 hours, the police were informed the same night and the coroner the following day. Throughout this period, Child K’s parents were regularly updated. 3.10.31 During the evening of 28 September 2011 the consultant paediatrician on call at SCNFT contacted the out of hours duty social worker in Barnsley Social Care to inform the social worker that Child K had died and to gather some background information. The consultant paediatrician mentioned that Child K had a "sibling" and it is recorded in the Barnsley Social Care IMR that this was the first time that social workers had been aware of this. The paediatrician and social worker agreed that the paediatrician would contact the Police and speak to MK and FK about the whereabouts of "the sibling" and would then contact the social worker with this information. After the call to the paediatrician ended, the social worker contacted the senior manager on call. After various phone calls it was established that the "sibling" was staying with "family members" but would be collected by "other family members" and taken to their home address, where the social worker and Police would undertake a safe and well check. It is recorded in the IMR from Barnsley Social Care that initially there was a difference of opinion between health staff at SCNFT and staff from Barnsley Social Care as to whether "the sibling" should be seen that night, given the late hour and the degree of risk. Finally, though the visit did go ahead and "the sibling" was seen asleep. 3.10.32 On 29 September 2011 the Assessment Team within Barnsley Social Care picked up the case and it was allocated to SW1 who commenced an initial assessment. In the afternoon of 29 September 2011 a post mortem examination was carried out and a strategy meeting was held. The strategy meeting was attended by the Police and Barnsley Social Care but health representatives were unable to attend and the Police asked BHNFT to provide a report to assist the post mortem. 3.10.33 Both Paediatric Consultant 1 and Paediatric Registrar 2, who had attended to Child K on 28 September 2011 were on leave the following day and the request for a medical report came to Paediatric Consultant 2. Paediatric Registrar 2 had dictated a medical report before going on leave and had passed it on a secretary to type. The report was still in draft form but, having undertaken various checks, Paediatric Consultant 2 made a copy, clearly marked as a draft, available to the strategy meeting. Paediatric Consultant 2 also returned a phone call to SW1 and expressed the view that the history was unusual and the injuries significant and that Paediatric Consultant 2’s initial thought was that non accidental injury was a significant possibility. 3.10.34 The outcome of the strategy meeting was that there should be a child protection medical examination of "the sibling" , that the Police would interview MK and FK that afternoon and that Barnsley Social Care would speak to them the following day. Barnsley Social Care would also make enquiries with Sheffield Social Care in view of information that had been Overview Report concerning Child K Page 52 of 115 provided about FK’s ex partner. Following the meeting SW1 contacted MK, FK and "other family members" to advise that contact for both MK and FK needed to be supervised by another adult. 3.10.35 SW1 also contacted "the sibling's" nursery school to inform staff of Child K’s death, and advise them that contact needed to be supervised and that additional support may be needed when "the sibling" returned to nursery. Records from the nursery suggest that "the sibling" attended the nursery everyday that week except for Friday 30 September 2012 but there are no records about who dropped them off or collected them. Staff at the nursery told the author of the Barnsley Education IMR that no significant changes were noted in "the sibling's" behaviour. 3.10.36 The author of the SWYPFT IMR has written that on 29 September 2011 the named nurse at BHNFT telephoned the Health Visiting Team to inform them that Child K had died and that FK had been taken into custody and "the sibling" had been removed from the family home and placed in care. HV5 was informed of this situation. By contrast, the report from Barnsley Social Care makes it clear that " the sibling" was not placed in care but was staying with "other family members". 3.10.37 On 30 September 2011 Paediatric Registrar 3 undertook a full child protection medical of "the sibling". A "family member" and SW1 were also present. No concerns were identified and the general physical examination was normal although the paediatric registrar identified grazes on "the sibling's" back and left arm, bruises on both knees and two very faint bruises on each side of the lower abdomen. "These were" attributed the grazes and bruised knees from playing football the previous day but could not explain the faint bruises on the lower abdomen. "The sibling" was asked about these bruises and said that they could not remember how they got them but they had not been hurt by anyone. The authors of the BHNFT IMR state that the paediatric registrar has not written a specific comment about the abdominal bruises. In addition to the physical examination, a blood count and clotting studies were undertaken and the results were within normal limits. The findings were discussed with Paediatric Consultant 3 after which "the sibling" was discharged to the care of "a family member". 3.10.38 Also on 30 September 2011, Barnsley Social Care and the Police continued their investigations and communicated with each other. A decision was made that FK should not have contact with "Child K's sibling" until the position was clearer and that contact between MK and "the sibling" should be supervised. 3.10.39 None of the IMRs have any record of action in respect of this case on 1 October 2011, the last day of the period covered by this review. 4. Analysis 4.1 Introduction Overview Report concerning Child K Page 53 of 115 4.1.1 This review considers the actions of 11 agencies over a period of over four years and consequently a wealth of information is available for analysis. IMR authors and the Independent Overview Author were asked to analyse agency involvement against 18 Terms of Reference. 4.1.2 In order to make the analysis manageable and meaningful Terms of Reference 3 and 4 are addressed first, by considering the key points and opportunities for assessment and decision making and the appropriateness of the action taken. This is by far the longest section of this analysis. The actions of organisations are then analysed against the other 16 Terms of Reference. Inevitably there is some overlap between the various issues and many of the interactions that professionals had with the family and with each other raised points that are relevant to more than one of these issues. The IORA has tried to address points in the most relevant place and to cross reference where a point is discussed under more than one issue. 4.2 ToRs 3 & 4 What were the key relevant points / opportunities for assessment and decision making in relation to Child K and his family? Do assessments and decisions appear to have been reached in an informed and professional way? Did actions accord with assessments and decisions made? Were appropriate services offered / provided, or relevant enquiries made in the light of the assessments? 4.2.1 Throughout the period of 4¼ years that this review covers there were numerous opportunities for assessment and decision making in relation to the various parties considered in this review. These can be divided into a number of broad themes which is how they are considered here, firstly considering issues relating to FK and "his previous partner" (in the context of his relationship with her) and then MK and "her first child" when they were in Sheffield and finally Child K, "MK's first child" MK and FK when they lived in Barnsley. Within each thematic section issues are considered largely chronologically. Issues relating to "FK's previous partner" and FK (in the context of their relationship) Child protection of "FK's first child" 4.2.2 Although the period prior to the birth of "FK's first child" is outside the period covered by this SCR and the SCR Panel decided that "FK's previous partner's" maternity records should not be included in the STHFT IMR it is appropriate to comment that, on the limited information available, it appears that professionals acted appropriately in light of what was known about "the previous partner". Action was taken before "FK's first child" was born in order that they could be protected from birth and their name was then on the Child Protection Register for approximately nine months until February 2008. Overview Report concerning Child K Page 54 of 115 4.2.3 There are issues in FK’s history which should have led to some concerns about his capacity as a father. However the author of the Sheffield Social Care IMR has identified that, whilst assessments did consider FK and his drug and criminal history, they largely focused on "his previous partner's" history. Furthermore, where information was collected about FK this relied almost entirely on self-reporting from him and information was not verified in any other way, such as by the social worker contacting other agencies. This was a shortfall in the thoroughness of the assessments that were undertaken at that time. 4.2.4 Whilst acknowledging that there should have been a more thorough assessment of FK, the IORA agrees with the author of the Sheffield Social Care IMR that it is questionable as to whether the information relating to FK alone would have been enough to warrant social care involvement, assessment and a Child Protection plan. 4.2.5 Whilst "FK's first child's" name was on the Child Protection Register the social worker and health visitor were the main professionals involved with the family; records suggest that they had an adequate level of involvement and that Core Group meetings took place every month as required. 4.2.6 The two Review Child Protection Conferences were key points for assessment and decision making. It appears that the main reason for the continuing registration of "FK's first child" at the first review conference was the concerns that had arisen in August 2007 when it came to light that a couple, who may pose a risk to children, were staying with "extended family members". This was dealt with promptly and with an appropriate level of concern; a Multi-Agency Public Protection Arrangements (MAPPA) meeting was held and FK, "his previous partner and family" were left in no doubt that it was not acceptable for "the child" to visit "these family members" whilst this couple were living there. The situation was then monitored and the couple soon left the property. The first Review Child Protection Conference was held on the same day as this MAPPA meeting and continued registration was agreed to enable the situation to be monitored. This was a sensible approach. 4.2.7 By contrast the IORA has some concerns about the decision in February 2008 to remove "FK's first child's" name from the Child Protection Register and not to instigate a Child In Need Plan. The IORA accepts that the level and number of incidents of concern that had occurred whilst "the child" had been on the Child Protection Register did not warrant continued registration. However, the IORA considers that there were two issues that should have received greater consideration at the Review Conference in February 2008. Firstly, prior to "the child's" birth the main concern had been about "their mother's" capacity to care for and protect a child. The first eight months of "the child's" life suggested that FK and "his previous partner" together could provide adequate care but they had separated one month before the Review Conference and there had been very little opportunity to assess the impact this separation would have on "the child" or on their parents’ ability to care for them. Overview Report concerning Child K Page 55 of 115 4.2.8 Secondly, having delayed his treatment for "an infection" in order to help with caring for "his child", FK was due to start his treatment. It was known and discussed in Core Groups that the treatment was likely to cause him to feel unwell. The IORA considers that it would have been appropriate to have considered the likely impact of the treatment on FK’s parenting and mood and to consider whether further support could be provided to the family. Although FK and "his previous partner" had separated, the impact of the treatment on FK was still an issue because he was having contact with "his child" and they had indicated that they were thinking about resuming their relationship. 4.2.9 Notwithstanding the above comments, the IORA acknowledges that no safeguarding concerns have emerged regarding the care provided to "FK's first child" after they were removed from the Child Protection Register which suggests that the decision was appropriate. Support provided once "FK's first child" was removed from the Child Protection Register 4.2.10 Because Sheffield Social Care effectively ended their involvement with the family when "FK's first child's" name was removed from the Child Protection Register the only service having any sort of planned contact with the family was the Health Visiting Service. It is unclear exactly what health visiting package was intended to be provided to the family during this period although the author of the Sheffield Health Visiting IMR indicates that it was an offer of universal services including the health visitor having monthly contact. However between March 2008 and January 2009, when "FK's previous partner and child" became homeless health visitors saw "the child" at home three times and in clinic twice. Therefore contact was, on average, approximately once every two months which does not accord with the plan of monthly contact but is a significantly greater amount of contact than would be provided under the core programme. 4.2.11 The author of the Sheffield Health Visiting IMR expresses the view that when "FK's first child" was first removed from the register a more defined package of support should have been put in place earlier. The IORA agrees that it would have been appropriate for the health visitor to have assessed the family’s support needs at the time of the child's removal from the register and clearly agreed the level of support that would be provided. The IORA is pleased to note that since 2009 all Child Protection plans that end in Sheffield are followed up by a Child in Need Plan as this provides a period of transition. Domestic Incidents 4.2.12 There were two domestic incidents of relevance to this review. 4.2.13 In the first of these incidents, in August 2007, FK allegedly hit "his previous partner" who was reported to be intoxicated. On being informed of these incidents Sheffield Social Care took action in a timely fashion with a social worker visiting to discuss the incidents with "both parties". Sheffield Social Overview Report concerning Child K Page 56 of 115 Care then made a written agreement with "the previous partner" and FK that they would not drink alcohol whilst caring for "their child". Whilst the timeliness of the response should be commended, the IORA is concerned about the use of a “written agreement” in this way for two reasons. Firstly, the IORA questions how realistic it was to expect the parents not to drink alcohol at all whist caring for "their child" Secondly it is unclear how this agreement was to be monitored or what the sanctions would be if the parents did not comply. There are no references to this written agreement at a later date, even when there was further alcohol misuse and/or domestic violence. The author of the Sheffield Social Care IMR has written that since this time the agency has recognised that child protection agreements are not a useful way of working with families as there is no way to monitor their effectiveness. Practice now encourages all agreements to be incorporated into a child’s plan where all agencies sign up to it, and this has proven to be a more effective way of working together with families and professionals. 4.2.14 The other domestic incident that occurred was in October 2007 and on this occasion FK alleged that "his previous partner" was attacking him. However when the Police visited there were no signs of any disturbance but FK was found to have been taking drugs. This incident took place in October 2007 the day before a planned meeting and much of the meeting was spent discussing it. FK was not present at the meeting and "his previous partner" reported that they had separated and FK was staying with "a family member". However when the social worker visited the family home 15 days later "the previous partner" and FK were both present and said they were back together. Although the author of the Sheffield Social Care IMR states that social work assessments took place after each domestic incident there is no indication of how this episode was addressed even though it occurred only two months after they had signed a written agreement that they would not drink alcohol whilst caring for "their child" Learning Lessons, Taking Action (Ofsted, 2008) is a report of the evaluation of 50 SCRs. One of the key messages from Learning Lessons, Taking Action is that “Agencies responded reactively to each situation rather than seeing it in the context of the case history.” This is an example of such behaviour as Sheffield Social Care did not relate the domestic incident in October 2007 back to the assurances made by "both parties" two months earlier. 4.2.15 In addition to these two domestic incidents, there were four more during the remainder of the period covered by this review; in May 2008, August 2008, January 2009 and November 2009. FK contacted the Police in connection with the first two of these incidents, both of which appeared to have involved verbal arguments. "FK's previous partner" contacted the Police in connection with the third and fourth incidents and on both occasions stated that FK had hit her although the last incident was the only one where there was any evidence of an injury. 4.2.16 Of these four incidents, the first three occurred whilst FK and "his previous partner" were living together although the third was on the day they separated. The fourth incident occurred 10 months after they had ceased Overview Report concerning Child K Page 57 of 115 to live together and apparently after FK had commenced his relationship with MK. 4.2.17 The Police recorded who was present at the second, third and fourth of these incidents and in each of these, they followed necessary procedures and made Sheffield Social Care aware of the incident. After the third incident they removed FK from the property and at the time of the fourth incident he was not living at the property anyway. 4.2.18 The author of the Police IMR has written that when Police Officers attended the incident in May 2008 they made the judgement that it did not meet the criteria of a domestic incident because no crime had been committed; consequently they did not submit the necessary domestic violence forms to the PPU which would have allowed the information to be passed to partner agencies. The author of the Police IMR explains that the officers were mistaken in their judgement and subsequent action. Despite this comment, it is recorded in the Sheffield Social Care IMR that on 2 June 2008 a report of this incident was received from the Police. 4.2.19 Police Officers only made reference to the parties being under the influence of alcohol or other substances on one of these four occasions. This was the January 2009 incident when it was recorded that both "parties" had been drinking. The Police had previously identified that "the previous partner" had been under the influence of alcohol during one of the incidents they had attended and FK had been under the influence of drugs during another of the incidents. 4.2.20 Sheffield Social Care had knowledge of three of these incidents, May 2008, August 2008 and November 2009 but there is nothing contained in social care records to indicate that they were aware of the incident in January 2009. The incidents in May and August were brought to their attention via police reports whilst the incident in November 2009 was self reported by "the previous partner". Sheffield Social Care informed the SCR that they undertook screening checks following the incidents in May and August and that the incident in November 2009 was addressed via the Initial Assessment undertaken as a result of an anonymous referral received a few days previously. The outcome of the assessment into the incident was recorded within this Initial Assessment. It is the understanding of the IORA that, with the exception of November 2009, Social Care did not complete Initial Assessments in respect of the reported domestic incidents and limited their assessment to screening checks which were reliant on the information provided by the police. The IORA questions how Social Care were able to adequately assess the seriousness of each incident in the absence of contact with the family and contact with all involved agencies via an Initial Assessment. 4.2.21 All of these incidents were relatively minor and were spread out over a number of months. Nevertheless it is clear that the relationship between FK and "his previous partner" was punctuated by a number of domestic incidents for which one or other felt the need to involve the Police. The IORA has some concern that Sheffield Social Care responded to each Overview Report concerning Child K Page 58 of 115 incident in isolation rather than in the full context of the case and as a result questions whether they were given sufficient consideration. Injuries to "FK's first child", including hospital attendances 4.2.22 Over 2½ years between four and 34 months of age "FK's first child" sustained four minor head injuries, two of which resulted in them attending the Emergency Department at SCNFT. The author of the Sheffield Health Visiting IMR concludes that health visitors were not sufficiently rigorous in considering the likely cause of some of these injuries. The authors of the Health Overview Report consider that the injuries could have been genuine accidents that occurred as described but could also have been “Harbinger injuries”, (a term to describe an accumulation of minor incidents giving rise to a level of concern, including frequent A&E attendances). 4.2.23 "FK's first child" was only four months old when they sustained an abrasion to their right ear in 2007. It has been difficult for this SCR to establish many details about this injury or how practitioners decided that it was not a possible NAI. Neither the health visitor nor social worker who were working with the family at that time are still working in Sheffield and they have not been interviewed in connection with this SCR. Therefore the IMR authors have been dependent on written information. The author of the Sheffield Health Visiting IMR has recorded that the abrasion was seen and discussed at a Core Group meeting but the social worker who attended the core group meeting has not made any record of the abrasion. The records from the health visitor do not describe the size or shape of the abrasion or whether there was any consideration of referring "the child" for a medical opinion. The Sheffield Health Visiting IMR does suggest that FK’s explanation that the abrasion had been caused by his ring was readily accepted. 4.2.24 Any injury to a non mobile infant should be a cause for concern and it is important that practitioners display ‘respectful uncertainty’ when investigating such injuries. In 2009, two years after "FK's first child" sustained the abrasion to their ear the National Institute for Health and Clinical Excellence (NICE) published guidance for health professionals on when to suspect child maltreatment. Pages 8 and 9 of the quick reference guide list a number of alerting features that should prompt health professionals to suspect child maltreatment and these include situations where a child who is not independently mobile sustains, amongst other things, lacerations and abrasions without a suitable explanation. Also in 2009 Sheffield Safeguarding Children Board issued a document “Section 47 Protocol for Responding to Concerns About Injuries or Abuse in Infants under 1 Year” a readily accessible internet based document designed to help practitioners to decide if there may be cause for concern and to outline the procedures to be followed where concerns are identified. 4.2.25 When HV5 noticed a small bruise on "FK's first child's" face during a visit in 2009 "the previous partner's" explanation that "the child" had fallen out of bed was accepted. HV5 did not remember this incident when the author of the Sheffield Health Visiting IMR asked about it but did remember that "the child" was very active and boisterous. This was only the second time that Overview Report concerning Child K Page 59 of 115 HV5 had seen "the child" and their mother which raises a question as to whether HV5 was sufficiently familiar with the history to accept the mother's explanation without further enquiry. The author of the Sheffield Health Visiting IMR draws attention to a question posed by Brandon et al, “For a child who is otherwise meeting developmental milestones might a parental explanation for injuries be too readily accepted?” (Brandon et al 2010) 4.2.26 On both occasions that "FK's first child" was taken to hospital, in 2008 when they had a laceration on their forehead and 2010 when they had a small graze/bruise on the upper gum and a small graze to the bridge of the nose, medical staff assessed the injuries as being accidental injuries that were consistent with the explanations given by the mother. Information provided in the SCNFT IMR is that it was documented that there were no concerns about NAI. This suggests that possible NAI was considered and discounted. Whilst FK was present when "his child" sustained the first of these injuries there is no suggestion that he was present when the second was sustained. 4.2.27 Sheffield Social Care closed this case shortly after they were informed of "the child's" first hospital attendance, in 2008, and although the social worker had phoned the Health Visiting Service to request an update there is no record of this being received. It appears that the case was closed without any contact with the family and without the update being received. 4.2.28 The IORA does not wish to overstate the potential significance of these injuries and it is important to emphasise that, even with the benefit of hindsight there is no information to suggest that any of the injuries sustained by "the child" were NAIs. It is, however, worthwhile emphasising the importance of treating all such incidents in the context of the family history and not viewing each one in isolation. In order to do this it is essential that thorough records are kept detailing the injury and how decisions about the likely cause and any necessary action were reached. The IMRs provided for this SCR do not include any information to suggest that practitioners considered "the child's" previous history when assessing injuries they sustained. Furthermore, the IMRs show that the records about the abrasion to their ear were insufficient. Medical treatment for FK 4.2.29 The IORA has discussed that, despite the social worker and health visitor being aware that FK was due to start treatment for "an infection" , this was not considered when the agencies were considering "other issues in the family" and these services did not communicate with the Infectious Disease Team as would have been appropriate. It is also important to consider whether the treatment impacted on "other family members" and how this was dealt with at the time. 4.2.30 Whilst FK was being treated, every out patient’s appointment provided an opportunity to assess how he was coping with the treatment and how it was impacting on those around him. It is clear that FK did identify, on six occasions, that he was being affected emotionally and there was some Overview Report concerning Child K Page 60 of 115 consideration of how this was affecting "his previous partner" but no consideration of whether it was having any impact on "other family members" 4.2.31 Although the GP assessed FK on one occasion there is no indication that this was done with any consideration for the welfare of "other family members" and there was no communication from the GP to the Infectious Diseases Team or to the health visitor. 4.2.32 The health visitor only saw FK twice whilst he was receiving the treatment. The first of these visits was in June 2008 and there is a comment in the record that FK had started his treatment and looked thin and pale but there is no indication that there was any discussion about his mood. Furthermore it is clear that there was no communication between the health visitor and the Infectious Diseases Team and the health visitor was never made aware that FK reported feeling ‘snappy’ and anxious. 4.2.33 The author of the STHFT IMR considers that communication with FK’s GP was excellent but acknowledges that there should probably have been some direct contact from the infectious diseases team to the health visitor. The IORA acknowledges that the Infectious Diseases Team did make the GP aware of the likely side effects of the treatment but, as with the health visitor, there is no indication that the GP was informed about FK describing himself as ‘snappy’ and anxious. 4.2.34 The author of the STHFT IMR also identifies that staff in the Infectious Diseases Team were of the understanding that Children’s Social Care were involved with the family. In that case, they should have made contact with Children’s Social Care when FK commenced his treatment. 4.2.35 It is not possible to say how much FK’s treatment affected his behaviour and whether it had any impact on " other family members" However it is a concern that the Infectious Diseases Team, the GP and the Health Visiting Service did not communicate more with one another and work together. 4.2.36 The author of the IMR from STHFT considers that the assessments undertaken by the Infectious Diseases Team were appropriate at that time. However the IMR author adds that there is now a wealth of literature that suggests that adult services should be more involved in the identification of children at risk and some changes are required in order to undertake accurate assessments of families in these services. The IMR author describes changes that have been made within STHFT since this incident to improve staff awareness of the need to have regard to the welfare of children. The IMR author states that, as a result of these changes, the number of referrals to community professionals is increasing considerably and there is the potential for a negative impact where by professionals become ‘swamped’ with routine letters and referrals that it can become difficult to highlight those at significant risk. This is addressed in the recommendations of this review. Assessments after "FK's previous partner" became homeless Overview Report concerning Child K Page 61 of 115 4.2.37 When FK and his "previous partner" separated in January 2009, she became homeless and moved, with her child, into bed and breakfast accommodation. This resulted in another change of health visitor to HV5 who worked within the HASS. This was a significant time of change and was therefore a key time for assessment. The involvement of HASS was appropriate due to the vulnerability of homeless people and it is clear that assessments were carried out to support "the previous partner and put arrangements in place for "re-housing" 4.2.38 HV5 saw "the previous partner and child" three times over a period of nine weeks up to April 2009. However it is unclear what further involvement HV5 planned to have because eight weeks later, when a member of the public contacted HV6 and reported concerns about a family, that turned out to be "the previous partner and child", HV5 did not know that they had been re-housed. There is no indication that HV5 had tried to visit "the previous partner and child" during that eight week period. 4.2.39 HV6 and a support worker from a housing agency worked together to assess the home situation when "the previous partner and child" were re-housed and HV6 liaised with Sheffield Social Care. This appears to have been a thorough assessment which resulted in a comprehensive package of support including the involvement of the support worker and an enhanced health visiting service. Delivery of this enhanced health visiting service was not without some difficulties; for example, "the previous partner" and HV6 agreed in July 2009 that HV6 would visit again in three to four weeks but she was out when HV6 tried to visit and there was actually a period of nearly three months until September 2009 before the next visit. In both November 2009 and February 2010 the health visitor and support worker experienced some difficulty contacting "the previous partner". 4.2.40 Anonymous referrals expressing concerns about "FK's first child's " wellbeing were received by Sheffield Care in June and November 2009. In both instances there was a prompt response to the referral and an Initial Assessment was carried out. However the basis on which Sheffield Social Care decided that the referral in June 2009 was malicious is unclear. Records suggest that HV6 only got to know about this referral because "the previous partner" told HV6 about it. This suggests that there was no communication from the social worker to the Health Visiting Service about the referral. Assessment of FK in Sheffield 4.2.41 Previous SCRs in Barnsley and elsewhere have identified that professionals paid insufficient regard to fathers and other male caregivers when working with families and this was considered by Brandon et al, in pages 51 – 54 of “Understanding Serious Case Reviews and their Impact, A Biennial Analysis of Serious Case Reviews 2005 – 07” (2009). More recently Ofsted, in its annual reports concerning the evaluations of serious case reviews, have made several references to practitioners not involving fathers and failing to adequately consider their needs. It is explained in this report that FK was included in assessments carried out but that these assessments relied on self-reporting. There are also comments from Overview Report concerning Child K Page 62 of 115 professionals about FK being involved in caring for "a child". These records suggest that FK was involved in the care of "his child" and that professionals were attuned to discussing his involvement and role. Records also suggest that, whilst FK and "his previous partner" were living together, she presented a positive picture of her relationship with FK. 4.2.42 As stated above, FK and "his previous partner" separated and it appeared that professional input to the family was entirely directed at "the partner". There is no indication that either the social worker or health visitor visited FK’s " home address" or offered any support to FK. 4.2.43 Following FK and "his previous partner's'" later separation in January 2009 FK again lived "with a member of his family". Sheffield Social Care had ceased their involvement with the family six months before this and there was no reason for them to be made aware that FK and "his previous partner" had separated. However, the IORA is of the view that the Health Visiting Service should have had contact with FK in order to support him and also to ensure that the care being received by "his child" and the home environment were suitable. As it is, neither HV5 nor HV6 ever met FK during the period covered by this review. 4.2.44 The author of the Sheffield Health Visiting IMR refers to there apparently being very little focus on FK’s parenting capacity. The author highlights the need to involve and support fathers, including non-resident fathers and points out that this is especially important when it is known that the father is a significant carer for the child(ren). The author draws attention to the Child Health Programme 2009 where it is written that “Fathers should be routinely invited to participate in child health reviews and should have their needs assessed.” 4.2.45 An incident in August 2009 is worthy of particular note. The author of the Sheffield Health Visiting IMR has written that HV6 contacted "the previous partner" to arrange a visit and was told that she was unwell so "her child" was staying with FK and "his extended family". HV6’s response was to carry out the visit the following week when "the previous partner" was better. This would have been an ideal opportunity for HV6 to have arranged to visit "the child" with FK but this opportunity was missed. Issues relating to MK and "her first child" when they were in Sheffield Assessment of "MK's first child" in Sheffield 4.2.46 The visit from HV8 to MK and "her first child" in June 2009 provided the first opportunity for any agency in Sheffield to assess this family. It is unclear what information Sheffield Health Visiting, received from their previous authority or if there was any communication between the services. It is also unclear exactly what MK meant when she said that she supervised contact between "her child" and their father and whether she was referring to a formal arrangement whereby contact had to be supervised for the safety and well being of the child. The IORA shares the view of the author of the Sheffield Health Visiting IMR that HV8 should have been more inquisitive about this issue and enquired further. This Overview Report concerning Child K Page 63 of 115 statement could have been an indication that there were child protection issues in respect of "this child" and this should have been clarified. However, enquiries carried out for this SCR did not reveal any safeguarding concerns relating to "this child". Hospital attendances for "MK's first child" 4.2.47 It is the view of the author of the SCNFT IMR that assessment and decision making around "MK's first child's" two attendances at hospital in 2010 was undertaken in an informed and professional manner. The IORA is satisfied that there is no evidence that hospital staff should have taken further action and does not consider it necessary to make a recommendation around this issue. MK’s pregnancy with Child K 4.2.48 MK was well supported in considering whether to have a termination of her pregnancy and when she was unsure about her decision to have a termination she received further counselling. 4.2.49 The author of the STHFT IMR explains that when the father of an unborn child is named no further routine checks are undertaken by the midwife, unless there are specific concerns raised within the social history that warrant further investigation and, in the case of MK’s pregnancy with Child K, no enquiries were made about FK’s history. The author of the STHFT IMR states that there was no exploration about how FK’s ADHD affected his day to day ability. Although other records suggest that ADHD was not a significant issue for FK by the time MK was pregnant with Child K, the IORA considers that it would have been appropriate for staff within maternity services to have made enquiries in order to appropriately assess whether FK’s ADHD may have an impact on the baby. 4.2.50 Although MK stated that she was no longer in a relationship with FK, when she booked for pregnancy care and there is no mention of him being present at any antenatal appointments, it now appears that MK and FK were together as a couple throughout the pregnancy. Furthermore MK and FK have both said that FK attended the first scan that MK had in connection with this pregnancy. 4.2.51 Potentially significant information about FK was that he was the father of another child, that he was receiving treatment for a viral illness, that he had a history of substance misuse and that there was domestic violence in his relationship with his previous partner. None of this information came to the attention of midwifery services during MK’s pregnancy with Child K. Information that FK was the father of another child was known to the maternity service at STHFT but was recorded within the records of "his previous partner" as it related to her pregnancy. Information about FK’s treatment for "an infection" was known to the infectious Diseases Team within STHFT but not to the maternity service. 4.2.52 The author of the STHFT IMR addresses this issue and identifies practical and ethical reasons why such information is not routinely shared within the Overview Report concerning Child K Page 64 of 115 Trust. The IMR author has written that midwives rely on the information that is provided to them by the women they care for and that whilst it is easy to check medical records (such as GP and hospital records) for the women that they care for, midwives will not have access to the records for the father of unborn babies. The IMR author also makes the point that these reasons are not unique to STHFT but will apply nationally. 4.2.53 It is the case that working with and engaging with fathers is a national issue and that many agencies need to bring about organisational and cultural change. Within maternity care, in 2011 the Royal College of Midwives issued guidance to midwives entitled “Involving Fathers in Maternity Care” and “Top Tips for Involving Fathers in Maternity Care”. In 2010 the Fatherhood Institute produced “The Guide for New Dads” which is given to new fathers to encourage them to become involved with their children and to provide information, including information about keeping children safe. 4.2.54 The author of the STHFT IMR explains that the format of the midwifery records had been changed which is aimed at gathering a similar social history for fathers as is currently done for mothers. The IMR author considers that this will be an improvement on the current situation but points out that it still relies on accurate and truthful information being obtained from women themselves, particularly in relation to the father. Furthermore, the IMR author states that it is difficult to see how, without significant investment in the sharing of information which is currently held within individual agencies on different incompatible systems, there will be a robust solution to this problem should parents deliberately withhold or provide false information. 4.2.55 The IORA recognises that this issue of gathering information about the parents of unborn children to be a difficult issue nationally and acknowledges the efforts that have been made in Sheffield to improve the quality and quantity of information gathered about fathers. There needs to be a balance reached between allowing information to be collected so that people with a history of behaviour that may pose a risk to children can be identified whilst not being overly intrusive. 4.2.56 Another area of concern in relation to maternity care for MK relates to her mental health. Information provided in the IMRs from Primary Care and STHFT each provide an incomplete account of the services and treatment provided in respect of MK’s mental health. Looking at the records together, and in conjunction with information provided by MK to the IORA and Designated Nurse, it appears that MK had two appointments with the Maternity Mental Health Team, approximately one month apart. At her first appointment it was suggested that she begin a course of antidepressants but she was reluctant to do so and by the time of her second appointment her mood had improved enormously, apparently as a result of taking iron tablets. It appears that the midwife did not receive a copy of a letter sent by the Maternal Mental Health Specialist to the GP in which MK’s assessment was summarised. The author of the STHFT IMR points out that, without correct information the midwife would be unable to assess the risk to the child and make any necessary referrals for support. Overview Report concerning Child K Page 65 of 115 4.2.57 Apart from being named as the father of Child K, FK is invisible in respect of agencies’ contact with MK and "her first child" during this period. Information provided by MK and FK when they met with the IORA and Designated Nurse suggests that they were in a relationship with one another throughout MK’s pregnancy and that this relationship continues to the present time. Furthermore, the information suggests that they were living together from around April 2010, six months before Child K was born. 4.2.58 It is to be commended that MW1 ensured that a home visit was carried out, prior to the birth of Child K even though the family were no longer living in Sheffield. However the IORA takes the view that the informal arrangement of using a midwife who lived nearby was not appropriate. Instead the IORA considers that it would have been appropriate for MW1 to contact midwives in Barnsley to inform them of MK and to ask if they would undertake a home visit. If BHNFT had responded to the effect that they did not undertake home visits MW1 could have further explored this with her manager and decided on the next step. It is not unusual for mothers to choose to give birth at a hospital outside the area in which they live and therefore it is to be expected that there will be other occasions when midwifes in Sheffield are providing antenatal care to women who live elsewhere. Consequently the IORA considers that appropriate arrangements should be put in place so that midwives understand their responsibilities in respect of initiating pre-birth visits. A further point is that health visitors in Barnsley are now required to carry out an ante natal visit for all pregnancies. This expectation was not in place at the time of Child K’s birth but, if it had been, health visitors would not have been able to fulfil this requirement because they would not have been aware of the family and the impending arrival of Child K. 4.2.59 It should be recognised that these shortfalls were partly the result of a unusual set of circumstances. Although MK moved home when she was less than half way through her pregnancy she did not change her GP until only a few weeks before Child K was born. Indeed her GP remained unaware that she had moved home until shortly before Child K was born. Consequently the health visitors responsible for "MK's first child" also remained unaware that the family had moved and therefore they did not inform Barnsley health visitors of "this child" until shortly before Child K’s birth. Issues relating to Child K, "MK's first child", MK and FK when they lived in Barnsley Postnatal midwifery involvement following birth of Child K 4.2.60 The authors of the BHNFT IMR comment that the care provided by midwives after Child K was discharged home was what would be routinely expected following a normal delivery without complications but that the visits would not usually all be undertaken by different midwives. BHNFT’s standard is that a woman should see three or fewer different midwives postnatally and this is audited on a three monthly basis. Of 20 women whose service was audited in the period when a service was provided to Overview Report concerning Child K Page 66 of 115 MK, two saw one midwife, eight saw two, 10 saw three and none saw more than three. There is no clear documented reason why four different midwives visited Child K and MK postnatally but one visit took place over the weekend and one midwife from the team was on sick leave throughout the period in question which placed added pressure on the team. Given that the midwifery service monitors continuity of care on a regular basis and that it is unusual for a woman to see more than three midwives postnatally the IORA has not made a recommendation about this issue. 4.2.61 Although the authors of the BHNFT IMR describe the care provided to be that which would be routinely expected they also identify that the information available to the community midwives was substantially less than would usually be the case. This is because the information that BHNFT received from STHFT about the family was not as extensive as the information that BHNFT would usually aim to gather in the antenatal period. In particular midwives in Barnsley will routinely ask questions about social history and the family situation in the antenatal period, including asking about domestic abuse, mental health and substance misuse. 4.2.62 Midwives in Sheffield had undertaken a family history during the antenatal period but this information was not shared with staff from BHNFT when care was transferred to Barnsley. Furthermore, the authors of the BHNFT IMR state that referrals into BHNFT from other areas are often made without any social history being provided. The author of the STHFT IMR has written that the phone call that was made to BHNFT to inform them of the discharge of MK and Child K was in accordance with current STHFT hospital policy. 4.2.63 The IORA is concerned that BHNFT were not notified of the family’s transfer until MK and Child K were discharged from hospital and that the information relating to the social history and MK’s referral to the maternity mental health service was not transferred. Whilst this might be usual practice it is the IORA’s view that it does not afford the best care to the family. The IORA would argue that, if it is deemed necessary to gather a social history then surely it is important to ensure that professionals providing a service to the family are aware of the social history. 4.2.64 Women have the right to choose the hospital in which they want to receive antenatal care and give birth and this SCR does not suggest that patient choice should be diluted. However it is important that arrangements are put in place to minimise any possible difficulties arising from the change of care provider that can then occur when the mother and baby return home. First Contact from Barnsley Health Visitor 4.2.65 The first visit from a Health Visitor to Child K took place at an appropriate time, one day after the final visit from the Barnsley midwife when Child K was 12 days old. However the health visitor had only received verbal handover information from the midwife, not a written discharge form as is required. Records of this visit suggest that the health visitor did not gather some of the information required by the Health Needs Assessment and this Overview Report concerning Child K Page 67 of 115 resulted in an incomplete understanding of the family which could have impacted on the assessment of the level of risk. The author of the SWYPFT IMR specifically comments that no details were recorded about FK and there is no information recorded about his previous relationships. Also there is no information recorded about the attachment of either child to MK. The IORA notes that there is no indication that HV1 discussed the potential danger of the family dog with MK and FK. Lesion inside Child K’s mouth – attendance at BHNFT CAU 4.2.66 When MK and FK took Child K to the GP in December 2010, the GP acted appropriately by referring Child K to the Child Assessment Unit (CAU) at BHNFT and asking the paediatrician to advise. It is of note that this attendance was only one day after GP1 had carried out a six week check of Child K and had not identified any abnormality when checking the inside of the mouth. 4.2.67 Following a thorough examination the paediatric registrar concluded that Child K had a “Viral URTI” (upper respiratory tract infection) and had “coughed up blood due to burst blood vessel in pharynx”. The authors of the BHNFT IMR explored with the paediatric registrar his understanding of safeguarding children and have recorded that the paediatric registrar said he would be particularly alert to safeguarding issues if he had known that there were previous concerns or if the history and examination did not fit. The view of the authors of the BHNFT IMR is that the paediatric registrar’s diagnosis of “burst blood vessel” would not be a common one but there was nothing in the notes he has written to point to a different or more sinister explanation. The author of the Primary Care IMR, however, comments that there was never a satisfactorily answered explanation for the bleeding in Child K’s mouth 4.2.68 This hospital attendance has been the subject of much discussion at SCR Panel meetings and concern has been expressed about the diagnosis made by the paediatric registrar. Whilst there is no evidence that the raw mucous membrane on Child K’s soft palate was an NAI it is fully accepted that it was a very unusual presentation in a young child. The IORA accepts the opinion of the authors of the Health Overview Report that because of the unusual presentation there should have been discussion with the consultant paediatrician and consideration should have been given to admitting Child K overnight to allow further investigations and enquiries to be made and to consider the possibility of NAI. With hindsight this was a missed opportunity. Admission to SCNFT in December 2010 4.2.69 It must be concluded that when Child K presented at SCNFT in December 2010 with an injury to his ear, there should have been a strong suspicion that he may have suffered an NAI and this should have been thoroughly investigated before he was discharged. From the information provided in the SCNFT IMR it is clear that the registrar in the Emergency Department considered that the injury to Child K’s ear may be an NAI. Staff in the ENT Team also had concerns about the cause of the injury and consequently Overview Report concerning Child K Page 68 of 115 Child K was referred to the Medical Team specifically for that team to look at child protection issues. However when Child K was examined by members of the Medical Team they appear not to have considered NAI and Child K was discharged without sufficient investigation into the cause of his injury. The author of the SCNFT IMR addresses this issue in considerable detail and identifies failings on the part of the SPRs in the Medical Team not to have considered the possibility of NAI, the staff nurse in the Medical Team for not considering NAI and the ENT team for not questioning why the Medical Team had not properly considered NAI. However, the author of the SCNFT IMR is unable to identify why these failings occurred. The staff members concerned were experienced staff members with considerable experience in Safeguarding Children. One issue that was raised during the carrying out of the IMR was whether the ENT doctors had communicated their concerns about NAI sufficiently clearly. This is addressed in the SCNFT IMR with a recommendation that will tighten the referral process to the acute paediatric medical team. The author of the SCNFT IMR also reports that Child K was in hospital during the winter flu season and both Medical SPRs reported that they were very busy and felt that this might have impacted on the care provided to Child K. This point is considered in the analysis of Term of Reference 8. 4.2.70 It was appropriate for ENT2 to contact BHNFT and the health visitor for information about Child K. The author of the SCNFT IMR explains that, whilst ENT2 could have contacted Children’s Social Care, it is the usual practice of this trust for other specialty professionals who have child protection concerns to pass these on to the acute medical team. Hence it is not unusual for ENT 2 not to have contacted social care personally. 4.2.71 The author of the SCNFT IMR has explained to the IORA that specialist doctors do not usually refer concerns to Social Care because they are not trained to carry out child protection investigations and these will still have to be carried out by the medical teams. 4.2.72 Considering this incident with the benefit of hindsight it is difficult to understand how the doctors with the medical team failed to realise that there were possible Safeguarding concerns in relation to Child K’s injury. Child K was a non-mobile infant of less than two months of age and the primary reason that ENT staff referred him to the medical team was so that possible NAI could be investigated. The suggestion that this was not made sufficiently clear on the referral is a matter of great concern. The author of the SCNFT IMR has told the IORA that the system usually works well and she cannot explain why things happened as they did this time around. 4.2.73 Once HV4 became aware that Child K had been discharged without a full investigation of a possible NAI there was a responsibility on HV4 to challenge and if necessary to make a referral to Social Care. In reality HV4 did not even see Child K for a further seven weeks. 4.2.74 With hindsight Child K’s admission to SCNFT in December 2010 seems to have been a very significant event. It is impossible to know what would have resulted from a thorough investigation of the cause of the haematoma Overview Report concerning Child K Page 69 of 115 but it is not unreasonable to suggest that it may have led to a very different outcome for Child K. 4.2.75 In addition to the haematoma, the potential significance of the bruise on Child K’s arm should not be disregarded. Child K was a non-mobile infant and therefore this bruise should have resulted in some concern from medics and an attempt to establish how it had been sustained. Records suggest that this was not pursued. 4.2.76 The IORA notes that a case review has been carried out in Sheffield regarding another child who was in SCNFT at the same time as Child K in December 2010 and that action has been taken as a result of that review to raise awareness and understanding of medical staff in relation to Safeguarding Children. The IORA agrees with the recommendation to tighten up the referral process made in the SCNFT IMR. Six – Eight week assessment of Child K by the health visitor 4.2.77 The six – eight week assessment of a baby is an important opportunity for health visitors to assess the development and well being of babies. At the time of Child K’s birth, health visitors in Barnsley worked to a policy that this assessment should be carried out between six and eight weeks of age. However, in January 2011 they adopted the “Healthy Child Programme 0-5 years Health Visiting Standards which require such a contact to be carried out at six weeks. Therefore, if HV3 had managed to visit Child K in December 2010, as planned, this would have been just inside the eight week limit in place at that time for this visit. No criticism can be levelled at the Health Visiting Service for the assessment not going ahead on the day of the planned visit and there was then a further unavoidable delay as a result of Child K being admitted to hospital. However the subsequent delay of approximately seven weeks between Child K being discharged from hospital and HV4 actually undertaking the six - eight week assessment is a matter of concern. Such a delay would be unacceptable in any circumstances but is of particular concern given that Child K had had two visits to hospital, including a period as an inpatient due to what may have been an NAI. It is also a concern that the delay in carrying out the assessment was recorded as being due to Child K being in hospital and a changeover of health visitor when Child K had only been in hospital for five days and had been discharged seven weeks before the visit took place. Furthermore HV4 had been working in this Health Visiting Team for eight weeks and had been the allocated health visitor for Child K throughout that time. 4.2.78 A further concern relates to where this assessment took place. Following MK’s statement that it happened at clinic not at her home, the assistant director of nursing at SWYPFT made further enquiries and established that this was indeed the case. Therefore HV4 never had an opportunity to assess Child K in his home environment or to assess the suitability of the home. Furthermore this leads the IORA to question when this assessment would have been carried out if MK had not taken Child K to the clinic. Overview Report concerning Child K Page 70 of 115 4.2.79 It is also necessary to consider the quality of the six - eight week assessment that was carried out. The author of the SWYPFT IMR has identified that HV4 did not complete the scorecard for the Edinburgh Post Natal Screening of MK and there is no record to indicate that HV4 discussed the relationship between Child K and either parent or identified that Child K’s weight had fallen from just below the 98th centile in November 2010 to just above the 75th centile at this visit. The IORA cannot be sure whether these issues indicate that the assessment was not sufficiently thorough or are the result of inadequate record keeping but either way they are an additional cause of concern on top of the delay in the completion of the assessment. 4.2.80 Managers within SWYPFT have investigated why the six – eight week assessment was incorrectly recorded as having taken place at the family home when in fact it took place at clinic. They have found that when practitioners record details of a contact on SystmOne there is a drop down menu to record the location of the contact. However if practitioners do not use this drop down menu the location of the previous contact is automatically retained for the new contact. This has been identified as a weakness in the system and it has been rectified. When recording details of a contact, practitioners must now use the drop down menu to record location, before they can progress to the next page of the record. Concerns about insufficient growth velocity 4.2.81 The issue of Child K’s weight is addressed in the IMR from SWYPFT and the Health Overview Report. Having dropped to just above the 75th centile at the time of the delayed six - eight week assessment it continued to drop and had fallen below the 75th centile by the end of March 2011 before climbing back to the 75th centile one month later. The authors of the Health Overview Report refer to guidance that was in place at the time which states that one trigger for Primary Care Assessment is when “weight has fallen across 2 centile spaces when weight is above the 9th centile”. However, in the case of Child K, evidence suggests that health professionals did not even note that there was a potential issue of concern, let alone take the action required by the guidance. The absence of any assessment as a result of Child K’s weight falling more than two centiles is of greater concern when one considers that this occurred in the weeks immediately after Child K was in hospital in December 2010. Incident that led to the death of Child K 4.2.82 The IORA and SCR Panel consider that the response from HV5 when the member of the public phoned on 27 September 2011 was inadequate and inappropriate. The member of the public expressed a clear and apparently cogent description of Child K’s condition which should have led HV5 to have concerns about Child K’s well being. Having received this information HV5 had a responsibility for taking action and it was insufficient simply to suggest that the member of the public could ring the Police or Social Care. The member of the public had acted responsibly by contacting “the authorities” and having done so should not then have been expected to make further phone calls. The author of the SWYPFT IMR Overview Report concerning Child K Page 71 of 115 considers that by failing to take responsibility for referring the concerns into Barnsley Social Care the health visitor breached the local Child Protection Procedures and a Local Work Instruction for Health Visiting Services. 4.2.83 It seems to the IORA that there were two factors that may have mitigated against HV5 taking responsibility for referring Child K into Social Care at this stage. Firstly, the phone call was taken at 17:10 hours, 10 minutes after the health visitor should have finished work for the day and, therefore, it is quite possible that the health visitor was about to leave the office. Secondly, the member of the public either could not, or did not want to, provide the name of the baby, which made it more complicated to take action. However, neither of these factors constitutes an acceptable reason for not taking action. Concerning the fact that the phone call was made outside normal office hours, the author of the SWYPFT IMR points out that the Professional Code of Conduct requires a Nurse to reasonably execute a duty of care at all times to uphold public confidence (NMC, 2008). Regarding the reluctance of the member of the public to provide the name of the baby the author of the SWYPFT IMR considers that with more persuasion and reassurance about anonymity, the member of public may, at the very least have divulged where the baby lived. The IORA agrees with this view. 4.2.84 The report “The voice of the child: learning lessons from serious case reviews” (Ofsted, 2009) highlights a number of occasions when adults, including members of the public not related to the child, have raised concerns about a child and these have not been taken sufficiently seriously. The report concludes that LSCBs should “consider how they can better engage the general public in safeguarding children.” The authors of the Health Overview Report draw attention to a new Hospital scheme which has been established by the National Society for the Prevention of Cruelty to Children (NSPCC) which allows members of the public to anonymously report concerns about a child by text. This is in addition to the more traditional telephone helpline provided by the NSPCC. The authors of the Health Overview Report explain that, within Barnsley, posters have been developed which advertise this texting service and these have been circulated for display in public areas to all GP Practices, General Dental Practices, Pharmacies and Opticians as well as public areas in BHNFT. Whilst the development of the NSPCC system is to be welcomed it must not be allowed to absolve local agencies from acting responsibly when they are made aware of safeguarding concerns. 4.2.85 It is unclear from the SWYPFT IMR why HV5 informed HV4 of this phone call during the evening of 27 September 2011. However, once this information was shared both health visitors shared the responsibility for not taking action. 4.2.86 The author of the SWYPFT IMR also makes the point that HV5 should not have told the member of the public that she could phone HV4 the following morning to ascertain whether the child had been taken to the GP. This is because it would be a breach of confidentiality to give such information about a service user to a member of the public. Overview Report concerning Child K Page 72 of 115 4.2.87 When the member of the public, phoned the Health Visiting Team on 28 September 2011, the staff nurse, like HV5 the previous day, failed to take professional responsibility for referring the case into Social Care. By this time, Child K was already on his way to hospital by ambulance so there was little that could be done. Nevertheless, it was important that Social Care were informed of the incident and it should not have been left to the member of the public to do this. It is unclear from the records whether the member of the public named Child K, or referred to him having a sibling during the phone call to the staff nurse. If it was evident at this stage that there was a sibling this should have been a further reason for the Health Visiting Team to make Social Care aware of the situation. 4.2.88 YAS staff acted appropriately by conveying Child K to hospital with his mother and informing both the Police and Barnsley Social Care of the incident. It is unclear whether the phone call from YAS to Barnsley Social Care made reference to there being another child in the household, as would have been advisable, but the child was referred to in the fax that was sent to back up the phone call. 4.2.89 Having been informed of Child K’s admission to hospital, Police Officers also acted appropriately by visiting the hospital to seek further information and by discussing the case with Barnsley Social Care. It is unclear whether Police Officers were aware, on 28 September 2011, that Child K had a sibling. However, the Police had not had any previous contact with the family and had not been present at the house when Child K had been taken to hospital. 4.2.90 Although Police Officers sought information from the hospital about the extent of Child K’s injuries the IORA notes that the account within the Police IMR of what they were told about the injuries is substantially different to the account within the BHNFT IMR of the injuries. In addition, the message the Police took from the hospital and passed on to Barnsley Social Care was that the injuries were compatible with the explanation given by the parents and were not suspicious. However Paediatric Consultant 1 was of the view that NAI should be considered a possibility and the named nurse expressed concern to the social worker about the Police stating the injury was not suspicious. 4.2.91 In an addendum to the BHNFT IMR, the Named Doctor for Safeguarding Children at BHNFT has written that the Emergency Department consultant “would undoubtedly state that child K was seriously unwell at time of presentation, based solely on the fact that his spontaneous breathing was insufficient, and he needed support with ventilation”. However, in the absence of any written record from the Emergency Department consultant about contact with the Police it is not possible to know what the Emergency Department consultant actually said about the seriousness of the injuries. 4.2.92 The Named Doctor for Safeguarding Children at BHNFT has also written in the addendum that neither the Emergency Department consultant nor the Anaesthetist “made any comments in the notes about whether they think the injury was accidental or non-accidental” and that “this would usually be Overview Report concerning Child K Page 73 of 115 for the paediatrician to indicate once a fuller history and examination had been taken.” 4.2.93 Whilst it is not possible to know exactly what was said to Police Officers at BHNFT on 28 September 2011 it is clear that their understanding that the injury was not serious and the cause of it not suspicious was at odds with the reality of the situation. Furthermore it is clear that this view affected how Barnsley Social Care considered the case during the rest of that day. The IORA is satisfied that this apparent misunderstanding did not have any bearing on the tragic outcome for Child K or on the ultimate welfare of "his sibling" but on another occasion the outcome could have serious consequences. Therefore the IORA is of the opinion that the Police, BHNFT and Barnsley Social Care need to develop a protocol around the sharing of information when a child attends hospital and there are possible safeguarding concerns. This needs to address how, when and by whom, information should be shared and should support all disciplines to cope with the uncertainty that exists with such situations. 4.2.94 Barnsley Social Care had never had any contacts with, or information about, this family prior to 28 September 2011 and therefore when contacts were received that day they had no history relating to the family or details about who was in the family. By the time the first contact was made with Barnsley Social Care, Child K was already at BHNFT receiving emergency medical care. Consequently there was no immediate action for Barnsley Social Care to take in relation to Child K. However there was a role for Barnsley Social Care in considering whether action was required to safeguard "the sibling". 4.2.95 It is clear from the information provided to this SCR that the relevant social work team within Barnsley Social Care received several contacts about this incident on 28 September 2011. HV4 contacted the team three times; YAS made a referral by phone and backed this up with a fax; an officer from the Police Public Protection unit, the named nurse from BHNFT and a consultant paediatrician also from BHNFT spoke to the social work team once each. Despite this total of seven phone contacts and one fax, by the time social work day time staff went off duty they remained unaware of the existence of "the sibling" and believed that Child K’s injury was not being treated as suspicious. Because of these two factors, the out of hours Social Care service was not told about the family and nothing had been done to check on the well-being of "the sibling". It is apparent from the Barnsley Social Care IMR that there were some organisational and resource issues that impacted on the handling of the information that was received on 28 September 2011. These issues are considered in the analysis of ToR 8. The issue of safeguarding "the sibling" is considered in greater detail in the analysis of ToR 18. Care and Treatment Provided to Child K in Hospital 4.2.96 The authors of the BHNFT IMR conclude that the overall management and care of Child K whilst he was in the emergency department was of a good and safe standard. One issue is that an out of date child protection medical pack was used. The significance of this is that the up to date pack Overview Report concerning Child K Page 74 of 115 in use at that time provided a trigger for doctors to explicitly include their professional opinion and to make it clear that this was a professional opinion. The authors of the BHNFT IMR explain that, in the case of Child K, the use of the out of date pack did not lead to a clearly identified opinion section in the report sent to Social Care. The authors of the BHNFT IMR explain the action that has been taken to ensure that no further out of date packs are in use and has strengthened arrangements to ensure that unused packs are destroyed when a new version is produced. 4.2.97 The author of the SCNFT IMR has concluded that the difference in interpretation of the CT scan did not make a difference to the outcome for Child K as, even when the cerebral oedema was identified the advice remained that he did not require a very urgent transfer. Nevertheless it is important to ensure that the interpretation of scans is of the best possible quality and therefore it is necessary to consider what can be done to minimise the risk of a repeat. The author of the SCNFT IMR refers to "another SCR" where there was an issue with an out of hours radiologist refusing to undertake a scan on the child. This led to a recommendation that BHNFT and SCNFT needed to come to an arrangement to ensure that CT head scans carried out at BHNFT are interpreted by a paediatric radiologist. The authors of the BHNFT IMR conclude that, where a child is to be transferred to SCNFT, radiology images should automatically be sent electronically to SCNFT so that any of the Hospital 2 clinicians likely to be involved in ongoing care can be assured they will have access to all relevant images without delay or confusion. 4.2.98 The statement in the BHNFT IMR that EMBRACE staff noted blood on the tip of Child K’s penis was a matter of some concern to the SCR Panel as the extent or cause of this blood was not addressed in any IMR. The Assistant Executive Director, Safeguarding Health and Social Care, Barnsley CYP&F made enquiries of the investigating police officer who had seen the injury, was not concerned about it and described it as a tiny scratch that a child of that age might well have caused himself with a fingernail. In light of this the IORA is satisfied that it is not an issue that requires further consideration in this SCR. 4.2.99 The care provided to Child K at SCNFT is considered to have been of a good standard, appropriate to his condition and consistent with policies and procedures. There is no suggestion that any different action could have been taken that would have led to a different outcome for Child K. Action taken after Child K had died 4.2.100 Relevant actions after Child K died relate to the welfare of "the sibling". This is addressed in the analysis of ToR 18. 4.3 ToR 1 Were practitioners aware of, and sensitive to, the needs of the children in their work and knowledgeable, both about potential indicators of abuse or neglect, and about what to do if they had concerns about a child's welfare? Overview Report concerning Child K Page 75 of 115 4.3.1 One would anticipate that staff working in the organisations involved in this SCR should be aware of, and sensitive to, the needs of the children in their work and knowledgeable, both about potential indicators of abuse or neglect, and about what to do if they had concerns about a child's welfare and certainly there are many examples of these factors being demonstrated. 4.3.2 However there were also some occasions when opportunities were missed, including the following: 4.3.3 As has already been described neither MSPR 1 nor 2 appreciated the significance of the information available to them when they assessed Child K when he was in SCNFT in December 2010 with the haematoma on his ear. During the interviews, both SPRs were quick to identify the risk factors and indicators of abuse , however due to reasons which neither of them could explain, their assessment of Child K’s injury was limited to the possibility of a clotting disorder despite documentation in the case notes by the ENT surgeons about their safeguarding concerns. Similarly the health visitors in Barnsley did not raise any concerns about this injury and did not challenge the staff at SCNFT about the decision to discharge Child K without fully investigating the possibility of NAI. 4.3.4 There is no evidence that the Health Visiting Service in Barnsley recognised that Child K had lost weight or took the action required by the guidance in place at the time. 4.3.5 The Health Visiting Team in Barnsley did not respond appropriately when a member of the public reported that she had seen a child with an apparent facial injury on 27 September 2011. It appears that the health visitor who took the initial call did not appreciate the severity of the injuries. The health visitor and staff nurse both tried to place responsibility for contacting Social Care onto the member of the public rather than taking professional responsibility for doing this themselves. 4.3.6 The Infectious Diseases Team at STHFT, Sheffield Social Care, Sheffield Health Visitors and FK’s GP all failed to consider the potential impact on "FK's first child" of FK’s treatment for "an infection" and no arrangements were put in place to ensure that this was monitored. The various agencies did not communicate sufficiently well with one another about this. 4.3.7 On one occasion, YAS staff did not fully appreciate the potential impact of domestic violence in the family home and did not share information with Children’s Social Care as they should have done. 4.4 ToR 2 Did the organisation have in place policies and procedures for safeguarding and promoting the welfare of children and acting on concerns about their welfare? 4.4.1 All the organisations that contributed to this SCR have provided information about the policies and procedures that they have for safeguarding and promoting the welfare of children and acting on concerns Overview Report concerning Child K Page 76 of 115 about their welfare. These include the South Yorkshire Child Protection Procedures agreed by the Local Safeguarding Children Boards across South Yorkshire as well as specific policies and procedures within individual organisations. 4.4.2 This SCR has already commented upon the failure of the Barnsley Health Visiting Service to follow the guidance relating to inadequate weight gain in the Barnsley Primary Care Trust document “Assessment & Management of Weight Faltering (Failure to Thrive)”. A further issue about this guidance is that it was issued in 2005 and was six years old and overdue for review by the time the service had involvement with Child K in 2011. 4.4.3 The most significant failings in this case – the failure to investigate Child K’s haematoma in December 2010 and the inadequate health visiting service provided to Child K – did not result from a lack of policies or procedures but, respectively, from a failure to identify possible signs of abuse and a failure to follow procedures. 4.4.4 STHFT is worth particular consideration as this trust primarily provides services to adults, not children. Section 11 of the Children Act 2004 placed a duty on many organisations, including NHS foundation trusts such as STHFT, to ensure that “their functions are discharged having regard to the need to safeguard and promote the welfare of children”. In the STHFT IMR it is explained that the Trust has a ‘Safeguarding Children Policy’ (STHFT 2011). The Lead Nurse, Children and Young People at STHFT has confirmed to the IORA that this policy was introduced in January 2008 and updated in December 2009 and February 2011. Prior to 2008, STHFT relied upon the South Yorkshire Child Protection Procedures when dealing with such issues. The involvement of the Infectious Diseases Team with FK was in 2007 – 2009 and was therefore during the initial development and implementation of this policy. 4.4.5 The STHFT policy that requires community midwives to carry out a home visit before a child is born was introduced following a previous SCR in 2008. The purpose of this visit is to enable midwives to ensure that the baby is discharged to suitable home circumstances. Whilst the IORA believes that the midwife should have liaised with Barnsley midwives regarding this visit it is encouraging to learn that this policy has become embedded in practice. 4.5 ToR 5 Were there any issues in communication, information sharing or service delivery, between those with responsibilities for work during normal office hours and others providing out of hours services? 4.5.1 A small number of events identified within this case occurred at times outside normal working hours. 4.5.2 In October 2007 Sheffield Social Care and the Police liaised appropriately about a domestic incident involving FK and "his previous partner" . Information was appropriately passed onto day time staff within Sheffield Overview Report concerning Child K Page 77 of 115 Social Care and was followed up by the allocated social worker the following day. 4.5.3 Child K’s attendance at the CAU in BHNFT in December 2010 took place in the evening but this does not appear to have had any detrimental impact. 4.5.4 The phone call to HV5 from the member of public expressing concern about the well being of Child K was made after 5.00 pm and the IORA has considered whether this might have had an impact on the way that the health visitor responded. 4.5.5 Child K died during the evening and the out of hours social care team became involved. They had not been briefed by the day time service because at the end of the day Barnsley Social Care staff were unaware that Child K had a sibling and they understood that the injury to Child K was not considered to be suspicious (this is addressed in detail in the analysis of ToR 18). When the out hours social care team were informed, by SCNFT, of the death of Child K the response was appropriate and there is no suggestion that the absence of information from the day time staff had an adverse affect on how the out hours team responded. 4.5.6 The Paediatric Medical Consultant at SCNFT described having spent a considerable amount of time dealing with arrangements regarding safeguarding "the sibling". She felt that this was not ideal as she was on call out of hours and had other responsibilities to deal with. She told the author of the BHNFT IMR that this would have been avoided if there had been a social worker on site. The SCNFT IMR does not make any recommendations about this. The IORA has sought further information from the author of the SCNFT IMR to try to establish if this is an ongoing problem relating to a deficit in the out of hours service. In response the IMR author informed the IORA that she believes that social workers from Sheffield Social Care come to the hospital, even out of hours and therefore she believes this problem arose because Child K was from Barnsley. In the absence of more detail from SCNFT the IORA does not consider this to be a priority issue for the SCR to pursue. However, if SCNFT consider this to be a significant problem they should discuss the matter with Barnsley Social Care. 4.6 ToR 6 Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability relating to Child K and his family? Were they explored and recorded? 4.6.1 All the children and adults whose records have been accessed as part of this SCR are white, British with English as a first language. For the most part, the agencies that have contributed to this review had recorded these basic details about the family members with whom they had contact. However the author of the SWPFT IMR has identified that the ethnicity of MK was not recorded on SystmOne and there were no details relating to FK. Overview Report concerning Child K Page 78 of 115 4.6.2 Several agencies, including Primary Care, SWYPFT, Sheffield Social Care and Barnsley Social Care do not have a record of the family’s religion. Where information relating to religion was recorded, family members were mainly described as either “Church of England” or “Christian”. There are no records in any of the IMRs to suggest that the family held strong religious beliefs that impacted on their daily lives or required services to be delivered in a particular way and no indication that the hospital chaplain was involved when Child K was dying. 4.6.3 The only known issue relating to Child K or any of the family members that could be regarded as a disability is FK’s childhood diagnoses of ADHD. The Health Overview Report contains useful information about ADHD, including the difficulty that doctors face in making a clear diagnosis and the differences of opinion that exist regarding the extent to which the condition persists into adulthood. The Health Overview Report also identifies challenges with the transition from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS) and concludes that “there continue to be gaps in provision for some young people once they have left Children’s Services with GPs continuing to monitor and prescribe medication for ADHD without specialist advice or support.” 4.6.4 It is clear from the IMRs that most agencies were unaware of FK’s history of ADHD. Given that he had not had any treatment for ADHD since he was 16 years of age, which was six years before the birth of his first child, and nine years before he moved to Barnsley with MK the IORA is not surprised by this and does not consider it to be a failing on the part of the agencies. MK told maternity staff at STHFT about FK’s ADHD when she booked for her pregnancy. The IORA expresses the view that maternity staff should have made further enquiries about this at that time. 4.6.5 With regard to cultural identity the IORA believes that a possibly significant factor that was overlooked was that FK was the main carer for Child K and "his sibling" once MK returned to work, three days a week, in May 2011. With the benefit of hindsight it can be seen that FK may have been isolated and lacking support when he was caring for the children. He had moved away from his home area, was not able to drive and he himself told the IORA and Designated Nurse that he found it difficult to go to groups such as baby and toddler groups as he felt awkward being the only man there. The IORA does not have any recent figures about the number of families with pre-school children where the mother is the only bread winner and father cares for the children. Nevertheless it is safe to say that this is still a relatively unusual situation and the vast majority of people taking children to groups such as baby and toddler groups, are women. 4.6.6 It is interesting to note that that the Barnsley Education IMR report that "Child K's sibling" attended sessions at the Children’s Centre “with Child K, MK and occasionally (the IORA’s emphasis) FK.” Furthermore, even after MK had returned to work she attended a Positive Parents Group at the Children’s Centre but FK did not. There is no indication that either the Children’s Centre or the Health Visiting Service were aware that FK was the children’s main carer, or that there was any discussion with him about what support he might need. Overview Report concerning Child K Page 79 of 115 4.7 ToR 7 Was the work in this case consistent with each organisation's and the LSCB's policy and procedures for safeguarding and promoting the welfare of children, and with wider professional standards? 4.7.1 Much of the work carried out with the families involved in this review was consistent with policies and procedures for safeguarding and promoting the welfare of children and with wider professional standards. Examples include the following: 4.7.2 During the first few months of "FK's first child's" life the social worker and health visitor were the main professionals involved with the family; records suggest that they had an adequate level of involvement and that Core Group meetings took place every month as required. 4.7.3 The first time "this child" attended hospital they were transported by ambulance which had been requested by FK and as per procedure YAS alerted the Police to the hospital attendance. Police officers who attended did not feel that the incident met the threshold for Child Protection but did feel that other agencies should be made aware of what had occurred. Consequently they completed a Gen 118a Concern for a Child Form which was also in line with procedure. 4.7.4 Health Visitors in Sheffield had regular child protection supervision in respect of "FK's previous partner" as required by the Safeguarding Children Supervision Policy for Clinical Staff in Sheffield. Sheffield Health Visitors also demonstrated good practice by having discussions with FK and "his previous partner" about the potential danger that dogs can pose to young children. 4.7.5 Occasions when work was not consistent with policy and procedures for safeguarding and promoting the welfare of children, and with wider professional standards included the following: 4.7.6 HV5 did not know that K3 and "his previous partner" had been re-housed in 2009. In addressing this, the author of the Sheffield Health Visiting IMR states that, on occasions in the past the Housing agency have not informed HASS when a family have moved out of interim accommodation into a permanent address. She adds that this practice has improved and currently HASS and Housing meet on a monthly basis to share information regarding vulnerable families who are homeless and this has resulted in improving communication between these services. 4.7.7 The community midwives from BHNFT did not complete a written discharge form when handing care of Child K on to the health visitors. 4.7.8 There were several ways in which the service provided by SWYPFT was not consistent with policy and procedures and with wider professional standards. These have been addressed in detail and include the omissions at the initial visit from the health visitor, the substantial delay in carrying out the six-eight week assessment, HV4 never visiting the family Overview Report concerning Child K Page 80 of 115 home, the failure to recognise and monitor Child K’s weight loss and the unacceptable response to the member of the public who phoned to express concern about an injury to a child, which turned out to be Child K. 4.7.9 The occasion described in the analysis of ToR 1 when staff from YAS did not appreciate the potential impact on a child of a domestic incident between adults resulted in staff failing to act in accordance with policies and procedures. 4.7.10 Good professional standards include keeping acceptable records. Sheffield Social Care’s records contain no reference to the abrasion to FK's" first child's" ear, although the health visitor has recorded that it was discussed at a core group meeting in September 2007 which was attended by the social worker. In addition Sheffield Social Care do not have any records relating to the core group meeting held in October. These omissions suggest a shortfall in the Sheffield Social Care record keeping for this case. 4.7.11 The author of the SWYPFT IMR found that record keeping within this case was not of a good standard, with omissions in relation to basic record keeping standards. Specifically the record keeping of the initial home visit was insufficiently thorough, there was a delay in making a record of the phone call from the member of the public on 27 September 2011 and the six-eight week assessment was incorrectly recorded as a home visit when it had taken place at the clinic. This last point has raised a concern about SystmOne. 4.7.12 The Emergency Department consultant at BHNFT did not make any record of having spoken to the Police following Child K’s admission on 28 September 2011. 4.8 ToR8 Were there any organisational difficulties being experienced within or between agencies? Were these due to a lack of capacity in one or more organisations? Was there an adequate number of staff in post? Did any resourcing issues such as vacant posts or staff sick or on leave have an impact on the case? 4.8.1 When FK received treatment for "an infection" the adult social work post in the team was vacant. Consequently FK did not receive social work support whilst he was receiving the treatment. It is impossible to know what level of support FK would have received if there had been a social worker in post or to establish whether this would have made a difference to the identified failure of adult and children’s services to talk to one another or to assess the impact of FK’s treatment on "his first child". 4.8.2 This SCR has identified a significant failing when Child K was taken to SCNFT with a swelling to his ear in December 2010 but the possibility of it being caused by NAI was not investigated. There are two organisational issues that may have contributed to this outcome. Firstly, it is reported that MSPR 1 felt that the ENT doctors did not communicate their concerns about NAI clearly. However, even without a clear statement from the ENT Overview Report concerning Child K Page 81 of 115 department, it should have been clear to the medics that Child K’s injury was suspicious and needed to be investigated as a possible NAI. Nevertheless, the IORA welcomes the recommendation made within the SCNFT IMR that telephone referrals from other specialties to the acute paediatric medical team should be backed up by a written referral. 4.8.3 The second issue raised as a contributory factor relates to the capacity within the service. It is reported in the SCNFT IMR that this admission took place during the winter flu season which is a time when a large number of children attend the hospital with respiratory problems. Both Medical SPRs reported that they were very busy and felt this may have impacted on the care provided to Child K. The author of the SCNFT IMR believes that, whilst the increased workload may have been a contributory factor to the substandard care Child K received, it is unlikely to have been a major contributory factor and no recommendation is made about increasing capacity. However as noted above action has been taken as a result of another review to raise awareness and understanding of medical staff at SCNFT in relation to Safeguarding Children and further recommendations are made in this SCR. 4.8.4 Significant organisational difficulties have been identified with the Health Visiting Service in Barnsley and these impacted on the service provided to the family once they moved to Barnsley. The author of the SWYPFT IMR identifies the following issues: � The movement of Health Visitors � High caseload numbers within an area of mixed deprivation � Staff working reduced hours � Staff on maternity leave � HV4 being the only full time permanent member of staff within the team to which they moved � Unclear lines of accountability in relation to management and leadership � The merger with SWYPFT � The introduction of a new electronic records system 4.8.5 These issues contributed to the situation whereby Child K and his family saw three different health visitors and a student health visitor, the lack of any follow up after Child K was discharged from hospital in December 2010 and the lengthy delay before the six – eight week assessment was completed. The IORA believes that it is highly likely that these organisational difficulties impacted on the quality of the service delivered by individual health visitors. 4.8.6 The author of the SWYPFT IMR has made five recommendations which address specific organisational and practice issues and has also recommended that “an overall review of the Health Visiting Service is undertaken which includes a robust consideration of the management and leadership structure within Health Visiting.” It is recommended that this review is undertaken by someone independent of the service and is completed by December 2012. Overview Report concerning Child K Page 82 of 115 4.8.7 Significant work has already been taken by SWYPFT to improve the Health Visiting Service in Barnsley. The following actions have been taken: � A service redesign group has been established. � A case file weighting tool is now in use. � A case file audit has been undertaken. � An analysis of case load is under way and a policy is in development with regard to prioritizing case loads. � A SystmOne record keeping group is addressing the technical and practical aspects of record keeping � The team leaders have a defined role with clear lines of accountability and support from a professional lead. � A new manager has been appointed with a strengthened job description. � A local safeguarding children action group in Barnsley SWYPFT is monitoring the actions and this is overseen by the SWYPFT safeguarding children’s committee. � There has been a realignment with The Safeguarding Children’s Team has been repositioned to the Corporate Directorate to ensure a direct link to the nurse director and leadership structure 4.8.8 The IORA is reassured that SWYPFT are taking appropriate action in response to the findings of this SCR and wishes to emphasise the importance of these changes being seen through to a conclusion in order to ensure that the organisation can deliver a safe Health Visiting Service within Barnsley. 4.8.9 Barnsley Social Care had no knowledge of Child K and his family until he was on his way to hospital on 28 September 2011. However, during that day they received seven phone calls and a fax about him from four different agencies. Organisationally, the initial contact about a case, before it has been accepted as a referral, will be taken by a member of the Business Support Team, who are clerical staff, not qualified social workers. Once information is entered on the computer system it appears directly on the work desk of the duty officer, who is a qualified social worker. 4.8.10 In the case of Child K, the phone call and fax from YAS were both received by a member of the Business Support Team and the investigation suggests that neither were brought to the attention of the duty social worker. This is of significance as the fax is the only contact where it is known for certain that reference was made to "Child K's sibling". 4.8.11 The author of the Barnsley Social Care IMR has found that there were organisational difficulties being experienced by the Business Support Service supporting this Assessment Team on the day in question. The minimum number of staff normally required to cover reception is two but on this occasion, due to staff sickness and leave there was only one person available in the afternoon. Furthermore this person had additional management responsibilities across several operational teams as well as being the initial point of contact with the service for the public and other agencies. Overview Report concerning Child K Page 83 of 115 4.8.12 The author of the Barnsley Social Care IMR goes on to explain that there have been reductions in the number of Business Support Staff over a number of years as a result of the Gershon Report and more recent pressures following the reduction in local authority budgets. As a result the Business Support Service provided within social work teams is adequate provided everyone is in work but there are difficulties covering for sickness and leave. The IMR author goes on to make four recommendations which are directly related to improving the service that business support staff can provide to social work teams. 4.8.13 A further difficulty identified within Barnsley Social Care concerns where the fax from YAS was filed. It could not be filed on ERIC, the computer based system that associates such documents with the service user’s case records and because of this it was filed on a different computer drive with no reference to it on Child K’s case records. The outcome of this is that the fax was effectively lost. The author of the Barnsley Social Care IMR has made three recommendations to address this issue. 4.8.14 The author of the Barnsley Education IMR identifies that the nursery had previously undertaken home visits for new parents but that these had ceased due to resource issues. The IMR author suggests that Early Years settings should review the potential value and feasibility of re-introducing home visits to new parents in order to help build up a picture of a child’s situation. There is, however, no evidence that the lack of a home visit from the nursery made any difference to the management of this case or the outcome for Child K. Communication issues between agencies 4.8.15 Many of the organisational difficulties identified in this review related to poor or no communication between organisations. Much of this has been considered in this analysis and so will only be mentioned briefly here. 4.8.16 As reported with regard to ToR 7, there was an organisational difficulty whereby the housing agency did not always communicate appropriately with HASS when people were re-housed. This is being addressed and the situation has improved. 4.8.17 On one occasion YAS did not inform Sheffield Social Care of a domestic incident involving MK's previous partner. "A child" was known to be present in the household but the professionals involved did not appreciate the potential impact of domestic violence on a child. 4.8.18 Although the Police made Sheffield Social Care aware of the domestic incidents that occurred between FK and "his previous partner" in May 2008, August 2008 and January 2009, records suggest that Sheffield Health Visiting Service were not made aware of them. Given that there was no involvement from Social Care at that time, and the Health Visiting Service was providing an enhanced package of care to the family it would have been beneficial for the service to have been informed of these incidents. Overview Report concerning Child K Page 84 of 115 4.8.19 A service manager from Sheffield Social Care has provided the IORA with information about the “Joint Investigation Team” that was established in September 2009. This is a joint venture between Sheffield Social Care, South Yorkshire Police and Sheffield Domestic Abuse Partnership and the purpose is to improve the efficiency and effectiveness of both the police and social workers in responding to safeguarding issues for children and young people. It is intended to make the best use of the respective skills of both police officers, social workers and the multi-agency team in the investigation of allegations or suspicions of child abuse, information sharing and assessing domestic violence referrals to the Police. The domestic violence protocol, delivered by the Team, ensures that every domestic violence notification/incident attended by the Police is reviewed and risk assessed daily by a multi-agency group including practitioners from Police, Social Care, Health, Sheffield Domestic abuse and the Multi-agency Support Team (MAST) to ensure that information is shared, that joint planning is agreed and matters are progressed in a timely way by the most appropriate agency. It is anticipated that if this team had been in existence when the Police made Sheffield Social Care aware of the domestic incidents that occurred between FK and "his previous partner" then the health visitor working with the family would have been made aware of the incidents at the time and would have been in a position to take any appropriate action. 4.8.20 The SCR Panel considered the development of the “Joint Investigation Team” as an example of good practice and within the Panel it was questioned whether a similar initiative should be developed within Barnsley. In response the Assistant Executive Director for Safeguarding, Health and Social Care provided information about a multi-disciplinary response to domestic abuse referrals that is being developed by Barnsley’s Stronger Families Project. This project will promote effective information sharing and will have a dedicated worker from the third sector who, with colleagues, will work directly with families where domestic abuse is a feature. The role will also take on an awareness raising role and provide learning opportunities for staff particularly around working with children who have experienced domestic abuse within their families. The team will also provide a consultative and supervisory role to colleagues working in the community. This project is currently being piloted within one area of Barnsley. 4.8.21 There was no communication between Family Support and the health visitor when the Family Support Worker ceased involvement with FK's " "previous partner and child "in July 2010. 4.8.22 The Infectious Diseases Team, Health Visiting Service and GP did not have sufficient communication about FK’s treatment for "an infection" and there was no communication with Children’s Social Care. 4.8.23 As described in the analysis of ToRs 3 and 4, there were difficulties with communication from the Maternal Mental Health Specialist and the community midwife when MK was pregnant with Child K. As the result, the midwife was not informed of the outcome of MK’s mental health Overview Report concerning Child K Page 85 of 115 assessment which could have affected her capacity to accurately assess the risk to Child K and make necessary referrals for support. 4.8.24 After MK and FK moved from Sheffield to Barnsley they changed GPs and their medical records were transferred to their new GP. However important information that FK’s "first" child, had been on the child protection register and that there had been several domestic incidents between FK and his previous partner were not included in FK’s medical record and therefore were not available to health professionals in Barnsley. In fact FK’s medical record did not even make mention of the existence of "his first child". 4.8.25 Communication from Sheffield Midwives to Barnsley Midwives in connection with Child K’s birth and discharge from hospital was in accordance with usual practice and with procedure. Nevertheless the IORA remains concerned that Barnsley midwives were not aware of the family until after Child K was born and did not receive information about the family’s history. Consequently the IORA makes recommendations to both STHFT and BHNFT to improve their information sharing processes when a woman is due to receive postnatal care from a different Trust to the one from whom she has received ante natal care and/or with whom she has given birth. 4.8.26 Contrary to procedure, Barnsley midwives did not provide any written handover information to the Health Visiting Service. Furthermore information held in the GP records was not shared with the health visitors providing care to Child K and "his sibling". 4.8.27 Barnsley Social Care were not informed of Child K’s admission to hospital with a haematoma although with hindsight, it is abundantly clear that there were grounds for a much more thorough investigation of the cause of this injury and that Barnsley Social Care should have been involved. It appears that this failure of communication was the result of the acute medical team at SCNFT not investigating the injury as a possible NAI and a lack of concern from the health visitor. 4.8.28 The author of the Barnsley Education IMR questions whether the level of communication between health care professionals and those working within early years settings is at a level which enables concerns about children to be developed. The IMR author recommends that this is reviewed. 4.8.29 HV5 should have contacted Barnsley Social Care on 27 September 2011 when the member of the public phoned up and expressed concern about Child K. When HV4 contacted Barnsley Social Care after Child K had been admitted to hospital the following day, HV4 should have told the social worker that Child K had a sibling living at home. 4.8.30 After Police officers attended BHNFT on 28 September 2011 they believed that Child K’s injuries were not serious and the cause was not suspicious. It appears that there was some miscommunication between the Police and the Emergency Department consultant. This issue is addressed in detail in this report. Overview Report concerning Child K Page 86 of 115 4.9 ToR9 Was there sufficient management accountability for decision making? 4.9.1 The organisations that have provided IMRs largely identify that management accountability for decision making was sufficient. On occasions staff sought management input in relation to specific issues. For example, the author of the SCNFT IMR states that staff appropriately sought advice from a consultant when there were difficulties getting a urine sample from "Child K's sibling" during their first attendance at the Emergency Department of SCNFT. There are also examples of decisions being taken and/or ratified at a pre-determined level of seniority. For example, in Sheffield Social Care, assessments were signed off by managers “in line with local procedures” whilst in the Police, risk assessments were carried out by departmental Sergeants. 4.9.2 On the day that Child K died, The Assistant Team Manager on the Assessment Team in Barnsley Social Care signed off the decision to await further information following a discussion with the Team Manager at the end of the normal working day and the IMR author states that this is usual practice. Furthermore, the EDT worker contacted the on-call senior manager on hearing that Child K had died and had a sibling and they made the decision together that "this child" should be seen that evening. The social worker then spoke with the manager a number of times during the evening. At both hospitals Child K’s care was consultant led and decisions were taken at the appropriate level. 4.9.3 Two areas are identified in the IMRs where there was insufficient management accountability and these are areas where other failings have been identified throughout the analysis. The first of these relates to the care provided to Child K when he was admitted to SCNFT in December 2010. Management accountability was another area where it appears that there may have been difficulties as there is no documentation to suggest that there was any input from the supervising consultant. However, this is unclear as MSPR1 has said that Child K was discussed in handover with PMC1 and therefore it is unclear if the problem was with a lack of management accountability or poor record keeping. If the case was discussed with a consultant then it is even more of a concern that the possibility of NAI was not recognised by staff. 4.9.4 With relation to SWYPFT, the analysis of ToR 8, above, identifies a significant number of organisational difficulties facing the Health Visiting Service. These include issues around management accountability. Concerns relate to management accountability for the Health Visiting Team as a whole and the author of the SWYPFT IMR provides information about the structure of the service at that time, the size of caseloads and the movement of individual health visitors between teams. The author of the SWYPFT IMR also identified that the team leader had been unaware that the six – eight week assessment of Child K was so late in taking place. In fact the Team Leader had no knowledge of Child K prior to his death. Overview Report concerning Child K Page 87 of 115 4.9.5 It is pointed out in the SWYPFT IMR that health visitors are not case managed and therefore team leaders will not have a detailed knowledge of health visitors’ caseloads. Nevertheless, the team leader does have a responsibility to ensure that a child’s welfare, development and safety needs are being met. It is the view of the IORA and SCR Panel that Child K did not receive the level or quality of service to which he was entitled and that this was not identified or addressed by anyone in a managerial position. This suggests that the organisation did not fulfil its responsibilities under Section 11 of the Children Act 2004 which states that “Each person and body to whom this section applies must make arrangements for ensuring that – their functions are discharged having regard to the need to safeguard and promote the welfare of children.” It is acknowledged that since Child K’s death SWYPFT have changed the arrangements for managing health visitors. This has included strengthening the team leader role, with respect to the supervision of health visitors, to ensure that SWYPFT is fulfilling its responsibilities under Section 11 of the Children Act 2004. 4.10 ToR 10 Were senior managers or other organisations and professionals involved at points in the case where they should have been? Senior manager involvement 4.10.1 Occasions when senior managers should have been involved in the case are largely addressed in the above analysis regarding management accountability for decision making. In addition the IORA considers the following issues to be significant. 4.10.2 All the health visitors in Sheffield accessed child protection supervision whilst being involved with the provision of care for FK's "first child" and their family and this was good practice. However the IMR author questions whether there was sufficient in-depth analysis of the family’s situation. As examples, the author explains that the minor facial injuries that were observed, were not all documented in the supervision records and also that little emphasis was placed on FK’s parenting, although he had frequent regular contact with "his first child". 4.10.3 As stated above, it would have been appropriate for the paediatric registrar who examined Child K at BHNFT on 10 December 2010 to have consulted with the consultant paediatrician who was on duty that evening. 4.10.4 With respect to Child K’s first admission (to SCNFT), MSPR 1 reported that the case was discussed with PMC1 as was the normal practice. Child K was however not seen by PMC1 prior to discharge. Involvement of other agencies 4.10.5 There were several occasions when other organisations or professionals should have been involved. These have been addressed in the analysis of ToR 8 in the context of communication between agencies. 4.10.6 There were also the following occasions when organisations appropriately involved others and worked effectively together. Overview Report concerning Child K Page 88 of 115 4.10.7 The Police informed Social Care of the domestic incidents. 4.10.8 There is evidence of good joint working and communication between Sheffield Health Visiting, Sheffield Social Care and a housing agency when HV6 first became involved in June 2009. Concerns had been expressed by a member of the public about a baby crying, the health visitor identified who this was, consulted with Social Care, carried out a joint visit with a worker from the housing agency and fed back to Social Care. Subsequently HV6 liaised with Sheffield Social Care, the nursery and the housing agency and instigated Family Support, when they ended their involvement. HV6 also liaised with Sheffield Social Care on occasion. 4.10.9 Medical staff from BHNFT and SCNFT worked well together following Child K’s admission with the injuries that resulted in his death on 28 September 2011 4.11 ToR 11 Establish whether there are any overlapping issues between this review and the Child H, Child L Serious Case Reviews and, if so, what has been put in place to address the issues? 4.11.1 Child H died in September 2010 at seven weeks of age and was the subject of an SCR commissioned by BSCB which was completed in June 2011. Child L died in February 2011 at five weeks of age and was the subject of an SCR commissioned by BSCB which was completed in March 2012. 4.11.2 There are the several similarities between the circumstances of Child H, Child L and Child K and these include the following: � None of the children were known to Social Care prior to sustaining the injuries that led to their death. � All three children died as a result of severe traumatic brain injury believed to be the result of an NAI. � Both families were white, British and were not felt to have any particular needs relating to their religion, race, language or ethnicity. 4.11.3 In the case of Child H the father has been convicted of murder and in the case of Child L the father has been charged with murder but has not yet stood trial. In the case of Child K a criminal investigation is ongoing and the father is currently on bail. 4.11.4 In the cases of both Child H and Child K there had been previous concerns in relation to the care of an older child of one of the parents and also issues relating to domestic violence with one of the parents. However the agencies which had contact with Child K knew nothing about these earlier concerns and therefore were not in a position to consider them when making decisions about services for Child K and "his sibling". 4.11.5 Child L and Child K were both born in hospitals outside Barnsley and, following discharge home, postnatal midwifery care was provided by midwives in Barnsley. The circumstances were somewhat different as MK Overview Report concerning Child K Page 89 of 115 was not known to Barnsley midwives prior to the birth of Child K whereas the mother of Child L had received some antenatal services within Barnsley and, consequently was known to the community midwife. Nevertheless, in the case of Child L it was found that community midwives had not completed a discharge form when passing the care of Child L onto the Health Visiting Team. It was determined that the failure to complete this paperwork was due to it not being included with the discharge information provided by the hospital. Child K was born in a different hospital to Child L but once again a discharge form was not completed by the community midwife. A recommendation was made in the Child L SCR to address this problem but this post dated the birth of Child K. The recommendation requires community midwives to “have readily available to them and use all the required paperwork needed to be completed antenatally and postnatally to meet local record keeping standards”. The IORA anticipates that this recommendation will also address the failure to complete a discharge form in the case of Child K and therefore a further recommendation has not been made regarding this issue. 4.11.6 In the case of Child K, however, there were additional difficulties which resulted from all antenatal care and the birth taking place outside Barnsley. These are addressed below. 4.11.7 An important finding in the Child L SCR was that no-one had discussed the dangers of shaking a baby with Child L’s parents and that, whilst at one stage this was done routinely, this is no longer the case. Recommendations were made to ensure that midwifery and health visiting leads meet to discuss who will take responsibility for this task and that a procedure to address this omission is written and disseminated by April 2012. The authors of the Health Overview Report describe the multi-agency actions that have now been taken to ensure that parents are informed by Children’s Centre staff, midwives and health visitors about the risks of shaking a baby and safe sleeping, at set times both antenatally and postnatally. 4.11.8 Another key finding in both the Child H and Child L SCRs concerned a lack of engagement of professionals with male carers in the child’s life. This is also evident on a number of occasions in this SCR. For example, FK was included in assessments in Sheffield prior to the birth of "his first child" but these assessments relied on self-reporting. After FK and "his previous partner" separated, health visitors did not have any contact with FK even though he was having frequent contact with " their child" who was on an enhanced package of support from the Health Visiting Service. When Child K was born, midwives and health visitors in Barnsley had very little information about FK and did not seek to gather more information. There is also no indication that health visitors ever assessed FK’s child care skills or were aware that he was the main carer for both Child K and "his sibling" during the days that MK was at work. By contrast, there was good engagement with FK in Sheffield whilst he was living with "his previous partner and the child" was on the Child Protection Register. Both the health and social worker consistently made reference to FK being present during visits and records suggest that he was included in discussions and assessments. Overview Report concerning Child K Page 90 of 115 4.11.9 Several recommendations have been made to ensure that midwives and health visitors gather more information about fathers and other significant male carers and also that they record who is present at visits. However, whilst it is relatively straightforward to implement procedural changes there needs to be a cultural shift so that professionals understand that a key part of their role is to safeguard children and that, in order to do so, they need to take a pro-active role in gathering information about the individuals involved in a child’s life and to take action if they have any concerns about the way any of those people are caring for the child. 4.12 ToR 12 What was the agencies' involvement with anger management for FK? 4.12.1 ToRs 12 – 15 inclusive, concern historical issues relating to FK. In considering these ToRs it is important to note that, prior to the death of Child K, no one ever identified that the father of "his first child" was also the father of Child K and consequently no information relating to FK as the father of "his previous child" or partner of "his previous partner" was available to agencies working with MK and FK in Barnsley. There is no evidence to suggest that midwifery staff in Sheffield or Barnsley or health visitors in Barnsley asked whether FK had any other children from previous relationships. However the BHNFT records from Child K’s attendance at CAU in December 2010 did name "the previous child" and refer to them as being FK’s child. It would have been relevant for health visitors to have known about "this child" as they reportedly visited MK and FK’s home on a frequent basis. 4.12.2 The IMR from Primary Care contains information about FK’s history in which it is written that one aspect of his ADHD was ‘low frustration tolerance’. There is little reference to specific assistance being given to FK to manage his anger although reference is made to him being prescribed Ritalin which, in 2001 when he was 16 years old, he used “as a tranquiliser”, when he became angry. It is clearly stated in the Primary Care IMR that FK had not received any intervention, with regards to anger management, since he was 16 years old. This was six years before the birth of his first child, and nine years before he moved to Barnsley with MK. 4.12.3 None of the other agencies that have provided IMRs to this SCR had any knowledge of FK having received help with anger management in the past and therefore their only knowledge of FK’s ability to manage his anger was their own observations during contact with him. 4.12.4 Between them, the agencies that have contributed to this review are aware of six domestic incidents involving FK during the period covered by this review. These took place in August 2007 (MK had been drinking), October 2007 (FK under the influence of drugs) May 2008 (just after treatment for "an infection" began), August 2008, January 2009 (MK and partner had both been drinking) and November 2009 and all involved FK and "his previous partner". Some of these were reported as being verbal only, although on one occasion the partner sustained a bleeding nose. FK was not prosecuted in connection with any of the incidents. Overview Report concerning Child K Page 91 of 115 4.12.5 Although FK described himself as feeling “snappy” at some of the out patient’s appointments in connection with his treatment, there is no evidence that these feelings resulted in him becoming angry with anyone. 4.12.6 None of the Barnsley agencies involved with the family identified any issues regarding FK having difficulty managing his anger. MK and FK both denied that domestic abuse was an issue when they were asked by the paediatric registrar in the Emergency Department and although there is evidence of domestic incidents between FK and "his previous partner" there is no evidence of any such incidents in the relationship between MK and FK. 4.12.7 In summary, although information provided to SCR Panel at the start of the process was that FK had a history of anger management problems it appears that agency involvement with anger management was restricted to work done with him as a teenager and this ended at least six years before the start of the period covered by this review. None of the agencies involved with the family during the period covered by this review were involved with anger management with FK. 4.13 ToR 13 Provide a commentary on the context of drug usage by FK and was this likely to have impacted on the family and the care of Child K. 4.13.1 Information provided by FK and reported in the Sheffield Social Care and Primary Care IMRs suggests that FK used drugs, including heroin and crack, extensively as a teenager and this led to his involvement in criminal activity which resulted in him spending time in prison. Having relapsed after he served a custodial sentence, FK sought help and successfully underwent a drug rehabilitation programme which he completed over a year before the birth of "his first child" and the start of the period covered by this review. 4.13.2 There is no information to suggest that FK used hard drugs at all during the period covered by this review. On two occasions, in February 2008 and December 2009, FK was found by the Police to be in possession of cannabis whilst away from home and without any children present and in October 2007 when Police were called to FK and "his previous partner's" home in October 2007 to attend to an alleged domestic incident they found him to be under the influence of a drug believed to be speed. "A child" was present in the home during this incident and therefore could have been affected by it but officers removed FK to protect "the child". There is no evidence of any drug use by FK after he was living with MK. 4.13.3 The possibility that FK was frequently under the influence of drugs whilst in the presence of his children cannot be excluded but there is no evidence that this was the case. 4.14 ToR 14 Was the information sharing and passing of referrals between agencies, with prior knowledge of FK, adequate and appropriate? Overview Report concerning Child K Page 92 of 115 4.14.1 In considering this term of reference three distinct periods need to be considered. Firstly, when agencies became involved because "his previous partner" was pregnant with FK’s child did they receive sufficient information about FK’s history? Secondly, when MK presented as pregnant with FK’s child what knowledge did maternity services have of FK and thirdly when MK and FK moved to Barnsley with "MK's first child" and Child K was appropriate information shared with relevant Barnsley agencies? When agencies became involved because "his previous partner" was pregnant with FK’s child did agencies receive sufficient information about FK’s history? 4.14.2 This Overview Report has already explained that an assessment was undertaken prior to the birth of "FK's first child" but that the focus of the assessment was on "his previous partner" and although information was gathered about FK this relied almost entirely on self-reporting from him. Having made that point, it is worth noting that FK was open and honest about his diagnoses of ADHD and his history of drug use and therefore the information that agencies held about FK at that time was largely accurate. When MK presented as pregnant with FK’s child what knowledge did maternity services have of FK? 4.14.3 Earlier paragraphs of this report explain that maternity staff only had limited knowledge of FK’s history during MK’s pregnancy with Child K and they did not identify that the father of Child K was also the father of "his first child" The reasons for this are also explained and explored in the aforementioned paragraphs. When MK and FK moved to Barnsley with "MK's first child" and Child K was appropriate information shared with relevant Barnsley agencies? 4.14.4 Because it was never identified that FK was the father of both "his first child" and Child K no agencies in Barnsley were given any information about FK’s history when the family moved to Barnsley. In addition the social history that was gathered by midwives in Sheffield was not passed on to midwives in Barnsley. This is addressed in earlier paragraphs of this Overview Report. 4.14.5 HV6 in Sheffield was aware of some of the domestic incidents and was told by "FK's previous partner" in March 2010 and July 2010 that FK was living in Barnsley with his new partner who was pregnant. On one of these occasions HV6 was also told that FK’s new partner had "another" child. The author of the Sheffield Health Visiting IMR considers, based on the documentation in the Family Health Record, that FK was a significant carer for "his first child" and in view of the complex history, it would have been appropriate for HV6 to liaise with the Health Visiting Service providing care for "Child K's sibling" and family. The IMR author points out that the NSF for Children, Young People and Maternity Services makes reference to the fact that the role of fathers in parenting is often over looked (DOH 2004) and adds that, if HV6 had liaised with the Health Visiting Service in Overview Report concerning Child K Page 93 of 115 Barnsley this would have provided an opportunity for the health visitor involved with the family of "MK's first child" and Child K to take account of the history in their risk assessment. 4.14.6 Notwithstanding the above comments it is important to be realistic about the practicalities of sharing information in this case. HV6 had not been told the name of FK’s new partner or where he was living. Therefore, at that stage, there was little in the way of information that HV6 could have provided to the Health Visiting Service in Barnsley. Even if HV6 had ascertained the name of FK’s new partner or where they were supposedly living, MK & FK both remained registered with a Sheffield GP until September 2010 and "MK's first child" was on the books of the Sheffield Health Visiting Service until September 2010. Therefore, if HV6 had contacted health services in Barnsley in either March or July 2010 this would not have led to the family being identified. MK also received antenatal care in Sheffield throughout the pregnancy and although she told the midwifery service in April 2010 that she had moved to Barnsley she also told staff delivering her maternity care that she was no longer in a relationship with FK and, as far as can be ascertained, he was not present during any appointments. 4.14.7 In theory, the most effective way of ensuring that relevant information is passed on when a person moves from one area to another is through the medical record. However, this Overview Report has already made reference to the lack of communication between the GP and Health Visiting Service and also that FK’s medical record did not contain information about the domestic incidents between "him and his previous partner "or the fact that FK’s older child had been on the child protection register. Therefore, even if communication between the GP and Health Visiting Service had been better, this important information would not have come to the attention of the Health Visiting Service. 4.14.8 If Sheffield Health Visiting Service had maintained some contact with FK after he separated from "his previous partner", as the IORA has suggested they should have done, then this may have enabled the service to have had useful information about FK which maybe could have been provided to the Barnsley Health Visiting Service when FK and MK moved there. 4.14.9 It is also important to keep the concerns about FK in perspective. Without wishing to minimise the seriousness of domestic violence, the domestic incidents between FK and "his previous partner" were relatively few and far between and did not all involve physical violence, FK was not always the perpetrator and none of them resulted in a prosecution. Furthermore there was never an occasion when FK was suspected of causing any harm to "his first child" and, as far as the IORA can ascertain, agencies in Sheffield had no concerns about FK caring for "the child". Therefore, whilst it would have been best practice for information to have been passed onto Barnsley health visitors the IORA considers it unlikely that any additional service would have been provided. 4.15 ToR 15 Overview Report concerning Child K Page 94 of 115 Had referrals been made for domestic violence between FK and a previous partner. Were agencies sufficiently aware of this and the potential impact on Child K and his family? 4.15.1 As has been stated earlier in this analysis there were six reported domestic incidents between FK and "his previous partner" during the period covered by this review. The Police, Sheffield Social Care, Sheffield Health Visitors and the GP with whom FK, "his previous partner and child" were registered each knew about some or all of these incidents. 4.15.2 This report has already explained that HV6 in Sheffield was told that FK had moved to Barnsley with a new partner who was pregnant and the report has considered whether HV6 could have taken action to make Barnsley health visitors aware of FK’s history. 4.15.3 This report has also explained, that the history of domestic violence was recorded in "his first child's" medical records but not those of FK. Therefore, once FK moved to a new GP practice this information was no longer available to his GP. 4.15.4 Sheffield Social Care had not had any involvement with FK or " his previous partner" for some months prior to him moving to Barnsley with MK. Therefore, in the absence of any enquiry to Sheffield Social Care from another agency they were not in a position to share information about the domestic violence. 4.15.5 The Police were never called to attend any domestic incidents between FK and MK. Indeed they were not called to any incidents involving MK through the entire period covered by this review, or any incidents involving FK after November 2009. Consequently they had no opportunity to identify that the father of Child K had previously been involved in domestic violence. 4.15.6 Because no-one identified the father of Child K as being the same person as the father of "his first child" and previous partner of "their mother" no agencies working with the family of MK, FK, "MK's first child"" and Child K had any awareness of the previous domestic incidents between FK and "his previous partner". 4.16 ToR 16 Establish whether the large number of health visitors contributed to concerns not being addressed adequately with regard to the care of Child K. 4.16.1 This term of reference was included because it was clear from the initial reading of records that several different heath visitors had been involved in the care of Child K in Barnsley. The IMRs have shown that, in addition to this, there were seven different health visitors involved with "FK's first child" in Sheffield during the period covered by the review. Consequently in addressing this term of reference the IORA will also consider the impact of the large number of health visitors involved with "FK's first child". Overview Report concerning Child K Page 95 of 115 Health visitors involved with "FK's first child" in Sheffield 4.16.2 Seven health visitors are referred to in the Sheffield Health Visiting IMR of which four were the allocated health visitor for "FK's first child" at different times. Of the others HV2 and HV7 each saw "the child" once at clinic whilst HV3 took a phone call from a social worker whilst the allocated health visitor was on annual leave. 4.16.3 Each change of allocated health visitor was the result of a change of address for "this child". Throughout the period covered by the review whilst each health visitor was allocated to "the child" they provided continuity of service. "FK's previous partner" never told the health visitor that she was moving home; instead on one occasion the health visitor tried to visit and found the flat empty, on another "the previous partner and child" failed to attend clinic and on the third a neighbour reported a disturbance. Consequently, there was never a planned change of health visitor. Nevertheless there is evidence that verbal handovers took place from one health visitor to another. 4.16.4 When "the previous partner and child" were in homeless accommodation they were provided with a health visitor who works in HASS. This is a specialist service that ensures families have access to health and other services when they may be at their most vulnerable. 4.16.5 There was a short period of time, following "the previous partner and child" leaving interim accommodation and moving into their own tenancy, when the Health Visiting Service were not in touch with the family. During telephone discussion between the Sheffield Health Visiting IMR author and HV5 it was clarified that sometimes the housing agency have not informed HASS when a family have moved out of interim accommodation into a permanent address. This practice has improved and currently HASS and the housing agency meet on a monthly basis to share information regarding vulnerable families who are homeless and this has resulted in improving communication between these services. 4.16.6 The IORA concludes that the involvement of several health visitors was not due to any difficulties with service delivery but was the result of several changes of address. This process was well managed and does not require any changes in policy or practice. Health visitors involved with Child K and "his sibling" in Barnsley 4.16.7 In several places in this analysis there are references to significant problems that have been identified with the Health Visiting Service that was provided to Child K and his family. One aspect of this was that there was no continuity in the provision of the service that was provided. Nevertheless the problems which have already been identified in this report were much greater than the use of several different health visitors. 4.17 ToR 17 Establish whether there are protocols in place which identify actions agencies should have / will take if birth parents do not take a child to Overview Report concerning Child K Page 96 of 115 appointments and another family member attends and if this contributed to concerns not being adequately addressed in relation to child K. 4.17.1 This ToR was included as early reports suggested that there were occasions when Child K was presented at medical appointments with a family member other than his mother or father. The SCR Panel wanted to investigate whether this was a feature of the care of Child K and whether it impacted on how concerns were addressed. 4.17.2 A more detailed consideration of this issue, through the IMRs has shown one recorded incident when "another family member" took Child K to a GP appointment. This was in June 2011 after MK had returned to work and the "family member" cared for Child K on a regular and frequent basis. In addition, there was an occasion in July 2011 when "Child K's sibling" was taken to the GP by "another family member". Both of these attendances were due to the children being unwell with infections. At least one of Child K’s parents was present each time he attended hospital or was seen by anyone from the Health Visiting Service. 4.17.3 Agencies contributing to this review have reported that there are no protocols in place which identify actions agencies should have or will take if birth parents do not take a child to appointments and another family member attends. However, there is no indication that this was an issue of concern in this case or that the two occasions when Child K was taken to the GP by family members contributed to concerns not being adequately addressed in relation to Child K. 4.18 ToR 18 How effective was the multi-agency response to "Child K's sibling" in terms of safeguarding their position. 4.18.1 This ToR was included due to concerns that there may have been a delay before agencies took action to safeguard "Child K's sibling" after Child K was admitted to hospital on 28 September 2011. Consequently in addressing this ToR, the IORA has considered the events of 28 September 2011 onwards. 4.18.2 "The sibling" was at home with MK, FK and Child K on the morning of 28 September 2011 when Child K became unwell and the ambulance was called. They remained at home with FK when Child K and MK were taken to BHNFT in the ambulance. It appears that they were then taken to nursery as usual. There is no record of who collected them from nursery but it appears that they were staying with a "family member" during the evening of 28 September 2011 whilst MK and FK were with Child K at BHNFT and then SCNFT. Agencies did not give active consideration to the welfare of "the sibling" until the evening of 28 September 2011 after Child K had died. Given that Child K’s injuries are believed to be the result of NAI it is important to consider whether anything could or should have been done differently. Overview Report concerning Child K Page 97 of 115 4.18.3 There are two main issues to consider in respect of the above; firstly, when were various agencies aware of the existence of "the sibling" and secondly, when were agencies aware that Child K’s injuries may be the result of an NAI. 4.18.4 Four agencies contacted Barnsley Social Care about Child K during the day of 28 September 2011; SWYPFT, the Police, YAS and BHNFT. However, according to the Barnsley Social Care IMR, social workers remained unaware of the existence of "the sibling" until the evening of 28 September 2011 when a social worker in the Emergency Duty Team was contacted after Child K died. It is therefore worth considering what knowledge each of the agencies, which contacted Barnsley Social Care, had about "the sibling" and what they told Barnsley Social Care. 4.18.5 HV4 from SWYPFT was aware of "the sibling" when HV4 contacted Barnsley Social Care on 28 September 2011 to refer Child K. HV4 should have informed Barnsley Social Care of the existence of a "sibling" in the household but it appears that this was not done. The SWYPFT IMR does not provide any reason for why HV4 did not tell Barnsley Social Care about "this child". 4.18.6 YAS staff who attended the house following the 999 call saw a young child present and were aware that this child remained at the house with an adult male when Child K and MK were conveyed to BHNFT. YAS staff contacted Barnsley Social Care by phone to inform them of the injuries to Child K and of his conveyance to BHNFT. They also sent a referral form by fax. It is unclear whether "the sibling" was mentioned in the phone conversation but there is reference to them in the fax. It appears that this fax was only seen by a member of clerical staff on the day that it arrived in the social work office and the information about "the sibling" was not brought to the attention of the social workers. It is the view of the author of the Barnsley Social Care IMR that the reference to "the sibling" was not in a very obvious way that would have focussed attention on them at a time when so much else was going on. The referral form is a standard form used by YAS which includes a specific section for YAS to provide details of any other children on the scene. In the form sent to Barnsley Social Care in connection with Child K the box in this section headed ‘Name’ was completed with “X year old child ”. Although YAS staff did not have a name for "the sibling" and their age was incorrect the IORA considers that it should have been clear to Barnsley Social Care that another chid had been present. 4.18.7 It is unclear whether the police officer who contacted Barnsley Social Care during the day on 28 September 2011 was aware that Child K had a "sibling". However, the Police had not had any previous contact with the family and had not been present at the house when Child K had been taken to hospital. 4.18.8 BHNFT records clearly state that Paediatric Consultant 1 told the social worker about "the sibling" during the afternoon whist Child K was in the hospital. The Social Care records confirm that there was a phone call between these two professionals but do not contain any record of Overview Report concerning Child K Page 98 of 115 Paediatric Consultant 1 referring to "the sibling" and the author of the Barnsley Social Care IMR is of the view that this would have been recorded if the information had been provided. 4.18.9 Considering all the above, it is clear that Barnsley Social Care was informed of "the sibling" during the day of 28 September 2011 but that this information was overlooked. It is also clear that the health visitor missed an opportunity to inform Social Care of "the sibling" when this should have been done. In addition there remains a clear and irresolvable difference of view as to whether Paediatric Consultant 1 told the social worker about "the sibling". 4.18.10 It is also necessary to consider what action, if any, Barnsley Social Care should have taken during the day time on 28 September 2011 if they had become aware of "the sibling". The author of the Barnsley Social Care IMR states that there was uncertainty as to whether Child K’s injury was non-accidental and considers that, during the afternoon of 28 September 2011, when Child K was obviously critically ill then even if the social work team had known about "the sibling" they may well have decided not to try to see them at that time. 4.18.11 Information in this Overview Report provides a confused picture as to whether or not there were concerns about the cause of Child K’s injuries. The IORA accepts that during the day time on 28 September 2011 no-one was sure about how Child K had sustained his injuries and it was possible that they had been sustained accidentally as described by his parents. Nevertheless, the IORA does not believe it was possible, on 28 September 2011, to rule out the possibility of NAI. Consequently, the IORA is of the view that, if Barnsley Social Care had been aware of "the sibling" they should have considered whether action was needed to safeguard them and, at the very least, should have contacted the nursery and health visitor to gather more information about them. Therefore it is the view of the IORA that the failure of the health visitor, and possibly others, to inform Barnsley Social Care about "the sibling" and the failure of Barnsley Social Care to properly process the fax from YAS, delayed appropriate action being taken to safeguard "the sibling". 4.18.12 By the time Barnsley Social Care’s Emergency Duty Team became aware of "the sibling", during the evening of 28 September 2011, Child K had died. SW4 from EDT liaised with a senior manager and took prompt action to ensure that "the sibling" was safe and well. This resulted in good joint work between Barnsley Social Care and the Police. 4.18.13 Action taken on 29 September 2011 to safeguard "the sibling" was appropriate and proportionate. This includes arranging and holding a strategy meeting, informing the nursery of the situation, making arrangements for "the sibling" to have a medical the following day and advising the family that any contact MK and FK had with "the sibling" should be supervised by another adult. 4.18.14 The authors of the BHNFT IMR consider that the medical assessment of "the sibling" on 30 September 2011 was comprehensive and well Overview Report concerning Child K Page 99 of 115 documented on an up to date pack. The IMR authors draw attention to the lack of commentary about how the bruises on the abdomen were interpreted. They acknowledge that the bruises were probably overlying bony prominences and could have been caused accidentally by a tight belt, for instance but state that the examining doctor at the time should have been explicit. The IORA shares the concern that no possible explanation was provided for these bruises. This medical assessment was being undertaken as a result of the death of "the child's" sibling in circumstances where there was suspicion that the death may have been the result of an NAI. In such circumstances it is imperative that the doctor undertaking the examination explicitly comments on any injury identified, however slight it may be. Following discussion at the SCR Panel and with the Named Doctor for Child Protection at BHNFT, the IORA makes a recommendation in connection with this. 4.18.15 In summary, it is the view of the IORA that there was a delay in safeguarding "the sibling" on 28 September 2011 as a result of poor or missed communication about their existence and the seriousness and possible cause of the injuries. Once Barnsley Social Care became aware of "the sibling" and of the concerns of the consultant paediatrician at SCNFT, appropriate action was taken in a timely fashion to safeguard them. However the possible cause of faint bruises identified at the medical assessment were not adequately explained in the medical report. 4.19 Challenge of IMRs 4.19.1 All of the IMRs produced for this review follow a set format specified by BSCB. As a result they are all well structured with a shared introduction explaining the background to the review and the reason it is being undertaken. They also contain a clear statement as to the time period for the review and the key issues to be addressed as set out in Terms of Reference produced by the Serious Case Review Panel. They include sections to summarise the agency’s involvement with the family and to analyse that involvement. Individual chronologies were written on a standard template to enable continuity and to facilitate the compilation of the integrated chronology. The IMRs have all been signed off at an appropriate level within the organisations. 4.19.2 Primary aims of SCRs are to learn lessons and to take action that will improve services in the future. In order to achieve these aims it is essential that all the IMRs provide a thorough analysis considering each and every one of the Terms of Reference identified by the SCR Panel. It is also essential that the IMRs draw out the key lessons to be learned and make recommendations based on these lessons. The IORA and SCR Panel have worked to ensure that all the IMRs follow such a framework. 4.19.3 The SCR Panel and IORA provided substantial challenge to the performance and practice of agencies throughout the SCR with the result that IMRs were revised on a number of occasions. This challenge was provided in SCR Panel meetings and in individual discussions that the IORA had with IMR authors. In some cases this challenge was the result of the IORA or SCR Panel members believing that the analysis within the Overview Report concerning Child K Page 100 of 115 IMR needed to be strengthened and on other occasions it was because information in one IMR was inconsistent with information in another. 4.19.4 Examples of incidents where the IORA and SCR Panel have provided challenge to IMRs include the following: � Decision making in respect of de-registration of "FK's first child" Sheffield Social Care response to domestic incidents between FK and "his previous partner" � Communication between adults and children’s services in respect of FK’s treatment for "an infection" � Pursuit of a urine sample for "the sibling" � Gathering and storing information about fathers during pregnancy � Communication between midwifery services when a pregnant woman receives antenatal care and/or gives birth with one Trust but is going to receive postnatal care from a different Trust � Insufficient response from BHNFT to lesion inside Child K’s mouth � Location of six-eight week assessment of Child K � Communication between BHNFT and the Police regarding Child K’s injuries on 28 September 2011 � The inadequate explanation for the faint bruises found on "the sibling's" abdomen at the medical assessment following Child K’s death 5. Conclusions 5.1 This SCR was commissioned following the tragic death of Child K and has involved detailed consideration of agency involvement with the family of MK, FK, "Child K's sibling" and Child K. The findings suggest that there were incidents that should have resulted in agencies having concerns about Child K’s welfare as early as December 2010. Such concerns should, in turn, have led to a different course of action in which case the tragic death of Child K may have been avoided. In view of the events of 27 and 28 September 2011, the two hospital attendances in December 2010 appear hugely significant. With regard to the first of these, when Child K was referred to BHNFT by the GP with a lesion in his mouth, the presentation was very unusual and it is suggested that the registrar should have sought the opinion of the consultant and also that consideration could have been given to admitting Child K whilst further enquiries were made and the possibility that it was an NAI considered. 5.2 With regard to the occasion when Child K attended SCNFT with a swelling to his ear, it is clear that this should have been investigated as a possible NAI and that this was recognised by the doctors in the emergency department and the ENT surgeons but was overlooked by medics. Furthermore, this highly suspicious presentation occurred only eight days after Child K’s aforementioned attendance at BHNFT with the lesion inside his mouth. This error was, at least in part, the result of an error of professional judgement but it has also led to a recommendation about internal referral processes, which is addressed in the recommendations. 5.3 It is very easy, with the benefit of hindsight, to criticise the actions of agencies and individuals who work under great pressure and have to make Overview Report concerning Child K Page 101 of 115 difficult decisions, often based on relatively little information. In her Review of Child Protection Professor Munro (2011) wrote that: “It is important to be aware how much hindsight distorts our judgment about the predictability of an adverse outcome. Once we know that the outcome was tragic, we look backwards from it and it seems clear which assessments or actions were critical in leading to that outcome.” 5.4 The IORA fully shares these views but considers that hindsight is not required to identify that a possible NAI should have been investigated when Child K was admitted to hospital in December 2010. 5.5 There were numerous problems with the health visiting service provided to Child K and his family in Barnsley. There was no continuity as to who provided the service, the initial visit was insufficiently thorough, the six – eight week assessment did not take place until Child K was 16 weeks old and even then took place at the clinic rather than at the family home, staff did not identify that Child K’s weight had fallen by more than two centiles and the policy regarding insufficient growth velocity in infants was out of date. Furthermore, when a member of the public alerted a health visitor to Child K’s injuries on 27 September 2011 the health visitor did not take appropriate action. 5.6 These substantial problems with the delivery of the health visiting service have resulted in significant action being taken as a matter of urgency and several recommendations within the SWYPFT IMR including the need for an overall review of the Health Visiting Service. It is essential that this is undertaken without delay. 5.7 Although the above issues are the major concerns to have emerged from this SCR, other lessons have also been learned that will help to improve practice. The following issues have emerged in relation to services provided to Child K and his family. 5.8 Pregnancy care given to MK in connection with Child K was generally of a good standard although there was insufficient communication between the maternal mental health team and the midwifery service. There was also a complete lack of contact with FK and very little information gathered about him. When MK booked for pregnancy care, she told midwives that she was no longer in a relationship with FK and he did not attend antenatal appointments, although both MK and FK report that he did attend for the first scan. MK named FK and provided some history about him although she did not include some important information. Given the increased awareness of the importance of fathers to the wellbeing of young babies; and the potential risk they can pose to young babies it is the view of the IORA that health professionals within maternity services and health visitors should gather as much information about father’s social and significant medical history as they can. The current systems, as described by the author of the STHFT IMR, are clearly not designed to facilitate the collection of such information about fathers. Even where it has been collected in connection with one pregnancy it will remain hidden if the man has a child with another woman, even if the same hospital trust provide Overview Report concerning Child K Page 102 of 115 maternity services for both pregnancies. This is because information about the father is filed within the mother’s records. Patient choice, which results in situations where the parents of a child are not always registered with the same GP practice, adds to this problem. There are no simple solutions to these issues and the IORA considers that they need to be addressed at a national level. 5. 9 MK moved from Sheffield to Barnsley during her pregnancy but continued to receive all her antenatal care in Sheffield and she gave birth at hospital in Sheffield. The midwifery service in Barnsley was not told about MK and Child K until they were discharged from hospital following Child K’s birth with the result that there was no antenatal contact from Barnsley midwives. Furthermore the social history gathered by STHFT midwives was not passed on to those from BHNFT. These factors together meant that Barnsley midwives had less information about the family than would usually be the case, in particular they had little social history. The IORA believes that both BHNFT and STHFT need to enter into agreements with neighbouring Trusts regarding information sharing when a woman is due to receive postnatal care from a different Trust than the one from whom she has received antenatal care and/or with whom she has given birth. 5.10 Although midwives from BHNFT visited MK and Child K an appropriate number of times after they were discharged from hospital, the visits were all carried out by different midwives. This is not best practice and is reported to be unusual. BHNFT have been unable to establish why this was the case. 5.11 This review has found two shortfalls in practice that were also found in another SCR completed recently in Barnsley. Firstly neither the midwives nor the health visitors addressed the dangers of shaking a baby with MK and FK and secondly the handover from the Barnsley midwives to the Health Visiting Service was only done verbally when policy requires the midwife to complete a discharge form and give this to the health visitor. These issues have both been addressed as a result of the previous SCR. 5.12 Professionals working with Child K and his family in Barnsley were not aware of key aspects of FK’s history including the fact that he had "another child" who had been on the Child Protection Register, that he had a history of drug misuse and that he had been involved in a number of domestic incidents with his previous partner. Because midwifery services in Sheffield did not have this information about FK it would not have come to the attention of midwifery services in Barnsley even if communication between the two sets of midwives had been better. Had the health visitor in Sheffield maintained contact with FK in connection with the care he provided to "his first child" this might have been a channel by which important information could have been shared with agencies in Barnsley. Alternatively it could be expected that relevant information from FK’s medical record could have been shared by the GP with the health visitor. In reality the GP and health visitor did not communicate about FK’s history and, furthermore information about the domestic violence and "his first child" having been on the Child Protection Register was on "the child's" medical record but not that of FK. Overview Report concerning Child K Page 103 of 115 5.13 The lack of knowledge that professionals in Barnsley had about FK also suggests that they were insufficiently inquisitive about his history and did not adequately assess his parenting capacity. This is a further example of professionals not engaging with male carers. In the case of FK this was particularly important as from May 2011 onward he was the sole carer for Child K and "his sibling" two days each week as MK had returned to work. As a male carer he felt uncomfortable accessing baby and toddler groups because there were no other men there and without access to a car he was isolated. Health visiting services need to be aware of the specific needs of men who are caring for their children. 5.14 It appears that the medical care provided to Child K after his admission to hospital on 28 September 2011 was appropriate and largely of a high standard. BHNFT did however encounter a problem with paperwork, in that the Child Protection Pack used by the paediatric consultant was an out of date pack with the result that social care were not explicitly informed of the Paediatrician’s opinion about whether injuries were suspicious. This issue has been addressed. 5.15 The EMBRACE consultant from SCNFT encountered difficulties being required to deal with incoming requests for service whilst at BHNFT attending to Child K. This issue has been addressed by SCNFT by way of a new protocol which will reduce the likelihood of such a situation occurring in the future. 5.16 Barnsley Social Care had no knowledge of Child K until after he had sustained the injuries that led to his death. The service then received seven phone calls and one fax from four different agencies and had some difficulty managing this. As a result the Barnsley Social Care IMR contains recommendations to improve the service that Business Support Staff can provide within the Social Work Teams. 5.17 The main impact of the difficulty faced by Barnsley Social Care was that staff were not aware that Child K had a sibling until the evening of 28 September 2011 after Child K had died and this resulted in a delay before any action was taken to ensure "the sibling's" safety. If Barnsley Social Care had managed the phone calls and fax regarding Child K more effectively on 28 September 2011, it is likely that they would have become aware of "the sibling" much earlier in the day. 5.18 An additional complication was that Barnsley Social Care did not believe that Child K’s injuries were being treated as suspicious during the day on 28 September 2011. This misunderstanding stemmed from the Police believing that medical staff considered the injuries to be not serious and the cause not suspicious. This in turn was the result of communication between the Police and the Emergency Department consultant. The IORA has made a recommendation to minimise the likelihood of a similar situation occurring in the future. 5.19 The result of Barnsley Social Care not being aware of "Child K's sibling" and understanding that the injuries were not considered to be suspicious Overview Report concerning Child K Page 104 of 115 was that there was a delay in taking action to ensure the safety of "the sibling". Once the out of hours team became aware of "this child" there was a quick response which was largely appropriate although the medical assessment did not adequately explain the small bruises to his abdomen. 5.20 In addition to consideration of the services provided to the family of MK, FK, "Child K's sibling" and Child K, consideration has been given to agency involvement in Sheffield with the family of FK’s older child. 5.21 "This other child" remains alive and well, living with their mother and the majority of agencies involved in providing services were never involved in providing any services to Child K. Therefore these agencies’ involvement in the SCR has been somewhat divorced from the events that led to it being commissioned. Nevertheless it was important that agencies’ involvement with "this other child" was considered as it enabled the SCR Panel to consider whether information was known about FK that should have impacted on the services provided Child K and his family. 5.22 Although the majority of agencies who were involved with "this other child" were never involved in providing services to Child K, their contributions to the SCR have resulted in some important lessons being learned which will be translated into changes in practice to improve their capacity to safeguard children in the future. 5.23 The review of services provided to FK and "his previous partner and child" in Sheffield has found several examples of good practice including the decision to carry out a pre-birth assessment when "the previous partner" was pregnant and the subsequent decision to place "the child" on the Child Protection Register. Subsequently, after "FK's previous partner and child" became homeless good support was provided by the health visitor. 5.24 The IORA considers that not all issues were fully considered when the decision was made to remove "FK's first child" from the Child Protection Register and is concerned about the lack of any involvement from Sheffield Social Care as soon as they were removed from the Register. Consequently the IORA is pleased to learn that the policy within Sheffield Social Care has changed and any child who now ceases to be subject to a Child Protection Plan will be classed as a Child in Need for a transitional period. This should ensure that, in the future, such cases will have a clear plan which will detail the support to be provided from services such as Children’s Social Care and the Health Visiting Service. 5.25 Shortly after "FK's first child" was removed from the Child Protection Register, FK commenced treatment for a viral infection. It was known that this treatment was likely to make him feel unwell and to have an impact on his emotional well being and subsequently he reported, at a number of out patient’s appointments, that he felt ‘snappy’ and/or anxious. However, there was no consideration of the impact of FK’s emotional situation on "his child". Furthermore, although the Infectious Diseases Team communicated with the GP about FK’s treatment there was no communication between the GP and health visitor or Infectious Diseases Team and health visitor. The IORA accepts that there is no evidence that Overview Report concerning Child K Page 105 of 115 this led to a negative outcome for "the child" but believes that more consideration should have been given to the potential for it to impact negatively on the child. This review has found that staff at STHFT have become more aware of the need to consider the welfare of children when providing services to adults and that STHFT have introduced a new policy in relation to this since the Infectious Diseases Team were involved with FK. 5.26 There were also other times when insufficient consideration was given to FK. The pre-birth assessment relied on self-reporting from FK about his history rather than information being checked and validated with other agencies and after FK and "his previous partner" separated, services had no further contact with FK even though he was regularly caring for his child and was living at "a family member's" home where there had been previous concerns about people who may pose a risk to children. Many SCRs have identified that professionals have not engaged with fathers and other male carers and although agencies are becoming more aware of this and adapting policies to encourage greater engagement, this is a slow process and much still needs to be done. 5.27 The Police were called to six domestic incidents between FK and "his previous partner" and in all cases they recognised the potential impact on "their child" and took appropriate action, including making Social Care aware of the incident. The IORA is of the opinion that Sheffield Social Care should have undertaken more thorough assessments in response to these incidents and their potential impact on "the child". Three of these incidents took place after Social Care ceased their involvement with the family and the main professional involved was the health visitor. However the health visitor was not informed of two of these incidents and was therefore unable to address them with FK or "his previous partner" or even to take them into account in respect of her work with the family. The Joint Investigation Team now operating in Sheffield appears to be a positive development that should help to ensure that appropriate agencies are now made aware of incidents such as these in a timely way. 5.28 YAS identified an occasion when ambulance staff attended an incident when "the previous partner" had been the victim of an episode of domestic violence. On this occasion there is no record of the identity of the perpetrator and therefore it is not known whether it was FK. The ambulance staff were aware that "a child" was present but did not identify the potential impact of domestic violence on a child and consequently did not inform Sheffield Social Care. YAS has taken appropriate action with regard to the individual staff involved in this instance and no further recommendation is made. 5.29 "FK's first child" sustained four minor head injuries during the period covered by this review. None of these was felt to be suspicious at the time and there is no evidence to suggest that any of them were suspicious. Nevertheless it is emphasised that professionals need to demonstrate ‘respectful uncertainty’ when faced with an injury to a young child, particularly a non-mobile infant which they were at the time of the first injury. It is also important that professionals consider incidents in the light Overview Report concerning Child K Page 106 of 115 of the family history rather than treating each incident in isolation. In order to do this it is important that the incidents and subsequent decision are thoroughly recorded for future reference. 5.30 At various times throughout the period covered by this review there are examples of some shortfalls in record keeping and communication within and between agencies. These are outlined in this report. 6. Recommendations 6.1 39 recommendations are made within the Individual Management Reviews and the Health Overview Report and these have all been accepted and signed off by the individual agencies. The Panel and IORA are in agreement with all the recommendations. They are not repeated here as they are in the individual IMRs and in the Integrated Action Plan which is included as Appendix 2 of this Overview Report. The Integrated Action Plan will be monitored by the Barnsley Safeguarding Children Board Quality Assurance Sub-Group to ensure that they are fully implemented. Implementation of recommendations that apply to agencies within Sheffield will be monitored by SSCB who in turn will report to BSCB. 6.2 In addition to the recommendations made in the IMRs the IORA and Serious Case Review Panel make the following recommendations: Recommendations to Barnsley Safeguarding Children Board 1. The Chair of BSCB, on behalf of the Board, should ensure that appropriate managers within South Yorkshire Police, BHNFT and Barnsley Social Care develop a protocol to guide communication between the agencies in cases where a child attends hospital and there are possible safeguarding concerns. 2. The Chair of BSCB should ensure that the Board consider what action it can take to promote the involvement of fathers in groups such as baby and toddler groups. Recommendations to Barnsley Hospital NHS Foundation Trust (BHNFT) 3. The Strategic Health Authority will work with the Head of Midwifery for Barnsley and the surrounding area to agree a process that ensures issues arising from recommendations in the Overview report are addressed. 4. The Named Doctor for Safeguarding Children at BHNFT should ensure, following discussion with consultant colleagues, that paediatricians are provided with additional guidance regarding the need to consider the possible causes of any injuries identified during medical assessments and to clearly record their interpretation of the injury in the assessment report. This should be completed by the end of July 2012 in preparation for the induction of new middle grade doctors in August 2012. Recommendations to STHFT Overview Report concerning Child K Page 107 of 115 5. The Head of Midwifery at STHFT should ensure that agreements are made with neighbouring hospital trusts regarding information sharing when a woman is due to receive postnatal care from a different Trust to the one from whom she has received ante natal care and/or with whom she has given birth. This should include agreement regarding which trust will undertake a pre-birth home visit, when information will be shared and what information will be shared. Overview Report concerning Child K Page 108 of 115 Appendix 1 – Genogram = MK FK MK's first child (Child K's Sibling) Child K dob .10.10 dod 28.09.11 FK's Previous partner FK's First Child Overview Report concerning Child K Page 109 of 115 Appendix 2 – Integrated Action Plan 1. The Executive Director for Safeguarding Children will ensure that all recommendations identified within the Health IMRs (including Sheffield Children’s NHS Foundation Trust and Sheffield Teaching Hospital’s Foundation Trust) are completed within the timescales identified 2 The Chair of BSCB, on behalf of the Board, should ensure that appropriate managers within South Yorkshire Police, BHNFT and Barnsley Social Care develop a protocol to guide communication between the agencies in cases where a child attends hospital and there are possible safeguarding concerns 3 The Chair of BSCB should ensure that the Board consider what action it can take to promote the involvement of fathers in groups such as baby and toddler groups 4 The Head of Midwifery at BHNFT should ensure that agreements are made with neighbouring hospital trusts regarding information sharing when a woman is due to receive postnatal care from a different Trust to the one from whom she has received ante natal care and/or with whom she has given birth. This should include agreement regarding which trust will undertake a pre-birth home visit, when information will be shared and what information will be shared. 5 The Head of Radiology at BHNFT should ensure that the service always has access to radiologists with the specialist skills and experience to interpret CT scans in very young babies. 6 The Named Doctor for Safeguarding Children at BHNFT should ensure, following discussion with consultant colleagues, that paediatricians are provided with additional guidance regarding the need to consider the possible causes of any injuries identified during medical assessments and to clearly record their interpretation of the injury in the assessment report. This should be completed by the end of July 2012 in preparation for the induction of new middle grade doctors in August 2012. 7 The Head of Midwifery at STHFT should ensure that agreements are made with neighbouring hospital trusts regarding information sharing when a woman is due to receive postnatal care from a different Trust to the one from whom she has received ante natal care and/or with whom she has given birth. This should include agreement regarding which trust will undertake a pre-birth home visit, when information will be shared and what information will be shared. Overview Report concerning Child K Page 110 of 115 8 The commissioning PCT need to be assured that staff working with families collate social information on parents and carers to assess parenting experience and wider support from family and friends. Develop an action plan and document in the records if further parenting support is required. 9 To ensure that the Health Visiting Service responds in a professionally accountable way, in line with policy and procedure and the NMC Code of Conduct an overall review of the Health Visiting Service is undertaken which includes robust consideration of the management and leadership structure within Health Visiting. 10 That Professional competency issues are considered and reviewed in relation to the practice of the practitioners involved in the case in relation to: 1. Following procedures and guidance in relation to safeguarding children. 2. Delivering assessments and care in line with the health child programme and to the required standard. 3. Individual professional accountability in line the NMC code of conduct 11 That the aide memoire that was developed for Health Visitors to ensure that all the relevant questions are asked during birth visits and subsequent other key contacts is re-launched and embedded within practice. This should include questioning ‘Why’ babies and small children have been presented to clinic or hospital away from their area of residence. 12 Where another professional contacts the Health Visiting Service regarding concerns about a child, that this leads to the gathering of further information which would enable a fuller assessment of the situation to emerge 13 That a learning event(s) takes place for all Health Visitors in relation to Record Keeping Standards for the Trust. 14 That SystmOne is accessible in all areas where baby clinics are held. Where this cannot be arranged consideration needs to be given to the movement of clinics to address this problem 15 The midwifery service at Hospital 1 should reassure itself that midwives use the required Maternity discharge/transfer notification paperwork needed to be completed when other hospitals are requesting post natal care be taken over by Hospital 1. 16 Hospital 1 should ensure that when the EMBRACE team transfer children to Hospital 2 that all medical images from CT scans etc. are transferred with them in all cases rather than the current case to case basis. Overview Report concerning Child K Page 111 of 115 17 Hospital 1 should ensure that regular checks are made in the Emergency Department to check that accurate and up to date documentation is in place for child protection medical assessments. 18 Hospital 1 should engage with partner agencies to ensure that there is two way feedback about specific safeguarding children cases. 19 Improve the generic information gathering on admission to early year’s settings. Ideally this would include a sibling checklist, previous names and addresses, any previous child care setting and the name of the Health Visitor. 20 Assess the impact on services of home visits for all new parents to early years settings as standard, including the practical implications and whether the systems in place adequately support families enough for this transitional period 21Develop a system whereby services (HV, School Health and Early Years) understand and establish their role in ensuring Universal Services/Early Intervention within relevant settings maintain a focus on families including those moving into the area 22 Children’s Social Care should review the level of administrative support available to individual teams and ensure that where initial referrals are being taken from the public minimum cover is always provided 23 Business Support staff should be experienced in the specific area of work they are engaged in and should have a good understanding of the operational needs and specific aims of that aspect of the service 24 Business Support staff should be able to focus on the specific task in hand and not have other responsibilities vying for their attention 25 The process for taking ‘contact-ins’ should be reviewed and further training offered to all Business Support staff to ensure that all areas of the ‘crib-sheet’ are covered. 26 Individual contributors to contact-ins should be clearly identified by name or initials. dates and times should be included to make it clear where additions have been made. 27 Where documents are received which are unable to be entered on ERIC a note must be made on the electronic record of their contents and receipt on the day they are received Overview Report concerning Child K Page 112 of 115 28 The use of the ‘R’ Drive for additional documentation which cannot be scanned into ERIC should be reviewed. If there is no alternative method it is essential that the existence of these documents is recorded as a case event 29 In procuring the new electronic recording system the lead for Social Care must ensure that documents can be scanned into or attached via hyper-link to the record itself 30 Telephone referrals from other specialties to the acute paediatric medical team should be backed up by a written referral in the clinical notes outlining clearly the reason for the referral and any risk factors or indicators of abuse identified 31 Discussions and decisions taken during medical handover sessions should be documented in the case notes routinely especially where there are safeguarding concerns. 32 Specialist registrars should discuss as a matter of routine, referrals from other specialties to the acute team with the on call consultant or consultant on service. Action Plans have already been put in place with regards to this recommendation as part of the action plans for Child E & F case reviews. 33 Risk factors and indicators for child maltreatment to be emphasised in training sessions for both nursing and medical staff. 34 Clinical leads in Infectious Diseases ensure where a course of out patient appointments are required for completion of treatment / ongoing reviews, that additional social information should be collected to include details of children in the household. 35 Clinical leads to ensure all Infectious Diseases staff comply with STHFT safeguarding children training plan (2011) 36 Head of Midwifery to ensure that background checks are performed on all women who refuse to give the name of the father of the unborn baby at the antenatal booking 37 Head of Midwifery to ensure that when referrals are made for specialist assessments (mental health & substance misuse) the lead professional (midwife or consultant obstetrician) receives appropriate feedback as to the outcome of those assessments. 38 Head of Midwifery to establish if recent changes to maternity records relating to fathers have been effective. Overview Report concerning Child K Page 113 of 115 39 When a parent/carer with a significant history is sharing the childcare once they are no longer living together in the same household, an assessment should be undertaken due to a change in circumstances 40 When an assessment identifies parenting concerns and that parent/carer moves to a different household, the current HV should inform new HV team of the history and concerns 41 Ensure all Health Visitors are aware of the Protocol for responding to Concerns About Injury or Abuse in Infants Under 1 year old (SSCB 2009) when assessing minor injuries 42 Ensure record keeping of Health Visitors are inline with SCFT policy and NMC standards 43 Practices encourage close working relationships with Social Workers and Health Visitors, by inviting them to attend Practice meetings 44 GP computer systems are reviewed to cross reference family members and read code any safeguarding concerns identified in the family, so if one member of the family moves GP, the information will follow 45 Any self reported information that comes to light during an assessment should be checked and validated with the relevant agencies in order to ensure the assessments are robust and objective 46 Sheffield Social Care to enhance their assessment processes to ensure that fathers views are captured and represented in assessments. This needs to include situations where children are not living with their fathers but have significant ongoing contact 47 Within the next 6 months, YAS will complete an information sharing qualitative audit with Barnsley District General Hospital Emergency Department and Paediatric Team, to test the robustness of information sharing during and following clinical handovers. Overview Report concerning Child K Page 114 of 115 Appendix 3 – abbreviations BHNFT - Barnsley Hospitals NHS Foundation Trust BSCB – Barnsley Safeguarding Children Board CAF – Common Assessment Framework CT scan – Computerised Tomography scan IMR – Individual Management Review IORA – Independent Overview Report Author LSCB – Local Safeguarding Children Board MAPPA - Multi-Agency Public Protection Arrangements MAST - Multi-agency Support Team NAI – Non accidental injury NHS – National Health Service NICE – National Institute of Clinical Excellence NSPCC - National Society for the Prevention of Cruelty to Children PCT – Primary Care Trust PICU – Paediatric Intensive Care Unit SCNFT - Sheffield Children’s NHS Foundation Trust SCR – Serious Case Review STHFT - Sheffield Teaching Hospitals NHS Foundation Trust SWYPFT - South West Yorkshire Partnership NHS Foundation Trust ToR – Term of Reference YAS – Yorkshire Ambulance Service Overview Report concerning Child K Page 115 of 115 Appendix 4 - References Barnsley Safeguarding Children Board (2011): Serious Case Review: Child H. Barnsley Safeguarding Children Board Barnsley Safeguarding Children Board (2011): Serious Case Review: Child L. Barnsley Safeguarding Children Board Brandon, M et al (2009): Understanding Serious Case Reviews and Their Impact. A Biennial Analysis of Serious Case Reviews 2005-07. Department for Children, Hospital 2ools and Families Fatherhood Institute (2010): The Guide for New Dads, Fatherhood Institute Gershon P (2005): Efficiency, efficiency, efficiency; The Gershon Review: public service efficiency and the management of change. The Work Foundation Laming (2009): The Protection of Children in England: A Progress Report. Her Majesty’s Stationery Office. Munro, E. (2011): The Munro Review of Child Protection – Final Report. Department for Education. NICE (2009): When to Suspect Child Maltreatment, NICE clinical guideline 89 – Quick Reference Guide, NHS Ofsted (2008): Learning Lessons, Taking Action: Ofsted’s evaluations of serious case reviews 1 April 2007 to 31 March 2008, Ofsted Ofsted (2011): The voice of the child: learning lessons from serious case reviews, Ofsted Ofsted (2011): Ages of concern: learning lessons from serious case reviews, Ofsted Royal College of Midwives (2011): Reaching Out: Involving Fathers in Maternity Care, Department of Health Royal College of Midwives (2011): Top Tips for Involving Fathers in Maternity Care, Department of Health Sheffield Safeguarding Children Board (2011): Serious Case Review: Child E. Sheffield Safeguarding Children Board |
NC50549 | Serious and life threatening non-accidental head injury to a 4-week-old boy in September 2015. Baby F was admitted to hospital with an intracranial bleed and resuscitated by senior medical and nursing staff. Family of Baby F was known to childrens social care and mother had been in contact with services sporadically since 2008. Parents were arrested and on bail during the serious case review, so did not contribute to the process. Case is still subject to police proceedings. Baby F requires continuous care and is being looked after by foster parents. Focuses on mothers care of 8-year-old half-sibling Child V and the missed opportunities to identify historic concerns over mothers parenting. In particular, record keeping and inter-agency cooperation and information sharing are presented as lacking. Similar concerns identified from other recent case reviews over a similar time period include: poor quality and inconsistent record keeping within childrens social care; absence of the voice of the child either in practice or in record keeping; a lack of professional curiosity about new male partners, their past history as a father and the potential impact this may have on an existing family unit. Recommendations include: ensure that each GP practice holds multi-agency safeguarding meetings involving midwifery and health visiting teams so that timely, accurate information regarding vulnerable families is appropriately shared; that childrens social care refresh its guidance on record keeping to ensure the accuracy and quality of chronologies maintained in case notes; reaffirm the importance of the voice of the child in the work of all services.
| Title: Serious case review: Baby F. LSCB: Coventry Safeguarding Children Board Author: Daryl Agnew Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. SCR Report: Child F v0.5 Page 1 Coventry Safeguarding Children Board Serious Case Review Baby F Date of serious incident: September 2015 Date of report: 1st May 2016 Agreed by Coventry Safeguarding Children Board: 24th May 2016 Independent author: Daryl Agnew SCR Chair: David Peplow SCR Report: Child F v0.5 Page 2 Contents Page no. 1. Summary of the case 3 2. Terms of Reference 3 3. The process 4 4. Background prior to the scoped period 4 5. Professional involvement with the family 6 6. Antenatal period and postnatal period 12 7. Findings & recommendations 16 SCR Report: Child F v0.5 Page 3 1. Summary of the case 1.1 The subject of this serious case review (SCR) is Baby F, a four week-old baby boy who was admitted as an emergency to University Hospitals Coventry & Warwickshire (UHCW) NHS Trust with a serious and life threatening intracranial bleed in September 2015. He was resuscitated by senior medical and nursing staff. Following a head scan, the consultant leading his care reported this serious non-accidental head injury to the police and children’s social care. 1.2 Baby F requires continuous care and is being looked after by foster parents. 1.3 This case is still subject to police proceedings and the overview report that follows is therefore based on analysis of evidence provided by most but not all of the professional staff involved with the family of Baby F. Once the criminal proceedings are concluded, an addendum to this report will be produced, if appropriate. 1.4 The family of Baby F were known to children’s social care. The mother had been in contact with services sporadically since 2008. 1.5 The focus of this review is Baby F and the non-accidental injuries sustained by him. However, the scope of this review includes a focus on parenting within this family. In particular, the review considers the parenting of an older half sibling, Child V and the risk factors and concerns raised about the family prior to Baby F’s birth, with an emphasis on understanding how agencies worked together and how the context of those agencies may have affected the work of their practitioners. 2. Terms of Reference 2.1 The terms of reference for the serious case review are as follows: How did services respond to various incidents that arose during the specified period? Was this appropriate? Is there any evidence from the siblings or any other source that the parents posed a risk? Did Services engage effectively with the family and identify subsequent risks and interventions? 2.2 The panels was made up of senior safeguarding representatives from the following agencies: West Midlands Police University Hospital Coventry and Warwickshire Coventry and Warwickshire Partnership Trust Coventry and Rugby Clinical Commissioning Group Coventry City Council Children’s Services Legal advisor to the Panel 2.3 It was agreed that the scope of the review would be a period of three years from 2012 when concerns were raised with children’s social care about Baby F’s older half SCR Report: Child F v0.5 Page 4 sibling, Child V, until September 2015 when Baby F sustained his head injuries. The SCR panel agreed that the history of Child V was also crucial in order to learn lessons for future practice. 2.4 In addition, the SCR panel requested that the reviewers consider recommendations from recent reviews, namely the importance of the voice of the child within professional practice. 3. The Process 3.1 The LSCB’s serious case review sub-committee met in October 2015 to consider the circumstances of Baby F’s injuries. It was recommended that the case met the threshold for a serious case review because of the serious harm to the child and the need to establish the way in which the authority and their Board partners worked together to safeguard him. 3.2 The parents of Baby F were arrested following the incident and were on bail during the period of the serious case review. The immediate family of Baby F therefore did not contribute to the SCR process. 3.3 Individual agency reports (IARs) and chronologies were sought from the five agencies involved with the family and the reviewers then conducted conversations with relevant practitioners. The SCR sought to understand practice from the viewpoint of the practitioners who were involved with the family of Baby F rather than using hindsight. 3.4 The independent reviewer presented the consolidated evidence, the key themes and lines of enquiry to the SCR panel for discussion and challenge. The subsequent evidence and analysis were shared at a practitioner event prior to completion of the final overview report. 4. Background prior to the scoped period Table of family members within the scope of this review Baby F Non-accidental brain injury sustained at less than 4 weeks old (Sept 2015) Relationship to child subject within the review Age at start of the review Mother (R) 31 Father (J) 29 Half sibling 1 (Child G) 11 Half sibling 2 (Child V) 8 Father of half sibling 2 (W) unknown 4.1 The mother of Baby F became known to children’s social care in 2008 in a key episode which lies outside the agreed timeframe for this review but which is an SCR Report: Child F v0.5 Page 5 important early indicator of her parenting skills and her future relationship with Baby F’s older half sibling. Key Episode 1: Mother’s parenting skills 4.2 In July 2008, at nine months old, Baby F’s older half sibling, Child V, was admitted to hospital for ‘failure to thrive’ (now known as ‘faltering growth’) but no medical cause was found. The child was referred by the health visitor (HV) who had been asked by the GP to arrange a visit to the family and to insist on the baby’s admission. The GP and health visitor were concerned that Child V was not gaining weight appropriately or reaching the expected developmental milestones. 4.3 After receiving a normal diet in hospital, Child V rapidly gained weight. Mother was educated in how to adequately feed her child during her admission. The hospital contacted the Referral and Assessment Service (RAS) in children’s social care and a social worker was invited to attend a meeting of professionals. Mother consented to social care being contacted. 4.4 Prior to Child V’s discharge from hospital, a discharge planning meeting took place to ensure that information was appropriately shared across the relevant agencies. This resulted in a health visitor led Common Assessment Framework (CAF)1 and agreement that there would be a referral to children’s social care if the proposed fortnightly HV appointments were not kept or if there was any weight loss. 4.5 Child V was eventually discharged from paediatric follow-up in March 2009 having continued to gain weight and to make good developmental progress. Analysis 4.6 This episode provides evidence of an early concern regarding the mother’s parenting skills and her ability to feed and nurture her child. One possible cause is wilful neglect however in this case, the support and advice provided for the mother enabled her to respond effectively to her child’s needs. The consultant paediatrician worked with social care and a joint decision was made to provide increased health visitor support and a health visitor led CAF, which proved effective. 4.7 Almost seven years later in 2015 when the mother was pregnant with Baby F, this previous medical information regarding concerns about the mother’s parenting skills was not known to the midwife who undertook the initial booking assessment nor to the health visitor who undertook a targeted antenatal visit in the 3rd trimester. The child’s record had been passed on to the school nursing service as Child V was by then of school age. 4.8 For the midwifery service however, this information would become known soon after the initial booking assessment as it would be part of the GP record used by the midwife undertaking the mother’s antenatal care. 1 CAF: The CAF (Common Assessment Framework) is a shared assessment and planning framework used by children’s services when it is felt that a child has additional needs. It is set up to identify those needs and coordinate relevant services. SCR Report: Child F v0.5 Page 6 4.9 It is recommended practice that GP practices hold regular multi-agency meetings at the surgery in order to share relevant information with professionals working with vulnerable patients. However, at the time of this review, the family’s GP surgery did not hold regular structured face to face safeguarding meetings involving the midwifery and health visiting teams. The practice nurse has some time to support vulnerable families and link to this team but contact with GPs is opportunistic, with support offered when an issue arises. 4.10 Currently, CWPT are implementing an electronic system of notes within health visiting. This will allow for easy access to family records for the health visiting service. If there are any concerns regarding a child or family, the HV will be required to make contact with the relevant school nurse to establish if there have been or are any concerns in respect of any siblings. 5. Professional involvement with Baby F’s mother and half siblings The Family GP 5.1 Throughout the three year scoped period of this review, Baby F’s mother and half siblings were registered with a GP practice. At the time of his injuries in September 2015, Baby F was in the normal process of being registered with the family GP but at less than four weeks old documents, including the birth certificate, were awaited in order to enable full registration. He had access to healthcare at the GP practice if required. 5.2 The mother has a previous history of anxiety and depression and had been offered counselling and anti-depressants by her GP. The mother had presented to the GP on several occasions with concerns about the behaviour of Child V and her failure to cope with her child. Over the course of an 18 month period when Child V’s parents were in dispute about custody and involved in court proceedings, the mother was diagnosed with anxiety and depression. The cause was noted as the stress with her former partner and Child V’s poor behaviour. 5.3 In April 2012, the GP referred Child V to Child & Adolescent Mental Health Services (CAMHS) but his initial referral was diverted in the assessment phase from a request for assessment to a positive parenting course. Child V’s case was seen as a behavioural rather than a mental health issue since the GP’s referral letter mentioned Child V’s behaviour rather than any concern about a mental health issue. This may account for the initial response from CAMHS. 5.4 In 2012, the mother also self-referred to children’s social care because she found Child V’s behaviour challenging and was concerned her child may be autistic. The social worker’s view was that the child’s behaviour was normal for the age and stage of development but that the mother’s management of misdemeanours was overly confrontational. A CAF was offered to the family but refused. 5.5 In late 2012, the GP referred the mother to Improving Access to Psychological Therapies (IAPT) as she had a two year history of symptoms and a reoccurrence SCR Report: Child F v0.5 Page 7 from five years previously. Assessments of need were undertaken and relevant support offered. The cause of the mother’s depression is recorded by her GP as having an autistic child although her anxiety and low moods go back further than Child V’s behavioural issues. Mental health services 5.6 The GP continued to make referrals to CAMHS during 2013 as mother had growing concerns about her child’s behaviour. In July 2013, a referral by Child V’s school to CAMHS was acted on and an assessment took place eight months later, in March 2014. Appointments for autistic spectrum disorder (ASD) diagnosis in the Trust currently take up to a year and so this assessment took place within the expected time frame. 5.7 From this assessment, Child V was diagnosed with ASD. The consultant clinical psychologist reported that Child V ’wouldn’t talk’ at the assessment session although she tried to get the child to speak. According to the clinical psychologist, ‘nothing stands out in this case’ and ‘there was nothing unusual in the accounts people gave of the child’s behaviour’. The clinical psychologist was not aware of the mother’s background history or her mental health issues at the time that she was assessing Child V. 5.8 The mother sought advice and was invited to a ‘managing angry behaviour’ course but failed to attend on two occasions. Her non-attendance was followed up but she did not engage well with CAMHS regarding her child’s behaviour. 5.9 Child V’s father (mother’s former partner) was not involved in the ASD assessment and queried this diagnosis. He reported that Child V’s behaviour at his home was normal, responding to sanctions appropriately although he did agree that the child lacked empathy. The Primary School 5.10 Child V had been the subject of a CAF while attending nursery and this was handed on to the primary school in September 2012. At the time of the child’s transition into primary school, concerns were raised by the nursery about the child’s behaviour and ability to adapt to change. Child V was described as a ‘selective mute’ by the nursery. 5.11 According to the school, Child V ‘settled into the class very well’ although concerns were raised about the child’s behaviour i.e. ‘would not share and would hurt other children’. In some situations, Child V ‘would stare adults out rather than communicate’. However, as time progressed Child V was able to engage with adults and children and the transition from nursery to school was described as ‘good’ by the school. The school’s CAF Coordinator led on this work with a focus on parenting needs and the mother’s difficulties in coping with her child’s behaviour. 5.12 The school made a referral to the family support worker (FSW) who gradually built a relationship with the mother. Together they discussed her difficult relationship with Child V and the FSW encouraged the mother to see her GP about her anxiety and SCR Report: Child F v0.5 Page 8 depression. The FSW was concerned about the mother’s differential treatment of her two children and her apparent lack of attachment to Child V. Key Episode 2: Primary school referral of Child V to children’s social care 5.13 On 14 May 2013, the school’s FSW made a referral to children’s social care because Child V’s father reported that he had observed bruises, which he thought were finger marks on his child’s arm, during a contact visit with him the previous weekend. 5.14 The referral was allocated to a social worker (SW) in the Referral and Assessment Service (RAS). Following discussion with a team manager, she undertook a joint home visit with the FSW to meet with the mother on 15 May 2013. They were concerned about conditions in the flat; a strong smell of urine as Child V reportedly ‘wet the bed nightly’. On checking the children’s bedroom, it was noted that on one side (for the older half sibling, (Child G) there was a ‘lovely made up bed’ but on the other side there was just a mattress and a few fleecy blankets on which Child V slept. Mother gave ‘lots of excuses’ for this, particularly Child V’s bed wetting. 5.15 It was made clear to the mother that this provision was not acceptable. The FSW had previously allocated money to the family (through the CAF) to provide new bedding for the children. The SW gave the mother two days to get a new bed for Child V. When the SW visited again a new bed had been delivered. As a result of her first visit, the SW reported that an initial assessment was required. 5.16 The SW was very new in her first post as a social worker at that time. She subsequently met with Child V but she was not able to recall whether this meeting took place at school or at home and the children’s social care file does not make this clear. She reported that Child V would not talk with her. No marks or bruises were seen by the social worker. 5.17 Following a strategy meeting attended by representatives from health, Child V’s school and the nursery school, the SW became the Lead Professional for the family. The FSW reported that she was told ‘quite clearly to stop working with the family’ at the strategy meeting. She was not happy about this decision and felt excluded from the ongoing support for this family. It was acknowledged that it may not have been made sufficiently clear to the FSW that as this case was now a child protection issue, the social worker would be the Lead Professional. 5.18 The SW conducted the initial assessment and noted the different ways in which the mother treated her two children, Baby F’s older half siblings. Mother did not respond well to challenges from the SW, confiding instead in her FSW. She disclosed to the FSW that the father of Child V, her former partner, had been abusive throughout their relationship. 5.19 During this assessment process, the father of Child V went back to court to obtain more contact with his child. The SW described him as ‘concerned’ about his child. In SCR Report: Child F v0.5 Page 9 total, the SW worked with the family for about a year and during that time developed a relationship with Child V who then started to relax with her and speak. 5.20 In June 2013, the school made another referral to the FSW. This was due to the lack of engagement between children’s social care and the family. The head teacher was concerned about the children during the summer period if other agencies were not sufficiently involved with the family. As a result, the FSW worked closely with the family during the summer to ensure they had enough food. She reported that mother’s moods seemed to improve as did her relationship with Child V during this time. The FSW eventually concluded her work with the family. 5.21 The outcome of the initial assessment in May 2013 was ‘No Further Action’ but the file was still open to RAS in August when management oversight recommended a CAF. However, in September 2013 this was changed to child in need (CiN) and transferred to the neighbourhood due to ‘ongoing concerns about Child V in the care of the mother’. 5.22 In October 2013, there were a number of referrals by the school. All were investigated and appeared to have no substance. A transfer summary was completed in December 2013 but the family case remained open in RAS. Children’s social care (CSC) reported for this review that it is difficult from the records ‘to determine the perceived level of concern about Child V and whether or how that perception changed or whether it simply drifted in the referral and assessment service’. The Police 5.23 On 16 May 2013, the Child Abuse Investigation Unit (CAIU) within the Public Protection Unit of West Midlands Police received a referral (see above paragraph 5.14) from children’s social care (made by the school to CSC) with concerns regarding the conditions of the mother’s flat and the sleeping arrangements for Child V. This referral was recorded on a child abuse (CA) non-crime number (i.e. when a third party referral discloses a vulnerable victim but where no police offences are disclosed) and referred on to the duty detective sergeant for review. 5.24 A strategy discussion took place later that day between the detective sergeant and the social worker in which it was recognised that although the state of the home was of concern it did not fall within the definition of criminal neglect. (The Children and Young Person’s Act 1933 i.e. neglected ‘in a manner likely to cause injury to health’ as a result of failure to ‘provide adequate food, clothing, medical aid or lodging’.) It was agreed that the investigation continue as a single agency CSC led enquiry with a view to an initial assessment being completed. Prior to this decision being taken, appropriate intelligence checks on the mother and her address were undertaken by the police. It was established that there were no historical concerns and this information was shared with the social worker and papers filed pending any further contact from CSC. This was effective practice that met the expected standards. Analysis SCR Report: Child F v0.5 Page 10 5.25 The referral to CSC in mid- May 2013 was appropriate and dealt with promptly but CSC report that it is not possible to follow the child’s journey thereafter ‘due to inadequate reporting’. The CSC agency report for the review acknowledges that record keeping within the service during this period was ‘very poor’. 5.26 Private family proceedings in relation to contact issues were initiated and CSC directed to provide a section 7 (CA 1989) report. The school was asked to report any injuries promptly to CSC. The Integrated Children’s System (ICS) file indicates a number of references to injuries and bruising reported by the mother and by the school during this period but poor recording means that it is difficult to understand the seriousness of the injuries or the dynamics between parents. There is only one record of Child V being seen in school by a duty worker in this period. According to CSC, ‘neither the voice of Child V, nor that of Child G, are evident’ from the records. 5.27 Child V was open to CSC on a child in need (CiN) plan from May 2013 – April 2014 and two home visits are recorded (24 hours apart following the first incident above). Child V was seen twice and that was in school (in May and October 2013 for separate incidents and by different workers). No CiN meetings are recorded. 5.28 Following a referral by Child V’s school on 23 May 2013 concerning an unexplained injury to the child’s hand, Child V’s social worker contacted the CAIU. Child V had explained to a member of staff the injury was the result of a bee sting. The SW and police officer from the CAIU discussed and agreed that the SW would visit the school to assess Child V’s injury and, if appropriate, arrange for a child protection medical. This took place the following day but no outcome is recorded. There are also numerous recorded telephone messages from the school and parents but no records of calls being returned. 5.29 Record keeping within the West Midlands Police Child Abuse Investigation Unit (CAIU) provides further important information. On 28 May 2013, the social worker provided an update for the police. She reported that she had visited Child V in school on the day that the referral was made to CAIU. Child V told the social worker the hand injury was a ‘bee sting’. The child protection medical was inconclusive with the paediatrician concluding that the injury could have been caused in a number of ways, including a bite. 5.30 The inter-agency working between CSC and the CAIU regarding these two referrals from Child V’s school met expected standards. However, the first referral to the CAIU (paragraph 5.23) focused on the state of Child V’s home and sleeping conditions and did not include the father’s concern about potential bruising on the child’s arm. In the case of the second referral (paragraph 5.28) where Child V had another concerning injury, and had the unexplained bruising (paragraph 5.23) been communicated to police, it would have been good practice in these circumstances for a joint police/social care visit to the child and to the child’s mother. 5.31 On 21June 2013, the police contacted CSC for an update on the outcome of the strategy meeting where the decision was made to progress to a section 17 child in need core assessment. CSC reported that the mother had been working with CSC SCR Report: Child F v0.5 Page 11 and they were pleased with the progress she had made. Given this progress, CSC felt the case did not warrant a section 47 enquiry with a view to an Initial Child Protection Conference. The case was accordingly filed by the CAIU unless and until any other concerns were raised. 5.32 CSC ‘management oversight’ in November 2013 records that Child V had bruising to her cheek and eye and that she said (to whom is not recorded) she did it whilst playing. There is no record that Child V was seen by a social worker or that either parent was spoken to. CiN meetings were held and further injuries investigated but they have not been recorded. According to the CSC agency report, the chronology was not sufficiently detailed. 5.33 The school also expressed concerns that minutes of meetings between agencies were not shared with them and therefore staff were not aware of any actions or outcomes for this family. Indeed, it was not until 28 April 2014 when the school contacted CSC again about the family that they were informed that the case had been closed. (The family file was closed following a paper review by a manager in April 2014.)The school’s view was that there was still work to do with this family and yet there had been no information or handover for them. Inter-agency working between CSC and the school appears to have been weak during this period. 5.34 It should be noted that this review covers a period when the RAS team was struggling to transfer cases to the neighbourhoods and caseloads were considered unreasonably high i.e between 30 and 50 cases. Staff were working on a three week cycle and SWs were getting up to 15 new cases each cycle making it very difficult to manage long term cases. Since that time, additional funding has enabled the recruitment of more social workers and the average case load is now about 20. 5.35 In addition, an external review of the Multi-Agency Safeguarding Hub (MASH) in late 2015 has led to further changes in practice with this team vetting initial calls and undertaking all the necessary background checks for any referrals. 5.36 The CSC agency report acknowledges that a child’s record should clearly identify professional concerns, the response of parents to those concerns, the child’s wishes and feelings and a clear analysis of the outcomes or actions necessary to ameliorate risk or to ensure that the child’s needs are being met. This approach clearly did not operate during the period under review. However, the attached social worker was able subsequently to describe her ongoing involvement with Child V during this period but she acknowledged that the lack of detailed recording means that their relationship is not fully captured in the child’s record. 5.37 Child V’s social worker described being ‘overwhelmed with things at that time – not progressing things so well’ as a result of her workload. It was acknowledged by a RAS manager that cases at that time were held for a very long time and as a result the status of a case was not always clear to the family or other professionals working with them, as in the case of the FSW. Interviews with RAS staff however indicate that practice is different today. The social worker described how this case would be treated today i.e. a single Child & Family assessment would be undertaken within 45 SCR Report: Child F v0.5 Page 12 days and a CiN meeting arranged if necessary. The case would then either continue as a CiN case, be stepped down to early help or go to a section 47 enquiry. 6. Antenatal period and postnatal period Key Episode 3: antenatal care 6.1 Baby F’s mother, R, booked for antenatal care around 12 weeks into her third pregnancy in late January 2015. She attended the booking appointment with J who she said was her new partner and father of her unborn baby (not the father of her two older children). She described him as her next of kin. 6.2 Her booking assessment was carried out by a midwife covering for another colleague who was on annual leave at that time. This booking appointment is a detailed process and includes questions about the mother’s past history and the completion of a mental health questionnaire. This questionnaire was important because mother reported problems with low mood and anxiety and that she had been on anti-depressant medication in the past. The mother responded positively to the question on whether she felt she might want support for her mental health issues. She also reported that her mood was currently ‘well controlled’ and was aware of the need to contact her GP if she needed further support. 6.3 It is normal practice for the mental health questionnaire to be faxed to the perinatal mental health team for referral for further assessment. It has not been possible to ascertain from the mother’s patient record if this form was received, whether it met the threshold for intervention nor any response to it. 6.4 The midwife described the mother as ‘quite honest and open about her involvement with social care’. She referred to her social worker and the occasion when the school reported bruising on Child V’s arms. She said that her daughter had behavioural problems and disclosed her ASD diagnosis. 6.5 As a result, the midwife completed a social care referral form in order to request further information from children’s social care about their involvement with the family and to inform CSC that mother was pregnant. This was not a referral with new concerns about a child but is the standard and currently accepted way of information sharing between health professionals and social care when requesting information. 6.6 A social worker in the multi-agency safeguarding hub (MASH) received the faxed referral from the midwife regarding the mother’s disclosure of previous social care involvement. She rightly considered this a request for information (and not a referral) and rang to speak with the midwife. She reported that the last involvement with the family was May 2013 and that the case was closed. They discussed the new father and the SW looked on the system to see if there were any reported concerns about him. She shared what she believed to be ‘relevant, proportionate information’ with the midwife i.e. the reasons why CSC had been involved with the family, in accordance with guidance on information sharing used within CSC at that time. SCR Report: Child F v0.5 Page 13 6.7 The midwife did not receive an adequate response from CSC and as a result the midwifery service at that point were unaware of the CAF and previous involvement with the family regarding mother’s parenting and her relationship with Child V. 6.8 The midwife reported that she did not ask mother the required question about domestic violence as her partner was present at the appointment. She said she knew there were plenty of other opportunities to do so in subsequent antenatal appointments. However she did ask appropriate questions of J and whether he had any children. He replied that he had a ten year old daughter but would not give her name or that of his former partner. J was described as ‘attentive’ during the appointment but the midwife was rightly concerned about his reluctance to disclose information about his daughter. Appropriately, she passed this information on to the midwife who would be supporting mother during her antenatal care. 6.9 There is no evidence on record that mother disclosed domestic abuse at any stage of her pregnancy, nor is there any suggestion that domestic abuse was a feature of this case. However, it is not clear from the review of records undertaken for this review whether or not mother was specifically asked about domestic abuse, as required. 6.10 As a result of this booking appointment, the midwife referred mother for consultant care because of her overall poor health. 6.11 Following a subsequent antenatal appointment in late February 2015, the attending midwife referred details of J (Baby F’s father) to RAS. However, since the case was deemed closed, the midwife was not able to speak with the social worker who previously worked with the family. The midwife gave the father’s name and date of birth and this information was entered onto system. The midwife also provided her contact details in case there were any questions about the family. 6.12 At the health visiting antenatal contact when Baby F was 7 months’ gestation, it was documented in the health visiting antenatal records that mother told the HV she was not living with her baby’s father (J) but they had planned for him to move in following the birth of the baby. No further information is documented in CWPT records regarding J or his role within the family. The HV antenatal records make no reference to Child V’s ASD diagnosis or its possible challenges for the family. This may have been because the mother did not disclose this information. Postnatal period 6.13 Following the birth of Baby F, mother and baby were discharged home two days’ later. In the postnatal period, mother and baby were seen for the primary postnatal visit by a midwife and both were reported to be well. Mother was reported to be well supported by her partner. Sleep safe advice was discussed with the parents and the sleeping environment checked. This indicates that recommendations from a previous SCR to check sleeping arrangements in addition to giving verbal and written advice have been embedded and followed by midwives. Further postnatal visits were undertaken including a home visit in response to a failure to attend the postnatal clinic. Baby F was gaining weight well and mother was reported to have ‘excellent’ SCR Report: Child F v0.5 Page 14 family support. It is not clear from records what this support involved nor whether the baby’s father (J) was living at the family home. Postnatal checks were completed. 6.14 On day 5 after birth, the health visiting service received notification of the birth. The HV admin team organises the allocation of the primary visit which should take place within 10-14 days (a national requirement). The allocated HV rang to arrange this home visit. 6.15 Mother agreed the home visit for seven days later. The HV went as planned but no one was at home. HVs usually give a narrow timescale for a visit e.g. between 10.00-11.00am. The HV was going on annual leave so the next visit was re-allocated to another HV. She called the mother and left a voicemail to visit at 10.00am on 8 September. This was already in breach of the national timeframe for the primary visit as Baby F would be 25 days old by that date. Once again, no one was at home and the HV left a calling card. It should be noted that the majority of primary HV visits in Coventry are all within the national timescale of 10-14 days. There is no alert if this timescale is breached. 6.16 The HV wrote that she planned to discuss this second missed appointment with a HV colleague but there is no documentation to confirm this discussion took place. The CWPT has a ‘Did not attend policy’ (DNA) to support and guide staff when access is an issue. A minimal requirement is to inform the GP and the referrer, in this case, the midwife. The records do not evidence that this occurred. 6.17 Twelve days later and well outside the required time period, the HV attempted to visit the family at home but was met by a police officer and informed of the incident and that Baby F was in hospital. Baby F was not seen by anyone from the health visiting service prior to his injury. 6.18 It should be noted that after the birth, Baby F’s mother visited the GP about her depression on 4 September 2015. Baby F was not assessed during this GP consultation. Analysis 6.19 CSC’s response to the midwife’s request for information was limited and inaccurate since the case was not closed in 2013. This has been acknowledged by CSC. One reason for this could be that only the initial assessment form on Child V’s case file was looked at by the social worker. This form had concluded that no marks were seen on Child V, the relationship between the mother and child had improved and that Child V had been referred to CAMHS for her challenging behaviour. ‘No Further Action’ was noted but as indicated above, the file remained open to the referral and assessment service. 6.20 However, if the case notes had also been looked at, the social worker would have seen CSC involvement regarding further injuries. Furthermore, if there had been a full chronology on record, it would have been possible to see whether there was a pattern to the reported incidents and whether that had any implications for a new baby. SCR Report: Child F v0.5 Page 15 6.21 Health and educational professionals interviewed for this review have expressed their frustration at the lack of access to the case social worker if a case has been closed and therefore feel that they are not able to get sufficient relevant information on their clients; for example, when children/families are going on or coming off a CAF. 6.22 At the time of this incident, all contacts and referrals to CSC would be treated the same. Now the multi-agency safeguarding hub (MASH) has introduced a differentiated system to enable a more effective and efficient response. 6.23 Over the past year, the Acting Early model has been rolled out across the city and enables professionals/agencies working with 0-5 year olds to learn about the work of other colleagues/teams and to share information and concerns. If this model had been in place at that time, the midwife would have been able to use it to find out more about previous family history where a social care case is deemed closed, as in this instance. 6.24 During the antenatal health visitor contact, there was a lack of professional curiosity regarding the new father J and his role within the family. It is recognised that more information should have been sought during the antenatal contact about the potential impact on the siblings of a new baby and a new male moving into the family home at the same time, particularly in relation to Child V. 6.25 It is evident from records that mother gave conflicting information to different health professionals regarding the living arrangements for the new father, J and also regarding the state of her mental health during the pregnancy i.e in some cases reporting that she was in good health with no issues of depression while being prescribed anti-depressants by her GP. There is no evidence that communications took place between the GP, midwifery services or mental health services with the health visiting service and so these issues were not explored any further with the mother. 6.26 The primary antenatal health visit did not take place within the required national timescale of 10-14 days but there is no recorded evidence that the health visiting service made contact with the mother’s GP practice to inform them about this lack of access to the mother and baby. Key Episode 4: Baby F’s admission to hospital 6.27 On 10 September 2015, Baby F was admitted as an emergency to UHCW with a serious and life threatening intracranial bleed. His father (J) attended with him; his mother was not present. He was resuscitated by senior medical and nursing staff and a detailed history of events leading up to his collapse was taken. 6.28 Following a head scan, the consultant leading his care discussed the findings with the father, his concerns about non-accidental injury and the need therefore to involve the police and social care. Details of this discussion and the father’s response have been documented in the medical records. SCR Report: Child F v0.5 Page 16 6.29 Baby F needed intensive care provided in a tertiary paediatric centre. For this reason, he was transferred to Birmingham’s Children’s Hospital. UHCW provided a detailed verbal and written handover to the hospital’s clinical team including a ‘clear and unambiguous referral letter’ from the on-call Paediatric specialist trainee who recorded that Baby F was felt to be the victim of non-accidental injury and as such would require further investigations including an ophthalmology examination and skeletal survey. In addition, the doctors at UHCW made immediate referrals to social care recognising the importance of safeguarding the welfare of other children in the family. 6.30 The management of this episode fully met the expected standards and rightly has been described as exemplary. Children’s social care involvement since Baby F’s admission to hospital 6.31 A social worker was attached to this case from Baby F’s admission to hospital and up to the first court date, a period of approximately four weeks. 6.32 Following a strategy meeting, it was decided that CSC undertake the supervision of the children and that Baby F’s two half siblings would remain in the care of the maternal grandparents. A police officer and social worker visited the two children and Child V was described as a ‘lovely child’ who talked and did not appear to have any communication difficulties. The social worker supervised contact meetings between the mother and her two children. She also reported that J, the father of Baby F, seemed to be well known to the two half siblings who appeared comfortable with him. 6.33 There was a clear procedural response from CSC during this period with the allocated social worker working closely with police and medical staff. The social worker’s involvement ended at court with the granting of the Interim Care Order; the two half siblings remain with their maternal grandparents and Baby F remains in foster care. 7. Findings and recommendations 7.1 There is little information in this report about Baby F. In the few weeks prior to his non-accidental injury, there was limited contact with agencies other than midwifery and his subsequent emergency admission to hospital. There were missed opportunities for health visitor contact as a result of mother’s failure to make herself and Baby F available for arranged HV calls and a failure to undertake the primary visit in his home. However, early midwifery visits report that both mother and baby were well. Baby F was gaining weight well and mother was reported to have ‘excellent family support’. 7.2 It is not yet clear who was responsible for the serious non-accidental injury of Child F or how it occurred. There is no evidence from this review to indicate that this injury could have been predicted or prevented by agencies working with the family. SCR Report: Child F v0.5 Page 17 7.3 It is clear though from the review that this family met the threshold for a CAF and effective information sharing across the agencies, as happens now with the Acting Early model, would have identified this need prior to the birth of Baby F. 7.4 However, the three year scope of this serious case review has focused also on the older siblings, in particular on Child V, and on the way in which services worked with the family to support them. Reviewing the care of Child V was important for assessing the risks for Baby F. This review has identified similar concerns from recent SCRs examining practice over a similar timeframe. 7.5 Most notably, those include: poor quality and inconsistent record keeping within children’s social care; the lack of an appropriate chronology for families involved with children’s social care which identifies accurate information, professional concerns and a clear analysis of action to be taken or outcomes; an absence of the ‘voice of the child’, either in practice or in record keeping; a tendency for ‘professional preciousness’ which sometimes results in the non-statutory sector being excluded or marginalised from ongoing practice with a client/family; a lack of professional curiosity about new male partners, their past history as a father and the potential impact this may have on an existing family unit; and timely and accurate information sharing by children’s social care with other agencies. 7.6 The Coventry LSCB should: seek assurance that the recommendation for each GP practice to hold multi-agency safeguarding meetings involving midwifery and health visiting teams is implemented so that timely, accurate information regarding vulnerable families is appropriately shared. Where relevant, these meetings should also involve school nursing teams; request that children’s social care refresh its guidance on record keeping to ensure the accuracy and quality of chronologies maintained in case notes; reaffirm the importance of the voice of the child in the work of all services, and in particular, within social care practice; ensure that agencies requesting information from children’s social care are clear about why the information is sought, and for what purpose; and seek assurance that there is a robust operational system in place to ensure that primary visits not performed in the 14 day timescale (where defined exceptions do not apply) are appropriately reviewed, responded to by the health visitor and appropriate actions taken. |
NC044970 | Partnership review into the support received by a 15-year-old girl, referred to children's services in September 2013, following an allegation of sexual abuse. Child D became a looked after child following admission to an inpatient setting and received services from a range of agencies including schools, acute services and mental health services. Review explored whether sufficient support had been offered to Child D during her childhood, which could have prevented the need for the most substantial level of state intervention during her adolescence. Identifies learning points, including: need for recognition of behavioural cues indicating abuse rather than relying on verbal disclosure; and need to use multi-agency safeguarding planning processes to address the variable pattern of cooperation in non-engaging families. Identifies areas of improvement for various agencies.
| Title: Learning from partnership review: Child D. LSCB: Reading Local Safeguarding Children Board Author: [Reading Local Safeguarding Children Board] Date of publication: [2014] This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. �����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������•�������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������•���������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������•�����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������• �����������������������������������������������������������������������������������������������������������• ��������������������������������������������������������������������������������������������������������• �������������������������������������������������������������������������������������������������������������������������������������������• ����������������������������������������������������������������������������������������������������������������������������• ������������������������������������������������������������������������������������• �������������������������������������������������������������������������������������������������• �����������������������������������������������������������������������������������������������������������������������������������������������������������������������• ����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������• �������������������������������������������������������������������������������������������������������������������������������• �����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������• ������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� |
NC52324 | Injuries to an infant due to shaking in April 2016. Learning includes: information offered to professionals by parents should be subject to professional curiosity; the importance of clarity of information regarding parental and family history; opportunity for multi-agency meeting and decision making should form an integral element of all work with young people and their families; timely information sharing between health professionals who are in significant direct contact with the family is a vital part of protecting children; safeguarding professionals need to understand and consider a variety of forms of domestic abuse to effectively assess risk and manage appropriate interventions. Recommendations include: consider revisiting the multi-agency pre-birth assessment pathway to ensure that partners are aware of and follow the pathway and that misconceptions regarding the timing of referrals for concerns regarding unborn children are addressed; ensure that concerns regarding unborn children are translated into current records pertaining to the child following birth; consider how agencies can best enable the family history to be incorporated into safeguarding assessment processes; ensure that the provision of domestic abuse services is not predicated on a stereotypical perspective in the context of recognition of abuse, understanding of the nature of abuse and recognition of the potential for physical harm to adults, unborn and living children. Please note that this report was written in 2017 but was published in 2022.
| Title: Report of the serious case review March 2017: Child R. LSCB: Blackburn with Darwen Local Safeguarding Children Board Author: Dallas Frank Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Report of the Serious Case Review March 2017 Child R 2 Contents 1.0 The Serious Case Review (SCR) 1.1 The context to the SCR 1.2 Key principles of SILP 1.3 Introductions to the case and family structure 1.4 Scope of review and terms of reference 1.5 The process/contextual information 2.0 Key Practice Episodes 2.1 Background prior to the scoped period 2.2 KPE one: Early pregnancy 2.3 KPE two: Later pregnancy 2.4 KPE three: Birth and first months 2.5 KPE four: Two months leading to incident of harm 3.0 Analysis of Practice 3.1 Knowledge and understanding of family history 3.2 Multi-agency communication and information sharing 3.3 Recognition of domestic abuse 3.4 Understanding of the nature of domestic abuse 3.5 Recognition of the risk of physical harm to the child as a result of domestic abuse 3.6 Assessment of risk of parental substance misuse and impact on Child R 3.7 Supervision and support of newly qualified workers 3.8 Cross agency understanding of services 4.0 Good Practice 5.0 Lessons learned 3 6.0 Conclusions 7.0 Recommendations 8.0 Appendices 8.01 Glossary 8.02 Bibliography 4 1.0 The Serious Case Review (SCR) 1.1 The Context to the SCR 1.1.1 This review was initiated because Child R experienced seriously harm whilst in the care of parents and this was considered by professionals to be non-accidental. 1.1.2 On the first of June 2016 Blackburn with Darwen Safeguarding Children Board (BwD LSCB) case review panel recommended that a serious case review in respect of Child R should be undertaken to consider how effectively agencies in Blackburn with Darwen had worked together to safeguard and meet the needs of Child R and to identify areas of learning. This decision was confirmed by the independent chair on the 7th of June. 1.1.3 Working Together 2015 is clear that professionals and organisations protecting children need to reflect on the quality of their services and learn from their own practice and that of others. Good practice should be shared so that there is a growing understanding of what works well. Conversely, when things go wrong there needs to be a rigorous, objective analysis of what happened and why, so that important lessons can be learnt and services improved to reduce the risk of future harm to children1 1.1.4 Serious Case Reviews and other case reviews should be conducted in a way which: • recognises the complex circumstances in which professionals work together to safeguard children; • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; 1 Working together to safeguard children 2015 5 • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • is transparent about the way data is collected and analysed and • makes use of relevant research and case evidence to inform the findings. 1.2 The Significant Incident Learning Process 1.2.1 The key principle of the Significant Incident Learning Process (SILP) is the engagement of frontline practitioners and first line managers, giving a much greater degree of ownership and a much greater commitment to learning and dissemination of lessons. SILP uses systems methodology, looking at how the actions of professionals are influenced by the organisations and systems in which they are working. The focus of this review was the effectiveness of professional systems to safeguard Child R and in understanding this, to consider events in the context of the child protection systems in Blackburn with Darwen at that time. 1.2.2 The chair of the review was Fiona Johnson, independent safeguarding consultant with significant experience of multi-agency working and practice and of facilitating serious case review; Fiona is an accredited SILP lead reviewer. The report author was Dallas Frank, an experienced strategic and safeguarding children board manager and accredited SILP lead reviewer. Neither Dallas nor Fiona had any previous knowledge or involvement in this case. 1.3. Introduction to the case and family background 1.3.1 Child R was the first child born to his mother and father who are both of white British heritage and had been in a relationship together for 13 months. Both parents were known individually to a range of services and there were child protection concerns about father when he was a child. 6 1.3.2 Child R was presented at the local accident and emergency department with a history of difficulty in breathing, vomiting and being unsettled. Subsequently Child R’s condition deteriorated and a head computed tomography (CT) scan identified subdural haemorrhage, the injuries were unexplained and a non-accidental cause was considered. Further investigations at a tertiary hospital found Child R to have subdural haemorrhage, brain injury and retinal haemorrhages. The only possible explanation for this constellation of findings was a non-accidental injury due to shaking. 1.3.3 At the time of writing Child R resides back with local authority foster carers as a result of the breakdown of the extended family placement. Child R is the subject of a Care Order made to the local authority. After initially experiencing an unsettled period, Child R is described as contented with good interactions to both parents and carers, smiling and vocalising. Child R’s prognosis remains unclear in respect of development of vision although professionals believe this to be more positive than initially anticipated. The local authority is currently undertaking assessments in regard to Child R’s long term permanent future. 1.4 Scope of the review and terms of reference The time period for the review is between January 2015, when mother was known to be pregnant, and April 2016, when the injuries occurred. The specific terms of reference as agreed by the Blackburn with Darwen Safeguarding Children Board include; • How well was the family history understood for the purpose of assessment? Where any specific tools used to analyse the history and if so, where they well used and shared within and across agencies? • Please analyse the approach taken to the parents’ historical missed appointment/non-compliance? How did the parents’ 7 continued poor engagement impact on service provision as the case progressed? • Please critically evaluate the quality of assessments generally. Was the risk to Child R well understood? • Multi-agency meetings were taking place in Child R’s case. However, could communication and information sharing have been improved between agencies as part of this process? Were the correct agencies in attendance at meetings? • How well did the professional network understand and respond to new developments within the case? Were services planned and prioritised appropriately? Were services effective in addressing need and reducing risk? • Did action plans clearly reflect where professional responsibility lay for the delivery of the plan? • Did the involvement of the Family Nurse Partnership lead other agencies to believe that Child R was adequately safeguarded? • Did communication within services operate effectively, for instance during transitions between parts of a service or between practitioners? What role did record keeping play in this? • Please identify examples of good practice, both single and multi-agency. 1.5 The Process and Contextual information Decision to undertake SCR; 1st of June 2016 Scoping meeting; 8th of July 2016 Authors Briefing; 25th of July 2016 Agency reports completed; 23rd of September 2016 Learning Event; 10th of October 2016 Recall Day; 11th of January 2017 Presentation BDSCB; 4th April, 2017 8 1.5.1 Individual agency reports were received from the following sources: • Children’s Services. • Homeless Charity. • Community Health Trust providing adult mental health & psychology services and Family Nurse Partnership. • Two Domestic Abuse Services. • Hospital Trust. • Two GP practices. • Police. • Probation Service. 1.5.2 2011 Census revealed that Blackburn with Darwen had approximately 57,453 households and 147,489 residents, and a younger than average age profile, with 28.8% of its population aged under 20, which is the fourth highest proportion in England. The borough’s population is diverse, with 13.4% of residents having Indian heritage and 12.1% Pakistani. Deprivation scores continue to be based on the 2010 Index of Multiple Deprivation, which ranks Blackburn with Darwen as the 17th most deprived borough in England. The generally high levels of deprivation have consequences for the borough as a whole, and the contrast between neighbourhoods also leads to significant internal health and social care inequalities2. 2.0 Key Practice Episodes 2.1 Background prior to the scoped period 2.1.1 Child R’s father has been described as ‘a very ‘bright young man who could rationalise well’ and is very ‘capable’. He and his siblings were known to children’s social care (CSC) from 2004 and were the subject of a child protection plan between May 2007 and January 2008, in the 2 Blackburn with Darwen Joint Strategic Needs Analysis (JSNA), 2014/15 9 category of neglect. During this period of intervention a sibling of Child R’s father disclosed sexual abuse, and the family were supported on a ‘child in need’ basis until the case was closed in January 2012. 2.1.2 Following his sibling’s disclosure Father experienced a turbulent adolescence when he displayed anti-social behaviour, undertook criminal damage and was a user of drugs and alcohol. In 2012 father became homeless and was signposted to a local homeless and housing chairty3, where he received a significant level of intervention and support over nine months. Father was also known to the youth justice services prior to 2014 when his further offences led to the involvement of Probation Services4 between June 2014 and June 2015. Child R’s father was involved in substance misuse and had expressed concerns regarding his ability to manage his anger. In January 2014 father was again homeless and moved to new accommodation where over a period of sixteen months staff noted concerns relating to cannabis use and abusive language, rent arrears and handling stolen goods. Probation was involved during this period and improvements were noted between April and November 2014. Father made a planned move to new accommodation with a social landlord in April 2015 as part of a move on process. 2.1.3 Child R’s mother has been described as a ‘pleasant young woman’ who spent a significant period of her childhood living with her own mother and sister in the home of her maternal grandparents. During this time Child R’s mother was exposed to a number of domestic violence incidents leading to referrals to CSC between 2007 and 2009, resulting in an assessment of her and her sibling’s needs. The outcome of this 3 A local homeless charity based in Blackburn providing holistic services to homeless young people aged 16 to 24 in Blackburn and Darwen. 4 Probation services work with offenders to help them lead responsible and law abiding lives, to reduce reoffending and protect the public. 10 assessment was ‘no further action’ as Child R’s grandmother was perceived to have the ‘capacity to protect’. Between November 2012 and January 2013, further referrals were received by CSC in relation to Child R’s mother. The identifying concerns included; substance misuse, anger management, anti-social behaviour and putative pregnancies. She was reported missing on several occasions and was perceived to have been at risk of child sexual exploitation (CSE) as a result of her association with an adult male in 2013. As a result, mother had a warning marker on the police national computer record indicating that she may have been a victim of child sexual exploitation. Mother had poor school attendance at primary school and was excluded from her secondary school as a result of her bringing drugs into the school. Mother also had limited involvement with youth justice services and there was police involvement due to anti-social behaviour and substance misuse. In April 2014 mother presented at the homeless charity and in January 2015 presented to the Council’s housing service as homeless; on both occasions it was ascertained that mother was residing at maternal grandmother’s house. 2.1.4 Parents continued to regularly access day centre services at homeless charity throughout the time period covered in this serious case review and after the injury to Child R. 2.2 Key Practice Episode One: Early pregnancy 2.2.1 In February 2015 Child R’s father was referred to the ‘Evolve’5 program by the probation service following his acknowledgement of continuing use of substances, an appointment he failed to attend. He was seeing his GP because of anxiety and stress and was being prescribed medication for his condition. 5 Evolve – a service to support young people regarding drug and alcohol misuse. 11 2.2.2 Information was received into the Multi Agency Safeguarding Hub (MASH) team from the police in mid May 2015 regarding an altercation between Child R’s parents. Information received indicated that father alleged he had been assaulted by mother who was two months pregnant. Father accused mother of ‘slapping him’ and she countered with allegations that he had used abusive and sexually explicit language towards her. Neither party wished to pursue a complaint regarding this incident and a standard risk protecting vulnerable persons (PVP) referral was made. Prior to sharing the PVP with other agencies, police officers in the MASH upgraded the risk assessment from standard to medium due to the past intelligence on police records and checks undertaken with the police officers in the CSE team6. This referral was shared across agencies in the MASH and resulted in no further action from children’s social care. Agencies involved with parents at the time of this incident include the Probation Service, GP and Homeless Charity. However, the parents respective GPs and Homeless Charity were not contacted by MASH following the PVP referral to assist in information collation. Domesitc Abuse Service 1 received the PVP and as there was no phone contact details, a letter was sent to mother to contact the service. Mother did not respond to the letter. Mother did not book her pregnancy with the hospital midwifery service until a few days after the incident. The midwifery service and Probation Service received the PVP referral and resulted in no further action. 2.2.3 Also in May mother attended an ante-natal booking appointment regarding her pregnancy with Child R. The midwife undertook a social needs assessment and mother disclosed previous substance use by herself and her partner and their previous history of social care intervention. A special circumstances form was completed and mother 6 The CSE Team works to identify and support children and young people at risk of sexual exploitation and their families 12 was referred to the children’s centre and the local authority early help teenage pregnancy worker which resulted in the Family Nurse Partnership (FNP) nurse becoming involved in June. 2.2.4 In June the Homeless Charity received information regarding mother’s pregnancy and father’s house being used as a ‘party house’ and submitted a referral to MASH following discussion and assistance from the local authority teenage pregnancy worker. The referral included concerns regarding; the welfare of the unborn child due to domestic abuse, drug and alcohol mis-use, parents on benefits, disguised compliance, young inexperienced parents, father’s chaotic past and criminal offending and mother being barred from Homeless Charity as a result of violent behaviour. This information was not considered in MASH until some days later and the reason for this is unclear. Two weeks later the MASH team including the local authority early help teenage pregnancy worker visited mother and following this the referral was passed to children’s services social care for a child in need assessment and was allocated to a children’s services social worker. By the end of July, the social worker had collated information for the assessment from the parent’s historical social care records, respective GPs and family nurse. Probation and the Homeless Charity were not contacted to contribute to the assessment. Service provision at this stage was listed as: ‘referral to the substance misuse midwife; engagement with the family nurse partnership and antenatal care; parents to undertake couple counselling and parents to work with a family support worker. The social worker to complete the assessment and escalate any non-engagement to a manager to review’. 2.2.5 In July father contacted his GP presenting with anxiety and stress symptoms. He was prescribed medication and advised regarding the process for self-referral for psychological treatment for anger 13 management and stress control. Also in July mother attended the early pregnancy unit following a fall to her abdomen there is no record of how the fall occurred and there is no evidence that domestic abuse was explored with mother. In August mother attended the Homeless Charity daycentre briefly with a facial injury, possibly a cut lip. When asked if these injuries had been caused by father she nodded and left the building. The worker pursued this with mother and was later told that the injuries were not caused by father but were the result of ‘fooling around’ with her sister with a skipping rope. Around the same time mother was found to have covered up facial bruising with excessive make-up when visited at home by the social worker. The Homeless Charity workers discussed the bruising with the local authority teenage pregnancy worker who in turn shared it with the social worker. The social worker immediately made an appointment with mother and spoke to father on the phone. Mother minimised the incident but father admitted he had caused the bruising whilst removing mother from his flat. The social worker referred mother to Domrestic Abuse Service 1. Also during this period a substance misuse midwife was identified although experienced some difficulty in contacting mother. 2.3 Key Practice Episode Two: Later Pregnancy 2.3.1 At the end of August the social worker referred mother to Domestic Abuse Service 1 however, the service was not aware of the previous parental relationship or their individual social care histories. An Independent Domestic Abuse Advisor (IDVA) was allocated to the case and an appointment booked for early September, the IDVA completed safety planning with mother over the phone. However, mother failed to attend the first appointment and the IDVA tried to contact mother and the social worker but without success. Mother did attend the IDVA’s offices some weeks later to request a new appointment and further safety advice was given. She did not attend this appointment either 14 and attempts to contact her by the IDVA were unsuccessful. Mother did attend an appointment with the IDVA in November when a risk assessment was completed which highlighted that mother was minimising her abuse. Safety planning was recommended for mother and she attended three sessions of the ‘freedom program’ in November before disengaging. 7 2.3.2 In September police attended an incident following an anonymous call indicating that mother and father were arguing and that mother had sustained bruising caused by father. On attendance police colleagues were informed by mother that the bruising was caused as a result of her slipping in the bath. Mother also indicated that she had hit father as he had insulted her mother. Evidence suggests that mother had attacked father who had defended himself by blocking the attack causing injury to mother. The attending police officer completed a PVP referral assessing the risk as standard and a crime report for assault. Police officers in MASH upgraded the risk to medium (the report author for the police agency is of the opinion that the incident should have been upgraded to high risk). The sharing of information with children’s social care and the new domestic abuse service 2, was completed nine days after the police home visit. The midwifery service received the PVP fourteen days after the home visit and the family nurse partnership received it after twenty two. Domestic Abuse Service 1 was no longer the local authority commissioned domestic abuse service and they did not receive the information. Domestic Abuse Service 2 contacted mother by phone on the second, fifth and sixth days after receiving the PVP but with no success. The service updated the police record to note that contact had been unsuccessful and closed their case record of the incident. 7 Domestic Abuse Awareness and Support Group for Women the Freedom Programme is a 12 week support group for women. 15 2.3.3 The social worker completed the child and family assessment in September and recommended that because of concerns about the parents’ age and the concerns around domestic abuse there should be consideration of a multi-agency child protection plan. The social worker was of the opinion at this time that parents needed to live separately as the risk to baby would escalate if they were living together. A strategy discussion took place in October 2015 between police and children’s social care which decided to progress to Initial child protection conference (ICPC). The conference was held within statutory timeframes and was attended by police, substance misuse midwife, family nurse and social worker. The Homeless Charity and Domestic Abuse Service 1 were not invited, although this is disputed by the local authority and nor was the father’s GP. The meeting agreed that Child R should be the subject of a child protection plan because of concerns about emotional abuse. A core group attended by the family, social worker and family nurse was held in October and a further core group in November at which the social worker was the only professional present. 2.3.4 In October 2015 father referred himself to a the Adult Mental Health service8 stating that he was ‘feeling down’ and had ‘suffered bad things from the past’. He was offered trauma focussed cognitive behavioural therapy (CBT) and placed on a waiting list for the service. 2.3.5 During this period the family nurse completed five visits to the family to offer support. However, given that the schedule for (Family Nurse Partnership) FNP visits (weekly visits in first month and fortnightly thereafter), at least eight could have been undertaken during this time although a number of unsuccessful attempts were made to contact the 8 The service contacted offered talking therapies wellbeing service. 16 parents and resulted in fewer visits being possible. Seven visits were arranged but then cancelled by either mother or father and one visit the parents did not attend. Rescheduled meetings were offered via telephone message and text message but no response was received. No home visits took place in September due to mother being away for a family bereavement and due to mother being ill, as a result the domestic abuse incidents in August and September were not discussed face to face. During one of the home visits in October the FNP nurse witnessed first-hand the parents arguing. Routine antenatal care continued and there was good engagement with the community substance misuse midwife. 2.4 Key Practice Episode Three: Birth and First Months 2.4.1 In December a family support worker was allocated and undertook a number of visits to the family. This work was undertaken alongside that offered by the FNP nurse who had visited the family and offered a significant level of support. 2.4.2 The third core group took place in this period. However, due to sickness the social worker was unable to attend and as a result there was no children’s social work representation at the meeting, the FNP nurse chaired the core group. 2.4.3 In January a review child protection conference (RCPC) took place following the birth of Child R and agreed that the child protection plan should continue under the category of emotional abuse. Father was offered an appointment for cognitive behavioural therapy, but failed to attend and was discharged from the service in line with the Mindsmatter normal practice. 2.5 Key Practice Episode Four: Two Months Leading to Incident of Harm 2.5.1 During February and March the relationship between the parents deteriorated with escalating incidents of dispute. A further incident of 17 domestic abuse was reported in February when mother contacted the police and alleged that father was refusing to let her out of the family home. The police visited and saw both parents who acknowledged there had been an argument but neither of them alleged any violence had occurred. The police shared this information with other agencies via a PVP referral and the incident was recorded as standard risk with a note made that this was the third incident of domestic abuse in the previous 12 months. Two weeks later there was a further altercation which was witnessed by the early help family support worker visiting the home who noted that Child R was present during the argument. The following day father contacted the police by telephone, and during the call mother was heard to say ‘let me out’. Police attended as a grade 1 emergency and forced entry. Neither parent was in the property but, father returned soon after and mother was found nearby. The parents said they had been arguing about money and that father rang the police because mother was being verbally abusive. Mother confirmed to officers that she had snatched the telephone from Father who let her out of the house. Following this incident the police passed the information to other agencies via a PVP and classified the incident as medium risk. 2.5.2 In February father told the social worker that he was feeling low in mood but had not seen his GP for a month and had not commenced CBT, although he reported that he was still taking his medication. 2.5.3 In March police attended a further incident outside the family home when mother was found to be outside with her eleven week old baby. The maternal grandmother indicated that mother had just been discharged from hospital and that father had been violent towards her, father had also been caring for Child R during mother’s hospital stay. A standard risk PVP was submitted and information shared with children’s social care, IDVA, health and probation. At a later home visit (6 days 18 later) by the social worker, father disclosed that he was still taking drugs and had not been taking his medication. A week after the first police incdent in this month, police were called again because of a verbal argument between mother and father. The police officer who attended recorded that the couple need more support as they appeared to be struggling adjusting to a new baby. The officer submitted a PVP domestic abuse report assessed as standard risk. At the end of the month the social worker observed the parents were arguing and shouting during a visit and that Child R had remained content throughout the visit and did not react to parents arguing. Also at the end of March mother attended the Homeless Charity’s day centre service alleging that father had thrown her out of the house. Nightsafe provided a place for mother to feed Child R and she used her mobile to call the social worker. However, whilst the staff member who overheard the call had believed mother was talking to a social worker, the social worker has stated that she did not receive the call. 2.5.4 At the beginning of April Child R was presented to hospital with injuries which were considered likely to have been as a result of non-accidental injury. Care proceedings were initiated by the local authority and an interim care order granted in respect of Child R who was placed in local authority care. 3.0 Analysis of Practice 3.1 Knowledge and understanding of the family history 3.1.1 Child R’s mother received midwifery care from nine weeks’ gestation when she attended ante-natal booking at the hospital. At this time the midwifery staff undertook a ‘social needs assessment’ and shared information with the children’s centre via an early notification form. The assessment identified the need for further communication with children’s social care although this was not initiated and the rationale for this is not 19 known. However it is possible that this was because staff believed that CSC would not accept a referral prior to sixteen weeks gestation. It could be argued that if this direct conversation had taken place and information pertaining to the parents own histories of complex family relationships, drug and alcohol misuse and possible child sexual exploitation (CSE) had been taken into consideration, an early assessment of mother’s needs and those of her unborn child could have been considered more fully leading to earlier intervention and support additional to that provided by health services. 3.1.2 The assessment undertaken by midwives was in line with their procedures positively identifed the need for additional support for mother. This led to a referral to the children’s centre for a common assessment framework (CAF) assessment. The Children’s Centre panel considered the information and agreed a referral to the Family Nurse Partnership (FNP). However, the full range of family history and the implications of this were not well known by all professionals and the importance of this information as a tool to measure parental capacity to protect was not acknowledged. Most professionals relied solely on information provided by mother. Disguised compliance is a common factor in families living with domestic abuse and the maintenance of a healthy level of scepticism is a vital component of good practice. Triangulation of information should be a central element of assessment and the concept of ‘respectful uncertainty’ integral, in particular where there are additional indicators of concern for example teenage pregnancy, domestic abuse and current or historical substance misuse. It is the case nationally that ‘almost 60% of children involved in serious case reviews were born to mothers under 21’. 3.1.3 Both of Child R’s parents were known to have experienced volatile and chaotic environments as children and Child R’s mother, to have been exposed to domestic abuse as a child. Both parents exhibited volatility during adolescence and their own relationship was pervaded by 20 violence from its onset. Historical information regarding childhood experience and the parents own experience of being parented could have attracted more prevalence in respect of the first assessments undertaken in regard to the potential risk to their unborn child and the impact of these experiences on them as potential parents. Midwives undertook a social needs assessment and did identify the need for additional support however, as previously argued this relied on information provided solely by the mother herself. 3.1.4 Information was received into the MASH from the police in mid May 2015 regarding an altercation between Child R’s parents. Children’s Services in MASH considered this information and undertook initial enquiries but did not complete this until nine days later, as a result of difficulty in making contact with the mother. The Children’s Services team in MASH did contact the maternal grandmother who gave assurances that although a previous history of complex relationships substance misuse, anger management, anti-social behaviour and putative pregnancies was correct, she also stated that since meeting Child R’s father 12 months previously ‘issues had reduced’. This information does not appear to have been triangulated with any additional information from health colleagues or information from Probation or the Homeless Charity who had a long history of intervention with Child R’s father and mother. It is likely that the Children’s Services workers in the MASH team would have had access to historical information pertaining to concerns regarding the mother and CSE and potentially could have linked this with previous concerns regarding CSE and mother’s current pregnancy. It is possible that if additional information had been sought and additional professional curiosity demonstrated, an initial assessment could have been undertaken and support offered to the family at an earlier stage. Systems which support the sharing of information within the MASH have undergone consideration and changes have been made to ensure that contact suggesting the need for further assessment is 21 transferred in a timely way to the assessment team. Further work is being undertaken within the local authority to consider the front door arrangements and mitigate the impact on services, ensuring that contacts and referrals to the service receive a robust and timely response. 3.1.5 There are a number of examples evident within this review to suggest that professionals within the system need to look wider for sources of information regarding safeguarding children. MASH standard health checks are undertaken with the health visitor, school nurse records and where there is a known pregnancy, with the hospital safeguarding team. Other health services are only contacted if these enquiries reveal additional concerns. GP, accident and emergency department, or midwifery services are only contacted where there are queries from health visitor or school nurse records, thus limiting potential sources of information to augment assessment. The child and family assessment did not include contact with the Homeless Charity, who held significant information pertaining to the parents and indeed were the referring organisation. It also did not include a check with Probation where father was just completing his community supervision order. 3.1.6 The assessment undertaken by the social worker identifies; GP, family nurse and midwife as organisations having been consulted during the assessment. It is notable that contact was not made with father’s GP, mental health services, Homeless Charity, and Probation Service which had significant involvement with father and it could be argued engendered a negative impact on the quality of the assessment and the subsequent analysis. The assessment includes a model of risk assessment including ‘BwD risk toolkit’ based on work by Calder (2008). However there is little reference to parental history of drug use or considerations of current substance misuse and the potential impact of this on parenting. 22 3.2 Multi-agency communication and information sharing 3.2.1 An early referral was appropriately made by the Homeless Charity regarding concerns for unborn Child R relating to the perceived escalating violence between the parents, chaotic lifestyles and possible substance misuse. The Homeless Charity had worked with Child R’s father for a significant period and were correctly concerned regarding the issues presenting within the couple’s relationship and the potential impact of this on their unborn child. The service had also worked with mother and at the time of referral, mother was banned from the address due to threatening language and behaviour towards other residents and reports of violence towards father. It is concerning that this referral was not acknowledged by the MASH in that the Homeless Charity received no feedback and were not involved in further assessment work, planning and service delivery with the family. 3.2.2 This case review has identified that third sector involvement in child protection processes has been limited and arguably has resulted in significant information not being made available to multi-agency meetings and resultant plans. A view presented during the learning event suggested that the concerns of third sector organisations were not given an equal level of cogency as other sources of information and this view was compounded by the failure to invite the referring organisation to the strategy meeting and to share their significant levels of information within the assessment and in subsequent child protection conferences. 3.2.3 It was the view of practitioners contributing to the learning event that in the early stages of this case professionals did not have a common understanding regarding the level of perceived risk to unborn R. The Homeless Charity expressed a view that the violence between the parents was escalating to a point which indicated a risk of significant harm but felt unable to translate this into intervention from Children’s Services and indeed the decision to consider the risk of significant harm 23 to unborn R was not made until some months later when a strategy discussion agreed that an ICPC should be convened. Furthermore, within the discussions some participants expressed the view that information from third sector organisations may be perceived as less valid than that of some statutory organisations. The referring agency was not invited to contribute additional information to the referral, was not invited to participate in the strategy discussion and was not invited to contribute to the initial child protection conference. Information provided by the Homeless Charity was not extensively shared in the strategy discussion and subsequent conferences. Opportunity to invite the Homeless Charity to the initial conference were missed and as a result information sharing in both directions will have been impaired. It is clear that Homeless Charity had a great deal of information pertaining to both historical information in relation to father and to current information regarding the couple’s current relationship. 3.2.4 During the early pregnancy period there is evidence of good communication between agencies on an informal front line basis but this seemed to be dependent on individual knowledge of services and strong relationships between professionals. Whilst police information was appropriately shared with safeguarding colleagues following domestic abuse incidents throughout the case history some PVP risk assessments were disputed and defined the response undertaken from other agencies. It also appears that information was received by agencies at different times and that there were some delays in processing information within individual agencies. Health colleagues were not consistently aware of incidents of domestic abuse as a result of various recording systems which do not automatically interrelate and GP’s do not receive PVP reports. 24 3.2.5 A decision to convene an ICPC was made within supervision between the ASYE (assessed and supported year in employment)9 social worker and the area team manager on completion of the assessment in September. Working Together (2015) anticipates that a decision to progress to ICPC is made as a result of S4710 enquiries instigated as a result of a multi-agency strategy meeting. A strategy discussion was convened in early October 2015. There is a period of eight days following a discussion and agreement within supervision that Child R was at risk of harm. It is significant that a period of in excess of a week was allowed to pass when a judgement had been made by the social worker and the manager that Child R was potentially at risk of significant harm. 3.2.6 The strategy discussion was conducted by telephone with representatives from CSC and from the police with no representation from any other agency including the referring organisation and significantly health colleagues given that Child R’s mother was in receipt of midwifery services and family nurse partnership and this telephone discussion was not followed up with a full multi-agency strategy meeting. Best practice, as outlined within Working Together (2015) identifies an expectation that; ‘A local authority social worker and their manager, health professionals and a police representative should, as a minimum, be involved in the strategy discussion. Other relevant professionals will depend on the nature of the individual case but may include: • the professional or agency which made the referral; • the child’s school or nursery; and • any health services the child or family members are receiving. 9 The ASYE is a twelve month programme for assessing newly qualified social workers (NQSWs). 10 Children Act 1989 section 47 25 All attendees should be sufficiently senior to make decisions on behalf of their agencies’.11 3.2.7 It is described as ‘not unusual’ in Blackburn and Darwen for telephone strategy discussions to be held which include phone calls to all relevant agencies. However, this arrangement does not allow for a full discussion between organisations potentially missing vital information pertaining to the assessment of risk. This strategy meeting should have constituted the first opportunity in this case for a full multi-agency discussion regarding risk to unborn R to have been undertaken and the inclusion of health and other agency practitioners in this discussion would have added to the richness of information and would have ensured that all agencies involved with the family were aware of the escalating concerns and able to contribute effectively to the management of risk. The lack of opportunity for full multi-agency discussion of issues in this case has compounded professional ability to assess the ‘cumulative and interacting risk of harm’12 including potentially pervasive patterns of intergenerational abuse and neglect. Lead reviewers have been advised that current practice utilises conference calling facilities to ensure that all agencies are involved and able to collectively consider concerns regarding safeguarding children. It is significant that the allocated social worker for the case was not invited to contribute to the discussions and have input into the development of the resultant strategy, this is despite working from the same open plan office as the manager who undertook the telephone discussion with police. Whilst best practice dictates that a strategy meeting be chaired by an appropriately senior and experienced CSC manager it is easy to speculate that connotation and nuance could be lost as a result of 11 Working together to safeguard children 2015 12 Sidebotham et al 2016 26 information being delivered by a third party, having the potential for limiting decision making in context. 3.2.8 Within the period between allocation of this case to the ASYE social worker and the conference some three months later, there were no opportunities for the multi-agency professionals to meet to discuss the case, develop an intervention plan and to eliminate the opportunity for the parents to divert workers from the needs of the child to their own significant unmet needs. As the case was allocated to a social worker at child in need level it would be anticipated that child in need planning meetings would have taken place. The Pan-Lancashire Multi-agency pre-birth protocol (2012) indicates its purpose is to ‘ensure that a clear system is in place to develop robust plans which address the need for early support and services’. It is clear from the CSC report that no opportunities were afforded to the other agencies involved with Child R’s parents to come together to identify a plan and to develop a full picture of the scope of concerns prior to the ICPC. It could be argued that a valuable opportunity was missed to enable a clear plan to be developed and to allow services to work together to provide the significant level of support which would have been required in this case and to work in partnership with the parents and avoid opportunities for their non-cooperation or miscommunication between services. Studies of evidence regarding multi-agency working provide consistent findings in regard to the benefit of such working including; clear aims, roles and responsibilities and timetables that are agreed between partners. 3.2.9 The ICPC took place in October and agreed that unborn Child R should be made subject to child protection plan in the category of emotional abuse. Invitations to ICPC are developed by the social worker and then passed to independent reviewing officer administrators to be sent out. It is significant that Homeless Charity as the referring organisation and 27 one with extensive knowledge and information regarding the parental relationship was not included in the invitations and as a result not able to contribute to the analysis of risk and need. Information from the father’s GP was also not made available to the conference as there had been no invitation to attend or to submit a report. Mother’s GP was invited to attend and to provide a report, neither of which was undertaken. It could be argued that this led to a lack of opportunity to consider father’s mental health in line with any potential impact of this on Child R both prior to and following the birth and that this was augmented by the apparent lack of challenge regarding the invitation list. The Police were also not in attendance at the RCPC. It is the case that police colleagues nationally face an on-going challenge around capacity to participate routinely in multi-agency child protection processes, such as conferences and strategy meetings and it is of concern that although the issues raised within this review pertain to a specific timeframe, similar capacity issues are inevitable for organisations at different times, including GP’s who often are unable to attend at short notice as a result of responsibilities in regard to pre-arranged clinics and this arguably will become more so as resources become more limited. 3.2.10 It is not clear from the information submitted to this review what level of discussion was had at core groups which were appropriately held in February and March, regarding the escalation of violence between the couple and their lack of attendance at appointments with IDVA and father’s CBT appointments. There is no evidence of a clear contingency plan relating to Child R including the potential to call an early conference to discuss increasing concerns in a multi-agency environment and to ascertain clear legal advice in respect of threshold for care proceedings and as such it would not have been clear to the parents or to professionals what actions should be undertaken if a failure 28 to adhere to and advance the plan was perceived. It could also be argued that the clarity and indeed legal advice provided to the parents as a result of instigation of the Public Law Outline process could have crystallised concerns and encouraged parents to work more openly with professionals. 3.2.11 The attendance of appropriate professionals and family members at core groups impacts on the effectiveness of this mechanism to monitor and develop the child protection plan. Child R’s maternal grandmother and aunt were present at core groups in the period between ICPC and RCPC and after this juncture did not attend. It is of note that the perceived support offered from the extended family appears to have diminished at this point and consideration of the impact of this on risk to Child R should have been considered within core group discussions. Practitioners involved in this review indicated that minutes of the core group were taken to the subsequent core group for consideration and presented an opportunity for the core group to develop and manage the child protection plan and progress against the objectives benchmarked against previous meetings. However, the core group attendance does not appear to have included the range of agency professionals working with the family and who could have offered additional insight and management of the plan including the substance misuse midwife and Homeless Charity, who were working with the couple to improve life skills and to secure tenancies and Domestic Abuse Service 1 who whilst in receipt of the outcomes letter from the conference were not invited to core groups. Positively the core group did include the FNP nurse who did have extensive knowledge of the family and was continuing to work with them. 3.2.12 Systems for inviting professionals to multi-agency planning meetings including strategy meetings, ICPC, RCPC and core groups appear to 29 lack systematic consideration. A prerequisite for attendance at conference is a robust system which ensures invitations are disseminated efficiently to all those who are required to attend, ensuring that they have sufficient notice. It is acknowledged that this can be particularly difficult in the context of ICPCs, where the nationally prescribed timeframes make the notice period inevitable. Current arrangements cite responsibility for development of invitation lists with the social worker and independent reviewing officer (IRO) responsible for the case. However IRO responsibility for the process also suggests that they should undertake increased levels of constructive challenge to ensure that all appropriate professionals are included in invite lists and as a result enhance safeguarding discussions in Blackburn with Darwen. An invitation was sent regarding the ICPC to the independent domestic violence advisor (IDVA). However, this invitation was sent directly to the practitioner and not through the agency and as a result was not received by the IDVA. It is likely that the social worker would not have been aware of the agency arrangements for invitations but could be argued that this should have been known by the IRO administration team who processed the invitation. BwD LSCB may wish to consider additional scrutiny regarding attendance and invitation to safeguarding meetings, including core groups, in order to ensure that there is robust challenge in regard to processes which, if not attended effectively have the potential to limit professional ability to safeguard children and young people. 3.2.13 Information pertaining to the date and time of review child protection conferences is included in a letter to professionals but is not followed up with additional reminders closer to the time of the conference. This has resulted in the child’s GP in this case not attending or sending a report to the RCPC which impacted on the breadth of information and on inclusion of the GP in the management and joint responsibility for the 30 plan. GPs are not routinely informed of information pertaining to domestic abuse concerns regarding pregnant mothers and MASH do not routinely share protecting vulnerable person reports (PVP) except in high risk cases and those which indicate the potential to be considered at a multi-agency risk assessment conference (MARAC). This has resulted in mother’s GP not being aware of concerns regarding domestic abuse and of referrals to other services and as such was unable to make a contribution to the assessment of risk. 3.2.14 Child R was discharged from inpatient midwifery care, following birth, without a pre-discharge planning meeting. As the child was subject to CP plan best practice considerations should include the facilitation of a pre-discharge meeting to ensure that the range of professionals responsible for the care of mother and child are fully cognisant of the plan for the child and for ensuring the child protection plan following discharge home, is clarified. Lord Laming indicated that ‘verbal handovers and referrals, either face-to-face or on the telephone, carry with them a high risk of ambiguous transfer of information and the creation of false confidence that actions have been understood and will be carried out. Such verbal exchanges alone, unsupported by clear documentation, undermine high-quality care’.13 The decision not to convene a discharge meeting was made by the social worker and was because it was felt that the regular core groups had already provided opportunity for planning. However core groups in this case did not always offer an opportunity for a full multi-agency discussion regarding the child protection plan and as a result of the substance misuse midwife not attending core groups she would not have had opportunity to engage in discharge planning. 13 Laming 2003 Climbie Inquiry report. 31 3.2.15 Although core groups took place within appropriate timeframes, they did not routinely include the full range of professionals and records indicate that on at least one occasion only the social worker was present. Clearly this impacted on the level of information available to be shared at meetings in particular in relation to domestic abuse and the ability of the core group to develop and manage the child protection plan effectively. 3.2.16 National and local procedures/guidance around the operation of core groups allow for different interpretations of multi-agency ownership and the leadership role of social workers. If the core group function is to be consistently effective, BwD LSCB needs to clarify its position in relation to this and reinforce implications across the multi-agency workforce to reflect the importance of core group meetings to the child protection process and consideration given to core groups being supported administratively in a similar manner to conferences. Where this is not possible a wider ownership of responsibility is likely to impact positively on the quality of meetings, as long as expectations are clearly defined. The attendance of parents and extended family members at core groups is essential to ensure that they are aware of progress against the plan and more importantly of any deterioration or drift which might lead to an earlier conference or indeed public law outline (PLO) procedures. 3.3 Recognition of domestic abuse 3.3.1 In July 2015 Child R’s mother attended the early pregnancy unit following a fall onto her abdomen, this was a gynaecology unit and staff there had no access to records kept by midwifery except the hand held notes. There is no evidence that the risk of domestic abuse was considered by staff at this presentation and no history of how the fall occurred is recorded in the notes. At a subsequent maternity appointment mother presented with a black eye which was questioned by the midwife who 32 documented that Child R’s mother reported that she ‘felt safe at home’. One explanation for this limited recording is that generally information is recorded in the hand held notes which are held by the mother. This creates a dilemma for health staff who need to be cautious in their record keeping to avoid creating additional risk to a potential victim of domestic abuse. The hospital midwifery team undertook routine enquiries regarding domestic abuse on two occasions with mother who maintained her position of denial. Without access to information regarding the PVP’s and with only the level of detail held within the hand held notes there was no opportunity for the midwives to assess ongoing or additional risk. Information regarding incidents of domestic abuse were emailed to the midwife but were not acted upon and as a result were not included in the maternity notes or on the special circumstances form and as such, were not immediately available to the hospital midwives or the community substance misuse midwife that were providing services to mother and Child R. 3.3.2 Generally information received from the police PVP’s regarding incidents of domestic abuse is graded by police colleagues as; standard, medium and high. Assessment is undertaken as a result of the information obtained at the time of the incident and concerns regarding whether a child is present. Assessments using the current DASH14 tool focus primarily on the risk to the adult victim and the potential for risk and harm to children is considered subsequently. This is of particular note when the child is unborn and not considered to be ‘present’ despite research which clearly identifies risk to unborn children and also of the potential for escalating violence during pregnancy. Some incidents in this case were recorded as standard and as a result were not prioritised for information sharing by MASH. It could be argued that in this case this 14 The Domestic Abuse, Stalking and Honour Based Violence (DASH 2009) Risk Identification, Assessment and Management Model March 2009. 33 practice has adversely affected the Children’s Service’s response to the family, limited at least one opportunity to review the case at MARAC and engendered delay in undertaking a full assessment. Assessment of risk based on whether a child is present at the actual altercation is in some respects fallacious and research is clear that children are adversely impacted by violence and aggression within the parental relationship regardless of their direct involvement in the event. ‘Because babies have little sense of self, they are very dependent on their parents or key carers for their psychological well-being.15 Consideration in this case could also have been afforded to the number of events and the short timeframe in which they had taken place and a higher assessment of risk correlated. Some of the reported incidents of domestic abuse state that ‘the incident was not witnessed by Child R’ who was described as ‘not having been present’. However, given the fact that the child was subject to a child protection plan and the significant previous history of domestic abuse, coupled with both parent’s individual vulnerabilities, it is of note that many incidents were identified as standard. Additionally the ‘flag’ relating to unborn Child R’s being subject to a child protection plan as a result of the ICPC was not then automatically translated to police records following the birth and acquisition of a name. As a result a ‘flag’ did not appear on the child’s records following birth and as such this information was not available to officers attending the four domestic incidents following the RCPC. 3.3.3 In line with other police forces local police officers often attend domestic abuse incidents without prior knowledge of previous history of abuse or verbal assault. It also appears to be the case that attending officers have failed to cross-check the history in the case when completing paperwork following incidents. However, this is likely to have been affected by the fact that the domestic abuse flag was not transferred 34 to the most current police file following the RCPC. Assessments of risk are made pertaining to the level of impact on the adults and include a raised level of concern only if a child is present which appears to make limited consideration of the impact of domestic abuse on the unborn child. The quality assurance processes which ensure a common understanding of risk appear inconsistent and police colleagues acknowledge that three of the six assessments were considered risk to be low or standard when in fact this should have identified as medium and in one incident high risk. 3.3.4 Domestic Abuse Service 2 was commissioned by the local authority in 2015 to provide services to individuals and families experiencing domestic violence. The service was aware that the putative victim was ‘heavily pregnant’. Three telephone calls were made to Child R’s mother in September 2015, none of which resulted in contact. In line with standard practice, a letter was then sent including an offer of support and the case was closed. At this point this new sevice did not have an information sharing process agreed with Domestic Abuse Service 1, the previous local authority commissioned service, and so were not aware that mother was open to Service 1 following the referral the social worker had made in August 2015. It is of note that the service was aware of the pregnancy but did not appear to prioritise this as a potential/additional risk factor regarding the domestic abuse and importantly as ‘a trigger for the onset of domestic violence in a relationship’. NSPCC research in 2016 suggests that any domestic violence incidents during pregnancy should be viewed as posing a high risk to the mother and the unborn child.’16 Additional persistence in attempting contact with young women in these circumstances may increase the chances that victims of domestic abuse engage with 16 NSPCC 2016 35 support over time, although in this specific case it is unlikely to have impacted on the outcome for Child R. 3.3.5 By the time of the February 2016 domestic abuse incidents reported to the police, both domestic abuse services had an information sharing protocol in place and both incidents in the month were passed to Service 1 by Service 2 to follow up with mother. The two incidents reported through police in March 2016 had different name spellings and a different address; Service 2’s recording system did not link the four incidents across the two months resulting in the March 2016 incidents not being shared with Service 1. Service 2 has now amended their recording system to ensure such issues do not re-occur. 3.3.6 The social worker had referred mother to Service 2 following mother being observed with bruising on her arm in August 2015. Mother’s risk assessment was completed in November following a number of missed appointments; the IDVA undertaking the risk assessment noted mother’s minimisation of the risks. Mother then attended for three sessions of the Freedom Programme before disengaging around the time Child R was born. Prior to the RCPC the social worker contacted the service to discuss the IDVA’s recommendation for continuing the CP plan; the IDVA recommended the plan to continue as progress had yet to be evidenced due to mother not attending Service 1 since the birth of Child R. The IDVA contacted mother after the first incident in February 2016 and was told that the incident was over reaction on her part, but agreed to attend the Freedom Programme that month. The IDVA recorded that she felt mother was minimising the incident. Mother did attend Service 1 offices on the day of the Freedom Programme and reported being under pressure due to the family’s house move; she did not stay to attend the session. The IDVA contacted mother twice without success after the second police reported incident in the month. Up to this period, 36 Service had received three of the four police reported incidents. They had also received the referral from the social worker in August 2015 though the meaning of the referral appears to have been lost, with Service 1 reporting that the referral was for a relationship that was abusive and volatile, and the social worker referring due to observed bruising that mother was attempting to conceal. At the end of February 2016, due to mother’s lack of engagement, the IDVA allocated the case to a manager to review for closure. The case was closed eight days later. Service 1 has reflected on their practice and have now changed procedures to ensure case closure processes also involve contacting relevant services involved with a family to inform their decision making. 3.3.7 Had multi-agency meetings at Child in Need level taken place or meetings at CP level (Core Groups) been effective (all relevant agencies invited and regular attendance by agencies), the various allocated workers involved with the family could have known that in addition to the six reported police incidents of domestic abuse there were also a further nine incidents reported by the parents or witnessed by professionals. At least two (August 2015 & September 2015) could have been considered as high risk incidents due to mother’s bruising on arm and then face. 3.4 Understanding of the nature of domestic abuse 3.4.1 Consideration of domestic abuse in this case appears to have been framed within a stereotypical view of a female victim. A growing body of empirical research has demonstrated that domestic abuse is not a single phenomenon and that types of domestic violence can be differentiated with respect to partner dynamics, context, and consequences. Four patterns of violence can be identified: • Coercive controlling violence where one person is violent and controlling (generally perpetrated by men against women); 37 • Violent resistance, usually a form of self-defence (often conducted by women against men); • Separation instigated violence, which occurs in the context of relationships ending (usually perpetrated by men on women); and • Situational couple violence, the most common form of domestic abuse, which is conducted by individuals of both genders nearly equally and is likelier to occur among younger couples, such as adolescents. 17 3.4.2 However, it could be argued that services locally and nationally are not developed on this premise constituting a systemic issue as opposed to individual understanding and interpretation. Discussions within the practitioner event evidenced that practitioners involved with the family were aware of mother’s potential for aggression and inability to manage her emotions but there is little evidence to support that this was a factor which was identified within the protection plan for the child or in the interventions provided to the family. Research into violence in young people’s relationships18 identifies that there are a number of forms of interpersonal violence and stresses the need to acknowledge that young people should be protected by legislation in respect of violence against them and should be considered in respect of the risk posed to them individually. Multi-agency safeguarding practitioners need opportunity to develop an understanding of forms of domestic abuse including situational couple violence and interpersonal violence in young people’s relationships and develop knowledge and understanding in order to achieve realistic and effective interventions to address this. Practitioners were aware of the potential for mother to have been an equal if not substantive perpetrator of the violence and 17 Johnson, M.P. (2008) A Typology of Domestic Violence: Intimate Terrorism, Violent Resistance, and Situational Couple Violence. The Northeastern series on gender, crime, and law. Lebanon, New Hampshire, US: UPNE 18 Research in practice (2016) violence in young people’s relationships. 38 that father was not perceived and assessed as a potential victim may have led to interventions which lacked focus and indeed failed to recognise mother as a source of risk to the child. 3.4.3 It is probable that the majority of the violence in this case was of a situational nature and there is a growing recognition that situational couple violence may respond to a different style of intervention. In many of the calls to police it was father who instigated the intervention as opposed to mother who was often identified as the victim. The fact that father sought the intervention of the police is unusual, in particular if he were the perpetrator of the violence and accounts from both parents needs to be sought to avoid a focus on women as victims as is often the case. Practitioners in this case did not question why father was contacting the police or consider whether this indicated that the nature of the violence between the couple was outside of normal parameters of coercive control types of domestic abuse. The services offered to the couple in this case focussed on father’s management of anger and were separated into victim/perpetrator interventions. Intervention was offered to mother but as part of a victim programme whilst consideration was given by the social worker and IDVA, although subsequently felt not to be appropriate, for a referral for father to ‘making the change19’ which seeks to engage with perpetrators to support them to become aware of the consequences of the abuse. 3.4.4 The ICPC recommended that father attend anger management sessions, a service which he was positive to attend. However, it appears that no consideration was given to the potential for mother to have benefitted from similar sessions in that she had displayed significant evidence of her lack of emotional control and verbal aggression. It is 19 Making the change is It is a behavioural change programme, as opposed to anger management, for men who recognise that they are or have been using power and control to abuse their female partner or ex partner, and want to address this behaviour. 39 likely that there was a stereotypical focus on the father as perpetrator and mother as potential victim, with little consideration regarding the potential for this to have been contrary. There appears to have been a prevailing understanding that the violence within the relationship identified the mother as the primary victim and that this has led to interventions which fail to acknowledge the situational nature of the violence20 and to undertake full assessment of the interpersonal dynamics of the parental relationship. It is likely that if full information regarding mother’s violence had been more widely known to services, referral to more relevent services could have been undertaken. Information within the Children’s Services’ report suggests that a discussion took place with the mother in respect of her moving into mother and baby accommodation. This discussion does not appear to have considered information pertaining to the likelihood that the mother was also a perpetrator of abuse within the relationship and at least was potentially an equal aggressor. 3.5 Recognition of the risk of physical harm to the child as a result of domestic abuse 3.5.1 It was the unanimous decision of the ICPC that a child protection plan be put in place in respect of Child R as a result of continuing risk of significant harm. Once the decision was made that a plan was required it was the responsibility of the IRO to determine (following discussion with conference members) which category or categories of abuse or neglect the child was experiencing or was at risk of suffering. In this case a decision was made to categorise the harm as emotional. Working together to safeguard children (2015) defines emotional abuse as; ‘the persistent emotional maltreatment of a child such as to cause severe and persistent adverse effects on the child’s emotional development’, which, it could be argued does not best describe the potential risk in this 20 Situational couple violence; TCCP 2016(1) 40 case. The definition goes on to describe emotional abuse as ‘seeing or hearing the ill-treatment of another’ and as such could apply in the context of the parental relationship. Given that agencies and professionals working with the family had a significantly high level of concern and information pertaining to parental volatility and a number of violent altercations between them it is notable that this does not appear to have influenced consideration of the category of physical abuse in recognition of the potential for Child R to have been exposed to physical risk within the context of parental volatility. 3.5.2 It is clear from practitioners that discussions took place within the conference regarding the potential for physical injury to the child as a result of parental volatility and domestic abuse. However, a policy of no dual registration was understood to be in place and it was the view of the conference that emotional abuse was the most appropriate category. In fact this is not the case and the BwD LSCB policy allows for dual registration in appropriate cases. It is interesting to consider the potential impact of this category of registration on the development of the plan and on interpretation of the risk to the child, specifically that which ensues from exposure to angry and violent episodes between the parents. It is possible that the focus of intervention was predicated on the potential for emotional abuse and that the risk of physical injury to Child R was not well recognised and was not specifically addressed within the resultant plan. 3.5.3 Research regarding children experiencing domestic abuse indicates an increased risk of physical harm to children, particularly babies or other non-mobile children, when they are living/in close contact with violent adults. There is clear research evidence of the increased risk of physical harm to children from men who are violent to their female partners. UK: In 40-70% of cases where women are being abused, the children are 41 being directly physically abused themselves (Stark and Flitcraft, 1996; Bowker et al, 1998)21. Domestic violence is also a key indicator for child abuse and neglect – with children experiencing domestic violence being three to four times more likely to experience physical violence and neglect. 22 3.5.4 The child protection plan developed as a result of the RCPC includes a number of recommendations regarding parental behaviours and their seeking support in regard to their management of anger and in regard to domestic abuse, albeit separately as putative victim and perpetrator. Recommendations developed to ensure the physical protection of Child R are not explicit and the inclusion of an overview of heath and development is not included. A clear recommendation that the child should not be ‘subjected to further incidents of domestic abuse’ is supported by the outcome ‘parents will understand the dynamics and cycles of domestic abuse to ensure this does not negatively impact on their baby's safety and welfare’ but does not acknowledge the propensity for harm as a result of being present during volatile episodes, work with the couple to augment their understanding of these issues is also not explicit. It is also likely that the language used within the child protection plan will have had little meaning to the parents making it difficult for them to understand and work towards the outcomes outlined. 3.6 Assessment of risk of parental substance misuse and impact on Child R 21 Stark, E., and Flitcraft, A., Women at risk: domestic violence & women’s health, Sage Publications, 1996 Bowker, L. H., Arbitell, M., McFerron, J. R., ‘On the relationship between wife beating and child abuse’, in K. Yllo & M. Bograd (Eds.), Feminist perspectives on wife abuse (pp.90-113), Sage Publications, 1988. 22 Stanley, N. (2011) Children Experiencing Domestic Violence: A Research Review, Dartington: research in practice 42 3.6.1 When the midwifery services completed their social needs assessment early in the pregnancy mother acknowledged previous use of substances but stated that she had not used any substances in the previous twelve months, although she later stated that she had and this conflicting information does not appear to have featured in assessments. Although the midwifery service did share this information with the specialist community midwife for substance misuse a referral was not made at this stage. However when the teenage pregnancy worker became involved she discussed a referral with the family nurse who made the referral and involved the specialist community midwife. Information contained within the referral from Homeless Charity in June 2015 indicated concerns regarding the father’s accommodation being the ‘party house’ and reported both parents as being involved in substance misuse. The CSC assessment in respect of Child R includes reference to historical substance misuse in regard to both parents but does not translate this into analysis regarding the potential for the use of substances to remain a feature of the relationship. A specialist community substance misuse midwife was allocated and worked with the family. The referral to this service was completed in July 2015, but the initial visit was not completed until the end of September as a result of difficulty in arranging the initial visit and of subsequent visits being cancelled by parents. At the initial visit, mother indicated that she had not taken drugs since knowing she was pregnant. This pertains to the differences in information and the lack of healthy scepticism in relation to conflicting information and over reliance on self reporting. Between September 2015 and January 2016 eight home visits were conducted by the specialist community midwife. The records for these visits has been limited as parents had lost hand-held postnatal records and the ante-natal hospital record had not been updated regularly by the specialist community midwife specialist substance misuse midwife. 43 3.6.2 The ICPC did not discuss substance misuse as a significant issue pertaining to risk and represents a missed opportunity to triangulate the parent’s assertion that they were no longer using substances. Issues of substance misuse were not included in the child protection plan despite illicit drug use being a significant feature of father’s history. Following the RCPC a subsequent conference was planned for six months later. It could be argued that given the complexity of the case and the relative length of time six months represented in relation to the child’s age that an earlier conference would have been more proportionate in this case. 3.6.3 During a home visit prior to the injury to Child R, father informed the social worker that he was no longer taking his mental health medication and was self-medicating with cannabis, this information did not result in a referral to substance misuse services for father as the social worker prioritised a referral into mental health services. 3.7 Supervision and support to newly qualified workers 3.7.1 Supervision and appropriate caseloads for safeguarding staff in all organisations needs to reflect the complexity and risk integral to the work. Social work staff, in particular, should have appropriate levels of support and challenge from senior managers. A newly qualified social worker, if allocated child protection work, should benefit from a protected caseload and should be afforded additional mentoring and reflective supervisory opportunities to ensure best practice. 3.7.2 This case was allocated in July 2015 to a social worker who was in the first year of her qualification and subject to an ‘assisted and supported year in employment23. Given the complexity of this case it is surprising that the local authority chose to allocate a worker with such limited 23 The ASYE is a twelve month programme for assessing newly qualified social workers (NQSWs). 44 experience. It could be argued that a more suitably experienced worker should have been allocated as a minimum, to oversee the work and to mentor the social worker in the management of the case. 3.7.3 When workers are inexperienced it is very important that there should be close and supportive supervision provided. ASYE social workers should expect to receive additional case supervision during this first year of practice to ensure that they are supported in the development of their social work ability. In this case the manager has reported that she provided extra support and management oversight however supervision records show only two formally recorded supervision sessions between allocation, July 2015, and March 2016, eight months later. Learning from serious case reviews identifies effective supervision as a vital element of professional good practice and states that a ‘lack of staff, high staff turnover, over use of unqualified staff, inadequate supervision, a lack of professional curiosity and a sense of helplessness and low morale were often identified as reasons for a lack of timely and holistic assessments and appropriate planning, these were often issues for all professional groups.24 3.7.4 At this time, following a reorganisation of service delivery, Children’s Services had difficulty in allocating work because of staff vacancies, significant levels of newly qualified social work staff, a high number of referrals and increasing complexity of cases. This meant that caseloads for social workers within the team were at times over 30 children. ASYE social workers should expect during their protected year to have a protected case load, usually under 20 cases. It is unacceptable that the ASYE holding this case had up to 30 cases on her case load at the time she was working with the family, a number which would be considered excessive for a more experienced worker. Research undertaken by 24 Sidebotham et al 2016 45 community care in 201625 identified ‘Patchy implementation of the ASYE leaves newly qualified social workers facing unprotected caseloads’. The research found significant variation in caseload numbers across the country with some social workers taking on cases not appropriate for their experience. Lead reviewers have been informed that a new supervision policy has been developed by children’s services outside of the scope of this review which was implemented in July 2016. The new policy ensures that all social work staff receive case supervision on a monthly basis, reflective supervision six weekly and a personal supervision on a quarterly basis. 3.7.5 Supervision of a relatively inexperienced member of staff in this case was insufficient given the complexity of the case and in particular child protection status. Child protection work, however has an additional level of scrutiny as it is independently monitored by an independent reviewing officer (IRO) who chairs the conferences and provides an oversight of the work. The IRO quality assurance function has a responsibility for; ‘appointing a lead statutory body and a lead social worker, who should be a qualified, experienced social worker and an employee of the lead statutory body’. It appears that the IRO failed to recognise the opportunity to challenge the appropriateness of the allocation of an ASYE in such a complex case or to advocate for additional support in respect of management of the complexities inherent in this case. 3.7.6 The independent reviewing service has a remit to ensure that the child protection plan is being progressed and if not to trigger a different intervention with the family usually by recommending initiation of a legal process. Liaison by the IRO with the social work team would have established that this was not the case, indeed in a supervision session on 25 By Rachel Schraer on January 27, 2016 in Caseloads, NQSWs, Workforce 46 the 1st of March between the social worker and her manager, this possibility was discussed but agreed that it would be initiated following a further event, this was not pursued following the three incidents in March, when mother was allegedly ‘thrown out’ of the couple’s home and the one occasion where the social worker witnessed first-hand arguments between the couple. Within the months following the RCPC there were a number of opportunities for the core group to acknowledge the increasing violence and to avoid drift in case planning and which could have led to additional clarity regarding increasing levels of concern and brought the parents to seek independent legal advice. 3.7.7 The child protection plan produced as an outcome of the RCPC includes information pertaining to the seeking of legal advice pending further deterioration of the parental relationship and further reported violence. However, despite increasing concerns and incidents of violence, legal advice was not sought by the local authority. Mechanisms to consider these issues including supervision of workers, core groups, liaison and challenge from the independent reviewing officer were not utilised to best effect in this case. There has been a lack of robust challenge from the IRO service with regard to attendance at conferences, in particular, predicated by an apparent acceptance that GP’s will not attend conferences nor send a report. 3.8 Cross-Agency understanding of services 3.8.1 It is apparent that a significant number of services were offered to Child R’s parents throughout the scope of this review and in the years preceding. However, it is difficult to make sense of each separate service and the different opportunities they offered to the parents. Indeed the social worker when referring father to an assessment and treatment team perceived this to be a crisis mental health support 47 immediate service when in fact this was not the case. It is a considered view therefore that a clear understanding of the responsibilities and service offered by the many professionals involved in the life of this family will not have been well understood by them. 3.8.2 It appears within Blackburn with Darwen there exists a general acceptance that GP’s will not attend conferences and no challenge to this assumption appears to have been established. Given the nature of the concerns in this case pertaining to both parents reported turbulent and complex childhood experiences, drug and alcohol misuse, mental ill health and lack of emotional regulation, it could be assumed that information which would have been available to the conference from GP services would have benefitted the discussion and the resultant child protection planning. The RCPC minutes suggest that there were ‘no concerns over their (the parent’s) ability to care for a baby’, despite clear information to suggest that they had exposed the unborn child to the volatility within their relationship and although they had undertaken some work to develop their understanding of the potential impact of this on Child R’s emotional development, there was limited evidence that they had understood this. 3.8.3 The outline plan developed as a result of the ICPC was sent to all professionals invited to the conference; although without follow up from a professional in attendance at conference, the list of outcomes and actions appear not to be related to the social worker’s assessment and are hard to interpret. The plan includes a recommendation that father will ‘continue to manage his medication successfully’, but as his GP was not invited and therefore not present at the conference and would not have been in receipt of minutes, it is not clear how this recommendation was to be managed or indeed assessed in line with the plan. The ICPC minutes evidence a discrepancy between involvement from Domestic 48 Abuse Service 1 and Service 2 and confusion regarding which agency was involved to provide services to mother and father and which led to neither service being invited to the core group. It is possible that this was as a result of a recent transition in the commissioning arrangements from Service 1 to Service 2 and that this engendered a level of professional confusion. The date of the next conference is included in the letter to professionals sent following the ICPC. However, this is not followed up with a reminder nearer the time. In this case this has prevented the mother’s GP surgery from identifying the date (from the letter) and then from attending the subsequent RCPC. Clearly it is the responsibility of the organisation in receipt of the correspondence to register and record the date of the next conference, additionally that the cost of postal invitations as a means of information may be preclusive. However, an email or phone call prior to the review conference to reiterate the date and importance of attendance would have significantly enhanced the depth of discussion in this case and allowed the GP to have had a full involvement and develop a level of ownership in relation to the on-going child protection plan. 3.8.4 Despite information being provided by the community safety partnership regarding the changes in commissioned services in Blackburn with Darwen in respect of domestic abuse there appears to have been a lack of professional understanding of information, leading to confusion regarding appropriate services. It has been reported to lead reviewers that more recent audit activity by the board suggests that this is now significantly clearer. 3.8.5 Within the safeguarding partnerships there appears to have been a number of common understandings including that referrals to MASH could not be made regarding unborn children prior to sixteen weeks gestation. This is in fact not the case and this is made clear in the Pan-49 Lancashire joint multi-agency pre-birth protocol26 which identifies the circumstances in which early referral should be undertaken. 3.8.6 A further common understanding pertains to the attendance of GPs at safeguarding meetings. The lack of attendance and reporting from GPs in this case was not appropriately challenged by the IRO and has resulted in limited information pertaining to father’s mental health in particular being available to conference and to be included in safety planning for the child. Additionally practitioners present at the initial child protection conference understood there to be a preclusion of dual registration which is also not the case and circumstances in which this is appropriate are included in BwD LSCB procedures. 4.0 Good practice A SILP review seeks to learn from good practice as much as from shortcomings. The following areas of good practice are identified: 4.01 The Homeless Charity correctly expressed concerns regarding the parental relationship, volatility and aggression and made a correlation between these issues and potential risk to their unborn child and made appropriate referrals. Professionals within this service anticipated a response within three working days from MASH following their referral but did not receive one, although a joint visit was arranged. Restructure at the Homeless Charity, new CEO, and refreshed policies and procedures including a review of staffing levels has been undertaken and additional staff employed to respond to increasing levels in demand. Formal recording processes have been introduced and Charity now routinely follow up MASH referrals within three working days where they do not know the outcome. 26 Pan-Lancashire joint multi-agency protocol 2012 50 4.02 Midwives undertook assessment in respect of Child R’s mother and she was identified as in need of support and early intervention. Midwives referred mother to the children’s centre for a child and family (CAF) assessment. The resulting consideration for the CAF included the local authority teenage pregnancy worker and as a result a referral was made to the FNP nurse who acknowledged the need for additional support for mother. The FNP nurse in turn identified the need for the specialist substance misuse midwife service. The FNP nurse provided an excellent level of provision in regular ante-natal and post-natal home visits and a high level of commitment and sustained intervention was evident on a range of risk and protection issues including; domestic abuse, child development, anger management, low moods/mental health, bonding/attachment, coping strategies when babies cry and safe handling of babies. Despite the lack of evidence of substance misuse at that time it was good practice that a service from the specialist substance misuse midwife was provided that involved regular ante-natal and post-natal home visits before discharge to the FNP nurse. 4.03 A high level of resources was offered to this family by a variety of organisations throughout the period of involvement and there is evidence of close working relationships between professionals working on this case. There is evidence of a significant level of persistence of front line professionals in attempting to engage the parents in work to address the issues in their relationship despite a level of resistance. Organisations have worked well individually with the parents although this work would have benefitted from being more ‘joined up’ in its nature. 4.04 Despite the family’s lack of willingness to engage, professionals persisted in the child protection processes to protect the child. Workers recognised the progress made by the parents in respect of contact with agencies following the ICPC but did not allow this apparent 51 engagement to be perceived as a long term safety factor and ensured that Child R remained subject to a child protection plan. 4.05 The relationship between professionals at the practitioner event and within BwD LSCB are positive and strong with evidence of constructive and supportive challenge. Reports received for the purpose of this review were considered and contained a good level of analysis and evidence of learning. Professionals in this case have offered a good level of support and challenge to very young, damaged parents who appeared to struggle with the responsibilities of being parents and in managing their relationship with limited support from extended family. Parents were difficult to engage and displayed a level of defensiveness regarding services and limited engagement. It is notable that despite parents attempts to minimise and deny concerns professionals persevered and continued to engage safeguarding processes in respect of Child R. 5.0 Lessons learned 5.01 Much information has been considered within this report which pertains to the importance of historical information being sought from a variety of sources, triangulated and used to assess current levels of risk and need. It is the case that the quality and effectiveness of assessment is predicated by the analysis of information both current and that which pertains to parents own experience of being parented, of adolescence and of young adulthood. Information offered to professionals by parents should be subject to professional curiosity and additional sources of information sought to support or discount information. 5.02 The process for inviting participants to key meetings does not consistently ensure that the right people will be in attendance and able to contribute to the assessment of risk and development of subsequent child protection plan. The original referrer was not invited to the strategy 52 meeting or ICPC despite having a high level of information and it is of note that this lack of information could have adversely affected the planning in this case. Opportunity for multi-agency meeting and decision making should form an integral element of all work with young people and their families including that which sits outside the child protection frameworks. The lack of multi-agency coordination and planning opportunities prior to the ICPC in this case has meant that safeguarding professionals had limited opportunity to establish a common understanding of levels of risk and to develop a multi-agency approach to supporting the family. 5.03 Community midwives do not have routine access to the maternity records as these are stored at the hospital and as a result may not be fully informed regarding domestic abuse. Information sharing between all professionals is a vital element of protecting children in particular the timely sharing of information between health professionals who are in significant direct contact with the family. 5.04 MASH standard enquiries following a contact do not routinely include liaison with extended health services which pertain to the parents. It is likely that this will impact detrimentally on decision making. Information was appropriately shared with partner organisations although this was received and processed by them in varying timeframes. 5.05 There appears to be a perception by professionals that it is CSC policy to not accept referrals for pre-birth assessment prior to sixteen weeks gestation. This common misunderstanding means that the opportunity to offer early help and support and to undertake a comprehensive assessment of need is not afforded in some cases. 53 5.06 There has been a lack of robust challenge from the IRO service with regard to attendance at conferences, in particular, predicated by an apparent acceptance that GP’s will not attend conferences nor send a report. Furthermore opportunity to challenge regarding allocation of appropriately experienced worker and progress of the plan appears to have ben missed. 5.07 Limited supervision for ASYE in management of this case is likely to have impacted negatively on interventions. Opportunity for supervision and case reflection have limited the development of effective intervention in this case further exacerbated by an unrealistically high caseload of significantly complex cases. 5.08 In line with other police forces local police officers often attend domestic abuse incidents without prior knowledge of previous history of abuse or verbal assault. It also appears to be the case that attending officers have failed to cross-check the history in the case when completing paperwork following incidents. However, this is likely to have been affected by the fact that the domestic abuse flag was not transferred to Child R’s new police file following the birth of the child and RCPC. Assessments of risk are made pertaining to the level of impact on the adults and include a raised level of concern only if a child is present which appears to make limited consideration of the impact of domestic abuse on the unborn child. The quality assurance processes which ensure a common understanding of risk are inconsistent and police colleagues acknowledge that three of the six assessments considered risk to be low or standard when in fact this should have identified as medium in two incidents and high in another. 5.09 Throughout this report it has been argued that stereotypical attitudes and understanding to domestic abuse have been prevalent and that 54 this may have affected the focus of interventions in this case. Safeguarding professionals need to understand and consider a variety of forms of domestic abuse in order to effectively assess risk and manage appropriate interventions. 5.10 Discussions throughout this review have identified a lack of contingency planning within this case which could have clearly articulated both to parents and to professionals the identified plan which would be put in place should progress not be made against the child protection plan within prescribed timescales for the child. It is possible that failure to obtain legal advice and to respond significantly to increasing levels of violence have impacted on the outcome in this case. 5.11 It is apparent that a high level of services were offered to the family in this case. However there also appears to have been a lack of coordination of services which potentially could have led to a shared understanding of risk and clarity regarding concerns for Child R and the risks posed. 6.0 Conclusions 6.01 It is clear from the work undertaken to arrange and contribute to this review that the Blackburn with Darwen Safeguarding Children Board and its partners are committed to the safety and welfare of children in the area and to learning from outcomes for children. The scrutiny of and reflection on practice in this case has resulted in a number of lessons learned for individual organisations and for the safeguarding partnership as a whole and offers opportunities to develop practice across Blackburn with Darwen and to contribute to wider national learning. 6.02 The importance of clarity of information regarding parental and family history and the consideration of information from all agencies with 55 knowledge pertaining to and providing services to families is clear within this report. It is vital that the full range of information is included in assessment and in safeguarding meetings and that all appropriate agencies are included in the development and implementation of safeguarding plans for children. The importance of triangulation of information obtained from parents is highlighted and professionals need to ensure that assessment and intervention does not solely rely on information sourced from them. Contingency planning regarding children subject to child protection plans should be clear and jargon free to ensure that parents and professionals are clear regarding actions to be initiated should the plan fail to progress within the identified timeframe. Information regarding missed appointments and perceived poor engagement needs to be fully shared to ensure that all agencies share a clear analysis of risk and understand their individual responsibilities regarding child protection plans. 6.03 It is clear that the quality of assessments is predicated by the quality of the information which underpins them and consideration has been given within this report to opportunities for information to be sought from a wider range of sources and for this to be considered with reference to historical information and also to include opportunity to update assessments in light of information pertaining to cumulative risk. Professionals working in the safeguarding arena need to have a clear understanding of the concept of professional curiosity and have organisational ‘permission’ to read between the lines. It could be argued that opportunities to undertake this were missed in this case as a result of the lack of multi-agency meetings and the range of professionals in attendance at those meetings. Furthermore that this lack of full multi-agency consideration of risk and of a shared understanding of increasing concerns in this case has meant that the safeguarding network functioned less well in regard to reducing and 56 managing the risk to Child R and to the delivery of the subsequent child protection plan. 6.04 There is no evidence within this review to suggest that the involvement of the FNP nurse led other agencies to believe that their responsibility to safeguard Child R was in any way reduced. Children’s Services staff appear to have have the perception that the parents were fully engaged with the FNP nurse service and that direct work to address safeguarding concerns was being undertaken when in fact this was not the case. This view is also disputed by the FNP nurse who recalls sharing informaiton regarding the lack of engagement, cancelled and missed appointments. However, there is also no information to suggest that this perception impacted in any way on the service provided to the family by CSC, or on the outcome in this case. 6.05 Professionals involved in this review have identified a good level of learning and identified impact on indivudal and agency practice as a result. Professionals involved in this process have stated that they would “challenge and would contact other agencies with less concern regarding data protection” as a result of learning generated. They have also ‘enjoyed the process’ and have felt able to use the opportunity to learn from their own practice and that of other organisations. They have clearly identified learning and significantly perceived gaps in service and improvements in safeguarding practice. 7.0 Recommendations 7.01 Lead reviewers have been advised that Blackburn with Darwen Safeguarding Children Board is currently undertaking a piece of work to consider ‘demand management and response’ regarding services and recognise that this presents an opportunity for the board to consider the recommendations and learning from this case within this wider piece of work. Blackburn with Darwen Safeguarding Children Board may also 57 wish to give consideration to the potential to form a single point of access regarding service delivery as part of the wider work currently being undertaken. 7.02 Blackburn with Darwen Safeguarding Children Board may wish to consider revisiting/re-launching the multi-agency pre-birth assessment pathway to ensure that partners are aware of and follow the pathway and that mis-conceptions regarding the timing of referrals for concerns regarding unborn children are addressed. The board may also wish to consider seeking assurance that agencies have mechanisms in place to ensure that concerns regarding unborn children are translated into current records pertaining to the child following birth and should consider a challenge to police colleagues in particular in regard to the potential development of their IT record systems to incorporate a change of name (following the birth of a child) to ensure that CP concerns and ‘flags’ on the system are automatically transferred. 7.03 Blackburn with Darwen Safeguarding Children Board should consider how agencies can best enable the family history to be incorporated into safeguarding assessment processes, including agency safeguarding enquiries. The board may also wish to seek assurance that partner organsations have robust strategies in place to ensure that internal processes are not overly reliant on self-reporting. 7.04 Lead reviewers have been informed that Blackburn with Darwen Safeguarding Children Board is currently undertakeing a piece of work to consider the role of the IRO and are assured that learning from this review will be considered within this. Inherent within this work should be assurance sought by the board that the full range of safeguarding meetings are appropriately convened and attended, that they identify clear actions and ensure that these actions are regularly reviewed. This 58 should include assurance that the IRO quality assurance function is robustly and consistently applied appropriately in the management of cases, throughout the range of safeguarding meetings and within the development and implementation of plans. Consideration could also be given by the IRO service to the dissemination of the full CP plan to all agencies to ensure that they are aware of and responsible for the management and progress of the plan and have a clear understanding of contingency planning. 7.05 Blackburn with Darwen Safeguarding Children Board should be assured that the provision of domestic abuse services is not predicated on a stereotypical perspective in the context of; recognition of abuse, understanding of the nature of abuse and recognition of the potential for physical harm to adults, unborn and living children. 7.06 Blackburn with Darwen Safeguarding Children Board should be assured that the supervision of multi-agency safeguarding staff is prioritised within agencies and that opportunity for reflective supervision in child protection cases is embedded. This should include renewed consideration of multi-agency supervision standards within the safeguarding partnership and consideration regarding work with partners to develop and support opportunities for joint multi-disciplinary supervision in CP cases. 7.07 Blackburn with Darwen Safeguarding Children Board may wish to consider revisiting/updating the domestic abuse policy, to include situational couple violence and interpersonal violence in young people’s relationships and to be assured that all professionals are made aware of, have access to and utilise this document. Information pertaining to emerging forms of domestic abuse should be considered 59 in the development of the multi-agency training needs analysis and included as information in the safeguarding policy. 7.08 The recommendations developed as a result of this learning do not include specific reference regarding substance misuse. However it is important to identify that learning pertaining to this issue is inherent within the framework of recommendations (and in the development of clarity regarding the commissioning and delivery of services) and consideration should be given by Blackburn with Darwen Safeguarding Children Board to issues of substance misuse in the development of action planning as a result of this review. 8.0 Appendix 8.01 Glossary ASYE Assessed first year in employment BDDWA Blackburn and Darwen District without abuse BwD LSCB Blackburn with Darwen Local Safeguarding Children Board CAF Child and family assessment CBT Cognitive behaviour therapy CRC Community rehabilitation company CSC Children’s social care ICPC Initial chid protection conference IDVA Independent domestic abuse advisor IRO Independent reviewing officer JSNA Blackburn with Darwen Joint strategic needs analysis AMH adult mental health FNP family nurse partnership MASH Multi-agency safeguarding hub NQSW Newly qualified social worker 60 RCPC Review child protection conference WT 2015 Working together to safeguard children 2015 8.02 Bibliography Calder. M (2008) Risk assessment in Safeguarding Children. Russell house publishing, Dorsett. Fahlberg, V.I. (1991) A Child’s Journey through Placement. BAAF: London Lord Laming (2003) The Victoria Climbié Inquiry; report of an inquiry. HMSO HMG (2015) Working together to safeguard children. Crown copyright. Public Health England (2016) A framework for supporting young mothers and fathers crown copyright Research in practice (2016) Frontline Briefing; violence in young people’s relationships. Dartington. Reder,P et al (1993) Beyond blame: child abuse tragedies revisited. London: Routledge Schraer. R (27/1/16) Patchy implementation of the ASYE leaves newly qualified social workers facing unprotected caseloads. Community care Tavistock Centre for Couple Relationships (2016) Working relationally with couples where there is situational violence. TCCR |
NC52842 | Assault of a teenage girl in a residential children's home. The incident is subject to an ongoing police investigation at the time of the review. Learning themes include: managing the risk of harmful sexual behaviour (HSB) in residential settings; support for adoptive parents; support available for families where child to parent violence is a feature; child blaming language used by professionals; and placement sufficiency and impact on finding placements for children with complex needs. Recommendations include: the national working group reviewing the adoption support arrangements should take action to ensure that the needs of adopted children are addressed at key transition points such as when they move area or school; consider developing a pathway to support an effective professional response to child to parent violence; seek assurance that partner agencies have guidance which addresses victim blaming language and ensures that professionals record with the child in mind on the understanding that the child may one day ask to see their records; suggest to the National Panel that they consider concerns about the impact on children and young people of the cost and shortage of appropriate placements for traumatised children; when seeking placements for children the commissioning team should seek reassurance about harmful sexual behaviours; propose that the children's home develop a harmful sexual behaviours policy and systematic approach to keeping children safe from sexual harm; identify whether other LSCPR's have highlighted a lack of guidance within children's homes about HSB and whether this issue is currently being sufficiently addressed through Regulation 44 Visits.
| Title: ‘Molly’: local child safeguarding practice review. LSCB: Stockport Safeguarding Children Partnership Author: Jane Wiffin Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. ‘Molly’ Local Child Safeguarding Practice Review Author Jane WiffinMay 2023The CSPR ProcessThe Stockport Safeguarding Children Partnership has undertaken a Local Child Safeguarding Practice Review (CSPR). It has identified about the professional involvement with a family where a teenage girl was assaulted in a residential children’s home.The incident is the subject of an on-going police investigation. Therefore the full review cannot be published until this has concluded.An independent lead reviewer worked with a panel of local managers and safeguarding leads and met with the professionals involved directly with the family prior to the assault. This provided the review with the opportunity to reflect on both the case and wider systems and practice in Stockport.The family were invited to meet with the lead reviewer and did so.Learning has been identified in the following areasHarmful sexual behaviour (HSB) and managing the risk of this in residential settingsLimited pre-emptive support for adoptive parents in managing stages of development for traumatised childrenLimited services and support available for families where child to parent violence is a featureChild blaming language used by professionalsIneffective information sharing between agenciesPlacement sufficiency and impact on finding placements for children with complex needsThe review made the following recommendations, and an action plan is being progressedNational action needs to be taken to ensure that the needs of adopted children are addressed at key transition points such as when they move area or school. In these circumstances unless they are already known to specialist services they will come into a new area as universal children without a very clear picture of their history or needs. This is very different for the systems and processes in place for those who are care experienced. This should be considered by the national working group reviewing the support arrangements for adoption support.The Stockport Children’s Partnership should consider developing a pathway to support an effective professional response to child to parent violence.Stockport Children’s Safeguarding Partnership should seek assurance that partner agencies have in place guidance regarding trauma informed recording, which addresses victim blaming language and ensures that professionals record with the child in mind. Understanding that the child may one day ask to see their records.This LCSPR is one of many nationally where there have been concerns about the impact on children and young people of the cost and shortage of appropriate placements for traumatised children. Stockport Safeguarding Children’s Partnership should suggest that this is something the National Panel could consider in terms of creating change for these children.When seeking placements for children the commissioning team in Stockport should seek reassurance about harmful sexual behaviours policy and systematic approach to keeping children safe from sexual harm from all settings.Stockport Children’s Partnership to propose that the children’s home develop a harmful sexual behaviours policy and systematic approach to keeping children safe from sexual harm.Stockport Children’s Partnership to propose that the children’s home develop guidance about trauma informed and non-victim blaming record keeping.The social worker for Molly to review how far the assertion that ‘Molly posed a risk to staff, visitors and other children’ has been incorporated into other case records, assessments, looked after reviewing materials and placement referrals and make sure these are amended.The Chair of Stockport Children’s Safeguarding Partnership should write to the national panel to find whether other LSCPR’s have highlighted a lack of guidance within children’s homes about HSB and whether this issue is currently being sufficiently addressed through Regulation 44 Visits. |
NC50551 | Death of a 14-year-old boy in August 2015 by having climbed a tree and got his neck caught in a rope that was hanging in the tree. He had been accompanied by a care worker from the children's home who was at ground level when Callum died. Callum and younger sibling were taken into foster care in March 2013, but because of violence and aggression between them, Callum was placed in a children's home in June 2013 where he stayed until his death. He was big for his age but his emotional and behavioural development was that of a much younger child. There were several risk assessments in place including one which specified he should not climb trees, fences or other obstacles because he had no regard for his personal safety. Ethnicity or nationality is not stated. Learning includes: to identify improvements in the assessment of risk and how this can be implemented through effective risk management plans; to identify whether there are improvements to supervision and management that would ensure better management of risky behaviours; to consider whether all aspects of Callum's care and behaviour were brought together to comprehensively appreciate his needs and how to manage them. Recommendations: for Local Authority children's homes to design and implement processes in which risk assessments can be developed with relevant partners and family members where appropriate; for Emergency Services to establish a best practice approach to working at suicide incidents; for school nurses to document any knowledge of a child attending A&E and share that knowledge with other relevant health professionals.
| Title: Serious case review concerning Callum Garland: overview report. LSCB: Leeds Safeguarding Children Board Author: Peter Ward Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Overview Report – Child B April 2018 Page 1 of 45 Leeds Safeguarding Children Board Serious Case Review concerning Callum Garland Overview Report April 2018 Author: Peter Ward Overview Report – Child B April 2018 Page 2 of 45 Independent Chair’s Overview of the Serious Case Review Commissioned by the LSCB following the death of Callum Garland. This Serious Case Review relating to the tragic death of Callum Garland was the very first ‘serious incident’ to come across my desk on taking up my role as Independent Chair of the Leeds Safeguarding Children Board. From the outset the circumstances of Callum’s death stood out as especially heart-breaking, and I am aware that whilst this has been incomprehensibly difficult for all concerned, this must be especially so for Callum’s family and all those who loved him, and my sincere personal condolences go out to all those affected by the death of this young man. Serious Case Reviews give an opportunity for careful consideration to be given to circumstances where things have gone wrong, so that we can all better understand what happened, why it happened and use what we learn from tragedies such as this to make sure that we do better in future. If at all possible I would like to think that what we learn from Callum’s death will help to ensure that something like this is now less likely to happen again, which perhaps will be of some limited succour for his family. What we learn from the review very clearly is that whilst the risk assessment for Callum fully addressed his propensity for climbing, and that this was known to everyone who worked with him, that this element of the risk assessment was not followed by Callum’s key worker on the day of his tragic death. The Review succinctly draws together a number of recommendations for risk assessments and for the process of reviewing looked after young people like Callum. Reflecting on the fact that whilst Callum’s needs were known, and there was agreement about how best to meet them, the actions taken by his key worker on the day he died fell short of what should have been reasonably expected. What is similarly made clear in the review is that whilst the risk assessment for Callum was detailed and extended to a wide variety of potential situations and circumstance, it cannot be argued that the risk Callum faced through climbing was somehow ‘lost in the detail’. But rather his attraction to climbing and high places was well known and, as such, should have been taken into account in all circumstances. I accept without reservation the findings and recommendations of this Serious Case Review, and will ensure that the LSCB requires of the relevant agencies, that they take steps to ensure that in future, risk assessments for looked after young people are kept up to date. Moreover that all those working with vulnerable young people like Callum, adhere to the direction of the risk assessment irrespective of their own personal feelings as to whether this is appropriate or not. I Overview Report – Child B April 2018 Page 3 of 45 will remind managers within all agencies providing services to looked-after young people that a regular aspect of staff supervision, should be discussion of individual current risk assessments, the degree to which these reflect evolving individual need and a commitment by all involved to accept and follow the guidance therein without reservation. Furthermore that the process of regular review for looked after children should be purposive, facilitating what is termed in this review “...a comprehensive appreciation of (young people’s) needs and how to manage them.” In taking the matters raised by this Serious Case Review forward, I will endeavour to ensure that Callum is not forgotten. This as a mark of respect to both Callum himself and to his family. Mark Peel Independent Chair LSCP Overview Report – Child B April 2018 Page 4 of 45 Table of Contents Page 1. Introduction 5 2. Aims and Objectives 6 3. The Statutory Basis for Conducting a Serious Case Review 7 4. The Review Process 7 5. Summary of Agencies Involved 9 6. Findings and Analysis using the Key Lines of Enquiry 11 7. Identification of Learning using the Aims and Objectives 32 8. Areas Requiring Action 36 Appendices Appendix 1 – Key Lines of Enquiry Appendix 2 – Abbreviations Appendix 3 – Actions taken by agencies since the death of Callum as reported in agency reports Appendix 4 – Recommendations included within agency reports Overview Report – Child B April 2018 Page 5 of 45 1. Introduction 1.1 This Serious Case Review concerns Callum Garland who tragically died from hanging in August 2015 whilst on an outing away from the children’s home where he was living. He was 14 years of age at the time and had been living in the children’s home for a little over two years. Callum died having climbed a tree and got his neck caught in a rope that was hanging in the tree. He had been accompanied on the outing by CO5, a care officer from the children’s home, who was at ground level near to the tree when Callum died. 1.2 Callum was born in 2001 and had several older half siblings and a younger sibling. Leeds Children’s Social Work Service (CSWS) involvement with his mother and her children dates back a number of years. Callum remained with his mother and younger sibling when his parents’ relationship came to an end. 1.3 Following social care involvement, in March 2013, Callum and his sibling were accommodated on a voluntary basis by the Local Authority and placed with foster carers. At the first Looked After Children Review a decision was taken that Callum and his sibling should be separated. This was primarily because of violence and aggression and because of Callum putting himself into risky situations. Attempts were made to find an alternative foster placement for Callum but despite a national search a suitable place could not be found. Consequently Callum was placed in a Leeds City Council children’s home in June 2013. He was made subject to a full Care Order in October 2013 and he remained in the same children’s home until his death in August 2015. 1.4 During the period of 26 months that Callum lived at the children’s home his behaviour fluctuated with periods when he appeared quite settled and others when he exhibited behaviour that challenged those around him. This included leaving the home without permission, aggression, self-harm and other challenging behaviour. In addition, he was considered to put himself at risk by climbing. He was also a victim of bullying and physical assault from other young people living in the home. 1.5 At the time of his death Callum was over six feet tall and weighed in excess of 14 stone. Therefore he was big for his age. By contrast, he functioned below the expected level for a young person of his age. He sometimes acted spontaneously and put himself into risky situations with little thought to his own safety or the potential consequences of his actions. The children’s home had several risk assessments in place for Callum one of which specified that he should not climb trees, fences or other obstacles because he had little or no regard for his personal safety. 1.6 Callum enjoyed regular face to face contact with his mother, one of his older siblings and his younger sibling and spoke to his father on the phone. He wanted to live with his mother and to see his father regularly. He also had a girlfriend whom he frequently saw with the support of staff from the children’s home and the girl’s mother. Callum was the youngest resident in the home at the time of his death. He had close relationships with all the care staff and his relationships with the other young people varied. He took pride in keeping his bedroom tidy and enjoyed gardening at the home; he also enjoyed singing. At school, Callum Overview Report – Child B April 2018 Page 6 of 45 appeared to enjoy supporting other children and he had recently received an end of year award from his school. 1.7 On the day of his death, CO5 had accompanied Callum to a play park so he could meet with his girlfriend. On their way back to the children’s home, and despite the aforementioned risk assessment, Callum had climbed up and down a nearby tree a few times. Later that day, the same member of care staff accompanied Callum to a take away to buy Callum’s tea. They returned to the tree that Callum had climbed earlier in the day and, after eating his tea, Callum climbed the tree again. It was whilst he was in the tree on this occasion that Callum tragically died. 1.8 The exact circumstances of Callum’s death will never be known but this review has not seen any information that suggests there were ever indications that he would seriously harm himself or take his own life. Staff from the children’s home and Callum ’s mother, who spoke to him on the phone shortly before he went to get his tea on the day that he died, were of the view that he had enjoyed seeing his girlfriend that day and was feeling happy. 2. Aims and Objectives 2.1 The aim of this review is to provide a rigorous, objective analysis of what happened in this case and why so that: a. important lessons can be learnt and services improved to reduce the risk of future harm to children; b. Good practice can be shared so that there is a growing understanding of what works well. 2.2 The time frame under examination is from March 2013 (the point when Callum became looked after to Leeds City Council) to the end of August 2015. 2.3 The objectives are: 1. To identify improvements in the assessment of risk, and how this can be implemented through effective risk management plans; 2. To identify whether there are improvements to supervision and management arrangements that would ensure better management of risky behaviours; 3. To identify whether there are training and staff development needs arising from the circumstances of this case; 4. To consider the emergency response and incident management arrangements for all agencies involved with this case and whether these can be improved; 5. To identify whether there are improvements to be made to information sharing processes which could improve care arrangements and the management of risky behaviour; Overview Report – Child B April 2018 Page 7 of 45 6. To consider whether all aspects of Callum’s care and behaviour where brought together and contributed to a comprehensive appreciation of his needs and how to manage them; 7. To consider how learning from this review can inform wider systems learning and improvement of local services and interagency cooperation. 3. The Statutory Basis for Conducting a Serious Case Review 3.1 This review was commissioned by Leeds Safeguarding Children Board on 18 August 2016 in compliance with Regulation 5 of the Local Safeguarding Children Boards (LSCBs) Regulations 2006 which came into effect on 1 April 2006. Regulation 5 sets out the functions of LSCBs including the requirement for them to undertake reviews of serious cases in specified circumstances. Regulation 5(1)(e) and (2) set out an LSCB’s function in relation to serious case reviews, namely: 5(1)(e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. (2) For the purposes of paragraph (1) (e) a serious case is one where: (a) abuse or neglect of a child is known or suspected; and (b) Either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 3.2 The relevant guidance for conducting Serious Case Reviews is contained within Chapter 4 of Working Together to Safeguard Children (HM Government 2015). Leeds Safeguarding Children Board and the Lead Reviewer have followed that guidance in conducting this Serious Case Review. 4. The Review Process 4.1 Chapter 4 of Working Together to Safeguard Children 2015, states that Serious Case Reviews and other case reviews should be conducted in a way which: Recognises the complex circumstances in which professionals work together to safeguard children. Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did. Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight. Is transparent about the way data is collected and analysed. Overview Report – Child B April 2018 Page 8 of 45 Makes use of relevant research and case evidence to inform the findings. 4.2 A Serious Case Review Panel with the following membership was established to oversee the review: Independent Chair; Independent Lead Reviewer; Assistant Manager, Leeds Safeguarding Children Board; Head of Service, Learning for Life, Children’s Services, Leeds City Council; Head of Integrated Safeguarding Unit, Children’s Services, Leeds City Council; Deputy Designated Nurse, NHS Leeds Clinical Commissioning Groups Partnership; Head of Service Safeguarding/Designated Nurse Children Looked After & Care Leavers, Leeds Community Healthcare NHS Trust; Service Manager, NSPCC; Chief Inspector, Safer Leeds, West Yorkshire Police. 4.3 Organisations which had been involved with the family between 28 March 2013 when Callum was first accommodated by the local authority and 6 August 2015 when he died were asked to provide chronologies and brief reports of their involvement including relevant background information which pre-dated this time period. In analysing their involvement the organisations were asked to consider 15 key lines of enquiry agreed by the Serious Case Review Panel (appendix 1). 4.4 Reports were provided by the following organisations: Barnardo’s; Leeds City Council Children and Families (Children’s Social Work Service); Leeds City Council Children and Families (Education); Leeds Community Healthcare NHS Trust; Leeds Teaching Hospitals Trust; NHS Leeds Partnership Clinical Commissioning Group (in respect of GP services); The National Society for the Prevention of Cruelty to Children (NSPCC); West Yorkshire Fire and Rescue Service (The Fire Service); West Yorkshire Police (The Police); Yorkshire Ambulance Service (The Ambulance Service); 4.5 In addition to the individual agency reports, the Lead Reviewer has had access to documents provided by West Yorkshire Police to the inquest touching the death of Callum, Looked After Children Reviews concerning Callum and Regulation 33 and 44 Reports concerning the children’s home in which Callum lived. 4.6 Chapter 4, paragraph 10 of Working Together to Safeguard Children 2015 lists seven “principles for learning and improvement” that should be applied to all reviews. One of these is that “professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith”. In writing their individual reports agencies involved first line managers and practitioners who had been directly involved in providing services to Callum and his family. Towards the end of the review process a ‘learning event’ was held at which relevant practitioners and their managers were able to contribute to the learning from the review and to help develop draft action plans which addressed the reviews findings. Overview Report – Child B April 2018 Page 9 of 45 4.7 Another principle is that “families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively”. The Lead Reviewer and the Assistant Manager of Leeds Safeguarding Children Board invited Callum’s mother, father and the older sibling with whom he had regular contact to meet with them. A meeting took place with Callum’s mother and her comments about her son and the services received are incorporated within this report. Neither Callum’s father nor sibling responded to the invitation. 4.8 Section 4 of this report addresses the 15 Key Lines of Enquiry (KLoE’s) presenting both facts and analysis relating to the KLoE’s. KLoE’s 4, 5 and 6 are addressed together due to the extent to which they are interlinked. Section 5 uses the seven objectives (see Section 2 above) identified by the Serious Case Review Panel to identify the learning from this review. Section 6 sets out recommendations for action. 5. Summary of agencies involved with Callum Barnardo’s; 5.1.1 Barnardo’s provided two distinct and specific services to Callum. A therapeutic health worker (THW1) undertook some work with Callum in 2015 and a children’s rights worker from the Children’s Rights Service for Looked After Children visited Callum in June 2015 at Callum’s request in connection with his desire to have contact with his father. Leeds City Council Children and Families (Children’s Social Work Service); 5.1.2 Callum’s day to day care was provided by staff in the children’s home where he lived. Of particular note are the Registered Home Manager, referred to as RHM1 throughout this report, Care Officer 1 who was Callum’s keyworker for the majority of the time he lived there and Care Officer 5 who became his keyworker in April 2015. Care Officers 1 and 5, and other care officers who worker in the home are referred to throughout as CO1, 2, 3 etc. 5.1.3 As a child looked after, Callum had regular Looked After Children Reviews which were chaired by an Independent Reviewing Officer (IRO). He had three different social workers (SW1, 2 and 3) during the time covered by this review and two team managers (TM1 and 2) managed these social workers. In addition the Therapeutic Social Work Team and the Co-ordinator for Challenging Behaviour were involved for short periods of time. Leeds City Council Children and Families (Education); 5.1.4 Callum attended one specialist school until September 2013 and then moved to a different one. In addition to school staff he had brief contact with an educational psychologist. Overview Report – Child B April 2018 Page 10 of 45 Leeds Community Healthcare NHS Trust; 5.1.5 One Child Looked After (CLA) Nurse was involved with Callum throughout the time he was a child looked after. The CLA nurse had contact with Callum from time to time throughout this period in connection with a variety of health issues. A school nurse also had contact with him. Callum was also seen by a practitioner from the Child and Adolescent Mental Health Service (CAMHS) in December 2014 after an incident of self-harm. Leeds Teaching Hospitals Trust; 5.1.6 Callum attended the Emergency Department of Leeds Teaching Hospitals Trust on one occasion in December 2014 after an incident of self-harm. Callum was taken to the hospital after he died. NHS Leeds Clinical Commissioning Groups Partnership (in respect of GP services); 5.1.7 Callum was registered with a GP practice whilst living in the children’s home and had occasional appointments with the GP in relation to health issues that are not directly relevant to this review. The National Society for the Prevention of Cruelty to Children (NSPCC); 5.1.8 Callum made contact with the NSPCC Childline on four occasions in December 2014 and once the following month. West Yorkshire Fire and Rescue Service (The Fire Service); 5.1.9 The only contact that West Yorkshire Fire and Rescue Service had with Callum was during the incident that led to this review. West Yorkshire Police (The Police); 5.1.10 West Yorkshire Police had sporadic contact with Callum during his time living at the care home. They were called to the home in respect of incidents of aggression from Callum, occasions when Callum was a victim of aggression and occasions when Callum had gone missing. Several different officers were involved in responding to these incidents. Officers from West Yorkshire Police were also involved during the incident that led to this review. Yorkshire Ambulance Service (The Ambulance Service); 5.1.11 The only contact that Yorkshire Ambulance Service had with Callum was during the incident that led to this review. Overview Report – Child B April 2018 Page 11 of 45 6. Findings and Analysis using the Key Lines of Enquiry 1. Critically comment on the efficacy and robustness of the risk assessment arrangements for (a) Callum and (b) vulnerable young people looked after whose behaviour places them at risk of harm. Risk Assessments at the Children’s Home 6.1 During the time that Callum lived at the children’s home there was a clear system in place within the home for creating, reviewing and sharing risk assessments for all the young people who lived there. Risk assessments were written on a specific form that was used in all of Leeds City Council’s children’s homes. All members of the care team at the children’s home Callum lived in were familiar with the risk assessment system and the forms. 6.2 At the time of Callum’s death the children’s home had 18 separate risk assessments in place for him relating to specific, identified risks. In addition there was a risk management plan for when Callum was out in the community and one for when he was in the home. CSWS advise that 18 is not an unusual number of individual risk assessments for a young person and is not considered to be excessively high. It is understood that all members of the care team at the children’s home were aware of the risk assessments that related to Callum including the one that related to him climbing. 6.3 Children’s home records for Callum do not detail when risk assessments were reviewed. When risk assessments were amended the previous version was overwritten and therefore there is no historic record of all risk assessments for an individual resident. This makes it difficult to track changes in a person’s behaviour or to gauge the efficacy of risk assessments. However, it is recorded in CO5’s supervision of 3 July 2015 that he had reviewed the risk assessments for Callum and these had been signed off by RHM1. Following Callum’s death, a copy of the risk assessment relating to climbing was given to the Police showing that this had last been modified on 30 July 2015, although the information within it was the same as a version dated 28 April 2015. 6.4 Evidence suggests that the risk assessments were very much an in-house arrangement for the children’s home. There is no indication that they were considered or referenced during Looked After Children reviews or that other services which were working with Callum were aware of them. Therefore, there is no sense of a shared view of the risks that Callum faced or of how these should be addressed. Social Worker (SW) 3 told the Police that she had been made aware that there was a risk assessment in relation to Callum climbing trees but that such assessments are carried out by the children’s home and would not necessitate social work involvement. The School and Child Looked After (CLA) nurse have stated that they were not aware of the risk assessment relating to climbing. Whilst some of the identified risks may well be quite specific to a young person’s care within the children’s homes it would be appropriate to share others with a wider network of agencies and practitioners or to seek specialist skills of others in Overview Report – Child B April 2018 Page 12 of 45 creating the risk assessments. Doing so would improve the robustness of the risk assessment arrangements. 6.5 It is the view of the CSWS report author that each risk assessment and the risk management plan relating to Callum comprehensively addressed potential risks with due consideration to his emotional and social developmental needs. This Serious Case Review has only considered the risk assessment relating to climbing and therefore can only comment on this one. It is written in the risk assessment that Callum should be given clear boundaries before commencing an activity and that if he starts to climb trees or obstacles when out in the community then he should be advised to come down immediately. The risk assessment does not detail what action staff should take if Callum does not follow their instruction to come down immediately. However, following Callum’s death CO3 told the Police that if Callum climbed on anything the staff member was expected to monitor the situation, encourage him to come down and to inform colleagues of their location to obtain support and assistance. The risk assessment also makes reference to Callum climbing on the roof of the home. It is written that when he does this, he should be told to come down, the care staff should monitor him whilst he is on the roof and all instances of him climbing on the roof should be logged on his file and the social worker should be informed. 6.6 The Lead Reviewer considers it to be a weakness in the risk assessment that directions were not given as to the action care staff should have taken if Callum climbed when out in the community and did not obey the instructions to come down immediately. In that regard this specific risk assessment could have been more robust. However, even without such instructions the Lead Reviewer considers that it would be unacceptable for a care worker not to seek help or to report the incident at the time. 6.7 In the version of the risk assessment that has been made available to this review, it is written under the heading ‘What further action is necessary?’ that Callum ’s keyworker had identified two climbing walls where Callum had been able to climb with qualified teachers in a safe way. There is no record as to what it was anticipated this would have on Callum’s tendency to climb elsewhere or how this was to be monitored. This review has been informed that Callum attended one of these on 27 April 2014 and 28 June 2014, when CO1 was his keyworker, but then lost interest and became engaged in other activities. Therefore he had not attended a climbing wall for more than a year before his death. Nevertheless, this action remained on the risk assessment. This suggests that the reviews of the risk assessment had been insufficiently thorough and the risk assessment had not been amended and kept up to date as circumstances changed. 6.8 This review has been told that, because there had been no reports of Callum climbing during the six months prior to his death, CO1, RHM1 and SW3 believed that he had stopped climbing. This belief is not reflected in the risk assessment which is further evidence that the risk assessment was not kept up to date despite being reviewed. 6.9 Notwithstanding the above comments, there is no evidence to suggest that Callum climbed a tree because of a problem with the efficacy or robustness of the risk assessment arrangements or the specific risk assessment. Instead, he climbed the tree because he was given an opportunity to do so despite the risk assessment. This is addressed in greater detail in the analysis of KLoE 2. Overview Report – Child B April 2018 Page 13 of 45 Other Risk Assessments 6.10 During the period covered by this review Callum was reported to the Police as missing on eight occasions. Three of these were in May 2013 whilst Callum lived in a foster placement, one was in July 2013 and four were between August 2014 and November 2014. 6.11 Between the first and last four occasions when Callum was reported as missing West Yorkshire Police’s approach to missing persons changed and a substantially amended policy was introduced in May 2014. Notwithstanding the change in policy West Yorkshire Police had ongoing problems with inconsistency amongst supervisory staff in risk assessing missing children. As a result of this inconsistency in risk assessment, a further revised policy was introduced on 1 July 2016. Her Majesty’s Inspectorate of Constabulary PEEL: Police effectiveness 2016 inspection report published in March 2017 reported: “The force has recently updated its missing person’s policy, with a good understanding of this being evident among staff within the force and partner organisations.” 6.12 This review has found that there was inconsistency in the risk assessments relating to Callum when he was reported to the Police as missing. In view of the change of policy that has already taken place no recommendations are made about this. 6.13 There were two occasions in 2014 when Callum disclosed to school staff that he had harmed himself and a third occasion, in 2015, when he disclosed to children’s home staff that he had done so (see KLoE’s 4, 5 and 6). The school could have instigated a pupil risk assessment which would have encouraged a multi-agency response for all professionals working with Callum to formally identify strategies to support him to address his self-harming behaviour. The resulting pupil risk assessment plan could have considered how to minimise any opportunity for him to cause harm to himself both at school and in the wider community. It could also be expected that the children’s home would have written a risk assessment aimed at addressing self-harm but there is no evidence that this was done. 6.14 Each of the calls made to NSPCC Childline, were identified as low risk against the Childline risk assessment criteria as there had been no indicators of suicidal ideation or abuse and Callum was appropriately utilising Childline support. He had also talked positively about a career in the home, who he said was helping and supporting him. As such, there was no further action taken and he was encouraged on each occasion to call Childline again if needed. 2. Evaluate the effectiveness, or otherwise, of how the risk assessment was managed and implemented in practice for this case. 6.15 As is noted in KLoE 1, all members of the care team staff at the children’s home were aware of the risk assessments relating to Callum climbing and therefore that aspect of its management was effective. 6.16 It is less easy to judge how effectively the risk assessment was implemented as inconsistent statements have been made regarding whether or not Callum had climbed this tree in the presence of CO5 prior to 6 August 2015 and also whether Overview Report – Child B April 2018 Page 14 of 45 any other staff from the children’s home knew that he had climbed the tree previously. 6.17 Considering all the information seen, the Lead Reviewer considers it highly likely that Callum had climbed the tree in the presence of CO5 prior to the afternoon of 6 August 2015. CO5 told the Police that Callum climbed the tree several times in the afternoon of 6 August 2015 after he met his girlfriend and before they returned to the children’s home. If he had not climbed the tree previously then it is to be expected that CO5 would have mentioned this to his colleagues on his return to the children’s home. Furthermore, if Callum had climbed the tree against CO5’s instruction then it would not have been appropriate for CO5 to have gone near the tree with him again that day. In addition, it was recorded by an Emergency Duty Team (EDT) social worker, on the day Callum died, that another care worker said that Callum had climbed this tree many times before. However, this review has not been provided with evidence of any specific occasions when Callum climbed the tree apart from the aforementioned occasions on the day of his death. 6.18 GP records from an appointment that Callum had 14 months before his death refer to him having recently had a fall from a tree. CSWS have no records relating to this incident so it is not possible to determine how Callum came to be climbing the tree or how it was handled afterwards. This incident occurred 14 months before Callum died and when it was known that he liked to climb. Callum was not seriously hurt in this fall and the GP appointment was in relation to a different matter. Nevertheless, it is a matter of concern that CSWS do not have a record of this incident, particularly as there was a risk assessment in place in respect of climbing. 3. How effective was the management and supervision of the care worker tasked with implementing the risk plan? 6.19 CO1 was the keyworker for Callum until April 2015 when CO5, who was new to the care home took over this role. This followed CO1 being promoted to a more senior role in the home. CO5 had moved from a different care home within Leeds which had closed. He was an experienced care officer who was used to the keyworker role and had experience of working with children with complex emotional and behavioural needs. He was also familiar with the risk assessment forms as these were used across the Leeds City Council children’s homes. 6.20 There is an expectation within CSWS that supervision is held every month with care officers from children’s homes and that they are supervised by the senior care officer and deputy manager. Records show that CO5 received formal supervision on three occasions over a 13 day period in the middle of April 2015 and again on 3 July 2015 but did not receive any formal supervision in May or June 2015. The first two supervision sessions took place with RHM1, the third was with CO3, a senior care worker and the final one with CO1 as CO3 was away from work having sustained a fractured leg. It was because of CO3’s fractured leg that CO5 did not receive supervision in May or June 2015. 6.21 The second supervision session between CO5 and RHM1 appears to be of particular significance. This took place on 13 April 2015, just four days after their first meeting and it is recorded that it took place because RHM1 had received an email from another member of staff expressing concern about aspects of CO5’s attitude to the safety of young people living in the home, including an allegation that Overview Report – Child B April 2018 Page 15 of 45 he had allowed one of the residents to climb trees in the park (this resident was not Callum). It is recorded that RHM1 made it clear to CO5 that there were risk assessments for each young person in the home and that these must be adhered to. It is further recorded that CO5’s response was that he did not see tree climbing as an issue, stated “boys will be boys” and shared a view that he thought they were too strict in the care home. 6.22 Of the supervision with CO3, which took place nine days later on 22 April 2015, it is written that CO5 was more settled in his role and that “he needed to develop his relationships with the young people in the home and ensure he reads all the paperwork including care plans and risk assessments.” Of the supervision with CO1 in July 2015 it is written that CO5 was now the keyworker for Callum and had reviewed the risk assessments which had been signed off by RHM1. 6.23 It is reported that informal discussions were held between RHM1 and CO5 during May and June 2015 but no evidence has been provided of these. There are no records to suggest that the concerns about CO5’s approach to safety, or his response when this was raised with him in April 2015 was ever revisited by RHM1 or anyone else. 6.24 There is no indication that RHM1 or CO5’s supervisor were provided with any information to suggest that CO5 or anyone else was not complying with the risk assessments for Callum. Nevertheless, in light of the concerns raised in April 2015 about CO5’s behaviour and his stated attitude to risk during the subsequent supervision session, it would have been appropriate for this matter to have been revisited with him and, if appropriate for further measures to be put in place to ensure compliance. 4. Consider to what extent Callum’s behaviour and needs were unusual or extreme, or required specialist support and whether this was available and used? 5. Examine whether there were any previous concerns, incidents or indications which might have signalled any risks of self- harm or given rise to other concerns. and 6. Investigate how any previous incidents of risky behaviour were managed and whether there was learning from these to inform Callum’s care plan. 6.25 According to CSWS records, Callum was assessed for Autism in 2009 but did not meet the diagnostic criteria for further assessment. Subsequently, the Therapeutic Social Work Team screened him for organic disorders such as Attention Deficit Hyperactivity Disorder (ADHD) and Autism but no diagnosis was made. Throughout the CSWS records Callum is referred to as having global development delay although in 2015, having considered inconclusive results from several tests, an educational psychologist stated that he should not be described in this way. Notwithstanding the absence of any formal diagnosis, it was believed that Callum required more significant levels of support than would be needed by other children of a similar chronological age and his emotional and behavioural development was that of a much younger child. Overview Report – Child B April 2018 Page 16 of 45 6.26 By contrast to Callum’s emotional and behavioural development being that of a much younger child, his large size would have made him more of a threat when he became aggressive and it would have been difficult for carers to restrain him if he was putting himself at risk. Sub consciously or otherwise, people may also have treated him as older than he was. 6.27 Paragraph 1.4 refers to various challenging behaviours exhibited by Callum whilst he lived at the children’s home. The following paragraphs describe these behaviours in greater detail and consider how they were addressed including what specialist support was available and used. Callum’s climbing behaviour is not considered in this section as it has been addressed in respect of KLoEs 1, 2 and 3. Going Missing/Leaving the Children’s Home without Permission 6.28 The Children’s home contacted the Police on five occasions and reported that Callum had gone missing. Four of these occurred in the second half of 2014 when things were particularly unsettled within the resident group at the children’s home. 6.29 CSWS report four other occasions when Callum left the children’s home without permission, twice within the first month that he was living there and once each in May and June 2015 after a decision had been taken that he could not go out without supervision (see paragraph 6.42). In addition, information seen by the Lead Reviewer suggests there was at least one other occasion when he left without permission. In all these instances Callum was only missing for a short time before returning to the home. The Police were not informed on these occasions. 6.30 West Yorkshire Police policy describes a persistent missing person as one who is missing or absent on four or more occasions within a month or six or more occasions within three months. Callum briefly met this criterion at the end of August/beginning of September 2014 but otherwise it appears that this was not a particular problem. Even at the time he met the criterion his absences were relatively short and he returned to the home of his own volition with no evidence that he was exposed to significant risk whilst he was missing. Consequently his behaviour, in this regard, is not considered to have been particularly unusual or extreme and it was managed in an appropriate way. Aggression 6.31 Children’s home staff contacted the Police on eight occasions when Callum had either assaulted a member of staff or had been involved in some other disturbance. Only one of these incidents was dealt with by formal Police action. In addition CSWS report three occasions during the first month that Callum was at the children’s home when he was verbally abusive or aggressive towards staff but the Police were not called. 6.32 As with the incidents of Callum going missing from the home, these incidents of aggression took place over three time periods. These were in the first few weeks following his admission, the unsettled period at the children’s home in late 2014 and late spring/early summer 2015 following the incident that had resulted in a decision that Callum could not go out alone. Overview Report – Child B April 2018 Page 17 of 45 6.33 Children’s home staff contacted the Police for support when it was considered necessary and restorative practice1 was used to help build relationships and repair harm. Self-harm 6.34 On 13 October 2014, 4 December 2014 and 26 June 2015 Callum was observed to have harmed himself by scratching his arm. On 4 December 2014 he also stated that he had been chewing a piece of glass during the morning but there is no evidence that he swallowed any glass. 6.35 The first of these incidents was identified by Teaching Assistant (TA) 1 at school who informed a member of staff at the children’s home. Callum informed TA1 that he had scratched himself with glass and he had done so because he was upset, due to not being allowed to sleep at his older sibling’s home on the Sunday evening. The recorded view of staff at the children’s home was that Callum had copied another child at the home although it is not clear what evidence there was to support this view. CO1 informed SW3 that staff would monitor the situation. 6.36 Callum himself brought the second incident to the attention of TA1, who then took him to the Emergency Department at hospital. Callum was admitted to hospital and seen by a worker from CAMHS in line with the local procedures before being discharged back to the children’s home that same day. A member of the care team from the children’s home also attended the hospital and was present when the CAMHS practitioner spoke to Callum who disclosed bullying and taunting at the children’s home. He said that the girls living there often picked on him but then wanted to be friends, which confused him. CAMHS records indicate that plans were arranged to address conflict and monitor risk at the children’s home and a follow up visit from CAMHS was arranged but then cancelled. The circumstances of the cancellation have not been clearly documented but it appears that a telephone call took place between the two services and CAMHS were told that Callum’s behaviour around wanting to harm himself was a direct cause of incidents of bullying which had occurred at the home but that this had been addressed and Callum was doing much better. The children’s home have no records relating to a planned follow up visit from CAMHS and staff have reported that they believe that Callum said that he did not want a further visit from CAMHS whilst he was still at the hospital. 6.37 The third incident occurred six months later, on 26 June 2015, and was identified by care staff. Callum told staff that he scratched himself because he was upset and angry that he had hurt a member of the care staff. It was suggested to him that if he was feeling low he should tell staff or find a place to calm down in order to prevent further episodes of self-harm. 6.38 The physical injuries that Callum inflicted upon himself with each of these incidents were superficial. However, any issue of self-harm should raise concern and be 1 “Restorative practice is a term used to describe a way of behaving which helps to build and maintain healthy relationships, resolve difficulties and repair harm where there has been conflict.” (We are child friendly Leeds; One minute guide, No27, May 2015) Overview Report – Child B April 2018 Page 18 of 45 addressed. It is positive that on each occasion discussion took place with Callum which acknowledged his behaviour and sought to understand the reasons behind it. He was also reassured by staff at the children’s home that he could talk to them if he needed to, which was good practice. It is unclear what led children’s home staff to conclude that the episode of self-harm in October 2014 was copycat behaviour on the part of Callum and this is a potentially unhelpful and dismissive explanation for the behaviour that is inconsistent with the explanation Callum gave to TA1 and which does not acknowledge whatever was upsetting Callum at the time. 6.39 Leeds Safeguarding Children Board, Leeds City Council and the NHS have produced guidance for staff working with children and young people in Leeds who self-harm or feel suicidal. The staff in the Emergency Department followed this guidance in their response to Callum but this review has not been provided with any evidence as to whether or not the other practitioners who worked with Callum considered the guidance when he self-harmed and whether it guided their responses. Better understanding of this guidance should have resulted in a more appropriate response from the children’s home. Challenging Behaviour/Identity 6.40 Callum experienced difficulties in terms of his understanding and behaviour regarding puberty, sex and relationships. Staff at the children’s home contacted the CLA Nurse for specialist support at the end of 2013. Initial support from the CLA Nurse was provided in early 2014 and included conducting one to one work and liaison with nursing staff at the school in order to maintain a consistent approach to supporting Callum ’s needs. 6.41 In early 2015 there was further concern about Callum’s understanding and behaviour regarding puberty, sex and relationships and the CLA nurse referred him to the Futures Service within Barnardo’s on 11 March 2015. It was agreed that a therapeutic health worker from Barnardo’s (THW1) would undertake work with Callum looking at a number of relevant issues. 6.42 There was a positive and appropriate response to Callum’s needs with regard to puberty, sex and relationships. Children’s home staff, the CLA nurse, the school nurse and Barnardo’s worked together to support Callum at his pace and in a way in which he felt comfortable although Barnardo’s have identified that it would have been good practice for THW1 to have had more direct contact with children’s home staff whilst this work was being delivered. As his behaviour became more of a concern action was taken to protect him and others and specialist help and support was sought. Bullying and assaults against Callum 6.43 There were times at the children’s home when Callum was a victim of bullying. Of the five Looked After Children reviews that were held whilst Callum was a resident of the home reference was made at the second, third and fourth to him being the victim of bullying from other residents. At the last review, held on 4 March 2015 it was recorded that the bullying of Callum had been addressed. Overview Report – Child B April 2018 Page 19 of 45 6.44 In addition there was one occasion when children’s home staff contacted the Police after Callum was assaulted by a resident and an occasion a few weeks later when they again contacted the Police after he was threatened by the same resident, whose behaviour was causing frequent difficulties in the home. There were also two occasions when Callum told staff at school that he had been physically hurt by other residents. The school contacted the children’s home on both occasions. This second incident was just a day before it was stated at review that the bullying had been addressed. 6.45 As with the aggression displayed by Callum, children’s home staff dealt with these incidents of bullying and aggression using restorative practice. There were also occasions when individual residents were moved into different placements as it was determined that the home could not contain them. Managing Risky Behaviour 6.46 The preceding paragraphs describe how some specific incidents of risky behaviour were managed. Also, as stated in KLoE 1, the children’s home produced a series of risk assessments for Callum which were reviewed every three months to assist with managing his risky behaviour. In more general terms, CSWS have explained that Callum was a young person who had a tendency to forget things and therefore he required regular reminders to reinforce the behaviour that was expected. This was done through regular key work sessions and was addressed in the risk assessment relating to climbing. In addition, the care team provided consistent, clear messages and focused on positive activities. Accessing Specialist Support 6.47 The preceding paragraphs describe some of the specialist support that was accessed to assist Callum, such as CAMHS, the CLA nurse and the Futures Service. 6.48 When Callum was first accommodated he was subject to a statement of Special Educational Needs and attended a specialist school. In September 2013, having moved to the children’s home he transferred to a different specialist school which provides education to children with a range of complex learning difficulties. Callum continued to attend this school until the time of his death. 6.49 Callum was referred to the Therapeutic Social Work Team on 13 January 2014 following a recommendation to that effect being made at the Looked After Children review held in November 2013. The purpose of the work was to help Callum understand the trauma he had experienced over a long period of time and the reasons he was a Child Looked After. After four months the work ceased because it was judged that Callum was not ready to engage. 6.50 At the Looked After Children review held on 3 March 2015 it was agreed that SW3 would refer Callum to the educational psychologist who, it was thought, might be able to provide some advice about how to help Callum to process information and to get the most from work done with him. This led to a meeting between CO1 and Overview Report – Child B April 2018 Page 20 of 45 the educational psychologist on 10 June 2015 and a plan for a follow up meeting with the psychologist, CO1 and Callum’s teacher in the autumn term. This did not take place due to Callum’s death. 6.51 At a Looked After Children review in March 2015 there was discussion of a possible referral to CAMHS as this was recommended by a health needs assessment. However, due to the other work that was planned it was decided not to refer Callum at that time but to reconsider at the next review, which would have taken place before 4 September 2015. Placement at the Children’s Home 6.52 When considering the specialist support that was accessed for Callum it is necessary to consider whether it was appropriate for him to live in the children’s home. When a decision was taken to move Callum from the foster placement with his bother the intention was to place him in a foster placement where he would be the only child present. However, despite a national search it was not possible to find a suitable foster placement and he was instead placed in the children’s home. 6.53 Callum lived at the children’s home for over two years without the placement ever being at threat which suggests a degree of stability. Nevertheless, CSWS acknowledge that there was a significant difference in both chronological and developmental age between Callum and other residents with Callum being the youngest resident and having a developmental age that was younger still. CSWS state that the decision to place him at the children’s home and to keep him there was finely balanced and under constant review with relationships continually considered and analysed to ensure that risks were addressed and managed. 6.54 Records show that the possibility of a fostering placement was discussed at the last three Looked After Children reviews that were held but that at the first of these the chair was of the view that therapeutic work needed to be undertaken first whilst at the second it was said that a placement would not be without risk as Callum’s family ties made it difficult for him to commit to living in a family. At the next review, held on 4 March 2015 it was again stated that a placement would not be without risk because of Callum’s ties to his family but also because of his recent negative behaviours. Notwithstanding these concerns, it was agreed that enquiries would be made with the fostering team regarding possible matches. The IRO met with Callum in advance of the review and Callum expressed a preference to live with his family but also said that he would rather live in a foster placement than in the children’s home. 6.55 The regulation 332 visitor has recorded that in a phone conversation on 18 March 2015, just two weeks after the Looked After Children review, SW3 said that further 2 Regulation 33 of the Children’s Home Regulations 2001 required the registered provider of a children’s home, in this case Leeds City Council, to have quality assurance arrangements in place. At a minimum these involved someone visiting the home at least once a month to observe the care provided, the practice of the staff, inspect compliance with regulations, systems and processes and the quality of the environment. The person who undertook the visit was also required to provide a report of the visit. Overview Report – Child B April 2018 Page 21 of 45 work was required before Callum would be ready for a foster placement and whilst ideally he would not be in residential care it was considered that greater stability needed to be achieved in terms of his behaviour. There is no indication that anything significant had changed during these two weeks. 6.56 The CSWS records for Callum include a record of a supervision session between SW3 and TM2 on 10 June 2015 where a discussion took place regarding the possible impact of a move on Callum. Subsequently, in a report for a Looked After Children review that was due to take place on 15 July 2015 SW3 referred to Callum having remained unsettled at the children’s home. SW3 wrote that the long term plan was for Callum to be moved to a foster placement but this would not be progressed until the ongoing work regarding puberty and identity was completed. It is not known whether Callum was aware of this change of plan and, if so, whether it had an impact on his behaviour. This planned review was postponed and due to be rearranged to take place before 4 September 2015. 6.57 The work did not take place until two months after the Looked After Children review of March 2015. It is not known why the decision of the Looked After Child Review that enquiries would be made with the fostering team regarding possible matches had not been acted upon during this two month period. 6.58 As a further complication, Regulation 443 reports show that from April 2015 the age range of the home was being changed from 12 – 17 years to 15 – 17 years but that Callum was going to remain at the home despite being only 14 years of age. It is written in the report of the Regulation 44 visit undertaken on 8 April 2015 that the staff team were very committed to Callum and confident that they were managing the different needs of the young people. It is also written that the plan was for Callum to remain in residential care until independence. This statement is not consistent with the outcome of the previous Looked After Children review or the statement in the report written by SW3 for the following review. Conclusions for KLoE’s 4, 5 & 6 6.59 Taken as a whole it can be seen that throughout the period covered by this review Callum exhibited a range of risky and harmful behaviours. The severity of these varied from time to time but generally they were not regarded as particularly unusual or extreme, especially considering his history. 6.60 The challenging behaviour displayed by Callum in late 2014 appears to have been linked to the behaviour of residents and the overall difficult environment at the home. Children’s home staff have also expressed the view that his behaviour deteriorated when he was told that he was not going home. As 2015 progressed, his challenging behaviour became increasingly risky and difficult to manage and there continued to be instances of aggression towards staff. 6.61 Appropriate action was taken to address the challenging behaviour exhibited by Callum, using a restorative approach and engaging with specialist services as 3 Revised Children’s Home Regulations published in 2015 amended Regulation 33 of Children’s Home Regulations 2001to require that visits to Children’s Homes are carried out at least once a month by an Independent Person. The revised amendment is Regulation 44. Overview Report – Child B April 2018 Page 22 of 45 required. There is evidence of this being done in a co-ordinated way, using the Looked After Children reviews to agree interventions in an attempt not to overwhelm Callum. Notwithstanding this careful approach Callum would not always engage with services so it was difficult for professionals to make progress in their work with him. 6.62 Although Callum lived at the children’s home for over two years without any risk to his placement it is acknowledged that it was not an ideal placement for him and it appears that much of the challenging behaviour he exhibited, particularly in late 2014, was linked to the behaviour of other residents. It is a concern that CSWS did not make enquiries about a possible foster placement for Callum after it was agreed in the review on 4 March 2015 that they would do so. It is also a concern that contradictory statements were made about whether the long term plan for Callum was to remain in residential care or to seek a foster placement. 7. Consider whether there were any significant changes in behaviour and relationships that might have indicated increased risk of violence or harm. 6.63 During the 10 weeks that Callum lived in a foster placement with his sibling he engaged in aggressive and risky behaviour, including climbing and going missing. This pattern of behaviour continued when Callum moved to the children’s home but after the first two to three months things settled down. 6.64 From around mid-August 2013 until mid-July 2014 Callum had a much more settled period at both school and the children’s home although there were some examples of him being bullied by other residents and he continued to put himself at risk by climbing. 6.65 From mid July 2014 until the end of December 2014, Callum was much more unsettled again. He went missing from the children’s home seven times, albeit for short periods of time, assaulted staff and on two occasions superficially harmed himself by scratching his left arm. He continued to be a victim of bullying and was also assaulted by other residents at the home. This very unsettled period for Callum coincided with a difficult period at the home generally, including a period of 2½ months when the Police were contacted by the staff at an average of almost once each day. Regulation 33 reports seen by the Lead Reviewer suggest that there were particular problems relating to two young people which unsettled the dynamics in the home. 6.66 From January 2015, following one resident moving from the home things appear to have been more settled again for Callum although there was an increase in his challenging behaviour, which culminated in May 2015. During this period, children’s home staff continued to describe his behaviour as challenging. In June and July 2015 there were further incidents of Callum being aggressive towards members of staff at the children’s home, he scratched his arm again and, on at least one occasion, he left the children’s home alone and without permission. 6.67 Callum’s mother told the Lead Reviewer that she frequently spoke to her son on the telephone and on 31 July 2015, one week before he died, he was quite upset and told her that staff at the children’s home had been picking on him. The following day Callum went out for the afternoon with his mother; he did not mention Overview Report – Child B April 2018 Page 23 of 45 the issues that he had raised the previous day and he seemed very happy. According to Callum’s mother it was not unusual for him to talk to her in this way but he was inconsistent in what he said. On 6 August 2015, Callum spent the afternoon at the park with his girlfriend and seemed happy to all who saw him, although he was disappointed when he had to say goodbye to her and return to the children’s home. After returning to the children’s home he phoned his mother and told her about his day and that he was going to get a takeaway. Her opinion is that he had enjoyed his day and was happy. 6.68 Considering all the available information, it is evident that Callum’s mood and behaviour fluctuated during the 26 months that he lived at the children’s home. It is also evident that there was an increase in challenging behaviours in the few months immediately preceding his death. The challenging behaviour displayed by Callum indicated an increased risk of harm to Callum and to vulnerable young people with whom he associated and appropriate action had been taken to try to address this. 6.69 However, this review has not seen any information that suggests there were ever any indications that Callum would seriously harm himself or take his own life. 8. Examine the inter and intra agency communication regarding Callum and whether there were gaps in information sharing that impacted on the risks he faced. 6.70 The school and home worked well together to establish behaviour management plans for Callum when he started to attend the school but school staff were of the opinion that, as time passed, the children’s home did not communicate sufficiently with them about things that were taking place in the home. This included occasions when Callum harmed himself and experienced bullying. School staff did contact the children’s home when they became aware of such incidents but did not make children’s home staff aware of their concerns about the level of communication at the time. CSWS made the school aware of the incident regarding aspects of his continuing challenging behaviour. However, although a home and community safety plan was compiled, it appears that it was not shared with the school. 6.71 Of the four Looked After Children reviews that were held at the children’s home after Callum started to attend the school, school staff only attended the first one. School staff state that they were not informed of the dates of the reviews although CSWS state that invitations were sent to the school. School staff should have been aware that reviews would take place every six months and there is one record of staff asking the Independent Reviewing Officer (IRO) for the date of the next review. The school in question usually attend Looked After Children reviews for their pupils and it is not clear why this did not routinely happen in respect of Callum. Ideally the IRO should have sent the review invitations to a nominated senior person at the school. 6.72 Children’s home staff did attend parent’s evenings at the school. 6.73 At the Looked After Children review held on 21 November 2013, SW1 said she had been trying to arrange a Personal Education Plan (PEP) meeting but had not heard Overview Report – Child B April 2018 Page 24 of 45 back from the school. In 2015 SW3 also experienced difficulty arranging a meeting with the school to review the PEP. 6.74 One CLA nurse worked with Callum throughout the period that he was a child looked after. The nurse did not attend the Looked After Children reviews held in November 2013 or April 2014 but did attend the following two reviews. CLA nurses initiate an annual health needs assessment for children looked after but do not have the capacity to attend all Looked After Children reviews and therefore prioritise which they attend. The CLA Nurse should review the records and if there are any changes to the Health Needs Assessment they will contact the Social Worker or IRO before the meeting. The CLA nurse knew these reviews were taking place; she sent apologies and submitted reports to the reviews she did not attend. There is no suggestion that her absence from the reviews caused communication difficulties. 6.75 The CLA nurse, care staff from the children’s home and Barnardo’s staff communicated with one another and worked together to support Callum with his issues relating to sexual health and puberty and there was also some engagement with the school. There was a delay before the CLA nurse was made aware of the first two episodes of self-harm from Callum. 6.76 It would have been appropriate for the CLA nurse to have been informed of Callum ’s self-harming behaviour in both October 2014 and December 2014 and it could reasonably have been expected that both the school nurse and the children’s home would have done so. However, this was not done at the time. Hospital staff informed the GP and SW3 of Callum’s attendance in December 2014, but did not inform the CLA nurse and would not usually expect to do so, considering that informing the GP and social worker was sufficient. The CLA nurse was informed of the June 2015 self-harming incident in a timely manner by CSWS staff and she visited Callum to discuss the self-harm. Callum said that he was unhappy at the care home and requested a visit from the Children’s Rights Service, who became involved over the next few weeks. 6.77 There was appropriate communication within the children’s home to ensure that care staff were aware of the risk assessments relating to Callum but it appears likely that information was not shared about Callum continuing to climb trees. There was also a lack of communication about the risk assessments with other agencies. 6.78 West Yorkshire Police involvement was limited to responding to specific incidents of aggression and of Callum going missing and communication between the children’s home and the Police was appropriate in respect of these incidents. West Yorkshire Police conduct return interviews with young people who have been missing. Copies of the actual interview form are not given to CSWS as they may contain confidential information about other people. However, representatives from CSWS and West Yorkshire Police attend a daily meeting where all missing children and the content of interview forms are discussed. During the latter part of 2014 the Police were concerned about the frequency with which this particular children’s home was making contact and initiated communication with the home to address their concern. Overview Report – Child B April 2018 Page 25 of 45 9. Review whether Callum’s relationships with adults and peers was analysed to inform care planning and risk management. 6.79 The descriptions of Callum that have been provided to this review suggest that he was a young person for whom relationships were important. He wanted to be liked and this impacted both positively and negatively on his behaviour. The following paragraphs consider Callum’s relationships with a variety of individuals and groups with whom he had regular contact and whether these relationships were analysed to inform care planning and risk management. Relationships with staff at the children’s home 6.80 It is written in the report that CSWS provided to this review that: “Callum experienced close and supportive relationships with members of the care team at (the children’s home) which represented a protective factor in his life and (these) relationships were considered as part of the care planning process.” 6.81 Throughout most of the time that Callum lived at the children’s home CO1 was his keyworker, although it appears that he was well known to all the care staff and had developed close relationships with them all. In April 2015 CO5, who was new to the home, became his keyworker due to CO1 being promoted to a more senior position. There is no evidence of any analysis of the likely or actual impact of this change on Callum. Relationship with residents at the children’s home 6.82 CSWS report that when making friendships Callum was drawn to children who were younger than him. This is not unexpected given the delay in his own emotional and social development but it did present some difficulties as physically he presented more like a young adult. According to the CSWS contribution to this review, this incongruity in respect of Callum’s development and his presentation was considered and analysed to inform care planning and risk management. 6.83 Although Callum was drawn to children who were younger than him, the majority of residents who came and went from the children’s home during the time that he lived there were older than him. At the Looked After Children review that was held on 25 April 2014, it was reported that the other three residents were older and more mature than Callum and relationships varied with bullying a concern. 6.84 At the Looked After Children review that was held on 30 September 2014, CO1 reported that Callum had built strong relationships with the care team but he was being targeted by other residents because he was trying to conform. This was having an effect on his emotional wellbeing and had led to him being assaulted by another resident. 6.85 At the next Looked After Children review, held on 4 March 2015, it was reported that the negative behaviours of other residents were impacting negatively on Callum and he was then responding in the same way towards members of the staff Overview Report – Child B April 2018 Page 26 of 45 team. As a result of the concerns about the placement it was agreed that enquiries would be made with the fostering team about a possible match for Callum although it was considered that there would be some risks associated with fostering (see paragraph 6.55). 6.86 Therefore it is evident that there was analysis of Callum’s relationship with other residents. Other Friendships 6.87 This review has been made aware of friendships that Callum had with children who did not live in the children’s home. He had a girlfriend whom he frequently saw with support of staff from the children’s home and the girl’s mother. This was considered, at the time, to be a positive relationship and is still believed to have been so. 6.88 There were evident risks associated with some friendships due to the vulnerability of Callum and other parties. These risks would have increased and there should have been analysis of them and clear plans in place for managing the friendships. This review has not been made aware of any such plans although there is a record of a discussion taking place on 1 May 2015 between SW3 and CO1 around Callum visiting a friend’s house and it not always being possible for staff to support him in doing this. It is not specified which friend this refers to. Relationships with family members 6.89 Family was very important to Callum; throughout his time as a child looked after, he wanted to be back living with his mother and he greatly valued family contact. This was discussed at each and every Looked After Children review and it was recognised that this was important within his life and needed to be a significant factor in his care plan but that there were a number of risks and needs that had to be balanced. 6.90 Callum had direct face to face contact with his mother, one older sibling and his younger sibling and frequently spoke to his father on the phone. Whilst he was living at the children’s home contact with his father resumed, initially by letter and then over the phone. Callum wanted this to progress to face to face contact and was unhappy with CSWS’s approach to this. He was assisted by the Children’s Rights Service provided by Barnardo’s to make a complaint about this and this was resolved. 6.91 There is some evidence that Callum’s understanding was that he was in care because he had misbehaved and that if he behaved well he would be able to return to his mother’s care. At a safeguarding risk management meeting held in February 2015 it was agreed that some life story work would be undertaken to try to help Callum to gain a better understanding of why he was in care. This work did commence but due to the need not to overwhelm Callum with interventions (see paragraph 6.62) structured life story sessions did not continue after an initial session. Overview Report – Child B April 2018 Page 27 of 45 Relationships at school 6.92 The Looked After Children review held on 21 November 2013 took place less than three months after Callum changed school. The school representative reported that Callum was “very popular with other children”; was “very helpful, affectionate and caring towards less able children” and had “strong relationships with staff”. No-one from the school attended the subsequent reviews although staff from the children’s home were able to provide some information about Callum’s progress at school as they had attended parents’ evenings. At the review on 4 March 2015, RHM1 said that Callum was described as being “caring of others at times” and also that “he has a role of looking after the other young children in school when preparing to leave for the end of school and he feels a sense of responsibility in doing this.” Changes of social worker 6.93 Callum received statutory visits from his social worker at a minimum of every six weeks. In June 2014 responsibility for Callum moved from a locality social work team to the looked after service in accordance with the usual procedure in Leeds. SW1 was the allocated social worker until the change of team. SW2, from another team attended the review held in September 2014 and all social worker contacts after then were with SW3, from the same team as SW2. The information provided by CSWS to this review provides no information as to the relationship between Callum and the social workers. CSWS state that there is no evidence that these changes were detrimental to the work undertaken with Callum. 10. Consider whether appropriate professional curiosity was exercised by those professionals and agencies working with Callum. 6.94 On 8 December 2014, the GP practice was notified by Leeds Teaching Hospitals Trust that Callum had attended the Emergency Department having swallowed glass and cut his left wrist. Callum attended the GP surgery 23 days later on 31 December 2014 and twice more during 2015. These appointments were not related to his attendance at the Emergency Department or to self-harm; nevertheless the author of the CCG report for this review suggests that this was a missed opportunity for the GP to ascertain if there had been any further episodes or thoughts of self-harm and to ensure that Callum had been followed-up by CAMHS. 6.95 Similarly the GPs never explored a recommendation in the Young Persons Care Plan dated 10 April 2014 concerning issues relating to sexuality and emotions or his ongoing needs with relationships and puberty that were noted in his Review Health Assessment on March 2015. These are regarded as further missed opportunities to exercise professional curiosity. 6.96 School staff contacted the children’s home when Callum drew their attention to scratches that he had made on his arm and when he said he had been eating glass. Contact was also made with the children’s home when Callum said he had been injured or bullied by other residents. In retrospect school staff have expressed the view that they were not satisfied with the response from the Overview Report – Child B April 2018 Page 28 of 45 children’s home. However, they did not pursue this at the time which suggests that they did not exercise appropriate professional curiosity. 6.97 West Yorkshire Police involvement was limited to dealing with specific incidents and professional curiosity appropriate to this level of involvement was exercised. The Police never had reason to believe that a greater level of involvement was required. 11. Identify whether those working with Callum had a shared understanding of his needs and the risks he faced. 6.98 Evidence suggests that the majority of care staff in the children’s home knew Callum well and had a shared understanding of his needs and the risks he faced. There was also regular communication between the care staff and the social workers to whom Callum was allocated at different times whilst he lived at the care home. 6.99 Looked After Children reviews took place at the required frequency and considered Callum’s needs and some of the risks he faced. The absence of school representation at some of these reviews (see paragraph 6.72) is likely to have negatively impacted on the development of a shared understanding regarding Callum. 6.100 The school developed their understanding of Callum’s education and behavioural needs through formal assessments such as the statement of need/Education Health Care plan, annual review meetings, and his individual behaviour support plan. Callum’s social worker and children’s home staff were consulted in the development of these assessments and plans so there was some shared understanding. 6.101 As stated in KLoE 1, the risk assessments in place at the children’s home were created and monitored in house with little or no communication with practitioners from other services. Reports of Looked After Children reviews suggest that they were not discussed at the reviews. 6.102 Staff from the school and CSWS appear to have had different perspectives regarding the episodes of self-harm whilst the CLA nurse was unaware of the self-harm until the summer of 2015. 6.103 West Yorkshire Police involvement with Callum was restricted to them responding to specific incidents without any wider input into his needs or the risks he faced. Given the relatively low level of Police involvement with Callum this can be considered appropriate. 12. Review how care planning and case oversight by Callum’s social worker and IRO was linked to the day-today management of his care by the residential home. 6.104 CSWS state that throughout the time that Callum was living at the children’s home the allocated social workers undertook statutory visits with the required frequency Overview Report – Child B April 2018 Page 29 of 45 of at least once every six weeks. In addition the author of the CSWS report refers to consistent and regular communication via email, telephone and meetings between the care team at the children’s home and the allocated social workers. It is considered that day to day management of Callum at the children’s home was very much informed by discussions that were held between the care team and the allocated social workers. 6.105 Despite these assertions, the information provided to this review includes few references to contact between children’s home staff and the social worker during the four month period at the end of 2014 when there was a marked deterioration in Callum’s behaviour. However, there are examples whereby contact between the children’s home and the social worker was good and communication led to appropriate responses regarding concerns around Callum’s behaviour. 6.106 Looked After Children reviews were held within the required timescale of at least once every six months with the same IRO chairing every review except for the final one. Every review was attended by a social worker and a member of the care team from the children’s home but there was a lack of consistency as to which individuals attended. SW1 attended the reviews in November 2013 and April 2014, SW2 attended the September 2014 review and SW3 attended the review in March 2015. From the children’s home four reviews were attended by CO2, CO3, CO1 and RHM1 in that order. CSWS state that the IRO was notified of significant events although the information provided by CSWS to this review includes very few references to any contact with the IRO between the reviews. 13. Consider Callum’s experience of School and how his behaviour and engagement differed from that in his residential setting or elsewhere. 6.107 Callum showed low level difficulties at the specialist school that he attended from September 2013 but did not exhibit behaviour that warranted any formal risk management plans. Overall there was an improvement in his behaviour at school with 34 incidents of low level, disruptive, challenging and defiant behaviour during his first academic year and six the following year. Reference was made to Callum experiencing some bullying at school at the first Looked After Children review after he commenced but this was not mentioned at subsequent reviews. Notwithstanding the overall improvement in his behaviour at school it was reported to the Looked After Children review in March 2015 that he had recently become more challenging of boundaries and there had been some outbursts at after school clubs. 6.108 Callum was given opportunities to help and support other children at school and it appears that he enjoyed and thrived upon this responsibility. Such opportunities were not available at the children’s home where Callum was the youngest and least mature resident. 6.109 The last school report for Callum was excellent in terms of his educational progress and his social interaction and engagement and he received an end of year award. 6.110 Overall his behaviour at school appears to have been less disruptive than it was in the children’s home. Overview Report – Child B April 2018 Page 30 of 45 14. Consider the sequence of events surrounding the incident and whether all reasonable actions were taken at the time by agency personnel. 6.111 CO5 told the Police that after finishing his tea on 6 August 2015 Callum climbed the tree whilst CO5 himself moved about five metres away into the sunshine. He could not see Callum in the tree. After about five minutes, CO5 shouted to Callum that it was time to go and Callum responded along the lines of “one minute”. After a further four or five minutes CO5 shouted to Callum again but on this occasion he did not receive a reply. CO5 walked to the bottom of the tree and looked up; he could see Callum and thought he was standing on branches quite high up. When Callum still did not respond to his shouts CO5 climbed up the tree to a point where he was face to face with Callum. At this point he could see that there was a rope around Callum’s neck and what looked like foam coming out of his mouth. CO5 tried to lift Callum but was unable to support his weight and hold onto the tree. He felt for a pulse but could not find one. CO5 then descended from the tree and phoned CO4 at the children’s home. CO7 was also in the children’s home and set off to drive to the area where she understood the tree to be. On her way there she saw CO5 walking hurriedly back to the children’s home. CO7 and CO5 returned to the tree and after CO7 saw Callum in the tree she was very concerned and told CO5 to ring 999, which he did. Later that evening CO4 told a social worker at EDT that this phone call was made at 17:50 although the Police referred to it as having been made at 18:24 when they interviewed CO5 in May 2016. 6.112 Whatever time CO5 phoned the children’s home there was a major failure on his part to initiate an emergency response when he first became aware that Callum was in difficulty. According to the information that CO5 provided to the Police and the inquest, he had seen the desperate situation that Callum was in. By any reasonable interpretation this was a situation that required emergency medical assistance and it is hard to comprehend his decision to phone the children’s home and then to start walking back towards the home, rather than phoning 999 and asking for emergency assistance from the Police, Ambulance Service and Fire Service. The explanation given by CO5 for his behaviour was that he went into shock and was not thinking clearly. 6.113 Emergency services’ records show that the first call received about Callum was made at 18:37 and was from CO5 to the Police. CO5 told the emergency call handler that a 14 year-old had climbed a tree, appeared to be stuck and CO5 was getting no response. The call handler understood this to be a call about a young person who was stuck in a tree, rather than a young person who had died or was injured, and determined that the information should be passed on to the Fire Service. 6.114 This information did not come close to conveying the seriousness of the situation and, as a direct result, the initial response of the emergency services was appropriate for a person who was stuck in a tree but insufficient for a person in a tree who had died or was injured. This review has considered whether the call handler who spoke to CO5 missed any clues to the seriousness of the situation or if they should have asked other questions. Within this, consideration has been given to whether the fact that English was not CO5’s first language was a factor. The view of this review is that the information provided by CO5 and his tone of voice did not suggest that this was a serious situation that required an emergency response and therefore the initial response by the emergency services was sufficient in light of the information that was available to them. Overview Report – Child B April 2018 Page 31 of 45 6.115 Having determined that the information should be passed to the Fire Service the call handler mistakenly contacted the Ambulance Service but this mistake quickly became apparent, the call was ended and the call handler contacted the Fire Service instead. This call was made at 18:40. Based on the information provided by the Police, the Fire Service mobilised one appliance with the intention of supporting the self-rescue of a young person stuck up a tree. This was in line with current policy and the intended action of the crew on arrival would be to provide a ladder to access the young person. If the Fire Service had received the call stating the young person was unresponsive and not conscious then the incident would have warranted and received a full attendance suitable for a Rescue from Height. 6.116 When Fire Service personnel arrived at the scene the officer in charge was able to ascertain that Callum was actually hanging. A fire fighter trained to Emergency Life Support standard climbed up to Callum and was unable to detect any signs of life. The officer in charge requested a Line Rescue Appliance to attend to remove Callum’s body from the tree and also requested that the Police and the Ambulance Service attend due to the nature of the incident. Based on the information provided by the caller, the Ambulance Service coded the call as Green 2 which is the second highest coding and has a target response time of 30 minutes. An ambulance was dispatched at 19:01 and arrived on the scene at 19:10, 12 minutes after the request was made and therefore, well within the target response time. 6.117 A key factor in the decision to code this call as Green 2 was that when the call handler was asked whether the casualty was conscious and breathing the answer given was ‘don’t know’. If the call handler had said that the casualty was not conscious and not breathing the incident would have been given the highest coding which has a target response time of eight minutes. The Ambulance Service have identified that when the Fire Service phoned to request an ambulance the call handler should have utilised the Secondary Emergency Notification of Dispatch which is used for calls made between emergency services. This would have given more structure to the call and the question about conscious level and breathing status would have been asked earlier within the call. However, as the Fire Service did not know if the patient was conscious and breathing it is unlikely this would have resulted in a different response from the one that was arranged. 6.118 Once the ambulance crew arrived on the scene policy and protocol was followed correctly by the Ambulance Service. All reasonable steps were taken to establish whether Callum was conscious and breathing. Subsequently, when he was removed from the tree, a more thorough clinical assessment took place which confirmed that there was no breathing and no pulse. The ambulance crew used the Recognition of Life Extinct protocol in line with Yorkshire Ambulance Service and national resuscitation procedures. They then followed the Yorkshire Ambulance Service policy for the conveyance of patients by taking Callum to the Emergency Department at Leeds General Infirmary. 6.119 Best practice from CSWS would have been for a member of the care team to have accompanied Callum to the hospital but that did not happen in this case. CSWS describe it as regrettable that this did not happen and they are unable to explain the reason. Overview Report – Child B April 2018 Page 32 of 45 15. Review how information was gathered and recorded about the incident and Callum’s death and how this was used to inform learning and investigations. 6.120 The Sudden Unexpected Death in Infants and Children (SUDIC) process was followed and agencies provided information to this as appropriate. 6.121 West Yorkshire Police investigated the death over the period of nearly a year and the investigation was reviewed by a Detective Superintendent who had had no previous involvement in it. Evidence was submitted to a senior Crown Prosecution Service (CPS) lawyer and a charging decision obtained which indicated that there was insufficient evidence to proceed with a prosecution. A full file was supplied to the Coroner to inform his deliberations and the identification of any lessons. 6.122 CSWS took immediate action to secure all information that related to Callum and the incident. Agency policy and procedure was subsequently followed in respect of staff involved in the incident. 6.123 The response by the emergency services was reviewed by the Ambulance Service Deputy Medical Director and Risk Manager and was discussed at Incident Review Group in August 2015. It was determined that it would not have been possible to categorise the 999 call from the Fire Service any higher given that information about the conscious level and breathing status of Callum was not available. There has been individual learning for Emergency Medical Dispatcher B about using the correct protocol when taking calls from other emergency services. 7. Identification of Learning using the Aims and Objectives 1. To identify improvements in the assessment of risk, and how this can be implemented through effective risk management plans. 7.1 Children’s home staff had identified that Callum put himself at risk by climbing and there is no dispute that the care staff at the home knew he should be discouraged from climbing trees. Nevertheless, some improvements could have been made to how the risk assessment was written; in particular it should have stated the action to be taken by staff if Callum refused to follow an instruction to come down from a tree immediately (see paragraph 8.1c). 7.2 When risk assessments were reviewed the previous risk assessment was overwritten with the new one so it was not easy to identify changes over time. This has been addressed by CSWS and risk assessments are now saved at each review as a standalone document. 7.3 It would be beneficial for children’s home staff to involve the young people themselves in developing and monitoring the risk assessments that apply to them. Such an approach would be consistent with the principles of restorative practice which recognises that outcomes are improved when practitioners work alongside people, rather than make decisions for them (see paragraph 8.1a). Overview Report – Child B April 2018 Page 33 of 45 7.4 It is essential that risk assessments are kept relevant and up to date. Although the risk assessment relating to climbing was reviewed as recently as July 2015 it contained out of date information and did not reflect that there had been no reports of Callum climbing during the previous six months (see paragraph 8.1b). 7.5 The risk assessments were kept very much in-house by the children’s home and appear not to have been discussed at Callum’s Looked After Children Reviews. There is no indication that children’s home staff consulted with other agencies when writing risk assessment or made other agencies aware of the risk assessments that were in place. Some risk assessments may well be very specific to keeping a child safe in the children’s home but others should be shared more widely(see paragraph 8.1e). 7.6 The risk assessment included action to be taken to enable Callum to climb in a safe environment. The impact of this action was not monitored and it remained as an action on the risk assessment months after Callum had stopped going to the climbing wall (see paragraph 8.1d). 7.7 There was a missed opportunity for the school to instigate a pupil risk assessment when Callum self-harmed. Action has been taken by Education Services to address this. 2. To identify whether there are improvements to supervision and management arrangements that would ensure better management of risky behaviours. 7.8 Callum’s tragic death was not a result of the risks associated with climbing not being recognised, or of the care team not knowing about these risks. Instead his death occurred because the risk assessment was not followed on the day of Callum’s death. 7.9 It appears highly likely that senior staff at the home, were incorrect in their belief that Callum had ceased climbing six months previously and the supervision and management arrangements did not identify that at least one member of staff was aware of this. 7.10 In view of CO5’s opinion expressed about the home’s approach to risk management, it would have been prudent to have explicitly revisited this matter with him and, if doubts remained about his attitude, to have ensured that he was not in a position where he had sole responsibility for enforcing risk assessments that he did not agree with (see paragraph 8.2). 3. To identify whether there are training and staff development needs arising from the circumstances of this case. 7.11 With hindsight school staff have expressed concern about a lack of day to day communication from the children’s home and have also expressed dissatisfaction with the response from the children’s home to incidents of self-harm by Callum and occasions when he suffered harm from other residents. These issues were not Overview Report – Child B April 2018 Page 34 of 45 raised at the time which suggests that staff at the school need some guidance on escalating concerns (see paragraph 8.5). 7.12 The GPs at the surgery require guidance around speaking to children and young people, specifically CLA and young people who have harmed themselves. The CCG has taken action to address this. 7.13 Other training and staff development needs arising from this case are identified elsewhere in the learning. 4. To consider the emergency response and incident management arrangements for all agencies involved with this case and whether these can be improved. 7.14 CO5’s actions when he became aware that Callum was in difficulty in the tree were inadequate. Thankfully few people will ever find themselves in a situation such as this and no-one knows quite how they would react in such a situation. Nevertheless, CSWS needs to consider how children’s home staff can be trained to deal with emergency situations (see paragraph 8.3). 7.15 The initial response from the emergency services was appropriate for a young person who was stuck in a tree, as was believed to be the case based on the information that had been provided by the care worker. Subsequently, when the seriousness of the situation became apparent the emergency services responded in line with policy. Three potential policy and practice changes to the response of the emergency services have been identified for further consideration by those services: a. The Ambulance Service currently use the highest category of response in cases where it is reported that the casualty is not conscious and not breathing and the second highest category when it is not known whether or not they are conscious and breathing. The SCR Panel query whether this policy should be amended to require that the highest category of response be used for this latter group. Using the higher category response would not have made a difference in this case but may do in another situation (see paragraph 8.9). b. Based on information provided, the Fire Service followed policy by sending one appliance to Callum. The Fire Service are to consider whether it would be appropriate to change this policy to require the full attendance of a Rescue at Height for any call stating people are involved where height is a safety consideration (Recommendation made by the Fire Service). c. Calls into emergency services cannot be transferred between the different services. Therefore information has to be passed from one service to another without direct input from the caller. This has the potential for relevant information to be missed at the collection stage or inaccurately passed between services. The Police, Ambulance and Fire Services should work together to identify how this can be addressed (Recommendation made by the Fire Service). 5. To identify whether there are improvements to be made to information sharing processes which could improve care arrangements and the management of risky behaviour. 7.16 Inconsistent and incomplete attendance at Looked After Children Reviews inhibited good quality information sharing. CSWS need to ensure that robust arrangements Overview Report – Child B April 2018 Page 35 of 45 are in place so that all appropriate agencies and individuals receive invitations. Equally, agencies which would expect to be invited to a Looked After Children Review need to put in place arrangements to ensure that when an invitation is received it is passed to the most appropriate person. Agencies and individuals should also take some responsibility for ensuring that they know when the next review is due and for making contact with CSWS if an invitation is not received (see paragraph 8.7). 7.17 The children’s home staff should have been more pro-active in keeping school staff appraised of significant incidents relating to Callum such as bullying, aggression and self-harm. If school staff considered that this was not happening they should have made children’s home staff aware of this (see paragraph 8.8). 7.18 There should have been prompt communication from children’s home staff, the GP and the school nurse to inform the CLA nurse of episodes of self-harm. LCH have identified that the CLA nurse should ensure that the children’s home staff are familiar with the role and responsibilities of the CLA nurse and know when it is appropriate to contact her (see paragraph 8.8). 7.19 Better communication is required between agencies to share information about risk (see paragraph 8.8). 6. To consider whether all aspects of Callum’s care and behaviour where brought together and contributed to a comprehensive appreciation of his needs and how to manage them. 7.20 This report has identified that Callum’s behaviour fluctuated whilst he was living at the children’s home. There were times when he was quite settled and other times when he exhibited a range of challenging behaviour. There is some evidence to suggest that the more challenging behaviour occurred when the children’s home was generally unsettled due to the behaviour of other residents and when Callum was stopped from going out alone. 7.21 Various aspects of Callum’s care and behaviour were brought together at Looked After Children reviews to inform the care plan. There is evidence that specialist support was accessed to try to address Callum’s needs but he would not always engage with the services that were provided. There was a thoughtful approach to how and when support was offered in an attempt to work at Callum’s pace and not to overwhelm him. There is also evidence that Callum was supported to maintain contact with family members and to see his girlfriend. 7.22 Not all appropriate agencies attended Looked After Children Reviews on a consistent basis and although other meetings such as Safeguarding Meetings and PEP meetings took place but there was never an occasion when all the agencies providing support to Callum met together. 7.23 A more co-ordinated response would have been appropriate when Callum inflicted injuries upon himself. In particular the CLA nurse should have been made aware of the first two incidents and it could reasonably have been expected that the GP, school nurse and children’s home staff would have done so. Children’s home staff Overview Report – Child B April 2018 Page 36 of 45 should also have listened to Callum’s explanation of why he had scratched himself rather than deciding that he had copied another resident. This response suggests that practitioners should be reminded of the self-harm and suicide protocol previously issued by Leeds Safeguarding Children Board, Leeds City Council and the NHS (see paragraph 8.4). 7.24 Although it was decided at Callum’s Looked After Children Review in March 2015 that enquiries would be made regarding a possible foster placement this was not done and inconsistent and contradictory statements were made about whether the long-term plan for Callum was to remain in residential care or to move to a foster placement. It is unclear whether or not this degree of uncertainty was known to Callum and whether it affected him. 7. To consider how learning from this review can inform wider systems learning and improvement of local services and interagency cooperation. 7.25 The learning identified within the preceding paragraphs is relevant to the wider safeguarding community within Leeds and should be disseminated to all relevant practitioners. 8. Areas Requiring Action Within their reports agencies have identified actions that they have taken since the death of Callum and other actions they will take. These are included in appendices 3 and 4 respectively. This review has identified the following areas where the LSCB should consider requiring action to be taken: 1. To strengthen children’s home risk assessments by requiring the following changes to the development and review of risk assessments: a. Young people should be involved in developing and monitoring their risk assessments (see paragraph 7.3). b. Risk assessments must be reviewed at an agreed frequency and kept up to date (see paragraph 7.4). c. Risk assessments should detail the action to be taken if a young person is in a risky situation and the carer(s) present cannot resolve the situation safely (see paragraph 7.1). d. Where actions are taken with the aim of reducing a young person’s risk-taking behaviour the impact of that actions needs to be measured and recorded whenever the risk assessment is reviewed (see paragraph 7.6). e. For every risk assessment, consideration should be given as to what specialist advice is required to complete the risk assessment and who should be made aware of the risk assessment (see paragraph 7.5). Overview Report – Child B April 2018 Page 37 of 45 2. Care arrangements at children’s home should be structured to minimise the possibility of a member of the care team not complying with a young person’s risk assessments and care plan (see paragraph 7.10). 3. Staff who provide care to children and young people should be equipped to deal with emergencies (see paragraph 7.14). 4. Agencies should ensure that staff are aware of the suicide and self-harm guidance and that its use is embedded in practice (see paragraph 7.23). 5. Agencies should ensure that staff are aware of the ‘resolving professional disagreements and escalation’ procedure and that its use is embedded in practice (see paragraph 7.11). 6. Robust arrangements are required so that all appropriate agencies and individuals receive invitations to Looked After Children Reviews (see paragraph 7.16). 7. Agencies which would expect to be invited to a Looked After Children Review need to put in place arrangements to ensure that when an invitation is received it is passed to the most appropriate person. Agencies and individuals should also take some responsibility for ensuring that they know when the next review is due (see paragraph 7.16). 8. Better communication is required between agencies caring for children and young people, including the children’s home, school, CLA nurse and GP (see paragraphs 7.17 – 7.19). 9. Yorkshire Ambulance Service should consider whether to amend their response categories to require that the highest category of response be used when it is not known whether or not an individual is conscious and breathing (see paragraph 7.15a). Overview Report – Child B April 2018 Page 38 of 45 Appendix 1 – Key Lines of Enquiry 1. Critically comment on the efficacy and robustness of the risk assessment arrangements for (a) Callum and (b) vulnerable young people looked after whose behaviour places them at risk of harm. 2. Evaluate the effectiveness, or otherwise, of how the risk assessment was managed and implemented in practice for this case. 3. How effective was the management and supervision of the care worker tasked with implementing the risk plan? 4. Consider to what extent Callum’s behaviour and needs were unusual or extreme, or required specialist support and whether this was available and used? 5. Examine whether there were any previous concerns, incidents or indications which might have signalled any risks of self- harm or given rise to other concerns 6. Investigate how any previous incidents of risky behaviour were managed and whether there was learning from these to inform Callum’s care plan. 7. Consider whether there were any significant changes in behaviour and relationships that might have indicated increased risk of violence or harm 8. Examine the inter and intra agency communication regarding Callum and whether there were gaps in information sharing that impacted on the risks he faced. 9. Review whether Callum ’s relationships with adults and peers was analysed to inform care planning and risk management 10. Consider whether appropriate professional curiosity was exercised by those professionals and agencies working with Callum 11. Identify whether those working with Callum had a shared understanding of his needs and the risks he faced. 12. Review how care planning and case oversight by Callum’s social worker and IRO was linked to the day-today management of his care by the residential home. 13. Consider Callum’s experience of School and how his behaviour and engagement differed from that in his residential setting or elsewhere. 14. Consider the sequence of events surrounding the incident and whether all reasonable actions were taken at the time by agency personnel. 15. Review how information was gathered and recorded about the incident and Callum’s death and how this was used to inform learning and investigations. Overview Report – Child B April 2018 Page 39 of 45 Appendix 2 – Abbreviations ADHD - Attention Deficit Hyperactivity Disorder CAMHS – Child & Adolescent Mental Health Services CCG – Clinical Commissioning Group CLA – Child Looked After CO – Care Officer CSWS – Children’s Social Work Service EDT – Emergency Duty Team EHC – Education Healthcare IRO – Independent Reviewing Officer KLoE’s – Key Lines of Enquiry NSPCC - The National Society for the Prevention of Cruelty to Children PEP – Personal Education Plan THW1 – Boys and Young People’s Health Worker RHM – Registered Homed Manager SEND – Special Educational Needs and Disability SILC – Specialist Inclusive Learning Centre SUDIC - Sudden Unexpected Death in Infants and Children SW – Social Worker TA – Teaching Assistant TM – Team Manager Overview Report – Child B April 2018 Page 40 of 45 Appendix 3 – Actions taken by agencies since the death of Callum as reported in agency reports Barnardo’s Barnardo’s has a Health and Safety Annual Quality Assurance process where individual risk assessments are sampled. In 2016/2017 it was identified that files have individual risk assessments where applicable. Health and Safety and Safeguarding are standing items on staff supervisions. Clinical Commissioning Group All GP Practices in Leeds have been written to, to remind them of the need to regularly review the Health Care Plans of Looked After Children and Young People to identify any unmet health needs, or requirements for further assessment and/or referral to another health agency. All GP Practices in Leeds have been sent the electronic link to The RCGP/NSPCC Safeguarding Children Toolkit for General Practice. All GP Practices in Leeds have been written to remind them to take the opportunity where possible to speak to children and young people who attend surgery for whatever reason following an episode of self-harm to ensure they are receiving appropriate care and support. Leeds City Council Children and Families (Children’s Social Work Service) There are already significant developments taking place at a strategic and operational level with regard to the development of an integrated EHC process for children and young people with SEND. CSWS have stated that since Callum died the children’s home has introduced the following changes to the risk assessment process: The completion of risk assessments are now the responsibility of the two managers in the home. These are completed in consultation with each child’s key worker and are an outcome focused document; Risk assessments are shared with the care team and there is a requirement that each member of the care team signs to evidence that they have read and understood the content; There is a single, overarching risk assessment for each young person; Assessments are saved at each review as a standalone document which ensures changes to presenting risks can be evidenced and analysed over time. Leeds City Council Children and Families (Education) The report author will ask the Chair of the LSCB Education Reference Group to send a reminder to all schools to instigate a formal pupil risk assessment plan for all pupils known to be self-harming. Overview Report – Child B April 2018 Page 41 of 45 West Yorkshire Police Action has been taken to improve consistency in respect of risk assessments for missing children and a process of internal audit is continuing to provide oversight of Force performance in this area. Overview Report – Child B April 2018 Page 42 of 45 Appendix 4 - Recommendations included within Agency Reports Barnardo’s - Leeds Children’s Rights; Looked After Children 1. On receipt of a referral or a self-referral from a young person then it needs to be explicit within the referral protocol that existing risk assessments should be requested as soon as practicably possible. 2. To build into an initial referral/assessment meeting a check list that ensures that workers are aware of existing risk assessments for working with the young person and to undertake their own risk assessment. 3. To ensure that when working with the same young people across Barnardo’s services that risks and relevant information is shared. Leeds City Council Children and Families (Children’s Social Work Service) 1. Regulation 44 and external inspection findings that relate to staff supervision in Children’s Homes in Leeds to be collated in a quarterly report and submitted to the Children’s Services Practice Improvement Meeting. 2. For Local Authority residential homes to design and implement processes in which risk assessments for children and young people can be developed, alongside and in partnership with, relevant partners including professionals and family members where appropriate. West Yorkshire Fire & Rescue Service 1. Attendance at Incidents a. To consider if appropriate any call received into Fire Control stating people are involved where height is a safety consideration to mobilise the full attendance of a Rescue at Height (Pre-determined attendance - PDA). b. For the data to be collated on number of incidents we attend where height is a factor in the mobilisation. c. To identify where height has been highlighted and the request for makeup of resources has occurred. d. To consider how many times this request would be made and if adopted would it adversely affect Fire Cover. Overview Report – Child B April 2018 Page 43 of 45 e. To be sent for consideration to Area Manager, Operations and the Technical Operational Knowledge Officer (TOKO) to consider if a multi-agency response to the request is appropriate. 2. Sharing Learning between Emergency Services. a. To consider where Emergency Services work together at an incident where death or serious injury has occurred following Suicide, a multi-agency debrief is routinely organised to establish any learning. b. Emergency Services frequently work together at suicide incidents; we should establish a best practice approach to these events. c. There are already established groups who meet to discuss incidents and share learning but they currently do not incorporate suicide. d. To be sent for consideration to Area Manager, Operations and the Technical Operational Knowledge Officer (TOKO) to consider if a multi-agency response to the request is appropriate. 3. Call Transfers between Emergency Services a. Calls into Police and vice versa to Fire are unable to be transferred maintaining caller on the line to any other Emergency Services. This has the potential for information to be missed or not gathered in the specific way for the responding service. b. To share learning across the call received where the need to mobilise a different service to the incident than the one initially requested occurs to identify the communication strategy used. c. Explore any system that can be adopted to allow this function to happen. d. Engage Police and Ambulance to establish if this would be practical and assess potential impact on service delivery and budgets. e. For this to be discussed there needs to be some collaborative working between Control Rooms to come together and share learning. Currently this has previously been tried but due to constraints and service priorities this has not come to fruition. f. To be sent for consideration to Area Manager, Operations, Technical Operational Knowledge Officer (TOKO) and Station Manager Control to consider if a multi-agency response to the request is appropriate. 4. Direction on Casualty Care in relation to Suicide a. Policy / Guidance are not currently in place to direct WYFRS crews on actions when attending incidents involving suicide. Overview Report – Child B April 2018 Page 44 of 45 b. To liaise with the Clinical Medical Director to ascertain our actions when attending suicide incidents. To discuss if our protocols are in line with YAS and adopt a position in line with our service delivery aims. c. Any change in policy or guidance can be circulated as an Operational Policy Information Document to all operational personnel. d. Guidance to support crews attending such incidents would assist both the OIC and Firefighters to develop a tactical plan to manage the incident and support other Emergency Services at scene. e. To be sent for consideration to Area Manager, Operations, Technical Operational Knowledge Officer (TOKO) and Clinical Medical Director to consider if a multi-agency response to the request is appropriate. Leeds Community Healthcare The author has identified three learning points to take from this review: 1. The school nurses to document any knowledge of a child attending A&E even if they have not been involved in the event leading to that presentation. For school nurses to share that information with the other relevant health professionals having contact with that child to ensure all health practitioner awareness. Action Named Nurse for Safeguarding Children to approach school Nurses regarding documentation of A&E attendance and information sharing. Action taken The named nurse for safeguarding children for Leeds Community Healthcare has met with a senior school nurse and the school nurse clinical lead regarding the need to accurately document any attendances at Emergency Departments. Information has been circulated to all SILC school nurses highlighting the importance of accurate record keeping and sharing information with other colleagues on a need to know basis. 2. There appears to be an area of improvement in terms of communication between children’s home staff and the CLA nurse. I have suggested that the CLA nurse approach children’s home staff to update them regarding her role and responsibilities to assist improved working practices. Action CLA nurse to approach children’s home staff and update them regarding her role. Action taken The CLA nurse who works with the children’s home where Callum lived has had a discussion with managers in the home regarding her roles and responsibilities and the need for relevant information to be shared with her. Overview Report – Child B April 2018 Page 45 of 45 3. Senior CAMHS Psychologist acknowledged that information could have been documented more clearly. This has been highlighted to other senior CAMHS practitioners for them to cascade to all CAMHS practitioners via an email. Action taken CAMHS have disseminated an email to remind practitioners of the importance of clear accurate documentation. Leeds Teaching Hospitals Trust The agency report author will ensure that the standard for the Trust’s record keeping audit does measure the issue of how practitioners record their name, signature and status. |
NC045589 | Disclosure of sexual abuse by a 14-year-old girl, following attendance at a Sexual Assault Referral Centre (SARC) in December 2012. Julia was made the subject of a child protection plan following this disclosure. Julia had made a number of disclosures of sexual assault and rape between 2010 and 2012. Following the December 2012 disclosure she gave a history of sexual abuse at ages 6 and 11. Family were well known to agencies and there were extensive and longstanding concerns about Julia and her siblings, regarding: neglect, intra-familial sexual abuse, physical abuse, domestic abuse and social exclusion. Identifies findings, including: a pattern of national and local policy focusing on sexual health and teenage pregnancy rather than sexual abuse in cases of underage sexual activity; lack of clear analysis and challenge of the language used by parents and young people regarding early sexual experiences leading to inadequate response or protection; lack of parental engagement with services taking attention away from the needs of the young person or child; and lack of developed understanding of adolescent neglect. Includes Thurrock Local Safeguarding Board's response to the review and a summary of responses to findings from partner agencies. Uses the Social Care Institute for Excellence (SCIE) systems model.
| Title: Serious case review: “Julia”. LSCB: Thurrock Local Safeguarding Children Board Author: Jane Wiffin and David Peplow Date of publication: [2014] This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Thurrock Local Safeguarding Children Board Serious Case Review: “Julia” 2 1 INTRODUCTION TO THE REVIEW PROCESS ........................................... 5 Reason for the Serious Case Review ............................................................................................... 5 Time scale for the SCR....................................................................................................................... 6 Succinct summary of case ................................................................................................................ 8 Methodology ..................................................................................................................................... 14 The Lead Reviewers ......................................................................................................................... 15 The Review Team .............................................................................................................................. 15 The Case Group ................................................................................................................................ 17 Family Member Involvement ........................................................................................................... 17 Structure of the Review Process .................................................................................................... 18 Sources of data ................................................................................................................................. 18 About Thurrock ................................................................................................................................. 18 2 APPRAISAL OF PROFESSIONAL PRACTICE IN THIS CASE .................. 19 Working with persistent non–engagement .................................................................................... 20 Professional recognition of adolescent neglect ........................................................................... 21 Uneven balance between “troublesome” rather than “troubled” Adolescence ........................ 22 Lack of assessment .......................................................................................................................... 22 Multi-agency meetings and planning processes .......................................................................... 23 Child in Need Processes .................................................................................................................. 23 Effective safeguarding referrals from the multi-agency network ................................................ 24 Difficulties in escalating to Child Protection ................................................................................. 25 The response to disclosures of sexual abuse and rape ............................................................... 26 3 THE FINDINGS ........................................................................................... 28 Analytic process for establishing systems findings .................................................................... 28 Categories of underlying patterns .................................................................................................. 29 3 Finding 1: There is a pattern whereby national and local policy agendas have driven practice in relation to underage sexual activity to have a stronger focus on sexual health and teenage pregnancy rather than sexual abuse/exploitation ....... 32 Why does it matter? ......................................................................................................................... 32 How did it manifest in this case? .................................................................................................... 34 How do you know it is underlying? ................................................................................................ 35 How prevalent is the issue? ............................................................................................................ 35 Finding 2: If professionals record the language used by young people and their parents regarding early sexually exploitative experiences without clear analysis and challenge it has the potential to leave children and young people without an adequate response or protection ............................................................................... 37 Why does it matter? ......................................................................................................................... 37 How did it manifest in this case? .................................................................................................... 38 How do you know it is underlying? ................................................................................................ 39 How prevalent is the issue? ............................................................................................................ 39 Finding 3: Is there a pattern whereby the Child in Need procedures are not routinely being used leaving children and young people without formal plans and review? 41 Why does it matter? ......................................................................................................................... 41 How did it manifest in this case? .................................................................................................... 42 How do you know it is underlying? ................................................................................................ 43 How prevalent is the issue? ............................................................................................................ 43 Finding 4: The lack of engagement with services by parents takes professional energy and attention away from the needs of children /young people and leaves them with an ineffective response ............................................................................. 44 Why does it matter? ......................................................................................................................... 44 How did it manifest in this case? .................................................................................................... 45 How do you know it is underlying? ................................................................................................ 46 How widespread is the pattern? ..................................................................................................... 46 How prevalent is the issue? ............................................................................................................ 46 4 Finding 5: Is there a lack of a developed understanding and awareness of adolescent neglect across the multi-agency network leaving young people at risk of harm? 47 Why does it matter? ......................................................................................................................... 47 How did it manifest in this case? .................................................................................................... 50 How do you know it is underlying? ................................................................................................ 51 How prevalent is the issue? ............................................................................................................ 51 Finding 6: Is there a pattern whereby multi-agency working has become overly focussed on information sharing, at the expense of a shared analysis, face to face meetings and shared plans to meet the needs of children and young people? .... 52 Why does it matter? ......................................................................................................................... 52 How did it manifest in this case? .................................................................................................... 54 How do you know it is underlying? ................................................................................................ 55 Finding 7: Is there a pattern whereby GP’s in Thurrock are not recognised by others or themselves as an integral part of the safeguarding network?................ 56 Why does it matter? ......................................................................................................................... 56 How did it manifest in this case? .................................................................................................... 58 How do you know it is underlying? ................................................................................................ 58 How widespread and prevalent is the pattern? ............................................................................. 58 CHAPTER 4 – ADDITIONAL LEARNING .................................................................... 60 1. The importance of holistic assessments ........................................................................... 60 2. Difficulties in escalating to concerns about Adolescents to Child Protection .............. 61 Thurrock Local Safeguarding Children Board Initial Response to the Serious Case Review 63 A summary of the response to the findings: ............................................................ 65 5 1 INTRODUCTION TO THE REVIEW PROCESS Reason for the Serious Case Review 1.1 Julia (14) attended Sexual Assault Referral Centre (SARC) in December 2012 after she made a disclosure of rape. When she was medically examined she was found to have a significant sexually transmitted infection. Julia gave a history of sexual abuse at age 6 and 11 and four recent experiences of being raped, which had been investigated. The Designated Nurse also became aware that there was an extensive family history of involvement with specialist services and historical allegations of sexual abuse. 1.2 The Designated Nurse referred the details of Julia’s circumstances to the Thurrock Serious Case Review subcommittee where it was agreed that it met the criteria for undertaking a Serious Case Review as outlined in Chapter 8 of Working Together to Safeguard Children 2010 (DSCF 2010i). 1.3 Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the requirement for Local Safeguarding Children’s Boards to undertake reviews of serious cases where: (a) abuse or neglect of a child is known or suspected; and (b) either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the Authority, their Board Partners or other relevant persons have worked together to safeguard the child. 1.4 Working Together was reissued in 2013ii and provided new guidance for undertaking a Serious Case Review which requires that they should be conducted in a way which: • recognises the complex circumstances in which professionals work together to safeguard children; i Education Department (2010) Working Together to Safeguard Children: a guide to interagency working to safeguard and promote the welfare of children. London ii Education Department (2013) Working Together to Safeguard Children: a guide to interagency working to safeguard and promote the welfare of children. London 6 • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • is transparent about the way data is collected and analysed; and • makes use of relevant research and case evidence to inform the findings. LSCBs may now use any learning model which is consistent with the principles in the guidance, including the systems methodology recommended by Professor Munroiii. The Thurrock LSCB agreed to undertake a review using the SCIE Learning Together methodologyiv. Time scale for the SCR 1.5 Although Julia and her family have been known to Universal and Specialist Services for many years, the SCR Review Team agreed that the period to be reviewed would be from November 2010 – to February 2013 when Julia became subject to a Child Protection Plan. This review was commissioned in May 2013 and completed in May 2014. iii Munro, E. (2011) The Munro review of child protection: final report: A child centred system. London RSO. iv Fish, S. Munro, E. and Bairstow, S. (2008) Learning Together to Safeguard Children: developing a multi-agency systems approach for case reviews. SCIE. London 7 Julia’s Family – all names have been changed for reasons of confidentiality 1.6 Relationship to Subject Age at start of review process – November 2010 Ethnicity Julia Subject of the review 12 White/ British School Sophia Mother 39 White/ British Working Non resident father of Julia - left the family in 2000. (Julia is not supposed to have contact because of concerns about allegations of his sexual offences against children. He now has a new family and Julia has visited them in the past) 39 White/ British Not known Natalie Half sister (her partner also lived in the family home in the period under review) 18 White/ British College Courtney Half sister 16 White/ British College Paige Half sister 15 White/ British Non resident father of Natalie, Courtney and Paige left in 1995 – unclear if there is any current contact. Little is known about Julia’s wider family, but that Julia remains in contact with her maternal grandparents and her uncle, and Julia’s mother said that she has a difficult relationship with maternal grandmother. 8 Succinct summary of case 1.7 The background to this case is a long history of contact with children’s welfare and child protection services for Julia, her siblings and parents. Julia’s mother and her father were known to children’s welfare services as children. Julia was assessed as having special educational needs for which she receives additional support at school. Historic health records report that as a child Julia’s mother was also considered to have learning difficulties, but no formal assessment has ever been undertaken, so the precise nature of these difficulties remains unclear. There has been long standing concerns about Julia and her half siblings regarding neglect, intra-family sexual abuse, physical abuse, domestic abuse and social exclusion/deprivation. These were addressed by a large number of referrals from Universal Services, Assessments, Child Protection Conferences, Child in Need processes, therapeutic support and police action. Over time there were concerns about the parent’s lack of engagement with services, but there was also evidence of sufficient change in the lives of all the siblings, which led to Children’s Social Care feeling able to withdraw from involvement with the family. When Julia was aged 12, in January 2010, she disclosed that she had been raped, she made three further disclosures of rape by boys (aged 15- 18) over a two year period, and despite good police investigation it has not been possible to achieve a prosecution. Over this period there were also periods when there were concerns about her poor attendance, behaviour and anger at school, and her mother complained about her behaviour and angry outbursts at home. As a result of Julia’s disclosure of rape in December 2012 Julia was made subject to a Child Protection Plan in February 2013 and Julia’s mother has also engaged with the Troubled Families project. 9 Timeline of critical incidents 1.8 Earlier contextual information Date Incident January 2010 Children’s Social Care received a referral from the police about allegations that Julia had been sexually assaulted by a male friend. February – March 2010 A Core Assessment was undertaken under Child Protection Processes (Sec 47 Children Act 1989) by Social Worker 1 and concluded that there were concerns about the sexual assault, but Julia was no longer at risk of harm. A Child in Need Plan was formulated and Julia and her family were transferred to a social work team. June 2010 Police conclude that they do not have enough evidence to pursue a conviction. July 2010 The Team Manager of the social work team contacted Safeguarding to query why there had been no Child Protection Conference for Julia. The electronic records provide no evidence of a response. July to November 2010 The allocated Social Worker 2 attempted to contact the family, via numerous texts, letters and unannounced home visits without success. Review Period Starts Date Incident 3 November 2010 School report to Children’s Social Care that Julia had told them she had sexual intercourse with a boy who was a friend. The allocated Social Worker 2 tried to make contact with Julia’s mother without success, and also contacted the police who visited the family home that evening. 4 November 2010 School contacted Julia’s mother and suggested she take her to the GP. 10 9 November 2010 Julia visited GP 1 with her mother and was prescribed contraception. The concerns about the sexual assault were discussed, and the GP agreed to contact the police. There is no recorded evidence that this happened. November/December 2010 During November and December many attempts were made to contact Julia and her mother by Social Worker 2 without success. The Social Worker 2 and her Manager agreed a Strategy Meeting should take place, and the police agreed. The Social Worker pursued this without success. 13 January 2011 A home visit was undertaken by allocated social worker 2 and police officer 1. Julia was seen with her mother. The police said that the rape disclosure was not supported by the available evidence, and there could be no further action. A referral to the Sexual Health Advisor and support activities for Julia was taken forward. February 2011 The Sexual Health Advisor attempted to make contact with Julia without success. Social worker 2 was also unable to make contact despite many calls and home visits. March/April 2011 Children’s Social Care considered closing the case because of lack of engagement, but continued to try and make contact with Julia and her family. May 2011 A referral to Children’s Social Care was completed by the Accident and Emergency Department of the hospital regarding concerns about lack of appropriate parental care and an injury to Courtney. An Initial Assessment was completed about Courtney, by Social Worker 2 and recommended case closure with referrals to parenting support and family mediation to address family conflict. June/July 2011 Julia’s mother sought support from Social Worker 2 regarding Julia’s disruptive behaviour and concerns 11 about sexual contact with boys. Referrals were made to parenting support and the Sexual Health Advisor by social worker 2. Mother also told GP 2 that she was concerned about Julia’s disruptive behaviour and the GP made a referral to Child and Family Consultation Service (one of the services of CAMHS). No other agency was informed of this referral. 8 August 2011 – September 2011 Children’s Social Care sent a letter saying the case had been closed, but reviewed this decision because of a referral received in September 2011 which meant that the case remained open until January 2012. 4 September 2011 Julia was given a final warning for an incident where she had thrown boiling water over her sister Courtney. Courtney went to hospital with her mother who told hospital staff that Julia had been sexually active since the age of 11. They appropriately made a referral to Children’s Social Care. A Core Assessment was undertaken by social worker 2 and concluded that there were no concerns regarding Courtney, and no need for services, but Julia would need further support which would be provided by the school and Coram would provide parenting support to her mother. 6 September 2011 The social work Team Manager sought advice for a second time from the Safeguarding Team because she thought a Strategy Meeting should be convened and a Child Protection enquiry carried out. There is no evidence in the records of a response to this request, or that any further action was taken. September 2011 Julia’s mother attended three sessions of the parenting programme, but did not complete the programme. 17 October 2011 Julia had her Annual Review meeting for a student with a Statement of Special Educational Needs at school, and concerns about her poor attendance and behaviour were discussed, goals were set in these areas. November 2011 Julia attended a sexual health drop in session at school 12 with the School Nurse. She said she was having sexual contact with a 14 year old boy and her mother was aware of this. She was assessed as Gillick competent and contraceptive advice and support was given, in line with existing health guidance. December 2011 Social Worker 2 was unable to make contact with Julia or her family and the school and Social Worker shared information. School said they were concerned about Julia’s attendance and behaviour/aggressive outbursts. January 2012 Julia continued to have difficulties at school and support/ counselling was provided by the Learning Mentor. The school struggled to contact mother. The Social Worker 2 made many attempts to contact and visit Julia and her family without success. 31 January 2012 Case closed to Children’s Social Care. February – May 2012 School remained concerned about Julia’s anger and behaviour, and made a referral to Children’s Social Care regarding bruising to Julia’s sister. There is no evidence in the electronic files or school records of a response to this referral. May 2012 Julia and her mother saw GP 2 twice regarding the contraception pill and once for advice regarding mothers concerns about Julia’s behaviour. June and August 2012 Julia’s mother contacted the Duty Social Work Team twice for advice about managing Julia’s behaviour, sexual behaviour and her wanting to meet boys. On the second occasion Social Worker 3 visited, but there was no one at home because the family had gone on holiday. A letter was left asking mother to make contact, but she did not. October 2012 During the course of an investigation of sexual assault of another young woman, the police were told that Julia had also been raped by the same perpetrator. The police interviewed Julia and she alleged that she had 13 been raped. When interviewed again by the police she said that it had been consensual and she had previously had sex with six other boys. The police made a referral to Children’s Social Care and a Core Assessment was initiated. This assessment was not completed before a further disclosure of sexual assault was made by Julia in December 2012. School were concerned at this time about her poor attendance and disruptive behaviour. 8 December 2012 Julia reported to the police that she had been raped by a 19 year old man. She was seen at the Sexual Assault Referral Centre where she was diagnosed with a sexually transmitted infection by the Doctor who examined her. She was seen by the nurse who made a referral to Children’s Social Care because she was concerned about Julia and her mother’s attitude regarding the infection. 12 December Julia was seen with her mother at the Genito-Urinary Medicine Department of Sexual Health (GUM) for treatment, where she told the Doctor that she’d had “15 to 20 sexual partners”. The nurse at the clinic also made a referral to Children’s Social Care. Julia’s mother did not take Julia to the follow up appointment to treat the sexually transmitted infection. 14 December/11 January 2012 Julia was seen with her mother at home by Social Worker 4 and the sexual assault was discussed. December 2012 The Inclusion Leader from the school and Lead from the Troubled Families Project visited the family, they were concerned that the house was in a poor state of repair and the three sisters were huddled in bed because there was no heating. 18 January 2013 Children’s Social Care convened a Professionals’ Meeting to discuss progress regarding the rape disclosures made by Julia. Three appointments with the police were cancelled by Julia’s mother. At this point 14 Julia’s attendance at school was 50% and there was ongoing conflict with peers at school. January 2013 The Core Assessment was extended to include the second rape disclosure and was completed by Social Worker 4 in January with a recommendation of Child in Need support from the social work team. 29 January 2013 The case was allocated to Social Worker 5 and she requested (with the support of her Team Manager) that an Initial Child Protection Conference be convened. This was held on 21 February 2013. Julia was made subject to a Child Protection Plan. Methodology 1.9 This serious case review has been undertaken using the SCIE Learning Together methodologyv. The focus of a case review using a systems approach is on multi-agency professional practice. The goal is to move beyond the specifics of the particular case – what happened and why – to identify the deeper, underlying issues that are influencing practice more generally. It is these generic patterns that count as ‘findings’ or ‘lessons’ from a case, and changing them should contribute to improving practice more widely. Data comes from semi-structured conversations with the involved professionals, and the young person and their family who are the subject of the review, from case files and contextual documentation from organisations. A fundamental part of the approach is to talk with staff to understand what they thought and felt at the time they were involved in the case, avoiding hindsight as much as possible. It is vital to try and make sense of what factors contributed to their understanding at the time and to the decisions they made. This is known as ‘local rationality’. Any appraisal of practice is then made in the context of those contributory factors. v Fish, S. Munro, E. and Bairstow, S. (2008) Learning Together to Safeguard Children: developing a multi agency systems approach for case reviews. SCIE. London 15 The Lead Reviewers 1.10 This review was undertaken by Jane Wiffin (Independent Lead Reviewer) and David Peplow, both of whom are SCIE accredited Lead Reviewers. Jane Wiffin was the Independent Lead Reviewer. She is a qualified Social Worker who has extensive experience of working in safeguarding. She is an experienced serious case review author and chair, having undertaken 18 reviews. She was accredited as a SCIE Learning Together Reviewer in 2011 and has undertaken a number of reviews using this methodology. She is currently engaged in work developing tools and frameworks for addressing childhood neglect and she is an experienced auditor and safeguarding trainer. She is independent from all the agencies involved in this review. David Peplow served 25 years as a police officer. He was the Essex Police lead for safeguarding matters and Head of Child Abuse Investigations. He has extensive experience of multi-agency working across three Local Authority areas. He left the police in 2012 and became an accredited Learning Together reviewer in July 2012. He is the Independent Chair of Thurrock LSCB and sits on a fostering panel. David is independent of all the agencies involved in this. Although he is Chair of the LSCB he has undertaken this serious case review from a critical and analytical standpoint. The Review Team 1.11 The review was conducted by a team of senior representatives from local agencies who has had no direct involvement with the case. They shared in the conversations, the analysis of documents, the identification of key practice episodes and contributory factors. This report is the shared responsibility of the Review Team in terms of analysis and conclusions, but was written by the joint lead reviewers. 16 Name Agency Yvonne Anarfi Designated Nurse for Safeguarding Children: NHS Basildon & Brentwood CCG /NHS Thurrock CCG Sandra Bryan Matron for Disabled Child Team for North East London NHS Foundation Trust Julie Cole Lead Consultant for Safeguarding and Quality: Coram Liz Chapman Manager – Operational Investigations: Essex Probation Kathie Clibbens Professional Lead & Consultant Nurse Safeguarding Children: West Essex Clinical Commissioning Group Anita Erhabor Associate Designate Nurse: Basildon and Brentwood and Thurrock CCGs Lesley Ford Detective Chief Inspector Head of Child Abuse Investigation & Police Online Investigations Teams / Head of Child Safeguarding Barbara Foster Head of Care & Targeted Outcomes, Children’s Directorate, Thurrock Council Cassandra Moore Named Nurse for Safeguarding Children, Basildon Hospital Lindsey Marks Principal Solicitor for Children’s Safeguarding; Thurrock Council Malcolm Taylor Principal Educational Psychologist 17 The Case Group 1.12 The members of the Case Group are the professionals who worked with or made decisions about the family, and who had individual conversations with members of the Review Team. The Case Group comprised of over 20 people (although not all these people attended Case Group meetings). Most were briefed on the methodology and then met with the Review Team on four further occasions to share in the analysis, the identification of contributory factors, and to comment and contribute to the report. Individual sessions were held with some professionals, either because they could not make the Case Group meetings or to clarify data. • Two Social Workers • Social Work Team Manager • School Liaison • Special Educational Needs Coordinators • School Nurse • Three police officers • Two nurse specialists • School counsellor and school support • Education Welfare Officer • GPs • Practice Manager for GP surgery • Parenting Workers • Specialist Doctor • Inclusion Leader, School Family Member Involvement 1.13 Julia and her Mother contributed to the Review by meeting with the Lead Reviewer on two occasions, once at the beginning of the process, and once at the end. 18 Structure of the Review Process 1.14 The Review Team met on six occasions, including four times with the Case Group, and worked with them on the information from the conversations to the identification of the Findings and issues for LSCB consideration. Sources of data 1.15 • The semi-structured conversations between members of the Review Team and 20 members of the Case Group; • The semi-structured conversations with family; • Documentation: All necessary documentation was made available to the review ranging from case files, procedures, and police attendance records. This meant that the reviewer did an in depth review of all the relevant information held during the period under review by Children’s Social Care, GP surgery, Police, School Nurses, Coram, school, GUM and SARC. About Thurrock 1.16 Thurrock lies to the east of London on the north bank of the River Thames and within the Thames Gateway, the UK's largest economic development programme. Thurrock has a strong manufacturing and retail focused economy. There is a very significant regeneration programme centred on five growth hubs: Purfleet, Lakeside, Grays, Tilbury and London Gateway. Thurrock has a resident population of approximately 40,200 children and young people aged 0 to 18, representing 25% of the total population of the area. In 2012, 25.7% of the school population was classified as belonging to an ethnic group other than White British compared with 22.5% in England overall. Some 12% of pupils speak English as an additional language. Deprivation levels in Thurrock are consistent with the national average, but there are significant pockets of deprivation and inequality, with several areas falling within the 20% most deprived areas in England. 19 2 APPRAISAL OF PROFESSIONAL PRACTICE IN THIS CASE 2.1 A Serious Case Review plays an important part in the efforts to achieve a safer Child Protection system. Consequently it is important to consider what happened and why in a particular case, but to then go further and reflect on what this might reveal about underlying gaps and strengths in the child welfare system that may reappear in other cases. This case should act as a “window on the system” and move beyond the case specific. We begin by capturing the appraisal of the practice response to this case, given what was known and knowable at the time. The Findings that follow in the next section then aim to provide an explanation of the “why”, outlining what got in the way of professionals being as effective as they wanted to be. 2.2 It is difficult for those professionals who were directly involved with Julia and her family to have practice they were involved in appraised in this way. They were very open to reflecting on practice, but wanted to make clear that some of what took place is historical, and some aspects of the practice reviewed has now changed and developed. The Review Team is grateful to them for being open and helping to make sense of the case and the context in which practice took place. It is clear that all individual professionals cared about what happened to Julia and her family. Many of the professions involved, for example the allocated Social Care Team and the police, were overloaded in the period under review and this had an impact on practice in this case. Less is known about whether there were capacity issues for the other services involved. 2.3 During the timeframe for this review (just over two years) there were four critical incidents, three of which were disclosures of rape and sexual assault by Julia and one related to concerns about the quality of physical and emotional care that Julia and her siblings received. There was an immediate response to most of these incidents. However, on occasions, established policies and procedures were not followed, including a Strategy Meeting/discussion, Child in Need 20 processes, processes for non-attendance at school and evidence that some health professionals did not make direct referrals to Children’s Social Care, although there is also evidence of good multi-agency referrals too. 2.4 Beyond these points of crisis, despite a lot of professional activity and concern, there was little progress in improving the safety and wellbeing of Julia and the professional responses appeared to ‘drift’. It is the task of this review to consider why this was so, and what this tells us about the strengths and weaknesses in the multi-agency Child Protection system. Working with persistent non–engagement 2.5 In part, the lack of progress for Julia was as a result of the passive resistance by Julia’s mother to most professional contact and help. Many agencies spent a great deal of time trying to see Julia and her family without success and Julia’s mother regularly missed meetings, did not follow up on referrals made for her daughter’s well-being and failed to return telephone calls or reply to letters about failed appointments. There was a mistaken belief that Julia could not be seen without mother’s permission. 2.6 The only time that contact with mother was possible was when there was a crisis, or she wanted advice about Julia’s difficult behaviour as she saw it. As soon as the immediate crisis had been addressed, Julia’s mother withdrew, meaning that Julia did not have contact with professionals and was unable to develop helping relationships with them. The cause of this withdrawal by mother was insufficiently analysed or challenged, and no solution was found to address it. The school were aware of Julia’s poor attendance at school and held meetings to discuss this with Julia’s mother. Although they discussed the potential for taking formal action, none was taken. The health professionals who advised Julia were aware that her mother did not always seek advice for her promptly enough, but did not explicitly challenge her. The consequence of this was that professionals lost sight of the fact that, because of the non-engagement of mother, Julia did not receive the services she needed. Working with chronic non-compliance with services is difficult. This is discussed in Finding 4 and 5. 21 Professional recognition of adolescent neglect 2.7 The lack of engagement by Julia’s mother to services designed to promote the wellbeing of Julia and her siblings should have been recognised as an indicator of adolescent neglect. There was evidence that Julia was not sufficiently supported to attend school, and there were times when she said she did not have bus fare because her mother had spent it. This had an impact on her ability to make use of the additional support she was provided with as a child with additional needs, and she was not able to attend counselling support provided at school because of her many absences. When Julia told school that she had been raped they appropriately suggested that her mother take her to see a health professional, which her mother delayed. Julia was not taken for her police interview (Achieving Best Evidence) on a number of occasions, and when a sexually transmitted infection was diagnosed she was not taken for her follow up appointment. 2.8 There were periods when the household she lived in was described as “chaotic” with the siblings being in conflict. This was of concern to the Accident and Emergency Department of the hospital who saw Julia’s sister with an accidental injury in May 2011, and when the Coram parenting worker visited in September 2011 she was concerned about the level of conflict at the house and the behaviour of all of the siblings. 2.9 Although most professionals recognised that Julia was a young person who had disclosed a number of rapes, had a difficult family history and at times poor quality parental care, the lack of engagement and resistance by her mother meant that they were not able to form a relationship with her. There was an urgent need for a multi-agency meeting or an assessment to analyse her needs and her mother’s response in the context of potential adolescent neglect – neither of which happened. This is discussed in Finding 6. 22 Uneven balance between “troublesome” rather than “troubled” Adolescence 2.10 A focus on Julia being “troublesome” was instigated by her mother and was not sufficiently challenged by professionals. Mother sought help from the GP and asked for Julia to be assessed by a Psychiatrist. A referral was made to Child and Family Consultation Service (one of the services of CAMHS) for Oppositional Defiance Disorder without an analysis of her very real difficulties or contact with any other professional. At school she was often difficult and badly behaved, and these concerns were a strong feature of her Statement of Special Educational Needs reviews’. The school did offer her counselling support, but poor attendance meant that these sessions were rarely attended. 2.11 The focus shifted to Julia as the problem, and this overshadowed the difficulties she was experiencing as young person with additional needs because of her mild learning disability and who had experienced a number of traumatic experiences. This was apparent after the incident when she threw boiling water over her sister. This was a serious incident and needed to be treated as such, but there is no evidence that once the criminal issues had been addressed, that her behaviour was analysed or linked to her recent disclosures of rape and sexual assault. The fact that she could be held responsible for her behaviour, yet none of her disclosures of rape had led to any prosecutions, despite significant and appropriate enquiries being made, was not acknowledged. Julia clearly needed help to make sense of this. There should have been a multi-agency plan to bring these two aspects together – the complex circumstances which were likely to have led to Julia feeling angry and the behaviour that appears to be the consequence. There was a need for a more holistic response. This is discussed in Finding 3 and Finding 5. Lack of assessment 2.12 An Assessment for Julia was carried out nine months before the period under review in January 2010 as a result of a disclosure of sexual assault when she was aged 12. She was next assessed in October as a result of the referral made by the police regarding a disclosure of sexual assault, a gap of two and a half years. In this time there was one further disclosure of sexual assault and there 23 were concerns expressed about Julia’s under age sexual activity. There were also concerns about family chaos and two specific incidents which led to two Assessments, both focussed on Julia’s sister rather than Julia. These were comprehensive pieces of work, which gave a good sense of history but which focussed in their analysis on the presenting incident, and did not fully consider Julia and the concerns about sexual assault. 2.13 This lack of Assessment was influenced by existing processes for assessing the primary referred child rather than the whole family, and this is discussed in Finding 3. This meant that the proposals for interventions, made at various points were not connected to a clear understanding or analysis of Julia’s needs and circumstances, and success, was unlikely. This is discussed in Additional Learning. Multi-agency meetings and planning processes 2.14 It is striking that in the period under review there was only one multi-agency meeting with regard to Julia and this was held at the very end of the review period in January 2013. It would have been expected that some multi-agency meetings would have taken place given the lack of progress of any of the proposed services offered to Julia and her family. It is easy to place this responsibility entirely onto Children’s Social Care, and although they had key worker responsibility, any other agency could have requested or called a multi-agency meeting, although all agencies do not seem to have felt enabled to do so. This is discussed further in Finding 3 and Finding 6. Child in Need Processes 2.15 Julia was considered to be a Child in Need from July 2010 to January 2012 without there being a Child in Need Assessment, Child in Need meeting or Child in Need review. Despite concerns that this case should have been escalated to Child Protection, the Child in Need processes could have developed an effective multi-agency plan. This did not happen. Overall there was reasonable multi-agency information exchange across the period of this review but it was not focussed or part of a clear plan of action. This was particularly noticeable with regard to the school, who were managing concerns about Julia’s non- 24 attendance, behavioural and emotional difficulties, her disclosures about sexual assaults and her special educational needs, without a clear overarching plan. Coram were asked to provide parenting support and provided this, but without it being clear how this fitted into an overall plan for this family. It is clear that the GP surgery was not included in the information exchange and did not also engage with any of the professionals involved with Julia. 2.16 The lack of any multi-agency meetings meant that there was no opportunity to establish goals, set the expectations for Julia’s mother and the rest of the family, and review progress. The review would have been an opportunity to reflect on the lack of progress being made and to consider next steps or a change in direction. A face to face meeting in this context might have enabled all professionals to challenge the status quo, but the multi-agency team could also have been a virtual one if there had been a clear plan of action. At no point was information held by all shared in one forum, and so it is not surprising that the response was fragmented. This is discussed in Findings 3 and 6. Effective safeguarding referrals from the multi-agency network 2.17 There were a number of occasions when the school, hospital, GUMvi and SARCvii and the police made prompt and clear referrals to Children’s Social Care about Julia and her sister, and these were responded to quickly. In October 2010 school contacted Children’s Social Care to inform them of a disclosure of sexual abuse by Julia. The hospital saw Julia’s sibling, Courtney, on two occasions (May 2011 and September 2011) and on both they were concerned about the care provided to all the girls, and on the second occasion mother’s discussion of Julia’s underage sexual activity. These same concerns prompted GUM and SARC to refer in December 2012. The police made a referral in October 2012 when concerns about sexual assault regarding Julia came to their attention. This was all effective multi-agency practice, but the fact that it did not lead to a multi-agency response is discussed in Finding 6. vi Genito-Urinary Medicine Clinic vii Sexual Assault Referral Centre 25 Difficulties in escalating to Child Protection 2.18 Given the seriousness of the concerns regarding the disclosure of sexual assault by Julia from the ages of 12 – 14 years and her mother’s attitude, it would have been expected that Child Protection procedures would have been considered. Julia made four disclosures of rape in a two year period. Rape of a child is sexual abuse, yet somehow this was not recognised. The police undertook extensive criminal enquiries to establish the facts of each case and to seek a prosecution of the perpetrators identified by Julia. The lack of a criminal prosecution should not have meant that there was no Assessment of significant harm and a decision made about whether a Child Protection response under Sec 47 of the Children Act 1989 was required. 2.19 When Julia made a disclosure of rape at the age of 12 in October 2010 there should have been a Strategy Discussion/meeting, as this was clearly an allegation of statutory rape. The Social Worker sought a Strategy Meeting but was hampered by delays in being able to contact the police. The Social Worker pursued this but ultimately it never took place. This appears to have been influenced by the fact that by the time the police officer and Social Worker were able to visit the family home and see Julia (some eight week after the incident) the police could take no further action because they did not have enough evidence to pursue a criminal investigation. As a result there was no Child Protection enquiry and Julia was seen as a Child in Need – not a child in need of protection. There were a number of professionals involved at this point, police, Social Worker, school, GP and School Nurse. All were aware of the seriousness of this incident, but because of the lack of any multi-agency meetings there was no forum to question why the case continued to be held at a Child in Need level. This is discussed in Finding 7. 2.20 A Child Protection response should have been considered when Julia threw boiling water over her sister. At this time the hospital raised concerns that Julia’s mother had told them that Julia had been sexually active from an early age and there had been recent concerns about sexual abuse. The social work team thought there should have been a Strategy Meeting and Child Protection Case Conference, and sought advice from the Safeguarding Team. They received a 26 reply asking for clarification of the engagement of other teams, and there was no further recorded response. 2.21 Julia made a disclosure of rape in October 2012 and this should have warranted a Child Protection response, but was held again at a Child in Need level and a Core Assessment started. A new disclosure of rape was made by Julia five weeks later and it was agreed that a Child Protection enquiry should be initiated and a Child Protection Conference convened. This did not happen. This final disclosure was incorporated into the Core Assessment started in November, and the conclusion was that Julia should once again be held at Child in Need level rather than being escalated to Child Protection, this was subsequently challenged by the social work team and an Initial Child Protection Conference held. 2.22 Over the period of the review the Case Group told the Review Team that adolescents were less likely to be subject of Child Protection processes and the social work team found this frustrating. This has changed over time, and there is now better recognition of the importance of Child Protection processes for this age group. This is discussed in Additional Learning in section 4. The response to disclosures of sexual abuse and rape 2.23 The sexual assault and rape of a 12 year old child is a serious issue. Julia made four disclosures of rape over a three year period from when she was just 12 to 15 years old. It was particular striking how the language used about Julia by her mother such as Julia “had 15- 20 partners”, and the language used by Julia herself such as “she had consented to sex” was recorded across professional records without any clear critique or analysis about what it meant for Julia and her well-being. This language needed to be challenged, and addressed, not recorded without comment. The danger of the lack of challenge and analysis is that it can appear that professionals agree with the negative ideas behind the language used, which in this case they did not, but this needed articulating in the records. This is discussed in Finding 2. 2.24 There also needed to be a clearer connection made between the sexual health advice Julia received from a number of professionals and the sexual abuse she 27 was experiencing. No one agency connected these two issues together so they were considered in isolation of one another. The lack of an assessment or multi-agency meeting meant there was no forum in which this could be discussed. 2.25 The police worked hard to achieve a prosecution. Given Julia’s learning difficulties and her difficult early childhood experiences, it was always going to be complex for Julia to provide a clear picture of what had actually taken place, and this was indeed so. The difficulties in achieving a criminal prosecution influenced the practice response at times. When Julia made a disclosure in October 2010, the difficulties of achieving a criminal prosecution led to the belief that a Strategy Meeting was no longer required. This was incorrect. There appears to have been confusion regarding the criminal response, carried out by the police, and the civil response, carried out by the multi-agency team in the context of a disclosure of sexual abuse and Child Protection processes. 2.26 There is now greater multi-agency awareness and response to the sexual exploitation of young people locally (see the section on learning from the fringes page) and nationally. However, over the period of the review Julia was not always understood to be a victim of sexual exploitation by professionals, her parent/siblings and significantly she also did not understand that this was what was happening to her. 2.27 This review highlights the importance of good quality multi-agency working and a shared multi-agency awareness of the importance of and responsibility for ensuring: • effective holistic assessments • effective Child Protection and Child in Need processes • analytical information sharing and particularly the sharing and appraisal of assessments and decision making • good quality planning and reviews • an understanding of adolescent neglect, • an appropriate balance between sexual health advice and sexual abuse/exploitation. 28 These are all essential elements of an effective response to child sexual exploitation and were often absent for Julia. The challenge for the Board is to reflect on the Findings that follow and to consider how the practice gaps identified in this case can be addressed to ensure that sexual exploitation of young people is effectively responded to in the future. 3 THE FINDINGS Analytic process for establishing systems findings 3.1 The aim of a Learning Together case review is to use a single case as a ‘window on the system’, to uncover more general strengths and weaknesses in the Child Protection system. A four-stage process of analysis is used to articulate how features of the case can lead to more general systems learning. The first is to look at how the issue manifested in the case specifics, this will often be presented as one example, even if there are several such examples. This evidence comes from the analysis of the reconstruction of the unfolding case, documentation and an examination of the key practice episodes. 3.2 The second step is to consider whether the issue observed in this case is ‘underlying’. That is, that it is not a ‘quirk’ of the case, but is likely to represent practice in other cases and by other practitioners. The third step is to consider how geographically widespread and numerically prevalent the issue is within the system. Sometimes it is not possible within the scope of a review to collect this data. The sources for these steps will be information from the Review Team and Case Group, any performance data, national research and other reviews in a variety of combinations. In this review, it has not been possible to obtain some of the data requested to populate these steps – this has been highlighted where relevant. 3.3 The last step is to articulate why this issue matters, what are the risks to the safeguarding system. Based on this finding, questions and considerations for the LSCB are formulated. 29 Categories of underlying patterns 3.4 The systems model that SCIE has developed includes six broad categories of underlying patterns. The ordering of these in any analysis is not set in stone and will shift according to which is felt to be most fundamental for systemic change. Not all the typologies will have a finding associated with them but they are designed to allow for structured enquiry as to what the data has revealed: • Human biases (cognitive and emotional): Are there common errors of human reasoning and judgement that are not being picked up through current case management processes? • Family-professional interaction: What patterns are discernible in the ways that professionals are interacting with different family members, and how do they help and or hinder good quality work? • Communication & collaboration in responses to incidents: Are there particular good or bad aspects to the patterns of how professionals respond to specific incidents (e.g. allegations of abuse)? • Communication and collaboration in longer term work: Were any good or bad patterns identified about ways of working over a longer period with children and families? • Tools: What has been learnt about the tools and their use by professionals? • Management system: Are any elements of management systems a routine cause for concern in any particular ways? 30 3.5 This review has prioritised seven findings for the Board to consider: Finding 1: There is a pattern whereby national and local policy agendas have driven practice in relation to underage sexual activity to have a stronger focus on sexual health and teenage pregnancy rather than sexual abuse/exploitation Communication and collaboration in longer term work Finding 2: If professionals record the language used by young people and their parents regarding early sexually exploitative experiences without clear analysis and challenge it has the potential to leave children and young people without an adequate response or protection. Communication and collaboration in longer term work Finding 3: Is there a pattern whereby the Child in Need procedures are not routinely being used leaving children and young people without formal plans and review? Communication and collaboration in longer term work Finding 4: The lack of engagement with services by parents takes professional energy and attention away from the needs of children /young people and leaves them with an ineffective response. Family-professional interaction: Finding 5: Is there is a lack of a developed understanding and awareness of adolescent neglect across the multi-agency network leaving young people at risk of harm. Communication and collaboration in longer term work Finding 6: Is there a pattern whereby Multi-agency working has become overly focussed on information sharing, at the expense of a shared analysis, face to face meetings and shared plans to meet the needs of children and young people? Communication and collaboration in longer term work 31 Finding 7: Is there a pattern whereby GP’s in Thurrock are not recognised by others or themselves as an integral part of the safeguarding network? Communication and collaboration in longer term work Additional Learning 1. The importance of holistic assessments 2. Difficulties in escalating to Concerns about Adolescents to Child Protection 32 Finding 1: There is a pattern whereby national and local policy agendas have driven practice in relation to underage sexual activity to have a stronger focus on sexual health and teenage pregnancy rather than sexual abuse/exploitation Why does it matter? 3.6 Nationally there is a clear legal framework with regard to sexual activity regarding children and young people. Children aged less than 13 years are not legally capable of consenting to sexual activity and sexual activity with a young person under the age of 16 is a criminal offence. However, there is some evidence that increasing numbers of young people under the age of 16 are engaging in sexually activity. Guidance from the Crown Prosecution Service states that young people who are of a similar age should not be prosecuted or issued with a reprimand or final warning where sexual activity was mutually agreed and non-exploitative. The law makes clear that children under 13 are particularly vulnerable, so to protect younger children any sexual activity with a child aged 12 or under will be subject to the maximum penalties – whatever the age of the perpetrator. 3.7 It is the task of all professionals to evaluate these early sexual experiences to assess whether they are sexually exploitative. This was raised by the Bichard Inquiry (2003)viii into the Soham murders which highlighted the importance of taking a critical approach to young people’s early sexual experiences and for professionals to be aware of the potential for exploitation. To support this approach a checklist was introduced into Working Together 2006ix and this has formed the basis for all current sexual exploitation frameworks. 3.8 Sexual exploitation has become an important policy objective, and one that is recognised as having been difficult for all professional groups to respond effectively: viii Cabinet Office (2004) The Bichard Inquiry London: The Stationery Office ix HM Government (2006) Working Together to Safeguard Children: a guide to inter-agency working to safeguard and promote the welfare of children, London: The Stationery Office 33 “The lack of curiosity about child sexual exploitation shown by all official agencies has been a running theme… professionals did not recognise the existence of the exploitation, were not aware of the scale of the abuse and were not sharing information, this was partly due to assumptions that victims were engaging in consensual relationships and the inability to engage with them.’ Beckett, H et al (2013x) 3.9 Professionals must ensure that young people are not being sexually exploited and have made an informed choice/consented to sexual activity. The issue of consent is important here and is described in Section 74 of the Sexual Offences Act 2003 as: 'if (s)he agrees by choice, and has the freedom and capacity to make that choice'. 3.10 Professionals should consider this in two stages. Whether a young person has the capacity (i.e. the age and understanding) to make a choice about whether or not to take part in the sexual activity at the time in question and whether he or she was in a position to make that choice freely, and was not constrained in any way. 3.11 At the same time professionals are also required to give young people advice and support about sexual relationships, contraception and sexual and reproductive health including pregnancy and abortion. 3.12 The Labour Government developed its Teenage Pregnancy Strategy (Social Exclusion Unit, 1999xi) with the aim of reducing teenage pregnancy rates by 50%. In the period between 1998 and 2011 the under 18 conception rate fell by 34% (Office for National Statistics, 2013). Teenage pregnancy and sexual health continue to be prioritised in the policies of the Coalition Government. The Public Health Outcomes Framework 2013-16 (Department of Health, 2011xii), against which national and local government will monitor improvements in public health, x Office of the Children Commissioner (2013) If only someone had listened – the final report of the Inquiry of the Office of the Children’s Commissioner into Child Sexual Exploitation in Gangs and Groups (CSEGG) xi Social Exclusion Unit (1999) Teenage Pregnancy Report, London: Social Exclusion Unit. xii Department of Health (2011) Health Survey for England, London: DH 34 includes reducing under-18 conception rates and late diagnosis of HIV, and increasing Chlamydia diagnoses among 15-24 year-olds as key sexual health indicators. Alongside this, the Framework for Sexual Health Improvement in Englandxiii highlights reducing rates of under 18 conceptions and STIs as two of the five priority areas for improvement (DH, 2013). 3.13 Although this policy guidance now makes clear that all professionals providing sexual health advice must be aware of child protection and safeguarding issues as well as having guidelines and referral pathways in place for risk assessment and management of child sexual abuse, there remains a potential contradiction between the responsibility to address sexual exploitation and promote positive sexual health. How did it manifest in this case? 3.14 Julia’s mother sought advice from the GP when she disclosed that Julia had been raped six weeks before her 13th birthday. This led to contraceptive advice, and there is no evidence that she was assessed to see whether her experiences had been abusive in line with existing policies and procedures and there was no referral to Children’s Social Care. The focus was on sexual health advice rather than safeguarding. 3.15 In November 2011 when Julia was 13 she sought advice about sexual relationships from the School Nurse who assessed her as Gillick competent under the Fraser guidelines, and she was provided with condoms. This was in line with existing procedures regarding sexual health support. The School Nurse was not aware of the other concerns regarding Julia’s sexual activity, and there was no opportunity or forum for her to contextualise the support for sexual health alongside all the other concerns about this vulnerable young person. xiii Department of health (2013) A Framework for Sexual Health Improvement in England: https://www.gov.uk/government/uploads/system/uploads/attachment data/file/142592/9287-2900714-TSO-sexualhealthpolicyNW accessible.pdf 35 3.16 The Child in Need Plan developed as a result of the Core Assessment undertaken in July 2010 and which remained unchanged over a period of two and a half years, focussed on sexual health advice and parenting support. How do you know it is underlying? 3.17 There were numerous occasions on which Julia made allegations and sought sexual health advice, and on each occasion there was a stronger professional focus on advice-giving rather than exploring issues of consent and abuse. It was at the end of the review period that concerns about sexual exploitation were voiced, and this was after four disclosures of rape and numerous allegations of underage sexual activity. The consistency of practice suggests strongly that this was an underlying tension inherent within the different role that professionals play. How prevalent is the issue? 3.18 No specific work was done by the Review Team to understand the prevalence of this issue in Thurrock, although the Case Group and Review Team both recognised that the imbalance was present in many of the polices regarding early sexual experiences. The extent of sexual exploitation is not well understood nationally, both because of the inconsistencies in data collection and because many young people do not recognise that they are being exploited. When talking about the scale of child sexual exploitation, Sue Berelowitz, the Children’s Commissioner told the Home Affairs Select committeexiv convened to look at this important issue that “there is not a town, village or hamlet in which children are not being sexually exploited.” The committee concluded that “it is obvious that child sexual exploitation is a large-scale, nationwide problem and evidence to the Committee indicates that it is increasing". At the same time increasing numbers of young people under the age of 16 are engaging in sexual behaviour under the age of consent. xiv House of Commons :Home Affairs Committee (2014) Child sexual exploitation and the response to localised grooming Second Report of Session 2013–14 : http://www.publications.parliament.uk/pa/cm201314/cmselect/cmhaff/68/68i.pdf 36 Finding 1 The principal finding of “If only someone had listened” − the Final Report of the Inquiry of the Office of the Children’s Commissioner into Child Sexual Exploitation in Gangs and Groups (CSEGG)xv was that despite increased awareness and a heightened state of alert regarding child sexual exploitation children are still slipping through the net and falling prey to sexual exploitation. Research published by Barnardosxviand the evidence provided to the Home Affairs Select Committeexvii suggest that gaps remain in the knowledge, practice and services required to tackle this problem. Part of an effective response will be to ensure that there is a professional balance between appropriate advice regarding sexual health and a heightened awareness that this might be an opportunity to consider the potential for sexual exploitation. Questions for the Board Does the Board recognise that this is an issue within Thurrock? Does this Board have any further information about what is getting in the way of enabling professionals to strike a balance between advice around sexual health and an awareness of sexual exploitation? What are the options available for tackling this issue? What action would the Board need to take to ensure that they know this has been addressed? xv Office of the Children Commissioner (2013) If only someone had listened” − the Final Report of the Inquiry of the Office of the Children’s Commissioner into Child Sexual Exploitation in Gangs and Groups (CSEGG) xvi Barnado’s (2012) Cutting them free: how is the UK progressing in protecting its children from sexual exploitation? London: Barnado’s. xvii House of Commons: Home Affairs Committee (2014) Child sexual exploitation and the response to localised grooming second report of session 2013-14: https://www.publications.parliment.uk/pa/cm201314/cmselect/cmhaff/68/68i.pdf 37 Finding 2: If professionals record the language used by young people and their parents regarding early sexually exploitative experiences without clear analysis and challenge it has the potential to leave children and young people without an adequate response or protection Why does it matter? 3.19 Finding 1 made clear the legal framework regarding underage sexual activity and the contradiction in policy which makes underage sexual relationships illegal, whilst at the same time recognising the need for support when it takes place in the context of choice and consent. This was not the case for Julia. She made disclosures of rape on four occasions, when she was 12, 13 and 14. This was her language and reflected her experiences. Professionals should have considered what this meant and been clear about making a professional analysis of what had happened, in order to address it effectively. It would have been more accurate for those agencies outside of the criminal justice system to record that Julia had been sexually abused. Sexual abuse is described in the SETxviii (Southend, Essex and Thurrock) procedures as “forcing or enticing a child/young person to take part in sexual activities, .....................whether or not the child is aware of what is happening” 3.20 There is growing recognition that child sexual exploitation (CSE) is a form of sexual abuse “that involves the manipulation and/or coercion of young people under the age of 18 into sexual activity in exchange for things ... and where the abusive relationship between victim and perpetrator involves an imbalance of power which limits the victim’s options”. 3.21 It is a form of abuse which is often misunderstood by victims and outsiders as consensual. (Barnardo’s 2012xix). This makes it complex because of the power xviii https://www.thurrock.gov.uk/how-we-keep-children-safe/set-child-protection-procedures xix Barnardo’s (2012) Cutting them free: how is the UK progressing in protecting its children from sexual exploitation? London: Barnardo’s. 38 dynamics of perpetrators and that young people themselves do not recognise that they are being abused or exploited. How did it manifest in this case? 3.22 Julia was described by a number of professionals as making “allegations” of rape – this is a phrase more suited to adults where there are legal issues regarding proof. For young people there is a need to consider whether what they are talking about is sexual abuse - which would now need to be seen in the context of sexual exploitation. There is a still a burden of truth here – but one which needs to be seen in the context of significant harm as outlined in the Children’s Act 1989 and enshrined in subsequent versions of Working Together. For young people under the age of 13, and for those with a learning difficulty in the older age range, professionals need to be focussed on the harm experienced, as well what actually happened. For Julia, professionals wrongly emphasised ascertaining the ‘truth’ of the ‘allegations’ – rather than focusing on what was the harm to her. 3.23 It was recorded that Julia told professionals that she “consented” to sexual activity without there being sufficient analysis or reflection of this statement. She needed professionals to help her understand that it is not uncommon for young people to be confused about this. A recent report, undertaken as part of the Children’s Commissioners’ review of sexual exploitation, highlighted the extent to which young people are confused about consentxx. Julie needed professionals to help her see what had happened to her was not actually consensual, and help her have an accurate understanding of issues of choice and accountability. This was pertinent when she was below the age of 13 and unable to legal consent, but also when she was 14 and 15. 3.24 A number of records across the multi-agency network recorded that Julia’s mother had told them that she had “15 - 20 partners” from the age of 12. This word was used without analysis or challenge, and the implications for Julia’s xx Coy, M., Kelly, L., Elvines, F., Garner, M. and Kanyeredzi, A. (2013). “Sex without consent, I suppose that is rape”: How young people in England understand sexual consent. London: Office of the Children’s Commissioner. 39 well-being were not explored. The use of this word had the potential to make her experiences of sexual exploitation hidden. 3.25 There was some professional confusion about the difference between “risky behaviour” and risk factors. In professionals records Julia was described as engaging in “risky behaviours” something her mother mentioned to all professionals she was in contact with. This phrase was used inaccurately and implies (without professionals actually intending to do so) that Julia might be responsible for what happened to her because of her own behaviour. This needed a clearer analysis and for professionals to distinguish between “risky behaviours” which are part of some adolescent’s behaviour and “risk factors” which were those aspects of her life that made normal risk taking more dangerous. How do you know it is underlying? 3.26 The Review Team and Case Group told us that it was common practice across all agencies to record what children and young people told them uncritically, in the context of early sexual experiences. They considered that professionals understood the importance of recording what young people told them as a way of being child centred. How prevalent is the issue? 3.27 Although there are no national or local figures regarding the number of young people who are being sexually exploited, research suggest that a significant number of young people are affected by this issue. The complex issue of language and its use in the context of exploitation was something that the Case Group and Review Team recognised affects all professionals. Nationally, the Children’s Commissioners Office inquiryxxi into sexual exploitation expressed concern about the language used by professionals which led to victims being xxi Office of the Children Commissioner (2013) If only someone had listened” − the Final Report of the Inquiry of the Office of the Children’s Commissioner into Child Sexual Exploitation in Gangs and Groups (CSEGG) 40 blamed for the exploitation with the consequence that they were not effectively safeguarded. Finding 2 Sexual exploitation is a serious issue and one that has a profoundly negative effect on young people’s lives and their wellbeing. It is essential that all professionals feel able to recognise young people who are being sexually exploited and that they are able to respond effectively. This response must be child centred and all professionals must take a critical approach to the use of language in this complex area of practice, so that risks are recognised and young people are not held responsible for the harm perpetrated by others. Questions for the Board Do the Board recognise that this is an issue that it should be concerned about? How can the Board ensure that this issue is addressed within its Child Sexual Exploitation strategy? Are there other opportunities or lever’s at the Boards disposal for changing professional practice and language in this area? How will the Board know if it is being effective in addressing this issue of language? 41 Finding 3: Is there a pattern whereby the Child in Need procedures are not routinely being used leaving children and young people without formal plans and review? Why does it matter? 3.28 The Child in Need processes outlined within the Children Act 1989 further reinforced by the Assessment Framework Guidance 2000 and Working Together 2010xxiiwere instigated to ensure that children and young people who were not subject to safeguarding plans received a carefully planned approach to their needs, which was reviewed over time. The SET procedures for Thurrock make clear that: “An initial Child in Need plan is used to support the provision of services by Children’s Social Care. The role of other relevant agencies should be considered within this initial plan and their involvement discussed and agreed with them, using a multi-agency meeting to formulate the plan, including parents. The initial plan must be reviewed within three months and thereafter monitored and reviewed at regular intervals, not less than once every six months. (Section 8.2 SET Procedures) 3.29 The Child in Need plan is an essential next stage after an Assessment has taken place. The purpose is to set a plan of action, based on the assessed need. This makes clear to young people how the Local Authority plans to support them and ensures that parent’s/carers know what is required of them to promote their children’s outcomes. It also creates the framework for multi-agency work. The ultimate aim is to improve children’s outcomes and so the review mechanism is an essential part of the process. This enables progress to be marked, and services provision to be amended if necessary. This process should activate multi-agency support for an agreed plan, and should not be dependent on a pre-existing network. xxii Department for Children, Schools and Families (2010) Working Together to Safeguard Children: a guide to interagency working to safeguard and promote the welfare of children. March 2010 42 3.30 During this review the Review Team were told by members of the Case Group that Child in Need meetings do not always take place when there are no other agencies involved with the child or young person, meaning that there appears no point in having a meeting. In Julia’s case there were times when other agencies were involved and particularly school – who were in fact a cluster of different professionals with differing responsibilities to Julia. This highlights fundamental misunderstanding of the process and the importance of planning for children and young people. How did it manifest in this case? 3.31 Julia was held from July 2010 to January 2012 as a Child in Need case. During this time there was no new plan made, no Child in Need meeting or review. The services proposed were not engaged with by Julia or her mother in any meaningful way. There was no opportunity for the professionals involved with the family to consider all the information they held about Julia and to consider whether the approach to her needs was working. The Case Group informed the Review Team that the reason there was no Child in Need meetings was because there was not ‘multi-agency involvement’ in addition to Social Care. However, there was at least two other key agencies involved throughout the review period. The school, for example, was providing counselling support, behavioural support, putting in place a plan for Julia’s special educational needs, attempting to address her poor attendance and providing sexual health advice. She was also receiving contraceptive advice from her GP who also acted upon concerns regarding her behaviour expressed by Julia’s mother. This work happened in isolation. 3.32 If there had been a plan which was reviewed, the many crises that occurred over the period of the review and the lack of engagement of Julia’s mother would have amply demonstrated that the approach being taken was not working, and the analysis of her needs inaccurate. 3.33 No professional involved with Julia and her family asked about the absence of Child in Need meetings or a review of the plan which was made six months before this review started. 43 How do you know it is underlying? 3.34 It has not been possible to establish how common it is for Child in Need processes not be used in the Adolescent Team or other teams in Thurrock. The Case Group members told us that pressures during the period under review led to difficulties in maintaining Child in Need planning and review processes. The fact that no agency involved with Julia asked about why a Child in Need meeting and review was not taking place suggests that Child in Need processes is not firmly established in the multi-agency network. Additionally, there was a belief that the absence of an established multi-agency network meant that Child in Need processes would not be helpful. Statistics are not collected nationally about Child in Need meetings or plans, as the focus is on Child Protection processes. Evidence from Serious Case Reviews suggests that Child in Need processes are not always prioritised. How prevalent is the issue? 3.35 It has not been possible to establish how prevalent this is as an issue. This is covered by the questions for the LSCB below. Finding 3 Effective processes to support children, young people and their families are essential. The Child in Need processes are intended to build on good quality assessments, by developing a plan of action , which is owned and developed by the multi-agency group, and is reviewed regularly to see what progress is being made to promote children and young people’s outcomes. If these processes are not used, interventions are unlikely to be clearly focussed on children’s needs and are unlikely to provide effective help and support. Questions for the Board Are the Board aware that Child in Need processes are vulnerable to pressures on Social Work teams, and of a potential misunderstanding of when Child in Need meetings should be convened? 44 Is there more the Board could do to establish the extent of this issue, e.g. case audit? What can the Board do to address this? How will the Board know they have been successful in ensuring that Child in Need processes is embedded in multi-agency practice? Finding 4: The lack of engagement with services by parents takes professional energy and attention away from the needs of children /young people and leaves them with an ineffective response Why does it matter? 3.36 Local Authority Children Services, other Local Authority departments such as Education and Health Authorities have a duty to safeguard and promote the welfare of children in their area who are in need and to promote the upbringing of such children, wherever possible by their families, through providing an appropriate range of services. In carrying out this responsibility the “client” or primary “service user” is the child or young person. In the Munro reviewxxiii of the safeguarding system, it was re-emphasised that children and young people should be at the heart of the provision of services. The vision of the Convention on the Rights of the Childxxiv and the Children Act 1989 is that they are individuals, members of a family and a community, with rights and responsibilities appropriate to their age and stage of development. They are not “the property of their parents” a point made by Baroness Butler-Sloss: ‘the child is a person not an object of concernxxv. 3.37 There is considerable evidence from research and serious case reviews that children and young people can become invisible to services because of the xxiii Munro, E. (2011) The Munro review of child protection: final report: A child centred system. London TSO xxiv The United Nations, (1989), The United Nations Convention on the Rights of the Child (available online at https://www.2ohchr.org/english/law/crc.htm) xxv Cm 412, (1998), Report of the Inquiry into Child Abuse in Cleveland 1987, London, HMSO. 45 needs of their parents or caregivers, and this is apparent when those parents choose not to engage with services targeted at improving the outcomes and wellbeing of their children. 3.38 Recent research by Eileen Munroxxvi suggests that “Did Not Attend” should be reconceptualised as ‘Was Not Brought’ – i.e. failure to attend/engage with appointments should be an indicator of neglect. How did it manifest in this case? 3.39 There was a long history of non-engagement by Julia’s mother throughout the period under review. Julia’s mother only responded to contact from services in times of crisis. She was not at home for appointments and home visits organised by the Social Workers, she did not return telephone calls or respond to letters. She failed to follow up on the referral to the Sexual Health Advisor and did not follow through on a number of referrals for parenting support and did not attend planned school appointments regarding concerns about attendance and behaviour. Paradoxically, the lack of engagement, suggestive of a poor level of care for Julia, resulted in Julia receiving less rather than more support from services. 3.40 The Social Workers considered seeing Julia at school, and one appointment was made. A decision was made that because the case was held at a Child in Need level it was not possible to see her without the consent of her mother. The lack of engagement by mother meant that consent could not be sought. Consent is of course important and respecting family life appropriate, but this approach served to allow mother’s non engagement to restrict access to a Social Worker for Julia. 3.41 This had clear consequences for the wellbeing of Julia: • She was not able to form a relationship with her Social Worker - which is essential if effective work is to be done about sexual abuse and sexual exploitation • Her emotional, educational and physical needs were neglected. xxvi Munro, E (2012) Review: Children and young people’s missed health care appointments: reconceptualising ‘Did Not Attend’ to ‘Was Not Brought’ – a review of the evidence for practice. Journal of research in nursing, 17(2). Pp. 193-194. 46 How do you know it is underlying? 3.42 The Case Group told us that working with parental non engagement, particularly in the context of adolescence, was a regular occurrence and a great frustration. The Biennial Review of Serious Case Reviewsxxvii highlighted the extent of parental resistance and its negative impact on improving children’s outcomes. How widespread is the pattern? 3.43 There is little information available nationally or locally about the extent of non-engagement in work with families at Child in Need level. Research and serious case reviews suggest that nationally this is a significant issue, which has a profound impact on children and young people’s outcomes. How prevalent is the issue? 3.44 Whilst this review has not established how prevalent this issue is, Ferguson (2010xxviii) suggests: “We have failed to acknowledge the sheer scale of resistance and hostility that professionals have to bear”. xxvii Brandon, M., Sidebotham, P., Bailey, S., Belderson, P., Hawley, C., Ellis, C., and Megson, M. (2012) New learning from serious case reviews: a two year report for 2009-2011. London: HMSO xxviii Ferguson. H (2010) Walks, Home Visits and Atmospheres: Risk and the Everyday Practices and Mobilities of Social Work and Child Protection. British Journal of Social Work 47 Finding 4 The non-engagement of parents in services aimed at promoting the well-being of their children/young people is a significant issue. It has an impact on young people’s well-being and their outcomes, and causes more pressures on over stretched professionals. It is also costly for services. A lack of recognition of this as a safeguarding issue means that children and young people are not always effectively protected. Questions for the Board Are the Board aware of this as an issue facing professionals? Does the LSCB know if staff locally has been equipped to work with resistant parents both in single agency and partnership working? How might the LSCB help practitioners overcome this obstacle to effective practice? How will the Board know when this has been effective? Finding 5: Is there a lack of a developed understanding and awareness of adolescent neglect across the multi-agency network leaving young people at risk of harm? Why does it matter? 3.45 There is considerable evidence about the developmental world of adolescents (Coleman and Hagell 2007xxix). This stage of development characterised for some young people as engaging in risky behaviour such as drugs, alcohol and sexual experimentation. This sense that this is “normal” adolescent behaviour has caused some professional confusion about risk taking behaviour, which is part of adolescence as opposed to “risk factors” which make appropriate “risk taking behaviour” more dangerous. This has been recognised particularly in the context of sexual exploitation, where young people are perceived as engaging in risky behaviours and a causal link is made with sexual exploitation, inadvertently xxix Coleman, J and Hagell, J. (2007) Adolescence, risk and resilience: Against the odds: Wiley.com 48 making those young people feel like it is their fault – that they are to blame. It is critical that we separate out these two issues and highlight the key issue of the risk factors such as adolescent neglect rather than focus solely on adolescent behaviour. 3.46 The recent House of Commons Inquiry into the operation of the Child Protection System in England and Walesxxx was presented with considerable evidence that young people aged 14- 18 are not receiving effective protection and support from the multi-agency safeguarding system. This Inquiry found that there was a lack of services to meet the particular needs of adolescents, a failure to look beyond behavioural difficulties, a lack of recognition of the abuse and neglect of teenagers and particularly the long term impact on them. 3.47 The neglect of children and young people is a national concern and is recognised as posing a significant threat to the wellbeing and outcomes of children and young people across the whole developmental spectrum, in the short and long termxxxi. Comprehensive help to children and young people has been hampered by professional concerns that it is often poverty and disadvantage which cause neglect and there has been reluctance by professionals to further discriminate against social excluded and disadvantaged communitiesxxxii. 3.48 Recent research (Stein et al 2009xxxiii) has highlighted the significance of adolescent neglect, and its link to sexual exploitation, early pregnancy, anti-social behaviour, poor mental health and self-harm. 3.49 Despite this there remains concern about the recognition and response to adolescent neglect. This is in part due to differing professionals understanding xxx House of Commons Education Committee (2013) Children first: the child protection system in England Fourth Report of Session 2012–13: children-first-the-child-protection-system-in-england.pdf xxxi Gardner, R. (2008) Developing an effective response to neglect and emotional harm to children. London: NSPCC xxxii Action for Children (2011) Neglecting the issue: impact, causes and responses to child neglect in the UK. London: Action for Children. xxxiii Stein, M., Rees, G., Hicks, L. and Gorin, S. (2009) Neglected adolescents: literature review. London: Department for Children, Schools and Families (DCSF). 49 of what neglect is – and although there is national and local guidance regarding the neglect of children more generally, there is no definition of adolescent neglect. 3.50 The definition in the SET (Southend, Essex and Thurrock) procedures echoes that outlined in National Guidance – Working Together 2013 which provides a much broader framework for understanding neglect, but the issues for adolescents are not explicitly covered. “Neglect involves the persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health and development. Neglect ...may involve a parent or carer failing to: • provide adequate food, clothing and shelter (including exclusion from home or abandonment); • protect a child from physical and emotional harm or danger; • Ensure adequate supervision (including the use of inadequate care-givers); or ensure access to appropriate medical care or treatment. • The neglect of, or unresponsiveness to, a child’s basic emotional needs. And Medical Neglect is failure to ensure access to appropriate medical care or treatment”. 3.51 One of the difficulties facing professionals who assess adolescent neglect is that many of the outcomes associated with neglect are also associated with young people who are struggling to come to terms with this new stage in their development. This can lead to an underestimation of both the present experience of being neglected and the cumulative impact of past poor quality care. Professionals can come to sympathise with the parents/carers at having to deal with difficult behaviour, rather than recognising that neglectful care can lead to adolescent difficulties. There is some evidence from serious case reviews that in this way adolescents move for being seen as “troubled” to “troublesome” and the service response changes. 3.52 In addition, research suggests that professionals are less likely to feel justified in labelling a young person’s experiences as neglectful if they recognise that the family circumstances are characterised by poverty and disadvantage, and if they 50 feel parents are not deliberately intending to cause children harm – but are struggling with their own issuesxxxiv. This has led to many children and young people’s circumstances not being sufficiently responded to – for adolescents this may mean that the difficulties they experience are seen as a function of who they are – rather than as a function of the care they receive. If professionals do not challenge the quality of care adolescents are provided with , the evidence suggest that they can turn in on themselves, and this can leads to poor self-worth and for some a sense of helplessness about who you can turn to for help. An effective response to adolescent neglect is therefore critical. How did it manifest in this case? 3.53 There was considerable evidence that Julia had been neglected from her early years, and that this continued thought to adolescence. 3.54 In May 2011 the hospital made a referral to Children’s Social Care because Julia’s sister, Courtney, had come to the Accident and Emergency Department with suspected concussion after being hit on the head by a falling door at the family home. The hospital said that the injury was accidental, but the reason for the referral was a concern about all the siblings who had reported to hospital staff that there was chaos at home, that their mother took no interest in them and provided no practical or emotional support. The referral from the hospital was responded to with an Initial Assessment of the sibling who received the injury. This concluded that the incident had been accidental and the decision was case closure. 3.55 These concerns about neglect were well supported by the recent concerns that Julia’s mother did not enable Julia to seek medical advice when she disclosed that she had been raped, and when a referral for Julia and her sister was made to the Sexual Health Advisor her mother did not enable them to attend and did not follow up on the advisors attempts to contact her. The school found it extremely difficult to make contact with her mother when they had concerns about Julia’s behaviour and angry outbursts, and her mother only intermittently xxxiv Action for Children (2011) Neglecting the issue: impact, causes and responses to child neglect in the UK. London: Action for Children. 51 attended appointments regarding special educational needs. This information was not assessed as part of a pattern of neglectful care. 3.56 Given this background, it was not surprising that Julia presented challenging and angry behaviour. Although it was appropriate that this was addressed, it also needed to be contextualised alongside the quality of care she received and her early sexually abusive experiences. The multi-agency balance for Julia moved to her being viewed as more troublesome than troubled. How do you know it is underlying? 3.57 The Case Group considered that adolescent neglect was a significant issue in their work. Researchxxxv and the Ofsted analysis of serious case reviewsxxxvi also suggest that adolescent neglect is a significant national issue. How prevalent is the issue? 3.58 Overall the national evidence suggests that neglect is a significant category of maltreatment both during childhood and adolescence. In Thurrock during 2012, 61% of children/young people were subject to Child Protection Plans because of neglect and 16% of all plans were regarding young people aged 12 years or older. xxxv Stein, M., Rees, G., Hicks, L. and Gorin, S. (2009) Neglected adolescents: literature review. London: Department for Children, Schools and Families (DCSF). xxxvi Ofsted (2011) Ages of concern: learning lessons from serious case reviews: http://www.ofsted.gov.uk/resources/ages-of-concern-learning-lessons-serious-case-reviews 52 Finding 5 Adolescent neglect is a significant issue which has a profound effect on young people’s lives. Recognising and responding to adolescent neglect is a critical part of addressing sexual exploitation, and an ineffective response leaves young people at risk of significant harm. Questions for the Board Are the Board aware that adolescent neglect is a significant issue facing professionals? How can this be tackled by the Board? How can professionals be supported to develop a more effective response to adolescent neglect? How will the Board know its response has been effective? Finding 6: Is there a pattern whereby multi-agency working has become overly focussed on information sharing, at the expense of a shared analysis, face to face meetings and shared plans to meet the needs of children and young people? Why does it matter? 3.59 Good quality multi-agency working is essential to the effective safeguarding of children and young people. This has been a core finding of all the public Inquiries regarding serious child deaths (there have been 75 since 1945xxxvii) and most of the serious case reviews that are undertaken in England. Poor multi-agency working was a central criticism of practice in the Victoria Climbié Inquiry xxxvii Winter, K (2011) Building Relationships and Communicating with Young Children: A Practical Guide for Social Workers: London: Routledge 53 and was also highlighted by Munro in her reviewxxxviii of the child protection system. These reviews and inquiries make it clear that effective multi-agency working is about more than effective and timely information sharing, although this is obviously critically important. 3.60 Multi-agency working must be about being prepared to share with others your own professional understanding of a child/young person’s needs and circumstances, contributing this analysis to the assessments being carried out by any agency. Researchxxxix shows that many assessments of children/young people collate information, rather than analyse it. Part of the analytical process is enabling the multi-agency group to comment on the completed assessment or the analysis and conclusion in order to connect with a shared understanding of the needs of the child/young person and to understand their role in any future plan of work. Serious case reviews have suggested that this is not the case and that a belief system has developed which suggest that it is not permissible to share the assessment with other professionals without the permission of the parents. The Guidance issued as part of the Assessment Framework makes it clear that this is not the case. 3.61 Multi-agency working also means multi-agency planning for a child/young person. The research is clear, where there is careful multi-agency planning, the outcomes for children tend to be better and where planning is weak, there is more evidence of drift and poor outcomes. 3.62 Research also suggestsxl the importance of the multi-agency network coming together to share their thinking and analysis in a face to face meeting. Although much of this work is done and can be done in a virtual way, it is necessary for professionals to meet to review progress, particularly where progress is not xxxviii Munro, E. (2011) The Munro review of child protection: final report: A child centred system. London TSO. xxxix Broadhurst, K et al ( 2010) Ten pitfalls and how to avoid them: What research tells us: NSPCC: http://www.nspcc.org.uk/Inform/publications/downloads/tenpitfalls_wdf48122.pdf xl J Selwyn, E Farmer, D Turney, D Platt (2011): Improving Child and Family Assessments: Turning Research Into Practice: Jessica Kingsley Press 54 being made. Reder and Duncan (1998)xli have highlighted the complexity of communication across networks in safeguarding practice where all interaction is virtual. Meetings matter to the outcomes for children, young people and their families. 3.63 Multi agency work is also about appropriate professional challenge. Serious case reviews highlight how barriers to effective challenge across professionals group and hierarchies have a profound impact on safeguarding practice. How did it manifest in this case? 3.64 There was evidence that all agencies (with the exception of the GP’s who were not included and did not contribute – something discussed in Finding 8) communicated with each other and kept each other informed of what was happening for Julia and her mother. There was overall some good information sharing between the school and social work team. The school became a mini team of professionals (teacher, school liaison, School Nurse, Attendance Officer, Special Needs Coordinator) and their information was usually amalgamated and passed on to the social work team. The unintended consequence of this approach was that the School Nurse appears to have been unaware that Julia had been in contact with Children’s Social Care, and that there had been serious concerns about her. 3.65 A number of agencies made referrals to Children’s Social Care regarding their concerns for Julia and her sisters, including school, hospital, SARC, GUM and the police. These were all appropriate and were responded to by Children’s Social Care as would be expected, but this did not lead to requests for further analysis and none of these agencies received information about the outcome of the Assessments emanating from these referrals, despite most agencies remaining involved afterwards. Coram explicitly asked to see the Assessment regarding Julia and her family and was told that permission would need to be sought from her mother. Mother’s lack of engagement meant this never happened, and that Coram provided services in a vacuum. xli Reder, P and Duncan, S (1998) Understanding communication in child protection networks: Child Abuse Review: Volume 12, Issue 2, pages 82–100, March/April 2003 55 3.66 There were no multi-agency meetings over the two and a half years of the review. This meant that the drift in the case was not discussed, that services were provided in isolation from one another and there was no mechanism for reviewing the lack of progress, or deciding on an alternative plan of action. Meetings matter and they mattered for Julia and her outcomes. 3.67 There was evidence across the review that although working relationships were perceived to be good, there was often a lack of effective challenge across the professional network. The delay in seeking a Strategy Meeting in November 2010 caused by the inability to contact the police officer, was frustrating for the social worker and ultimately this delay meant no Strategy Discussion occurred. This was not discussed or challenged. The allocated social care team manager tried to escalate the case to Child Protection, and the emails were not responded to. At the time there appeared no mechanism to address this. The school made a referral to the Duty Team at Children’s Social Care which was not responded to and was not challenged. Effective challenge is a critically important part of good multi-agency working. How do you know it is underlying? 3.68 It is unclear whether this is an underlying issue. The Case Group told the Review Team that there were good working relationships in Thurrock across professional networks, and there were effective working relationships which had built up over time. 56 Finding 6 Information sharing is a critical component of multi-agency safeguarding practice, but if multi-agency processes are to be effective there is a need to move beyond the provision of information to sharing and exploring a professional analysis of a child or young person’s circumstances. Assessments and plans need to be developed and reviewed by the multi-agency network. If this does not happen children and young people are left at risk of harm, and plans become one dimensional. Drift is not challenged, and the lack of progress not noted or addressed. Questions for the Board Do the Board accept this finding? How will the Board establish whether this is a significant issue? What can the Board do to address it? How will the Board know it has been successful? Finding 7: Is there a pattern whereby GP’s in Thurrock are not recognised by others or themselves as an integral part of the safeguarding network? Why does it matter? 3.69 General Practitioners have a critical role to play in safeguarding children and are vital to inter-agency collaboration in Child Protection processes and to promoting early intervention in families. There is considerable advice to support GPs in their safeguarding roles with children, especially concerning confidentiality and their duties as a GP and doctor, from the regulatory and professional bodies and 57 Royal Colleges (e.g. GMC, RCGP, RCPCH, BMA). Despite this, researchxlii and serious case reviewsxliii have highlighted that it is often problematic to engage GP’s in safeguarding processes. This concern is characterised by the difficulties in obtaining information and attendance at key meetings, such as Child Protection Case Conferences. 3.70 Research suggestxliv that GP’s are aware of their responsibilities regarding the safeguarding of children and young people, but that there are a number of systemic gaps which makes engagement difficult. This research highlights that GP’s are concerned about the large reports they receive regarding children, which they do not have time to read or analyse. Where there are medical concerns about children, GP’s are used to receiving succinct and focussed reports, which give a clear account of the main issues and the proposed plan of action, including their role. They argue that much of the paperwork they receive regarding safeguarding is lengthy and they cannot get a clear idea of the key issues, or the role that they are required to play. GP’s are required to give six weeks’ notice to cancel clinics, and find it difficult to attend meetings at particular times of the day, because of patient appointments, yet they feel little account is taken of this when they are asked to attend meetings. Researchxlv also suggests that some GP’s have lost confidence in the safeguarding system because of delays or a non-response to the referral that they make to Children’s Social Care. xlii Tompsett, H., Ashworth, M., Atkins, C., Bell, L., Gallagher, A., Morgan, M., and Wainwright, P. (2010) The child, the family and the GP: Tensions and conflicts of interest in Safeguarding Children. DCSF Research Briefing. London: HMSO. xliii Brandon, M., Sidebotham, P., Bailey, S., Belderson, P., Hawley, C., Ellis, C., and Megson, M. (2012) New learning from serious case reviews: a two year report for 2009-2011. London: HMSO xliv Tompsett, H., Ashworth, M., Atkins, C., Bell, L., Gallagher, A., Morgan, M., and Wainwright, P. (2010) The child, the family and the GP: Tensions and conflicts of interest in Safeguarding Children. DCSF Research Briefing. London: HMSO. xlv Tompsett, H., Ashworth, M., Atkins, C., Bell, L., Gallagher, A., Morgan, M., and Wainwright, P. (2010) The child, the family and the GP: Tensions and conflicts of interest in Safeguarding Children. DCSF Research Briefing. London: HMSO. 58 How did it manifest in this case? 3.71 Julia was seen on six occasions by the GP’s at her local Health Centre regarding under age sexual activity, the need for sexual health advice and concerns expressed by her mother regarding Julia’s behavioural difficulties. The GP surgery made no contact with any of the other agencies involved with Julia or her siblings. The Assessments carried out regarding Julia acknowledged the GP, but the GP surgery has no record of any contact with Children’s Social Care, they did not know Assessments were being undertaken and did not receive a copy or a summary of the analysis, or proposals for sexual health advice and support. No other agency made contact with the GPs, despite, for example, the school knowing that Julia’s mother was seeking GP advice and support. The GP surgery was unaware that Julia was a Child in Need and therefore they were not able to inform anyone of their referral to Child and Family Consultation Services. During the period under review they worked in isolation. They did not seek to connect with the multi-agency network charged with promoting the welfare of Julia and they were not ever engaged in that network. This meant that important historical information that they held, particularly about Julia’s mother learning difficulties, got lost and they provided sexual health advice without ever contextualising this alongside the other concerns regarding Julia. How do you know it is underlying? 3.72 The Case Group told the Review Team that they considered that there were often difficulties engaging GP’s in safeguarding work. The GP’s who work in the Health Centre raised similar issues about their work in safeguarding to those highlighted in the national research. How widespread and prevalent is the pattern? 3.73 It has not been possible to gather data about how widespread this issue is, but the Case Group suggested that this is a significant issue. The GP surgery was clear that the issue raised by them were replicated in other GP surgeries and national research suggest that this is an important issue to address. 59 Finding 7 GPs are a critical part of the safeguarding network. It is essential that any barriers to their effective engagement in safeguarding processes are actively addressed. This is particularly important in the context of underage sexual activity and sexual exploitation, where GP’s are likely to be a key point of contact for young people. Questions for the Board How will the Board establish whether this is a significant issue and which needs addressing? How will the Board explore the engagement of GPs in the safeguarding network? What are the options for addressing this issue? 60 CHAPTER 4 – ADDITIONAL LEARNING 1. The importance of holistic assessments 4.1 Historically national guidance regarding Initial and Core Assessments encouraged Social Workers to be incident focused and only analyse the circumstances of the referred child, leaving other children in the same family without a clear analysis of their needs or a plan 4.2 There were two referrals regarding Julia’s sibling during the period under review and both focussed on the sibling rather than Julia. The Review Team recognised that the existing processes regarding Assessments did not support a holistic whole family approach. This is in the process of change with the development of the Single Assessment process. 4.3 In September 2011 Children’s Social Care received a referral from the hospital regarding Courtney who had been seen in A&E with burns caused by her sister throwing water from a boiling kettle on her back whilst she was in the bath. The referral also said that the hospital was concerned because Julia’s mother had told them that Julia “had been sexually active since she was 11- 12 years old”. A referral was opened regarding Courtney, but not Julia. 4.4 The completed Assessment contained a lot of information and family history. The focus was on Courtney and her circumstances, but there was also information provided about Julia. Information was provided about Julia not having contact with her father because her mother said that he is a risk to children and was allegedly involved in the sexual abuse of a child. The School were said to have raised concerns about Julia who was refusing to follow instructions, truanting from class, being disruptive and had hit another student in class. In the context of the two previous disclosures of rape and the allegations made in the referral, these were worrying issues, which indicated that Julia had significant needs. 4.5 Crucially the conclusion of the assessment focussed almost exclusively on Courtney and the incident which led to the referral. This meant that the referral 61 was not considered to have met the threshold for services because the incident had been dealt with. Julia’s needs were not analysed and no formal plan of action was put in place, beyond continued support from school for her. 4.6 The lack of any Assessment of Julia’s needs during the majority of the period under review meant her needs were not well understood, the issues of sexual abuse not explored fully and the need for Child Protection processes to be put in place not fully discussed. Issues for the Board to consider: • Does the Board recognise that the quality of assessment in Thurrock is an issue for the safety and wellbeing of children and young people? • Does the introduction of the Single Assessment provide an opportunity to improve the quality of assessments, and ensure that a holistic approach is taken? • Does the Board have any evidence about the quality of Assessments locally and what the barriers to effective practice might be? • Does the Board have an awareness of the key issue for effective assessment of young people who are being sexually exploited and what needs to be put in place to optimise assessment practice in this area? • How will the Board know it has been successful? 2. Difficulties in escalating to concerns about Adolescents to Child Protection 4.7 Over the period of the review the Case Group told the Review Team that adolescents were less likely to be subject of Child Protection processes and the social work team charged with meeting the needs of teenagers found this frustrating. This has changed over time, and there is now better recognition of the importance of Child Protection processes for this age group. 4.8 Given the seriousness of the concerns regarding the disclosure of sexual assault by Julia from the ages of 12 – 14 years, and her mother’s unresponsiveness, it would have been expected that she would have been subject to Child Protection procedures. Julia made four disclosures of rape in a 62 two year period. Rape of a child is sexual abuse, yet somehow this was not recognised. The police undertook extensive criminal enquiries to establish the facts of each case and to seek a prosecution of the perpetrators identified by Julia. The lack of a criminal prosecution should not have meant that there was no assessment of significant harm and a decision made about whether a Child Protection response under Sec 47 of the Children Act 1989 was required. Issues for the Board to consider: • How will the Board know that these changes have occurred and are embedded in practice? 63 Thurrock Local Safeguarding Children Board Initial Response to the Serious Case Review Introduction: The publication of the Serious Case Review of “Julia” has learning for all organisations involved both locally and nationally. The SCR is 52 pages in length and covers the period between November 2010 and February 2013. The report contains seven findings and specific challenges to which the LSCB will seek reassurance of change. The case was referred formally to the Thurrock Local Safeguarding Children Board (LSCB) on 10th January 2013 and their Serious Case Review Panel met on 4th February 2013 to consider the case under Regulation 5 of the Local Safeguarding Children Board Regulations 2006. The Panel found that this case met the criteria for a Serious Case Review and agreed the commissioning arrangements in order to meet the requirements of such reviews as laid out in HM Government ‘Working Together to Safeguard Children, 2010 At the time of this referral Working Together 2013 was about to be implemented which allowed LSCB’s to use any learning model consistent with the principles in the guidance, including systems based methodology. After considering the options for the review, it was decided to hold off the commissioning of the review under the “old” IMR procedures pending the guidance implementation to enable the board to commission a systems based approach for this SCR. In May 2013 the Board formally commissioned an independent and co reviewer using the SCIE methodology. The findings within the report have been agreed by the LSCB Full Board on 19th May 2014 and service improvements are already in hand. Since the period in question most agencies have demonstrated a clear commitment to learn and improve and have provided evidence to this effect to the LSCB and its sub structures. With regard to the specific challenges of this serious case review, the LSCB has sought answers to the questions and supporting evidence from all agencies. Having agreed the findings the SCR Group met on 6 June 2014 and each agency has agreed an action plan of the challenges and where changes have not yet been effected, the commitment to make such necessary changes and improvement in practice is detailed within these plans. Many of the agencies acknowledge that they need to do much better when listening to children and how this is reflected in the actions they take to safeguard and protect. The Board is focusing on this as a priority area for improvement over the coming year. 64 This detailed response will be actively monitored by the Board, through its Audit Group to provide continuing evidence of impact. The LSCB will continue to maintain focus on how agencies are managing organisational change and ensuring safeguarding remains a priority. LSCB key actions going forward: The Board will carry out its responsibilities to co-ordinate and monitor the safeguarding arrangements in Thurrock and aims to ensure agencies are transparent within their own organisation, with its partners and the public and the children and young people with whom they work, by requiring that: The LSCB will:- via its Audit sub group provide an evaluation of the progress of the responses by agencies and challenge agencies to produce evidence to determine there has been an impact for children. The Board will check that agencies responses have been factored in their improvement process and safeguarding reports to the Board and included in the 2015/16 LSCB Annual Report. Coordinate a multi-agency learning event available for all organisations to attend to disseminate the learning from this review. Request each organisation to provide details to the Board of the improvements emanating from this SCR within their agencies Annual Report. The LSCB training programme will be reviewed to reflect the findings. The Board will produce a presentation (PowerPoint) and briefing notes that can be cascaded to all agencies for use as part of organisational learning and included on its website. Agencies will be encouraged to make available time for their practitioners to access the report and absorb the learning. Jane Foster-Taylor LSCB Vice-Chair 14th November 2014 65 A summary of the response to the findings: Following the Board meeting where the findings were agreed each agency was asked to respond. This proved to be a longer piece of work than the Board and Serious Case Review Panel originally thought it would be. Some of the findings are phrased as a question to the LSCB and agencies. This is a feature of this method of review and reflects the fact that the hard evidence was not readily available but that the Reviewers, the Review Team and Practitioners had a sense that this was the situation. In formulating the detailed response no evidence to counter the questions completely was found and so they are accepted as areas that need development. The result is a detailed action plan which is quite long therefore a brief summary of the nature of the responses is below. The plan is being actively monitored by the LSCB and a Sub-Group and is available on request to accompany the serious case review report. We need to acknowledge that whilst the responses have been put together the Rotherham Report (Independent Inquiry into Child Sexual Exploitation in Rotherham (1997 – 2013) by Alexis Jay OBE) was published and we have started work with our neighbouring Essex Boards and the partners to ensure that our previous plans around child sexual exploitation (CSE) are still fit given the issues highlighted in this new report. To help with this a new strategic group has been formed to consider the report and the all Essex CSE group, under a new Police chair, is considering all aspects of CSE. There is also a Thurrock CSE group in place to ensure the local perspective is properly considered. Tackling the issue of child sexual exploitation was and remains a high priority for Thurrock LSCB and the individual agencies. The move away from a series of simple recommendations made by a reviewer to findings which need to be worked through by the multi-agency partnership is challenging. It is also a shift in thinking to try and come up with some responses that are more than just “train the workforce”. Whilst we have a detailed response and actions from agencies this is not the end of the response to the findings but a starting point for Workforce Development to address the matters found by this review. The summary below and the full agency response should be read with this in mind. That said, training the workforce and sharing findings from a review remain important tools. As an LSCB we are looking hard at how we measure the impact of any training that is delivered and our latest full LSCB meeting ran with a theme as to how individual agencies know that training is making a difference to peoples’ practice and therefore making a difference to children. Finding 1: There is a pattern whereby national and local policy agendas have driven practice in relation to underage sexual activity to have a stronger focus on sexual health and teenage pregnancy rather than sexual exploitation 66 This issue was widely acknowledged by partners and in particular people who work in health and deal with children and young people. There was already in place a programme of training to help staff recognise when someone might be at risk of being exploited which was happening whilst this review was being done. There is more work to do around this to ensure there is a good understanding of the issue amongst all professionals and that any response is consistent and timely across the partnership. Thurrock has recently “gone live” with a Multi-Agency Safeguarding Hub (MASH). This puts a number of people from different professions into one place to consider any concerns about children and young people. This model is recognised as being a strong tool to help recognise and deal with child sexual exploitation. The House of Commons, Home Affairs Committee, Child Sexual Exploitation and the response to localised grooming, Second Report of Session 2013- 14 said: “We recommend that each Local Children Safeguarding Board be required to set up a Multi-Agency Safeguarding Hub which would house representatives from Social Care, local police, health professionals, education, Youth Offending Teams and voluntary organisations…The police and the CPS should also produce guidance on data sharing via the MASH… “ The LSCB will be monitoring the results of this new structure to ensure it is making a difference to the children and young people of Thurrock. Finding 2: If professionals record the language used by young people and their parents regarding early sexually exploitative experiences without clear analysis and challenge it has the potential to leave children and young people without an adequate response or protection Unfortunately this is not a new issue and has been highlighted in other reviews. The nub of this is about children and young people using words like “relationship” and adults thinking about that in an adult way without exploring what the child really means. Again the new MASH will help but there needs to be a broad understanding of this amongst people working with children in many situations. A workshop is planned by some health colleagues. The response from agencies shows a commitment to change and challenge people’s use of language. Individual supervision and the LSCB multi agency audits will consider this issue to ensure that there is a clear analysis of what the professional has been told. 67 The LSCB ran a conference last year with a theme of hearing the voice of the child and a more recently a themed LSCB meeting in March 2014 asked agencies to report on how they hear the voice of the child and ensure what they hear makes a difference to practice. The detailed action plan in response to this finding builds on this earlier work. Finding 3: Is there a pattern whereby the Child in Need (CIN) procedures are not routinely being used leaving children and young people without formal plans and review? Whilst all agencies are involved in these processes the lead here is Children’s Social Care. It was recognised in a mock inspection done is November 2013 that adherence to CIN processes, particularly in regard to regular review was not established, predominantly in the Adolescent Support Team. Since then action has been taken to address this before this review was finalised. New processes have been put in place including supervision to help discuss and challenge the response to the young person. In order to conclude this finding the LSCB needs to be satisfied that these new procedures are the normal practice for everyone and those children and young people have appropriate formal plans and reviews. The LSCB will monitor this as part of the Performance Sub Group and report back to the Full Board. Finding 4: The lack of engagement with services by parents takes professional energy and attention away from the needs of children /young people and leaves them with an ineffective response Resistant parents are well known to be a blocker to working with children and young people and this is recognised by all the LSCB agencies. Training has previously been undertaken. The Early Offer of Help approach of starting work earlier with a family may help, dealing with “missed appointments” of children by health workers may also help. Appropriate early escalation for supervision and a multi – agency response could also assist. The LSCB needs to closely monitor this finding to be sure that suitable mechanisms are in place to recognise and deal with resistant parents. This is a complex issue for which there is not a “quick fix” such as training alone but needs a range of tactics. Monitoring the situation is also a challenge and the LSCB and the sub-group will continue to consider what work could be done to assist professionals working in these circumstances so that the best possible outcome can be achieved for children and young people. Finding 5: Is there is a lack of a developed understanding and awareness of adolescent neglect across the multi-agency network leaving young people at risk of harm 68 It is agreed that the impact of adolescent neglect is not always fully understood by professionals and perhaps not dealt with as firmly as neglect in younger children. Some behaviour that could be part of a pattern of neglect could also be seen as part of adolescent behaviours where there is not neglect. The LSCB is undertaking a new serious case review where neglect of an older child is a feature which reinforces the fact that this is an area of practice that needs to become better developed. The annual conference, due in the autumn of 2014 has a focus on neglect and adolescent neglect will be part of that. This will help in increasing awareness of this also there is a cross over with child sexual exploitation work where older children, those aged over 16 but under 18, can be particularly challenging for professionals to work with. Some training is being planned and Children’s Social Care are working with a new assessment tool to help recognise the neglect of adolescents. Finding 6: Is there a pattern whereby Multi-agency working has become overly focussed on information sharing, at the expense of a shared analysis, face to face meetings and shared plans to meet the needs of children and young people? Put simply this finding was suggesting that people were sharing information as they should but not getting to the heart of the matter by really thinking about what the information was telling them about a situation. Part of the remedy to this is to make sure each agency shares their information including their own analysis. The MASH should assist greatly in this and we are eager to start seeing the performance data that will be produced so we can see what a difference it is making. A good shared analysis should lead to better planning, the end result being the right children having the best response at the right time, for only as long as it is actually needed. We can determine if this has happened by undertaking audits of cases as part of audit programme. Finding 7: Is there a pattern whereby GP’s in Thurrock are not recognised by other professionals or themselves as an integral part of the safeguarding network? Part of the response said that most GP’s did recognise themselves as being part of the network. So this finding is not fully accepted by all agencies. However it remains a challenge to consistently engage all GP’s, this is recognised by some of the practitioners as they have made suggestions as a result of this finding as to how they might better be able to contribute. The LSCB needs to undertake some work to see how widespread the issue actually is to make sure any effort to correct this is focused in the right way. The reasons could be many and 69 diverse and it is likely there needs to be a re-think as to how best to work with GP’s to ensure their important contribution is included every time. There is now improved engagement with Primary Care with over 90% of Thurrock’s GPs trained to Level 3. There is 100% Board level awareness for Thurrock CCG and currently Section 11 Audits are being undertaken. Also a Named Safeguarding Doctor for Thurrock CCG has now been appointed. |